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158 Cards in this Set
- Front
- Back
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What are the basic components of an audiometer?
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-Power switch
-Interrupter -Stimulus mode switch -Frequency control/dial -Hearing level (attenuator) control/dial -Output selector |
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What is an amplifier?
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Makes the sound louder
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What is an attenuator?
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Makes the sound softer
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What are the additional components (special options) of an audiometer?
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-Masking/noise interrupter and level dial
-Microphone input -Recorded speech input (tape, CD) Special tests -Patient response signal -Patient response microphone -Computer interface -Printer interface |
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What are the different kinds of output transducers?
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Earphones
-supraaural -insert Bone conduction vibrators/oscillators Loudspeakers |
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What are the two organizations that provide standards for calibration?
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American National Standards Institute (ANSI)
International Standards Organization (ISO) |
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What happens if equipment is not properly calibrated?
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The data is meaningless
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Are calibration standards equal for all transducers?
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No. Calibration standards are different for each type of transducer.
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What are the basic parameters of electroacoustic calibration?
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Frequency
Intensity Linearity Duration Rise/fall times Distortion |
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What are the essential parts of a listening check and biological calibration?
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Daily looking and listening checks
Never assume that the equipment is working properly Entire procedure should take no more than 5 minutes Detecting problems before patients are seen |
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Why do we need to calibrate equipment before patients are seen?
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If equipment is not calibrated, data is meaningless and results are erroneous/invalid
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What needs to be controlled in the test environment to be sure results are accurate?
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The ambient noise
If ears are uncovered, it needs to be much quieter. |
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What is involved in a basic audiologic evaluation?
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Case history
Visual and otoscopic examination Pure tone audiometry Speech audiometry Immittance audiometry |
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Case history
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Single most important procedure - gives necessary info for establishing an audiologic otologic diagnosis
You can only get good information if you ask good questions |
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What is involved in a case history?
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Patients chief complaint and associated symptomatoloty explored with specific questions.
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What is the scope of audiology?
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From prevention/evaluation to treatment/follow-up
Sometimes a single audiologist is involved in the whole process, sometimes only a specific part |
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Can audiologists diagnose?
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Only about audiological issues (site of the problem, type of problem - e.g. conductive HL)
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What is the rationale for doing a case history?
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-Development of a diagnostic impression
-Plan for audiological remediation -Appropriate referrals to other professionals Obtain relevant information, basis for further testing, basis for further referral |
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What kind of identifying/biographical information can you get from a case history?
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Name, DOB, gender
Address, phone # SS# and medical insurance carrier Referral source |
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Threshold
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The level at which the tone is so soft that it can be perceived only 50% of the time
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Sensation Level
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Number of decibels above the threshold of a given individual
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A tone presented at threshold has a sensation level of _____.
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0 dB SL
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Pitch
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The subjective impressions of the "highness" or "lowness" of a sound
Unit - mel |
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Loudness
What is it? What contributes to it? What is the unit? |
The subjective experience of intensity
duration and frequency contribute to loudness Unit - phon |
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Pure-tone audiometer
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A device that allows for a comparison of any person's hearing threshold to that of an established norm.
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Air Conduction
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Using circumaural, supra-aural, insert earphones or loudspeakers in a sound field
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Bone Conduction
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Signal is transduced through vibration of the skull
Held either on the forehead or on the mastoid bone Maximum power outputs are lower than for air conduction |
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What provides the signal for a speech audiometer?
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A microphone, CD player or tape recorder
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How do you measure airborne sounds?
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Using sound-level meters
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Acceptable noise levels for bone conductors vs. air conductors
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Noise level needs to be lower for bone conduction since the ear is uncovered
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What is the psychoacoustic method of checking reliability of audiometers?
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Testing a group of subjects with known normal hearing
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How can audiometers be calibrated?
-For air conduction and bone conduction |
By using a coupler (artificial ear) for air conduction and an artificial mastoid for bone conduction
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What type of information can you get about auditory and communicative status from a case history?
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Presenting complaints and concerns
Specific symptoms Previous tests and results Previous recommendations |
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What type of medical information can you get from a case history?
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Illnesses
Previous conditions Symptoms and signs Previous and current medications Testing and results Recommendations, follow-up and results Other health professionals |
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What type of developmental information can you get from a case history?
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Pregnancy
Delivery and birth Infancy and early childhood milestones (hearing, speech, language, motor, etc.) |
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What type of educational information can you get from a case history?
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Academic performance - how is it relative to peers?
Current school status - is there an IEP?, when was it created?, when is it due? School personnel concerns - what are they already doing? |
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What type of family information can you get from a case history?
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Hereditary factors/Genetic issues (e.g. Usher syndrome)
Family structure - birth order, etc. |
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How does a case history give rationale for further testing?
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Directions for initial test protocols and sequence of protocols - May be altered based on situation (some kids are afraid of doctors)
Hints for what may be further required beyond the basic battery |
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How does a case history give rationale for further referral?
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Medical
Counseling/psychological Vocational (case managers to help with employment issues) Hints for remediation needs and directions |
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What is the format for doing a case history?
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It is a matter of personal style and interviewing skills
Form/Questionnaire Interview (open ended or structured) Combination |
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What kinds of factors could stand in the way of getting a good case history?
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age, sex, culture, ethnicity, socioeconomic status
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Forms/Questionnaires format of case history
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Formal case history forms with very specific area-related questions
Vary in length and detail Completed in advance and reviewed, clarified in person OR Completed at time of session Pencil and paper format |
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What are the limitations of the forms/questionnaires format for case histories?
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Reading skills and cognitive level may impact responses
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What are the types of interview formats for case histories?
-Give an example of each |
Open ended - How can I help you?
Structured - Do you have difficulties listening in noisy situations? Structured but somewhat open ended questions - What specific difficulties do you have listening in noisy environments? Combination |
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What is the best interview format to maximize information in a case history?
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Structured but somewhat open ended questions
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When can you obtain a case history?
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Before testing
During testing After testing |
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Obtaining a case history before testing
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Most common
To know what areas to focus on in the assessment |
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Obtaining a case history during testing
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As a supplement
Expanding on case history to shed light on certain results |
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Obtaining a case history after testing
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Results can guide questioning
Helps avoid bias in testing |
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What factors may influence the time required to get a comprehensive case history?
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Complexity of patient's history
Client age (young/old may take longer) Physical condition (may get worn out) Language skills (interpreter needed?) Reading skills Rapport and comfort level Cultural influences |
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How can you help establish patient comfort and rapport for a case history?
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Introducing yourself and stating your role in the clinic
Address client with appropriate title Brief overview/explanation of what you will be doing Ensure confidentiality |
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How can you help ensure the accuracy of a case history?
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Write down or record all relevant information
IF recording, get persmission first |
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What information can an otoscopic exam give us?
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Information on current status
Information on previous conditions Information on current function |
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What information on current status can an otoscopic exam give us?
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Preauricular tags
Malformations Obstructions Swelling/Edema Effusion/drainage |
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What information on previous conditions can we get from an otoscopic exam?
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Surgery
Reconstruction Scar Tissues |
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What information on current function can we get from an otoscopic exam?
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Implications of how status and previous conditions currently affect function - implications for audiological test procedures and findings
Involves visual exam of the pinna and mastoid process Information on the pinna and mastoid (involving palpitation) May involve pneumatic otoscopy |
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What does pneumatic otoscopy test?
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Middle ear function and mobility
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What instruments can you use in an otoscopic exam?
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Hand held otoscopes
Video otoscopes |
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How do you conduct an otoscopic exam?
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Seat patients in a chair that is easily accessible to the audiologist (height and angle)
Explain what you are doing to the patient and do not remove hearing aids until instructions are given |
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What is an example of instructions you can give a patient before an otoscopic exam?
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I'm going to look in your ears. Please remain still as I place the otoscope into your ear. I will pull backward gently on each ear so I can complete my examination. This will only take a few moments. Do you have any questions?
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What is involved in the visual and physical inspection during an otoscopic exam?
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Inspect the pinna & post auricular skin
Size, shape, position and symmetry of each auricle (top of pinna should be in line with the eye) Check for surgical scars Check for congenital anomalies Inspect the entrance of the ear canal for debris or pus Palpate the pinna to see if tender |
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What are the steps for conducting an otoscopic exam?
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Use a clean speculum (choose largest size that can be comfortably inserted)
Hold like a pencil and rest hand against patient's cheek (for tactile reference point) Straighten the outer ear canal Turn on light and adjust focus Identify the landmarks Optional - pneumatic otoscopy |
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How do you straighten the outer ear canal of an adult?
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By pulling upwards and backwards on the pinna
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How do you straighten the outer ear canal of a child?
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By pulling horizontally and backwards on the pinna
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What landmarks should you look for in a normal healthy eardrum?
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umbo, cone of light, manubrium of the malleus, long process of incus, pars tensa, annular ligament, color of TM
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What results and interpretations can be reported from an otologic exam?
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Landmarks are present and appear normal
TM color and status Condition of EAC Cerumen presence and amount Presence of foreign objects Discharge/effusion Signs of infections |
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What are some examples of foreign objects that should be reported after an otologic exam?
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Objects, creatures, pe tubes
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What is the rationale/purpose of conducting pure tone audiometry?
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Assess hearing capabilities, specifically sensitivity, through air conduction and bone conduction
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What is the purpose of AC (air conduction) audiometry?
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To specify the amount of a patient's hearing sensitivity at various frequencies
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What is the purpose of BC (bone conduction) audiometry?
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To specify the patient's sensorineural sensitivity at various frequencies
Tells you a person's "potential to hear" |
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What is involved in a screening for pure tone audiometry?
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Only air conduction
Quick efficient and only test at levels that most people should be able to hear |
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What is involved in diagnostic pure tone audiometry?
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Air conduction and bone conduction
Use different transducers for more advanced procedures |
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What does pure tone AC audiometry tell us?
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"Does a person have a HL?"
If yes, then: -At which test frequencies (configuration) -How much (degree/magnitude) -One ear or both (unilateral/bilateral) -Same in both ears or not (symmetrical/asymmetrical) |
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What does pure tone AC audiometry NOT tell us?
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"Where is the possible problem/cause/site of the disorder?"
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What does pure tone BC audiometry tell us?
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"Does a person have a HL?"
If yes, then- Where is the possible problem/site/cause of the disorder (In order to answer this question, need to do both AC and BC) |
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ASHA: "Pure tone threshold audiometry is the measurement of an individual's ___________.
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hearing sensitivity for calibrated (normative) pure tones.
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Which frequencies need the least pressure to hear?
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mid-frequencies
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dB SPL
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Physical measurement of sound
Uses an arbitrary reference |
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dB HL
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Perceptual scale
Uses the softest that average young, normal-hearing human listeners can hear at each frequency |
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Minimal Audibility Curve
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Curve for absolute threshold for the average listener
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Normal hearing
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0 dB HL
Average threshold for a particular sound for a population of normal people A different SPL at each test frequency |
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Threshold
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Smallest intensity of a sound that a person needs to detect its presence for pure tone audiometry
The softest level or lowest intensity that a person can just barely hear 50% of the time |
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dB SL
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decibels sensation level
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What part(s) of the auditory system does AC test?
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"Whole system"
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What part(s) of the auditory system does BC test?
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Inner ear on up
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How do you know the site of the lesion?
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Difference in test results between AC and BC
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What are the types of transducers for air conduction? What results do they give you?
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supra-aural earphones: individual ear results
insert earphones: individual ear results loudspeakers: better ear results (unless masked/blocked) |
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What are the types of transducers for bone conduction? What results do they give you?
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Bone conduction vibrator: better ear results (unless masked)
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What are the pretest considerations for pure tone audiometry?
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Case History
Behavioral Observations Otoscopic Examination |
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What are the possibilities for orientation of the patient for pure tone audiometry?
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Full face forward
In between full face and profile Face away/back forward |
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What are the considerations for orientation of the patient?
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Unintended visual cues to the patient
Unintended and intended visual cues from the patient Efficiency and effectiveness of testing |
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What are some visual cues you can unintentionally give the patient?
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Clinician gestures, facial expressions, body language
Test equipment: manipulation of dials and buttons, signal light indicator illumination |
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What are some unintended and intended visual cues you can get from the patient?
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Patient gestures, facial expressions, body language
Speechreading cues for clinician with or without hearing loss |
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How can the orientation of the patient affect the efficiency and effectiveness of testing?
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Re-instructions: easier if full-face forward
Reinforcement: especially for kids Patient comfort/ease Patient/clinician safety |
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What are the two types of instrumentation setup needed for audiometric testing?
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Audiometer controls
Transducer selection and placement |
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What needs to be set up with regard to audiometer controls?
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Audiometer on, calibrated (daily looking and listening)
Interrupter switch to manual/off dB increment to 5 dB Stimulus selector to tone Transducer to phone (or insert or bone) Stimulus route (R/L phones) |
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What needs to be set up with regard to transducer selection and placement?
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All interfering hair, earrings, hearing aids, etc. removed
R/L phone over/in correct ear Diaphragm over ear opening Forehead vs. mastoid bone placement of vibrator |
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Modifications to instructions to clients may be required due to patient's ______________.
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Age
Language Cognitive level Hearing loss |
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What is optimal for patient response modes?
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Want a response that does not interfere with hearing stimuli.
Raising a finger/hand or button pushing preferred over verbal Modifications may be needed depending on age, cognitive level, physical capabilities, etc. |
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Interpretation of response behavior
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Latency of the on-response should be consistent
Each response should have an onset, duration and offset |
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What kinds of false responses can you get?
What do they require you to do? |
False positives: "Yes" when no tone is present
False negatives: "No" when tone is heard Both require re-instructions |
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What are the two categories of people for false positives?
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People who like to guess
Pleasers |
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What are the two categories of people for false negatives?
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People who don't like to guess
Fakers |
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Hughson-Westlake up 5-down 10 approach
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When in the threshold seeking stage:
If tone is heard, go down 10 dB If tone is not heard, go up 5 dB |
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Threshold of hearing
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arbitrary
The lowest decibel hearing level at which the response occurs in at least half of a series of ascending trials. |
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Minimum number of responses needed to determine threshold:
ASHA 1978 ASHA 2005 |
1978: Three responses at a single level
2005: Two responses out of three presentations at a single level |
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Familiarization phase
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Initial stage (point at which the tone is heard once)
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Threshold seeking
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When it gets closer to threshold and you start doing the up 5, down 10 approach
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How do you record results for audiometric testing?
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The patient's threshold at each test frequency are recorded on an audiogram
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What values are represented on the ordinate?
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(y-axis) -10-120 dB HL
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What values are represented on the abscissa?
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(x-axis)
125-8000 Hz For high frequency testing, this can be expanded to 20,000 Hz |
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In what cases will you not be able to determine exact threshold?
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With clients that have severe HL, you may not be able to test high enough on the audiogram (due to equipment)
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What are the different kinds of audiograms?
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Graphic audiograms - using symbols - can represent both ears together on the same audiogram or each separately
Numeric audiogram Bekesy/self tracking audiogram: Push the button down until they can't hear the sound, then let go, then push it again until they hear it again, then keep pushing until they can't hear it |
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What can be interpreted if AC score equals BC score and both are within normal limits?
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Normal hearing
Patient is hearing to their potential |
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What can be interpreted if AC = BC and they are outside of normal limits?
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The patient is hearing to their potential but they have a sensorineural HL
The site of the problem is the cochlea on up |
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What can be interpreted if AC HL is greater than BC and BC is within normal limits?
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Patient's potential for hearing is not being met
Conductive HL |
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What is considered WNL for adults?
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Less than or equal to 25 dB HL
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What can be interpreted if AC HL is greater than BC and BC is outside of normal limits?
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Mixed HL
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True/False:
If a person passes a screening (doesn't have a HL), they are hearing at their potential |
False. A person may not have a HL, they may not be hearing at their potential. You can't tell this on a screening (conductive HL may be there but doesn't show up because they could hear the tone at 20 dB)
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Air Bone Gap
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AC threshold minus BC threshold
Conductive part of hearing loss = whole HL minus sensorineural part of HL |
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Significant air-bone gap
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Greater than 10 dB difference
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What are the degrees of HL?
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Normal: less than or equal to 15 dB
Slight: 16-25 dB Mild: 26-40 dB Moderate: 41-55 dB Moderately-severe: 56-70 dB Severe: 71-90 dB Profound: equal or greater to 90 dB |
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How can you determine the pure tone average?
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3 frequency: "speech frequencies"
-500 Hz, 1000 Hz, 2000 Hz -Add together and divide by 3 2 frequency: "Fletcher" -500 Hz and 1000 Hz usually -Add together and divide by 2 (May better reflect how they hear the speech signal if they have a high HL at just one frequency) |
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Unilateral vs. Bilateral
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HL in one ear or both (doesn't have to be symmetrical to be bilateral)
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Symmetrical vs. Asymmetrical
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HL is bilateral and either the same or different degrees
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What are the different audiometric configurations of HL?
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Flat
Gradually sloping Precipitously sloping Rising Notch @ 4000 Hz Saucer Sharply sloping Trough/Cookie bite |
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Flat audiometric configuration
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Not as common - congenital
could be later stages of meneirs disease |
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Gradually sloping audiometric configuration
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May be due to aging
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Rising audiometric configuration
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May be the early stages of meneirs
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Notch @ 4000 Hz
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Classic for noise induced HL
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Saucer audiometric configuration
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Better in mid-frequencies (worse for high and low)
Usually hereditary |
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Trough/cookie bite audiometric configuration
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Rare
Usually hereditary |
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What are the patient related influencing factors?
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Occlusion effect
Collapsing of cartilaginous portion of ear canals |
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What are the bone conduction pathways?
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Osseotympanic: outer ear, ear canal
Inertial: middle ear Distortional: inner ear |
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What is the occlusion effect? What does it result in?
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Additional energy reaches the cochlea due to the placement of the earphone or slippage of bone oscillator over the ear.
Results in artificial improvement of bone conduction thresholds |
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True/False:
With bone conduction, only the inner ear is involved |
False:
Primary way of hearing is inner ear but the ossicles are involved because of inertial b.c. and the column of air is also set into motion, affecting the EAC So, all 3 areas are somewhat involved |
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When does the occlusion effect happen?
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Occurs for normal and sensorineural HL
Does not occur in persons with conductive HL Effect is greatest (15-30 dB) in the lower frequencies (125, 250, 500 Hz) Effect is small (5-10 dB) at 1000 Hz and negligible at higher frequencies |
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What are the patient related influencing factors?
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Tactile, vibratory responses to low freq. signals - causing a clinician to possibly report that hearing is better than it is.
Patient's ability or willingness to cooperate Age and related cognitive skills Response criteria/personality Attention/interest to task Fatigue effects Interfering "head noises" or tinnitus and auditory distortion |
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What are the clinician related influencing factors?
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Clarity of instructions
Accuracy of testing procedure Timing cues, visual cues, etc Proper placement of earphones Criterion for response acceptance (too lax/too strict) Knowing when to use masking |
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What are the equipment and environment related influencing factors?
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Malfunction
Out of calibration Inappropriate testing environment |
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Is the maximum testable hearing level higher for bone conduction or air conduction?
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air conduction
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How can ambient room noise be attenuated?
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Earphone attenuation devices
Insert earphones Sound-isolated chambers |
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What are the advantages and disadvantages of hand/finger raising as a form of patient response in pure-tone audiometry?
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Advantages: Audiologists can observe when and how the patient responds. If the patient is more hesitant, the sound is probably closer to their threshold.
Disadvantages: Patients may either forget to lower their hands or keep them partially elevated. |
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What are the advantages and disadvantages of push-buttons as a form of patient response in pure-tone audiometry?
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Advantages: Limits subjective information (all or nothing type of response)<br /><br />Disadvantages: Reaction time for pushing and releasing the button may vary. Usually not a good idea for children or the physically disabled
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What are the advantages and disadvantages of vocal responses in pure-tone audiometry?
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Advantages: Often useful for children
Disadvantages: The response could interfere with the patient hearing the tone. |
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What is the first step in manual pure-tone audiometry?
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To make patients aware of their task in the procedure - Best if given written directions ahead of time and oral directions at the time of testing.
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What might supra-aural earphones cause that may create an artificial conductive hearing loss?
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The outer ear could collapse
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What colors signify which ear?
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Red = right
Blue = left |
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Which ear should you test first?
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This decision is purely arbitrary unless a difference in hearing sensitivity between the ears is known or suspected (in which case, you should test the better ear first)
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When should mid-octave points be tested?
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When a difference of 20 dB or more is seen in the thresholds of adjacent octaves
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At which frequency should you begin testing?
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1000 Hz
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According to ASHA guidelines, a pure tone is presented initially at ____ dB.
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30
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If no response at 30 dB, what do you do?
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Raise it to 50 dB. If still no response keep raising it in 10 dB increments until a response is obtained or you reach the limit of the audiometer.
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What is the primary method that a signal is heard through bone conduction?
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Distortional bone conduction
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Should ears be covered or uncovered during BC audiometry?
Why? |
Both ears should be uncovered so you don't get an occlusion effect, which occurs at frequencies of 1000 Hz and below
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True/False:
The cochlea being tested in bone conduction is always the one on the same side as the vibrator. |
False:
Clinicians really cannot be certain which cochlea is being tested |
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If high-frequency tones radiate from the bone-conduction vibrator and the patient hears these signals by air conduction, what false impressions could be made? What can be done to avoid this on retesting?
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The clinician may think there is an air-bone gap and misdiagnose a sensorineural HL as a mixed HL
An earplug could be inserted to limit the effects of acoustic radiation (safe because occlusion effect is not present in the high frequencies) |
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Tactile responses to pure-tone stimuli
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Some patients may feel the vibrations and respond when intense tones are introduced, even though they have not heard the tone.
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