midterm must know (study first) Flashcards
why are guidelines/protocols important?
-Streamline processes that we know to be good practice
-Makes clinical activity more predictable across clinicians, clinics and regions
-Ensures patient receives high quality care regardless of practitioner, clinic and/or location
-Enables evaluation of patient and program outcome
-Supports clinical research
-Helps answer future questions
Hierarchy of listening
Detection (sound vs no sound)
Discrimination (sounds are different)
Identification (what is the sound) *point to picture of sound
Comprehension (what does the sound mean) sound means happiness or soundness;
arousal test
High frequency signal with bell- Not sensitive or specific
first hearing screening process
presenting 90db narrowband signal a ft away from babies’ ear & see if they reacted
when was the Joint committee on infant hearing (JCIH)
1970, same year first position statement
screening
triage to help determine if child needs further assessment (newborn hearing loss & hearing loss for adult screening is not diagnostic or therapeutic)
assessment
Comprehensive testing used to identify hearing loss (test battery) in each ear
intervention
Individualized plan; supports necessary based on what you found in the assessment
Universal newborn hearing screening
Infant hearing screening- Systematic system to scan all babies for hearing loss (regardless of status) AKA population screening
Early hearing detection and intervention (EHDI)
comprehensive program with 3 components (Screening, assessment and intervention)- typically a public health program
Hard of hearing
Permanent partial or total inability to hear in 1 or both ears, term is used to describe a person who has the condition & usual method of communication is spoken language
permanent hearing loss
SNHL, something you can’t recover or have surgery on
5 components of EDHI program
- Universal screening of all newborns (UNHS) regardless of the presence of risk indicators
- Identification of babies with PHL using evidence based diagnostic techniques
- Provision of evidence-based intervention services which include support for technology (hearing devices) and communication development (spoken and/or signed language) based on informed and engaged parental choice
- Provision of family support
- Monitoring and measuring the impact of the interventions and EHDI programs
Updated recommendations: 1-2-3 (JCIH, 2019)
- All infants should undergo hearing screening by 1 month corrected age
- All infants who don’t pass their hearing screening will have a complete audiological assessment by 3 months corrected age
- All infants with confirmed PHL should be referred immediately for early intervention
- Early intervention services should reflect the goals of the family and begin as soon as possible after diagnosis but no later than 6 months
- Regions who meet the 1-3-6 benchmark should strive to meet a 1-2-3 month timeline
Which provinces are sufficient:
Alberta, BC, Ontario, Nova scotia, NWT, Yukon (6)
ontario IHP components
- Universal newborn hearing screening (UNHS) for infants 2 months or younger
- Audiological surveillance is provided for all infants born with or who acquire a risk indicator known to cause late onset or progressive PHL
- Hearing assessment by audiologists to confirm the presence or absence of PHL and provide necessary referrals
- PHL is confirmed intervention is available for the infant & support to families offered
- Evaluation of the need for assistive technology is provided by the IHP audiologist. Provision of HA is conducted by the audiologist
o Devices are funded fully or partially through other provincial programs - Family support is provided by social workers knowledgeable in working with families of infants with PHL
- Language development services are provided and include spoken or signed language
what is IHP screeners role
- Explain the hearing screening and risk factor screen
- Obtain and document the required consent on the screening form
- Assess the infant for any known risk factors for hearing loss
- Conduct the hearing screening according to the protocol
- Explain the results of the hearing screening to the family
- Provide information about next steps to the family
target population for EHDI
infants with permanent HL
SNHL >25 dB HL
conductive losses longer than 6 months
not targeted population for EHDI
transient ME issues due to fluid or infection this is dealt with in medical system (OHIP)
purpose of risk factor assessment
- Determine whether screening should be bypassed; or
- Decide which type of screening test to us (ADPOE OR AABR)
- Record information that will determine whether the infant should receive later audiological testing (surveillance) and if so what type of surveillance
Timing of hospital ADPOAE screening Vaginal delivery
should be screened as late as possible before discharge and not less than 15 hrs after birth
timing of hospital ADPOAE screening C-section
should be screened as late as possible before discharge ideally after 36 hours and not less than 22 hours after birth [infants more likely to have unresolved ME fluid and resulting very high false positive rates so the later they are screened before discharge the better]
when can AABR screening begin
infant is medically stable and never under 34 weeks gestational age
Risk factor group 1
complete AABR screen, discharge if pass
Risk factor group 2
complete AABR screen, surveillance if pass
Risk factor group 3
do not screen, directly to audiology
Atresia/microtia, CHARGE, cCMV, meningitis, genetic screen positive
standardized IHP scripts for screeners aim to
- Support the delivery of high quality, accurate info from screeners to families
- Facilitate families proceeding with necessary follow-up
- Reduce family anxiety
goal of bloodspot risk screening
- Improve the effectiveness of the current risk assessment process
- Allow for earlier and more accurate identification of infants with specific risk factors for PHL and their subsequent assessment or surveillance monitoring
CCMV screen positive pathway
- Reporting, retrieval & care coordination managed by dedicated regional nurse practioner
- Referral to community pediatricians for initial evaluation/developmental surveillance
- Infectious disease (ID) referral for symptomatic infants
- Referral for STAT ABR assessment
genetic screen positive pathway
- Retrieval centralized by NSO genetic counsellor/audiology team
- Seen by Audiology
- Referral to ENT & genetics
audiologic assessment objectives
- Estimate hearing levels in each ear at several frequencies
- Determine presence, type and configuration of PHL so data can be used for accurate and prompt hearing aid fitting
ontario IHP assessment protocol
- AC ABR tone burst threshold at .5, 2 & 4KHz (Smin=25 dB eHL); also 1KHZ when indicated
- BC ABR tone burst threshold at .5, 2 & 4KHz when indicated
- Click ABR to assess cochlea-neural status (as needed)
- Diagnostic DPOAE for cross check (discretional) and neuropathy (mandatory)
- Tympanometry with 1000Hz probe
- Ipsilateral reflex at 1 KHz with a 1000Hz probe
- VRA where feasible- frequency specific using inserts when possible (Smin=25 dB eHL);
What does it take to achieve good outcomes
(1) Linguistic input (2) audibility (3) consistent HA use
Elements of pediatric HA fitting
(1) Assessment (2) prescription & selection (3) Verification (4) Evaluation/Validation
why is impact greater for HL in children
- Children need higher sensation level sounds (speech) compared to adults
- Children are still acquiring speech, learning language but adults have context and can fill in the blanks, already have access to language, therefore Children need higher sensation levels and better SNR
Goals of pediatric hearing aid fitting
comfort, ease of listening, audibility
Types of outcome measures
- Objective: Capacity measure: what can the child do in clinic ex., ability to detect low level speech sound
- Subjective: performance measurement: what can child do in real world ex., parent observation of child’s preformance using a questionnaire
Advantages of objective
(1) direct measure of child’s aided hearing (2) most clinics are already equip.
Disadvantage of subjective measures
1) language and literacy barriers (2) reliability and validity of caregiver report
Disadvantage of objective measures
(1) difficult to conduct with some children (2) child must be alert (3) specific equipment needed (4) specific measurement technique and stimuli needed for different ages & developmental level (5) capacity in quiet, low reverb
Advantages of subjective
(1) can be completed while child being assessed or in waiting room (2) performance of child in real world (3) appropriate for children with complex needs
Statistically tool should have good
(1) test-retest reliability (2) internal consistency (3) validity (4) responsivity
A good outcome evaluation tool should have
- Conceptual clarity (covers relevant domains)
- Normative data
- Appropriate measurement model (capture true breadth & detail of group by avoiding floor & celling effects)
- No item/instrument bias
- No respondent or administrative burden (length & content should be acceptable to respondent; easy to administer, score and interpret by clinician)
Goal of LittlEARS
assess auditory development during first 2 yrs of hearing
- Receptive and semantic auditory behaviour
- Expressive vocal behaviour
when to discontinue LittlEARs use
score is greater than or = to 27/35 & the child is > 24 months old
when do we score using chronological & adjusted age
37w or earlier relative to 40w term
LittlEARS early speech production questionnaire assesses what
age appropriate speech development in young children from birth to 18 months, evaluates speech production skills (not auditory development) of children with HL wearing hearing devices & assists professionals in monitoring progress over time up to 18 months of hearing age
at 3 months what is vocal development
exploration of vocal tract & production of vowel-like sounds followed by more refined and controlled vocal behaviours
3-8 M vocal development
begin to produce variety of vocalizations (vowels, glides, growls) & high-pitched squeals and also begin primitive attempts at combining consonant-like an vowel like sounds known as marginal babbling
5-10M vocal development
begin to coordinate behaviours of multiple systems (tactile, perceptual, auditory, neurophysiological) producing canonical syllables
how are canonical syllables [Different from marginal syllables
quick production of the vowel & consonant without any brakes in phonation or drawn-out transitions
when do first words emerge
10-13 M (16 months for some typically developing kids)
when do 2 word combinations emerge
emerge after child has at least 50 word vocab, may occur around 18 months
canonical babble defined
vocalization containing min. of a consonant and vowel, is a precursor to first words and emerges in children with normal hearing b/w 7-10 months
GOAL of PEACH and what is accroynm name
Parent’s Evaluation of Aural/Oral performance in children (PEACH)
to evaluate effectiveness of devices for infants and children with hearing impairment
Importance of outcome evaluation
Patients
(1) track & monitor (2) involve parents- results: good observers (3) shared language
Importance of outcome evaluation EHDI
(1) measure how program is doing (2) help describe patterns that affect children within program
Importance of outcome evaluation audiologists
(1) way to measure impact of HA fitting (2) improve efficency & effectiveness of service delivery (3) improve communication w families and professionals
Ontario IHP service pathway
- UNHS screen 2. Hearing screening 3. Audiology assessment 4. Confirmation of PHL (either discharged from IHP along stages 1-3 or at risk and skip to step 3).
Considerations for pediatric HA services
- Teach parents about DL
- Offer frequent remote check-ins over time following the HA fitting
- Guide parents in identifying and resolving barriers
- Collaborate to provide coordinated support
Pediatric filtered tone hooks:
Filtered earhooks ensures a smoother response promoting better target alignment and minimizing the risk of feedback (unfiltered ear hooks add resonant peaks causing feedback issues and complicating MPO target adjustments)
follow-up timeline
every 3 months for 1st year of HA use, 6 months for second year, every year thereafter, always as requested by family
- Reevaluate hearing levels & middle ear & HA function
- Visual inspection of the ear
- Re-make earmolds
- Electroacoustic analysis of HA
- Listening check of HA
- Obtain RECD (if new earmold)
- Conduct outcome evaluation (subjective & objective)
Watermeyer et al., Main communication challenge
(1) caregiver’s lack of acceptance of child’s HL (2) difficulty communicating due to language mismatches
Some children with UHL/MBHL may have poorer outcomes that children with more severe HL why
often bc thought is “they will be fine” so no interventions are provided to them)
- Children with more severe losses were identified earlier and received more services
Permanent mild bilateral HL:
PTA (0.5, 1, 2KHz) b/w 20-40dB HL
Permanent high frequency HL:
PT threshold > 25dB HL at 2 or more freq above 2kHZ (normal until 2kHz then drops off)
Permanent unilateral HL
PTA (0.5, 1, 2KHz) greater than or equal to 20dBHL or Thresholds greater than 25 dB HL at 2 or more frequencies above 2kHz in the affected ear
uptake of amplification for MBHL or UHL
Of the 90% children with HA or FM amplification, 65-70% used it consistently or at school (No variation in uptake between HL groups)
Davis et al 2001: <50% of children with mild bilateral or unilateral loss
2 management strategies have been developed for MBHL/UHL
- Failure-based approach
- Audiometric approach
why is monitoring important
- As the child’s ear canal grows and changes, the acoustic properties change which impact hearing thresholds (dB HL)
- Children in the first 3 years of life experience otitis media with effusion (OME) which can increase hearing thresholds (include immittance measures in monitoring protocol)
- Audiologists should closely monitor the child’s functional auditory abilities as part of routine evaluation (every 3-6 months and adjust intervention as needed)
definition of UHL
any degree of HL in one ear and normal hearing thresholds in other
Limited usable hearing unilaterally (LUHU):
a unilateral SNHL often profound on the affected side, characterized by the apparent or predicted lack of benefit from an air conduction HA
Single sided deafness (SSD):
unilateral HL with “unaidable” affected side [usually severe-profound level of loss]
LUHU & CI
- good outcomes for those with intact auditory nerves (binaural listening & localization benefits)
- Severe to profound UHL
- Financial support for unilateral CI
LUHU & Bone conduction device
- Doesn’t restore binaural listening/localization
- Surgical option for children 5 years and older
- Suitable for mod-severe conductive or mixed bilateral HL or UHL
- limited evidence from adults and fitting/prescriptive approach for LUHU unclear
- Refer to BC addendum in the Ontario protocol, BCD fitting considerations: Laurie Mauro
LUHU & CROS
- Can assist with environmental awareness: safety
- Can be detrimental in noisy setting (classroom) particularly for very young listeners who cannot manage listening environment; less effective for school aged children
- Consider ear canal size in normal hearing ear: avoid occluding normal hearing ear
LUHU & RM
- Can assist with noise and distance listening and is familiar technology for educators
- Improved outcomes in noise when compared to CROS, BC and BCD with RM
- Considered ear canal size in normal hearing ear: avoid occluding normal hearing ear
IHP provision of amplification wheel categories
With LUHU example
Family factors: readiness and motivation
Tech options: HA, CI, remote mic
Imaging results: CT &/or MRI scans, available? results?
Configuration and degree of loss: usable hearing on affected side, LUHU
Child factors: Developmental status, ear canal size, learning environment, readiness & acceptance
