Audiology Notes Exam 2

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OEA: Most normal cochleas react to acoustic stimulation with a very tiny sound of its own. So these are low intensity sounds generated by the cochlea and transmitted into the middle ear and ear canal. That is why if there is a middle ear problem, the OAE will be absent except in the case of ventilation tubes. This equipment is used to detect and amplify this miniscule response. This has become a popular test for newborn screenings. There are different types of evoked otoacoustic emissions:

OAE - Otoacoustic Emissions aka Evoked Otoacoustic Emissions -

Tuning forks come in different sizes. The larger the tines, the ____the frequency or the more the bass. The smaller the tines, the ___the frequency.

lower higher

for a child who cannot repeat or an individual who cannot discriminate words, the point at which they are able to detect the speech and respond by raising their hand or pushing a button.

SDT - speech detection threshold:

HL-SRT=

4. SOAE - This is not an evoked response. Many normal ears (50 - 70%) have natural emissions and these may be measured. It was initially thought that this would explain tinnitus, however, this has not proved to be the case.

SOAE (spontaneous otoacoustic emissions)

HL-SL=

SRT

the point where they are able to repeat 50% (2 out of 4) of the spondee words (compound words of equal emphasis) correctly after they have been familiarized with the words. ASHA recently recommended this be changed to speech recognition threshold.

SRT - speech reception threshold:

With air conduction testing, the crossover threshold is ______.

40 - 60dB

moderate hearing loss

40 - 60dB

VERY POOR

40% OR BELOW

When testing, one of the measurements obtained is the ear canal volume is ECV. If the overall volume is greater than ___, or if one ear's volume is twice that of the other ear, then the ear probably has a perforation or a patent ventilation tube.

5.0

severe hearing loss

60 - 90dB

POOR

68% OR BELOW

FAIR

70-80

GOOD

80-90

The lowest level at which the reflex is obtained twice

ART (ACOUSTIC RELFEX THRESHOLD)

**********COCHLEAR DISORDERS***************

**********Hearing loss scale*******************

Some old tests used without tuning forks by ENTs were: ______ ______

the whisper test the watch-tick test

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*****************Note***********************

****************CASE HISTORY******************

***************Middle ear*******************

**************ACOUSTIC REFLEX**************

**************Speech tests*******************

*************THE AUDIOMETER**************

**************THE AUDIOMETER**************

*************TYMPANOGRAMS****************

************IMMITTANCE AUDIOMETRY************

***********ACOUSTIC REFLEX DECAY**************

***********OUTER EAR****************

**********SITE OF LESION TESTING************* *JUST KNOW WHETHER THESE ARE A TEST OF RECRUITMENT OR ADAPTATION*

**********SITE OF LESION TESTING************** JUST KNOW WHETHER THESE ARE A TEST OF RECRUITMENT OR ADAPTATION*

**********SPEECH DISCRIM********************

********CENTRAL AUDITORY NERVOUS SYSTEM DISORDERS*********

********OTHER BEHAVIORAL MEASURES************

*****Problems with Tunning Fork Tests*****

****HEARING TESTS****

****KNOW THE FOLLOWING NAMES OR INITIALS, BUT KNOW ABR BETTER*****

****Static Acoustic Compliance or Static Immittance*****

*The following are the main causes of ototoxicity: 1 ________- bacteriocidal antibiotics which include among them amikacin, gentamicin, kanamycin, neomycin, netilmicin, streptomycin, tobramycin, viomycin, garamycin. 2 ________ - generally drugs for cancer - hearing should be periodically monitored and keep the patient well hydrated. (cisplatin/carboplatin) 3 __________ - most commonly inhaled on the job are styrene, toluene, and trichlorethylene 4__________- most commonly seen with lasix, furosemide, and ethacrynic acid. Lasix is very popular and causes degeneration of the stria vascularis.

*AMINOGLYCOSIDES ANTINEOPLASTIC INDUSTRIAL SOLVENTS LOOP DIURETICS

*congenital malformation, primarily of the ear canal. At some point, the ear canal is closed off. There may be no problems past the point of closure or there may be other accompanying abnormalities such as congenital ossicular malformations. This will cause a significant conductive hearing loss if the sensory mechanism is intact which may be corrected through the surgical opening of an ear canal, assuming all structures of the middle ear are present and normal.

*Atresia

*a form of dizziness characterized by latency of onset when in a certain position, severe vertigo for seconds, transiency, and fatigability. It is the most common cause of dizziness in the elderly but may occur due to head trauma, cold, whiplash, etc. Otoliths made of calcium carbonate crystals are not reabsorbed into the body and float in the semicircular canals, causing temporary vertigo when the head is turned toward the side with the excess. This may be cured with a canalith repositioning maneuvers.

*BENIGN POSITIONAL PAROXYSMAL VERTIGO (BPPV)

*this is an infection of the ear canal or auricle. There may be inflammation, bacteria, or even fungal growth (otomycosis). The most common type known is "swimmer's ear". This can be treated by the physician, usually with topical agents. Systemic medications rarely work. Hearing loss, if any, is conductive and when the inflammation is gone, hearing returns to normal.

*External Otitis

*rounded hard bony nodule growing from the osseous portion of the EAM and caused by extended exposure to cold water Usually wide base, usually bilateral, history of exposure to cold, can occlude the ear canal, not round. Unless so large it becomes obstructive, it usually does not affect hearing.

*Extoses

*caused by infection, the vestibular labyrinth becomes inflamed and may produce vertigo, with or without hearing loss. It may be transient or may become toxic and become permanent along with hearing loss. In the more severe form, the membranous labyrinth of the cochlea is usually affected and hearing loss is permanent. Hearing aids would be suggested.

*LABYRINTHITIS

*often used synonymously with endolymphatic hydrops. There is excessive fluid in the cochlea and the vestibular labyrinth and symptoms include fullness in the ear, reduced hearing, roaring in the ear and vertigo. Cochlear Meniere's may only have fluctuating hearing loss without the vertigo and vestibular Meniere's may have the extreme vertigo without the hearing loss. Over time, any hearing loss may become permanent and be progressive. Often, patients are told to watch their diet, avoid salt and caffeine, and are given diuretics. When hearing loss is permanent, hearing aids may be suggested.

*MENIERE'S DISEASE

*it is a congenital condition of excessive enlargement of the auricle. Again, this may not affect hearing in any significant way. They may be made smaller surgically.

*Macrotia

*congenital malformation of the auricle This may not affect hearing in any significant way, however it may affect sound localization and affect the acoustics of how we are accustomed to listening to sound. Also remember, when there is a craniofacial anomaly, there may be other abnormalities linked to it.

*Microtia

*continual exposure to loud noises over long periods of time without ear protection will cause a sensori-neural hearing loss. This may also occur from a one-time blast of extremely loud noise near the ear. Shorter exposures may cause something called TTS (temporary threshold shift) such as after a concert, when the hearing is muffled but eventually returns to normal. When it no longer returns to normal it becomes PTS (permanent threshold shift). Use of ear protectors to avoid loud noise and hearing aids if desired are the only solutions.

*NOISE INDUCED HEARING LOSS/ACOUSTIC TRAUMA

*sensori-neural hearing loss caused by drugs and chemicals that are toxic to the ear. It may also affect the vestibular system. It is usually permanent but in the case of aspirin and quinine, it may be reversible. For the majority, hearing aids or CI will be the only solutions.

*OTOTOXICITY

*skin covered bone growth, usually round, narrow base, Usually unilateral, skin covered, may obstruct normal migration of squamous epithelium outward. Unless so large it becomes obstructive, it usually does not affect hearing.

*Osteoma

*gradually decreasing hearing due to the aging process. Mostly affects those over age 65 with sensori-neural hearing loss. Other issues during the normal lifetime may exacerbate this such as noise exposure, reduced oxygen due to vascular disease, medications, etc. Usually begins as a sloping hearing loss with most hearing loss in the higher frequencies. Hearing aids are the only solution.

*PRESBYCUSIS

*this is due to a viral infection and usually affects the child in utero during the first trimester. In the 60's, this was the leading cause of nongenetic congenital sensori-neural hearing loss in infants and the one of the prime factors for the development of all the educational laws, including inclusion and mainstreaming that have occurred since. As with CMV, hearing aids, CI, and appropriate educational placement are the treatments.

*RUBELLA

*usually the superior canal is involved. Symptoms mimic many other disorders including dizziness, vertigo and disequilibrium. May also have symptoms of patulous ET dysfunction (blocked feeling in ear or echo sensation when talking - autophony). A thinning or weakening of the bone covering the SSC resulting in a 3rd window. Usually induced by loud sound or pressure change. Sometimes surgery is performed.

*SEMICIRCULAR CANAL DEHISCENCE SYNDROME (SCDS)

*of unknown etiology, lack of hearing on one side is suddenly noted. Best to be seen and treated within 24 to 48 hours. Treatment is steroids, usually Medrol dosepak (although transtympanic placement of steroids may be used as well) and some might add antivirals. If no improvement, loss is permanent and the only treatment left is amplification.

*SUDDEN SENSORI-NEURAL HEARING LOSS

*usually congenital, it is a narrowing of the ear canal. Again this may or may not affect hearing. It does often cause wax to build up in the individual. Sometimes the ear canal is widened surgically. It may also occur later in life as the body changes.

*Stenosis

*This is also a recessive genetic disorder. There is usually hearing loss that is sensori-neural as well as retinitis pigmentosa causing a progressive loss of vision. Again, the hearing loss may be treated with hearing aids.

*USHER SYNDROME

*a genetic syndrome with the following as the most common characteristics - white forelock, multi-colored iris, with displacement of medial canthi, hearing loss. The hearing loss may be unilateral or bilaterally, may be symmetrical or asymmetrical, may be of any degree. Hearing aids would be helpful.

*WAARDENBURG SYNDROME

EXCELLENT

90-100

____ is the minimum compliance for normal ears ____ to_____ is the maximum compliance for normal ears

.3 MINIMUM 1.6 TO 1.75 MAXIMUM

normal hearing

0 - 25dB

With bone conduction testing, the crossover threshold is ____.

0dB

One may look at hearing loss as being 1. 2. 3

1) hearing sensitivity loss 2) supra threshold hearing disorders 3) functional hearing loss

profound hearing loss

90dB+

*Other tests which do not involve voluntary responses are:* 1. 2.

1. Auditory evoked potentials (AEPs) 2. Otoacoustic emissions (OAEs)

There are 3 main types of hearing loss, these three are losses of hearing sensitivity:

1. Conductive 2. Sensori-neural 3. Mixed

List *cochlear* disorders

1. SYNDROMIC a. ALPORT SYNDROME b. BOR (BRACHIO-OTO=RENAL SYNDROME) c. CHARGE ASSOCIATION d. PENDRED SYNDROME e. USHER SYNDROME f. WAARDENBURG SYNDROME g. CERVICO-OCULO-ACOUSTIC SYNDROME h. CHARGE ASSOCIATION i. JERVELL AND LANGE-NIELSON SYNDROME 2. NONSYNDROMIC a. PRESBYCUSIS b. NOISE INDUCED HEARING LOSS/ACOUSTIC TRAUMA c. CYTOMEGALOVIRUS (CMV) d. RUBELLA e. SYPHILIS f. OTOTOXICITY i. AMINOGLYCOSIDES ii. ANTINEOPLASTIC DRUGS iii. INDUSTRIAL SOLVENTS iv. LOOP DIURETICS g. MENINGITIS h.LABYRINTHITIS i. HERPES ZOSTER OTICUS j. MENIERE'S DISEASE k. COCHLEAR NEURITIS l. AUTOIMMUNE DISEASE m. BENIGN POSITIONAL PAROXYSMAL VERTIGO (BPPV) n. PERILYMPHATIC FISTULA o. ENLARGED VESTIBULAR AQUEDUCT SYNDROME

So these thresholds may:

1. detect a loss of hearing above a specific degree 2. detect an auditory disorder; conductive, sensori-neural, or central

So what does the audiogram tell us?

1. gives the degree of hearing loss (mild, moderate, severe, profound) 2. describes shape of loss (flat, sloping, low frequency, high frequency, precipitous, cookie-bite, reverse slope or rising) 3. measures interaural symmetry (the difference between ears) 4. differentiates hearing loss (conductive, sensori-neural, mixed)

Immitance audiometry has 4 main functions:

1. it is very sensitive to middle ear disorder 2. it can separate out cochlear from retrocochlear involvement 3. it may help estimate hearing sensitivity 4. it may help confirm your audiometric results

There are 3 (4) measurements made in the plane of the TM: 1. 2. 3. 4.

1. static acoustic compliance or immitance 2. tympanometry 3. acoustic reflexes 4. acoustic reflex decay

hearing loss may also be identified by:

1.time of onset 2. time course 3. # of ears involved 4. configuration

The tone is given at ___dBSL or ___dB above the reflex threshold and maintained for ____ seconds. It the reflex does not decay to half its original amplitude, it is _____. If it is _____, there is a more central problem to worry about. Abnormal decay may be defined as a ___% reduction of the reflex. Your handout says within 5 seconds, however, all previous literature uses 10 seconds. The Comprehensive Dictionary of Audiology Illustrated (2nd Edition) defines acoustic reflex decay as "perstimulatory reduction in the magnitude of the acoustic reflex reduced by over 50% of the initial amplitude within____ seconds of stimulus onset".

10;10;10 NEGATIVE POSITIVE' 50% 10

Note :Also, probe tone frequency should be taken into account. When testing newborns and young infants, it is common to use a ___kHz probe tone versus the 226Hz tone used for adults.

1kHz

TOAE aka as TEOAE - These are produced by brief acoustic stimuli such as tone pips or clicks. The response is usually all or none. Anyone with normal hearing and normal ear structures should have emissions. A middle ear problem or hearing loss greater than 35 - 40dB will eliminate the response.

2. TOAE (transient otoacoustic emissions) aka as TEOAE (transient evoked otoacoustic emissions) -

mild hearing loss

25 - 40dB

ABR: aka BAER (brainstem Auditory "Evoked Response aka BERA (brainstem evoked Response Audiometry): This occurs in the first 10 - 15 ms and the response comes from the 8th nerve and brainstem to the midbrain. It is the most commonly used test of the the evoked potentials. There are 5 waves we measure. We can approximate hearing sensitivity for high frequency click stimuli from this. It is also a good test for neonates, and until recently, the gold standard for newborn screening in the screening version called is the AABR (Automated Auditory Brainstem Response). If there is a delay of waveforms, when using this test for diagnostics, we can guess where the probable site of pathology lies: Wave I from the distal portion of the VIIIth nerve where the fibers leave the cochlea (also the equivalent of the ECoG), Wave II from the proximal portion of the nerve near the brainstem, Wave III from the proximal portion of the nerve and from the cochlear nucleus, and waves IV and V have contributions from the cochlear nucleus, superior olivary complex, and lateral lemniscus. These waves are referred to as Jewett Waves. Interpeak latencies are also evaluated, I-V, I - III, and III-V. Finally, the interaural latency difference, or ILD is looked at. This is the difference for the same measurement between ears and should not exceed .3msec. This test may be used to find acoustic neuromas (vestibular schwannomas). One may assess the integrity of the central auditory pathway using a fast rate to find demyelinating disease (MS). *1,3,5 are the most impt* Multiple components to this may be: a. The standard ABR - just look at absolute peak latencies, interpeak latencies, and differences between ears b. The Latency-Intensity Function - may obtain wave V down to within 10 - 20dB of threshold, good for babies and malingerers c. Rate series: same sound and click but at different speeds, sensitive to demylinating disease (MS). The ABR has proven to be sensitive, specific, and efficient I detecting lesions or tumors which affect the auditory pathway through the brainstem.

ABR (Auditory Brainstem Response)

the most common growth affecting the auditory nerve. It is always benign and may or may not cause hearing loss, depending on the size. They are most often unilateral and often develop from the vestibular branch of the VIIIth nerve. There may be tinnitus, hearing loss, unsteadiness, difficulty understanding words, etc. They are bilateral for those suffering from NFII. If very small they may be watched, if surgically removed, the hearing is generally lost, or the newer treatment using the Gamma Knife/Cyberknife may be used and then the area is monitored for necrosis of the tumor over time. This is one way the hearing can be preserved if it had not been affected.

ACOUSTIC NEUROMA (AKA COCLEOVESTIUBLAR SCHWANNOMA)

AEP: There are neuroelectric events; they are measured from the scalp via electrodes. The electroencephalograph (EEG) is used and looks for a change in activity. All waves, except for the change associated with the introduction of the click stimulus, are then filtered out. They are subdivided based on where and when they occur:

AEP - Auditory Evoked Potentials

AMLR - This originates in the midbrain and occurs in the fist 50 ms after the introduction of the stimuli. It reflects the activity at or near the auditory cortex. It uses tone pips and may provide information for frequencies below 2KHz as ABR measures 2 - 4kHz. It is characterized by 2 positive peaks, Pa at 25 - 35msec and Pb at 40-60msec after stimulus presentation. It is of questionable use with infants and uncooperative patients. May also be used with central auditory processing disorder. At times it may be used for threshold determination as well.

AMLR (Auditory Middle Latency Response)

This occurs with disease or damage to the auditory nervous system and may or may not be accompanied by physical hearing loss.

Auditory Nervous System Impairments

the governing body that sets the standard for audiometers, hearing aid specifications, etc. These may change. The current standard is ANSI 1996, prior to this was ANSI, 1969. An association of specialists, manufacturers, & consumers that determines standards for measuring instruments, including audiometers. They are the specs by which our equipment is calibrated.

ANSI - American National Standards Institute

type of Auditory Nervous System Impairments: When the problem is from a developmental disorder or diffuse changes, such as auditory processing disorder in children or central changes from the aging process, then we have Auditory Procession Disorder. There may be ADD, LD, and language problems. These may exhibit as receptive language processing disorders or may be neuropsychological disorders (auditory attention and auditory memory - deficits in cognitive ability). In the elderly, this is due to neural degeneration. In children, it is generally idiopathic.

APD

(ASSR): This test uses modulated tones that can be used to predict hearing sensitivity. It is evoked by a periodic modulation of a tone (usually 500Hz, 1kHz, 2kHz, or 4kHz) and the potential follows the time course of the modulation. Good for those who cannot response normally and clinical time is less than that for the ABR. Can also perform in sound field with and without amplification to assess the efficacy of your intervention.

ASSR AUDITORY STEADY STATE RESPONSE

a disorder in which the body produced antibodiesthat attacks itself, one common example being rheumatoid arthritis. May affect the auditory system and may be characterized by bilateral, progressive, SN hearing loss. Treatment would be hearing aids or CI.

AUTOIMMUNE DISEASE

the hearing test as measured through supra-aural or insert earphones, tests the entire auditory system.

Air conduction

the difference between the air conduction and bone conduction

Air-Bone Gap -

a congenital malformation of the pinna - there is none. It is not recommended to do surgery as the grafted tissue does not grow the same. Plastic pinnas can be made. There is no obvious effect on hearing if the rest of the hearing mechanism is present.

Anotia

changes the intensity of the signal - usually in 5dB steps, some may be even smaller

Attenuator dial

This occurs when there is a sudden, extreme change in atmospheric pressure, whether due to diving and coming up too quickly or as occurs when an airplane is descending. Even if the change is not extreme, if the ET is not functioning correctly, this can still occur. Extreme negative middle ear pressure may be observed. If any hearing loss occurs, it will be conductive. If not corrected, it can become an otitis media. Treatment may include nasal sprays and decongestants or, if it persists, even ventilation tubes.

BAROTRAUMA

these may have brachial clefts, fistulas, cysts, renal malformation. There may be preauricular tags. It is also possible to have hearing loss whether conductive, sensori-neural, or mixed. Hearing aids would be the treatment.

BOR (BRACHIO-OTO-RENAL SYNDROME)

List *central auditory nervous system* disorders

BRAIN INFARCTS MULTIPLE SCLEROSIS ACOUSTIC NEUROMA (AKA COCLEOVESTIUBLAR SCHWANNOMA) CPA TUMOR (CEREBELLOPONTINE ANGLE TUMOR) CEREBROVASCULAR ACCIDENT (STROKE) DIABETIC CRANIAL NEUROPATHY AUDITORY PROCESSING DISORDERS *TINNITUS (may be involved with middle ear, inner ear, or mixed losses)*

when testing ________, the entire skull vibrates. This is a ____ crossover. If one ear is better than another, the better ear always responds. That is why we need the audiometer, so we can "____" the better ear with a noise and separate out the test ear.

Bone Conduction; 0dB; mask

________: the hearing test via a bone vibrator, tests the nerve of hearing directly - may be felt due to bone oscillator vibration in those with severe hearing losses and the tactile sensation usually occurs at 250Hz & 500Hz. This is called a _________.

Bone conduction vibrotactile response

So why are we evaluating these patients?

CASE HISTORY. Get Information from referral source, patient, or family begins to give you an idea of where you are going. Is it self-referral? Medical referral? Family decision? Child? Adult? Obtain before testing patient. May be done in interview or printed form. This will give us an idea of what we are looking for. Maybe they are merely looking for an augmentative device, perhaps they are dizzy or have tinnitus. Perhaps a parent suspects a hearing loss in a child or the child failed a screening before entering school or at birth. Perhaps it is a workman's comp or other litigious case. Perhaps they have a learning disability or may have a tumor. We begin to decide what we are going to do and the order in which we go about it based on the information we obtain. So a case history is a must. It can give us much valuable information. From this, we can being to determine the onset of the problem, possible causes (ototoxicity, NIHL, sudden onset, hereditary disorders like otosclerosis, etc) and begin to determine the next step in the process. It may be that we are the ones who determine that the disorder is treatable and an ENT consultation is needed. Or it may be that we are the ones determining that it is the services of the SLP that is truly what is needed. Sometimes we may be the ones to tract a dizzy or tinnitus complaint to medications being taken/recently changed/recently added and this may be the true cause of the problem.

CHARGE stands for Colomboma, Heart disease, Atresia Choanae (nasal cavity), Retarded growth, Genital Hypoplasia, and Ear anomalies. The ear anomalies may cause any type of hearing loss, conductive, sensori-nerual, or mixed. Depending on the child is how the hearing loss will be handled but usually with hearing aids.

CHARGE ASSOCIATION -

This can occur following chronic OM or due to a chronic retraction pocket of the TM. A pocket of cells form and results in a growth. If unchecked, it can erode through the bones of the skull. Adhesions can grow on the ossicles. It may or may not cause a conductive hearing loss, depending on the size and extent of the growth. It must be removed surgically but should be watched as it is not unusual for it to recur. There are also congenital cholesteatomas which must also be removed.

CHOLESTEATOMA

This stands for the compliance measurement and should be between .3ml and 1.75m. If below .3ml, the system is hypocompliant and you can expect a conductive hearing loss. There may be fluid, otosclerosis, a perf, or other ME problem. If above 1.75, the system is hypercompliant and may or may not have a conductive problem. There may be a disarticulation.

COMP

this is a congenital infection and it induces a sensori-neural hearing loss. This is the leading cause of congenital hearing loss that is not genetic and it usually transmitted in utero. It may be of delayed onset, it may be progressive, it may be asymmetrical. The mother may not even know she has this as she may think she only has a cold. Hearing aids or cochlear implant and appropriate educational placement are the treatments.

CYTOMEGALOVIRUS (CMV) -

the sound goes in the ear opposite the probe and the reflex is picked up by the ear with the probe. Sound ---> OE ---> ME ---> cochlea (IE) ---> along 8th nerve and to the brainstem. In the brainstem, it is received by CN ---> SOC and crosses over to the opposite SOC ---> facial nerve (VII) contralaterally, and descends to innervate the stapedius muscle, thus evoking a contralateral reflex.

Contralateral reflex pathway

__________: a. can happen with a narrow ear from the pressure of the headphones b. may give a false conductive hearing loss c. may be overcome by the use of insert headphones or holding the headphone off the ear

Collapsing ear canal

When we hear through the entire ear system, the sound is conducted by air. If there is a problem within the outer ear or middle ear system, then the conduction of sound is partially blocked and we cannot hear as well, the sound is attenuated. There is a loss by air conduction but no loss by bone conduction.

Conductive

also known as a discontinuity. There is a separation somewhere in the ossicular chain causing a separation within the chain. This may occur in the incus, in the incudostapedial joint, in the crura of the stapes, or even of the malleus. The result would be a conductive hearing loss. Again, surgical treatment would be necessary. Hearing aids might be selected instead.

DISARTICULATION OF OSSICULAR CHAIN

DPOAE - For this test, 2 primary tones are presented and the normal ear produces energy at additional frequencies known as the distortion product. As the primary tones vary, so does the distortion product. A response may be obtained as long as the loss does not exceed 40 - 50dB.

DPOAE (distortion product otoacoustic emissions)

the difference between the SRT and the UCL is the range of useful hearing.

Dynamic Range

This stands for the ear canal volume and is given in ml. Again, when one ear ECV is twice the other or more, or, if the ECV is great than 5ml, there is a perforation or open tube.

ECV

ECog: this is the electrical response generated within the cochlea. This test is used primarily for determining Meniere's disease. We look at the action potential (AP), cochlear microphonic (CM), and the summating potential (SP). Reflects activity of the cochlea and VIIIth nerve and is the earliest of the Evoked Potentials, occurring in the first 5 ms.

ECoG or Electrocochleography:

We need to ____ for ____ and ________ for all concerned, the hearing impaired and their family/significant others/caregivers.

EMPOWER INDEPENDENCE QUALITY OF LIFE

This tube allows for pressure equalization between the ME and the outside. If it becomes restricted due to swelling, or even because of the small, torturous curvature of young children, then oxygen or fluid can be trapped. First, with oxygen, the pressure is negative, much like being on a plane and not equalizing. If left unchecked and to persist, then this can lead into a bout of OM. ET dysfunction may or may not cause a conductive hearing loss. If the negative pressure persists, then skin cells can become trapped in a pocket and cause a cholesteatoma. Treatment may include nasal spays, decongestants, and even ventilation tubes if it persists.

EUSTACHIAN TUBE DYSFUNCTION

the level where increased masking noise will no longer result in a shift of threshold

Effective Masking -

configuration can be

Flat, sloping, reverse curve, cookie-bite, reverse cookie-bite, precipitous, noise-induced notch, corner audiogram, etc.

This is the most common tumor of the middle ear. It may occur on the jugular bulb, in the middle ear, or along the vagus nerve. It is a heavy vascular supply of cells that arises in the middle ear near the jugular bulb and may cause pulsatile tinnitus. It is bluish in color. It may cause a conductive hearing loss and if untreated, can press on the cochlea causing a reduction in oxygen getting to the cochlea and thus resulting in a mixed hearing loss. Depending on the location, there may also be facial nerve paralysis. Hearing loss maybe anything and the most common treatment is surgery. -dont worry too much about

GLOMUS TUMOR

aka Ransay Hunt syndrome. Caused by the chicken pox virus and often occurs in older people or when there is extreme stress. Must have had the chicken pox when younger. Causes little pimple-like eruptions that are very painful, may cause facial nerve paralysis, dizziness, and sensori-neural hearing loss. Medical treatment and hearing aids if necessary are the treatments.

HERPES ZOSTER OTICUS

SRT+SL=

If the system exceeds the norm, then there is greater than normal mobility and the system is ______. Some examples that could cause this problem are a separation of the ossicles (disarticulation) or a very thin eardrum characterized by abnormal elasticity (monomeric membrane). This may occur due to a healed perforation.

HYPERCOMPLIANT

If the system is below the norm, there is less than normal mobility and the system is stiff or _______. Some examples that could cause this problem are otitis media or otosclerosis where the stapes is fixed.

HYPOCOMPLIANT

refers to a functional limitation imposed by a hearing impairment. As defined by your text, "relates to an individual's difficulty in performing biologically and socially useful functions

Hearing Disability

refers to the obstacles to psychosocial function resulting from or imposed by a disability. As defined by your text, "the ways in which individuals are disadvantaged in fulfilling their desired roles (usually defined on self-assessment scales)"

Hearing Handicap

refers to abnormal or reduced function; the actual dysfunction described by the measures of hearing status. As defined by your book, "an abnormality that is psychological, physiological, or anatomical"

Hearing Impairment

the method by which we obtain threshold Verbal instructions to a patient - A review of testing technique - down 10dB and up 5dB Frequencies tested: 1kHz, 2kHz, 4kHz, 8kHz, repeat 1kHz, 500Hz, 250Hz. If there is more than a 20dB difference between frequencies, and there is a middle frequency, then test the middle frequency. They may be 750Hz, 1500Hz (or 1.5kHz), 3kHz, 6kHz. Bone Conduction is tested the same way but stops at 4kHz. Note that infants and children use modified methods we will review later in the course.

Hughson-Westlake "Ascending Method" or Hughson-Westlake technique - p. 78

another standard used but not usually in the US, usually in Europe.

ISO - International Standards Organization

a sound in that ear evokes a response from the same ear. *Sound ---> OE--->ME ----> cochlea (IE) ----> along 8th nerve and to the brainstem. In the brainstem, it is received by CN -----> SOC ----> facial nerve (VII) ipsilaterally, and descends to innervate the stapedius muscle.*

Ipsilateral reflex pathway

this is a newer way of testing, whereby a receiver, covered by a foam cushion is inserted deeply into the ear canal and reduces external noise (ambient noise) as well as the need for masking. Often used with collapsing ear canals.

Insert Headphones

the amount of reduction in intensity that occurs as a signal crosses over the head (is transmitted by bone conduction) from one ear to the other ear; the point at which the better ear begins to respond: a. about 40 - 50dB for air conduction (depending on phones) b. at 0dB for bone conduction c. also the loss of intensity of a sound introduced to one ear and heard by the other.

Interaural attenuation -

the switch that may keep a sound on or keeps the sound off until pressed; controls duration of sound.

Interruptor

LLR or (ALR ) or LER - Occurs beyond 60ms, within the first 250msec and comes from the cortex, specifically the activity of the primary-audiotry and association areas of the cerebral cortex. It has a negative peak, N1, at about 90msec and a positive peak, P2, at about 180msec after sound presentation. At 300ms it is known as the P300. It may assess neurological function. The patient must be alert. Be aware that there is a developmental effect for the ALR during the first 8 - 10 years and then it becomes robust.

LLR (late latency response) ALR Auditory Late Response LER (Late Evoked Response)

just talk to them and tell them to tell you when your voice is comfortable or "just right". I like to tell them to tell me when my voice is at a level where they would like to listen to television for 2 hours.

MCL - most comfortable listening level or most comfortable loudness level:

bacterial infection may cause inflammation of the cochlea or labyrinth. The meninges become inflamed. It may cause total deafness, it may be asymmetrical. If early treatment with corticosteroids is initiated, it may arrest the hearing loss before it becomes severe. Hearing aids, CI, and educational placement are the final outcomes.

MENINGITIS

This stands for middle ear pressure. This is where the peak of the most compliant point is. If it is between -100daPa and +100daPa, then the pressure peak is normal. If it is more negative than -100daPa, then you may have Eustachian tube function problems.

MEP

List *outer ear* disorders

MICROTIA MACROTIA ATRESIA ANOTIA STENOSIS IMPACTED CERUMEN EXTERNAL OTITIS PREAURICULAR TAGS CARCINOMA OF THE AURICLE (Basal/Squamous Cell) EXOSTOSIS/OSTEOMA

monitored live voice: the tester gives the words while monitoring their voice level through a VU meter

MLV

the introduction of a noise into the nontest ear as needed, usually when there is great asymmetry. a. typically used for air conduction when the difference between ears is equal to or greater than 40 - 50dB b. typically used for bone conduction when there is any difference between ears c. typically used for speech when there is a difference between ears of 40 - 50dB or greater Use 40dB with supra-aural headphones, 70dB with insert earphones, and 0dB for bone

Masking

a way to remove the nontest ear from the test procedure when cross-hearing is suspected. The difference for air conduction is based on the BC of the better ear to the AC of the worse ear. Noises used for pure tones are: a. white noise b. narrow band noise For speech testing we use: a. speech noise b. pink noise

Masking -

occurs when the difference between the BC threshold in the test ear and the AC threshold in the non-test ear approaches the amount of interaural attenuation. Most often seen in bilateral conductive hearing loss.

Masking dilemma -

This is one of the most common childhood problems. It will cause a conductive hearing loss. The most common type is OM with effusion. Without effusion, there is just inflammation. Purulent effusion has pus and mucoid effusion thick and mucus-like. It can be acute or chronic or recurrent. Depending on type and duration, this can cause educational problems. While the child has OM, there is usually some conductive hearing loss. If left untreated, it can become permanent and become sensori-neural. Usually, antibiotics are used and if this does not help, then a myringotomy and placement of ventilation tube may be needed.

OTITIS MEDIA

This is a stiffness of the ossicles in the middle ear. It usually affects the stapes and it is usually hereditary (70%). If a female does not exhibit this before childbirth, it may often rear its head when she is pregnant. It is usually hereditary and more often in women. It is characterized by resorption of bone and then new, spongy formations occur about the footplate of the stapes and where it attaches to the oval window. The cure is surgical. They may chip away and free the stapes or place a prosthesis so the ossicular chain moves and transmits sound again. Hearing loss often begins as a low frequency conductive hearing loss and may become a flat conductive hearing loss across all frequencies.

OTOSCLEROSIS

when the intensity of the tone during bone conduction is increased due to the one of the ears being covered. Usually for 1000Hz and below. Does not occur in conductive hearing loss.

Occlusion effect -

generates pure tones at discrete frequencies and controlled by frequency dial; changes the frequency of the signal.

Oscillator/ Frequency dial

1. it is difficult to determine with mixed hearing loss 2. may report the tone for the wrong (better) ear because what they hear makes no sense to them (even though they hear it in the worse ear, they think they shouldn't)

Problems with the Weber:

This test is a pre-neural response giving information up to but not including the auditory nerve. They are an active byproduct of the outer hair cell system. If there is a compromise in the outer or middle ear, the response will be affected and most likely be absent. Remember, this is not a direct measure of hearing.

Otoacoustic Emissions Audiometry

the device that converts one form of energy to another such as acoustical or vibratory. These may include earphones (insert or supraaural), loudspeakers, or bone conduction vibrators.

Output Transducer

This is a recessive genetic disorder of the endocrine metabolism. There may be goiter and congenital hearing loss. The loss is generally symmetrical, moderate to profound, sensori-neural. Treated with hearing aids.

PENDRED SYNDROME

Generally,__________ are used to elicit these responses. The response is a contraction of the___________in response to an acoustic stimulus that is usually at least 60dB greater than the hearing threshold. If there is significant hearing loss (greater than 60dB) or a conductive problem, there will be no _____. The ipsilateral (probe ear) is measured at ___kHz and ___kHz. The contralateral (opposite ear) is measures at ___Hz, ___kHz, ____kHz, and ___kHz. White noise may be used as well. The intensity of the tone is raised until a reflex is obtained or until you hit the maximum allowable level, whichever is first. For example, ipsilateral reflexes have a limit of 105dB and contralateral reflexes go to 110dB. Due to recent lawsuits, there is controversy whether to go up to 110dB or stop at 105dB as is done with ipsilateral reflexes. Above 110dB you will see a message to warn that this level can cause damage to the ear. The pattern for measuring the acoustic reflex is the same as with all other measurement, down 10 and up 5.

PURE TONES stapedius muscle reflex ipsilateral (probe ear) is measured at 1kHz and 2kHz. The contralateral (opposite ear) is measures at 500Hz, 1kHz, 2kHz, and 4kHz.

1. examiner must have normal hearing 2. sometimes it is difficult to distinguish between normal and conductive loss as they hear the tone the same amount of time 3. difficult to interpret in the case of mixed hearing loss 4. difficult to interpret in the case of asymmetrical hearing as the better ear will hear the sound

Problems with the Schwabach:

1. When the inner ear not being tested responds to the tone, this is due to the immediate crossover of sound.

Problems with the Rinne and Bing:

______This is a whole other type of hearing loss. There appears some hearing loss on a test but they really have normal hearing or there is no pathology to explain the loss. There really is not hearing loss, even though the individual says there is. Other names for this are functional hearing loss, malingering, non-organic hearing loss, as well a psychogenic hearing loss. We have to tease out the truth using our diagnostic tests. Another type of nonorganic loss or pseudohypacusis might be* ________,* defined as a *rare psychogenic disorder* of hearing caused by conversion of emotional trauma to a physical manifestation. This might happen after a trauma, and it is possible to regain this as it was never really lost. Other terms for this are ________,_____,______,_______. We must be careful using these terms . Various reasosn for this problem are: 1. 2. 3.

Pseudohypacusis; Psychogenic Hearing loss or Hysterical Deafness Other terms for this are nonorganic hearing loss, functional hearing loss, malingering. We must be careful using these terms. Various reasons for this problem: 1. hysteria 2. attention-getter (mostly children) 3. accident case for: a. reward b. workman's compensation

the instrument by which we measure hearing. It measures frequency, intensity, and speech. It runs from -10dBHL to 120dBHL for intensity and measures from 125Hz - 12000Hz in frequency. Some special audiometers, known as high frequency audiometers, may measure up to 20000Hz. It also produces broad-band noise, speech noise, and narrow-band noise. May also direct signals from an external CD player or tape recorder for speech testing or use a microphone for monitored live voice.

Pure tone audiometer

___________ - this is an average by which to estimate the severity of the hearing loss: a.the more common average is 500Hz, 1000Hz, and 2000Hz b.now we often use 500Hz, 1000Hz, 2000Hz, and 3000Hz for a more accurate representation in the presence of high frequency hearing loss. c._________- when there is a precipitous drop at 1kHz, may be more accurate, this is the best 2 frequency average so in this case you might average 250Hz in.

Pure tone average Fletcher Average

an unusually rapid growth of loudness of an impaired ear. Loudness grows more rapidly than normal at intensity levels just above threshold in an ear with a cochlear problem. It may also be defined as a disproportionate increase in loudness as a function of intensity of the impaired ear. This is symptomatic of the majority of hearing losses that are sensory. *Sensori Problem*

Recruitment

You do this when you feel additional help is needed. Forward reports and results of audiogram.

Referrals

this also uses clicks and high pass pink noise masking. It is the composite of activity from all frequency regions of the cochlea (5). - may screen and detect for small acoustic tumors and may be a good estimation of threshold for hearing for those who are difficult to test. In the case of a tumor, the stacked ABR will have a smaller amplitude than the normal response.

STACKED ABR

In a typical report you want to give:

SWPDFO - Statement of the problem - Why services are sought - Patient's own attitude - Duration and degree of loss - Family history - Other pertinent history like noise exposure or trauma

A venereal disease which can affect hearing during the more advanced stages if left untreated. It can be transmitted in utero from an infected mother and may result in progressive sensori-neural hearing loss. In adults, during the later stages of syphilis, the hearing will deteriorate both sensory-wise and neurally. Hearing aids and antibiotics such as penicillin if it is not too late are the treatments.

SYPHILIS

changes from pure tone to masking to speech, etc.

Second selector switch

changes from air conduction to bone conduction to insert phones, etc.

Selector switch

This is a popular test for predicting hearing sensitivity. It is based on the difference between acoustic reflex thresholds to the pure tones and the reflex threshold to broad band noise (BBN). *SPAR = Reflex PTA (500, 1, &2kHz) - BBN +5dB correction factor* If a SPAR value is less than 15, there is a high probability of a SNHL. In most normal hearing individuals, the reflex threshold for BBN is much lower than for tones. In a SNHL, the reflex threshold for BBN is significantly higher while the pure tones do not change. Thus, the closer the BBN reflex threshold to the PT reflex thresholds, the greater the likelihood of SNHL. *This test may be used for children who cannot respond. It may also be used for malingerers.*

Sensitivity Prediction by the acoustic Reflex (SPAR):

When there is no problem in conducting the sound through the outer ear or middle ear, however, there is a problem in the inner ear, then the nerve is affected. This is called a sensori-neural hearing loss. That is because we did not know if it was the sensory (cochlear such as the inner ear) or neural (retrocochlear such as the auditory nerve) system affected without further testing. There is a loss by air conduction and an equal loss by bone conduction.

Sensori-neural

when the stimuli, whether speech or pure tone or noise, are delivered through speakers in the room. This maybe used to check the efficacy of hearing aids or to test children who won't tolerate headphones. May also be used for localization for infants and toddlers. With children, pictures of the spondees may be used and the child will point for the response. Ensure you do not allow them to read your lips.

Sound field testing (SF):

lowest level at which a speech signal is audible or detected 50% of the time; this is used when the individual cannot speak, has a profound hearing loss, or is a child who cannot communicate, this may be used in place of SRT if they cannot repeat spondees The SDT/SAT requires that the client merely detect the present of speech, the SRT requires that the client recognize the words. So the STD/SAT may often be at a somewhat better threshold than the SRT as it often reflects the best threshold.

Speech detection threshold (SDT) = Speech awareness threshold (SAT) -

The lowest level at which speech can be detected or recognized. The minimum level where spondee words that they have been familiarized with can be correctly detected 50% of the time. AKA Speech detection threshold or speech recognition threshold

Speech reception or recognition threshold (SRT) -

the percentage correct of 50 or 25 monosyllabic word lists presented at some level above the SRT, usually 30 - 40SL (SL meaning above the minimum hearing threshold of the spondee threshold). The ability to perceive and recognize speech Lets us know the prognosis with amplification.

Speech recognition or discrimination -

This refers to the isolated contribution of the middle ear to the overall acoustic immittance of the system. It's a measure of the height of the peak relative to the minimum or start height. It may be thought of as the absolute height of the tympanogram at its peak. (Stress point versus maximum mobility) Thus, a normal system and a negative system may both have the same peak or static immittance.

Static Acoustic Compliance or Static Immittance

Disorders of the outer and middle ear are usually _____ due to ________ or secondary to _____ or ______. They may be _____ or ____.

Structural; congenital malformations; infection or trauma; hereditary or acquired

A noise in the ears or head, usually described as crickets, whistle, steam, sometimes a roaring, but may also be voices. May accompany middle ear, cochlear, or even CANS disorders. If there is hearing loss, a hearing aid often helps. Sometimes maskers, TRT, or Neuromonics device, or other devices help retrain the brain so this becomes a nonissue. *may be involved with the middle ear, inner ear, or mixed losses*

TINNITUS

Both the _____and _____give a measure of outer hair cell function. That is why they are sensitive to cochlear vs retrocochlear pathology for hearing loss below 65dBHL.

TOAE , DPOAE

rare genetic disorder characterized by craniofacial abnormalities, underdevelopment of certain bones of the head. Many involve the ear, mostly malformation of the external ear and middle ear structures, including atresia. 40% are autosomal dominant inheritance but 60% are likely new mutations. Most hearing loss will be conductive.

TREACHER-COLLINS SYNDROME

this is a hole of the eardrum. It may occur due to spontaneous bursting due to otitis media, a foreign object being pushed though the canal too far, or even due to a trauma such as extreme changes in pressure or jumping into a pool on the side. Hearing loss may or may not occur, depending on the cause. If there is hearing loss, it will be conductive. There may be pain and even dizziness. Sometimes it will heal on its own. Sometimes a paper patch is used. If this doesn't work, an graft may be placed to replace the damaged membrane. Surgical repair is called myringoplasty.

TYMPANIC MEMBRANE PERFORATION

List *middle ear* disorders

TYMPANIC MEMBRANE PERFORATION TYMPANOSCLEROSIS OTITIS MEDIA EUSTACHIAN TUBE DYSFUNCTION BAROTRAUMA OTOSCLEROSIS GLOMUS TUMOR DISARTICULATION OF OSSICULAR CHAIN CHOLESTEATOMA

This can occur due to aging or as a change in the structure of the tympanic membrane due to chronic otitis media. White plaques are formed on the TM and cause an increased thickness and stiffening of the TM. Depending on the severity, conductive hearing loss can occur. This is usually a surgical treatment.

TYMPANOSCLEROSIS

a. compares examiner's hearing and patient's hearing b. place the fork stem on the mastoid and alternate between examiner and patient c. when the patient no longer hears the tone, the examiner places it on his/her mastoid d. If: i. both stop hearing at the same time, the hearing is normal ii. patient stops hearing before the examiner, then it is a diminished Schwabach and there is a SN hearing loss iii. if they not only hear as long as the examiner but beyond the examiner (prolonged Schwabach), there is probably a conductive hearing loss.

The Schwabach Test

*A test of lateralization* a. place the fork stem on the mastoid bone b. as you close off the ear by pressing on the tragus, ask them if it is louder, softer, or the same when you close the ear c. if they say: i. louder - then hearing is normal or SN hearing loss ii. the same - then the problem is conductive

The bing test

establishes threshold sensitivity across the frequency range important for human communication and is placed on a graph.

The pure tone audiogram:

compares length of time tone is perceived by air conduction versus bone conduction a. alternate holding a vibrating tuning fork against the mastoid versus next to the entrance to the ear b. ask them where the sound is heard louder c. if they say: i. it is louder next to the ear versus at the mastoid - hearing is normal or there is a sensori-neural hearing loss (positive Rinne) ii. heard louder on the mastoid - there is a conductive hearing loss (negative Rinne)

The rinne test

a. place the fork stem midline on the forehead b. ask where they hear the sound c. Depending on where they hear it (lateralization), we can make certain assumptions: i.midline = normal or symmetrical hearing loss (sensori-neural or conductive) ii.lateralize = conductive hearing loss, unilateral sensori-neural hearing loss if the loss is conductive, the tone is louder in the poorer ear, if the loss is sensori-neural, the sound is louder in the better ear.

The weber test

1. air conduction is greater than bone conduction 2. crossover does not occur (if your good ear hears at 0dB and the bad ear is at 110dB and the person is saying they don't hear, the person is lying b/c under the headphones crossover occurs somewhere in 60dB so the person should have heard through the deaf ear by 70dB bc it was crossing over from good ear) 3. they answer you when you whisper behind their head 4. Stenger test ( add ten to the good ear and subtract ten from the bad ear) 5. tests we will learn about being tympanometry, acoustic reflexes, OAEs, ABRs, partial spondee response, inconsistent speech and tone results.

Things to look for on your tests to check for malingering.

The level at which the patient can just barely detect the signal correctly 50% of the time. This is the same for pure tones and speech; air conduction and bone conduction; the *"just-audible" concept*

Threshold

this is a chart that shows your curve of compliance. (where its at, at every point) To measure this, we start at +200daPa (aka mmH2O), measure the compliance, and gradually change the pressure until -200daPa. This highest peak shows the point of greatest compliance. A low-frequency probe tone of 220 or 226Hz is used to bounce off the TM and measure the distance back to determine compliance at each point of the tympanogram.

Tympanogram

There are five types of tympanograms: 1.______ __: 2:_____ ___: 3._____ ___: 4._____ ___: 5._____ ___:

Type A Type As Type Ad Type B Type C

the level at which speech is uncomfortably loud. May also be done with pure tones. A normal ear should tolerate 90 - 100dB. If there are tolerance problems, it suggests a cochlear problem and it sets the limits of the hearing aid output.

UCL or ULL- uncomfortable listening level or uncomfortable loudness level aka TD (threshold of discomfort) and LDL (loudness discomfort level):

monitors output of the oscillator, microphone, or auxiliary items such as tape or CD player

VU meter

usually seen at 250Hz and 500Hz and the stimulus is felt as a vibration rather than hears; usually occurs primarily for bone conduction testing.

Vibrotactile response (VT) -

There are 4 types of tuning fork tests: 1.The _____ test 2.The _____ test 3. The_____ test 4. The _____ test

Weber, Bing, Rinne,Schwabach

Why use speech tests?

Why? - Gives us a threshold to crosscheck against our pure tone average - Measurement of threshold for speech - Assists in differential diagnosis - Assesses central auditory processing - Gives estimates of communicative function, aided as well as unaided

In order to truly understand the effects of hearing loss on any individual, we must look at:

a. *degree* of hearing loss (mild, moderate, severe, etc.) b. *configuration* of hearing loss (flat, sloping, reverse slope, cookie-bite, precipitously sloping, low frequency, high frequency, etc.) c. *type* of hearing loss (sensori-neural, conductive, mixed, APD) d. *speech* perception deficit (if any) e. *age* at onset (congenital or acquired - pre or postlinguistic) f. *sudden or gradual* (has or does not have compensatory strategies) g. patient's *normal communication demands* (sitting home versus being in school and learning language)

Sensitized tests for retrocochlear problems may be:

a. PB rollover b. SPIN test (Speech Perception in Noise) c. SSI (synthetic sentence index): SSI-C or SSI-I d. SSW (Staggered Spondaic Words) e. DSI (Dichotic Sentence Identification)

So, OAEs are applicable for the following:

a. infant screening (all or none phenomenon, sensitive to the most minimal of hearing losses) b. pediatric assessment - if we can only obtain sound field results, we cannot determine if one ear is better than another, but this would give us ear specific results easily and without needing a response from the child c. cochlear function monitoring - are potentially ototoxic meds having an effect on the cochlea d. some diagnostic cases - is the problem in the cochlea?, outer hair cells vs inner hair cells, auditory neuropathy? e. Also good for verifying hearing in pseudohypacusis f. To diagnose cochlear dys-synchrony (aka neuropathy). Is the inability to hear or discriminate words due to disruption of synchronous neuronal firing in the auditory pathways? This is especially helpful for early infant detection when combined with ABR testing. If OAE only without ABR, this disorder would have been missed.

Ways to respond to pure tone testing:

a. raising a hand or finger b. pushing a button c. verbally d. dropping a block in a pail or box in the case of a child

Some advantages to using OAEs over the ABR in newborn testing:

a. the test time is much faster b. noninvasive tests that does not involve the use of electrodes c. less sensitive to environmental noise

Ways to deliver speech stimuli: a. b. c.

a. through the headphones b. via bone conductor c. via speakers for sound field testing

The sound comes in the *outer ear*; collected by the concha, funneled down the ear canal and hits the eardrum. This is _____ energy

acoustic

A test battery that has become as common as pure tones and speech is ____________. This is a term that can be used to refer to___________ or ________. Either terminology is correct, but ___________ is the inverse of_________ . It is now accepted that the BEST measure of middle ear disorder is this battery of tests. *just refer it to impedance.

acoustic immittance acoustic impedance acoustic admittance acoustic impedance acoustic immittance

time course can be:

acute chronic sudden gradual temporary permanent progressive flactuating

Bekesy Audiometry

adaptation

Olsen-Noffsinger tone decay test

adaptation

Rosenberg tone decay test

adaptation

STAT - suprathreshold adaptation test

adaptation

TDT or tone decay test

adaptation

in an ear with a neural involvement, audibility of suprathreshold sounds diminish rapidly due to excessive auditory adaptation. The normal ear adapts at low levels and the audible signal becomes inaudible. However, at loud suprathreshold intensity levels, the sound remains audible. In the retrocochlear disorder, the sound disappears rapidly. *Neural Problem*

adaptation

There are also ________disorders. These are not types of hearing loss but are auditory problems nonetheless. These may or may not have physical hearing loss. They result in a reduced ability to hear suprathreshold sounds properly. Know these but they ARE NOT types of hearing loss. ________: this occurs with disease or damage to the auditory nervous system and may or may not be accompanies by physical hearing loss. They include: 1. 2.

auditory nervous system disorders Auditory nervous system impairment 1.Retrocochlear 2. APD

How well does the patient process the auditory information? this evaluates_____. This is the process by which the central auditory nervous system transfers information from the 8th nerve to the auditory cortex. This plays a role in localization of sound and in detection of desired signal in the presence of extraneous noise.

auditory processing

There are some special speech tests, outside of the usual monosyllabic words, to evaluate_______, or the transmission of information from the nerve to the auditory cortex via the various levels of the brain that make up part of the central auditory nervous system. Rather than just words in quiet, we tax the system by assessing speech recognition in the presence of competing speech signals, processing 2 different signals presented simultaneously to both ears (dichotic listening), etc. We may change the speech signal by using low-pass filtering, time compression, high level suprathreshold testing (as in PB rollover), speech in competition (as with SPIN), or dichotic measures (as in SSW). We reduce the extrinsic redundancy of speech to tax the system.

auditory processing

Normal hearing

better than 25db with air conduction and bone conduction equal

Mixed hearing loss

bone conduction thresholds are worse than 25 db and there is an air-bone gap greater than 10db in the same ear at the same frequency

There are various types of cell carcinoma that may occur such as basal call, epidermoid, and squamous cell. This must be treated or it can spread. Sometimes the external portion with this problem is surgically removed. As with the above disorders, this may or may not cause hearing loss, however, important acoustic information dependent on the shape of the auricle may be lost.

carcinoma of the auricle (basal/squamous cell)

Much evaluation is done via patient questionnaires. These scales assess the extent of hearing disability as well as the social and emotional consequences of hearing impairment. These questionnaires are now known by the term _________. These self-assessment scales are likely the most efficacious way of measuring the activity limitations, the extent to which the auditory disorder is causing ah erring problems, the extent to which the hearing problems is affecting the quality of life. Scales have also been similarly developed for vertigo and tinnitus. In some cases, the effects of vertigo and tinnitus on quality of life may be worse than the hearing loss.

clinometrics

creates an artificial conductive loss by pressure on the tragus causing it to move forward and block the ear canal. Patient doesn't notice it but it creates a false conductive hearing loss. The solution is to use insert earphones. Most often seen with young children with soft ears and geriatric patients as the ear becomes more flaccid.

collapsing external auditory canal

When held in front of the ear, we are testing the _____

conduction system

Time of onset can be:

congenital acquired adventitious

acoustic reflexes:

contraction of the middle ear muscle to very loud sounds; a reflex of the stapedius muscle, however, in animals it may be the tensor tympani muscle

3) functional hearing loss includes

fabrication of a hearing loss

patient does not respond when they do hear a tone - may happen in the case of malingerers

false negative response:

patient hears something when there is nothing

false positive response:

The goal for ______

goal is to quantify a patient's ability to understand everyday communication at suprathreshold levels.

Sensori-neural hearing loss

hearing worse than 25db with air conduction and bone conduction equal

The piston action of the stapes pushing against the round window sets fluid moving in the *inner ear* which moves the sensory cells (cilia or hairs) in the cochlea, causing sound to continue to the nerve of hearing. So the mechanical energy has been transformed to _____ energy to _____energy.

hydraulic;electrical

________, they are unusually sensitive to sounds at levels that would normally not be bothersome.

hyperacusis

2) suprathreshold hearing disorders may or may not include sensitivity loss include

i) APD ii) Other central issues

1) hearing sensitivity loss include

i) conductive hearing loss ii) sensori-neural hearing loss iii) mixed hearing loss

The most efficient way of answering these questions, aside from superficial otoscopy, is through_____________: an electroacoustic assessment technique measuring middle ear function.

immittance audiometry

an accumulation of wax in the ear canal. It causes a conductive hearing loss of varying degrees from 15dB to as much as 60dB. A good cleaning should take care of the problem.

impacted cerumen

Immittance audiometry is now an all-encompassing term to describe eardrum membrane ______, ______, or _______. It is also known as middle-ear measurements. All the measures of ME function are indirect as they are determined by measurements made in the plane of the eardrum membrane. It assesses how energy flows through the outer and middle ears to the cochlea. *It indirectly assess the appropriateness of the flow of energy throughout the system*

impedance, compliance, admittance

Masking level differences - MLDs

just know its another test

The *middle ear* now plays its role. The eardrum vibrates and sets the 3 middle ear bones to vibrating which pushes against the oval window. This is _____ energy.

mechanical

________, they react to certain sounds, and can almost become violent in their dislike.

misophonia

When there is both a problem in the conductive mechanism (outer and middle ear) as well as a problem in the nerve, we have both types of hearing loss and this is called a mixed hearing loss. There is a loss by air conduction and a loss by bone conduction, however the loss by air conduction is at least 15db greater. both conductive and sensori neural

mixed

*Static compliance and tympanometry measure _____.*

mobility

static acoustic compliance or immitance:

mobility of the TM at a given volume of pressure

The ability to repeat what is heard is considered _______. If we use a picture-pointing test, that is a_______, which limits possible choices.

open-set material closed-set approach

Referral we might make to are: 1. 2. 3. 4. 5.

physicians; clinical psychologists; speech language pathologists; teacher for Hearing impaired; regular teacher

Times when the SRT/SDT will not agree with the PureToneAvg: a. when there is a ____ _____ of hearing in the high frequencies (e.g., hearing is normal at 500Hz and then drops to 70 at 1000Hz, etc) - SRT better than PTA, closer to the best 2 frequency average (that is when you use the Fletcher average. b. When there is a ____ ____ problem, the elderly may have a problem in recognizing words and thus cannot get 50% correct - the SRT is poorer than PTA c. In _______ or malingerer - anything goes here: NOTE: often, in the case of spondees, they will give half the word correct and not the other half. d. SAT or SDT usually matches the single best frequency.

precipitous drop; central auditory; pseudohypacusis

*Acoustic reflexes and acoustic reflex decay give information about ________.*

probable disorders

a cassette or CD is hooked up to the audiometer and the speech stimuli are delivered this way. Built into some audiometers now.

recorded

SBLB (Simultaneous Binaural Loudness Balance Test)

recruitement

ABLB - Alternate Binaural Loudness Balance Test

recruitment

AMLB - (Alternate Monaural Loudness Balance Test

recruitment

SISI - Short Increment Sensitivity Index

recruitment

type of Auditory Nervous System Impairments: (due to a change in neural structure and function such as what is caused by a space-occupying lesion (like an acoustic neuroma) or by stroke. The more peripheral the lesion, the more impact on auditory function, the more central the lesion, the less impact on auditory function.

retrocochlear

When held against the mastoid bone, we are testing the ______

sensori-neural system

Do we need to refer for medical consultation? There are many common problems that are medically treatable. Some are:

stenosis, impacted cerumen, perforation, tympanosclerosis, and ossicular discontinuity. Such reduction in function may be due to structural changes and are amenable to medical management.

acoustic reflex decay:

the ability to hold the contraction for 10 seconds)

tympanometry:

the graph of how the ear drum is moving as we vary the pressure from positive to negative; how the immittance of the middle ear changes as air pressure is varied in the external canal

Conductive hearing loss

there is a gap of greater than 10 db b/w the air conduction and bone conduction of the same ear at the same frequency

measurement of hearing sensitivity

threshold

The earliest tests we had for the testing of hearing were the ________. This helped us to differentiate where the hearing problem might be, if anywhere. It also, by using it with different sized tines, allowed us to estimate damage to specific frequency areas.

tuning fork tests

this indicates normal middle ear function. It is almost an inverted V. The limits of the peak to still remain normal are +100daPa. The pressure in the outer ear and the pressure of the middle ear are equal

type A

the peak of the curve is within normal limits but the compliance is above the upper end of normal. The "D" stands for discontinuous (or disarticulation).

type AD

the peak of the curve is within normal limits but the compliance is below .3. The "S" stands for stiff.

type As

this is basically flat with little compliance and no peak. It usually indicates fluid is present. If the probe is packed with wax, this can occur as well as with cerumen impaction of the ear canal or a perforation of the eardrum.

type B

in this, the compliance is normal but the pressure peak exceeds the bounds of +100daPa. This might be seen on someone after a flight or with Eustachian tube dysfunction due to a cold.

type C

We characterize hearing impairment by ____ (site of the disorder) and degree of ___ (extent it affects normal function).

type;loss

# of ears involved can be

unilateral bilateral

In the low frequencies, with bone conduction, they may experience a ______________ where they feel a vibration rather than hear a response.

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