Week 12, Spring 2008

I didn't see much this week, so I thought that I would include an article review instead.

This article, Audiologists with Hearing Loss by Sandra Mintz, Samuel Atcherson, and Ally Sisler, follows the story of three indviduals with hearing loss. Although this article was not a study per say, I believe that it describes an important issue that we may face as audiologists.

http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=23265918&site=ehost-live

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=54&hid=101&sid=5077a623-7531-4b3a-a840-604f8d099f9b%40sessionmgr106

Of all of the "difficult" patients that we could have, perhaps the most difficult patient would be a fellow audiologist or fellow audiology student. The article focuses on 3 individuals who have used cochlear implants to help them succeed. Most relevant to us, as students, is the story of Ally Sisler. Ally was born premature with a congenital mild to moderate S/N hearing loss in both ears. She used hearing aids for the majority of her life. However, in 2004, she suffered a head trauma following a car accident. She noticed a decrease in her hearing and was implanted in her right ear in 2005. After she had finished her B.S. degree in Speech Pathology/Audiology, she decided to get implanted in the other ear so that she would have a greater opportunity to succeed in her Au.D. program and in her future career as an audiologist.

What a difficult choice!

Week 11, Spring 2008

In honor of the Bellis presentation that we all attended this week & the subsequent cancellation of all of my clinic slots, my post this week relates to APD.

The following article, Can We Differentially Diagnose an ADD without Hyperactivity from a CAPD?, addresses an issue that is a core concern of my client's mother ... differentiating ADD from APD. The article describes a case study about a boy named Corey. Corey was having difficulty in school. He was not staying on task, he was asking his teachers to repeat instructions, he was acting out, and he had a history of phonological delays and OM. Corey underwent a full psychoeducational evaluation.

During an interview with Corey, the investigators found that he had skewed social competence. Specifically, he blamed others for his difficulties and didn't understand why he kept getting in trouble and getting rejected from same-age friends. Both a speech-language pathologist's and a school psychologist's interpretations of results were given. Both professionals cited similiar difficulties, such as inability to maintain attention, difficulty processing complex sentences and directions, and weak figure-ground scores. However, the two professionals suggested two different diagnoses: APD and ADD. This article provides a real-world example of a child who may not fall neatly into a diagnostic category. It emphasizes that APD and ADD can be mistaken for each other and can also occur concurrently. Significantly, the authors also advised multiple case histories and interviews with the children in order to arrive at more accurate diagnoses.

As we've learned in our APD class, a test like the ACPT would be useful in differential diagnosis as well. Still ... very tricky!

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=39&hid=101&sid=5077a623-7531-4b3a-a840-604f8d099f9b%40sessionmgr106

Week 10, Spring 2008

The client visited the clinic because she stated that family members suspected that she had hearing loss. Although the client reported difficulty understanding speech in noise, she did not report difficulty hearing in quiet settings. She stated that her family believed that her hearing sensitivity had decreased gradually. A hearing evaluation by an ear, nose, and throat physician more than ten years ago revealed Eustachian tube dysfunction in the right ear, according to the client. She has continued feeling persistent fullness in her right ear since that time. Tinnitus was noted in both ears, but was described as only noticeable in complete quiet. The client stated that she did not feel bothered by the tinnitus. She related changes in the perceptibility of tinnitus to modifications of types and dosage of blood pressure, diabetes, and arthritis medications. No dizziness was noted. No other outstanding case history information was provided.

Cerumen accumulation, partially occluding the ear canal, were observed. Still, intact tympanic membranes were observed bilaterally. Slightly abnormal (Type AS) tympanograms were observed bilaterally.

Pure tone air conduction testing was performed from 250 to 8000 Hz, and pure tone bone conduction testing was performed at 500, 1000, 6000 Hz. Pure tone testing revealed normal hearing from 250 to 4000 Hz with a moderate high-frequency sensorineural loss bilaterally. A slight conductive component was observed at 6000 Hz in both ears. Speech recognition thresholds were 25 dB HL in the right ear and 10dB HL in the left ear. SRTs were in good agreement with pure tone averages bilaterally, and word recognition testing was excellent bilaterally.

Results were discussed with the client. Slightly abnormal tympanometric results and otoscopic examination of the ear canal indicated a moderate occlusion from cerumen. A bilateral, high-frequency sensorineural hearing loss was found.

The client was encouraged to see a physician in order to have excessive cerumen accumulation removed from her ear canals. Yearly hearing evaluations also were recommended in order to monitor her hearing sensitivity. Lastly, assistive devices, such as television amplifiers, were discussed with the client; however, she did not wish to pursue purchasing assistive technology at that time.

I could NOT resist including this article. It describes a man who was vacationing on an island. While on vacation, he experienced an impaction of cerumen. Instead of seeking medical treatment from an audiologist or other qualified health professional, he, instead, sought counsel from an engineer who owned the resort where he was staying. Otoscopy revealed bilateral impaction and hardening of the cerumen. The engineer suggested using a Super Soaker (water gun) to irrigate the man's ear. A family and emergency physician on the island was recruited to perform the irrigation after he assessed the Super Soaker's potential utility.

Here's the interesting part - when they irrigated with the Super Soaker ...

IT ACTUALLY WORKED!

Not only did it work, it did not cause pain, and it was much quicker and more efficient than typical irrigations from syringes.

Now...wouldn't clinic be even more interesting if we were using Super Soakers for cerumen management???

http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=18939158&site=ehost-live

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=5&hid=116&sid=5b7088be-e3c7-45f7-9df3-20ac14811b59%40sessionmgr108

Here's a more scholarly article on a related topic.

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=40&hid=101&sid=5077a623-7531-4b3a-a840-604f8d099f9b%40sessionmgr106

This study found that children with cerumen impaction are more prone to developing OME and also conductive hearing loss. Interestingly, a higher incidence of sensorineural and mixed hearing loss was also found in this population.

Week 9, Spring 2008

The client was an older women who visited West Virginia University Hearing Center with complaints of residual positional vertigo that persisted for three weeks following treatment for BPPV.

The client first noticed true vertigo in the early 1990s, but had experienced intensified symptoms for the last three months. Following a worsening of symptoms, the client visited her primary care physician. The client stated that she was diagnosed with an “inner ear infection” and, subsequently, was prescribed an antibiotic. After finishing the full course of the antibiotic, the client’s symptoms did not improve, so the client sought clinical evaluation at the WVU Hearing Center three weeks prior to the current visit.

At that time, the client reported true vertigo lasting less than one minute that was initiated from lying down/getting up from bed; bending down/rising up; and turning right and left. The client noted that the dizziness was worse when turning to the right side and was often accompanied by nausea and vomiting. The Dix-Hallpike maneuver revealed a small amount of rotational nystagmus on the right side only. Two rotations of the Epley maneuver were performed, and the client reported lessening of symptoms. She was asked to return to the WVU Hearing Clinic for additional treatment if her symptoms persisted more than one-week post-treatment.

At the current visit, the client described a complete elimination of symptoms four days post-treatment; however, she stated that symptoms returned two-weeks later. Currently, she described true vertigo, lasting less than one minute, initiated by leaning forward, lying down, or turning to the right or left. She reported that symptoms were worst when turning to the left.

When the Dix-Hallpike maneuver was performed on the left side, no nystagmus was observed. When the Dix-Hallpike maneuver was performed on the right side, a small amount of rotational nystagmus was observed. Two rotations of the Epley maneuver were performed on the right side directly following positive findings for Benign Paroxysmal Positional Vertigo (BPPV).

Following two rotations of the Epley maneuver and re-administration of the Dix-Hallpike maneuver on the right side, no rotational nystagmus was observed. Alleviation of true vertigo was noted by the client after the second rotation.

Results were discussed with the client, and she was informed that some residual dizziness could persist for approximately one week following treatment. However, she was strongly encouraged to schedule a follow-up appointment if residual symptoms persisted more than one week or if vertigo returns. No post-treatment restrictions were prescribed.

On a really awesome note ... this client was so over-joyed to be symptom-free that she hugged my supervisor and me!!! :-)

Health-Related Quality of Life in Patients over Sixty Years Old with Benign Paroxysmal Positional Vertigo by Maria Gámiz and Jose Lopez-Escamez.

Thirty-two patients with BPPV were included in the study. Twenty-four were between 60 and 70 years old, and 8 were older than 70 years. Subjects in this study had been diagnosed with unilateral BPPV based on a history of recurrent positional vertigo and a positive Dix-Hallpike test. A full neurotologic examination, including pure-tone audiometry, Romberg, Barany and Fukuda tests, was conducted at the initial visit. All patients were treated by a single rotation of the Epley manuever without mastoid oscillation, and they were instructed to sleep sitting in a recliner or propped up in bed for the first 2 nights post-treatment.

To assess BPPV health-related quality of life in elderly the Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) and the Dizziness Handicap Inventory Short Form (DHI-S) was used.

The study established that the SF-36 shows high internal consistency reliability and validity in elderly patients with BPPV for all dimensions. BPPV has a significant impact on individuals’ perception for role limitation due to physical problems, body pain, role limitation due to emotional problems, and mental health. After treatment, all SF-36 scale scores improved, and showed significant improvement after 30 days. role limitation due to physical problems, body pain, vitality, social function, and mental health.

DHI-S total score significantly decreased from 17.19 prior to treatment to 9.70 at 30days post-treatment. They also found that BPPV treatment in the elderly was just as effective as treatment of younger individuals.

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=26&hid=101&sid=5077a623-7531-4b3a-a840-604f8d099f9b%40sessionmgr106

http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=12246815&site=ehost-live

Week 8, Spring 2008

The client, who was 5 years old, visited the clinic for an audiometric re-evaluation, following medical evaluation. Previous case history information indicated that she was referred for a hearing evaluation by her classroom teacher. Her mother reported that professionals at the child’s school have documented articulation errors, including omission of initial and final /s/, and have attributed hearing loss as a possible cause. The client’s mother also reported that she has noticed her daughter listening to the television at loud levels and expressed concerns that she may not be hearing normally. One recent ear infection, as well as five ear infections from ages 0 to 1, were noted. Normal newborn hearing screening results and no other outstanding medical or developmental problems were reported. The child's physical development appeared to be normal, and the length and complexity of her utterances were age-appropriate. She presented as an energetic, happy child, and she was able to attend to directions and tasks.

At the current visit, information obtained, approximately five weeks prior, from a medical evaluation by an ear, nose, and throat (ENT) physician was discussed. Reports from the client’s mother indicated that the ENT believed that the client had Eustachian tube dysfunction. This information was consistent with previous audiometric results which suggested suspected middle ear involvement when the client was evaluated previously at our clinic. In addition, the client’s mother also reported that her daughter was recently disciplined at school because she did not follow oral directions; however, she believed that the child may not have heard the directions due to transient hearing loss.

Otoscopy revealed normal ear canals and visible, intact tympanic membranes bilaterally. Abnormal tympanometric results were observed bilaterally. A Type B tympanogram in the right ear and a Type C tympanogram in the left ear were recorded.

Pure tone air conduction and bone conduction thresholds were obtained at 500, 1000, and 2000, and 4000 Hz using a conditioned play response mode. Pure tone audiometry revealed a moderate rising to normal configuration in the right ear and a slight rising to normal configuration in the left ear. Despite normal air conduction thresholds at some test frequencies, a conductive component (10 to 20 dB HL) was evident bilaterally at all test frequencies. Speech recognition thresholds (SRT) were 20 dB in the right ear and 30 dB in the left ear and were consistent with pure tone averages bilaterally. All audiometric results were found with excellent reliability.

At the child's last evaluation, auditory sensitivity was worse in the right ear than in the left ear; however, at the current evaluation, the left ear was most involved which is highly suggestive of a fluctuating conductive disorder. Bilateral conductive hearing loss and abnormal tympanometry along with extensive case history reports indicate middle ear involvement.

Results were discussed with the client’s family. Continued medical evaluation from an ENT was strongly encouraged in order to pursue treatment for Eustachian tube dysfunction and resultant bilateral conductive hearing loss. An audiometric re-evaluation was advised, following medical treatment so that audiological treatment, including potential use of an FM system, and aural rehabilitation strategies may be discussed in detail. Biannual hearing evaluations were also encouraged in order to monitor the status of the middle ear.

Since behavior problems at school had been noted by my client's teacher, I chose an article that addressed parent, teacher, and ENT perceptions of children with OME. This article, Parent Parent Versus Professional Views of the Developmental Impact of a Multi-Faceted Condition at School Age: Otitis Media with Effusion (‘glue ear’) by Josephine Higson and Mark Haggard.

Otitis media with effusion (OME) occurs in 5–10% of 5 year old children and in 10-20%from the late fall into the spring. For the most part, OME resolves on its own; however, in about 50% of cases, it does not.

In this study, questionnaires were mailed to parents, teachers, and ENT physicians of children with OME. Each questionnaire covered seven concern areas: presentation/ illness, hearing, behavior, balance, speech and language, concentration, and education. The questionnaire emphasized that the family impact of OME was being examined, and respondents were asked to consider symptoms that were observed in children, ages 3-7, with OME.

The questionnaire results indicated that teachers rated language and education much higher than ENT specialists and parents do. Parents rated hearing most highly. Teachers also give behavior a higher weight than ENT specialists do. Behavior and balance problems show the least differences between groups. Teachers and parents
display similar patterns with respect to behavior problems and balance problems by rating them both slightly lower than ENTs did.

This information emphasized the importance of getting input from all stakeholders in a child's life. It also emphasized the need for a multidisciplinary team.

http://search.ebscohost.com/login.aspx?direct=true&db=eric&AN=EJ722135&site=ehost-live

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=5&hid=101&sid=5077a623-7531-4b3a-a840-604f8d099f9b%40sessionmgr106

Week 7, Spring 2008

The client was an older woman who visited the clinic to be fit with a pair of Unitron Moda Element 8 hearing aids. Prior to the HAO, a HAE was performed and audiometric results revealed a bilateral sensorineural hearing loss that sloped slightly beyond 1000 Hz. Unitron Moda Element 8 hearing aids were recommended at that time.

At the current visit, amplification was programmed according to heraudiogram. The manufacturer’s recommendations for fitting were modified by slightly according to the client’s listening preferences. The prescribed amount of overall gain was reduced, with additional decreases in the low and mid frequencies. Instructions were given about operation, insertion, maintenance, and troubleshooting her hearing aids. The client practiced inserting and removing the domes from her ear canals. Practice inserting and removing batteries was provided. Warranty information also was discussed.

The client was encouraged to wear her hearing aids in quiet situations at first and gradually wear them more in all conditions, including reverberant and relatively noisy environments. She was asked to make a follow-up appointment in order to discuss the performance of her hearing aid. She also was urged to call the clinic if she experienced any significant difficulties prior to her next appointment.

Since acclimatization was discussed, I chose the article Changes in Hearing-Aid Benefit Following 1 or 2 Years of Hearing-Aid Use by Older Adults written by Larry E. Humes, Dana L. Wilson, Nancy N. Barlow, and Carolyn Garner.

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=34&hid=101&sid=5077a623-7531-4b3a-a840-604f8d099f9b%40sessionmgr106

http://search.ebscohost.com/login.aspx?direct=true&db=c8h&AN=2004010111&site=ehost-live

Subjects between 60 and 89 participated in this study. They all had flat or gently sloping sensorineural hearing loss. One hundred thirty-four subjects were evaluated at 1 month, 6 months, and 1 year post-fitting, and 49 of those subjects returned for a 2-year follow-up appointment.

Benefit measures included several objective tests of speech recognition, such as the Connected Speech Test (NST) and the CUNY Nonsense Syllable Test (CST), and subjective tests, such as the Hearing Aid Performance Inventory (HAPI) and the Hearing Handicap Inventory for the Elderly (HHIE).

Neither the objective measures nor the subjective measures changed for most hearing aid wearers over the first 2 years of use. However one exception was observed. The some of the subjective measures actually declined, which indicated less benefit, during the first 6 to 12 months of hearing-aid use.

In other words, this study did not demonstrate proof of acclimatization. What do you think about acclimatization???