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AUDE 6120 - Pharmacology and Ototoxicity > Ototoxic Monitoring > Flashcards

Ototoxic Monitoring Flashcards

1
Q

How many drugs (prescription and OTC) are reported to have ototoxic and vestibulotoxic effects?

A

Over 200
Hearing loss or balance deficits from these medications can be either temporary or permanent, mild or severe

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2
Q

What two classes of medications have the greatest potential for ototoxicity and iatrogenic hearing loss?

A

Aminoglycoside antibiotics
Antineoplastic (chemotherapeutic) medications particularly platinum-based drugs

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3
Q

What is the only way to detect ototoxicity/vestibulotoxicity?

A

By directly assessing hearing and balance functions
Unfortunately cochlear damage and hearing loss may often not be noticed till it affects speech understanding
Similarly, by the time symptoms of dizziness are reported, vestibular damage may already have occurred

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4
Q

Are there currently no standard protocols for ototoxic monitoring?

A

No
Still not considered standard of care

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5
Q

How do ototoxicity and vestibulotoxicity affect patients?

A

Loss of hearing
Debilitating tinnitus
Difficulty with understanding speech, which affects communication/socialization leading to social isolation
Altered balance and coordination
Inability to perform physical activities
Negative impact on job/educational performance
Negative impact on independence

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6
Q

Are the consequences of hearing loss from ototoxicity the same as hearing loss from other causes?

A

Yes

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7
Q

What are the consequences of ototoxicity for children?

A

Speech and language acquisition
Educational challenges
Psychosocial challenges
Economic status (future economic gains)
Quality of life

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8
Q

What are the consequences of ototoxicity for adults?

A

Occupational challenges
Psychosocial challenges
Economic status (current employment opportunities and retirement economic security)
Quality of life

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9
Q

What is the overall incidence of pediatric cancers?

A

Low
Remains fairly stable

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10
Q

What is the prevalence of childhood cancer?

A

Has increased due to survival rates
Reaching upwards of 80% due to advancements in diagnosis and treatment

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11
Q

Is ototoxicity one of the most common causes of acquired pediatric hearing loss?

A

Yes

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12
Q

What are the two purposes for performing ototoxic monitoring?

A

Early detection of changes to hearing status attributed to a drug regimen (need baseline)
Audiologic intervention can occur when significant hearing loss has occurred (hearing aids and assistive listening devices, educational support for children, programming hearing aids to adapt to changes in hearing sensitivity)

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13
Q

May the hearing loss be unavoidable for these drugs?

A

Yes
Because the priority is effective management of life-threatening conditions

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14
Q

What patients should have their hearing monitored?

A

Monitoring for patients receiving highly ototoxic drugs (cisplatin and I/V gentamicin)
The very old and very young patients
Patients in poor general physical health including low levels of red blood cells and serum proteins
Co-morbidities (especially liver or kidney disease)
Poor hydration status
Genetic tendency for ototoxic susceptibility (e.g., aminoglycoside)
Patients receiving large/multiple doses or more than one ototoxic drug
Patients with a history of noise exposure (already have a damaged system - easier to continue damage)

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15
Q

Will the target population dictate the choice of tests to be used for ototoxic monitoring?

A

Yes

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16
Q

When should the baseline be done?

A

No later than 24 hours after administration of chemotherapeutic drugs
No later than 72 hours following administration of aminoglycoside antibiotics
A recheck of thresholds within 24 hours of the Baseline Test can be helpful for determining patient reliability

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17
Q

How is ototoxicity determined?

A

By comparing baseline data to the results of subsequent monitoring tests
Each patient serves as his/her own control

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18
Q

When are monitoring evaluations performed?

A

May be a pared-down version of the baseline
Periodically throughout treatment, usually prior to each dose for chemotherapy patients
1 to 2 times per week for patients receiving ototoxic antibiotics

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19
Q

What dictates the frequency of monitoring evaluations?

A

A patient’s particular drug regimen, which can be determined by reviewing the patient’s medical chart
Physician’s recommendations

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20
Q

When is monitoring and further testing warranted? (in-between testing sessions)

A

When the patients report increased hearing difficulties, tinnitus, aural fullness, and dizziness

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21
Q

Will retesting the patient reduce false positive rates?

A

Yes
Recommended by ASHA

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22
Q

Are post-treatment evaluations necessary?

A

Yes
To confirm hearing is stable
Because ototoxic hearing loss can be progressive, occurring > 6 to 12 months after drug regimen is discontinued

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23
Q

What is the most effective indicator of ototoxic hearing loss?

A

Detecting changes in pure-tone thresholds using serial audiograms
Especially when ultra-high frequencies are included (> 8000 Hz)

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24
Q

What is the goal of serial monitoring?

A

To detect those who exhibit a hearing change and those who do not (based on cutoff criteria)

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25
Q

Why is serial monitoring after baseline monitoring preferred?

A

There is no standard criteria accepted universally
Allows the patient to be their own control

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26
Q

What is needed to have standardized criteria for clinical research for ototoxicity?

A

Use of well-accepted statistical methods for determining test performance in large groups of patients receiving ototoxic drugs
Hospitalized (control) patients receiving non-ototoxic drugs (can prove that changes in thresholds is not due to hospitalization, but specifically the ototoxic drugs)

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27
Q

What is ASHA’s 1994 guideline for clinically significant thresholds changes?

A

> 20 dB pure-tone threshold shift at one frequency
10 dB shift at two consecutive test frequencies
Threshold response shifting to “no response” at three consecutive test frequencies

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28
Q

Why does ASHA have this clinically significant threshold shift criteria?

A

Threshold shifts for two or three frequency averages have been shown to increase test performance for detecting ototoxicity- and noise-induced hearing shifts
Presumably because threshold shifts at adjacent test frequencies indicate more systematic change compared to shifts at any single frequency

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29
Q

Does the ASHA criteria include confirmation of test results?

A

Yes
Because threshold shifts obtained on repeat tests are more likely to represent a true hearing change compared to results obtained on a single test
Need to be confirmed within 24 hours of the initial test

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30
Q

What is the CTCAE?

A

Common terminology criteria for adverse events
Published by the national cancer institute at the national institute of health

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31
Q

What is CTCAE?

A

Set criteria for the standardized classification of adverse effects of drugs used in cancer therapy

32
Q

Do the guidelines for the CTCAE differ from ASHA?

A

Yes
They categorize changes in HLs, functional impact to some extent, descriptions of severity, and the need for intervention
Also consider frequencies involved in the loss (peds)

33
Q

What are the CTCAE hearing impairment categories?

A

4 grades (1-4) ranging from adverse effects mild to severe
Urgent intervention indicated is grade 4

34
Q

What pediatric populations are most vulnerable to ototoxicity?

A

Newborns who are extremely premature and/or carry life-threatening diagnoses and require extensive medical interventions prior to initial discharge home
Children, of any age, who have been diagnosed with cancer and are being treated with chemotherapy and/or radiation
Children, of any age, who have a condition that makes them highly vulnerable to opportunistic infections

35
Q

How are grading scales used?

A

Help communicate complicated audiological information to other healthcare providers (such as oncologists) to facilitate good decision-making with regards to chemotherapy dosing

36
Q

What is the society of pediatric oncology grading scale?

A

Recent and international
It does not require a baseline audiogram
It is sensitive to small changes in high-frequency hearing
It is relevant to reduced audibility of important speech sounds
It requires very few frequencies to successfully assign an adverse event grade

37
Q

What measures besides pure tone audiogram are useful for adult and pediatric ototoxic monitoring?

A

Extended high frequency audiometry/high frequency audiometry
Auditory brainstem response (ABR)
Otoacoustic emissions (OAEs)

38
Q

What are some important factors for ototoxic monitoring?

A

The status of patients typically targeted for testing
Both their ability to provide reliable behavioral data and their baseline hearing sensitivity
Patient responsiveness can be determined, in part, by physician or nurse reports/chart notes in the patient’s medical chart
Speed of the test and its analysis
Cost of performing and interpreting the test results
Availability of equipment and personnel

39
Q

What can ototoxic hearing loss appear like?

A

May occur days or weeks after use of drugs
May be progressive even after discontinuation of the drug (especially common with aminoglycoside antibiotics and platinum-based chemo)

40
Q

What is the timeline for continued monitoring determined by?

A

Drug toxicity and physician’s recommendations
Typically, follow-up audiograms performed after drug discontinuation can continue for up to a year (3 months, 6 months, 9 months, and 12 months)
Some require annual tests after (especially for platinum-based chemo)

41
Q

Does ASHA recommend that you do a full audiometric evaluation?

A

Yes, for patients who are alert and responsive
Physiologic measures should be included in the Baseline Evaluation if there is a possibility that patient will become less responsive over the course of treatment
An abbreviated test battery is required for patient who tire easily or show limited responsiveness or awareness (difficulty identifying their location or purpose for being in the hospital)

42
Q

What does the abbreviated test protocol focus on?

A

Targets range of frequencies near each patient’s upper frequency limit of hearing

43
Q

What is required after a hearing change is observed using the abbreviated protocol?

A

A complete monitor evaluation

44
Q

What does data obtained using a test-battery approach allow?

A

Hearing changes to be verified
Threshold shifts due to middle ear dysfunction to be ruled out
Determination of effects of hearing changes on speech recognition

45
Q

Is high frequency audiometry also important?

A

Yes
Because it can detect ototoxicity much earlier than conventional audiometry
Because all ototoxic drugs affect the basal end of the cochlea first with subsequent hair cell damage/death, resulting in a high frequency sensorineural hearing loss

46
Q

Is it important to establish pre-exposure baseline thresholds for high frequency audiometry?

A

Yes, so they can act as their own control
Well accepted standard threshold data for HFA are not available
Adults (> 30 years) even without any pathologies have poorer thresholds above 1600 Hz
Limitations to HFA

47
Q

What are the test-retest differences for ultra high frequency thresholds?

A

10 dB
Consistent
False positive rates for HFA are low in young and older adults

48
Q

Is the test-retest reliability poor in young children?

A

Yes
Better to do it on older children and adults

49
Q

What class of patients are unable to provide reliable behavioral data?

A

Infants and non-responsive adults in hospitals

50
Q

How do you monitor changes in non-responsive patients?

A

Physiologic measures

51
Q

Does ME dysfunction need to be ruled out in order to determine that changes are due to the cochlear function?

A

Yes
The ME can impact OAEs and ABRs

52
Q

Are OAEs an indicator early ototoxic damage?

A

Yes
If ME function is normal and hearing is good
Because they are a measure of OHC function
But abnormal middle ear function and baseline hearing loss > 40 dB HL may prevent effective monitoring using OAEs
Great for kids

53
Q

What population are OAEs and ABRs particularly useful to include in the test battery?

A

Younger children who have limited attention spans
Patients of any age with questionable reliability
Unresponsive patients
Patients with low cognitive abilities
Very sick patients who cannot tolerate behavioral evaluation

54
Q

Is there current published guidelines that define a significant change in DPOAE levels?

A

No
Many researchers have suggested a change in the overall DPOAE amplitude ranging from 5 to 9 dB at two or more frequencies

55
Q

Can damage caused by vestibular toxicity result in compensation by the central vestibular system?

A

Yes
With minimal long-term effects

56
Q

In some cases, can the vestibular damage be permanent?

A

Yes
Especially if there is bilateral peripheral vestibular damage
Balance and mobility problems can ensue, which can be debilitating

57
Q

How do you monitor vestibular toxicity?

A

Assessment of the balance system including the vestibular reflexes such as vestibulo-ocular reflex (VOR) by caloric and rotary chair testing

58
Q

What can treatment for vestibular toxicity include?

A

Medication
Vestibular rehabilitative therapy

59
Q

How many patient who receive chemo develop tinnitus?

A

About 40%

60
Q

What is the tinnitus ototoxicity monitoring interview (TOMI)?

A

Developed to detect tinnitus onset or changes in existing tinnitus perception during treatment with potentially ototoxic drugs
Adapted from the tinnitus retraining therapy initial interview
One page instrument that can be completed in 5 minutes
Ideally administered by an audiologist or ENT (but it is scripted so it can be administered by a nurse or other health care professional - can be used as a screening tool)

61
Q

Is cranial radiation therapy used to treat a variety of brain tumors as well as head/neck cancers?

A

Yes, in both children and adults

62
Q

Can radiation potentially damage any of the auditory structures within the radiation field?

A

Yes
Extending from the external ear to the higher auditory pathways
The hearing loss can, therefore, present as conductive, mixed, sensorineural, or retrocochlear

63
Q

How can radiation therapy degrade the external ear and middle ear system?

A

By thickening to TM, stenosis of the ear canal, changes to the ET and ossicles resulting in a temporary or permanent CHL
Acute complications to the outer/middle ear system have been reported in ~ 40% of patients in some studies

64
Q

How many people treated with cranial radiation experience a SNHL?

A

About 1/3
Radiation results in cochlear microvascular fibrosis, in turn causing degeneration of OHCs, IHCs, and VIII N fibers

65
Q

Do radiation and hearing loss exhibit a dose-response relationship?

A

Yes
As radiation dose increases, so does the risk and degree of severity of the hearing loss

66
Q

Does cranial radiation typically exacerbate hearing loss when administered concurrently with platinum-based chemotherapies?

A

Yes
Your risk raises

67
Q

Does the SNHL from radiation typically affect high frequencies more than lows?

A

Yes, but can affect any
It is typically irreversible and progressive
It is typically considered a late adverse effect with onset occurring several years after treatment
Long-term (up to 10 years) audiologic follow-up post treatment is recommended

68
Q

Can drugs (including OTCs and herbal medicines) cause cognitive side effects that may affect auditory/vestibular assessments?

A

Yes

69
Q

What can pharmaceutical side effects include?

A

Impaired concentration/attention, disorientation, & confusion
Loss of mental acuity, slowed thinking, & mental clouding
Drowsiness & stupor
Forgetfulness & dementia

70
Q

What can cognitive side effects result in?

A

Poorer word recognition scores
Poorer pure tone threshold results
Poor compliance with use of hearing aids

71
Q

How do you manage ototoxic hearing loss?

A

Counseling prior to therapy with ototoxic drugs to make patients aware of potential otototoxcity
Counseling patient and family after ototoxicity and recommending technology/aural rehabilitation
Appropriate intervention with hearing aids or CI
Amplification with frequency lowering hearing aids may be needed due to significant high frequency hearing loss
Children with ototoxic hearing loss will likely require the use of technology with remote mic technology to improve SNR in the classroom
Frequent follow up and counseling due to potential progressive loss and cognitive pharmaceutical adverse effects

72
Q

Are there specific ICD-10-CM codes for ototoxic hearing loss?

A

Yes
H91.01 Ototoxic hearing loss, right ear
H91.02 Ototoxic hearing loss, left ear
H91.03 Ototoxic hearing loss, bilateral
H91.09 Ototoxic hearing loss, unspecified

73
Q

What are some codes that the H91 codes (ototoxic) cannot be billed with?

A

Hearing loss (H90 series)
Abormal auditory perception (H93.2 series)
Impacted cerumen (H61.2 series)
Noise-induced hearing loss (H83.3 series)
Psychogenic deafness (F44.6)
Transient ischemic deafness (H93.01 series)

74
Q

Does the drug or toxin that is giving rise to the hearing loss need to be reported too?

A

Yes
Must also be reported with the code for ototoxic hearing loss

75
Q

How should you code if the hearing loss is due from a drug or toxin?

A

Code for the hearing loss second
Code for the poisoning (T codes) first

76
Q

Is there a code for extended high frequency audiometry?

A

No
Audiologists may use CPT code 92552 for pure-tone audiometry, with the modifier – 22 to indicate that the work was substantially greater than typically required

AUDE 6120 - Pharmacology and Ototoxicity (8 decks)

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