Introduction to Audiological

Assessment

Lecture

2009

Topics

• Introduction to hearing assessment

• Referral source

• Case history

• Otoscopic examination

• Types of audiological assessments

What is the main purpose of Hearing Evaluation?

• Define the nature & extent of a hearing problem

• First step of the process: To start the medical intervention To find out the communication difficulties

• Why the patient is here today for an assessment?

Two important sources of information:

Referral source Case history

Referral Source

• Sources:

Self Physicians Teachers Spouse Children Other medical specialists (i.e. SLP) Lawyers Nurses

How to obtain information about your client?

1) Referral source information

2) Case History

A guide Helps to formulate a plan for testing Provides clues to factors that contribute to hearing impairment Differs depending on cases load

(infants/pediatrics/adults/geriatrics, or by specialty such as cochlear implant, auditory processing disorders (APD), etc.)

1 .Referral Source Information

• Family physician

• Medical specialist (i.e. ENT)

• Other health care providers

• Educational sources

• Self-referrals

Components of Referral information

• Identifying information (name, address, DOB, phone/e-mail)

• Diagnosis (if available)

• Client’s compliant

How do you collect info for your case history?

A. Hospital chart

B. Observation

C. Pre-assessment questionnaire

D. Interview

Case History

A. Hospital Chart • Includes:

History Doctor’s order Nurse’s notes Doctor’s progress notes X-ray Lab pathology Consults Allied health professionals

B. Observation

• Verbal information “The most important thing in communication is to hear what is being said !”

• Non-verbal information Eye contact Facial expression Intonation Body posture Gesture

C. Pre-assessment Questionnaire

• Usually sent out to the client when referral is received

• In most places, the first thing the client will be asked to do when he/she arrives for his/her appointment

• Audiologist should review the information before he/she see the client

• Double check the info with the client

• Advantage: saves time

D. The Interview

• Could be carried out with the pre-assessment questionnaire

• Sometimes only the interview will be done without the pre-assessment

• i.e. (acute care hospital sites, sites where support staff is not available)

• Medical Model (direct, highly specific and briefly stated questions);

Provides the maximum amount of info in he minimum amount of time

Interview Format

1. Reason for referral/ reason for visit

• Sometimes major compliant is known from the referral source

• Ask a preliminary questions to discover the client’s “chief compliant”

• Remember to record it exactly as stated by the client

Interview Format

2. History of the problem:

Onset of problem / How long? Who first noted? Problem in one ear or both? If both, which is the better ear? Associated pain? Tinnitus, one ear? Both ears? Previous diagnosis and treatment, when and where? Family history of problem Dizziness and vertigo Course of problem History of occupational or environmental noise exposure Estimate of severity “how much of a problem” Results of previous audiological evaluation (when and where ?)

Interview Format

3. Medical history:

Current major illnesses Childhood illnesses Head injuries Exposure to ototoxic drugs Current medications Allergies Ear infections Operations

Interview Format

4. Social history

Work environment Leisure environment

5. If your client is a child, include the following

Birth history Developmental history (developmental milestones) Speech and language development history Previous speech and language assessment (When and results) Educational history (regular or special school, learning environment,

learning difficulties)

The Interview Skills

Set the tone (introduction – comfort check)

Privacy

What you are about to do

What the client will be expected to do

Emphasis on confidentiality

Must establish an atmosphere of mutual RESPECT

Interview Skills

Learn To Listen

• Become familiar with questions

• Understand the sequence of questions

• Watch how questions relate to other questions

Frame Questions Clearly

• State questions briefly and simply

• Medical model (direct, highly specific and briefly stated questions)

• Don’t forget to use common terminology

Interview Skills

Avoid Yes/No Questions

• Open-ended questions provide more information

• (i.e. Does Ahmad has allergy? Tell me about Ahmad General Health?)

Interview Skills

AVOID LEADING QUESTIONS

• Leading questions inhabit freedom of responses (i.e. “ You never use Q-tips in your ears, do you?”)

• Avoid putting answers in client’s mouth

• Provide a rating scale

PROVIDE TRANSITIONS IN QUESTIONS

• Avoid abrupt changes in questions

• Return to topic if the client goes off track

• Follow lines of questionings that produce relevant info

Interview Skills

AVOID TALKING TOO MUCH

• Helps the client feel free to talk

• It is not necessary to “fill-up” silences

• The client should usually be doing more talking than you

• Give the client time to answer

• Use verbal encourages (i.e. “I see”, “OK”)

ATTEMPT TO PROBE BENEATH ANSWERS

• Client may need assistance

• Summarize; rephrase

Interview Skills

HANDEL EMOTIONAL SCENES TACTFULLY

• Be prepared, you never know how someone may react (anger, guilt, fear)

• Emphasize

• Don’t say “ I know how you feel” unless you explain that your self or your relative has the same problem

• Don’t make client fell uncomfortable or embarrassed if he/she cries

• One of the aims of the interview is to establish rapport with the patient before examination started

Interview Skills

Record Your Information

• If the interview is long, you may wish to record/video

• Obtain permission for taping

Be Prepared For Questions

• Know why you are asking each question

• Don’t say “ I am just asking !” or “ I am just a student, and I should ask this question” or “I don’t know why I am asking this question !!”

• If you are unsure about something, admit it.

Interview Skills

Bring The Interview To A Close

• Explain what will happen next

• Ask if client has any questions

• Express appreciation for the info provided

Otoscopy

• The evaluation of the external auditory canal and tympanic membrane with a device called an “Otoscope”

• Purpose of Otoscopy: to inspect the Outer ear (OE), external auditory canal and (EAC) & Tympanic Membrane (TM)

• An important prerequisite to the hearing evaluation

• Types: Hand-held otoscopy Pneumatic otoscopy Video otoscopy

Hand-held Otoscopy

Traditional otoscope Components: Head Power handle (battery

compartment) Ear specula Fiber optic producing light

The TM & EAC are only viewed by the examiner

Pneumatic Otoscopy

A regular hand-held otoscope with a rubber bulb attached to it

It allows the examiner to send a small puff of air into the ear. This changes the pressure inside then the examiner can watch how the eardrum responds to pressure

The TM & EAC are only viewed by the examiner

Video Otoscopy

Otoscope Separate light source Fiberoptic cable Video camera Color mointor

TM is viewed through the video monitor

Pt. and other interested people can watch as well

Possibility of videotaping and photography for documentation

The Interview Skills

Set the tone (introduction – comfort check)

Privacy

What you are about to do

What the client will be expected to do

Emphasis on confidentiality

Must establish an atmosphere of mutual RESPECT

Interview Skills

Learn To Listen

• Become familiar with questions

• Understand the sequence of questions

• Watch how questions relate to other questions

Frame Questions Clearly

• State questions briefly and simply

• Medical model (direct, highly specific and briefly stated questions)

• Don’t forget to use common terminology

Interview Skills

Avoid Yes/No Questions

• Open-ended questions provide more information

• (i.e. Does Ahmad has allergy? Tell me about Ahmad General Health?)

Interview Skills

AVOID LEADING QUESTIONS

• Leading questions inhabit freedom of responses (i.e. “ You never use Q-tips in your ears, do you?”)

• Avoid putting answers in client’s mouth

• Provide a rating scale

PROVIDE TRANSITIONS IN QUESTIONS

• Avoid abrupt changes in questions

• Return to topic if the client goes off track

• Follow lines of questionings that produce relevant info

Interview Skills

AVOID TALKING TOO MUCH

• Helps the client feel free to talk

• It is not necessary to “fill-up” silences

• The client should usually be doing more talking than you

• Give the client time to answer

• Use verbal encourages (i.e. “I see”, “OK”)

ATTEMPT TO PROBE BENEATH ANSWERS

• Client may need assistance

• Summarize; rephrase

Interview Skills

HANDEL EMOTIONAL SCENES TACTFULLY

• Be prepared, you never know how someone may react (anger, guilt, fear)

• Emphasize

• Don’t say “ I know how you feel” unless you explain that your self or your relative has the same problem

• Don’t make client fell uncomfortable or embarrassed if he/she cries

• One of the aims of the interview is to establish rapport with the patient before examination started

Interview Skills

Record Your Information

• If the interview is long, you may wish to record/video

• Obtain permission for taping

Be Prepared For Questions

• Know why you are asking each question

• Don’t say “ I am just asking !” or “ I am just a student, and I should ask this question” or “I don’t know why I am asking this question !!”

• If you are unsure about something, admit it.

Interview Skills

Bring The Interview To A Close

• Explain what will happen next

• Ask if client has any questions

• Express appreciation for the info provided

Hand-held Otoscopy

• Procedure:

We need to direct the light into the TM

Adults are examined from below the head - pinna is pulled up and back to better straighten the canal for a more direct view of the TM

Infants and young children are examined from above the head - pinna is pulled down and back for, why? (canal is angled downward rather than upward and is at a more acute angle)

The examiner fingers should brace the head to prevent injury to the ear canal if the pt. should suddenly move

Pressing the pinna against the head while looking into the ear canal will reveal any potential for ear canal collapse during testing with supra-aural earphones

What do we see from an Otoscope?

• Landmarks:

The EAC Tympanic Membrane (Pars Tensa & Pars Flaccida) Cone of light (result of light reflection from the TM directed inferiorly and

anteriorly) Umbo (the point of greatest retraction (inward pulling of the TME to the ME)

caused by the tip of the handle of Malleus Some of ME structures (i.e. Incus, manubrium)

What can we detect from Otoscopy?

• Get an idea of the size and shape of the EAC (important to select the appropriate ear tip required for testing)

• Abnormalities detected:

Small, missing or malformed auricle Atresia (absence of EAC) Stenosis (narrowing of EAC) Collapsed EAC (blocking of EAC opening due to the pressure of supra-aural

earphone cushions on the auricle) Inflammation (otitis extena, otitis media) Ear discharge / runny ears Growths Foreign bodies (cotton pieces, insects, food…etc.) Excessive cerumen TM abnormality (perforation, thickening “ Tympanosclerosis” Ventilation tubes/Grommets in TM or falling in the ear canal Trauma

Results of Otoscopy

• If any abnormality is found, the pt. should be referred for medical evaluation & management:

Excessive cerumen ……… referred for GP or ENT for cerumen removal (unless the audiologist is trained for cerumen management)

Ear discharge, TM perforation, Otitis media, Otitis Externa, growths…etc. ………..referred for medical evaluation and treatment

Grommets………..referred for ENT for follow-up

Medical management should precede audiological assessment in the following cases

if wax is blocking the EAC (usually if we can’t view the TM, the wax should be removed before testing, otherwise wax accumulation can affect test results)

If the ear has discharge or its inflamed, the ear should be treated and get dry before the hearing test

Foreign bodies should be taken out before assessment

If the patient is experiencing ear ache, the audiological assessment should not be performed

BUT…we can still perform audiological assessment with the existence of the following abnormalities

Dry TM perforation

Outer ear OR Middle ear abnormal growth

Grommets in TM or EAC

Trauma

Collapsing EAC (Canal can be opened by replacing the supra-aural earphones with insert earphones)

Audiological Assessment

• Types of Audiological Assessments:

1) Screening

2) Basic/Routine/Regular

3) Diagnostic

Audiological Screening

• Usually Known As (UKA): Hearing Screening

• For who?

Neonates after birth in the hospital before or shortly after they get discharged to rule out the presence of hearing loss (Neonatal Hearing Screening “NHS”) – ideally for all the newborns (universal hearing screening) – but still done in many hospitals only for babies who fulfill the criteria for HRR “High Risk Register”

Adults as part of pre-employment medical check-up to assure the candidacy for getting a job

School-age children before their admission to school as part of the pre-school admission medical check-up

Audiological Screening

• The available Audiological Screening tests:

Air conduction pure tone audiometry (adults & school-age children) Air conduction pure tone play audiometry (pre-school children) Automated Auditory Brainstem Response (ABR) – (neonates) Evoked Oto-acoustic Emissions (EOAEs) – (all age groups) Middle ear immittance (Tympanometry and Acoustic Reflexes) – (All

age groups)

Audiological Screening

• Results are interpreted on the basis of Pass/Fail criteria:

Pass: means no audiological follow-up required Fail: means audiolgical follow-up required

• Fast and quick procedure

• We don’t diagnose hearing loss type or degree from screening results

Basic Audiological Assessment

• UKA: routine or regular

• Used to asses or monitor the status of the peripheral auditory system (Outer ear (OE), middle ear (ME) and inner ear (IE))

• Done for both adults and pediatric patients

• Takes more time than screening procedures

• We can diagnose hearing loss (type & degree)

Basic Audiological Assessment

• Available procedures:

Audiological case history Pure Tone Audiometry PTA (Air conduction and Bone conduction):

foundation of basic audiological assessment Speech Audiometry (Speech Recognition Score (SRT)) Middle ear Immittance measures (Tympanometry & acoustic

reflexes) EOAEs Threshold Estimation ABR (Auditory Brainstem Response) • Case history and basic audiological assessment results will either:

recommend further testing (refer for diagnostic assessment) Or offer management options (i.e. HA use)

Diagnostic Audiological Assessment

• UKA: site of lesion testing because it helps sometimes to locate the site of impairment (i.e. peripheral, central, cochlear, retrocochlear)

• Results leads to more specified diagnosis

• Done for both adults and pediatric patients

• Advanced & sophisticated assessment procedures

• Usually will be recommended based on the results of basic assessments

• Usually includes basic audiological assessment procedures plus other procedures

Diagnostic Audiological Assessment

• Components:

Pure Tone Audiometry PTA (Air conduction and Bone conduction)

Speech Audiometry (Word Discrimination Score (WDS))

Behavioral site of lesion tests (SISI, ABLB, Tone Decay)

Objective site of lesion tests (Acoustic Reflex Threshold (ART), Reflex Decay, EOAEs, Diagnostic ABR)

CAPD (central auditory processing disorder) tests

Audiology I – (RHS 371)

Introduction to hearing assessment

Referral source

Case history

Otoscopic examination

Tuning Fork Tests

Pure Tone Audiometry (Air conduction) Pure Tone Audiometry (Bone conduction) Clinical Masking

Introduction to Speech Audiometry

Audiology I

• Theoretical information:

Basic Physics of Sound & the Decibel Scale

Types of Hearing Loss

Basic Pathologies of The Auditory System