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???

Week 6, Spring 2008

Today, I saw a 25 year old male who had a history of noise exposure. He noted going to many concerts and drag racing as teenager. He also had a history of hunting and shooting. Hearing protection was not used during any of these activities.

Otoscopy revealed normal, intact TMs bilaterally. Type A tympanograms were also found bilaterally. ART testing was not performed due to time constraints.

Pure tone AC thresholds were normal bilaterally, but were slightly worse (5-10 dB HL) in the left ear. This may have been due to right-handed shooting.

The following article Hearing Loss and Hearing Handicap in Users of Recreational Firearms, by Michael Stewart, Rebecca Pankiw, Mark E. Lehman, and Thomas H. Simpson, evaluated a total of 232 shooters ranging in age from 13 to 77 years with a mean age of 40 years. There were 187 males and 45 females, all subjects reported using firearms during the previous year. The hearing acuity of the subjects ranged from bilaterally normal across the frequency range to a severe to profound high-frequency hearing loss bilaterally. All subjects had normal ME systems.

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=3&hid=113&sid=9da9fc7b-df51-43f3-8378-8d188e7a3ab6%40sessionmgr109

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/detail?vid=5&hid=106&sid=55fb21cd-5a39-4c5b-b0a2-4842d09d2093%40sessionmgr108

http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=6717781&site=ehost-live

(These were the only links available. If they don't work for you, I provided the reference as well.)

I don't know about you, but I've never known quite the right way to explain why shooters have worse hearing on the side contralateral to gun. Here is how the authors explained it: "Because the ear contralateral to the shoulder supporting a rifle in a firing position is closer to the source of the sound (gun bore), and the ipsilateral ear is slightly protected by head shadow, asymmetry in high-frequency hearing may occur, with the contralateral ear being worse. Also, the directionality of the noise causes the level of the impulse noise to be reduced to the ipsilateral ear." In layman's terms, when you're shooting, your ear nearly rests against the shoulder that the gun rests on. This blocks some of the sound from damaging that ear. However, the other ear is closer to the source of the sound receives no protection, so it often becomes more damaged by the noise from the gun.

All participatnts completed a questionnaire related to demographic information, knowledge and use of hearing protection, firearm safety training, and shooting habits. Otoscopy and pure tone audiometry were performed. PT thresholds were obtained at .5, 1, 2, 3, 4, and 6 kHz bilaterally. A screening version of the Hearing Handicap Inventory for Adults (HHIA-S) was administered to any individuals whose thresholds were equal to or worse than 25 dB HL at any test frequency in either ear.

The results of this study revealed that many of the subjects who reported shooting
firearms for sport purposes exhibited varying degrees of high-frequency hearing loss and associated self-reported hearing handicap. Certain demographic groups of the recreational firearm users, including males, older individuals, and blue collar workers, exhibited more high-frequency hearing loss and reported more hearing handicap than others.

Males and blue collar workers also tended to shoot more powerful guns than their demographic counterparts. Hearing loss in blue collar workers may also be attributed to industrial noise.

Individuals with more significant high-frequency hearing loss tended to report more hearing handicap. Based on these results, it appears that the HHIA-S may be useful as a screening tool in populations in which NIHL is prevalent, such as shooters and industrial workers. It may also be useful as an aid to counseling individuals with
high-frequency hearing loss and to assess the benefits of intervention strategies by comparing pre- and post-intervention scores.

Different formulae were used to identify those who may be handicapped by HL. However, high-frequency pure-tone average formulae, used to identify patients who may be hearing handicapped, were more likely to identify populations with high-frequency hearing loss than those using formulae that employ 500 Hz.

Thus, in the future, it may be helpful to administer a scale like the HHIA-S with those who are prone to NIHL. It may also be benefical to report a high-frequency PTA as well as a standard PTA of .5, 1, & 2 kHz.

Week 5, Spring 2008

This week in clinic I saw an older gentleman who was having obvious difficuly understanding normal conversational speech during the case history interview. I found myself raising my voice substantially and repeating myself often in order to communicate with him. Direct view of my face was also needed for him to understand what I was saying.

The client had normal EACs and normal tympanograms. Acoustic reflex testing revealed elevated ipsilateral and bilateral ARTs. The client had sloping mild to moderately-severe sensorineural hearing loss bilaterally. His PTA and SRT were in good agreement for both ears, and his WR scores were fair (82% in the right ear and 78% in the left ear).

Significantly, the client noted that he and his wife had been fighting about his inability to hear lately. He said that she was constantly "nagging" him about not listening, and it was becoming an issue in their marriage. He also stated that he was no longer able to talk on the phone because of his hearing loss. According to the gentlemen, the purpose of his visit was mostly to appease his wife.

The following article titled "Effect of Hearing Aids on Hearing Disability and Quality of Life in the Elderly" describes a study that measured perceived benefits on social and emotional wellbeing following a hearing aid fitting. A total of 98 participants, who were first-time hearing aid users, were fit monaurally with a hearing aid. At the beginning of the study, prior to the fitting, the participants were given the Hearing Handicap Inventory for the Elderly short version (HHIE-S) and other questionnaires. All inventories were given again six months after the intial fitting. Most hearing aids used were BTEs, but ITEs were used as well. Some were digital and some were analog hearing aids.

Prior to the fitting, the HHIE-S revealed that almost 70% of the participants felt that their HL was handicapping, and over 50% noted that it limited their lives. The mean HHIE-S score was 28.7 prior to the fitting and 12.7 six months post-fitting. Lower scores in indicate lessening of a perceived handicap, which presented in 40-60% of the participants post-fit. Thus, being fit with hearing aids made most individuals feel substantially less handicapped.

Hopefully, being fit with hearing aids will also increase my patient's perceived quality of life. However, careful counseling will be needed to ensure that he has appropriate expectations.

http://web.ebscohost.com/ehost/pdf?vid=3&hid=114&sid=b45b12c1-d016-427f-aba0-46dfc4f04186%40sessionmgr109

Week 4, Spring 2008

This week, I saw a grumpy man with a history of noise exposure. Throughout the case history interview, he offered short, vague answers, and he acted as though he would rather be somewhere else. He was a bit impatient during immittance testing, but he had normal tympanograms bilaterally.

During pure tone testing, he was directed toward the right speaker; however, he didn't make any attempts to look my way. In fact, he kept his head down during testing. I tried to be as cheery as possible during our interactions in order to make him feel more at ease, but the client never seemed to warm up. I just assumed that he was a grumpy man who didn't want to be there, but was required to come for an annual evaluation.

Pure tone testing revealed a slight to moderate sensorineural hearing loss in his right ear and a slight to moderately-severe hearing loss in his left ear. My supervisor and I reviewed his audiogram prior to discussing results with the patient. We observed that his hearing had worsened 10-15 dB HL since last year. He had been coming to our clinic for several years for annual evaluations, and I expected that explaining results wouldn't be particularly eventful. Still, we asked the client to come into the hearing aid room so that we could explain results and discuss amplification.

What I didn't anticipate was ... the patient's reaction to the results.

While I explained how to interpret the audiogram, the client was very quiet. I talked about pitch and loudness and sounds that those with normal hearing perceive at various frequencies. I then described the amount of hearing loss that was displayed on his audiogram. We talked about what sounds might be difficult for him to hear, and we used the speech banana as a visual aid. Throughout the explanation, the client remained silent.

Then, when my supervisor and I talked with him about the change in his hearing from last year and the possibility of amplification, the client became visibly upset. At that point, he began to open up about the increased difficulty with communication that he has been facing and the mounting tension between he and his wife. In part, he seemed relieved that he could tell his wife that he actually had a hearing loss. He even asked for a copy of his audiogram so that he could explain it to her. Conversely, he also seemed deeply saddened that his hearing had deteriorated.

My supervisor and I spent some extra time talking with him and counseling him about amplification options. However, he just didn't seem ready to pursue amplification at that time. I talked with him about making an appointment for a later date if he ever decided that he would like to try amplification.

The most important thing that I learned from this experience was ... Sometimes, irritability masks a more profound problem. In this case, I think he was afraid to learn the outcome of our test results. This was a great learning experience that emphasized the importance of being kind and patient with all clients ... especially the crabby ones!

In the article "How Personality Types Correlate with Hearing Aid Outcome Measures," the authors sampled 21 adults ages 60-80. All individuals had mild to moderate bilateral, symmetric SNHL and were first-time hearing aid users. Subjects underwent a HE and a HAE and also completed the COSI and the Myers-Briggs Type Indicator (MBTI). From the MBTI, 16 possible personality types could emerge from combinations of 4 personality dimensions: 1)extroversion vs. introversion; 2)sensing vs. intuition; 3)thinking vs. feeling; 4)judging vs. perceiving. After 4 and 8 weeks of hearing aid use, participants were asked to rate the degree of change resulting from hearing aid use, and the COSI was re-administered in order to monitor perceived benefit. These results were compared to established personality types in a correlational analysis.

The authors found several trends. A moderate negative correlation was found between perceived hearing aid benefit and the thinking and judging personality types. On the other hand, a strong positive correlation was found between perceptive individuals and their perceived benefit from amplification. Using this information, clinicians could informally assess patients personality preferences and use results to tailor appropriate informational counseling. In particular, it may be necessary to spend more time counseling "thinkers" and "judgers" about realistic expectations.


http://www.audiologyonline.com/theHearingJournal/pdfs/HJ2005_07_pg28-34.pdf

Week 3, Spring 2008

Today, I saw client with an interesting case history and pattern of test results. Also, first and foremost, she was a very sweet lady.

The client had previously visited our clinic due to auditory fullness and ear pain related to middle ear infections approximately one year ago. She was advised to seek medical attention at that time.

At the current visit, the patient described medical conditions including hypertension and rheumatoid arthritis. Medications used to lower blood pressure and used to manage inflammation and pain, secondary to rheumatoid arthritis, were taken regularly. The patient also reported “a cotton ball feeling” in her left ear and intermittent high frequency tinnitus lasting less than one minute. Her tinnitus was described as alternating between her ears. Head trauma from a car accident occurred in the 1980s. CAT scan results following the accident were normal, according to the client’s account.

Two episodes of true vertigo were reported. The first episode was approximately five to ten years ago and lasted at least two hours. The patient fell unconscious for a few minutes at work and was hospitalized. No conditions seemed to initiate or worsen the attacks. Meclizine was prescribed by the patient’s physician in order to manage future attacks, if needed. The second episode was also five to ten years ago and occurred at home. The patient reported a sensation, which she characterized as “spinning in bed and moving down a tunnel,” that lasted for approximately four to five hours. When she was hospitalized for the second episode, her physician reported that her blood pressure was extremely elevated. Continued use of Meclizine during attacks was the recommended course of treatment at that time.

Recent bouts of shingles, within the past few years, were noted as well. The first outbreak occurred eight or nine years ago. Symptoms included sores on the thoracic region up to the left side of the neck and head, including a sore on the left ear. A vision specialist was consulted, at that time, due to concerns about viral attacks on the optic nerve. A hearing evaluation was completed by the client’s ENT specialist following episodes of shingles; however, the client was not able to remember the exact results of that evaluation.

Residual numbness along the jawline has not remitted since the onset of shingles outbreaks. The client is currently undergoing evaluation for subcutaneous growths of unknown pathology around the shoulders and neck on her left side and will soon have an MRI.

Otoscopy revealed a subcutaneous node behind the left ear. Normal ear canals and clear, intact tympanic membranes were observed bilaterally. A normal (Type As) tympanogram from the right ear and a normal (Type A) tympanogram from the left ear were observed. Acoustic reflexes were tested ipsilaterally and contralaterally at 500, 1000, and 2000 Hz bilaterally. Normal ARTs were found with right ipsilateral and left contralateral stimulation. Absent ARTs were observed with left ipsilateral and right contralateral stimulation. Stimulation beyond 105 dB HL was not attempted due to tolerance problems and reports of associated nausea. Reflex decay did not occur in the left ear at 1000 Hz with contralateral stimulation. Right contralateral reflex decay could not be tested due to absent ARTs.

Normal hearing sensitivity in the right ear was observed. A unilateral, mild sloping to moderately-severe, high-frequency sensorineural hearing loss was documented in the left ear, beginning at 4000 Hz. Asymmetry of 10-35 dB HL between ears was found at all test frequencies with the most pronounced difference, of 35 dB HL, occurring at 6000 Hz. Significant asymmetries, of greater than 10 dB HL, were observed from 4000 to 8000 Hz.

Speech recognition thresholds were normal and in good agreement with pure tone averages bilaterally. However, a pronounced difference, of 15 dB HL, in SRT was noticed between ears, with the right SRT at 10 dB HL and the left SRT at 25 dB HL. Word recognition scores were excellent bilaterally with no outstanding ear differences.

The client had normal hearing sensitivity in her right ear, and a mild to moderately-severe high-frequency sensorineural hearing loss in her left ear. Significant asymmetries, of greater than 10 dB HL, were observed from 4000 to 8000 Hz. Case history information, including multiple bouts of shingles and an immunocompromised system, is highly suggestive of viral etiology. A viral insult on the vestibular branch of the VIII nerve also is suspected due to complaints of true vertigo. Reports of left-sided facial numbness and absent acoustic reflex thresholds on the probe side, ipsilateral to the shingles-effected side, were consistent with potential VII nerve involvement.

Results were discussed with the client, and a release of medical information was signed. Following client contact with her primary care physician, findings from the hearing evaluation performed at our clinic will be faxed to the appropriate medical facilities. The client was strongly encouraged to request an ENT consultation during or following a previously-scheduled MRI, which was intended to evaluate the nodes on her shoulder. Following neurootologic evaluation by a physician, the client was asked to return to our clinic every six months for follow-up hearing evaluations. In addition, a formal vestibular evaluation may also be warranted. Lastly, the client was advised to consult an ENT specialist immediately if sudden changes in her sensory perception occurred.

Because I am not a medical doctor, I couldn't make a specific conjecture about the origin of the patient's symptoms in my report in or in my discussions with her. However, in my blog, I will!

I think that this patient has Ramsay Hunt Syndrome (RHS). Varicella-zoster virus (VZV) reactivation causes zoster lesions in the auricle or oropharyngeal epithelium, as well as facial paralysis (FP) in patients with Ramsay Hunt syndrome(RHS). RHS is frequently complicated by disorders of the auditory nerve, such as hearing loss, tinnitus, and vertigo.

This article, Varicella-Zoster Virus Load and Cochleovestibular Symptoms in
Ramsay Hunt Syndrome by Fumio Ohtani, MD; Yasushi Furuta, MD; Hiroshi Aizawa, MD; Satoshi Fukuda, MD, compared two sets of patients with RHS.

Twenty-nine patients exhibited acute facial paralysis (FP) along with cochleovestibular symptoms (CVSs) and were categorized as group 1. Twenty-four of these patients also had zoster lesions on the skin or the oropharyngeal epithelium, and the remaining 5 patients did not have zoster lesions. In group 2, comprised of 27patients, cochleovestibular symptoms were absent. Those 27 patients also had acute FP and zoster lesions on the skin or oropharyngeal epithelium.

The study aimed to examine the association between varicella-zoster virus (VZV)reactivation and the onset of CVCs. They performed this analysis by analyzing saliva and blood samples. Results were somewhat inconclusive, but they did make some conjectures based on their findings.

They suspected that CVSs in RHS might be caused not only by the spread of inflammation to the cochleovestibular system through VZV reactivation in the geniculate ganglion, but also by reactivation of VZV in the spiral and/or vestibular ganglia themselves.

Importantly, prompt monitoring and treatment of clients with RHS is essential to appropriate care, as are necessary referrals.

http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=20255771&site=ehost-live

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=39&hid=116&sid=5b7088be-e3c7-45f7-9df3-20ac14811b59%40sessionmgr108

Week 2, Spring 2008

This week, I saw a 20 year old college student who indicated that he has had difficulty processing auditory information in the classroom since enrolling in college. He reported a history of reading problems as a child. A neck surgery, due to an infection in the muscle, was noted, but no other outstanding medical history was provided.

Ear canals were clear, and tympanic membranes were visible and intact bilaterally. Tympanometry revealed normal, Type A, results bilaterally; however, the left TPP was slightly negative. Acoustic reflexes were normal for both ipsilateral and contralateral stimulations bilaterally.

Pure tone audiometry revealed normal thresholds at all test frequencies. Speech recognition thresholds were 15 dB HL bilaterally and were in good agreement with pure tone averages. When performed at 30 dB SL, word recognition scores were excellent, at 100%, bilaterally.

For the APD evaluation, the SCAN-A, the Auditory Fusion Test-Revised (AFT-R), and Staggered Spondaic Word Test (SSW) were administered. The SCAN-A is a screening measure that taps into many different types of processing. The AFT-R is a temporal processing test, and the SSW is a dichotic listening test that requires binaural integration. The client was normal on all test measures and did not exhibit any patterns on the chosen tests that suggested an APD. However, the client still reported difficulty understanding orally-presented information, particularly when background noise was present. These complaints occurred with normal hearing and no obvious APD.

Strange you say?!???!

That's what I thought too ... I found an article that represented a syndrome that causes problems that are similar to my client's complaints. The following article, Distortion Product Otoacoustic Emissions in Patients with King-Kopetzky Syndrome, by Fei Zhao and Dafydd Stephens details a comparison of a control group and a group with suspected King-Kopetzky syndrome.

http://web.ebscohost.com/ehost/pdf?vid=7&hid=107&sid=57c0ad2a-5431-4a2d-bd6d-82ab981bccc1%40sessionmgr102

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=4&hid=106&sid=55fb21cd-5a39-4c5b-b0a2-4842d09d2093%40sessionmgr108

King-Kopetzky syndrome (KKS) is thought to be a multifactorial disorder with possible autosomal dominant inheritance. The chief complaint of those with KKS is hearing difficulties, particularly in noise, in the presence of normal pure tone thresholds. Although those with KKS have "normal" hearing, the test group in this study have thresholds averaged over 0.5 - 4 kHz that are significantly worse than age/sex-matched normals. Psychological factors, such as anxiety and depression, psychoacoustical factors, such as peripheral or central HL, and hereditary factors, such as family history and late-onset, dominant genetic inheritance may all contribute to KKS. The authors noted that KKS is present in 1% of ENT clinic patients complaining of problems with their ears or hearing and in 5-10% of those reporting hearing problems at audiology clinics.

This study used 35 males and 35 females ages 16-50 with one person per gender for each calendar year. All subjects had normal hearing, defined as thresholds better than or equal to 20 dB HL between 250 and 4000 Hz in the poorer ear. No threshold between 250 & 8000 Hz could be poorer than 30 dB HL. No other obvious signs of difficulty or signs of conductive pathology could be present. The control group had no recent hearing problems, and the KKS group had recently sought help for hearing difficulties, particularly understanding speech in noise.

TEOAE, DPOAE, and SOAE testing was performed. For TEOAEs, BB nonlinear clicks of 77 dB SPL (+/- 3 dB) were used. Clicks were presented for 80 usec at a rate of 50 clicks/sec. Responses were found when 260 sweeps were averaged with 50% or better reproducibility. A 0.5-6 kHz pass-band was used, and responses greater than or equal to 3 dB above the noise floor were considered "passes." When a statistical significance level of 0.05 was used, a significant difference was found when the normal responses of the control group (96%) and the KKS group (77%) were compared.

For DPOAEs, an f2/f1 ratio of 1.22 was used, and L1 = L2 = 70 dB SPL. Higher intensity levels were used because TOAEs were absent for many of the subjects in the KKS group. The response at 2f1 - f2 was analyzed. The global mean levels of the DPOAEs were significantly lower in the KKS group, and mid-frequencies (1.398-5.582 kHz) were most negatively affected.

Lastly, SOAE testing was performed, and fewer SOAEs were found in the KKS group.

This study indicated that a decrease in DPOAEs in the KKS groups from ~1-6 kHz (with the exception of 4 kHz) may indicate an area of minor dysfunction of the OHCs. Consideration of DPOAEs, case history, and probable subcategories of KKS may guide rehabilitation. (The subcategories are as follows: 1)ME dysfunction, 2)mild cochlear pathology, 3)central/medial olivocochlear efferent system auditory dysfunction, 4)purely psychological problems, 5)muliple auditory pathologies, 6)combined auditory dysfunction & psychological problems, 7)unknown.) Finally, additional testing, medical, &/or psychiatri referrals may be needed if patients seemingly have normal peripheral and central hearing, but persistently claim to have difficulty with speech in noise.

Although I did not do DPOAE testing with my client, that may be warranted in the future. However, when I saw him, I recommended compensatory classroom strategies, such as moving to the front of the room and asking for handouts of orally-presented material, to address his difficulties. I also recommeneded that he should seek additional disability services in our University's Disability Services Office.

Week 1, Spring 2008

Clinic started off this semester for me with an interesting client. The client was an older man who had suffered from tinnitus for about 25 years. He stated that his tinnitus had been "cured" nearly 20 years ago following 6 years of treatment with various tinnitus masker devices.

Recently, the client reported a return of symptoms. Since the return of bothersome tinnitus, the client first sought assistance from a certified audiologist at our clinic. She completed initial testing including otoscopy, tympanometry, pure tone AC and BC testing, tinnitus pitch matching, and a tinnitus questionnaire. She found normal outer and middle ear appearance and function. Her results for pure tone testing were described as inconsistent and not reliable because the client repeatedly coughed and moved while she was presenting stimuli. Therefore, she recommended repeating pure tone testing in order to determine reliable thresholds.

Findings regarding tinnitus revealed bilateral, generally tonal, high-frequency tinnitus that fluctuated in intensity. The client noted that the tinnitus was sometimes equal in both ears and sometimes perceived as more intense in the left ear. Although persistent, he reported that tinnitus was sometimes pulsating. Relaxation, sleep, and tinnitus maskers decreased his perception of tinnitus while silence made tinnitus worse. A history of noise exposure and current noisy activities, previously regular use of aspirin, and occasional feelings of aural pressure were noted.

Results from the tinnitus questionnaire revealed that the client believed his tinnitus had re-emerged due to exposure to a moderately-loud sound. The questionnaire also uncovered the client's feelings of sadness and moodiness since the return of his bothersome tinnitus. The client was aware of his tinnitus during 50% of his waking hours and was disturbed by it 50% of that time. Patient counseling regarding hearing loss as the likely origin of his tinnitus and discussion about treatment options occurred at the time of his initial visit. However, the audiologist reported that conversations about hearing loss were not particularly well-received, but that the client was willing to try amplification in order to treat his tinnitus.

When I saw the client, he was scheduled for a HE and HAE. In order to help combat some of the patient's obvious apprehension, we talked through some of the case history information again, and he told me more about his tinnitus. He discussed his recent use of a prescribed anti-anxiety medication, and he suggested that he was finding some relief. He denied having any trouble hearing, although he was not able to understand me without use of visual cues. Since the audiologist's report suggested that the client may not be cooperative, my supervisor recommended that I move directly to pure tone and speech audiometry. Results of pure tone audiometry revealed a bilateral sensorineural hearing loss. At low and mid-frequencies, the client's hearing loss was mild to moderately-severe and generally flat. Beyond 3000 Hz in the right ear and 2000 Hz in the left ear, a sloping moderate to severe sensorineural loss was discovered.

A modified speech recognition threshold (SRT) procedure was used to find the lowest level at which the client could accurately repeat low and mid-frequency phonemes in the CID W-1 spondees. The modified SRT was 50 dB HL bilaterally. Word recognition testing was performed at a loud conversation level of 60 dB HL. WR scores were 88% for the right ear and 70% for the left ear. WR scores were good, but below normal, when stimuli were presented at a loud conversational level in an optimal, sound-treated environment. However, in normal reverberant environments at home and in social situations, the client would likely have significant difficulty understanding even loud conversational speech.

Most comfortable loudness levels were obtained at 65 dB HL in the right ear and 55 dB HL in the left ear. During QuickSIN administration, 3 word lists were given, and a mean score of 15.5 revealed a severe signal-to-noise loss.

Bilateral amplification with directional microphones, feedback control, and automatic gain control was recommended. The client was a good candidate for CICs; however, he preferred the look and available features of miniBTEs with RITE technology. Preliminary discussion about amplification occurred, but additional patient counseling was needed. Therefore, the patient was encouraged to return for additional hearing aid consultation following medical clearance.

The following article: Clinical Guide for Audiologic Tinnitus Management I: Assessment by James A. Henry, Tara L. Zaugg, Martin A. Schechter was written about current practices for assessing and treating clients with tinnitus.

This article describes a minimal test battery for those who have tinnitus. This minimal test battery includes the following:

-1. Written questionnaires
-2. Tinnitus Intake Interview
-3. Audiologic assessment
a. Pure-tone thresholds
b. Spondee thresholds
c. Tinnitus loudness and pitch matching
d. MMLs and RI
e. LDLs (only if a sound tolerance problem is reported)
f. Word recognition scores
g. Tympanometry (reflex testing is generally not advised for tinnitus
patients who often have reduced tolerance to sound)
-5. Hearing aid assessment (if needed).

The authors suggested the test battery in this order so that sound stimulation would be minimized prior to obtaining thresholds for pure tones and speech. They stated that sound stimulation can trigger tinnitus, so saving suprathreshold testing for after threshold testing could be of great benefit.

I wanted to talk briefly about some of the tests that I did not perform, including MML and RI testing. MML stands for minimum masking level. The procedure suggested includes instructing the patient to raise their finger (for unilateral tinnitus) or corresponding fingers (right for RE and left for LE for bilateral tinnitus) when they can no longer hear their tinnitus.

For unilateral MMLs, you would present BBN in the ear with tinnitus and ascend in 1 dB steps until the tinnitus is not heard. Then, you would ask the client if they could hear the tinnitus in the contralateral ear.

-If so, you would keep the noise constant in the ipsilateral ear and begin
presenting noise in 1 dB ascents in the contra ear until the tinnitus is not
heard.

-If not, record that level as the MML.

For bilateral MMLs, lock the stimuli ascents so that they are raised in equal increments in both ears. Continue ascending in 1 dB steps until a patient raises at least one finger. When one finger is raised, keep that level constant and continue raising the level in the other ear until the patient signals that they cannot hear their tinnitus. Record both MMLs.

RI testing can also be performed following MML testing. "RI refers to the phenomenon whereby the tinnitus perception is reduced in intensity, or eliminated altogether, following auditory stimulation." "A clinical procedure was developed
that demonstrates the effect in 80%–90% of patients." Reportedly, RI lasts less
than 2 min in 60% of patients, and less than 4 min in 80% or patients. Thus, clients must be made aware of the limitations of this phenomenon, but it can be used as a counseling tool when discussing the benefits of noise generators or amplified environmental noise from hearing aids. RI IS NOT PART OF TRT though!

An abbreviated explanation of RI is as follows: 1. present BBN at 10 dB SL above the MML for 1 minute, 2. following the cessation of the noise, clients should rate their perception of their tinnitus, 3. rate the level of their tinnitus ~ every 10 seconds for 2-4 minutes or until their tinnitus returns to its orginal level. 4. varioius averages can be computed.

All and all, treatment of clients with tinnitus is something very new for me. Sorry if I bored anyone, but I got into all of this! If you'd like more info., this article was a good reference. Enjoy!

http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=17870819&site=ehost-live

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=3&hid=106&sid=55fb21cd-5a39-4c5b-b0a2-4842d09d2093%40sessionmgr108