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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4612_Библиотеки_им_академика_М_И_Перельмана
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Audiology Review: Preparing for the Praxis and Comprehensive Examinations
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372
4. You complete sinusoidal harmonic acceleration testing. What are your expected results?
a.
Normal gain, phase, asymmetry
Normal gain, low-frequency phase lead, normal asymmetry
b.
c.
Reduced gain, low-frequency phase lead, significant asymmetry
Reduced gain, normal phase, normal asymmetry
d.
Explanation: Acute vestibulopathy most often presents with reduced gain, low-frequency phase lead,
and significant asymmetry. Therefore, c is the correct answer.
5. VEMP responses are expected to be abnormal in cases of SSCD. What is NOT an expected
abnormality?
a. Absent response in the affected ear
Enhance amplitude in the affected ear
b.
c.
Present response at 4 kHz
d. Reduced threshold in the affected ear
Explanation: SSCD provides an unexpected “third window” into the inner ear, enhancing sound
pressure conduction. VEMP responses are expected to demonstrate enhanced amplitude, reduced
threshold, and present responses at unexpected frequencies. Therefore, a is the correct answer.
6. What is an expected characteristic of peripheral nystagmus?
a. Down-beating nystagmus noted in gaze center
b. Nystagmus follows Ewald’s law
c. Nystagmus is enhanced with fixation
d. Nystagmus changes direction in eccentric gaze
Explanation: Peripheral nystagmus follows specific expectations outlined by (b) Ewald’s law. Vertical
nystagmus, nystagmus that enhances with fixation, and nystagmus that changes direction are characteristics of central nystagmus.
7. What stimulus frequency is most commonly used for VEMP testing?
125 Hz
a.
b. 250 Hz
c. 500 Hz
d. 750 Hz
Explanation: VEMP responses are influenced by the frequency tuning characteristics of the otolith
organs. Responses are most reliably recorded using (c) 500 Hz stimuli.
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8. In a patient with acute vestibulopathy, what SOT conditions are expected to be abnormal?
a.
Conditions 1–6
Conditions 3, 6
b.
c.
Condition 5
Conditions 4–6
d.
Explanation: SOT condition patterns relate to underlying balance dysfunction. An acute vestibulopathy most often presents with (c) abnormal 5. Balance performance in this condition relies on
appropriate vestibular system performance.
9. Which aspect of vestibular rehabilitation is used for a patient with bilateral vestibular areflexia?
Habituation
a.
Substitution
b.
c.
Adaptation
d. Rehabilitation
Explanation: A patient with bilateral vestibular areflexia does not have adequate VOR performance.
Therefore, the patient must use (b) substitution for maintaining appropriate balance performance.
10. Which measure of VOR performance is most appropriate for evaluating a 4-month-old child?
a. vHIT
b. oVEMP
c. SHA
d. Caloric testing
Explanation: The most effective method for evaluating children <6 months of age is (a) vHIT. For
these young children, vHIT is usually done with a remote camera system. Due to tolerance, the remaining options are not typically attempted until 6 months for SHA, 3 years for oVEMP, and 6 years for
caloric testing.
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Section IV
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Prevention, Identification,
and Treatment
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Audiology Review: Preparing for the Praxis and Comprehensive Examinations
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377
Screening and
Hearing Conservation
Introduction
Chapter 8
Leigh Ann Reel
Audiologists provide services designed to prevent, identify, diagnose, and treat hearing, balance, and
related disorders in children and adults. Screening measures can be useful in preventing and identifying
hearing loss, as well as balance, speech-language, and cognitive disorders. By identifying at-risk individuals, appropriate steps can be taken to prevent further decline and/or improve function in a particular
area. For hearing loss, prevention primarily focuses on using hearing conservation efforts to prevent
noise-induced hearing loss (NIHL). This chapter will review important topics related to screening for
hearing and balance disorders and preventing NIHL through hearing conservation services for children
and adults. Concepts relevant to evaluating speech and language and screening for cognitive disorders
are covered in Chapter 4 and Chapter 5, respectively.
Screening Measures for Auditory and Balance Disorders
Undetected hearing and balance disorders can have a negative impact on many areas of life for children
and adults. Screening measures can identify individuals who are at risk and may need more comprehensive testing, preventative measures, and/or intervention. As a result, appropriate screening may lead to
better outcomes and improved quality of life. This section will focus on hearing and balance screening
measures for children and adults.
Newborn Hearing Screening
Hearing screening for children includes newborn hearing screening (NBHS), early childhood screening, and school-age screening. Early Hearing Detection and Intervention (EHDI) guidelines (American
Speech-Language-Hearing Association [ASHA], n.d.-d) include completing the NBHS by 1 month of
age, diagnosis of any hearing loss by 3 months of age, hearing aid selection and fitting within 1 month
of confirmation of hearing loss, and initiation of early intervention services by 6 months of age. Otoacoustic emissions (OAEs) and/or auditory brainstem response (ABR) testing may be used for NBHS.
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378
n
ABR: Screening with ABR can be conducted using nonautomated (i.e., diagnostic) or
automated ABR (i.e., AABR) equipment. AABR equipment includes internal stopping rule
criteria based on comparison to a template or statistical algorithms. Click stimuli are presented
at 35 dB nHL at a rate of 30 to 37 clicks/second. Screening with ABR is less sensitive to outer
ear debris and allows for detection of both neural and cochlear hearing losses. A drawback
of only screening with the ABR is that it often misses minimal to mild hearing losses. The
Joint Committee on Infant Hearing (JCIH, 2007) recommends ABR screening for newborns
who stay more than 5 days in the NICU due to increased risk of neural hearing loss/auditory
neuropathy spectrum disorder (ANSD).
n
OAE: In well-baby nurseries, NBHS can also be performed using transient-evoked (TEOAE)
or distortion product (DPOAE) otoacoustic emissions. Typically, results are considered to be
passing when OAEs are present at 2000, 3000, and 4000 Hz at signal-to-noise ratios (SNRs)
of at least 6 dB. OAEs are absent in cases of outer or middle ear problems, resulting in a
higher false-positive rate than ABR due to the incidence of outer ear debris and/or middle
ear fluid in newborns. OAEs are also not sensitive to disorders central to the outer hair cells
(e.g., ANSD). As a result, screening with OAEs is only recommended for newborns in wellbaby nurseries.
n
Two-tier screening: Some locations use a combination of OAE and ABR screening. In two-tier
screening, an OAE screening is completed in both ears first. If the OAE screening is not passed
in both ears, an ABR screening is performed in the same session. If the newborn does not pass
the ABR screening in one or both ears, he or she is referred for outpatient diagnostic testing.
Early Childhood and School-Age Hearing Screening
Failure to detect and appropriately manage hearing loss in children can lead to deficits in speechlanguage, academic, psychosocial, and emotional development. This can be true for even a minimal
degree of hearing loss (thresholds of 15–25 dB HL). Screening all children will help identify any
who failed the NBHS but were lost to follow-up or those with hearing loss that developed after birth
(ASHA, n.d.-b).
n
Early childhood: In early childhood, this includes ongoing hearing screening for children after
the newborn period, required screening of hearing, vision, and overall development within
45 days of entering into Early Head Start and Head Start programs, monitoring children
identified as high-risk of delayed-onset hearing loss by JCIH (2007) criteria, screening when
a parent/caregiver/teacher/service provider raises concerns, and screening as part of any
comprehensive speech-language evaluation.
n
School-age: For school-age children, screening should be performed when a child first enters
a school or transfers to a new school and every year in Grades K–3, 7, and 11 (ASHA, n.d.-b).
In addition, hearing screening should be included as part of monitoring for children who are
homeschooled or in private school. Hearing screening for school-age children should also be
performed when a parent/caregiver/teacher/service provider raises concerns and should be
included as part of any comprehensive speech-language evaluation.
n
Screening protocols
Otoscopy/visual inspection: Otoscopy/visual inspection of the outer ear allows for
visualization of the pinna, external auditory canal, and tympanic membrane. Any redness,
drainage, foreign bodies, cerumen, or other abnormalities should be noted. Otoscopic
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results are important in interpreting failed hearing screening results and determining the
need for medical referral.
Pure-tone screening: Screening with pure tones should be performed at 1000, 2000,
and 4000 Hz in each ear at 20 dB HL. Programs should consider including 6000 and
8000 Hz to help identify early NIHL in children. Pure-tone hearing screening results are
considered to be passing when responses are present at each frequency in each ear. Rooms
used for school hearing screenings should be free of distractions. If a child has thresholds
at 0dBHL, the allowable ambient noise levels would be: 1000 Hz = 50 dB SPL, 2000Hz
= 58 dB SPL, and 4000 Hz = 76 dB SPL (ANSI 2003, as cited in ASHA, n.d.-b). If a
sound level meter (SLM) with octave band filters is not available, a biologic check can be
performed in which a person with known normal hearing is tested to ensure that thresholds
can be obtained at least 10 dB below the screening level at all frequencies.
OAE screening: Use of OAEs may be appropriate for children who cannot be tested with
pure-tone screening. It can also be helpful in identifying early NIHL. However, there are
currently no ANSI standards for the screening environment when OAEs are used.
Tympanometry: Tympanometry can be added to a pure-tone or OAE screening protocol
to measure movement of the tympanic membrane. Tympanometric results are useful in
identifying conditions that require medical referral, such as Eustachian tube dysfunction,
otitis media, perforation of the tympanic membrane, or other middle ear disorders.
n
Referral and rescreening: When the hearing screening is failed, a rescreen should be performed
within 6 to 8 weeks based on the expected timeline for spontaneous recovery from middle
ear effusion. Some schools may choose a timeframe of 2 to 4 weeks, which may result in over
referral of children with resolving middle ear effusion.
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Adult Hearing Screening
Without appropriate treatment, hearing loss in adults can result in higher risk of depression, anxiety,
and dementia (e.g., Lin et al., 2011). Routine hearing screenings may help reduce the negative impact
of hearing loss by reducing the likelihood of undiagnosed and untreated hearing loss. Adult hearing
screenings can be performed at primary care visits, residential facilities, speech-language pathology visits,
and health fairs, as well as through occupational hearing screening programs and via remote methods
(e.g., phone, online) (ASHA, n.d.-a). Adult hearing screening consists of screening for disorder (health
condition), impairment (body structure and function), and disability (activities and participation).
n
Screening for disorder is accomplished through case history and otoscopy.
n
Screening for impairment involves pure-tone screening. ASHA (n.d.-a) recommends screening
at 1000, 2000, and 4000 Hz in each ear at 25 dB HL. In order to pass, responses must be present
at each frequency in each ear. The screening environment should be free of distractions. Noise
levels can exceed recommended maximum permissible ambient noise levels (MPANLs) for
audiometric test rooms but must be low enough to allow accurate screening. If an SLM with
octave band filters is not available, a biologic check can be performed in which a person with
known normal hearingis tested to ensure that thresholds can be obtained at least 10 dB below
the screening level at all frequencies.
n
Screening for disability can be performed using self-report questionnaires, such as the Hearing
Handicap Inventory for the Elderly–Screening Version (HHIE-S; Ventry & Weinstein,
1983); the Speech, Spatial and Qualities of Hearing Scale (SSQ; Gatehouse & Noble, 2004);
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Self-Assessment of Communication (SAC; Schow & Nerbonne, 1982); and Significant Other
Assessment of Communication (SOAC; Schow & Nerbonne, 1982).
Vestibular Screening
Vestibular screening can help identify individuals with dizziness/imbalance symptoms who need more
in-depth diagnostic testing or evaluation by a physician who specializes in vestibular disorders. Screening for vestibular disorders can include case history, questionnaires, and functional screenings.
n
Case history questions should gather information on the person’s symptoms and any factors
that point to a possible cause of the symptoms. Symptoms of balance problems may include
dizziness, vertigo (sensation of the room spinning), lightheadedness, motion sickness,
unsteadiness, falling, trouble walking, and blurry vision (ASHA, n.d.-c). It is important to
note the duration, frequency, onset, and pattern of the symptoms, as well as any aggravating
(e.g., motion, position, diet) and alleviating factors. Causes of dizziness/imbalance problems
include inner ear disorders, sudden hearing loss, tumors on the auditory nerve, viruses/
infections, medications, injury to the ear or vestibular system, or cochlear implant placement.
n
Questionnaires may be used to screen for vestibular problems in children and adults.
Dizziness Handicap Inventory for Children (DHI-C): The DHI-C consists of 25 items
typically completed by the child’s caregiver (McCaslin et al., 2015). The items are
essentially the same as the adult version of the questionnaire (see below).
Pediatric Vestibular System Questionnaire (PVSQ): The PVSQ consists of 10 items that
identify and quantify the severity of the child’s vestibular symptoms (Pavlou et al., 2016).
There is also an 11th item that asks if the child’s symptoms prevent participation in
activities.
Pediatric Visually Induced Dizziness Questionnaire (PVID): The PVID includes 11 items
that quantify the severity of visually induced dizziness (e.g., crowds, scrolling computer
screens) (Pavlou et al., 2017).
Dizziness Handicap Inventory (DHI): Validated in adults, the DHI consists of 25 items
divided into three subscales: emotional, functional, and physical (Jacobson & Newman,
1990).
The Activities-Specific Balance Confidence (ABC) Scale: The ABC scale consists of 16
items validated for adults 65 years and older (Powell & Myers, 1995). The purpose is to
identify senior citizens at risk of falling.
n
Functional screenings can also provide information helpful in determining when a full
vestibular evaluation should be performed. Examples include:
Clinical Test of Sensory Integration of Balance (CTSIB): The CTSIB consists of six
conditions (Shumway-Cook & Horak, 1986). The patient stands on a flat firm surface and
on a compliant foam surface in three visual conditions: eyes open, eyes closed, and while
wearing a sensory conflict dome with no shoes and the feet together. Results are used to
evaluate the patient’s use of visual, vestibular, and proprioceptive sensory information for
posture.
Timed “Up and Go” (TUG) Test: The TUG was developed for use with elderly adults. The
patient is asked to get up from a chair, walk for 3 minutes, turn around, walk back to the
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chair, and sit down (Podsiadlo & Richardson, 1991). Research has shown the TUG to be
useful in assessing fall risk in individuals with vestibular disorders.
5 Times Sit to Stand Test (FTSST): The FTSST measures how long it takes a patient
to move from sitting to standing five times in a row. Results can be helpful in assessing
postural control, risk of falling, lower-extremity strength, proprioception, and disability
(Whitney et al., 2005).
Beside Dynamic Visual Acuity (DVA) Test: The bedside DVA test assesses how well the
retina can focus on an object while the head is moving (i.e., the vestibulo-ocular reflex)
(Barber, 1984). Patients with vestibular hypofunction (unilateral or bilateral) will experience
oscillopsia (i.e., blurring or bouncing of visual objects with movement of the head). As a
bedside screening, the test is performed with the patient using their best-corrected vision.
An Early Treatment Diabetic Retinopathy Study (ETDRS) eye chart is placed at a specific
distance, and the examiner moves the patient’s head back and forth (less than 20 degrees) at
a frequency of 2 Hz while the patient reads the lines on the chart.
Beside Head Impulse Test (HIT): The beside HIT uses the oculocephalic response (i.e.,
doll’s eye reflex) to screen for unilateral and bilateral peripheral vestibular disorders
(Halmagyi & Curthoys, 1988). It is performed by having the examiner gently grasp the
patient’s head, tilt it forward 30 degrees (i.e., to position the lateral semicircular canal
coplanar to the ground), and passively turn the head 10 degrees from center. The patient
is asked to fixate on the examiner’s nose. The examiner then rapidly moves the patient’s
head 15 to 20 degrees to midline. The test is repeated on the other side. If peripheral
vestibular function is normal, the rapid head turn to each side will elicit a compensatory eye
movement that is close to 180 degrees out-of-phase from the movement of the head. Left
side peripheral vestibular damage will result in a catchup saccade to the right when the head
is rapidly turned to the left, with normal results when the head is turned to the right. This
pattern of results will be reversed when there is damage to the peripheral vestibular system
on the right side.
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Single-Leg Standing: In single-leg standing, the patient is asked to stand on one leg. The
other leg cannot touch the weightbearing leg (e.g., Horak et al., 1992). The patient is asked
to not move the weightbearing leg or the arms from the start position. The amount of time
the patient can maintain this position is timed, and changes are tracked over the course of
rehabilitation.
Hearing Conservation
Hearing conservation is an essential “preventive medicine service provided by all audiologists, regardless
of their work setting” (Beamer, 2008, para. 1). Audiologists can provide a variety of different hearing
conservation services, including:
n
Measuring noise levels
n
Assessing the risk of developing NIHL
n
Providing and supervising audiometric monitoring
n
Reviewing problem audiograms to determine need for further evaluation or management
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