Tymps and ARTs

Question 1

what is tympanomentery?

Answer 1

-quick +objective test which assess the state of the middle ear, e.g. tympanic membrane middle ear cavity and ossicles

Question 2

who is it used for?

Answer 2

-conductive/mixed losses
-paediatrics
-complex patients`

Question 3

what equipment do we need for tymps?

Answer 3

-tympanometer
-tymp tips
-otoscope
-cavity
-speculea

Question 4

how do you calibrate the tympanometer?

Answer 4

• check end of the probe for blockages
  -use the calibration to make sure the ECV is normal. the trace should be flat

0.5 (no tolerance)

2.0 (5% tolerance)

-Perform a tymp on a known subject if safe to do so. This checks the pump is working properly

Question 5

what do you do after calibration?

Answer 5

clean everything you have used on yourself and document that the tymp has been calibrated

Question 6

contraindications for tymps and ARTs

Answer 6

the usual 5 with surgery being especially stapedectomy
-too much wax
-foreign bodies
-swollen
-collapsed ear canal
-very retracted for bulging TM

Question 7

special care consideration for tymps and ARTs

Answer 7

• can be used for grommets in situ to check tube is clear
• can diagnose a preformation (even healed)

-hyperacusis, noise exacerbated tinnitus and phonophobia

Question 8

tymp and art patient instructions patient instructions

Answer 8

“This test consists of two parts. First I will insert a soft tip into the opening of your ear canal. You will feel a slight pressure in your ear for a few seconds while I measure the function of your middle ear. You may hear a sound but you do not need to respond or tell me about it. The second part will then begin, which involves playing short, loud sounds. These may take you by surprise when they first begin, and they may get quite loud. You do not need to do anything other than sitting still and remaining quiet. Should you find any of this procedure uncomfortable, or the sounds too loud, please say “stop” or raise your hand”.

-it is important that you dont speak swallow talk

any questions

Question 9

how do you do tymps?

Answer 9

start on better ear
-otoscopy - pick probe size (check for contraindications)
-instruct the pateint and insert probe and do a quarter turn
-start sweep
-once trace is finished(equal side tail) stop
-do arts
-otoscopy

Question 10

how do tymps work?

Answer 10

• Probe produces pressure and sound.
• Probe measures what sound is admitted and what is reflected
• It compares pressure either side of the tympanic membrane
• It measures ear canal volume

Question 11

what should happen in tymps (theory)?

Answer 11

• equal pressure on either side of TM if all middle ear structures (especially the Eustachian tube) are functionally correctly
• sound from theSound from the probe should be admitted (and travel through the middle ear system) and none (or very little) should be reflected back into the ear canal.
• Movement of the middle ear system (compliance - measured in ml*) should be detected.

Question 12

normal tymp values

Answer 12

pressure = +50 to -50daPa
compliance = 0.3 to 1.6 ml
ECV = 0.6 to 2.5 cm3

Question 12

how would we explain perforation?

Answer 12

Perforation- The test we have just done shows your ear canal volume is larger than we woud expect which could indicate a hole in your ear drum.

Question 12

how would we explain otitis media?

Answer 12

Otitis media The test we have just done shows that your ear drum is not moving as we would expect it to which could indicate an infection in your middle ear

Question 12

how would we explain otosclerosis?

Answer 12

Otosclerosis- The test we have just done shows your ear drum is not moving as much as we expect it too, this could indicate a problem in your middle ear

Question 13

how would you explain ossicular discontinuity?

Answer 13

Ossicular discontinuity- The test we have just done shows your ear drum is moving more than we would expect it to, therefore ENT may want to look at the bones in your middle ear.

Question 13

how would you explain a grommet?

Answer 13

Grommet- a) The test has shown a large amount of volume in the ear canal, this indicates that the grommet is working well and still in place. b) The test has shown your ear canal volume to be within normal range, this is indicating that the grommet may be blocked.

Question 14

what probe tone is used for reflexes?

Answer 14

Acoustic reflex assessment usually uses a 226Hz probe tone unless testing neonates in which higher frequency 1000Hz probe tones are used.

Question 15

what’s the difference between ipsilateral and contralaterl?

Answer 15

Ipsilateral reflex= measured in the same ear as the stimulus (patient/customer will have just a single probe in their ear)

Contralateral reflex= measured in the opposite ear as the stimulus (patient/customer will have a probe in both ears; one presenting and one recording)

Question 16

where does sound travel in reflexes?

Answer 16

from the stapedius muscle and middle ear to the cochlea up the 8th nerve to the ventral cochlear nucleus (here contralateral would switch ears) to the superior olivary complex and ventral nucleus down the 7th back to the ME and SM

Question 17

what are you measuring when recording reflex?

Answer 17

-the AR is the contraction of the SM elicited by the presentation of an acoustically loud sound

-when either ear is presented with a loud sound, the SM on both sides contract

-contraction of the stapedius muscle tilts the anterior stapes away from the oval window and stiffens the ossicular chain

• this results in increased impedance which is measured as a small decrease in compliance by the ear canal probe

Question 18

should you choose contra or ipsi?

Answer 18

ipsi=
Highly susceptible to artefacts
Sensitive to middle ear pathologies
Not affected by disorders of the opposite ear
contra=
More sensitive to disorders involving the crossed reflex pathways (meaning retrocochlear pathology could be missed out if not performing contra)
Not as susceptible to artefacts
More extensive normative data available for contra assessments

Question 19

who could we perform ARTs on?
which conditions can it detect?

Answer 19

-patients of SNHL (usually one sided) as you can detect a suspected acoustic neuroma

• patients who are unwilling to cooperate with behavioral testing

-suspected non organic losses

• balls palsy
• nerve damage
• facial paralysis

-acoustics neuroma

Question 20

do we do any traditional calibration for ARTs?

Answer 20

no only tymp calibrations

Question 21

what are contraindications that ARTs have that tinnitus doesn’t?

Answer 21

• tinnitus (severe or intrusive)
• hyperacusis
• phonophobia
• severe recruitment

Question 22

which frequencies can you test at for ARTs ? which one am i doing in the OSCEs?
why not 4k

Answer 22

500,1k and 2k

ONLY do 1k

4 kHz ART may be elevated or absent in subjects with normal hearing, so this should not be taken as clinically significant.

Question 22

what intensity do you start at for ARTs?

Answer 22

The intensity should start at 60 dB if using broadband noise and 70dB if using pure tone stimuli.

I AM STARTING AT 70

Question 23

how do you ARTs?

Answer 23

-otoscopy
-tymps
-start ARTs at 70
-if a reflex is no observed (002ml or more) then increase the stimulus by 5db. continue this until a reflex is found
-once you find a reflex increase again by 5db to check for growth (bigger dip)
-if growth continues, reduce the sound by 10dB and repeat to check if its a genuine reflex or artefact
-

Question 24

what is the dB that we stp at for reflexes?

Answer 24

105dB

Question 25

what is the normal value for tonal ARTs

Answer 25

75-95 (normal middle ear function
20-45 (sensorineural HL)

Question 26

what are the expected results for conductive HL?

Answer 26

Reflexes will be absent as the middle ear disorder will prevent the probe measuring a change in compliance when the stapedius muscle contracts

Question 27

what are the expected results for normal hearing/ normal middle ear function?

Answer 27

Generally both ipsi and contra reflexes will be present at all frequencies

Question 28

what are the expected results for cochlear HL?

Answer 28

It is possible for the reflex to be elicited at sensation level of less than 60dB. The sensation level is the difference between the ART and the hearing threshold. E.g. if the hearing threshold was at 50dB and the reflex is 90dB then the sensation level is 40dB.
A sensation level less than 60dB indicates a cochlear site of lesion (sensorineural loss)

Question 29

what are the expected results for retrocochlear hearing loss?

Answer 29

Usually elevated above what they would be for normal hearing or a cochlear hearing loss.
Often absent at maximum stimulus levels.

Question 30

reasons for repeating reflex meaurements

Answer 30

Client swallows, talks, laughs, coughs during the test.
You get an odd result that does not look correct or does not match audiogram findings.

Question 31

would you confirm a condition with only ARTs?

Answer 31

Keep in mind that acoustic reflex results should be analysed in combination with the patient case history, audiogram, speech and tympanometry findings for differential diagnosis.
Often an MRI is also needed to complete the picture.
Acoustic reflexes is a test that can be used in conjunction with other investigations.