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OSCE prep > REMS > Flashcards

REMS Flashcards

1
Q

what is hearing aid verification?

A

involves assessing the extent to which hearing aid meets specific measurable specifications or expectations

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2
Q

what is the benefit of hearing aid verification?

A
  • it helps to get the correct ‘prescription’ onto the hearing aid
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3
Q

what are some different types of verification? other than REMs

A
  • REIR (Real ear insertion gain)
  • RECD (Real ear coupler difference)
  • Speech- mapping
  • Probe tube free speech mapping
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4
Q

whats the use of probe microphone measurements?

A
  • used to verify frequency response and other performance of hearing aids ensuring they are set to provide optimal prescribed gain and output for users
  • its a reliable way of making sure the prescription target matches
  • used to verify digital features like directionality, noise reduction etc
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4
Q

what are some prescription formulas?

A

NAL,DSL,CAMEQ

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5
Q

what’s the difference between NAL-NL1 and NAL-NL2?

A

NAL is the most common adult prescription
- NAL-NL1 is the older version of the prescription it didn’t take into account patient demographics
- NAL-NL2 takes into account patient demographics e.g. age, gender and its suitability for speech intelligibility

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6
Q

what’s DSL?

A

most commonly used with paediatrics
- DSL helps with speech audibility and awareness

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7
Q

would you change prescription formulas without an appropriate clinical reason?

A

no, as the speech recognition ability of these patients may be compromised by changing the acoustic characteristics of their amplification

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8
Q

what equipment do yo need for rems?

A

-auricle
-probe tube
-otoscope
-speculum
-minifit
-hearing aids
-domes and tubes

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9
Q

what’s the room set up for rems?

A

-the patient chair in line with the speaker
-the patient chair 80-100cm distance to speaker
-patient shouldn’t be bear a reflected surface
-speaker should be eye level with patient (don’t stand behind the patient)
-quiet room, no ambient noise

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10
Q

when should you perform room calibration?

A
  • if furniture has be drastically altered
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11
Q

what is the correct probe tube placement?

A

women-28mm
males-30mm
attach probe tube to collar with end of the tube next to the reference mic

-probe tube should be as near to the ear drum as possible without touching the drum, the tip do the probe should be within 5mm of the tympanic membrane

-keep checking patient comfort

-the tube should be as flat as possible along the bottom of the canal

-once you’re happy with placement, check with otoscopy BUT try not to move with the scope

-the black marker is still visible and sitting at the inter-tragal notch

-make sure there’s not too much tension n the probe tube, adjust the blue strap

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12
Q

why is probe tube calibration performed?

A

-to remove the acoustic effects of the probe tube from the measurements

-to detect a damaged probe tube

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13
Q

do you carry out probe tube calibration with or without the patient?

A

-hold the free-fit 0.5m away from the patient where the patient would be seated

-calibrate before the patient comes in

-calibrate with the patient in in situ and the headset placed on the patient’s ear

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14
Q

how often should you calibrate the probe tube?

A

every new patient and every time a new tube is used (regardless of its the same person)

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15
Q

how do we know the probe tube calibration was successul?

A

the screen would say successfully and the wave would be within the blue curve

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16
Q

when would you need to replace the tube completely?

A

-the tube is blocked

-if there are any holes that shouldn’t be there or any damage to the tube.

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16
Q

what might wrong is the calibration fails?

A

-the tube might not be on the measurement microphone correctly

-the tube might not be in line with the centre of the reference mic

-you might have forgotten to put a probe tube on at all

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17
Q

what are the contraindications for REMs?

A

-pain, inflammation, discharge, infections

-completely occluding wax or foreign objects

-lack of consent

  • collapsed ear canal
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17
Q

how do we set up the hearing aid?

A

-check notes to select correct hearing aids/which ear is being fitted

-ensure you have opened the hearing aid software

-detect the hearing aid

-check pre-parameters are correct e.g. age, gender, experience level, what type of fit (thin tube or mould) and appropriate sizes of tubes/domes/vents are all correct

-mute the hearing aid if unmuted

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18
Q

what are some special care considerations?

A

-grommets & perforations

-mastoid cavities

-wax occluding more than 1/3 of the ear canal - may affect the accuracy of tube placement and readings

-hyperacusis/ noise exacerbated tinnitus (loud sounds will be played during the procedure

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19
Q

how do you prepare the patient for REMs?

A

1) explain the procedure to the patient/ why are you doing what your’e doing

2) position patient/ speaker correctly

3) perform otoscopy to check condition of ears and if its safe to proceed

4) measure appropriate length of the tube, attach with the appropriate dome and check patient comfort, adjust if needed.

5) if using a mould then measure then measure the length of the tubing and fit of the mould with the hearing aid.

6) check pre-parameters are correct on hearing aid software. Adjust if needed.

7) perform tube calibration if not done already

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20
Q

what’s a checklist to go through before inserting the probe tube?

A

-otoscopy?
-explanation of procedure and tickly cough feeling?
-CONSENT?
-calibrated and measured the tube?
-measure earmould length and length for hearing aid?
-hand hygiene?

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21
Q

what is the recommended sound stimulus you will need for REMs?

A

ISTS

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22
Q

what is the first measurement we take with REMs?

A

REUG
Real Ear Unaided Gain

-REUG is the measure of the natural amplification provided by the unoccluded ear and pina

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23
Q

How do we measure REUG?

A

-put the probe tube in the ear, use a 65d ISTS stimulus to record a response

-after the response has stabilised record

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24
Q

what should the REUG trace look like?

A

-trace should have a natural peak between 2-4kHz

-natural ear canal resonance shows a max peak at approximately 3kHz

-if the REUR trace at 6kHz is above by 5db or more then it too deep vice versa

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25
Q

after REUG, what measurement should we take for REMs and why?

A

REOG
Real Ear Occluded Gain

-used to measure the venting characteristics of the hearing device fitting or extent of occlusion of the ear canal by the acoustic coupler

SO how ‘open’ is the fitting?

-it also confirms the rove tube is still correctly positioned and open when the ear mould or dome is inserted in the ear

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26
Q

how do we perform REOG?

A

-insert the ear mould or dome into the ear and with the hearing device muted or switched off, record using an identical stimulus to that used to measure REUG

27
Q

what do we expect from the REOR?

A

-if using an open fitting, with an open dome, you’d expect the pink line to follow the black line

-the more occluded the dome the further the pink line will fall below the black line

-if you’re using a mould or a power dome then the pink line would mirror the black line

-if the pink line has gone way above the black link, then its likely you left the aid unmuted, so mute it and run it again

28
Q

how do we perform system calibration?

A

-a system calibration is performed for each patient by placing th erefrence mic near the ear (neat the mic in the hearing device).

2 methods can be used depending on the type of hearing device being fitted:

1) Modified Pressure Method with Concurrent Equalisation (MPMCE)

2)Modified Pressure Method with Stored Equalisation (MPMSE)

29
Q

how is MPMCE (closed fittings) performed?

A

calibration is performed with the patient present and with the speaker sound continuously and automatically adjusting to the desired level at the patients ear, using the reference mic to compensate for any movements by he patient

30
Q

how would we class a trace as a closed fitting?

A

-if the pink line goes passed the baseline for the majority of the trace then it needs to be classed as a closed fitting

31
Q
  • when you perform an openREM calibration what is happening during that calibration?

how do we use MPMSE (opened fittings)?E

A

-the reference mic is used for equalisation or calibration while the patient and hearing device is in place (muted)

-its then stored and used for the rest of the testing rather than being dynamically controlled during the rest of the probe mic measurement as in the MPMCE

-any change in position of head/torso may change the signal level at level of the ear and will require the calibration to be repeated

32
Q

how do we class a trace as an open fitting (MPMSE)?

A

-if the pink line stays above the baseline (0) for the majority of the trace then it will be classed as an open fitting

-

33
Q

what kind of trace would you expect with an open dome?

A

you would expect the pink trace to follow the black line.

-if its occluding too much then consider troubleshooting the size of the dome

34
Q

what are some things you must confirm when performing an OpenREM calibration?

A

-keep aid muted

-instruct the patient to keep their head still as any significant movements will require you to keep this calibration

-tick the box for OpenREM in the verification

35
Q

after REOG, whats the next measurement do you take for REMs?

A

REAR
Real Ear Aided Gain

-to perform this, switch the device on /unmute it, it should be on the everyday listening programme with all its usual features left on, other than frequency lowering features (e.g. soundrecover)

-if the hearing device software provides acclimatization/ adaptation levels, set to the highest level

-select a mod (65dB SPL) input stimulus and record

35
Q

how do we measure the REAR trace?

A

-explain to the patient what will happen

-gain consent to proceed

-unmute aid

-run trace at 65dB

-patient doesn’t need to respond to anything

-keep observing you patients comfort levels

36
Q

what do we do once we get the 65dB REAR trace?

A

-compare the measured response to the target values and adjust hearing aid gain to best match the target (prescription target) with a +/- 5dB tolerance between 250-6kHz

-once you’re happy with the 65dB, move onto the 50dB trace

-once happy with 50dB, move onto the 80dB trace (if safe to do so

-monitor the patient, if the patient shows signs of discomfort STOP

36
Q

what do you do if you tried adjusting and its still not at the target REAR trace?

A

examine why this may be the case and consider alternative aiding strategies e.g. alternative hearing device or receiver/ mould instead of slim tube fitting/ frequency lowering tech

37
Q

if you can’t do all 3 traces for REAR, which is most important?

A

65dB is most important

  • if patient is uncomfortable, can’t sit still

-if you spend time matching 65dB trace, 50 and 8- should be easier

38
Q

What’s MOSPL?

A

maximum output sound pressure level

-defines upper limits of the dynamic range of the hearing aid’s amplification, it should be performed where possible

-sensorineural HL, reduced the dynamic range

38
Q

how should you run the MOSPL trace?

A

-pre warn the patient of the loudness and get consent

-the green line shouldn’t exceed the dotted line, if it does, it needs to be reduced in the hearing aid software

-if its significantly below the dotted green line, consider increasing the MPO on the hearing aid. It could be limiting the dynamic range otherwise.

39
Q

what should you do post REM?

A

-save the REM
-talk to the patient and see how their hearing sound
-perform subjective listening checks
-make any adjustments to the aid if necessary
-discuss programmes/volume control with the patient
-save the settings of the aid on the computer and on the aid
-disconnect the aid from the computer
- remove the aid and the probe tube and take a final look in their ear

39
Q

what should you do if you’re unable to run MOSPL?

A

-a good alternative is running MOSPL in the coupler instead of in situ on the patient customer

-subjective loudness checks can be performed e.g. clapping hands, banging the table to check the patient shows no signs of discomfort

40
Q

what are the steps for REMs?

A
  1. Instruct and position the patient correctly
  2. Otoscopy - measure the dome size and tube size and check fit and comfort
  3. Otoscopy (if you can remember the direction and length of the canal then this check can be dismissed) – insert probe tube – otoscopy again
  4. Measure REUR (unaided response)
  5. Insert muted aid
  6. Measure REOR (occluded response)
  7. Based on REOR decide if MPMSE or MPMCE is most appropriate (choose OpenREM if MPMSE)
  8. Run OpenREM calibration if OpenREM is selected
  9. Unmute aid
  10. Measure REAR @ 65 dB (aided response)
  11. Adjust software to match target
  12. Measure REAR @50 dB
  13. Adjust software to match target
  14. Measure REAR @80 dB (if safe to do so)
  15. Adjust software to match target
  16. Repeat 65 dB trace to check still within +/ - 5 dB deviation tolerance
  17. Check MOSPL at 85 dB (if safe to do so)
  18. Check patient is comfortable and perform subjective live voice checks
  19. Save all settings
  20. Remove tube - otoscopy
41
Q

explain what is meant by MPMCE?

A

-Modified Pressure Method with Concurrent Equalisation

  • used when the fitting is occluding enough that leaking sound will not contaminate the reference mic
    HENCE
  • equalisation can take place while signal is being played and aid is unmuted
42
Q

explain what is meant by MPMSE?

A

-Modified Pressure Method with Stored Equalisation

  • used when fitting is ‘open’ as sound leaking out of the ear may contaminate reference mic.
  • signal is played with aids muted and this level is ‘stored’ in the system.
  • signal is played again with aids unmuted and reference mic no longer measuring sound pressure level (SPL)
43
Q

how would you select the correct prescription method?

A

DSL- speech audibility and awareness. for children with no speech understanding, ppl who have been previously fitted with DSL and if the patient doesn’t understand a spoken language
NALs are for speech intelligibility but NALNL2 takes into account parameters such as gender. NAL is for people w

44
Q

why is it important to have the correct gender, language, experience age (prescription specific )permeameters)?

A

so the hearing aid is programmed specifically for that patient

45
Q

why do you need to select the correct adaptation level with REMs? what is it?

A

level 3, its the most gain they can get from the hearing aid, so start them off here, if its too loud, turn it down to level 2 and work your way up to level 3

46
Q

why do any special features of the hearing aid need to be disabled during REMs , e.g. speech rescue?

A

so it isn’t taken into account when running the REMs procedure?

46
Q

why is the selection of the correct acoustic parameters related to the earmould or tube/dome/receiver important

A

check your audiogram, if mild to mod, use opne, if severe to proufound use closed

47
Q

when performing otoscopy for the first time for REMs, other than contraindications, what else are we looking for?

A

the direction of canal and dome size

47
Q

why choose REMs over any other previously mentioned verification methods? What does REMs provide that other methods don’t?

A

it takes into account the patients real ear

47
Q

if the patient is having a thin tube for their HA, how do we choose what type of dome we use for them? And why does it matter what type it is?

A

check the severity of the audiogram

48
Q

how would you instruct the patient as an overview of what you’ll be doing in that appointment?

A

im gonna be fitting your hearing aid, im gonna be doing multipe tests which will help match your hearing aids to your specific loss

49
Q

Why do we calibrate the probe for a REM and why is it important?

A

to make it acoustically invisible and check any blockages

50
Q

if you run your unaided trace and it is cutting through 6KHz at minus 10, what would you do to troubleshoot this?

A

pushit in, its not deep enough

51
Q

what trace would you expect for an open dome on REOR and why?

A

if using an open fitting, with an open dome, you’d expect the pink line to follow the black line

-the more occluded the dome the further the pink line will fall below the black line

-if you’re using a mould or a power dome then the pink line would mirror the black line

-if the pink line has gone way above the black link, then its likely you left the aid unmuted, so mute it and run it again

52
Q

For an openREM is it an MPMSE and why?

A

-using the MPMCE method in open fitting has a risk that amplified sounds may leak out to the reference mic, contaminating the results

  • therefore, using probe mic measurements method such as MPMSE should be used for verification of open fittings
  • In this method, the reference microphone is used for equalisation or calibration while the patient and hearing device is in place (muted).
  • It is then stored and used for the rest of the testing rather than being dynamically controlled during the rest of the probe microphone measurement as in the MPMCE.
  • Any change in position of the head/torso may change the signal level at the level of ear and will require the calibration to be repeated.
53
Q

when running MOSPL at 85fB what is showing? What do we need the trace look like?

A
  • Before running the trace pre-warn the patient/customer of the loudness and get consent.
  • The green line shouldn’t exceed the dotted green line. If it does then it needs to be reduced in the hearing aid software.
  • If it significantly below the dotted green line then consider increasing the MPO on the hearing aid. It could be limiting the dynamic range otherwise.
54
Q

what alternatives do you have to MOSPL other than performing loudness checks?

A

running MOSPL in the coupler

or subjective loudness checks e.g. clapping hands/ banging the table

55
Q

If you had an adult, first time hearing aid user, what prescription formula would you use and why?

A

NALNL2 because it takes into account all the parameters and speech intelligibility

56
Q

How would you explain your REMs results in a suitable way to the patient?

A

-this is you current hearing with the loss, and this is me amplifying the sound to the correct level. It should be within 5db of the target.

57
Q

Give me some examples of some live voice checks you can do and explain what you are trying to achieve with them?

A

-how was your day?
-what is your shoe size?
- what did you eat for breakfast?

to see f there are specific sounds you struggle with

58
Q

what is the clinical need for REMs?

A

to programme the hearing aids to make it more tailored for the patient

59
Q

when would you use DSL? And what would be the benefit of using this?

A

DSL- speech audibility and awareness. for children with no speech understanding, ppl who have been previously fitted with DSL and if the patient doesn’t understand a spoken language

60
Q

what part of the pathway is being tested for REMs?

A

the whole pathway because it tests processing sound all the way to the brain

61
Q

what are factors that could influence the accuracy of the test results?

A

-ambient noise levels
-patient instructors
-talking patient
-probe mismeasurement
-wrong dome
-no calibration

62
Q

what alternative do you have to MOSPL other than performing loudness checks?

A

Real-Ear to Coupler Difference (RECD)

  • involves comparing the response in the real ear to the response in the coupler allowing clinicians to calculate the max output in the coupler and adjust the hearing aid without needing MOSPL.
  • suitable for patients who cannot tolerate MOSPL testing, like young children or ppl with complex needs
  • BSA guidelines recommend when patient safety or comfort is a concern

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