exam 1

Question 1

norms for ear canal volume

Answer 1

0.3 to 2.0 ml

anything below 0.4 is considered very low ECV

Question 2

what is ear canal volume

Answer 2

an estimate of the volume of the cavity the probe encounters

Question 3

what is compliance

Answer 3

the height of the peak which indicates the mobility of the eardrum in response to pressure change

the higher the peak, the more compliant the eardrum (the more it moves)

a low peak indicates a less compliant eardrum (stiffness)

if compliance is outside of the norms, it may be indicative of a problem in the middle ear

compliance = where on the y axis the peak occurs

Question 4

compliance norms

Answer 4

NORM= 0.2 mL (greater than 0.2 = pass)
no max for peak height, but it would indicate hyperflaccid TM (but we dont refer for this)

if compliance is less than 0.2 mL, fail tymp, refer for rescreen in 6-8 weeks

Question 5

patient fails tymp and fails hearing test- what do you do?

Answer 5

refer to MD and then to AuD for follow up

Question 6

patient fails tymp and but passes hearing test, you refer them for rescreen in 6-8 weeks. they come back and compliance is less than 0.2- what do you do?

Answer 6

refer to MD and then to AuD

Question 7

things we screen for during otoscopy (5 things)

Answer 7

impacted cerumen

foreign body in ear canal

perforation of TM

blood in ear canal - bright red, active bleeding (not scab or scar)

Obvious abnormality of the ear, head, or neck that was previously undetected

Question 8

infection control protocol

Answer 8

sanitize hands between every patient

can use the same specula for both of the patients ears but always use a new one between patients

if you see blood, infection, or fungus in the ear, tell jennifer (speculum will be discarded)

Question 9

Otoscopy protocol

Answer 9

1. ask/tell patient you’re going to look in and touch their ear, ask to move their hair
2. pull up and back on pinna with L hand and notice how the opening changes shape as you pull. find the point of the pull that provides the largest, roundest, opening
3. hold otoscope like a pencil, use your pinky against the side of patients face to brace the head - may need to kneel or bend down so you’re at their level
4. you might need to aim the light towards the patients nose
5. look for malleus (bone connected to the ear drum), cone of light, and that the eardrum is a normal color (no blockage from cerumen)

Question 10

REFERRAL CRITERIA FOR OTOSCOPY

Answer 10

1. impacted cerumen COMPLETLEY fills the ear canal
2. foreign body in the ear canal- refer to MD
3. perforation (hole) of TM- refer to MD
4. blood in the ear canal - refer to MD
5. obvious abnormality of the ear, head or neck that was previously undetected - refer to school for advice

NOTE: scarring of the TM is not a criterion for referral but should be noted on the screening form as baseline/ history info. Wax is a normal condition but may require professional removal

Question 11

patient passes hearing screening and otoscopy but fails tymp (either from gradient or compliance or both)- what do you do ?

Answer 11

refer for rescreening in 6-8 weeks

Question 12

REFERRAL CRITERIA FOR OUTER EAR EXAM

Answer 12

refer to MD for …
1. ear drainage
2. structural deficit of the ear that has been previously undetected
3. cereumen impactation, foreign bodu, or blood in ear canal upon visual exam
4. perforation of TM or abnormally high ECV AND flat tymp (usually indicated by NP) or blocked PE tube

Question 13

when to refer to AUD for eval

Answer 13

if prechool age 3-18 and thresholds greater than 20dB HL at 1K, 2K, or 4K in either ear

if adult over 18, and thresholds greater than 2 dB at 1K, 2K, or 4K in either ear

Question 14

when to refer to MD and then AuD

Answer 14

when pt has middle ear AND inner ear concerns (fails tymp and hearing screen) OR middle ear concerns at rescreen (fails tymp at rescreen)

Question 15

adult screen recomendations

Answer 15

hearing within typical limits and no history of noise exposure/ medical concerns: rescreen in 10 years

hearing within typical limits and positive history of noise exposure/ medical concerns: rescreen in 5 years

hearing is within typical limits with tinitis- refer for complete aud exam

hearing is outside of typical limits at any frequency- refer for complete aud exam

otoscopic examination atypical - consult MD

Question 16

goal of school hearing screenings

Answer 16

to identify children with hearing impairments and related problems and to refer them to the appropriate professionals for follow up

Question 17

otitis media

Answer 17

caused by an open eustation tube which cannot effectively equalize air pressure in the middle ear to atmospheric pressure.

ET dysfunction causes the middle ear space to be sealed for an abnormally long period of time. The mucosal lining tissue of the middle ear requires oxygen so without a fresh supply of oxygen, the pressure in the middle ear becomes negative in relation to atmospheric pressure –> pressure in the middle ear builds up because it pulls O2 from air in the middle ear space and becomes a higher pressure area than whats outside the ear.

ET dysfunction: when pressure is negative in relation to atmospheric pressure (but if peak height and gradient are WNL –> pass tymp)

Question 18

early stages of otitis media (mild OM)

Answer 18

middle ear fluid secreted from lack of oxygen to middle ear space (bc ET isn’t opening) –> likely to clear up without treatment

if you see this with no other abnormalities –> PASS screening

Question 19

if child complains of ear pain or you see redness of TM and/or bubbles from fluid on the inside of TM

Answer 19

consider discussing concerns with family as they may want to have a referral

Question 20

later stages of otitis media

Answer 20

middle ear fluid infectioed, viscous, puss-like, TM movement may be compromised.

Tymp may show a low peak, wide gradient, or both. Peak pressure may also be negative.

if you see this and child does not pass tymp but passes hearing test, rescreen in 6-8 weeks.

IF fail tymp at rescreen, refer to MD (regardless of hearing screen results)

if otitis media is left untreated, can result in perforated TM

for chronic otitis media, you might see a pressure equalizing (PE) tube in the TM to aerate the middle ear

Question 21

if child passes outer / middl ear screening (otoscopy, tymp) but does not pass hearing screening for one of both ears - what do you do

Answer 21

refer to AuD (potential inner ear problem)

Question 22

if child passes tymp and hearing screening but you see impacted cerumen in one or both ears - what do you do

Answer 22

Refer to MD

Question 23

if child passes otoscopy and hearing screening but fails tymp what do you do

Answer 23

RESCREEN in 6-8 weeks

Question 24

if child passes otoscopy but fails tymp and hearing screen for one or both ears

Answer 24

refer to MD and then to AuD

Question 25

if this is a rescreen and child passes otoscopy and hearing screen but fails tymp

Answer 25

Refer to MD and then to AuD

Question 26

tympanometry purpose

Answer 26

assessing the function of the TM and middle ear

Question 27

how does tymp work

Answer 27

the probe on the device establishes a seal. device plays a sound at a certian volume level and adds pressure which pulls on the TM. when we reduce the pressure we pull on the TM which happens when the sound pressure (volume) changes of the sound that was put into the ear. if the pressure or volume change is different from the establshed norms, middle ear system is not WNL TM is most mobile when pressure in the ear canal and in the middle ear are equal -- allows us to make conclusions about the pressure in the middle ear relative to the pressure in the ear canal

Question 28

steps for tymp

Answer 28

tell child this device is going to draw a picture with their ear, show them the screen 1. look at the patients ear to determine probe tip 2. put it on and make sure theres no gaps between probe and device 3. place the device in the patients ear after pressing the respective button (for R or L ear) and check that you are testing the correct ear throughout 5. make sure it says "test ready" before you start 6. pull back the pinna with non dominant hand 7. insert the probe tip to the opening of the ear canal with the screen facing towards you 8. look for probe to say "in ear" 9. hold still until the display says done 10. remove probe by angling it inward (towards head) to break the seal. once probe is parallel to head gently pull it away to break the seal

Question 29

pressure (tymp)

Answer 29

the pressure at which the peak occurs is an estimate of the pressure in the middle ear as related to atmospheric pressure pressure near 0 (atmospheric pressure) = ET is functioning normally NORM: -100 to 100 daPa (not a concern unless it’s +/- 200)

Question 30

gradient

Answer 30

the width of the peak at 1/2 its height, indicates how the eardrum responds to pressure change (quick vs slow eardrum movement) NORM: less than 250 dPa if gradient iis higher than 250, fail tymp and refer for rescreen. if they fail the rescreen, refer to MD and then AuD

Question 31

what does high gradient indicate

Answer 31

response of TM is more sluggish than normal- could be because of a middle ear problem but its not our job to figure out why

Question 32

if ECV is greater than 2.0

Answer 32

it could mean perforation of TM OR patent PE tube - if TM perforation, refer to MD - if you see in otoscopy that PE tube that is open and functioning, pass + let school know and note on screening form that PE tube is functioning inability to maintain a seal with the probe is sometimes an indication of PE tube (open)

Question 33

ECV greater than 2.0 and tymp has no peak- what does this mean

Answer 33

perforation (refer) or PE tube (pass as long as its functioning) why? bc this tymp result means there is a hole in the eardrum --> ECV becomes volume in ear canal + volume of middle ear --> large ECV --> no measurements for other tymp criteria bc TM is not showing any resistance to changes in pressure (bc of hole) gradent, pressure, compliance: -- (bc no peak)

Question 34

in what situation would you refer when ECV is below 2.0

Answer 34

when you see a PE tube but ECV is normal, refer to MD to clear the tube. Normal ECV with PE tube indicates that the tube is blocked. Tube needs to be open so pressure can equalize between the middle ear and ear canal ECV is normal bc were just pressurizing the ear canal (not ear canal + middle ear) and can get some movement of TM when the PE is blocked

Question 35

what does a very low (below 0.4) ECV indicate

Answer 35

could be a very small ear canal, impacted cerumen, or it could be that the probe is positioned incorrectly (against the ear canal)

Question 36

what does negative pressure indicate

Answer 36

the ET is not working to equalize pressure in the middle ear with ambient pressure- often occurs from cold or allergy. Negative pressure isn't criteria for referral. If you see negative pressure but peak height and gradient are WNL, pass.

Question 37

what to do if you see shaky lines on the tymp

Answer 37

repeat the test if second test has a stable tymp, print both and attach to chart. show results to jennifer. shaky lines/ multiple peaks is not referral criteria could result from patient moving or chewing gum, need to make sure they stay as still as possible and that you hold the probe steady

Question 38

Pediatric thresholds for typical hearing and mild HL

Answer 38

typical: -10 to 20 dB HL - kids need to be able to hear softer sounds for learning speech, lots of listening in school, etc Mild HL: 21-40 dB HL

Question 39

Adult thresholds for typical hearing and mild HL

Answer 39

typical: -10 to 25 dB HL Mild HL: 26-40 dB HL

Question 40

threshold range for moderate, severe, moderately severe, profound (same for peds & adult)

Answer 40

Moderate: 41-55 dB HL Moderately severe: 56-70 dB HL Severe 71-90 dB HL profound : above 90 dB HL

Question 41

drawing tymps- where on the graph is pressure, compliance, gradient, volume

Answer 41

volume: not on the graph pressure: x axis coordinate of where the peak is compliance: peak height- y axis coordinate of where the peak is gradient: width of the peak at half of its height - go halfway down the compliance value and half of the gradient value out on each side.

Question 42

what does tymp for TM perf or PE tube look like

Answer 42

Tymp is flat line pressure, gradient, compliance: ---- large ECV

Question 43

what would tymp for ear infection look like (go through what volume, gradient, pressure and compliance would look like)

Answer 43

ECV: typical (0.3-2.0) gradient: atypically high (above 250 daPa) - eardrum has to push against fluid compliance: atypically low (less than 0.2) - eardrum won't be able to move as much against fluid

Question 44

compliance (define)

Answer 44

the height of the peak- mobility of the eardrum in response to pressure change, how much the eardrum is moving

Question 45

when would you have a flat tymp (3 scenarios)

Answer 45

○ severe ear infection (normal ECV) ○ impacted cerumen (small ECV) ○ Perforation of TM (large ECV)

Question 46

what does high compliance mean and when would you have it (3 scenarios)

Answer 46

high compliance --> hyperflacidity scenarios- ○ Healed TM perforation (thin) ○ Ossicular discontinuity ○ Normal characteristic of TM for some ethnic groups

Question 47

what does high gradient mean and when would you have it (2 scenarios)

Answer 47

High gradient → TM is moving slower than typical scenarios- ○ Something blocking TM ○ Middle ear issue, such as ear infection note: If compliance is WNL, it’s probably an early stage of ear infection since the TM still has some movement so it’s not completely fluid filled

Question 48

in what scenario would you have High ECV and no peak

Answer 48

perforation of the TM or P.E. tube ((in PE case, its normal and child passes screening, in TM perf case abnormal, refer to MD bc they would fail otoscopy and tymp (or MD/ AUD if they also fail hearing))

Question 49

when would you refer on a child with a PE tube?

Answer 49

if they have a normal ECV → refer to MD to clear the tube

Question 50

if impacted cerumen what would you see on tymp?

Answer 50

low ECV

Question 51

if you see low ECV what do you do?

Answer 51

○ First, try repositioning the probe and repeat ○ Could be just a naturally small ear canal ○ possibly bc Impacted cerumen, confirm with otoscopy and refer to MD

Question 52

if pressure is abnormally negative on tymp what does this mean?

Answer 52

Negative pressure → eustachian tube dysfunction ○ The ET is not working properly to equalize middle ear pressure with ambient pressure ○ Due to allergies or a cold

Question 53

dichotic digits for APD

Answer 53

● One method of testing auditory processing ■ Measure of binaural integration skills (without possibility of it being hampered by linguistic load) ■ Reduced linguistic load- numbers are simple and familiar, making it easier to focus purely on auditory processing rather than language or memory skills. ■ 4 numbers, 2 in each ear ■ Patient must report back all numbers heard ■ Presented at 50 dB SL above SRT ■ toal # correct responses multiplied by 2.5 to derive a percentage score rounded to the nearest digit ■ This test could provide insight into how the central auditory nervous system is functioning with language factors removed ■ Could help determine the specific profile of APD and form recommendations and referral