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Audiology Review: Preparing for the Praxis and Comprehensive Examinations

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Other medical phenomena: hormonal changes, thyroid issues, diseases of the heart/blood,

medication interaction, ear and sinus infections, Ménière’s disease, tumors, obesity

Research has suggested that there are definitive and possible risk factors for tinnitus (Hoffman & Reed, 2004). These are discussed in Table 5–18.

Prior to the start of any assessment, case history is important to obtain.

Useful in understanding any definite or possible risk factors that may be present

Allows for the patient to share the chief complaint (CC), which can impact procedures and

diagnosis

TABLE 5–18. Risk Factors for Tinnitus

RISK FACTORS

Definite Risk Factors • Cardiovascular/cerebrovascular disease

• Drugs such as salicylate analgesics, anti-inflammatory

drugs, antibiotics, loop diuretics & chemotherapy agents)

• Ear infections

• Head/neck trauma or injury

• Hyper and hypothyroidism

• Noise exposure

• Meniere’s disease

• Otosclerosis

• Presbycusis

• Sudden SNHL

• Vestibular schwannoma

Possible Risk Factors •

Alcohol

• Anxiety

• Depression

• Familial inheritance

•

Geographic region

• Health status of fair-poor

• Obesity

• Limited education

• Low height

• Low socioeconomic status

• Low weight

•

Lyme disease

• Rural residence

• Smoking

Source: Adapted from Hoffman, H. J., & Reed, G. W. (2004). Epidemiology of tinnitus. Tinnitus: Theory and Management, 16, 41.

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CASE EXAMPLE

Patient is a 36-year-old male who presents with hearing loss and tinnitus concerns. Patient stated that his main concern is understanding the noises that he hears. During case history, you learn that he has high blood pressure and is now in high-stress scenarios at work, which has increased his anxiety and depressive symptoms. Additionally, you learn that he does not sleep well at night.

The information gained during your case history can help you present your

findings and recommendations to the patient.

In addition to case history, questionnaires and inventories are a vital part of any tinnitus assessment. Since tinnitus perception is variable in patients, questionnaires can assist the audiologist to understand to full impact of tinnitus on each individual. Questionnaires and inventories can assist individuals in describing the nature of their tinnitus, medical and psychological impacts, medication use, history of hearing loss and/or noise exposure, and overall impact on the individual. There are a variety of validated questionnaires that pose questions, scored into a numerical value to quantify the impact of tinnitus. The outcomes of the inventories can be used to assist in treatment planning. Inventories include:

Tinnitus Reaction Questionnaire (TRQ; Wilson et al., 1991)

Tinnitus Severity Index (TSI; Meikle et al., 2008)

Tinnitus Handicap Inventory (THI; Newman et al., 1996)

Tinnitus Functional Index (TFI; Meikle et al., 2012)

Although there is no diagnostic criterion when working with tinnitus, there are clinical assessments that can be utilized to address patient concerns (Deshpande & Hall, 2022).

Otoscopy: assess for any external/middle ear disorders or diseases

Immittance: evaluate potential middle ear issues that could indicate a potential diagnosis

and/or referral

DPOAEs: determine cochlear (OHC) integrity and function

Pure-tone audiometry (250–20,000 Hz with interoctaves): identify presence of hearing loss

since the pitch of tinnitus often aligns with elevated thresholds on pure-tone testing

Speech audiometry: testing may not be as important as the other methods suggested in terms

of measuring tinnitus

ABR: assess peripheral and central auditory function. This testing is not a typical component

of a tinnitus assessment.

The psychoacoustic assessment of tinnitus includes loudness discomfort levels (LDLs), pitch matching, loudness matching, minimal masking levels (MML), and residual inhibition. The psychoacoustic assessment can only be completed if the individual is currently experiencing tinnitus at the time of the visit. Table 5–19 highlights what is completed during the test and why each is used (Deshpande & Hall, 2022).

TABLE 5–19. Aspects of Psychoacoustic Assessment

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ASSESSMENT STIMULI AND IMPORTANCE ASSESSMENT PROCEDURE

Loudness Discomfort Levels (LDLs)

Pitch Matching •

• Stimuli: tonal and speech signals

•

Assesses: recruitment and

sound sensitivity

Stimuli: pure tones,

FRESH noise, or narrowband noise (NBN)

Assesses: frequency range

•

of an individual’s tinnitus

•

Completed in right and left ear conditions Patient listens to stimuli and tells the audiologist

•

to stop when the stimuli become uncomfortably loud

•

Completed: in right, left, and binaural conditions

depending on individual complaints

•

Assessment:

Completed in the opposite ear than the tinnitus

1. ear (if unilateral) at a comfortable level. If bilateral, start in one ear, complete the other ear, and complete in binaural conditions

2. Present signal at 1000 and 2000 Hz. Matching should occur using a two-alternative approach, which forces the individual to decide which stimuli presented is closer in frequency.

3. Depending on patient response, either present a lower or higher frequency until it is reported that the stimuli sound like the tinnitus.

Complete in other ear and in binaural condition

if necessary.

Loudness Matching

Minimal Masking Levels (MML)

• Stimuli: pure tones, FRESH noise, or NBN

Assesses: loudness of the

•

perceived tinnitus

• Stimuli: NBN or white noise (WN)

• Assesses: if masking noise is beneficial to the individual experiencing tinnitus; to determine the amount and type of noise needed for masking individual’s tinnitus

• Completed: right, left, and/or binaural conditions depending on individual complaints

• Assessment:

1. At the frequency where the individual pitch

tone threshold.

In 2-dB steps, increase loudness until the

individual tells you to stop.

Repeat at least two times and obtain the

average.

4. Repeat in opposite ear and binaural conditions

if necessary.

• Completed in right, left, and binaural conditions.

• Assessment:

1. Some audiological practices have you complete

MML at all frequencies, where some only have you complete at the frequency that was matched for the individual’s tinnitus.

2. Increase masking noise in 2 dB steps and

have the individual tell you to stop when the masking noise just covers up their tinnitus.

3. Repeat in opposite ear and binaural conditions

if necessary.

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TABLE 5–19. continued

ASSESSMENT STIMULI AND IMPORTANCE ASSESSMENT PROCEDURE

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Residual Inhibition

• Stimuli: BBN or NBN

• Assesses: amount of

noise needed to suppress perception of tinnitus

Completed in binaural condition

•

• Assessment:

1. At the pitch and MML level of the individual’s

tinnitus, present noise for 60 seconds.

After that time, the patient is asked to describe

if their tinnitus changed/was not noticeable.

Sound Sensitivity

Noise, defined as acoustic energy that interferes with hearing, is subjective and individuals will describe different things as “noise.” Some individuals, however, are more sensitive to or intolerant to sounds, which are often described as having hyperacusis. As is evident, there is not agreement on the presence and degree of distress that is present for the diagnosis of hyperacusis.

Hyperacusis can be defined in a variety of ways, such as a poor tolerance to everyday sounds, an intolerance to environmental sounds, and/or inappropriate responses to these sounds (Aazh et al., 2018; Klein et al., 1990; Vernon, 1987).

Research suggests that there are four categories of hyperacusis: loudness, fear, pain, and

annoyance (Tyler et al., 2014).

These categories are based on the reaction that patients have to sounds.

Like tinnitus, hyperacusis is considered a symptom of a medical condition.

Audiometrically, these patients will typically have normal pure-tone thresholds, speech thresholds,

and word recognition scores but will have abnormally low UCLs. An individual without hyperacusis with normal hearing will typically have UCLs around 100 dB HL (Tyler et al., 2014).

Questionnaires regarding hyperacusis include the Hyperacusis Questionnaire (HQ; Khalfa

et al., 2002) and the Multiple Activity Scale for Hyperacusis (MASH; Dauman & BouscauFaure, 2005).

Table 5–20 displays a breakdown of the type of hyperacusis, the reaction, and findings.

In addition to hyperacusis, individuals can also experience misophonia.

Misophonia is described as the hatred of sound in which individuals have a strong emotional

reaction such as anger, disgust, hate, and rage toward the individual emitting the sounds, most commonly people eating and breathing.

The perceived loudness of these sounds does not typically matter to an individual’s reaction.

Similar to hyperacusis, misophonia is a hearing disorder that may be associated with a mental

health condition/disorder such as attention-deficit/hyperactivity disorder (ADHD), obsessive compulsive disorder (OCD), and mood and/or panic disorders (Ferreira et al., 2013).

Questionnaires for misophonia include the Amsterdam Misophonia Scale (A-MISO-S;

Schröder et al., 2013), Misophonia Questionnaire (MQ; Wu et al., 2014), and the Selective Sound Sensitivity Scale (S-Five; Vitoratou et al., 2020).

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TABLE 5–20. Types of Hyperacusis and Patient Reactions

TYPE OF HYPERACUSIS REACTION

Loudness Sounds are deemed to be uncomfortably/painfully loud

even when it is not

Fear Dread of certain sounds which causes abnormal behaviors

such as avoidance

Pain Perception of pain in response to sounds that are not

typically perceived as loud.

Annoyance Regardless of loudness level, negative emotional response

to sounds

AUDIOLOGY NUGGET

Misophonia and hyperacusis are often confused for one another. An easy way to remember the difference is that misophonia has more of an extreme emotional response to sounds than hyperacusis. A typical trigger for misophonia is chewing and breathing sounds.

Assessment for tinnitus and other sound sensitivity can be completed quite quickly, typically in under 90 minutes. Time should be built into any appointment for counseling. While the psychoacoustic assessment provides useful information, clinicians must leave ample time to address the individual’s complaints and concerns.

A medical referral should be provided immediately if the patient is complaining of secondary

tinnitus, suicidal thoughts, rapid onset of tinnitus, and other medical issues.

Tinnitus Treatment

Typically, tinnitus cannot be cured unless there is a treated medical

condition present. There are a variety of options that can be utilized to assist a patient managing and learning about their tinnitus.

First, counsel the patient about their tinnitus. Counseling should

address the individual’s CC, review audiogram and findings, and information about tinnitus/sound sensitivity,

Counsel on current trends in therapies and/or mindfulness techniques

(cognitive behavioral therapy [CBT], mindfulness therapy, tinnitus retraining therapy [TRT], progressive tinnitus management [PTM]).

Audiologists should refer to appropriate mental health providers who

specifically work with tinnitus for these therapies.

CHAPTER 5 Adult Assessment and Differential Diagnosis

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Additionally, one can consider utilizing devices and applications (HAs,

ear level maskers, phone applications/noise generators), and referrals to other health professions for medical and/or psychological management.

Alternative treatments include hypnotherapy, neuromodulation,

biofeedback, transcranial magnetic stimulation (TMS), and vagus nerve stimulation (VNS).

It is important to remember that not one therapy or device may work

for each patient, so it is critical to discuss a variety of options with the patient.

Sound Sensitivity Treatment

Treatments for sound sensitivity disorders are similar to those used in

tinnitus.

Informational counseling, CBT, and sound therapy (such as music,

broadband noise, and exposure therapy to bothersome sounds) are all possible treatment options.

Individuals with either hyperacusis or misophonia may find hearing

protection alleviates their symptoms, however this is not a viable longterm treatment plan.

Referrals to other healthcare providers (e.g., psychologists, psychiatrists,

primary care physicians, occupational therapists) to create an interprofessional team for the treatment of sound sensitivity disorders is important as well.

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Special Populations

Developmental/Neurodevelopmental Issues

A population that is commonly seen in audiology settings due to its comorbidity with hearing loss are individuals with intellectual and developmental disabilities (IDDs). To begin, a thorough case history is necessary. The case history should include questions surrounding previous medical history, including surgeries and interventions, communication strategies, and caregiver/individual concerns.

Sometimes a thorough case history is not available if the individual is brought by a case worker

who is not familiar with the individual’s medical history.

Through the case history, the examiner is able to start to assess what tests and procedures may

need to be completed by the patient’s responses or lack thereof.

Case history can also provide the audiologist with information on how the patient may

respond to testing and what modifications may need to be made.

Testing individuals with IDDs may require modified testing techniques in order to make certain that behavioral thresholds are accurate. Although individuals with IDDs are adults, their mental and

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physical capacity may not match their chronological age. As such, it is important to assess everyone’s mental and physical function. Individuals with IDD have the possibility of CHL, MHL, and SNHL (Willems et al., 2022).

A retrospective study of Special Olympics athletes over a 10-year period determined that

cerumen impaction was found in 40.7%, middle ear issues in 29.5%, and confirmed hearing loss in 26.9% of athletes (Willems et al., 2022).

Otoscopy is an imperative part of testing this population. During otoscopy, it is important

to assess for microtia/atresia, stenosis, cerumen impaction, otitis media with effusion (OME), and tympanic membrane landmarks.

When performing otoscopy, it is important to be cognizant of touch sensitivities that an

individual with IDD may have. As such, clinicians may have to deviate from typical testing technique to leave otoscopy and immittance testing for the end so as to not upset the patient prior behavioral testing.

Due to the high prevalence of middle ear issues, immittance testing should be completed.

It can provide insight into the probable type of hearing loss even if masking cannot be accomplished.

Depending on the individual patient, it may be difficult to obtain reliable behavioral

testing, so OAEs should also be utilized.

Some individuals with IDD can complete the typical comprehensive audiological testing with

no issues, whereas others may need modifications to testing, conditioned play audiometry (CPA), or visual reinforced audiometry (VRA) for pure-tone assessment.

Once the testing technique is decided on, it is suggested to complete control trials that require

the audiologist to not provide any stimuli to see if there may be false positives due to the patient’s wishing to please others (i.e., liberal response bias).

For speech testing, individuals may not have sufficient language abilities to complete

adult speech tasks such as the NU-6, so alternate lists may be used: Phonetically Balanced Kindergarten (PBK), Northwestern University of Children’s Perception of Speech (NU-CHIPS), Word Intelligibility by Picture Identification (WIPI), or spondee board picture pointing.

It is important to consistently monitor the hearing status of an individual with IDDs, since

minor changes in middle or inner ear status may not be accurately expressed by the individual.

AUDIOLOGY NUGGET

The American Association on Intellectual and Developmental Disabilities (AAIDD, 2023) describes IDDs as differences that impact one’s physical, intellectual, and/or emotional development that are typically present at birth. IDDs can impact the nervous system, sensory system, and metabolism. Some IDDs can also be degenerative disorders, where individuals meet developmental milestones and then lose certain abilities, whereas others can be fully present at birth. IDDs can include individuals with autism spectrum disorders (ASDs), brain injuries, cerebral palsy, Down syndrome, and fragile X syndrome (AAIDD, 2023).

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Diminished Cognitive Function

Cognition includes the different processes that allow humans to function on many different levels on a daily basis. This allows for individuals to do such things like learn, solve problems, and memorize materials. As one ages, there are both normative and nonnormative changes to cognitive functioning (Harada et al., 2013).

Normal age-related brain changes can have an impact on an individual’s quality of life and

day-to-day functioning; it is becoming far more important to understand these changes. Numerous studies show a correlation between age and cognitive decline, but the age at which a cognitive decline becomes evident is a subject of considerable debate (e.g., Salthouse, 2009).

Typically, these cognitive changes are noted to be a decline in cognitive functioning, but it is

crucial to note that not all cognitive changes result in a decline, since some cognitive functions (e.g., language) improve with age or are resilient in the aging brain.

Memory (most common cognitive complaint among aging adults): declines typically

beginning around the age of 60 (Hedden & Gabrieli, 2004).

Complex attention: declines around the age of 30 beginning with processing speed (Salthouse

& Meinz, 1995).

Executive function and perceptual motor function: peak in the third decade of life and then

steadily decline (Salthouse, 2012).

Vocabulary and general knowledge: remain stable or even improve until the sixth to seventh

decade of a person’s life (Lezak et al., 2012; Salthouse, 2012).

These normative cognitive changes can potentially have a minor impact a person’s daily

activity of living.

There are a variety of factors that produce additional nonnormative changes in the brain, which can increase the degree of cognitive decline (Murman, 2015).

Nonnormative changes include cerebral ischemia, mild cognitive impairments, dementias

(e.g., Alzheimer’s disease), and head traumas.

A variety of different impacts can be seen on cognitive function, including increased memory

issues, poor attention, and executive function, as well as a decline in language abilities, perceptual motor function, and social cognition.

Depending on the severity of cognitive decline, the individual may experience major impacts

on their activities of daily living and may require long-term care.

KNOWLEDGE CHECKPOINT

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V ) determined that cognitive functioning can be separated into six key domains: executive functioning, complex attention, learning and memory, language, perceptual motor function, and social cognition (Silverman et al.,

2015). Each domain has various subthemes associated with it. Such separation allows clinicians and researchers to establish the etiology and severity of each neurocognitive disorder.

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Research trends over the past 20 years have suggested that there is a relationship between hearing loss and cognitive decline (e.g., Lin et al., 2013; Surprenant & DiDonato, 2014).

Research suggests that those with hearing loss are at a greater risk for cognitive decline and

dementia even when sex, age, race, diabetes, smoking history, education, and cardiovascular issues are controlled (Lin et al., 2013).

When compared to normal-hearing individuals, individuals with a mild, moderate, and severe

hearing impairment, respectively, had a two-, three-, and fivefold increased risk of incident all-cause dementia over >10 years of follow-up (Lin et al., 2011).

The exact relationship is not fully understood, but research does suggest that one exists. Due to the current trends, it is important to understand that cognitive functioning can have an impact on your patients with hearing loss. Cognition is needed to process all sensory information. When there is diminished cognitive functioning, it can impact how sensory information, such as auditory information, is processed.

The Framework for Understanding Effortful Listening (FUEL) was adapted from the capacity

theory (Kahneman, 1973; Pichora-Fuller et al., 2016).

FUEL incorporates the aspect of cognitive demand and the supply of cognitive capacity

available to listening situations.

Persons with hearing loss must allocate more resources to comprehend, remember, and

respond to events and auditory information, which could negatively impact working memory and attention, similar to what those with normal hearing experience in difficult listening environments (Pichora-Fuller et al., 2016).

It may be beneficial for audiologists to complete cognitive screenings on their patients, which

may help understand why certain patients experience more difficulties than others.

There are a variety of screening measures that are sensitive enough to mild cognitive changes,

such as the Mini-Mental State Exam (MMSE), Montreal Cognitive Assessment (MoCA), Mini-Cog, or clock drawing.

Differential Diagnoses

Common auditory and vestibular pathologies are discussed in Chapter 2. For a list of the clinical utility of audiological tests and their corresponding anatomical area of evaluation, see Appendix 5–A. Appendix 5–B provides a series of common pathologies with common or expected patterns of adult diagnostic results.

Conclusions

While many focus on a comprehensive audiologic evaluation as the main form of an adult diagnostic assessment, it is important to remember that clinicians have access to an extensive battery of tests, including many objective assessments. Each test has its own unique contribution to the adult diagnostic assessment, and each will provide a certain amount of value dependent upon the individual case.

CHAPTER 5 Adult Assessment and Differential Diagnosis

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