Exam 1 - Intro and Assessment pt. 1

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an individual who, by virtue of academic degree, clinical training, and license to practice and/or professional credential, is uniquely qualified to provide a comprehensive array of professional services related to the audiologic identification, assessment, diagnosis, and treatment of persons with impairment of auditory and vestibular function, and to the prevention of impairments associated with them
Father of audiologyRaymond Carhart (1912-1975) -developed speech audiometry -medical administrative corps (assisted 16k war veterans with HL) -northwestern: 1st academic program in audiologyWhy does audiology matter?-30 million people in US have a HI -impact of hearing and balance -psychosocial and emotional consequencesAudiologist scope of practice1. prevention 2. identification 3. assessment 4. rehabilitation 5. advocacy/ consultation 6. educational/ research/ administrationstate licensure for audiology-course work -2000+ hours of clinical practicum -praxistraining in breadth of topics-physics -anatomy and physiology -psychology -neuroscience -electronics -geneticsspecialties in audiology-Medical Audiology -Educational Audiology -Pediatric Audiology -Dispensing/Rehabilitative Audiology -Industrial Audiology -Tele-Audiology -Forensic Audiology -Recreational & Animal Audiologymedical audiology-hospitals, physician, VA, etc. -diagnostic in nature -management of hearing and balance disorders -hearing screening (newborns) -hearing monitoring -treatments with medications that cause HL -intra-operativeeducational audiology-rehab, monitoring equipment, classroom amplification -school environment -works with SLPs and teachers of Deaf community duties: -identification -fitting of devices -ensuring working of devices -recommending improvement for class acoustics -training other personnelpediatric audiology-diagnostic and hearing aid fitting, support -evaluate hearing in children -fit hearing aids, cochlear implants -monitor progress -work with facilities for device uptake -works with SLPsdispensing/rehabilitative audiology-private practice, clinics -dispense hearing aids and related technology -adjust hearing aids -works in hospitals, physicians office, private clinicsindustrial audiology-noise measurements, monitor hearing, etc -monitor noise levels in industries -design hearing conservation programs (awareness, monitor hearing, consult to reduce noise level) -fit hearing protection devicestele-audiologyThe use of electronic and telecommunications technology to provide distance audiology services -80% of those with hearing loss live in low and middle income areas -overcomes barriers to care such as geographical, cultural, and financial barriersforensic audiologyoften called to serve as expert witness in court cases that involve issues pertaining to the nature and extent of hearing loss caused by some compensable actionanimal audiologyA new and small specialty area of audiology focusing on the hearing of non-human animals, in particular canineswhat can SLPs do?-hearing screening -therapeutic aspects of audiology rehab -basic checks of HA -multidisciplinary teamshow can you test human hearing1. air conduction (AC) 2. bone conduction (BC)parts of the auditory systemperipheral (before the brain) -outer ear -middle ear -inner ear -auditory nerve central (in the brain) -auditory brainstem -auditory cortexouter ear structureincludes pinna/auricle, ear canal, and tympanic membraneouter ear functioncollects sound, directs sound, protection, amplification, localizationouter ear sound transmissionvia air vibrationpinna structuremade of cartilage held together by ligaments and covered in epidermis (skin)parts of the pinnahelix, scapula, anti helical fold, antihelix, antitragus, fossa, concha, external auditory meatus, tragus, lobulehelixouter rim of the earscaphaThe groove between the helix and the antihelix.antihelical foldA fold that is just inside the rim of the ear.antihelixthe inner rim of the earantitragusA small eminence obliquely opposite the Tragus on the superior border of the lobe of the ear.fossadepression in superior portion of pinna between helix and conchaconchathe concave shell of the ear; the deepest depression of the earexternal auditory meatusear hole in the temporal bonetragusCartilaginous projection anterior to the external opening of the earlobuleearlobefunctions of pinnafunneling, amplifying, sound localizationear canal (external auditory meatus) structurestructure: lined with skin, two curves that form an s-shaped pathway -outer 1/3: cartilaginous, contains hairs and sebaceous (oil) and ceruminous (wax) glands -inner 2/3: bony, derived from temporal bone, thin skin and more sensitiveear canal (external auditory meatus) functiondirects sound to eardrum, amplifies higher frequency sounds, protects the eardrum from foreign bodies, debris, temperature, humidityeardrum (tympanic membrane) structuretwo main portions: 1. pars tensa- greatest surface area of TM is taut, contains all 3 layers 2. pars flaccida: at top of TM, tissues are looser and only contain outer and inner layers three layers: 1. outer layer- seen from ear canal, made of skin 2. middle layer- tough, fibrous connective tissue which contributes most to the TM's ability to vibrate 3. inner layer- lined with mucous membrane umbo= point of greatest retractioneardrum (tympanic membrane) function-moves in a complex pattern in response to sound pressure -it is in contact with the ossicular chain -responsible for efficiency of energy transfer through the middle earmiddle ear cavitynarrow-air filled, in the temporal bone behind the ear drum that houses the ossicular chainossicular chain-malleus: manubrium is imbedded in the tympanic membrane -incus: connects malleus to stapes -stapes: footplate of stapes pushes into the oval windowmiddle ear muscles1. tensor tympani- pulls inward on malleus and tenses eardrum 2. stapedius- stabilizes the stapes, adds stiffness to ossicular chaineustachian tubeA narrow tube between the middle ear and the throat that serves to equalize pressure on both sides of the eardrum -in adults, at 45 degree angle downward -children it is almost horizontal -first 1/3 surrounded by bone, remainder surrounded by elastic cartilage -cartilage keeps the tube closed -opens during swallowing, yawning, sneezingfunction of middle ear-impedance mismatch, protection from loud sounds (kinda), tuningimpedance mismatchproblem: when sound travels from air to water, 98% of energy is reflected back, which equates to 30 dB loss in energy -to match impedance of liquid with air, the middle ear needs a way to match and prevent loss of sound energy by intensifying sounds between air and fluidhow to overcome impedance mismatch1. area ratio: sound pressure collected over the surface area of the TM is concentrated on the smaller surface area of the oval window (20x smaller than TM). 26 dB in pressure gain 2. lever action: malleus and incus act as a level. longer the lever, less force required, which means output force is greater than input force. 2.3 dB in gainacoustic reflex1. protection: suggests that it protects the inner ear from damaging sound levels. unlikely because it has a delay 2. tuning: activation of ME muscles stiffen the ME system, attenuating low-frequency sounds. this is why humans can hear while eating, talking, communicating in noisy environmentseustachian tube function-provides pressure equalization between middle ear space and ear canal to maximize mobility of TM and transmission of sound -drains secretions from middle ear to keep it ventilated. connects to nasopharynx. in kids it is more horizontal, leading to less drainage and more ear infectionshow much hearing loss would we have without the ossicles?28-30 dBossicles/ middle ear are adult size by ___birthhow much energy gets reflected back without the middle ear?98%inner ear structurelocated in temporal bone 1. cochlea (hearing) 2. vestibular system (balance)cochlea functiona coiled, bony, fluid-filled tube in the inner ear through which sound waves trigger nerve impulses -frequency analyzer -contains organ of corti which has hair cells that are the sensory receptors of hearingvestibular system functionthree semicircular canals that provide the sense of balance, located in the inner ear and connected to the brain by a nerve -utricle and sacculeWhat are the three inputs that contribute to balance?utricle, saccule, semicircular canalsutriclefluid-filled chamber in the inner ear that detects changes in gravitypurpose of vestibular mechanism1. prevent falling 2. accurate perception of body in the environment & direction and speed of movement 3. maintain a clear visual image of the external world while the individual or environment is in motionsacculeA small, fluid-filled sac under the utricle in the vestibular system that responds to static positions of the head.function of inner ear1. transduce mechanical energy from middle ear into electrochemical signal sent to the auditory nervous system where sound is processed in the brain 2. provide info to the brain regarding body's position and movement in spacecochlea structure-scala vestibuli (top of cochlea) -scala media (middle of cochlea) -scala tympani (bottom of cochlea) -reissner's membrane -basilar membrane -organ of corti -hair cells -tectorial membranescala vestibulifilled with perilymph, begins near the oval window; high sodium concentrationscala mediafilled with endolymph, contains large concentration of potassiumscala tympanifilled with perilymph, contains large concentration of sodiumreissner's membraneseparates scala vestibuli from scala mediabasilar membraneseparates scala media from scala tympaniorgan of cortisensory organ of hearing -lies within scala media -sits on basilar membranehair cellsThe hairlike sensory receptors for sound, which are embedded in the basilar membrane of the cochleatectorial membranegelatinous flap that is fixed on its inner edge and forms the overlying membrane of the organ of corti -stereocilia on tips of outer hair cells are embedded in this membrane -direction that the stereo cilia bend determines if nerve cells are stimulatedouter hair cells structure-tube-like shape -three rows -12,000-15,000 -nerve fiber to OHC ratio is 1:10; one nerve fiber to many OHCsouter hair cell functionmechanically amplify soft sounds (active stimulation) -motility (shortens and lengthens by pulling and pushing in response to stimulation) -movement adds energy to signal by enhancing motion of basilar membrane enhance reception of sound by IHC -IHC are stimulated by basilar membrane movement; when OHCs contract and expand, BM movement is enhanced and IHCs are stimulated -without assistance of OHCs, IHCs are limited to stimulation from the motion of the fluid and only respond to sounds above 60 dB SPL (passive stimulation)inner hair cells structure-flask shaped -one row -3,000 -nerve fiber to IHC ratio is 20:1; many nerve fibers to one IHCinner hair cell functionsend auditory signal to brainwithout inner hair cells, we would bedeafwithout outer hair cells, we wouldhave 60 dB SPL hearing lossfrequency analyzerstapes moves at oval window. creates pressure differential in scala vestibuli and tympani, displaces basilar membrane (and organ of corti).frequency and amplitude coding-frequency: place of maximal displacement of BM -amplitude: amount of displacement of BMBM physical composition-narrow and stiff at base (near stapes) -wide and flaccid at apex (near helicotrema)BM tuning-tonotopic organization; frequency specific -high frequency at base and low frequency at apex -every place on the BM has a maximal displacement corresponding to a particular frequencywavelength and location of stimulationlow frequency sound has a longer wavelength and shows maximal displacement near apical end of the cochlea high frequency sound has shorter wavelengths and shows maximal displacement near basal end of cochleatraveling wave theory-describes how frequency is coded by place in the cochlea -theory that sound waves move in the cochlea from its base to its apex along the basilar membrane; the crest of the wave resonates at a particular point on the basilar membrane, resulting in the perception of a specific pitchstiffness gradient creates a special wave patterntravels from the base up toward the apex, called traveling wavelocation (place) of traveling wave peak along the basilar membrane depends on the ____ of the soundfrequencythe traveling wave is the mechanism that translates ___ into ____ along the BM.signal frequency; place of stimulationthe basilar membrane and tectorial membrane move, giving rise to:1. the stereocilia moving as a result 2. activation of hair cells leading to excitation of associated auditory neurons and transduction of the signal to the brainmain stations of ascending pathwayCCSLIMA Cochlea? Cochlear Nucleus Superior Olivary Complex Lateral Lemniscus Inferior Colliculus Medial Geniculate Body Auditory CortexCANScentral auditory nervous system -processes signals for recognition of sounds -localization, attention, pattern recognition -controls attention to target sounds in background noise -assign recognition and meaning to soundo What connects the peripheral and auditory pathways?the auditory nerveIn what station does binaural processing begin (what station is the first to receive inputs from both ears?superior olivary complexstages of sound transmissionAcoustic energy, in the form of sound waves, is channeled into the ear canal by the ear. Sound waves strike the eardrum, causing it to vibrate (like a drum) and changing the acoustic energy into mechanical energy. The malleus (bone), which is attached to the eardrum, starts the ossicles into motion. The stapes moves like a piston in the oval window of the cochlea creating a mechanical-hydraulic energy. The fluid movement within the cochlea causes membranes in the cochlea to move against some particular cells. This movement creates an electrochemical signal which is sent via the auditory nerve up through the central auditory nervous system to the brain, where sound is interpreted.When you hear through air conduction, sound travels through what?Depends on outer ear (OE), middle ear (ME), inner ear (IE), and neural pathways beyondWhen you hear through bone conduction, sound travels through what?Depends on function of inner ear (IE) and beyondconductive hearing lossWhen sound is unable to transfer through the outer and middle ear with normal function air conduction (AC) is affected but bone conduction (BC) is not inner ear is intact, but either outer or middle ear is compromisedperceptual consequence of CHLattenuation (decrease) of sound volumesensorineural hearing lossoccurs when the cochlea or auditory nerve are compromised bone conduction (BC) is affected OE and ME are intact but not the IE perceptual consequence: attenuation of volume, and reduced clarity, of soundmixed hearing losswhen the outer ear/middle ear AND inner ear are compromised AC and BC is affectedcase historypatient's subjective account of symptoms an attempt to obtain an account of the patient's life and factors that might contribute to the present conditionparts of case historyHearing-related Medical/health-related Hearing aid history (if applicable)how does case history helpGathering pertinent information helps to shape the clinicians initial impressions of the hearing disorder and how it may impact/limit the patient's activities, successful participation in social, educational, and vocational aspects of life may lead to communication with or referral to one or more other professionals who may contribute to patient's overall care ease the patient/family members and promote needed rapportHow do you perform otoscopy on patients? Adults vs children?adult: -describe what will be done -hold still -indicate if there is pain -monitor patient during the procedure -pull pinna back and up child: -hide otoscope -shine light on hand so they can see it won't hurt -"look" in patient's ear -distract with bubbles or toys -pull pinna back and downotoscopyvisual examination of the ear canal with an otoscopewhat are you looking for in an otoscopy?1. deformity of pinna 2. active drainage 3. impacted cerumen 4. no visible tympanic membrane 5. foreign object 6. microtia 7. atresia 8. stenosis 9. collapsing canalsmicrotiaunderdeveloped pinnaatresiaabsence of normal body openingstenosisnarrowingwhat parts of the ear can be visualized with otoscopy?post-aurical area, pinna, ear canal, tympanic membraneyou touch the wall of a patient's ear canal, what reflex can occur?cough or sneeze vagus nerve (CN X)pinna/area deformitiesatresia, anotia, pre-auricular pit, skin tagear canal deformitieswax/cerumen foreign bodies collapsing ear canal debris/pus skin conditionlandmarks of the tympanic membrane-annulus -pars tensa -pars flaccida -malleus (manubrium and short process) -umbo -cone of light -quadrantsannulus of tympanic membraneouter ringpars tensathick, taut, central-inferior section of tympanic membranepars flaccidasmall, slack, superior section of tympanic membranemalleusfirst of the three auditory ossicles of the middle earumboknob of the malleus that shows through the tympanic membranecone of lightreflection of light from otoscope; 5 o'clock in right ear 7 o'clock in left earquadrants of the tympanic membraneposterior superior anterior superior posterior inferior anterior inferiorWhen looking at the tympanic membrane, how do we know what ear we are looking at?if the cone of light is on the right side, it is the right earexostosessmall, hard, bony protrusions in the lower posterior bony portion of the ear canalotitis externainflammation of the outer earotitis mediainflammation of the middle ear and tympanic membranePE Tubes of Otitis Mediapressure equalization tubes between ear canal and middle ear act as a Eustachian tube allowing air into the middle ear and help prevent fluid formation and infectionHow do audiologists report on otoscopy?can only report what they see, not diagnose "...suggestive of..."cerumena waxy substance secreted by sebaceous (fatty/lipid/oily) and ceruminous glands (modified apocrine sweat glands)why do problems with cerumen matter?-plug your patients' hearing aids and assistive listening devices -may also interfere with a hearing screeningWho is more likely to experience cerumen accumulation?-no obvious gender diff -Elderly (coarser hairs, narrower ear canals, etc.) -People with hearing aids (ear molds block cerumen from exiting ear canal) -people who sweat a lotways cerumen can be removedmechanical, irrigation, suctionmechanical removal of cerumencurettes, loops, hooks, forcepsirrigation removal of cerumenroom temp water syringes, electrically poweredcerumen softening agentsTriethanolamine Mineral oilyou can't perform irrigation if you can't see the eardrum because:impaction, hole in eardrum, push it farther incontraindication of cerumen removalEar drum perforation Middle ear infection Ear canal injury/ inflammation do not perform if you cannot see the eardrumpure tone audiometrya procedure that is used to assess hearing sensitivity at discrete frequenciespure tone stimuliused for audiometric testing; have energy at discrete frequencies presented at various hearing levelsgoal of pure tone audiometrydetermine degree of hearing loss, configuration, and typefrequencies tested for air conduction (AC)between 250 Hz and 8 kHzfrequencies tested for bone conduction (BC)between 250/500 Hz and 4 kHzfrequencyunit: Hz perceptual equivalent: pitchintensityunit: dB perceptual equivalent: loudnesspuretone stimuli used in audiometry-continuous -pulsed -warble tone/frequency modulatedsoundfield testingpresenting sound through a loudspeaker Cochlear implant testing Hearing aid testing Pediatric testing DOT examstransducerssupraaural headphones circumaural headphones insert earphonessupra aural headphonesearphones that rest on the pinna with a diaphragm aligned with the opening of the external auditory canalcircumaural headphonescushion fits around pinna, used for high frequency testinginsert earphonesDisposable foam tip is inserted into the ear canal Avoids the potential for a collapsing ear canal pinch and roll foam to insert Aim for full insertion - lateral end of tip flush with ear canal entrancewhat do we measure in pure tone audiometry?threshold - lowest intensity at which a patient is able to detect pure tonesAC and BC testing helps us determine the ____ of hearing losstypeAC tests what?the whole system (conductive and sensorineural) if there is an HL with AC pure-tones, then test BCBC tests what?tests sensorineural (bypasses the conductive system)do you need both AC and BC to determine the type of HL?its best if they are both tested. if AC fails, then test BC. if BC is better than AC, there is a conductive hearing loss. if AC and BC are equal (no ABG) then the patient either has normal hearing or sensorineural HL.clinical threshold procedure1. familiarization -present stimulus at a presumed audible level -1000 Hz tone is initially presented for 1-2 sec at 30 dB HL 2. if YES response: threshold search begins -decrease tone intensity in 10 dB steps until the patient stops responding -increase intensity in 5 dB steps until patient responds (first response) -repeated until the patient responds at least twice of three presentations (has to be in the ascending runs) 3. if NO response: increase stimulus level until the patient responds as follows: -present the tone at 50 dB HL and then in successive increments of +10 dB until a response is obtained -threshold search beginsthresholdLowest level at which patient can correctly identify at leasttwo out of three ascending presentations at a single intensity levelwhy present tones for 1 - 2 seconds with variable silent intervals (3 - 5 sec) between presentations?that way, the participant will not catch on whether that is subconscious or notwhat does "no response" mean?if thresholds are not found at maximum levels possible, it is marked on the audiogramWhat is the recommended frequency to start testing for pure tone audiometry?1000 Hz tone is initially presented for 1-2 sec at 30 dB HL then complete higher octaves (2000, 4000, 8000 Hz) then repeat 1000 Hz Continue with 500, 250, 125 (if needed) Hz AC then BCthreshold for normal hearing-10 to 15 dB HLthreshold for slight hearing loss16 to 25 dB HLthreshold for mild hearing loss26 to 40 dB HLthreshold for moderate hearing loss41 to 55 dB HLthreshold for moderately severe hearing loss56 to 70 dB HLthreshold for severe hearing loss71 to 90 dB HLthreshold for profound hearing loss>91 dB HLpure tone average (PTA)The average of hearing threshold levels in dB HL. The pure tone average is usually at test frequencies of 500, 1000, and 2000 Hz. These frequencies are in the speech frequency region. useful for predicting threshold for speech audiometry provides info about degree of HLair bone gap (ABG)the difference, in decibels, between the air conduction threshold and the bone conduction threshold >10 dB no ABG in sensorineural and normal hearing patients some degree of ABG in conductive or mixed HLIn what types of HL would you see an ABG?conductive or mixed hearing lossconfiguration of HLshape of the hearing loss Refers to the degree and pattern of hearing loss across frequencies illustrated in audiogramslopinglow frequency sloping to high frequency hearing loss thresholds are worse as frequency increasesrisinglow frequency rising to high frequency hearing loss thresholds are better as frequency increasescookie-bitethresholds are worse at mid frequenciesnotchnotched high frequency hearing lossstability between earsstable progressive sudden fluctuatingstableno significant change over time (<_10 dB change)progressivehearing loss. becomes worse over time (>10 dB change)suddenmore than 30 dB HL over at least 3 frequencies in less than 72 hoursfluctuatinghearing loss changes over time sometimes improves, sometimes worsenssymmetrythreshold comparison between ears bilateral unilateral asymmetrybilateral symmetrical hearing losshearing loss is similar between both ears (<15 dB between ears)unilateral hearing losshearing is normal in one ear but there is hearing loss in the otherasymmetry hearing lossmeans the degree or configuration are different between ears (>_ dB is considered asymmetrical) at three contiguous frequenciesA licensed audiologist must have certification from ASHA to practice in any statefalseThe peripheral auditory system is made up of what three divisions?outer ear, middle ear, inner earwhat is one function of the outer ear? -the pinna attenuates sound in speech frequencies -external auditory meatus directs sound -tympanic membrane vibrations transfer mechanical energy to acoustic energy -auricle repels soundexternal auditory meatus directs soundthe middle ear space consists of three middle ear bones called ___ossiclesthe middle ear converts sound pressure waves into ___ vibrations -chemical -neural -mechanical -acousticmechanicalwhat is the purpose of the eustachian tube? -to keep the tympanic membrane vascularized -to vibrate the ossicles -to equalize pressure on either side of the tympanic membrane -to equalize fluid on either side of the tympanic membraneto equalize pressure on either side of the tympanic membraneto which ossicle is the stapedius muscle attached? -stapes -mastoid -malleus -incusstapesthe middle ear matches impedance in two main ways:area ratio, lever actionthe tensor tympani is activated by normal conversational level soundsfalsethe muscles responsible for the acoustic reflex contract and decrease the stiffness of the ossicular chainfalsewithout the middle ear, ____% of sound energy would be reflected back out the ear canal98the area of the oval window is ___ times smaller than the area of the tympanic membrane -25 -10 -15 -2020what is the goal of pure tone audiometry? -determine if there is normal hearing -determine if there is hearing loss -determine if hearing loss is sensorineural -determine if hearing loss is conductivedetermine if there is hearing losswhat types of signals are used in audiometry? -warbled tones, pulsed, continuous -continuous, pulsed -frequency modulated, warbled tones, continuous -pulsed, warbled toneswarbled tones (frequency modulated), pulsed, continuouswhat transducers are used to present signals? -bone oscillator, insert earphones, supra-aural headphones, aural headphones -insert earphones, supra-aural headphones, aural headphones, circum-aural headphones -supra-aural headphones, circum-aural headphones, insert earphones, bone oscillator -aural headphones, insert earphones, bone oscillator, circum-aural headphonessupra-aural headphones, circum-aural headphones, insert earphones, bone oscillatorwhat is the recommended frequency and level to start testing for pure tone audiometry? -60 dB @ 1000 Hz -30 dB @ 500 Hz -60 dB @ 500 Hz -30 dB @ 1000 Hz30 dB @ 1000 Hzwhat are the two common types of patient response errors? -false negative, false positive -true negative, false positive -false negative, true positive -false positive, true negativefalse negative, false positivethreshold is the lowest intensity at which a patient can detect pure tonestruecerumen is made up of secretions from the sebaceous and ceruminous glandstruecerumen can be removed from the ear canal by professionals in the following ways: -irrigation, mechanical, suction -mechanical, irrigation, q-tip -suction, q-tip, irrigation -none of these methodsirrigation, mechanical, suctionthe purpose of case history is to -obtain the patient's subjective account of symptoms -obtain an account of the patient's life and factors that might contribute to the present condition -all of the above -none of these optionsall of the abovewhen conducting otoscopy on a pediatric population, the pinna should be pulled: -up and back -down and back -up and forward -down and forwarddown and backinfection in the ear canal is known as: -acute otitis -otitis media -otitis media with effusion -otitis externaotitis externaaudiologists perform diagnostic otoscopyfalse