Tympanometry and Audiogram Integration

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The lecture will focus on integrating tympanometry (TIMP) results with audiograms.
TIMP results alone are not very helpful, integration with other tests is key.
More tests are to come during the year to help with integration.
Any TIMP result is possible with any audiogram, but some are more likely and make more sense.
Inconsistencies may indicate errors in testing or unusual cases.
TIMPs can aid in diagnosing pathologies.

Definition:
- A peak is present.
- Pressure is more positive than -100 daPa (inclusive).
- Compliance is between 0.3 and 1.6 cm3.
- Ear canal volume must be normal.
Interpretation:
- With reflexes present: normal middle ear function.
- Without reflexes: air-filled middle ear with normal middle ear compliance.

Definition: Compliance less than 0.3 cm3, with other criteria matching Type A.
Significance:
- May not always indicate a problem.
- Can be normal, but should be evaluated with other results.
- If combined with conductive loss, suggests an issue.

Definition: Compliance greater than 1.6 cm3, with other criteria matching Type A.
Pathologies:
- AS: Stiffening of the ossicles, scar tissue (tympanosclerosis).
- AD: Ossicular discontinuity, thinning of the eardrum (e.g., post-grommet).
TIMPs are useful, but what do the TIMPs mean in the context of this patient, their history, their audiogram, and then deciding what we're going to do about it.

Two Subtypes:
- Type B Low: Middle ear pathology.
- Type B High: Non-intact eardrum.
Type B Low:
- Appearance: Flatline.
- Adults: Indicates middle ear pathology (effusion, wax occlusion).
- Volume with wax occlusion: Abnormally low.
Type B High:
- Volume Cutoff: Around $2.0 \, cm^3$ (but consider ear canal size).
- Indicates a non-intact eardrum (perforation or grommet).
Otoscopy is critical to differentiate between middle ear pathology, wax occlusion, perforation, and grommets.
Wax Removal:
- If suspected, remove wax and re-test.
- Wax removal competency varies among audiologists.
- Rehab clinicians are typically better at wax removal.
- After removing wax that caused a type B, repeat tympanometry to check for underlying issues.

Cannot always predict hearing levels based on TIMP results alone.
Consistency between TIMP and audiogram is key for diagnosis.
Expectations:
- Predict expected TIMP results based on audiogram and vice versa.
- If results don't match, double-check testing procedures or consider unusual pathology.

Example 1:
- Left Ear: Normal hearing, expect Type A.
- Right Ear: Low-frequency conductive loss, expect Type C (eustachian tube dysfunction).
Example 2:
- Right Ear: Sensorineural hearing loss, expect Type A.
- Left Ear: Flat conductive loss, expect Type B (low volume).
Example 3:
- Right Ear: Type C, may not be significant if mild and consistent with history.
- Left Ear: Type AD with large conductive component, suggests ossicular discontinuity.

Tympanometry is a vital part of the test battery because full audiometric data isn't always obtainable.
Reporting is more lenient.

Typically indicates normal middle ear function.
Acoustic reflexes not mandatory to be present as with adults.
Unless there is a conductive hearing loss present - in that case, do not report normal middle ear function
AS tymps are common in young children.

Typically indicates middle ear effusion, NOT middle ear pathology as with adults.
Volume:
- Low: Wax occlusion.
- High: Non-intact eardrum (perforation or grommet).

Indicates eustachian tube dysfunction.
Just as with the adult population, a Type C tympanogram in pediatrics doesn't always indicate a need for major medical invention.
Consider:
- Audiogram degree.
- Observation of the tympanic membrane when performing otomscopy.
- How long the patient has been presenting with the type C tympanograms (long-standing?)
- Parental concerns.

Middle ear effusion or fluid without infection.
Fluid is not infected, not sore, not angry - this differs from Acute Otitis Media
Fluid is simply mucus that is blocking sound and causing a conductive loss
Inadequate opening of the eustacian tubes and congestion of the nasopharyngeal area are commonly seen in the pediatric population
Stagnant mucus can be a response for the cells and fill the middle ear as a stress response as the eustacian tubes do not open to let additional air into the middle ear space.

Due to lack of compliance, a handheld tympanometry probe is used to get a better seal in the ear canal.
As a result, it is common to induce a false type B tympanogram.
For peds, pull pinna back the whole time you are performing the procedure - just as how you perform otoscopy.
Redo If Type B tympanogram is present to ensure it is truly there.

Lily, 2.5 years old, speech delay, normal hearing and tympanometry: No further audiological action needed; refer out to speech pathologist
Oscar, 13 years old, only produces 3 words, mild conductive hearing loss with type C tympanograms: Followup with 3 month review to see what happens. History must be considered in order to proceed with testing.
VRA requires separate ear information as it is difficult to mask appropriately with this test.
Always integrate test findings.