Pediatric's 2nd Exam Flashcards
(173 cards)
1
Q
What are the four main purposes for a pediatric audiologic assessment?
A
- to obtain a measure of peripheral hearing sensitivity that rules out or confirms hearing loss as a cause of the baby’s or child’s problem
- to confirm the status of the baby’s or child’s middle ear
- to assess auditory functioning using speech perception measures when possible
- to observe and interpret the baby’s or child’s auditory behaviors
2
Q
Why is using a test battery approach so important?
A
- furnishes detailed information
- avoids drawing conclusions from a single test
- allows for the identification of multiple pathologies
- provides a comprehensive foundation for observing a child’s auditory behaviors
3
Q
ASHA recommendation for test protocols birth - (4ish) months of age
A
- adjusted for prematurity
- primarily physiologic measures of auditory function like ABR
- frequency-specific stimuli to estimate the audiogram
- OAEs and acoustic immittance measures should be used to supplement ABR results
- also perform: case history, parent/caregiver report, behavioral observation of the infant’s responses to a variety of sounds, developmental screening, and functional auditory assessments
4
Q
ASHA recommendation for test protocols 5-24 months of age
A
- behavioral assessments should be performed first
- CRA being the behavioral test of choice
- OAEs and ABRs should be assess only when behavioral audiometric tests are unreliable, ear-specific thresholds cannot be obtained, behavioral results are inconclusive or auditory neuropathy is suspected
5
Q
ASHA recommendation for test protocols 25-60 months of age
A
- suggests that behavioral tests (VRA or CPA) and acoustic immittance tests are usually sufficient
- speech perception tests should also be performed in combination with developmental screening and functional auditory assessments
6
Q
The expected outcomes of pediatric audiologic protocols are extensive and include:
A
- identification of hearing loss
- identification of auditory neuropathy, if present, or of a potential central auditory processing/language disorder
- quantification of hearing status based on behavioral and electrophysiologic tests
- development of a comprehensive report of historical, physical, and audiologic findings, and recommendations for treatment and management
- implementation of a plan for monitoring, surveillance, and habilitation of hearing loss
- provision of family-centered counseling and education
7
Q
Why is behavioral testing not the preferred method for evaluating hearing & selecting hearing aids in infants birth to 4 months old?
A
- the prolonged cooperation required from the child
- excessive test time needed
- poor frequency resolution
- poor test-retest reliability
8
Q
What are some tests used for pediatric assessments?
A
- Behavioral Observation Audiometry (BOA)
- Visual Reinforcement Audiometry (VRA)
- Conditioned Play Audiometry (CPA)
- Immitance
- Transient Otoacoustic Emissions (TOAE)
- Distortion product OAEs (DPOAE)
- Auditory Brainstem Response (ABR)`
9
Q
What is the cognitive age range of BOA?
A
birth - 6 months
10
Q
What is the cognitive age range of VRA?
A
5-36 months
11
Q
What is the cognitive age range of CPA?
A
30 months to 5 years
12
Q
Which pediatric assessments can be conducted for any cognitive age?
A
- immitance
- TOAEs
- DPOAEs
- ABR
13
Q
What are some benefits of BOA?
A
- enables the audiologist to obtain valuable behavioral responses in infants, part of the cross-check principle
- testing can be conducted in sound-field, with earphones, with bone oscillator, hearing aids, or cochlear implants
- enables accurate fitting of technology because minimal response levels (MRLS) can be obtained
14
Q
What are some challenges of BOA?
A
- requires careful observation of infant sucking on the part of the audiologist
- cannot be used with infants who do not suck (e.g. infants with feeding tubes)
- testing can be performed only when the infant is in a calm awake, or light sleep state
- BOA has t been generally accepting int he audiology community because audiologists typically have no been trained to use a sucking response paradigm
15
Q
What are some benefits of VRA?
A
- enables the audiologist to obtain valuable behavioral responses in infants and young children, park of the cross-check principle
- because responses are conditioned, more responses can be obtained in one test session
- testing can be conducted in soundfield, with earphones, with bone oscillator, hearing aids, or cochlear implants
- enables accurate fitting of technology because MRL can be obtained
- the state of the infant or child is less problematic because the child can be more easily be involved in the task
16
Q
What are some challenges of VRA?
A
- some children will not accept earphones so obtaining individual ear information can be challenging
17
Q
What are some benefits of CPA?
A
- accurate reponses can be obtained at threshold level
- testing can be conducted in sound field, with earphones, with bone oscillator, hearing aids, or cochlear implants
18
Q
What are some challenges of CPA?
A
- keeping the child entertained and involved long enough to obtain all the necessary information can be challenging
19
Q
What are some benefits of immittance?
A
- provides information about middle ear functioning and about intactness of the auditory system reflex arc
20
Q
What are some challenges with immittance?
A
the child must sit still, not speaking or moving during the test battery
21
Q
What are some benefits of TOAE?
A
- measures outer hair cell function
- presence of emissions indicates no greater than a mild hearing loss
- contributes to evaluation of the overall function of the auditory system
22
Q
What are some challenges of the TOAE?
A
- the infant or child must sit still, not speaking or moving during test battery
- cannot rule out mild hearing loss
23
Q
What are some benefits of DPOAE?
A
- measures outer hair cell function
- presence of emissions indicates no greater than a moderate hearing loss
- contributes to evaluation of the overall function of the auditory system
24
Q
What are some challenges of DPOAE?
A
- the infant or child must sit still, not speaking during testing
- cannot rule out moderate hearing loss
25
What are some benefits of ABR?
- tonal ABR provides frequency specific threshold information
- click ABR provides information about the intactness of the auditory pathways, including measures contributing to the diagnosis of auditory neuropathy
26
What are some challenges of ABR?
- the infant or chid must be asleep, sedated or very still for the duration of testing
- ABR testing is not a direct measure of hearing and is not substitute for behavioral audiologic testing
27
What are some areas in which information should be obtained in case history?
- birth and prenatal history
- health history
- developmental history
- communication history
- hearing history
- amplification history
- communication history: speech and language
- social history
- educational history
- special services
- other evaluations
28
What is the expected infant/child response of a BOA?
- change in sucking in response to auditory stimulus; other behavioral changes are not accepted because they usually indicate supra-threshold responses
29
What is the expected infant/child response to VRA?
- conditioned head turn to a visual reinforcer; usually a lighted animated toy
30
What is the expected infant/child response to CPA?
- Child performs a motor act in response to hearing a sound (e.g. listen and drop task)
31
Which tests don't require a infant/child response?
- immitance
- TOAE
- DPOAE
- ABR
32
What tests are generally a part of the adult test batter?
- case history
- otoscopy
- immittance measures (as needed)
- pure tone, conventional audiometry (air and bone)
- Speech audiometry (SRT, WRS, SPT)
33
Pediatric Test Battery
- Case History
- DEPENDS TOTALLY ON KID
- otoscopy
- immitance measures
- OAE
- Puretone audiometry
- Speech audiometry
- ABR, if all else fails
34
Steps to take before beginning
- Determine Child's cognitive age
- evaluate child's physical status
- choose the test room setup
35
How do you determine a child's cognitive age?
- case history
- other evaluations
- infant developmental screening scales
36
How do you evaluate a child's physical status?
- upper-torso control
- head and neck control
- vision
- ability to mainipulate toys
37
What are some options for test room setup?
- 1 room/ 1 aud
- 2 room/ 2 and
- 1 aud/ 1 test assist
- 2 rooms/ 1 aud and a parent
38
Why do you use cognitive age?
- age ranges are good guides, but cognitive age best
- use case history/interaction
- - speech/language skills?
- - motor development?
- - other professional evaluations?
- - intuition
39
What audiological assessment involve physical response?
- BOA
- VRA
- CPA
- this means their physical development comes in to play here
40
What are the three things you should have completed before you actually begin testing the child?
- determine child's cognitive age
- evaluate child's physical status
- chosen the test room setup
41
What is the goal of behavioral audiometry
- to obtain an ear-specific, frequency-specific description of the child's hearing
42
If a hearing loss exists, what is the goal of amplification?
- to make speech sounds audible, we must know what the child hears in order to achieve this goal
43
What factors could influence the results of hearing test?
- age (developmental)
- Presence of other impairments (cognitive, sensory, or physical)
- language development
- child state (hungry, tired)
- attention span
44
How could age (developmental) affect a hearing test?
- - unconditioned responses, < 5 or 6 months
- ---- Behavioral Observation Audiometry (BOA)
- - conditioned responses, > 5 or 6 months
- ---- Conditioned Orientation Reflex (COR)
- ---- Visual Reinforcement Audiometry (VRA)
45
What testing does ASHA recommend for birth - 6 months?
- ABR, OAE primary
| - BOA secondary
46
What testing does ASHA recommend for 5 - 36 months?
- VRA primary
- ABR, OAE if needed
- Functional assessment tools
47
What testing does ASHA recommend for 30 months to 5 years?
- CPA or VRA primary
| - Speech perception
48
What factors can influence the outcomes of BOA?
- developmental age
- infant/child state
- observer/judge
- stimuli
- environment
49
What two things can be affected by the infant variables/state in regards to a BOA test?
- response repertoire
| - habituation
50
What may be in an infant's response repertoire?
- motor activity
- eye movement
- cessation of movement
- crying
- startle
51
What are the observer variables of a BOA test?
- observer probably doesn't affect responses
| - observer's expectations and biases could affect judgement
52
Judge Reliability in Infant Testing (Moncur, 1968)
- used control trials: observers viewed tapes without knowledge of stimulus
- overall, judges responded "YES" to 30% of trials for which no stimulus had been presented
- the risk of false negative
53
Behavioral Audiometry Stimuli
- Speech - SRT/SAT
- Pure tones 250 - 8000 Hz
- Transducer Type
- --- Soundfield - warbled pure tones/ narrow bands of noise (at least 500, 1000, 2000, 4000 Hz - order may vary depending on needs and expectations
- ---- Insert phones - pure tones/ narrow bands/ speech
54
What is important to keep in mind for your testing environment with kids?
- positioning
- assistant
- transducer
55
BOA: Test technique
- spend a couple of minutes simply observing the infant in the absence of auditory stimulation
- try to elicit responses using stimuli of low to moderate intensity
- change stimuli to reduce habituation
56
How does BOA fit into the test battery?
- even if you cannot obtain reliable threshold measures, there is a use for BOA
- preliminary/supplementary data for "objective" tests (ABR)
- provides opportunity for parent or caregiver to observe auditory response behavior
57
What ages are appropriate for visual reinforcement audiometry?
6 months to 2.5 years
58
What is VRA?
- child seated (high chair or parent lap) facing forward with sound source placed 45 to 90 degrees from child
- when stimulus presented, look for appropriate head turn toward sound source
- turn on reinforcing toy to promote future head turns
- think pavlov's dogs
59
Why would you choose VRA?
- Infants 6 - 30 months of age (always exceptions)
- can get monaural pure-tone thresholds
- reliable
- valid
60
What are the two steps of VRA protocol?
conditioning & threshold search
61
What is involved in VRA conditioning?
- stimulus attributes (audibility and salience)
- "criterion" response: head turn
- getting an infant to turn to a signal is easy!
- getting an infant NOT to turn head is hard
62
What should be kept in mind for VRA threshold search?
- can the examiner bias the outcome?
- do we see what we expect to see?
- can we influence how the infant responds?
63
How do you know where to start your test?
Case history
64
How do you get a head turn for VRA?
, direct them to the place to look if you need to
You can’t have a protocol because they are all done – you need to be as quick as possible and get what you can while you can
65
Rules for NOT making a response
- WAIT, WAIT, WAIT
- The problem with false responses:
- -- unreliable threshold estimates
- -- the false negative
66
What is the role of a test assistant?
- visually bring child back to midline to enable examiner to obtain clear response
- minimize distractions in test room
- pitfalls to avoid:
- --- cueing child of presence of stimulus
- --- interaction that is more interesting than test task
67
Threshold Assessment
- minimum response levels
- norms and infant-adult differences
- sensory versus non-sensory factors
68
What is normal hearing for a kid?
10-15 is normal hearing - within normal limits you want to know if they have adequate hearing for learning and developing speech and language
69
What is a correct response for VRA?
Doesn’t matter which side they turn to when you are doing this testing – you are just looking for a full turn response. They may turn more to the correct side, especially with the headphones
Speakers – “at least the better ear” you can’t specify sides with speakers
70
What is CPA?
- conditioned play audiometry
- 2.5 yrs to 5 yrs
- Hold the toy, block in the bucket when you hear the sound
Still training session/conditioning session
- use this until they can do typical hearing testing
71
What is conventional Audiometry?
- 5 yrs +
- When the kid can move on to follow the directions and be able to listen and react the way they should.
- They could be able to do this for tones but not for speech or the other way around
- Need to be able to put the headphones on etc, be able to be little adults and do what they’re told
- Yell your favorite food or whisper it,
- Don’t make it more fun than it needs to be but keep them interested
- TROCA is old way of doing this
- Tangible reinforcement operant conditioned audiometry
72
What are the different threshold speech tests?
- Speech Awareness Threshold (SAT) or Speech Detection Threshold (SDT)
- Speech Recognition Thresholds (SRT)
73
What is important about speech audiometry with kids?
Spondee, equal stress on two syllable word
Best frequency threshold should match speech awareness threshold
PTA
Usually don’t respond better to tones than to speech, could be better to speech than tone
You want at least four, 18 mo old can point to the pictures instead of saying words this could help them point out and tell you that they understand the words without having to have the ability to repeat the whole world back to you
74
What are the most commonly used word recognition tests/speech perception tests for kids?
- NU-CHIPs
- WIPI
- PBK
- NU-6
- kids need to be able to at least point to a picture to be able to do this
75
What tests are used to get an idea of acoustic immittance?
- tympanometry (@ 226 Hz or 1000 Hz)
- acoustic reflex threshold
- compliance measure
- volume reading
76
Tympanometry
A graphic representation of admittance with changing air pressure
Assesses how much energy passes into the middle ear
Assesses the movement of the TM in response to changing pressure--cannot directly measure TM movement- rather we measure amount of reflected sound or amount of sound passing through TM to middle ear
77
Why/when would you use a 1000 Hz Probe tone for tympanometry?
- use for infants <7 months of age
- ME system mass - dominated
- effective in identifying ME effusion in infants
78
What is immittance testing?
- useful for determination of middle ear status
- normal tympanometry (including higher frequency probe tones) with normal acoustic reflexes
- --- unlikely there is a middle ear pathology or significant hearing loss
- Should be used in conjunction with ABR or behavioral tests
- Should be completed before ABR
- --- change in ME pressure while sleeping
79
What is an ABR?
A complex response to particular types of external stimuli that represents neural activity generated at several anatomical sites (Hood, 1998)
- The underlying assumption is that a temporal relationship exists between the sensory stimulation and the resulting neural response.
80
What factors affect the ABR?
- Pathologic
- Non- pathologic:
- - various testing parameters (intensity, stimulus type)
- - patient characteristics
(there are LOTS of other things can affect the ABR, but these are all you're responsible for in this class)
81
Patient factors affecting the ABR
- CNS Pathology: hearing loss, tumors, diseases
| - Age
82
How does age effect ABR?
Recorded as early as 27-28 weeks GA
Only waves I, III, V observed at birth
Wave I may be more prominent and prolonged (.3-1.0ms) in infants and the latency decreases after birth
Later waves are also prolonged in neonates
Infants more sensitive to changes in click rate
Maturation over first 18 months
83
What types of ABR can you do with infants?
- screenings
| - diagnostics
84
What is used for Infant ABR screenings
- clicks
- alternating polarity
- 30-35 dB nHL intensity
- Auto detection algorithms (ALGO, ABaer)
85
What are some cons to ABR screens?
- may miss a low frequency loss
| - may miss precipitous high frequency loss
86
What are some pros to ABR screens?
- will detect auditory neuropathy
- quick
- don't have to be performed by audiologist
87
Diagnostic ABR
- air conduction:
- --- click
- --- tone bursts at 500, 4000, 1000, and 2000 Hz
- bone conduction (click)
- extensive examiner control
88
Why do we use the auditory brainstem response test?
- Ability to predict the type and degree of loss as well as the audiogram’s contour
- -- Click, to within 5 dB of behavioral threshold
- -- Tone burst
- ----- Frequency-dependent (5- 30 dB)
89
Cautions in interpreting ABR for threshold information
- you are assuming an intact neural system
- if an ABR is absent even at high intensities may reflect severe to profound hearing loss or a problem of neural integrity (auditory neuropathy, hydrocephalus)
- OAE will help in diagnosis
90
Principles of sedation for pediatric ABR (who and when)
- children 6 months to 5 years of age
- multiply involved or patients who cannot be tested behaviorally
- children at risk for neurological dysfunction
91
Protocol for sedation for ABR
- medical history and physical exam
- documentation in medical record prior to procedure
- informed consent required
- administered under immediate direction of physician
92
Who must be present when sedating an infant for ABR?
- minimum number of staff is 2
- audiologist
- monitoring staff (MD, CRNA, NP, RN, PA)
- - minimum monitoring includes: pulse & oxygen rate, oxygen saturation (pulse oximetry), level of consciousness determined at 15 minute intervals or less
93
What is an Auditory Steady State Response (ASSR)?
- an evoked potential
- - instrumentation/recording similar to ABR, insert earphones, surface electrodes, averaging computer
- similar to ABR in electrode montage but analysis is in frequency domain
- stimuli are pure tones - frequency specific, steady state signal
- - result of presenting stimuli at high repetition rates causing an overlap of responses to successive stimuli
94
What are OAEs?
- not a test of hearing
- depending on the integrity of the middle ear system
- measure of normal outer hair cell function
- are by products of the normal hearing process, most likely originating from OHC movement
95
Why do we do OAEs?
- objective
- easy to administer
- relatively inexpensive
- easy to learn
- setup time is minimal
- robust
- highly sensitive to forms of cochlear damage
- OHCs and OAEs are highly dependent on blood flow to the cochlea, due to demands of metabolism
- OAEs are pre-neural and, therefore, not affected by retrocochlear auditory dysfunction
96
What are some uses of OAEs in Peds?
- ototoxicity monitoring
- AN
- school-aged screening
97
How do OAEs measure hair cells?
- OHCs and OAEs are highly dependent on blood flow to the cochlea, due to demands of metabolism
- OAEs are pre-neural and, therefore, not affected by retro-cochlear auditory dysfunction
98
What should you keep in mind when using OAEs for newborn screenings?
- time of testing
- noise effects
- tester experience
- ABR vs OAE
99
What are the two types of evoked otoacoustic emissions (EOAEs)
- TEOAE
| - DPOAE
100
TEOAEs
- elicited by a broadband click stimulus
- TEOAEs are considered present if they are 3 dB above background noise
- reproducibility of 50% or more (each frequency)
- larger amplitude by approx 10 dB over most of frequency range
- spectrum of click shows more high frequency energy
101
Why are TEOAEs different in children than for adults?
- size and resonance characteristics of ear canal and middle ear
- - impedance properties of TM, middle ear and cochlea
- Possible cochlear differences
- - mass and stiffness differences of cochlea
- maturation of efferent system
102
What are DPOAEs?
- acoustic energy, recorded in the ear canal, resulting from the non-linear interaction of two pure tones in the cochlea
103
What is important about DPOAEs when used for screenings?
- DP-NF should be at least 5 dB
- Noise floor should be -15 dB or below
- DP amplitudes should exceed -10dB
104
What factors affect the test outcome of DPOAEs?
- probe insertion (should be snug and deep)
- condition of the ear canal (blocked with debris, stenoisis)
- middle ear status (effusion, negative pressure, other pathology)
- noise (internal - breathing or movement, external - fan, loud talking)
- cochlear function (OHCs)
105
What should you look for with middle ear function for a DPOAE?
- cerumen
- PE tubes/perforation
- OME
106
What is important to consider as far as test conditions with DPOAEs?
- reduced environmental noise
- quiet patient
- relatively normal middle ear function
107
What is the clinical utility of the DPOAE?
- Screening (newborn, early childhood)
- diagnostic (cross-check, auditory neuropathy)
- monitoring (otoxicity, noise exposure)
108
Individuals with Disabilities Education Act (IDEA)
- initially known as Education for All Handicapped Children (PL94-142)
- Enacted in 1975; re-authorized 2004
109
What is mandated by IDEA
- requirements for special ed teachers (part A)
- special ed federal funding (part B)
- state funding for EI (part C)
- there are 5 others
110
Early intervention
- part C of IDEA is an under used resource
- services are generally quite good for babies with severe profound bilateral loss, but less adequate for babies with more moderate loss
111
Federal regulations for IDEA require all states to provide part C services to any child who:
- is experiencing developmental delays, as measured by appropriate diagnostic instruments and procedures in one or more of the areas of cognitive development, physical development, communication development, social or emotional development, and adaptive development; or
- has a diagnosed physical or mental condition which has a high probability of resulting in developmental delay.
112
Current challenges in USA for IDEA
- > 50% of babies are lost to follow-up following discharge
- Educational needs (physicians, audiologists, speech pathologists, etc)
- Communication between Part C and EHDI programs
- Reporting
113
What are the components of EHDI?
- Screening: Before 1 month of age, Ideally before leave hospital
- Evaluation: All infants not passing screening should have diagnostic evaluation before 3 months of age. Infants with hearing loss should have complete medical evaluation
- Intervention: All infants with hearing loss should receive EI services before 6 months of age
114
Essential components of a successful early hearing detection and intervention program:
- screening
- diagnosis
- intervention
- medical home
- data management and tracking
- program evaluation and quality assurance
- family support!!
115
What happens after a baby is screened?
- parents should be told results
- should be more than just "passed" or "failed"
- Consider:
- -- culturally and linguistically sensitive educational materials
- -- reading level
- -- logistical challenges
116
Parent Support: What EI can do for them:
- immediate counseling to help parents adapt to the diagnosis
- rapid intervention for the child's hearing loss
- implementation of rich symbolic communication system involving the entire family
117
What are the two frequencies used for tympanometry?
- 226 Hz
| - 1000 Hz
118
Why do we need a probe tone in tympanometry
The reason we need a probe tone - we aren't really measuring the movement of the TM, we are measuring a change in sound pressure level in the external auditory canal. You have to have a tone that is set level and frequency.
119
What are you actually measuring with tympanometry?
- NOT TM MOVEMENT
| - admittance of sound into the middle ear space
120
What is resonant frequency
- the best frequency for an object to vibrate
| - think the glass and opera singer
121
What are you actually measuring with acoustic reflex?
- same as tympanometry, you are measuring a change in admittance
- this time you aren't changing the pressure level you are introducing a loud sound so that the ear stiffens from the inside - middle ear ossicles/muscles tighten
122
Why are volume readings and compliance measures difficult to use with kids
- they are really helpful, but it is hard to find norms for kids
123
When you are doing ABR and Immitance testing - which do you do first and why?
- immitance testing, because if you were to get a flat tymp you want to wait until there is no fluid in the me before you run the whole ABR
124
How far up the pathway does the ABR go?
- integrity of the auditory nervous system from the level of the cochlea to (roughly) the level of the inferior colliculus
- some argue not even up to the IC
- brainstem test
125
What are the most prevalent waves on an ABR?
1, 3, 5,
- used more often for diagnosis with us
1: distal portion of the auditory nerve, where it leaves the cochlea
3: roughly from superior olive
5: roughly from the inferior coliculus
126
What is an ABR doing?
- taking your ongoing brain activity and focus only on what information is responding to the clicking
127
Which of the waves is the most important to AuDs?
wave 5 is the most important waveform when you are trying to get an idea of a patients hearing
- most robust, we can follow it's trajectory as we increase the stimulus
- based on a temporal or timing relationship. so as you decrease intensity, increase in latency
128
Describe the temporal relationship within the ABR
- as you decrease intensity, increase in latency
| - inverse relationship
129
Can you use puretones for ABR?
no, you need an abrupt stimulus like a click
| but this sends a broad band signal to the basilar membrane, so it isn't good at frequency specific hearing information
130
How can you get frequency specific information from an ABR?
- by using tone bursts
| - most typical 500, 1000, 2000, 4000 Hz
131
Why would an infants ABR not be adult like at birth?
- still establishing neural connections
- still strengthening pathways
- developmental and maturational
132
Max output of an ABR?
- 80 or 85
133
Max output of ASSR?
- goes up to 120 dB, so CI candidates usually need to have this
134
What is different with fitting kids vs adults with hearing aids?
- kids can't describe as well how the aid sounds - an adult can give better feedback
- kids have smaller ear canals and that causes different acoustics
- don't follow the same protocol
- ear mold considerations - adults want smaller tiny aids, can't do that with kids
- baby may need new molds every few weeks
135
What are the four parts of the fitting process?
- assessment
- selection
- verification
- validation
136
What are the important measuring auditory characteristics?
- you need ear specific and frequency specific thresholds for air and bone stimuli
137
What is the negative assumption in audiology? Why is this not true?
Regardless of the signal transducer used in audiometry, the thresholds in dB HL will be the same
- we are introducing a human being! for adults it may be the same - but babies aren't the same as the 2 cc coupler used to standardize the equipment like adults may be
138
What is important to remember about the acoustics of the infants ear canal?
- characteristics of the ear may change the SPL at the TM
| - dB HL -> dB SPL makes it louder at the TM of a baby
139
Real Ear to Couple Difference
The difference, in dB as a function of frequency, between the level of a signal delivered into the ear of an individual
vs the same signal in a 2cc coupler.
140
What are the Key Points to RECDs in Infants?
- RECD in infants and toddlers differ significantly from average adult values
- RECDs vary from infant to infant
- RECDs will change for a given infant over time
141
How often should RECDs be measured?
- Each child's RECD values should be measured at the time of the initial fitting and monitored over time whenever possible
- - whenever earmold changes
- - whenever middle ear status changes
142
What are some pointers to keep in mind for RECD?
- RECD measurement can be performed while infant sedated/asleep for ABR
- Use a mirror so older child can see waht is happening (having a partner helps)
- pre-set probe insertion length
- use 'too-ease' / 'too-ferm'
143
Why is there a clip on the Real-Ear?
- to help with setup, you fasten clip across patient's shirt to hold probe module in place
144
When is a good time to do real-ear testing on baby?
- it's best to do while they are sleeping or quiet
| - if the child is vocalizing or crying, measurement can be affected
145
When you are not able to do real-ear to couple difference on a certain child what can you do?
- use age-appropriate average RECDs (predicted RECDs) may be used when measurement isn't possible
146
If you haven't made the child's earmold yet what can you used to get RECDs?
- you can use the foam ear tips, but you will get a difference shape - not interchangeable with the earmold, you will need to re-do with their earmold
147
Predicted RECD values are provided for clinical use:
- for tips and earmolds
- across frequency
- nearest month of up to age 3 years
- - 6 months up to age 5 years
148
What are some limitations for predicted RECD values?
- all subjects had normal middle ear function
- high variability in RECD measures associated with children of the same age
- THEREFORE, whenever possible, predicted values should not replace a more precise RECD measurement
149
Conclusions: Using ABR for predicting thresholds
- When certain variables are considered, it is possible to use ABR threshold estimates to accurately predict behavioral thresholds
- It will require application of special correction factors to go from ABR threshold estimates to equivalent dB HL thresholds
- When needing to use ABR threshold estimates to fit hearing aids on small children (i.e., sans behavioral measures), DSL m[i/o] 5.0 will facilitate the application of the necessary corrections and do all of the math for you !
150
What is the problem they found with selecting hearing aids for children?
“The methods used to select and evaluate
amplification for infants and children with
hearing loss vary widely among facilities.
Few audiologists use any systematic approach
for selecting and fitting amplification for
young children and many do not use current
technologies in the fitting process.”
151
What is the most important piece of information that an audiologist can keep in mind when giving a hearing aid to a child
- make the adjustments, don't over amplify and be sure to check the programing before you send it home to them (after repair they may reset etc)
152
What are the physical characteristics of hearing aids we consider during hearing aid selection?
- BTE casing
- pediatric sized earhook
- filter in the earhook that provides a minimum of 6 dB attenuation at 1000 Hz
- a system for locking the volume control
- direct audio input
153
Why do we use BTEs for kids?
- greater durability
- potential for greater electroacoustic flexibility
- - hearing aids with flexibility of adjustment in terms of tone, gain, output limiting and signal processing (compression) are preferable
- Easier access for repair
- - loaner aids can be provided to be used with the child's own ear mold(s)
- body aids may be appropriate of the child has physical limitations preventing the use of BTEs
- Compatibility with personal FM systems must always be considered
154
Hearing aid retention options
- tonehooks
- earmolds
- toupee tape
- huggie aids
- loss prevention clip ons (ex. farm clips)
155
What is important to consider for device coupling with BTE hearing aids?
- All BTE hearing aids prescribed for children must include DAI
- For both pre-school and school-age children, considerations should be given to the availability of coupling options so that the child will be able to access the various forms of current assistive device technology
156
Parent Friendly Orientation
- hearing aid fitting is a process not an event
- - not just a one-time "care, maintenance, parts" talk, but discuss communication, adjustment, emotional reactions to the aids/situation
- be sensitive to parent's feelings
- - ask parents how quickly the want to proceed
- provide support materials
157
What are we trying to learn from verification?
- That we have achieved a good match between the amplification characteristics of hearing instruments and the auditory characteristics of infants and children so that the use of residual auditory capacity can be maximized.
158
Why are aided sound field threshold measurements not the preferred procedure for verifying electroacoustic characteristics of hearing instruments in infants and children?
- output characteristics should be verified using a probe microphone approach that is referenced to ear canal SPL
- determination (prediction) of audibility at several input levels is the ideal method of verification
- you are only looking at soft inputs, what about when you talk normally? or they're at school? maybe you are overshooting their ears, you don't want to blow their ears
159
How can you provide subjective validation?
- speech perception questionnaires
- - how does the child perform in everyday listening environments with amplification?
- - are they using amplification to access spoken language?
- - are there specific sounds or situations that are more problematic than others?
160
What is IT-MAIS/MAIS
- Structured interview schedule designed to assess child’s spontaneous responses to sound in everyday environment
- - Is the child’s vocal behavior affected while wearing his/her sensory aid (HA or CI)?
- - Does the child produce well-formed syllables and syllable sequences that are recognized as “speech”?
- - Does the child spontaneously respond to his/her name in quiet with auditory cures only when not expecting to hear it?
- - Does the child spontaneously associate vocal tone with its meaning based on hearing alone?
161
What is verification?
- the gain the hearing aid can provide is matching the prescribed targets
- those prescribed targets are based on the real-ear measure for that child
- is this really the right hearing aid and is it doing what it is supposed to
162
What is validation?
- have I done all I need to do
- what are they doing with it?
- Are they developing language etc.
163
What can you use to do objective validation?
- speech perception tests
- - valid, reliable, standardized speech recognition materials
- ex. ESP, HINT-C, LNT, MLNT
164
ESP
- pattern perception
- spondee identification
- monosyllable identification
- results
- -- 1 = no pattern perception
- -- 2 = pattern perception
- -- 3 = some word identification
- -- 4 = consistent word identification
165
HINT-C
- (A/The) boy got into trouble
- The yellow pears taste good
- The pond water (is/was) dirty
- (A/The) rancher (has/had) (a/the) bull
- The ground (is/was) very hard
166
MLNT/LNT
- open set tests
- recorded or live voice
- scored by number of words and number of phonemes correct
- LNT: 4 lists (2 lists with lexically easy words and 2 with lexically hard words)
- MLNT: 4 lists (2 lists with lexically easy words, 2 with lexically hard words)
167
What are some closed set tests?
- WIPI
- Minimal pairs
- NU-chips
- Speech pattern contrast test (SPAC; older kids)
- Iowa consonant confusion test (older kids)
- Iowa vowel confusion test (older kids)
168
What are some open set tests?
- Mr. Potato Head
- PBK
- BKB
- CNC
- NU6
- CID sentences
169
What kinds of FM systems exist?
- personal
| - sound field
170
What are the two types of sound field FM systems?
- infrared
| - induction loop
171
What are the three parts of the FM system?
- microphone
- transmitter
- receiver
172
What are some benefits for students when using an FM systems?
- Improved academic achievement, especially for younger students
- decreased distractibility and increased on-task behavior
- increased attention to verbal instruction and activities and improved understanding
- decreased number of requests for repetition
- decreased frequency of need for verbal reinforcers to facilitate test performance
- improved spelling ability under degraded listening conditions
- increased language growth
- improved student voicing when speaking
- increased student length of utterance
173
What are some benefits for teachers and schools when using FM systems?
- increased preference by teachers and students for sound-field amplification int he classroom
- improved ease of listening and teaching
- increased mobility for teachers
- reduced special education referral rate
- increase in seating options for students with hearing loss
- cost-effective means of enhancing the listening and learning environment
- decreased test-taking time
- reduced vocal strain and fatigue for teachers
