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Paeds Osce > NBHSEIP > Flashcards

NBHSEIP Flashcards

1
Q

Aim of NBHSEIP

A

Identify children w/ permanent HL for better language, educational & psychological outcomes

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2
Q

1-3-6

A

Screen by 1month
Diagnose by 3months
Intervene by 6months

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3
Q

Target permanent congenital hearing loss (PCHL)

A
  1. Established by ABR testing any HL >35dB eHL@500Hz
    HL >30dB eHL@1-4kHz in either ear
  2. This includes ANSD or retrocochlear lesion related impairment
  3. This includes CHL associated with structural anomalies but NOT TTS attributable to non-structural ME conditions
  4. Eligible for amplification
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4
Q

Children requiring monitoring of hearing

A
  1. Mild HL of 25-30 dB due to higher risk for progressive HL& TTS from CHL
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5
Q

Types of assessments

A
  1. ABR based
  2. OAE based
  3. Behaviour based
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6
Q

Behaviour Based assessments

A
  1. VRA
  2. CPA
  3. PTA

*choice is at the discretion of audiologist

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7
Q

Hearing Surveillance

A

AKA Targeted FU
Referral from paediatricians, nurses, midwives to screeners who will refer them to audiology

  1. Requiring OAE testing at 18months
  2. Requiring audiological care on a case by case basis but needs triage by audiologist due to low incidence
  3. Risk factors with specific pathways for audiological testing
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8
Q

Risk factors w/ specific pathways for audiological testing

A
  1. Down Syndrome
  2. Cleft Palates
  3. Cytomegalovirus
  4. Meningitis
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9
Q

Risk factors requiring triage

A
  1. Atresia
  2. Jaundice levels at or above transfusion is recommended
  3. Head or brain trauma
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10
Q

Risk factors requiring OAE testing @18months

A
  1. Continuous ventilation>5days: IPPV ECMO nitric oxide excludes CPAP
  2. Severe asphyxia (lack of oxygen supply)
  3. Brain haemorrhage
  4. Ototoxic meds
  5. Other syndromes associated with HL including but not limited to Pierre Robin, Sticklers, Goldenhar, CHARGE, Waardenburg, Pendred
  6. Toxoplasmosis
  7. Rubella
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11
Q

Cleft Palates

A
  1. Likely to develop OME
  2. Even if passed NBS —> FU at 7-9 months
  3. Management : BCHA needs to be determined based on timing of repair surgery & degree of loss
  4. Conventional not appropriate due to the nature of fluctuating HL in cleft
  5. Discussion w/ family
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12
Q

Discussion with family

A
  1. Good communication strategies
  2. Ways to enhance the listening developments
  3. How to recognise signs that hearing may have changed
  4. what to do if concerned about hearing
  5. Give brochures about hearing milestones and HL
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13
Q

Down Syndromes

A
  1. Mild HL can severely impact development of speech & Lang
  2. ME dysfunction leading to frequent OME
  3. Grommets not easy due to small sized ear
  4. Usually consider BCHA (at a younger age) than BTE due to fluctuating nature of CHL and small ear canal size
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14
Q

CMV

A
  1. Either normal or abnormal from screening
  2. Normal CMV have 4.3% risk of late onset SNHL
  3. Abnormal have risk of progression of HL
  4. If normal —> OAE at 5months then yearly till 5yo
  5. If abnormal —>ABR at 2~6wk and continue monitoring & intervention
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15
Q

Amplification goals

A
  1. Access to speech signal that’s consistently audible
  2. Avoid distortion
  3. Ensure flexibility electro acoustically for changes related to ear growth or acoustics of the child’s ear. (Sufficient headroom)
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16
Q

Amplification components

A
  1. A completed audiological result for both ears
  2. Acoustic characteristics of the baby’s ear canal in RECD
  3. Ear impression
  4. Assessment of non-electro acoustic of the baby
  5. Electro acoustic analysis of prescribed HA (ANSI test)
  6. DSL v5 target ear canal SPL for the amplified LTASS
  7. DSLv5 target ear canal SPL for defining the max saturation
  8. Response of the HA
  9. DSL v5 target ear canal SPLs for soft & loud speech
  10. Verification of whether HA are meeting the targets electro-acoustically
  11. Simulated REAR &RESR
  12. Education & counselling sessions with the family about first HA fitting &FUs
  13. Evaluation of the outcome of the intervention (LittlEARS PEACH)
  14. Appropriate FU
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17
Q

ABR based assessment

A
  1. Otoscopy
  2. Should be in both ears regardless of the referral
  3. Tone burst ABR including 500, 2k & 1 &4kHz if alerted
  4. High intensity click
  5. HF tympanometry + ART starting @80dB for BBN
  6. DPOAE amplitude & noise floor measurements @ 1.5, 2, 3, & 4kHz
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18
Q

Transducer for ABR and reason

A

Inserts unless contraindicated (structural abnormality in which case supra-aural are optional) to avoid AC masking

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19
Q

Indications for high intensity click ABR

A

All cases except when baby

1. Passes tone burst ABR & starting to wake up

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20
Q

Possible consequence for not doing click ABR because baby passed tone burst

A

Missing ANSD

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21
Q

ABR-based assessment: If the baby passes DPOAE protocols

A

Not essential to perform immittance testing

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22
Q

ABR completed + No DPOAE or immittance + baby wakes up & unable to finish testing

A

DC if no concern

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23
Q

High intensity click starting levels

A

80dBHL if tone burst normal

95dBHL (or the max. Intensity) if tone burst elevated (no identifiable waveform)

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24
Q

BC ABR

A

Placement- superoposterior to the canal opening

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25
Q

ABR Electrodes & impedance

A
  1. High forehead as close as possible to the hairline (non-inverting)
  2. On each mastoid process (inverting)
  3. On lateral forehead at least 3cm away from non-inverting (common)
  4. Impedance should be <3kohms and inter impedance differences within 1kOhms
26
Q

Recording channels

A
  1. AC- channel ipsilateral to the stimulated ear must be recorded
  2. BC- 2 channel recordings - both ipsi and contra must be acquired
27
Q

What determines response present

A
  1. Repeatability of the waveform at thresholds
  2. Replication of no response at the level below any elevated threshold
    * *I.e. replications typically 10dB below threshold level except threshold>70dBHL where a final step size of 5dB is employed
    * *when waveform is present with minimal noise (SNR 3:1) no need replication
    * *recording @ levels below passing level not required
  3. Growth of response (decreased latency & increased amplitude)
    * *Typically 10dB higher if threshold is elevated (if not at the maximum intensity level)
    * *typically 20dB higher if threshold was @ minimum passing level (MPL)
28
Q

How many trials typically in each average?

A

2000 but could be more or less depending on the noise level

29
Q

Final threshold bracket size

A

No greater than 10dB.
From 60dB eHL, a 5dB step size may be used for the final bracket.
**This is important for accurate prescription amplification if the residual dynamic range is very limited.

30
Q

50Hz artefact

A

LF artefact
If suspicious should be inspected by running a no sound trial (0dB no audible sound)
If large, 50Hz notch filter may be used (shouldn’t be a routine procedure & documented)

31
Q

Efficient strategy for stimulus levels

A
  1. Start @ minimum required level (MRL)
  2. Ascend in steps of at least 20-30dB (small step size only used when questionable response @ MRL)
  3. Descend in 10 dB steps
32
Q

Order of testing frequency for ABR tone burst

A
  1. AC 2kHz @ 30dB eHL
  2. AC 500Hz @35dB eHL
  3. BC 2kHz if AC2kHz > or =40dB eHL
  4. BC 500Hz if AC500Hz> or = 50dB eHL (slight elevations of AC for 2k &500Hz do not trigger mandatory BC testing)
33
Q

BC stimulus artefact

A

At the highest stimulus levels (typically 50dB) stimulus artefact can be large
And may obscure half of the averages

34
Q

Ways to minimise BC stimulus artefact

A
  1. Blocking- helps control the scaling

2. Reposition BC transducer: on high mastoid w/ low electrode placement may reduce the size of artefact

35
Q

How do you tell which cochlea is responding in BC? What if equivocal?

A

Comparing response amplitude & latency in the ipsilateral & contralateral to the test ear.
If equivocal —> stimulus level should be reduced in an attempt to isolate the responding side

36
Q

When to use contralateral masking? How is it minimised?How much masking do we apply?

A

When an asymmetry >60dB (IAA of inserts) occurs.
Because we use inserts & BC two channel
60-65dB is adequate enough (more masking runs the risk of crossover and central masking)

37
Q

DPOAE indicator for 4kHz ABR

A

When DPOAEs clearly depressed or absent for 4kHz (despite normal ABR for 2kHz)

38
Q

When do we do ABR AC 4kHz? Exceptions?

A

No response @30dB for 2kHz
When there is CHL for 2kHz as we need to bring back for another ABR.
However routine 4kHz is recommended to establish baseline.

39
Q

When do we do ABR AC 1kHz?

A

If there the threshold difference between 500Hz & 2kHz thresholds in dBHL >30dBHL.
(If the difference is <30dBHL testing is discretionary but not mandatory)

40
Q

Purpose of High intensity Click ABR

A
  1. To evaluate neural synchrony by stimulating broad regions of cochlea to look for following things
  2. ANSD
  3. Retro-cochlear pathology
  4. Residual hearing
41
Q

Things to check for in high intensity ABR

A
  1. Presence of CM

2. Inversion of waveforms when signal polarity changes (=ANSD)

42
Q

Recording polarities for high intensity ABR

A
  1. Rarefaction- initial outward movement of TM —> depolarisation —> shorter latency
  2. Condensation-initial inward movement of TM —> hyperpolarisation —> longer latency
  3. Alternating- neural responses (addition of rare. & cond. by eliminating artefacts and CM). Waves should present if normal
  4. Differential-CM & artefacts as it cancels out all the neural components
43
Q

Purpose of running no sound trial?

A

Demonstrate the presence of stimulus artefact & absence o response from the patient

44
Q

High intensity click recording conditions

A
  1. All 4 polarities
  2. Records must be replicated
  3. Have at least 1000 sweeps/average
  4. Low noise level in the waveforms
45
Q

How do you differentiate CM from stimulus artefact?

A

When a repeatable deflection in the first 5ms is found —> clamp tube or detach from the transducer and position as far as possible from it.

46
Q

Diagnosis of ANSD

A
  1. CM ringing (overtaking the wave responses)

2. Inversion of waveforms with polarity change (because it’s CM not neural responses)

47
Q

ANSD & Neurogenic activity

A

With ANSD click recording may contain neurogenic activity which may or may not be a recognisable ABR
Neurogenic activity DOESN’T INVERT.
Neurogenic activity may not be present for both stimulus polarities & increase in latency as stimulus level decreases (acting like true response)

48
Q

ANSD management

A

Dependent.
Delayed Deferral of amplification until a behavioural assessment is recommended.
Cortical AEP should be considered

49
Q

ANSD and its effect on thresholds from tone burst

A

If ANSD diagnosis is made (whether it’s definite or presumptive) —> toneburst ABR invalid because what we obtained at lower threshold is not reflecting the neural synchrony.

50
Q

DPOAE parameters

A
  1. Nominal F2 frequencies of measure include 1.5,2,3,4kHz
  2. F2/F1 = 1.2 best overlap
  3. F1=65 & F2=55dB SPL
51
Q

Purpose of DPOAE

A

Cross-check ABR threshold inferences & assess the potential for ANSD

52
Q

Probe tone for tympanometry for babies under 9mo (corrected) & older & why?

A

Babies <9mo = HF (1kHz probe tone), because it is mass-dominated system
Children >9mo = LF (226Hz probe tone), because it is stiffness-dominated system

    • HF overcomes mass
  • *LF overcomes stiffness
53
Q

ART frequencies and stimulus levels for

  1. Babies <9mo
  2. Babies =>9mo
  3. Determining the presence or absence of MEE
A
  1. BBN starting @80dB with at least 2 replications
  2. Minimum 1kHz @90dB with at least 2 replications
  3. BBN stimulus @90dB and increase it to max level (95dBHL) to confirm the absence of the reflex (absent = type B, present = type A or C)

** goal is to check for clear response at any age stimulus level

54
Q

Purpose of ART

A

For cross check when

  1. ABR edB HL =>70dB eHL
  2. ANSD suspected
  3. Abnormal tymp.
  4. ABG > 10dB is inferred from ABR thresholds
55
Q

What age does 5dB age correction factor apply? And why?

A
  1. For babies under 3m corrected age and younger

2. Smaller ear canal —> 5dB louder in younger babies —> add 5dB

56
Q

Correction factors in ABR

A
  1. Age correction factors for babies younger or equal to 3m corrected age
  2. Stapelle correction factor (ABR is more transient than PTA hence harder to hear therefore subtract 5dB)
57
Q

DPOAE presence is defined by

A
  1. SNR at least 6dB

2. Absolute response amplitude -5dB or better

58
Q

Reflex presence is defined by… what can happen in HF probe tone ART?

A
  1. Clear repeatable deflection

2. Positive deflection may be recorded

59
Q

Tymp norms for

  1. Up to 8month
  2. 9-11month
  3. 12 months and above
A
  1. Find peak (or can be double peaked or no peak)
  2. Peak admittance <0.2/TW>235daPa/pressure 200daPa/pressure
  3. Peak admittance < 0.3/ TW>200daPa/ pressure
60
Q

Things to check for when running DPOAE

A
  1. SNR >6 & Signal >-5
  2. Ear canal resonance responses are flat across the freq.
  3. Check Nlo & Nhi (we want Nlo to be high & Nhi to be low)
  4. Time ran for the test
  5. F2/F1 ratio = 1.2
61
Q

Meningitis

A
  1. Urgent assessment (within 4wks) required to identify sev-prof HL before cochlear ossification takes place
  2. CI referral if profound due to cochlear ossification

Paeds Osce (7 decks)

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