CSD 433 - Exam 1

chief complaint

a patient’s main concern/the reason the patient is seeking care

How is information about the patient’s chief complaint acquired?

• from a review of the patient’s health history

• careful questioning

What percent of people with hearing loss are younger than 40 years of age?

25%

What percent of people with hearing loss are younger than 60 years of age?

70%

What is one goal of the initial patient encounter?

to obtain information about the social and emotional impact of the patient’s hearing loss

What is useful in estimating the impact of a patient’s hearing loss?

A paper-and-pencil scale or inventory administered at the time of the first encounter

How long does it take the average person to schedule a hearing appointment?

7 years

Do all US states require hearing tests on newborns?

Yes

EHDI

Early Hearing Detection and Intervention

Service needs for newborns

great emphasis on early identification and service provision for young children with hearing loss

Why is early detection important for kids?

It allows them to be on an even playing field.

Possible venues for newborn’s service needs?

• EHDI

• preschool

• Head Start facility

Why is it important for the whole family to be a part of the treatment plan for children?

It affects the whole family so everyone needs to be informed.

• (include sibling in therapy)

Service needs for school-age children

Communication with peer groups is a high priority

Services for school-age children

• Educational planning

• Accommodation in the classroom with assistive tech

• Support in transition from elementary to secondary/postsecondary school settings

(*some won’t qualify for speech if intervened early enough)

Initial Patient Encounter

• Patient history

• Statement of chief complaint

• Answer to question: what brings you to the clinic today?

• Impressions from family members about patient’s hearing status

• Completion of inventories to assess hearing handicap

Order of working with your client

1. Initial Patient Encounter

2. Diagnostic Assessment

3. Intervention

   1. Non-Technology

   2. Content Counseling

      1. Personal Adjustment Counseling

         1. Professional Counseling (As needed)

   3. Technology

      1. Technology Information and Orientation

Non-technology intervention examples

• Lip reading

• Visual cues

• Signing

Content Counseling intervention examples

• Explanation of test findings

• Answers to family questions

• Review of management options

Technology intervention examples

• Amplification (hearing aids)

• Cochlear implant or other implant

• FM technology

• Hearing assistance technology

Personal Adjustment Counseling

• Be a good listener

• Be accepting and nonjudgmental

• Counseling is family focused

• Appreciate patient and family members social style and personality preference

• Help each family member with their emotional needs and response to hearing loss and intervention

• Empower patient and family

Information Counseling

• Effective counseling requires considerable skill, experience, and sensitivity to the emotional state and needs of the patient and family members.

• Information recalled by a patient and the patient’s family after the initial content counseling session is often incomplete and inaccurate.

• 80% of the information is almost immediately forgotten

• Don’t just explain the audiogram when diagnosing

• Ask if they have any questions after giving diagnosis and make sure they understand

Professional Counseling

• need to know when professional counseling is required for a patient

  • when the patient, and possible family members, should be referred to a professional counselor.

• indicated if a patient has a need or requirement for help that is outside the bounds or limits of an audiologist’s or speech pathologist’s education, training, experience, or scope of practice

Service needs for adults

• With appropriate aural rehabilitation services and support, they can continue to make contributions in workplace and communities.

• The passage of the Americans with Disabilities Act (ADA) reflects this reality.

Service needs for older people

• *doesn’t want to be restricted by hearing loss

• Baby-boom generation has expanded demand for services.

• Many want to continue their careers, or desire to communicate with friends and family, and participate in community activities.

• For many, due to health advances, hearing loss is their only physical restriction.

Counseling and Education of Adult Hearing aid patients

• most of these individuals with hearing loss aren’t interested in hearing aids

• the majority of these individuals with hearing loss do not pursue amplification for a variety of reasons

• Following identification and diagnosis of hearing loss, audiologists often devote considerable time and effort to educating patients about their hearing problem and how they might benefit from hearing aids.

Adult hearing aid patients

• A hearing-impaired patient can learn to hear and listen more effectively in different situations and conditions even without amplifications with proper education and counseling

• Hearing-impaired patients who are bothered by tinnitus can acquire strategies for minimizing the impact of it on their quality of life

• Info given to a patient who is not ready to use hearing aids can eventually lead to a decision to pursue amplification.

Family and frequent communication partners

• the ones it affects

• Techniques are available for optimizing communication with those with hearing loss (i.e. speaking slowly).

• Some will need support from a speech and hearing professional to better manage relationship with affected friend/family member.

Speech Reading

• a component of intervention that falls into the non-technology category.

• Sometimes referred to as lip reading

• a natural strategy to enhance communication of people with hearing loss and also normal hearers.

• Goal is to determine what a person is saying from visual cues associated with the moment of the structures that produce speech

• Gain essential info from this and other nonverbal cues like facial expressions and body language

• minimizes the negative impact of hearing loss on communication

• alone is not adequate for communication

• Not all speech sounds are differentiated or even detected visually

Challenges in Rehabilitation of Elderly Adults

• Speech perception deficits are more common and more complicated

• Visual acuity and processing must be considered in these patients undergoing hearing assessment.

• Age-related cognitive decline adversely impacts auditory function in multiple ways

Computer-Based Auditory Training

• Ex: Amptify

• well-organized, focused, and intensive form of environmental stimulation designed to maximize neural changes necessary to improve hearing function

• SLPs and Audiologists work together

Cost-effectiveness and Costs

• Services today are provided in an environment of spiraling health care expenses, and budget cuts.

• Research shows the quality of life of those with hearing loss improves greatly with aural rehab services

• Services and equipment can be pricey

What can coverage be classified as in the US?

• Private (HMOs)

• State (Blue Cross and Blue Shield)

• Federal (Medicare)

• State and Federal (Medicaid)

*(policies vary in what they will cover in terms of cost)

What does aural rehabilitation plans need to be supported by?

Empirical evidence

• ASHA encourages that services should be provided based on EBP.

What should clinical decisions for patient care be based on?

• Clinical expertise

• Patient values

• Best research evidence

• Not “this is what we’ve always done”

*use well-documented research of outcomes

Five-step approach clinicians follow when engaging in EBP:

• Ask a straightforward question.

• Find best evidence to answer the question.

• Critically assess evidence, decide if it applies to patient.

• Integrate evidence with clinical judgment, patient values.

• Evaluate the performance of the plan.

Who does the diagnosis of hearing loss?

Audiologist

Who does the counseling and treatment options?

Audiologist

Who does auditory training?

Audiologist and Speech therapist

Who does speech reading?

Speech Therapist

Who does overall family support?

It takes a village

Case history questions for pediatrics

• Do you have concerns about their hearing?

• Do they have speech and language delays?

• Have they had any ear infections?

• Family history of hearing loss?

  • Grandparents don’t matter

  • Somebody who was born with it

  • Cochlear implant/surgery

• Abnormalities during birth?

  • Syndromes

  • Genetic

  • Lack of oxygen

  • Meconium aspiration

• Developmental History

  • Did they walk, speak, etc on time?

• How are they doing in school?

Case history questions for Adults

• What brings you here?

  • why?

• What kind of problems are you having?

• Family history of hearing loss?

• Do you have ringing or tinnitus?

• Do you have any dizziness or Vertigo?

• Do you work around noise?

  • ex: food service, casino, hair dressers, dentists, bouncer, USPS, UPS, FedEx driveres

• Have you had surgery on your ears?

• What medications do you take?

  • side effects

  • sometimes not warned bc medication is more important than the HL

• Use the COSI to name their top 4 problems hearing

• If you had them fill out a questionnaire before they came you are using this as a guide to ask them questions

• Having them fill out forms before they come is a big time saver. Makes the intake more efficient

Otoscopy: Don’ts

• Perform otoscopy on an ear with visible drainage.

• Push the process if ear pain is reported.

• Perform otoscopy on a child first, if the child is hesitant about the testing process. You can always go back and look after audiometric testing is complete.

How to hold an otoscope

• Hold it like a pen in between the first and second fingers

• Secure the patients head

  • place their free fifth finger of the hand, holding the otoscope against the patient’s cheek to support and brace the hand during the examination

• Free hand

  • grasp and gently pull the patient’s pinna to help straighten the patient’s external auditory canal

    • *pull up on ear

Middle Ear Test Evaluation

• Evaluates the physical properties of the ear.

• Part of the audiological test battery but not a direct measure of hearing.

• Rules in/out middle ear pathologies which may contribute to a hearing loss.

*sometimes might not get to certain evaluation

Type A tympanogram

• Normal hearing

• Sensorineural hearing loss

• Eardrum is moving (peak)

Type B tympanogram

• Moderate hearing loss

• Eardrum is not moving

• Something is preventing (fluid or infection)

• Ear canal volume!!

• Down syndrome have small ECV bc of smaller features

Normal ECV

Infection

Large ECV

hole

Small ECV

wax

Type c tympanogram

• Doesn’t mean you have hearing loss

• Congestion, sinus infection, your flying

• Will turn into B if illness keeps getting worse

• Transitional phase

“S”

• Soundfield

• 6 months-24 months

• didn’t wear headphones

• look right and left to look for sounds

• VRA: Visual Reinforced Audiometry

• Can be used on adults (who are developmentally delayed)

Conditioned Play

• 3-4 year olds

• Game with cottonballs, etc

ABR (electrodes) and be sedated

• Autism or hearing loss at 3 years old

• If VRA and OAE doesn’t work because kid won’t let you touch them

Air Conduction

the normal means of sound transmission in day-to-day situations

• ex: sit in booth and put headphones on

• in class with professor using the mic

What does pure tone air conduction audiometry determine?

the loudness or intensity threshold in dB at which a person just begins to hear sound for this normal mode of sound transmission.

circle

red, right

x

blue, left

Bone Conduction Oscillator

• Vibrates skull

• Not in ear

• SN HL should be same

  • can’t hear from bone conduction or air conduction

• Conductive HL

  • Can hear bone conduction (vibrates cochlea)

  • Air conduction doesn’t work

• Important for knowing which HL type someone has

Bone Conduction Audiometry

• Placement on mastoid or forehead

• The better cochlea will always respond first

• Instructions and responses are the same as air conduction testing

• Bypasses the middle ear

• Results differentiate between conductive and sensorineural hearing loss

Masking

• Keeping one ear busy to ensure valid response from other ear

• white noise in one ear

VRA

Visual Reinforcement Audiometry

Visual Reinforcement Audiometry

• used for a child who is developmentally between (approx.) six to seven moths and 24 months of age

• Based on a child’s natural instinct to turn searchingly for an interesting sound when it’s heard

• Important so you make progress with speech therapy

• Explain to mom it won’t be a waste of time

WDT

Word Discrimination Testing

WRT

Word Recognition Testing

Possible causes of sensorineural hearing loss

• Noise exposure

• family history

• aging

• ototoxicity

Possible causes for conductive hearing loss

• ear infection

• wax

• otosclerosis (bones not moving)

• no ear

• foreign body in ear

OAE

Otoacoustic Emissions

OAE

• soft clicking sounds or tones played into ear

• outer hair cells in cochlea vibrate

• tiny echo bounces back out

• small, soft rubber tip or probe place in ear canal sends sounds and records echos

• patient needs to be asleep or very chill and still

ABR

Auditory Brainstem Response

ABR

• electrodes placed on patient’s forehead and behind the ears

• measure electrical activity traveling along the hearing nerve and brainstem

• used for newborn hearing screenings

• patient needs to be asleep or very chill and still

Where are frequencies on an audiogram?

top

Where are dB on an audiogram?

on the sides

Normal hearing range

0-25 dB

Mild hearing loss range

26-40 dB

Moderate hearing loss range

41-55 dB

Moderately severe hearing loss range

56-70 dB

Severe hearing loss range

70-90 dB

Profound hearing loss range

90-110 dB

Outer ear - ear canal issues

• Swimmers ear

• wax-cerumen

• foreign body

Middle ear - ear canal issues

• ear infection

• eustachian tube dysfunction

• osteosclerosis

Inner ear - ear canal issues

• sensorineural hearing loss

• vestibular deficits

Organization of the cochlea

frequencies are organized in the cochlea with the high frequencies first

Sensorineural hearing loss causes

hereditary factors, Viagra, oxycotin use, aging-related presbycusis (age-related HL), and noise exposure

Cause for the notch on audiogram

noise exposure

When is OAE absent?

When there is a hearing loss

Outermost portion of a patient’s ear

pinna

Outer Ear disorders

• Congenital Malformations

  • present at birth

  • risk for infant hearing loss

  • pre-aurical pits and tags

    • pit: small depression in front of the tragus

    • tag: 1+ small stalks of skin infront of earlobe

    • family history of ear malformations

    • referred to an otolaryngologist for further evaluation

  • microtia and atresia

    • microtia: more pronounced malformation of the ear

    • absence of portions of pinna to total absence of pinna

    • conductive HL

    • atresia: absence of external ear canal or outer ear totally

    • test hearing with BC & AC with over the ear headphones

  • Treacher Collins

    • headband

    • doesnt do other devices until older

    • headband needs to be tight to put pressure on skull

  • Cerumen

    • wax

    • blocks sound

  • debris and foreign bodies

    • object that should not be in external ear canal

    • ex: pebbles and insects

  • Inflammation and Infections

    • otitis externa

      • bacterial, viral, and fungal infections

      • inflammation of outer ear

    • swimmer’s ear

  • Stenosis

    • constriction of the external ear canal

    • conductive HL

  • Bony Abnormalities

    • osteomas & exostosis

      • osteomas: growths projecting into the ear canal on a stalk

      • found in the outer portion of one ear canal

What do middle ear disorders involve?

• Tympanic membrane

• Three ossicles connecting the tympanic membrane to the inner ear

• Middle ear space where the ossicle are located

• Spaces nearby that are continuous with the middle ear

• Conductive HL is common in patients with these types of ear disorders

Middle Ear Disorders

• Eustachian Tube Dysfunction

• Perforation of the Tympanic Membrane

• Otitis Media

• Cholesteatomas

• Fixation of the Ossicular Chain and Otosclerosis

• Disarticulation of the Ossicular Chain

• Trauma and Head Injury

Inner ear disorders

• produce a sensory neural hearing loss

• sensorineural: to describe hearing loss that may be due to either cochlear or eigth nerve dysfunction

• 
  

Causes of sensory hearing loss

• exposure to excessive levels of noise (noise-induced hearing loss)

• cochlear dysfunction due to advance age (presbycusis)

• Infections

  • meningitis

  • rubella

• herpes viruses

  • cytomegalovirus (CMV)

• HIV

• Autoimmune inner ear disease (AIED)

• Potentially Ototoxic Medications

  • Aminoglycoside antibiotics

    • gentamycin

    • loop diuretics

    • anti-cancer drugs

      • cisplatin

      • carboplatin

      • OxyContin

      • Hydrocodone

      • Aspirin

• Meinere’s Disease and Endolymphatic Hydrops

  • Endolymphatic hydrops: buildup of fluid pressure in the cochlea

  • Meniere’s disease: fluctuating hearing loss, vertigo, tinnitus, ear fullness or pressure

• Idiopathic Sudden Sensorineural HL

  • HL of unknown etiology that occurs suddenly

• Barotrauma

  • pressure-related damage to the ear

  • inner ear trauma

• Head Trauma

• Noise-induced HL (NIHL)

• Presbycusis

  • age-realted HL

Notch-type decrease

in the region of 3000 to 4000 Hz

What do hearing aids do?

Make sounds louder

• aka amplification

Components of a hearing aid

• Microphone

• Amplifier

• Receiver

Microphone

detect sounds and convert them to electrical signals

Amplifier

• heart of the hearing aid

• important part of the electrical circuit

• enclosed within a hearing aid case

• electrical energy produced by sound passing through the microphone is increased by a specific amount

Receiver

receives amplified electrical energy from the amplifier and changes it back to sound

Ear Mold

• custom-fit to the patient’s external ear canal

• ear mold is made before the hearing aid fitting

  • be careful bc with out cotton you could pull out eardrum

• for kids

  • still growing

• most don’t get an ear mold