final exam Flashcards
(193 cards)
1
Q
pre-lingual deafness
A
deafened before developed language
2
Q
post-lingual deafness
A
deafened after acquired language
3
Q
oral communication
A
- taught to maximize aided hearing, to listen and to develop natural speech and language
4
Q
signing
A
use signs, body movements, facial expressions, gesture, mime and finger spelling.
o Signing languages: American Signing Language (ASL), British Sign Language (BSL) and Australian Sign Language (AUSLAN)
5
Q
total communication
A
use any combination of signs, finger spelling, listening with amplification, speech, lip-reading, facial expression, body language, reading and writing
6
Q
who are CI players
A
patient (+ family), family physician, CI team, CI manufacturer, CI program, OHIP
7
Q
who is on CI team
A
audiologist, SLP, social worker, Surgeon, psychologist, Child-life specialist, AVT
8
Q
where are the adult CI program
A
Sunnybrook, LHSC, Ottawa Civic Hospital
9
Q
where are the pediatric CI programs
A
sick Kids, LHSC, Ottawa civic
10
Q
what are the 4 CI companies in Canada
A
- Advanced bionics (Sonova) USA
- Cochlear Americas Australia
- Med-El corporation Austria
- Oticon medical France
11
Q
CI referral
A
A physician’s referral is required but
Initial contact can often be made by:
o Physicians
o Family members
o Teachers/therapists
o Audiologists and/or other professionals etc…
The exact referral process varies by program
12
Q
when is implementation considered
A
- tried appropriately fit hearing aids and does not receive benefit from them
*hearing loss is so profound that an appropriate fit of hearing aids is not possible - no medical or psycho-social contraindications
13
Q
audiological profile for CI candidacy
A
PTA of 500 Hz, 1000 Hz, 2000 Hz AND
Speech perception test scores of 30% or worse on either the MLNT or LNT for children
14
Q
CI criteria younger children
A
- 12- 24 months of age
- Profound bilateral sensorineural hearing loss
- Limited benefit from hearing aids (Little Ears, IT-MAIS)
- No medical contraindications
- Spoken language as a primary mode of communication
- Educational placement with strong auditory component
- Realistic expectations by family
- Strong motivation and family support
15
Q
CI criteria older children
A
- 25 months to 17 years, 11 months
- Severe to profound bilateral sensorineural hearing loss
- Open set speech perception score of less than or equal to 30% (MLNT or LNT dependent upon the child’s age)
- All other criteria are the same as younger children range
16
Q
CI candidacy adults
A
- 18 years or older
- Moderate to severe/profound bilateral sensorineural hearing loss
- Limited benefit from optimally fitted amplification (AzBio <50% in the CI ear and <60% in the opposite ear or binaurally)
- Post-lingually deafened and pre-lingually deafened but are oral communicators
- All other criteria are the same as older children
17
Q
absolute contraindications
A
Lack of auditory nerve (narrowing of meatus on imaging)
* Cochlear ossification
* Hearing loss originated in the auditory nerve or CAP
* Severe malformations inner ear
* Allergy/intolerance of device materials
18
Q
relative contraindications
A
- Mastoid cavity
- Tympanic membrane perforations associated with recurrent middle ear infections
- Mild and moderate malformations inner ear
- General health - general anesthesia
- Lack of commitment or social support
- Unrealistic expectations
19
Q
60/60 guideline for referring adults for CI
A
95% had a pure tone average > or equal to 60 dB
92% had a better ear unaided monosyllabic word score < or equal to 60%
20
Q
what was the detection rate of 60/60 guidelines
A
96%
21
Q
what was the false positive rate of the 60/60 guidelines
A
34%
22
Q
what is the general assessment process
A
- Inquiry to questionnaire/info package
- info session
- audiological evaluation (possible HA trial)
- medical evaluation
- Speech & language assessment (AVT trial period)
- psychology evaluation
- social work evaluation
- CI team meeting
- either approval with surgery and follow-up or declined (annual follow-up)
23
Q
round window approach
A
electrode goes directly through the round window
24
Q
cochleostomy
A
classical technique (through scala tympani)
25
round window challenges
still need to break window and the angle in which electrode is inserted is a bit off
26
implementation surgery details
2-3 hr operation unilateral, 4-5 hr bilateral 1w post-operative check healing period 4w
27
initial stimulation steps
MAPping of speech processor accessory kit and troubleshooting in-service
28
what is the facial recess
during cochleostomy triangle where we are trying to drill above facial nerve, high enough to see round window but not cut tympani
29
timeline of reprogramming
1 week, 2 week, 1 month, 3 months
30
timeline of reprogramming and speech perception testing
6M, 12M, 18M, 2,3,4,5,7 and 10 years post-op
31
AVT and CI
Child receives AVT once a week for an hour, it can be hard to find AVT so families often have to travel to obtain therapy services which is time consuming and costly
32
importance of rehab after CI
* CI is ‘only’ an amplification device, accesses info to the development of speech and language
* The implant alone is not enough and preference for AVT initially to monitor progress and recognize when it is time to introduce other forms of rehabilitation (e.g., introduction of ASL)
33
why is binaural input important
o Improved audibility (due to binaural summation) and ease of listening
o Improved speech perception in noise
o Elimination of head shadow and increased ability to hear from both ears
34
rehabilitation goals
* Process sound in order to understand spoken language
* Recognize and interpret environmental sounds
* Derive pleasure from listening (e.g., music)
* Develop spoken language
35
what does the MOH cover
o The cost of the pre-and-post implant appointments
o The surgical costs
o The initial equipment kit
36
what is the warranty on the interal component
10 years
37
what is the warranty on speech processors
varies based on manufacturer 3 years (AB) or 5 years (Med-EI, Cochlear)
38
what are extended warranty policies
vary by company, but estimate is between $600 and $700/year
39
when does ADP help
purchase of new device after 3 years, if the patient’s equipment is no longer working and is not under warranty
o Will cover 75% of cost up to a maximum of $5444
o Will cover up to $7258.67 if patient is on ACSD/ODSP
40
neuronal survival
neurons needed for speech comprehension is at least 5-10,000 with some in high freq areas
* With CI, observed speech comprehension with only 3000 of surviving neuronal population
41
factors influencing CI success
* Amount of residual hearing
* Age at identification of hearing loss and at beginning of intervention
* Duration of hearing loss
* Access to sound prior to implantation
* Status of the cochlear (meningitis) and auditory nerve (ANSD)
* Degree of involvement in (re)habilitation program post-implantation (WEAR TIME)
* (Re)habilitation approaches
* Other medical, social, emotional and cognitive variables
* Electrode insertion, activation and dynamic range
42
important CI points
* Refer meningitis early
* Earlier the better - should we be implanting even younger?
* Malformations not necessarily a contraindication
* (Re)habilitation program with a focus on oral communication
43
CI contraversies
* Deaf culture genocide?
* Age - how old is too old?
* Other disease - what if limited life expectancy
* Total communication
* Severe malformation of cochlea
* Marginal candidates (e.g., Deaf-Blind)
* Bilateral Implantation?
44
common CI misconceptions
Patients with residual low-frequency hearing do not benefit from CI
CI surgery is a dangerous/high-risk
The CI will sound bad or worse, it will not work for me
Patients will have permanent dizziness after CI
Patients with CI cannot undergo MRI
45
what is rejection rate and failure rate of CI
low rejection rate (0.2%) & failure rate (0.5%)
46
when did the FDA first approve CI for adults
1985
47
when did the FDA first approve CI for children
1990
48
when did Stevens & Jones identified 3 mechanisms potentially responsible for electric hearing and what are they
1930s
1. Cause hair cells to vibrate
2.Cause TM to vibrate
3.Cause direct electrical activation of the auditory nerve
49
who was the first manufacturer to have FDA approved CI and when
3M in 1984
50
what was the period of CI research and development
1950-1980
51
when was the CI commercialization period
1980-2008
52
similarities of internal CI components
* All have antenna
* All have a receiver/stimulator
* All have electrode arrays
* All have a magnet
53
standard array
deep insertion (typical patient cochlea 31mm)
54
split array
2 electrodes for sig. ossified cases
55
medium array
20mm insertion- for fibrosis, re-implantation or special cases
56
compressed array
Mondini or other malformation
57
Flexsoft
31.5mm, increased mechanical flexibility and enabling ccc
58
flex28
28mm suitable for 96% normal cochlear anomalies, optimized for insertion into apical region
59
flex24
24mm array designed for combined electric acoustic stimulation with insertion less than 1.5 turns
60
flex20
20mm array designed to be used in cases of partial deafness
Form- comes in 24 or 19 they are array featuring SEAL design for open or malformed cochlea, also where CSF fluid leakage expected
61
standard
31.5mm array designed for long cochlear duct
62
medium
24mm array designed for cases where deep insertion not desired or probable due to anatomic reactions
63
compressed
15mm array designed for partial ossification or malformation of the cochlea
64
AIM
active, insertion monitoring
*Real-time monitoring during CI surgery
*Automated objective audiometry
*Quick NRI, ESRT, impedance measurements
65
In the Ear Processors components
* All have a microphone(s)
* All have a battery source
* All have an accessory port
* All have a cable
* All have a coil
66
Benefit of MIPS
Reduced risk of infection, better cosmetics, direct sound transmission
67
What is MIPS
oticons BAHs minimally invasive ponto surgery
68
what is dermalock technology
* Ability to bond living tissues thanks to SPECIFIC absorption of important cell-binding proteins
* Provide good soft tissue stability with minimal epidermal down growth and pocket formation
69
bone implant
Vibration directly to bone- transcutaneous skin intact (active transcutaneous)
70
BAHA
Vibration directly to bone- percutaneous (permanent wound)-
71
hearing glasses with BC headband
Vibration through skin- fixed from outside
72
passive transcutaneous BC system
Vibration through skin- fixed by implanted magnet
73
BAHD Assessment Process
* Assessment typically includes:
* Otoscopy
* Tymps and acoustic immittance
* Standard PT audiometry and BC audiometry
* Speech testing
* Imaging
* ENT assessment
74
Which surgeries Average 30 min for an experienced surgeon
Cochlear Baha Connect System & ponto system, Sophono system
75
Which surgeries Average 45 min for an experienced surgeon
Cochlear Baha Attract system or Bone bridge system
76
what is Osseointegration
process by which a bone bonds directly to the surface of an implant, typically made of a biocompatible material like titanium. This creates a stable and strong connection between the bone and the implant without any intervening soft tissue. BAHA where the titanium implant integrates into the skull bone to transmit sound vibrations directly to the inner ear.
77
benefits with baha connect
*transfer vibrations directly through an abutment which connects the sound processor to a small titanium implant
*Direction connection maximizes the hearing performance
* can be MRI scanned safely.
78
benefits with BAHA attract
* The internal implant is completely hidden
*SoftWear Pad adapts comfortably to the shape of the head, distributing pressure evenly to maximize the wearing comfort
* internal magnet can be scanned safely up to 1.5 TESLA
* Transition path if hearing deteriorates
79
efficient single point sound transmission
- With multiple screws the vibration energy is spread over several contact points resulting in lower transmission efficiency (multiple screws, better retention but will dilute the vibration)
- BAHA attract system designed to transmit the sound more efficiently by focusing the vibrations in one single point
- Benefit of having like this is the whole vibration that is generated from outside is focused at one point on mastoid and gives it a better shape
80
BAHA implant procedure
1. Prepare the site
2. Make the incision
3. Drill through bone
4. Place implant
5. Place implant magnet
6. Close & suture
81
attenuation of baha
* Baha Attract System is expected to provide similar or better hearing performance than a Baha sound processor on a Baha softband
* Due to the soft tissue attenuation, the Baha Connect system will always give a better performance, especially in the higher frequencies
82
ponto superpower
boosts signal to vibrator & highly advanced feedback management technology
83
feedback
1-structure-borne mechanical feedback
2- acoustic feedback
3- electrical feedback
4- magnetic feedback,
84
structure-born feedback
transducer vibrations that are mechanically transmitted through the housing back to the microphone
85
magnetic feedback
magnetic leakage from the transducer are magnetically transmitted to the microphone or possible a telecoil (if such is used in the vicinity of transducer)
86
acoustic feedback
caused by the sound radiated from the skull bone and from the hearing aid housing which are acoustically transmitted back to the microphone
87
electrical feedback
voltage fluctuations in the output amplifier are electrically transmitted to the pre amplifier or the microphone within the electric circuit
88
Bonebridge
bc implant where skin is intact and transducer underskin
89
what is the BC range suitiable for bonebridge
up to 45dB Bc
90
benefits of bonebridge
no damping of signal across skin
decreased risk of infection and pressure pain
91
what angle does the bonebridge need to be placed at
sinudural
- best chance of not interfering with sigmoid sinus or dura
92
how do we verify bone conduction implants
we cant we would use free-field sound booth to check
93
AD-Hear
non-surgical BCD that works like a sticker (think soft band) for BC thresholds up to 25dB often for SSD or conductive loss
94
OSIA implant and MRI
newest version 3000 uses diametric magnet that sits in a casing and rotates to align with magnetic field of MRI machine
95
what is the MPO delivered by OSIA implant
55dB onpar with many BCI meaning it is high frequency powered
96
sophono
magnetic BAHD up to 45dB bc loss ,smallest on market
97
TRANSEAR
looks like BTE for SSD but uses bone conduction
98
ADP for Bone conduction devices
every 5 years for 75% up to $2650
99
vibrant soundbridge
transcutaenous (direct drive) middle ear implantable device
100
eligibility for MEI
mild-severe SNHL or mixed or conductive if using round window
pediatric 10+ years
ability to benefit from amplification
speech adequate to PTA with understanding of 50% or more WRS
absence of retrocochlear or central auditory disorders
101
how does MEI work
processor converts environmental sound to electrical signals which are transmitted to implant that relays signal down floating mass transducer
102
role of FMT
floating mass transducer converts signals into mechanical vibrations directly stimulating the ME structure (ossicular chain causing it to vibrate)
103
what is VORP
vibratory ossicular replacement prosestisis
104
3 parts of MEI
VORP coupler and acoustic processor (speech processor)
105
couplers
incus, stapes or round windoww
106
which coupler is the standard for MEI
incus either on long or short process
107
when do we use round window couplers
when there is a breakdown of the ossicular chain causing mixed or conductive loss
108
when do we use stapes coupler
when round window not possible
109
what are the benefits of MEI
improved speech reception abilities in quiet and noise
improved mid-high freq gain over hearing aid
110
how long do the improvements in hearing and speech recognition from a MEI last
long term stability
111
telemetry
the process of recording and transmitting the readings of an instrument can be direct or reverse
112
types of telemetry
impedance check
eSRT
eCAP
eABR- electrically evoked A
113
eSRT stands for
electrically evoked stapedius reflex threshold
114
eCAP stands for
electrically evoked compound action potentials
115
eABR
electrically evoked auditory brainstem response
116
eCAP
reverse telemetry
near-field version of wave I
gives P1N1
117
eCAP stimulus
single biphasic current pulses delivered using monopolar coupling
118
eCAP record
CI electrodes
119
eCAP N1 and P1 values
N1 0.2-0.4ms P1 0.6-0.8ms
120
what is reverse telemetry
implant sends response back to external processor where audiologist is
121
what is eCAP assessing
how the auditory nerve responds to stimulus from cochlear implant
122
advantages of eCAP
can be done even if using anesthetic
no large muscle noise (myogenic)
larger responses so fewer averages
present in 1st year of life (can use w kids)
123
what does eCAP measure
1. amplitude growth function
2. refractory recovery
3. spread of excitation
124
amplitude growth function
measures how responses get bigger as stimulus increases
125
refractory recovery
looks at how quick the nerve fibers recover after firing
- refractory period shorter with less nerve fibers
126
more neurons leads to
better fine tuning of what is said
127
spread of excitation
spatial spread (fixed stimulation electrode with a different recording electrode) and spatial masking (forward masking to subtract nerve response)
128
what is eCAP & eABR used for clinically
to confirm device function
to confirm auditory nerve function
assists with sound processor programming (map)
used when behavioural responses are unclear
129
Compare eCAP to behavioural thresholds
often above behavioural thresholds and exceed upper comfort levels
130
why do we use forward masking
it allows us to ensure we are looking at nerve fiber response by first persenting pulse getting artifact and the nerve response then just presenting the masker pulse before recovery ends to get artifact only. subtract this from inital to get actual nerve response
131
eABR latencies
1.5ms earlier
132
how is eABR recording syncrhonized
Trigger pulse used to align the systems
133
advantages of eABR
no reverse telemetry
goes up to brainstem
can be recorded when eCAP too noisy
wave V easier to isolate
134
what measurements can be done with eABR
amplitude growth function
threshold
growth of response with level
refractory recovery
binaural interaction
135
when does wave I mature
2 months
136
when does wave V mature
2-3 years
137
where is temporal information process
left auditory cortex
138
where is spectral information processed
right auditory cortex
139
what does early auditory depravation lead to
reorganization in the auditory system, visual input is now processed in the auditory cortex in adults with early onset deafness
140
unilateral CI user what happens to ABR brainstem function
poor latency initially but reach normal wave V latencies over time
141
unilateral CI user what happens to cortical responses
longterm similar to normal but differences occur at later latencies (i.e 250ms) they become more peaky
- postulated because of increased auditory training
142
after CI exposure for years what happens to ABR and cortical responses
still mismatched from other ear
- poor perception of speech on the naive side, even with bilateral CI experience
143
who does CI stimulation provide most benefit to
children who are immersed in oral environment
144
early bilingualism and language development
no disadvantage and had positive impacts on multiple aspects of development
145
effect of sign language on spoken language development
does not harm deaf children spoken language development after they receive ci and may lead to greater success with spoken language
146
continnum of speech
ASL to CASE to SSS to english
147
what does CASE stand for
conceptually accurate signed english
148
what does SSS stand for
Sign supported speech using voicing spoken english and MCE (manually coeded english)
149
ANSD and CI
if no benefit or little benefit from HA can try CI but success depends on lesion location
- implanted at later age than those without ANSD
150
MUSIC and CI what can they identify best in familiar songs
melody and timing better than pitch
can score well on rhythm
151
what prosody do CI users identify more accurately in music
face prosody (happy vs sad) is better than speech prosody
152
how do CI users do compared to normal hearing peers with music
identify emotions with less accuracy and take longer reaction time
153
ci candidacy for ski slope
2-8KHZ is 85dB greater 125-1500Hz (0-65dB), 5 years+, ABG smaller than 15dB, monosyllabic score <60dB (aided)
154
ci candidacy for asymmetrical or SSD
18+, 65dB loss or greater, onset of HL less than 10 years, monosyllabic word score <5%
155
how do we determine neuronal survival
MRI shows presence of nerve
SPT aided 250-3000HZ shows neuronal survival
156
post CI surgery what do we need to know
1. is the implant placed properly- imaging
2. has patient recovered to allow implant activation (swelling decreased incision healed)
157
AGC
automatic gain control
attempts to minimic stiffness of BM and OHC function
158
2 steps of AGC
dynamic (slow vs fast) and static
159
dynamic AGC slow
used most of the time reacting to change in volume
160
dynamic AGC fast
reacts to loud transient sounds by quickly compressing to avoid discomfort
161
static AGC
converts IDR to EDR
162
speech processing strategies
complex programs that convert sound picked up by processor into electrical signals that can be sent to implant
163
what mimics IHC function
MAPLAW or Qvalue determining where soft medium and loud sounds are mapped into individuals dynamic range acting on AGC output
164
pulse amplitude
maps loudness and loudness growth
165
what do we need for CI sound to sound natural
effectively encode frequency intensity and timing
166
frequency
dictates bandwith
167
intensity
encoded by pulse duration AKA pulse width
- default pulse paradigm is biphasic
168
timing
pulses per second encoded by stimulation rate
169
what is default pulse paradigm
biphasic pulses
170
what happens when we increase pulse width
stimulation over wider area of cochlea
sufficient loudness at lower M rate
slow stimulus rate (which can impact speech outcome)
171
what happens if we decrease pulse width
decrease stimulation area
higher m levels needed to reach sufficient loudness
faster stimulation rate
172
when do we alter the pulse parameter
when non-auditory stimulation present or excessively high m levels
173
increased stimulation rate does what
increased loudness perception due to temporal summation often leading to better speech perception test results
174
decreased microphone sensitivity does what
increases comfort in noise but decrease low level sound audibility
175
CI troubleshooting equipment check steps
change cord, battery, battery pack/controller, headpeice/coil
try loaner processor
use working equipment in other ear if bilateral
176
if equipment is working well what is next cI troubleshooting step
soundfield test of both audiogram for sound detection and speech perception testing with the MAP patient is using- looking specifically for consistent errors ex. d instead g
177
troubleshooting workflow
telemetry
basic parameter
assess upper and lower limit EDR
stimulation and outcomes
178
telemetry
tells us about function of CI internal components
179
impedance outcomes
normal
open circuit
short circuit
180
open circuit
high impedance
181
short circuit
neighbouring or distant electrode impacted
182
basic parameter workflow
adjust speech coding strategy grounding method and pulse characteristic
183
if there is high impedance it could be
air bubble, otosclerosis, extrusion of array
184
if M/C is too high pt will experience
discomfort
hinder speech
adverse reaction to CI
185
if M/C is too low pt will experience
poor speech recognition and poor sound quality
186
if T is too high
soft sounds are too loud
may hear humming or buzzing
187
if T is too low
unable to hear soft sounds
188
if we cant do psychophysics we use
eSRT
Middle ear reflex correlates well with max comfort
189
automatic sound management 3 parameters
ambient noise reduction
transient noise reduction and adaptive intelligence i
190
adaptive intelligence includes
ANR TNR and microphone directionality
191
of programs in CI
range from 4-5
192
what to do if non-auditory stimulation
like FNS
- deactivate electrode
increase pulse duration
triphasic pulse
193
what to do if loudness perception/growth is a concern
increase M level, AGC MAPLaw stimrate
increase and measure T
