Diagnostic Pediatric Audiology from Birth to Intervention - PowerPoint PPT Presentation


PPT – Diagnostic Pediatric Audiology from Birth to Intervention PowerPoint presentation | free to download - id: 2a54a-NDViN


The Adobe Flash plugin is needed to view this content

Get the plugin now

View by Category
About This Presentation

Diagnostic Pediatric Audiology from Birth to Intervention


Infants with hearing loss diagnosed by 3 months ... Timely and Appropriate Diagnosis ... Use B-70 bone vibrator. Use mastoid placement. Pediatric ABR summary ... – PowerPoint PPT presentation

Number of Views:1694
Avg rating:3.0/5.0
Slides: 49
Provided by: fayemcco


Write a Comment
User Comments (0)
Transcript and Presenter's Notes

Title: Diagnostic Pediatric Audiology from Birth to Intervention

Diagnostic Pediatric Audiology from Birth to
  • Karen M. Ditty, M.S.
  • Antonia Brancia Maxon, Ph.D.

Timely and Appropriate Diagnosis of Hearing Loss
  • Newborns screened by 1 month
  • Infants with hearing loss diagnosed by 3 months
  • Amplification use begins within 1 month of
  • Benchmarks (JCIH, 2000)

Timely and Appropriate Diagnosis of Hearing Loss
  • Infants enrolled in family-centered early
    intervention by 6 months
  • Ongoing audiological management - not to exceed 3
    month intervals
  • Professionals working with these infants are
    knowledgeable about all aspects
  • Benchmarks (JCIH, 2000)

Newborns screened by 1 month
  • Approximately 90 of all newborns in the United
    States have their hearing screened at birth
  • The number of infants referred for diagnostic
    audiological evaluations has dramatically
    increased .

Infants with hearing loss diagnosed by 3 months
  • Progress has been made however it is affected by
  • Testing site may influence age of diagnosis
  • Goal is often met in hospital clinics
  • Less likely in non-hospital centers
  • Geographic access to services may influence age
    of diagnosis
  • Rural communities are less likely to meet the goal

Impediments to Lowering Diagnostic Age
  • Audiologists lack experience with very young
  • uncomfortable making the final diagnosis.
  • Defer to and refer for second opinion
  • Facilities do not have the equipment needed to
    assess very young infants.
  • Frequency specific ABR
  • AC and BC ABR
  • High frequency tympanometry

Impediments to Lowering Diagnostic Age
  • Audiologists are not familiar with clinical
    protocols necessary for making accurate diagnosis
    with very young infants.
  • Do not have norms
  • Cannot read ABR for this population
  • Inadequate number of audiologists with pediatric
  • No academic training to work with very young
  • No clinical training to work with very young

Aids to Lowering the Age of Diagnosis
  • Although there are no national protocols or
    standards many states have guidelines for their
  • These guidelines can be obtained via the
    following link on the NCHAM website
  • http//www.infanthearing.org/states/table.html

Aids to Lowering the Age of Diagnosis
  • Audiologists can get training through continuing
    education provided by national associations
  • NCHAM audiology training
  • Pediatric Diagnostics
  • Covers the initial diagnostic procedure
  • Pediatric Amplification Fitting
  • Covers behavioral assessment, hearing aid
    selection, fitting and validation and cochlear

Pediatric Audiologist
  • Have the appropriate audiological equipment and
    protocols for testing newborns and young infants.
  • Can evaluate a childs hearing within a short
    period of time after being contacted for an
  • Specializes in working with infants and young
  • Wants to work with infants and young children.
  • Has worked with Part C program in their state

Pediatric Audiologist
  • Is familiar with the procedures of the Part C
    system, including IFSP development and procedures
    for acquiring hearing aids or assistive
  • If dispenses hearing aids
  • can make earmolds,
  • has loaner hearing aids available
  • provides hearing aids on a trial basis
  • has resources to repair hearing aids quickly

Pediatric Audiologist
  • Is willing to review the test results of the
    audiological evaluation face to face with the
    family, respecting the Cultural Differences of
    family units.
  • Is willing to provide a comprehensive written
    report with a copy of the test findings in a
    timely manner.
  • Is willing to continue to explain results at
    follow-up evaluations

Pediatric Diagnostic Test Battery
  • Comprehensive Case History
  • Frequency-Specific Auditory Brainstem Response
  • High Frequency Probe Tone Tympanometry
  • Transient and/or Distortion Product Otoacoustic
  • Hearing aid Fitting with Real Ear Measurements
  • Behavioral Audiometry
  • Referrals

Comprehensive Case History
Frequency Specific Auditory Brainstem Response
  • Air Conduction Clicks
  • Abrupt or rapid onset of a broad frequency
    bandwidth .
  • Greatest agreement in the 2000-4000Hz frequency
  • Not enough information across the frequency range
  • Low frequencies absent

Frequency Specific Auditory Brainstem Response
  • Tonebursts
  • Provides information for narrower frequency
  • Better relates to pure tone audiogram
  • Bone-Conducted Clicks
  • Should get when either the click or 500-Hz
    tonebursts responses are not present at expected
    normal levels.

Frequency-Specific ABR
  • Accuracy of pure tone threshold estimates with
    tone burst ABR
  • High correlation (.94) for infants and older
    children (Stapells, et al, 1995)
  • 90 of ABR thresholds within 20 dB of PT
    thresholds with most within 10 dB
  • audiometric configuration does not affect
    accuracy of match (Oates and Stapells, 1998)

Frequency Specific Auditory Brainstem Response
  • Auditory Steady State Response (ASSR)
  • An electrophysiologic response, similar to ABR
  • Generated by rapid modulation of carrier pure
    tone amplitude or frequency.
  • Signal intensity can be as high as 120 dB

Frequency Specific Auditory Brainstem Response
  • Auditory Steady State Response (ASSR)
  • Done in conjunction with ABR Clicks, or on a
    separate occasions
  • Major advantage is it estimates
    severe-to-profound HL
  • Best used in conjunction with ABR and tone burst

ABR (Click and Tone Burst) versus ASSR Clinical
  • Advantages
  • Estimates normal hearing
  • thresholds
  • Ear-specific BC findings
  • Diagnosis of AN
  • Estimates severe to
  • profound HL
  • Disadvantages
  • Cant estimate profound HL
  • Skilled analysis required
  • Limited BC intensity levels
  • No ear-specific BC findings
  • Requires sleep or sedation

R. Ruth, 2003
Pediatric Sedation for ABR
  • Who and When
  • 4 months to 5 years
  • Options
  • conscious sedative
  • mild general anesthesia
  • Monitoring
  • administered and managed by nurse
  • monitor O2, HR and BP
  • crash cart and suction available
  • (J. Hall, 2001)

Pediatric Sedation for ABR
  • Negative outcomes associated with
  • overdoses, drug interactions
  • non-trained personnel
  • injuries on the way to facility (administered at
  • drugs with long half-lives (chloral hydrate,
  • (J. Hall, 2001)

Pediatric ABR summary
  • Air conduction measures should be done with
    insert earphones
  • Headphones can affect latency of waveform
  • Bone conduction measures are needed to rule out
    conductive loss or find conductive component.
  • Use B-70 bone vibrator
  • Use mastoid placement

Pediatric ABR summary
  • Use earlobe inverting electrodes
  • Use alternating tone burst to minimize artifact
  • A slower rate (e.g., 11.1/sec) enhances Wave I
  • Begin testing near maximum intensity (50 dB nHL)
  • Allows good waveform to be seen
  • Identify Wave I in ipsilateral ear to verify test
  • Plot I-L function of Wave V

Pediatric ABR summary
  • Air conduction measures should include frequency
    specific tone bursts and/or ASSR as part of a
    battery of electrophysiological tests.
  • Of the audiological test battery, only an ABR can
    help determine an auditory neuropathy case
    therefore, ASSR should not be performed alone,
    but as part of a battery of electrophysiological

High Frequency Probe Tone Tympanometry
  • Tympanometry provides information about middle
    ear status
  • add information to BC results
  • May be affected by conditions in very young
    infants ears
  • Ear canal and eardrum are very compliant
  • Use of high frequency probe tone (800 Hz or
    greater) increases reliability and accuracy in
    young infants.

Transient Distortion Product Otoacoustic
  • Infants and young children with normal hearing
    have robust
  • transient evoked otoacoustic emissions (TEOAE)
  • distortion product otoacoustic emissions (DPOAE)
  • TEOAEs and DPOAEs are easily measured in infants
    and children.

Middle Ear Effects on OAEs
  • Middle ear effusion may
  • obliterate emission
  • eliminate low frequency component
  • Negative middle ear pressure may
  • reduce amplitude, particularly in high frequencies

OAE Summary
  • OAEs are objective evidence of healthy cochlear
  • function
  • The vast majority of hearing impairment in the
  • population is a result of malfunction of the
    outer hair
  • cells
  • the most sensitive and vulnerable part of the
  • hearing mechanism tested by OAEs.
  • OAEs provide meaningful information when
  • retrocochlear lesions and/or auditory
  • are a concern.

Amplification Assessment and Fitting
  • Initiate amplification process immediately after
  • Includes medical clearance
  • Federal regulation - ENT
  • Includes earmolds
  • overnight mailing to get within 1 week
  • continue to remake to avoid fitting problems

Pediatric amplification fitting
  • Does not require exhaustive audiological data
  • Target audiogram
  • Individual ear information
  • Ability to conduct real-ear measures
  • Scheduling flexibility and immediacy
  • Experience with functional measures of benefit

Real Ear to Coupler Difference Procedure (RECD)
  • The infant ear is smaller than an adult ear
  • More SPL for same input compared to adult
  • Differences can be as large as 15-20 dB
  • Many hearing-aid fitting algorithms do not take
    these differences into account.
  • RECD affects estimates of
  • Threshold
  • Real-ear gain and output

Real ear measurement
  • The insert phone is coupled to the earmold
  • The probe microphone is placed into the ear canal
  • The earmold is inserted into the ear
  • Test stimulus is presented
  • Total test time 5-10 minutes per ear

  • After the RECD is obtained, all hearing aid
    testing can be done in the test box
  • RECD values are entered into the hearing aid
    fitting program to provide a more accurate
    estimate of real-ear aided gain and output
  • The RECD will change as the child grows. A good
    rule of thumb is to obtain a new RECD when a new
    earmold is needed

Basic Audiological Information Used to Fit
  • Hearing Sensitivity
  • ABR frequency specific information - low, mid and
    high frequency
  • Individual ear measures insert phones
  • Middle Ear Status
  • Tympanometry - high frequency
  • BC to rule out conductive loss

Basic Audiological Information Used to Fit
  • Cochlear status
  • ABR intensity-latency function
  • OAEs
  • Behavioral Responses
  • target audiogram
  • speech awareness

Behavioral Response Audiometry
  • Provides information about how an infant or young
    child uses hearing
  • Behavioral observation techniques can be used to
    give functional information
  • Sometimes only suprathreshold information is
  • will get better responses to speech than tones
  • Can look at amplification benefit

Behavioral Response Audiometry
  • Look at amplification benefit
  • Need to provide speech at greater than detection
  • Cannot learn language with threshold-only
  • All of normal conversational level speech needs
    to reach child through amplification

Speech Sounds
  • Range from softest to loudest speech sound 30
  • th ah
  • Low frequencies carry suprasegmental, vowel, and
    voicing information.
  • High frequencies carry consonant, perceptual, and
    syntactic cues.

Referral to and Enrollment in Early Intervention
  • Know established Part C guidelines in state
  • Know child eligibility criteria
  • automatic enrollment - diagnosed condition
  • significant developmental delay
  • Know state guidelines for selecting a program

Enrollment in Early Intervention
  • Develop Individualized Family Service Plan (IFSP)
  • All services
  • speech and language development
  • auditory development
  • assistive technology
  • Goals and objectives
  • Timelines

Components of IFSP for I/T with Hearing Loss
  • Amplification provision
  • Parent education
  • Audiological monitoring
  • Development of auditory skills
  • Communication development
  • listening skills - speech perception
  • speech production
  • language development
  • Monitoring middle ear status

Status of EHDI Programs Early Intervention
  • Many of the programs in the current system
    designed to serve infants with bilateral
    severe-profound losses
  • BUT, majority of those identified have mild,
    moderate, and unilateral losses
  • Programs and professionals not appropriate for
    children and families
  • Therefore, Part C of IDEA is severely under

Status of EHDI Programs Early Intervention
  • State Coordinators estimate
  • Only 53 of infants with hearing loss are
    enrolled in EI programs before 6 months of age
  • Only 31 of states have adequate range of
    choices for EI programs

Barriers to Early Intervention
  • 30-40 of children with hearing loss demonstrate
    additional disabilities that may affect
    communication and related development.
  • Families who live in under-served areas may have
    less accessibility, fewer professional resources,
    deaf or hard of hearing role models, or sign
    language interpreters available to assist them.
  • A growing number of children with hearing loss
    in the United States are from families that are
    non-native English Speaking.
  • JCIH, 2000

Pediatric Audiology
  • Pediatric Audiology with newborns and young
    infants can be challenging!

Pediatric Audiology
  • But also rewarding!

Some babies are born listeners..
  • If we
  • use the elements of an effective EHDI program
  • use the JCIH 2000 Benchmarks
  • use appropriate diagnostic protocols and
  • refer to early intervention
  • are active participants in early intervention
About PowerShow.com