Found. of Aud. Exam 3: Pediatric Testing & Vestibular

BOA: what is it used for, and for what developmental age?

• Behavioral Observation Audiometry

• Children with a developmental age up to 6 or 7 months (youngest babies)

• The most basic and most difficult test

BOA: what kind of responses does the baby give?

• Reflexive responses: eye blinks, eye widening, startle responses, stop sucking reflex

• Passive response/engagement to the auditory stimulus

BOA: do the responses show the softest sounds the child can hear?

No; unlikely to be the softest sounds the child is actually capable of hearing

BOA: how should the results be interpreted?

• In conjunction with all other available test results

• Multiple test sessions are commonly needed to get enough behavioral information

What is the goal of testing babies as early as possible?

Get the child access to language as soon as possible

VRA: what is it used for, and for what developmental age?

• Visual Reinforcement Audiometry

• Children developmentally between about 6 to 7 months and 24 months

VRA: what natural instinct is it based on?

• A child's instinct to turn searchingly toward an interesting sound

• Based on Pavlov's laws of conditioning

VRA: why does the child keep turning to the sound?

They are rewarded with an appealing visual stimulus (lights, lighted animated toys, videos)

VRA: list the steps

• Give the tone

• Look for the head turn

• Give the visual reward

• Bring the child back to center

VRA: who performs it, and where?

• In the sound field

• Two audiologists, or one audiologist with an SLP/assistant

VRA: where are the visual reinforcers placed?

On top of each speaker in the sound field

VRA: what does each tester do?

• One faces the child and keeps them engaged

• The other runs the audiometer on the control side and presents the sounds through the speakers

VRA: where does the child sit?

Intentionally between the two speakers

VRA: what stimuli can be used?

• Warbled tones

• Narrow bands of noise

• Live or recorded speech

CPA: what is it used for, and for what developmental age?

• Conditioned Play Audiometry

• Children developmentally about 2.5 through 5 years

CPA: how does it work?

• Makes pure tone audiometry (air and bone conduction) into a game

• Child listens for the sound, then drops an object

• The response must be consistent, quick and accurate

CPA: where can it be done?

In the sound field or with headphones

Order the pediatric tests from youngest to oldest

• BOA (up to 6-7 months)

• VRA (6-7 to 24 months)

• CPA (2.5 to 5 years)

Soundfield audiometry: what is it?

Audiogram testing without headphones; stimuli come directly from the speakers

What is the main limitation of soundfield testing?

It does not give ear-specific information

Soundfield testing: if a child has binaural hearing loss, what may happen?

They may favor one speaker/side more (look toward where the sound comes from)

What symbol is used for soundfield results on the audiogram?

• S

• Sound field warbled tone = WT with S

• Sound field narrow band noise = NB with S

Why use a warble tone?

It is a more novel stimulus

Before behavioral measures in infants, what nonbehavioral tests are relied on first?

• OAE

• ABR

Developmentally normal infants (Table 12.1): what does the table show?

• The age-appropriate responses expected at each age

• Typical stimulus levels needed to get those responses

Table 12.1: what responses are expected at 0 to 6 weeks?

• Eye blink

• Eye widening

• Startle

• Arousal/stirring from sleep

Table 12.1: at what levels does a 0 to 6 week old respond?

• Warble tones about 78 dB HL

• Speech 40 to 60 dB HL (conversational level)

• Noisemakers 50 to 70 dB SPL

Table 12.1: what new responses appear at 6 weeks to 4 months?

• Eye shift

• Quieting

• Rudimentary head turn starts by 4 months

Table 12.1: 6 weeks to 4 months, what warble tone and speech levels?

• Warble tones about 70 dB HL

• Speech about 47 dB HL

• An infant responding to speech around 50 dB is age appropriate

Table 12.1: what responses appear at 4 to 7 months?

• Head turn laterally toward the sound

• Listening attitude

Table 12.1: 4 to 7 months, what speech level?

About 21 dB HL; speech levels drop because the child is more experienced

Table 12.1: what responses appear at 7 to 9 months?

• Directly localizes to the side

• Indirectly localizes below ear level

Table 12.1: what responses appear at 9 to 13 months?

• Directly localizes to the side and below ear level

• Indirectly localizes above ear level

Table 12.1: by 13 to 24 months, how does the child localize?

Directly localizes to the side, below and above ear level

At what level is a startle response to speech expected for all ages?

65 dB HL

Why can't you rely on behavioral thresholds near 20 dB in a newborn?

A newborn can't respond to a 20 dB stimulus; you won't see responses until much louder levels (about 2 years before near-adult levels)

Pediatric testing: why does it usually start with speech testing (SRT)?

• To gain interest and build rapport with the child

• Children have the most experience with speech

SRT with picture cards: how many items for 2 to 3 year olds?

2 to 3 items

SRT with picture cards: how many items for 4 to 5 year olds?

5 to 8 items (cards)

Pediatric SRT: what if the child loses interest at low levels?

Use a carrier phrase (given around 40 dB) and drop the level for the stimulus

Pediatric SRT: what else can be used instead of picture cards?

Body parts (so it is not a true spondee SRT)

Pediatric testing: how should parents and caregivers help?

They can help, but must not give the test signal away (no cues or jerking)

Pediatric pure tones: which frequency do you start at, and why?

• 2000 Hz

• Rules out high frequency loss, especially if the SRT is normal

Pediatric pure tones: which frequency is second, and why?

• 500 Hz

• Rules out conductive loss

Pediatric pure tones: frequency order after 2000 and 500 Hz

1000 Hz, then 250 and 4000 Hz (and any others that can be tested)

Pediatric testing: why switch ears often?

• To get maximum information in the minimum amount of time

• Do SRTs in both ears first, then audiograms

Pediatric testing: when do you do a bone-conducted SRT?

• If pure tones cannot be obtained

• Soundfield/air SRT gives AC and bone-conducted SRT gives BC; compare to get the air-bone gap

Pediatric testing: how do you verify behavioral results?

• With immittance measures (tympanogram)

• Also ABR and OAE

Pediatric testing: word recognition scores

• Get them if possible (least concern)

• Picture pointing task

Pediatric testing: how can SLP skills help?

Evaluate receptive and expressive language skills

Testing ages 5 to 10: what helps?

• Lots of verbal praise

• No lag time between tests (keep things moving)

• Children under 5 are harder to test, but over 5 still need special attention

Testing ages 10 to 16: how is it done?

• Essentially adult testing

• This group is known for attention-getting techniques like malingering

Testing ages 10 to 16: how do you catch malingering?

• Use soft speech and ask everyday conversational questions to throw them off guard

• Example: turn the mic down and ask something like 'what grade are you in?' and see if they respond

Testing ages 10 to 16: who should be included in counseling and explanation of results?

The child

Pediatric testing: who can serve as an assistant?

• Parent, caregiver, secretary, etc.

• It is always easier to test children with an assistant

Define dizziness

• An umbrella term; a symptom, not a diagnosis

• Has 4 categories that help identify which system is involved

What are the 4 categories of dizziness?

• Vertigo

• Imbalance

• Lightheadedness

• Presyncope (feeling like you're about to pass out)

What do the semicircular canals detect?

Head rotation (angular acceleration of the head)

What do the otolith organs detect?

• Linear acceleration and head orientation relative to gravity

• Example: going up in an elevator or forward in a car

What does the vestibular nerve do?

Carries sensory information from the vestibular organs to the brainstem

What are the 3 functions of the vestibular system?

• Gaze stability: move without vision bouncing

• Postural control: move without falling

• Spatial orientation (proprioception)

Define vertigo

A false sensation of movement, often spinning

Vestibular dizziness (as a symptom): how does it differ from vertigo?

Disturbed spatial orientation WITHOUT a false sensation of movement

Define imbalance

Difficulty maintaining stable posture or walking (motor function)

Vestibular dysfunction: what visual disturbance can occur?

Blurred or bouncing vision during head movement (secondary symptom)

Which symptoms may accompany vestibular dysfunction besides vertigo, dizziness and imbalance?

• Visual disturbances

• Nausea and motion sensitivity

BPPV: define it

• Brief episodes of positional vertigo triggered by changes in head position

• 'Rocks in the head' (displaced otoconia)

Which test is used for BPPV?

Dix-Hallpike

Meniere's disease (vestibular lecture): define it

Recurrent vertigo episodes accompanied by fluctuating hearing symptoms

Meniere's: what must all be present to diagnose it?

• Dizziness/vertigo

• Tinnitus

• Aural fullness

• (with fluctuating hearing)

Vestibular migraine: define it

• Episodes of vestibular symptoms associated with migraine

• Can occur with or without headaches

Vestibular migraine: symptoms and triggers

• Sensitive to light, sound, smell, motion

• Classic migraine symptoms, but dizziness; similar triggers

Vestibular migraine: key facts

• Doesn't show up on testing

• Doesn't have an auditory component

• Genetic link (maternal line)

• More common in women and children

• Treated with medication

Ocular migraine: what does the person see?

A bunch of lights

Vestibular hypofunction: define it

Reduced vestibular function that can cause imbalance and visual instability

Vestibular hypofunction: how does it differ from Meniere's and BPPV?

• Dizzy spells for days, non-recurrent

• Slowly gets better

What can a concussion cause?

• Visual disturbance

• Auditory disturbance

How do audiologists assess vestibular function? (5 areas)

• Patient history: symptoms, triggers, duration, associated complaints

• Eye movements: vestibular reflex pathways and signs of dysfunction

• Head movement responses: semicircular canal function

• Muscle responses: otolith pathways

• Balance testing: functional stability and sensory integration

Define nystagmus

Rhythmic movement of the eyes

VNG: what does it use and evaluate?

• Infrared cameras record eye movements

• Evaluates oculomotor function, positional responses (BPPV), and responses to caloric stimulation

Caloric stimulation: what is it?

Hot or cold water or air in the ear; non-room-temperature makes you dizzy

VNG: what patterns does it help identify?

Peripheral vs. central vestibular dysfunction

vHIT: what does it evaluate and measure?

• Video Head Impulse Test

• Semicircular canal function during rapid head movements

• Measures the vestibulo-ocular reflex (VOR)

• Identifies reduced VOR function and corrective eye movements

Define the vestibulo-ocular reflex (VOR)

The eyes move opposite to the head to stay focused

VEMPs: what do they measure?

• Vestibular Evoked Myogenic Potentials

• Reflexive muscle responses to sound or vibration

Cervical VEMP: where are electrodes, and what does it assess?

• Neck muscle

• Saccular and inferior vestibular nerve function

Ocular VEMP: where are electrodes, and what does it assess?

• Under-eye muscle

• Utricular and superior vestibular nerve function

Functional balance assessment: what does it evaluate?

• Postural stability during standing and walking (functional gait assessment)

• How vision, somatosensation and vestibular input contribute to balance

• Functional limitations and fall risk

Functional balance assessment: limitation and when to refer

• Does not give system-specific information

• Refer to PT if there is a fear of falling

Static balance testing: what are the conditions?

• Eyes open and eyes closed, on a firm surface then on foam

• If they fail a and b, don't test c and d

Canalith repositioning maneuvers: what do they treat?

BPPV, by relocating displaced otoconia

Vestibular rehabilitation: what does it promote?

• Adaptation

• Habituation

• Compensation

Medical management: what conditions does it address?

• Vestibular migraine and Meniere's disease (vestibular therapy doesn't help these)

• Examples: gentamicin, surgical intervention, which can be more harmful than good

Who provides interdisciplinary vestibular care?

Audiologists, physical therapists and physicians working together

Clinical case: 91-year-old falling when bending forward, PT didn't help. What was found and done?

• Positional testing identified BPPV

• Canalith repositioning maneuver was performed

• Falling was not a consequence of aging

What changes in balance as we age?

We lose perception

Audiology beyond hearing: key points

• Hearing and balance are both inner ear functions

• Vestibular disorders affect vision, mobility and independence

• Audiologists help people hear, move and connect

Which hearing conditions can cause vestibular dysfunction?

• Presbycusis

• NIHL