Week 7

On Tuesday there were no patients for me, so I found some recruits. One recruit had been screened several years ago by a speech pathology graduate student; however, all she remembered from the exam was that the clinician told her that "her hearing was failing." I was unable to review her chart at the time of her visit because it had been stored in long-term storage. The recruit was an active, elderly woman who reported no outstanding medical problems or medications. She reported having difficulty listening in noise, but noted no additional problems. Otoscopy revealed normal EAMs, and visible, intact TMs bilaterally. Tympanometry revealed normal (Type A) tympanograms bilaterally. Due to time limitations for the client, acoustic reflex testing was not performed.

Pure tone air conduction testing revealed that the recruit had normal hearing in the low and speech frequencies bilaterally. However, between 6000 and 8000 Hz, the recruit had a mild to moderate hearing loss in the right ear and a mild to moderately-severe loss in the left ear. Before I explained the results to the client, my supervisor reminded me of a presentation from a hearing aid representative that we had attended earlier in the year. Improved localization skills correlated to improved thresholds in the high frequencies was one of the topics that the representative discussed. By explaining the need for hearing in the high frequencies made the, seemingly insignificant, loss more relatable to the client. Normally, when I have explained losses that do not involve the speech frequencies, I have often forgotten the everyday effects that high-frequency losses have on some individuals. Explaining a high-frequency loss in a different manner was a great way to expand on my informational counseling skills.

The following article explains the precedence effect (PE) and the effects of aging on localization skills. The PE involves two click stimuli played in succession from two different loudspeakers. At short intervals (< 1 msec) between the stimuli, the clicks seem to be heard somewhere between the two speakers for normal listeners. At slightly longer intervals (~1-6 msec.), the stimuli seem to originate from the leading loudspeaker. Still, when longer intervals are present, normal listeners will perceive two distinct clicks.

The study focused on 4 groups: young/normal hearing, young/hearing impaired, elderly/normal hearing, elderly/hearing impaired. The criteria for being hearing impaired were a mean bilateral high frequency average of greater than 30 dB HL. The study found that hearing impairment impaired localization for both hearing impaired groups; however, the elderly/hearing impaired group was most severely affected.

http://jslhr.asha.org/cgi/reprint/36/2/437

On Thursday, I saw an extremely interesting client. The client had visited the clinic before, and he had resided in a group home for several years. He was accompanied by his caretaker, and because the client was unable to speak, gesture, or nod consistently, all case history information was obtained by interviewing the caretaker.

History of blunt head trauma, brain surgery of uncertain origin (possibly a lobotomy), and persistent seizure disorder were all reported. Additionally, a host of medications, including Lasix, Depakene, and Topamax, which are all potentially ototoxic, were listed as well. In review of previous year's reports, Behavioral Observation Audiometry (BOA) results had proven inconsistent but had still suggested the possibility of a high frequency hearing loss, which the clinicians in previous years attributed to aging. Diagnostic OAE results from 3 years ago, however, were normal.

At the current visit, otoscopy and tympanometry were normal and were completed first. Next, screening DPOAEs were obtained between 2000 and 4000 Hz with a 4/6 pass criterion with some resistance from the client. Results did not meet the 4/6 pass criterion in the right ear. In the left ear, after 2 frequencies were re-screened, results met the 4/6 passing criterion; however, the client did not pass the screening at all frequencies.

BOA revealed that the client was aware of frequency-modulated tones at 250 and 1000 Hz when stimuli were presented between 30 and 50 dB HL in the sound field. Reliability of BOA was poor; however, tentative responses were obtained at 30 dB HL at 500 Hz and 50 dB at 1000 Hz. Results of speech awareness testing were more consistent. The client was able to attend to monitored-live voice providing prompts and speech sounds at 40 dB HL. Testing ceased when the client became agitated.

Restricted behavioral testing, DPOAE screening results, advancing age, and case history information, which described intake of potentially ototoxic medications, indicated the possibility of a cochlear hearing loss. DPOAE screening results indicated a greater likelihood of greater cochlear hearing loss in the right ear. However, despite passing the screening in the left ear, a mild to moderate hearing loss (approximately 25-40 dB HL) could still be present. These results were discussed with the client's caretaker, and annual hearing evaluations were strongly encouraged in order to monitor any changes in the client's hearing.

Although other clinicians attributed the client's possible hearing loss only to advancing age, I believe that the use of ototoxic medications may have significantly contributed as well. I was not able to do enough research to understand dosage effects of his medications; however, the following article describes possible side effects of anti-convulsant medications in those with intellectual disabilities.

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An Analysis of Side-effect Profiles of Anti-seizure Medications in Persons with Intellectual Disability Using the Matson Evaluation of Drug Side Effects (MEDS) conducted by Matson, Mayville, and Bamburg evaluated two groups. The control group was composed of participants with intellectual disabilities and seizure disorders who were not being treated with medications. The other experimental group was composed of individuals who also had intellectual disabilities and seizure disorders, but were being treated with medications. Interestingly, the article noted that hearing loss was more prevalent in both groups, but it was not listed as a major side effect of the medications used in the study group. However, I do not know if those medications are ototoxic as my client's were. Still, vestibular side effects were noted in the experimental groups as well as many others such as gastro-intestinal problems, slurred speech, and CNS dysfunction.

Week 6

On Tuesday, I did not have any clients; however, I assisted with a hearing aid orientation session. The client had visited the clinic before, and she had previously worn hearing aids. She had recently purchased new bilateral Oticon Delta 6000 or 8000s, after wearing older hearing aids (likely analog hearing aids) in the past. She was not my patient, and I did not review her chart. However, when she first listened with her new hearing aids, she reported that they sounded very "different," which led me to believe that she had used analog hearing aids previously. Observing the steps that are necessary to make adjustments using the Oticon software was helpful. As a new clinician, it is intimidating to use unfamiliar programs, but observing others, first, definitely helps. Would you all agree?

I included an article that describes differences in perceived perfomance of new digital aids compared to analog hearing aids in long-time analog users. The authors cited a study by Gatehouse (1992) that showed that it takes several months of hearing aid use before users become acclimated to a new hearing aid. This is important to remember when clients report that they are not satisfied with the sound quality of their new hearing aids yet, particularly if they have just switched from analog to digital hearing aids.

In the study, participants rated their old analog hearing aids and their new digital hearing aids according to three dimensions of sound quality. Clearness/dullness, softness/sharpness, and overall impression when listening to seven test sounds were all measured. In general, users preferred digital aids; however, this experiment occurred over a 1-month period. Users that preferred their analog aids cited sound quality and missing volume controls as pitfalls of digital aids.
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On Thursday, I saw a DPS client. The client had not been evaluated since 2004. He reported target shooting, hunting, and ATV riding as frequent hobbies, and he reported noise exposure at work. He noted that he wore ear protection regularly at work, but only intermittently during recreation.

Otoscopy revealed slight redness in the right EAM; however, TMs looked normal bilaterally. Tympanograms were normal Type As bilaterally. ARs were slightly elevated at 500, 1000, and 2000 Hz bilaterally. Pure tone air conduction testing revealed normal hearing up to 4000 Hz bilaterally. In the high frequencies, the client had a slight unilateral sensorineural loss in his right ear. This pattern was consistent with his audiogram from 2004. SRTs were normal, and WR was excellent. Bone conduction testing was completed, but was considered unreliable due to patient fatigue. In fact, BC scores were actually significantly worse (15 dB) than AC scores at some test frequencies. Inattention or overmasking were also possible; however, step masking was used in order to decrease the risk of overmasking. Continued use of ear protection at work and consistent use of ear protection during recreation were strongly encouraged, and the patient was advised to continue annual hearing evaluations in order to monitor changes in his hearing related to age and noise exposure.

The following article, Can Bone Conduction Thresholds Really Be Poorer Than Air, by S. Joseph Barry, poses two important questions: 1. Can BC thresholds be worse than AC thresholds? 2. If so, how do you record them on an audiogram?

The author noted that variability resulting in "negative air/bone gaps" of up to and including 15 dB HL were "normal" in some individuals. However, if "negative air/bone gaps" greater than 15 dB HL existed, mechanical or placement errors should be explored.

In terms of recording "negative air/bone gaps" on an audiogram, BC thresholds should be recorded at the level that they were found - not at the level that AC thresholds were found. This seems like common sense; however, this is a question that I asked my supervisor because we have been taught that BC thresholds cannot signficantly exceed (by greater than 10 dB HL) AC thresholds. Although this is normally true, recording results that may not seem to make sense may have particular uses. Specifically, when significant "negative air/bone gaps" are recorded, the author noted that early mechanical failure and inadequate calibration may become apparent. Additionally, recording test results precisely also preserves the ethical guidelines for audiologists and ensures the accuracy of test/re-test reliability and validity as well. Still, my supervisor advised me to make a note on the patient's audiogram about the BC thresholds. http://aja.asha.org/cgi/reprint/3/3/21.pdf

Week 5

On Tuesday, we had some DPS scheduling problems, but I did get to see one DPS client. The client didn't have any specific time constraints, so I was able to run a more complete test battery. Otoscopy, tympanometry, acoustic reflexes, and AC audiometry were all normal, and all of his results were consistent with previous years' findings. Seeing this client helped me gain some more experience and greater comfort delivering services. During clinic, I also saw a child for a kindergarten re-screening. Otoscopy revealed a PE tube moving out of one of the child's ears, tympanometry was normal, and pure tones were heard at 20 dB HL.

Thursday, in clinic, I saw my first pediatric client (other than kindergarten screenings)! The client was 6 years old and had been seen previously in the speech clinic. The client had normal otoscopy, tympanometry, pure tone AC thresholds, SRTs, and WR scores. Thresholds were obtained with an "adult" mode of response. Although there was nothing particularly outstanding about the case, the client made the process very valuable. Trying to move as fast as possible, remembering to use lots of reinforcement, choosing the most necessary tasks and tests first, and projecting a positive attitude were absolutely essential to keep the client on task. While I was seeing this particular client, the A/C was also off, so the need to be speedy and effective was magnified even more. Overall, it was a great experience!

Below, I included a link to the article Listening Effort and Fatigue in School-Age Children with and without Hearing Loss by Hicks & Tharpe, which evaluated differences in listening fatigue and effort between children with and without hearing loss. I included this study in my blog because, during testing with my pediatric client, I worried that he would become tired during the testing process. This study was significant because, according to the authors, it was one of the first studies that investigated listener fatigue in children. The study found that listener fatigue was no greater in children with hearing loss, as was speculated. However, listener effort was greater in children with hearing loss, which has implications on multitasking during audiological testing and during activities in a school setting.
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Week 4

On Wednesday, July 4, there was no clinic because of the holiday. On Thursday, I saw a child who came in for a kindergarten re-screening. Otoscopy revealed that the child had a PE tube that was moving out of his right ear. Tympanometry and the air conduction pure tone re-screening were also normal.

In the evening, I saw a recruit who graduated from the Music Education program. The recruit had been a musician since she was very young and had played in marching bands in junior high, high school, and college. She also practices frequently and plays with several performance groups. She was recruited because of her history of noise exposure and also because, previously, she expressed a desire to obtain musicians' earplugs and custom iPod earbuds.

In addition to persistent noise exposure, case history also revealed that the recruit often has tinnitus that sounds like "static;" however, she reported that it wasn't bothersome. The recruit also noted that she has chronic allergies.

Otoscopy revealed a moderate amount of cerumen in the lateral EAM, and I was able to remove a significant amount with the guidance of my supervisor.

Tympanometry and acoustic reflexes were normal. Pure tone AC audiometry, with the 6000 Hz test frequency included, revealed no outstanding findings, so we proceeded to make impressions for her earplugs.

The recruit expressed that she typically sits in front of brass and percussion performers in concert formation, so my supervisor recommended musicians' earplugs with the greatest level of attenuation. She also recommended purchasing counter-sunk filters, which would provide greater stability for the filters. She explained that when filters are not counter-sunk, they often get knocked off and lost. Because of the cost of replacement-filters, the recruit chose to get the musicians' earplugs with counter-sunk filters. The recruit also chose to purchase custom iPod earbuds. Both sets of earplugs were ordered from ProSonic because they offered the most affordable products.

My experiences with my recruit were valuable because I was able to remove cerumen for the first time and also because I learned about a product (musicians' earplugs) that was not familiar to me. I included some links about current studies that emphasized the need to monitor the hearing of musicians. Both studies, Hearing Development in Classical Orchestral Musicians and Hearing Development in Classical Orchestral Musicians: A Follow-up Study, completed by the same authors, Kähäri, Axelsson, Hellström, & Zachau, explored frequency-specific, gender, and individual ear differences. The longitudinal study found that males expressed more significant losses, particularly at 6000 Hz. The studies also found a right-ear advantage. The links to the studies are listed below:

Kähäri, K., Axelsson, A., Hellström, P., & Zachau, G. (Jan2001). Hearing assessment of classical orchestral musicians. Scandinavian Audiology, 30(1), 13-23.
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Kahari, K., Axelsson, A., Hellstrom, P., & Zachau, G. (2001). Hearing development in classical orchestral musicians. A follow-up study. Scandinavian Audiology, 30(3), 141-149.
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Week 3

I was not able to attend clinic the week of June 25 - June 29 because I had a class conflict. However, I found some interesting articles to share because I am still trying to locate funding for a client who wished to apply for the Starkey 'Hear Now' program. The following article, Funding Hearing Technology by Tina Mullin, describes different resources available for those who cannot afford hearing aids on their own. This article helped me explore more resources in addition to local and national organizations that were already familiar to me. I'm making a more complete list of contact information for helping organizations so that we can all have something to use when we have clients who have significant financial need.
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The following article, A Survey of Public Heath Policy on Bilateral Fittings and Comparison with Market Trends: The Evidence-Base Required to Frame Policy by Stig Arlinger, provided a broader frame of reference for reimbursement. The authors described varying levels of public assistance for financing hearing aids in several different countries. It was interesting to see the differences in compensation patterns. Ten European countries, Australia, Canada, and the US were all compared. All countries, except for the US, provided some public assistance for those in need of hearing aids. The variability between countries was great, ranging from free bilateral hearing aids to caps on unilateral aids. Although the US provided no public assistance to civilians, their incidence of bilaterally fittings was the greatest at ~82%. Still, the US only provided hearing aids for 5-7 per 1000 inhabitants.

It makes me think ... other countries must know something that the US doesn't!?!
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