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OTITIS MEDIA Otitis media (OM) may be defined as inflammation of the middle ear due to any cause. OTITIS MEDIA -- DIAGNOSIS Children with acute otitis media frequently present with sudden onset of fever, ear pain, and fussiness. OTITIS MEDIA -- COMPLICATIONS Complications of acute otitis media were common in the pre- antibiotic era.
HEARING LOSS Conductive hearing loss Cerumen impactions Swelling of the external auditory canal Tympanic membrane perforation Middle ear fluid Ossicular chain abnormalities Sensorineural hearing loss Injury to hair cells in the cochlea or neural elements innervating the hair cells.
HEARING LOSS -- AUDIOMETRY Hearing threshold levels are determined between 250 and 8000 Hertz (Hz) for pure tones and measured in decibels (dB). HEARING LOSS -- AUDIOMETRY A conductive hearing loss in the left ear due to otitis media with effusion.
HEARING LOSS -- AUDIOMETRY This audiogram suggests noise exposure that may be encountered occasionally in younger individuals who have been exposed to hazardous or “toxic” noise.
HEARING LOSS -- TYMPANOGRAM Tympanometry is commonly used to evaluate the tympanic membrane (TM) and middle ear status.
Three tympanograms demonstrating change in compliance of the middle ear (vertical axis) with changes in ear canal pressure. OTITIS EXTERNA Otitis externa (OE) is an inflammation or infection of the external auditory canal (EAC), the auricle, or both This condition can be found in all age groups. OTITIS EXTERNA -- CONSIDERATIONS Ramsay Hunt syndrome, more accurately known as herpes zoster oticus, is caused by varicella-zoster virus (VZV) infection.
OTITIS EXTERNA -- TREATMENT Commonly used topical eardrops are acetic acid drops (which decrease pH), antibacterial drops, and antifungal preparations.
DIZZINESS Patients frequently present with a complaint of “dizziness,” including symptoms such as disequilibrium, syncope, lightheadedness, ataxia, and vertigo. DIZZINESS – VESTIBULAR TESTING Vestibular testing can be performed to help determine whether the problem exists within the vestibular (balance) portion of the inner ear. DIZZINESS – VESTIBULAR TESTING There are four main parts to ENG testing Calibration test, which measures rapid eye movements Tracking test, which evaluates the ability of the eyes to track a moving target Positional test, which measures responses due to head movements Caloric test, which measures responses to warm and cold water introduced to the ear canal.
BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV) One of the most common causes of vertigo is benign paroxysmal positional vertigo (BPPV). BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV) BPPV can usually be successfully treated with a canolith reposition maneuver (Epley or Semont maneuver) in the office setting.
Bedside maneuver for the treatment of a patient with benign paroxysmal positional vertigo (BPPV) affecting the right posterior semicircular canal. LABRYNTHITIS -- TREATMENT Treatment is symptomatic Vestibular suppressant medications (meclizine) Antiemetics Short, tapering course of oral steroids It may take several weeks for symptoms to completely resolve Residual vestibulopathy that persists for months or even years is not uncommon, and is best managed with vestibular rehabilitation. Who are our clients with hearing loss and how can we best facilitate effective communication?
What are the characteristics of hearing loss and what are ways of diagnosing and treating people with hearing loss?
How can vocational rehabilitation professionals appropriately prepare to serve consumers with hearing loss? Where can people with hearing loss find current information, long-term support and tools for self-advocacy?
The case history is typically taken first and is essential to ensure the best hearing evaluation and management possible. The first question asked of any patient is ‘Why are you here today?’ Understanding what problems the patient him- or herself may be experiencing with hearing is important and will help the audiologist with the rest of the evaluation. Does the person have trouble on the telephone, watching television, in restaurants, hearing signaling sounds such as the doorbell, smoke detector or alarm clock. Does the person have any medical conditions, such as wax build up,  bleeding from the ears, earaches, or had surgery on the ears? Tympanometry is the name of the test used in audiology to find out how well the middle ear is transmitting sound.
Type A Tympanogram – This result indicates normal function of the eardrum and middle ear. Type B Tympanogram – Audiologists see a Type B usually when there is fluid filling up the middle ear space (red line). Type C Tympanogram – This result tells us the person’s Eustachian tube isn’t working well. There are two muscles in the middle ear, the stapedius and tensor tympani, that contract when people hear a loud sound. Audiologists measure the acoustic reflex to look at whether a person’s nerves in the reflex pathway are working correctly. The difference here, compared to regular hearing, is that the sound triggers the nerve that makes the stapedius muscle contract, so that information is traveling down to the ear from the brainstem rather than from the ear all the way to the brain. See the gray region of the CPT Codes for those used by audiologists for tympanometry and acoustic reflex decay.
Over the last three decades, particularly since the 1980s, scientists have made many discoveries about how the cochlea works. OAEs refers to the sound that the outer hair cells in the cochlea actually sends out through the middle ear and ear canal when they are working properly.
These OAE sounds are very faint, and to be detected a special machine that has a very sensitive microphone is placed into the ear canal. Outer hair cells can echo back sounds because scientists have discovered that the outer hair cells, but not the inner hair cells, have muscle fibers inside them that cause the cells to move up and down.
Functioning outer hair cells are important for hearing to occur, but they are not the same thing as ‘hearing’.
There are currently two types of OAEs that are measured in audiology clinics: distortion product otoacoustic emissions (DPOAEs) and transient evoked otoacoustic emissions (TEOAEs). Picture A below is the result one gets with DPOAEs, while Picture B is the result with TEOAEs. B) The blue areas represent the emissions from various pitches in this ear while the red areas represent the noise in the room at the time of measure. When most people think about a hearing test, they typically think of pure tone testing, raising your hand when you hear some beeps.
Hearing thresholds are measured at several pitches, or frequencies, given in cycles per second or Hertz: 250, 500, 1000, 2000, 3000, 4000, 6000 and 8000. In the 1940s a couple of engineers at Bell Laboratories performed an experiment to figure out what pitches were important for understanding speech. It is important to test hearing along these two pathways because that allows the audiologist to diagnose whether a hearing loss is conductive (the problem is in the outer or middle ear or both) or sensorineural (the problem is in the cochlea or more rarely in the nerve). Below are several audiograms to demonstrate conductive versus sensorineural hearing losses on paper. In an audiogram, soft sounds are indicated at the top (-10, 0 dB HL, etc.) and very loud sounds at the bottom (110 or 120 dB HL).
Symbols located anywhere between -10 to 25 dB HL are considered to be in the normal loudness range for adults.
Audiologists have several different ways to describe the results of pure tone testing, which can be quite confusing.
A second way audiologists may talk about a hearing loss is to describe the configuration across frequencies, for example, a sloping sensorineural hearing loss or a flat conductive loss. Before going further, the field of audiology has renamed one of the speech tests that we generally give patients. When the SRT is measured, the audiologist is looking for the softest level that a person can repeat words correctly 50 percent of the time. The QuickSIN is a set of six sentences which is played at the same time four people are talking at once; this type of noise is called “speech babble”. Both the sentences and speech babble are presented from a speaker directly in front of the client. The sentences and babble are played through both headphones simultaneously, with one ear done then the other. However the test is administered, the result is given as a signal-to-noise ratio, which represents how much louder the speech needs to be compared to the noise for the client to correctly repeat back 50% of the sentences. Verbal communication requires at least two individuals, and thus it’s important to involve family members and other significant communication partners in the hearing evaluation, hearing aid fitting and assistive technology assessments processes. Geneticists generally are medical doctors while genetic counselors most often have earned master’s degrees in genetic counseling.
Hearing aid dispensers are licensed in the states in which they practice, although this may vary by state, as will other requirements. The ear-nose-throat (ENT) doctor is oftentimes quite important in treatment for hearing and balance problems. Additionally, the ENT is the surgeon who will perform cochlear implant surgery as well as bone anchored implant surgery.
The speech-language pathologist (SLP) has earned a master’s degree and all states require licensure to practice. In the case of adults with acquired hearing loss, SLPs will most often be called on to provide audiologic or aural rehabilitation. In terms of interacting with the audiologist, the VR counselor can be quite helpful for the client if they let the audiologist know the various pieces of information that are needed. Williams syndrome (WS) is a rather rare congenital disorder characterised by a series of cardiovascular, maxillo-facial and skeletal abnormalities. Surgical Sciences Department, Otolaryngology Section, University of Udine School of Medicine, P.


JavaScript is currently disabled, this site works much better if you enable JavaScript in your browser. Due to: persistent noise exposure, age-related (presbycusis), genetic factors, and infectious or postinflammatory processes. The 0-dB level is “normalized” to young, healthy adults and doesn’t mean there is absence of detectable sound.
Note that bone conduction thresholds are normal in both ears, but air conduction on the left is 30 dB poorer than that measured on the right. Note that low-tone thresholds are relatively normal, with a drop in thresholds at higher frequencies. This test assesses the mobility of the TM and its response to pressure changes in the external auditory canal. Type A is normal, with the greatest compliance at the point where the pressure in the ear canal is equal to that of atmospheric pressure (peak is at 0). If the condition does not respond to treatment as expected, an otolaryngologist should evaluate the patient. It is characterized by facial nerve paralysis and sensorineural hearing loss, with bullous myringitis and a vesicular eruption of the concha of the pinna and the external auditory canal (EAC). True vertigo (an illusion of motion) is primarily associated with the balance organs of the inner ear. BPPV is caused by sediment, such as calcium carbonate crystals, that have become free floating within the inner ear.
Dislodged otoliths repositioned into the vestibule is about 80 percent effective in eliminating symptoms of BPPV. The presumed position of the debris within the labyrinth during the maneuver is shown in panels A–D. It is thought to be caused by inflammation, secondary to a viral infection, of the vestibular portion of the eighth cranial nerve or of the inner ear balance organs (vestibular labyrinth). This is important to know because that person’s  history of and attitude toward hearing health care and amplification can have a large impact on the course of treatment. They can also see a Type B when there is a hole in the eardrum (blue line) that will be higher on the graph than the fluid. Understanding the functioning of the cochlea proved more difficult than understanding the eyes or smell, for example, because the cochlea is hard to get to, tucked inside the hardest bone in the body, the temporal bone. However, scientists and audiologists aren’t sure right now whether these represent different ways for the cochlea to work, so they are considered to be interchangeable.
The main difference between the two is that to get  DPOAEs two pure tones are played into the ear canal simultaneously to cause the echo and to measure TEOAEs the sound sent into the ear canal is a click. These results indicate normal or ‘robust’ emissions from this ear. They were interested in this question because they wanted to determine how much bandwidth they needed to put into telephone lines. The first (photo A) is regular earphones that fit either over the ears or into the ear canals (photo B). This earphone sits on the skull on the bony piece behind the ear (mastoid process) or it might be placed on the forehead. A medical referral for individuals who have conductive hearing losses is most often made, unless that person is already under a physician’s care for the problem or they have been told by their physician that no further medical treatment is available. On an audiogram for air conduction thresholds, Xs are used to denote air thresholds for the left ear and circles for the right ear.
The lower on the audiogram a symbol is located, the louder the listener needs it to be in order to detect it. If the symbols are physically lower on the audiogram, graphed next to higher numbers on the Y-axis, that person has hearing loss. One method is to calculate the pure tone average, which is typically the average of the air thresholds at 500 Hz, 1000 Hz and 2000 Hz.
The report received from the audiologist will, most likely, state the degree of hearing loss based on the pure tone average, but this is not always done. Also included are probable characteristics for that DEGREE of hearing loss, that is, how ‘bad’ the hearing loss is, in terms of day-to-day communication. They can benefit from amplification, particularly ‘open-fit’ technology (see the Hearing Aids and Implants module for a description). Ross’ website, which displays two vastly different hearing loss configurations that will likely result in different challenges to the listener, but each ear has the same pure tone average. There are two types of speech testing that are always performed as part of a routine hearing evaluation: speech reception threshold (SRT) and word recognition in quiet. In the past we performed what was called ‘speech discrimination’ testing; now that same test is called ‘word recognition’ testing.
The words used in the SRT test are 2-syllable words called spondees and are generally spoken by the audiologist.
The volume of the speech stays the same and the volume of the speech babble starts off fairly soft but gets louder as the test goes on.
Research has been done for individuals with normal hearing, and those values are the standard that clients with hearing loss are compared to. They must have a graduate degree; formerly audiologists needed a master’s degree to practice and must now have a Doctor of Audiology degree (AuD). That person needs to inform the professionals about their communication needs, particular situations in which they are having problems, medical history, work history and communication needs at work, how the hearing loss is impacting their daily life, lifestyle and emotional state. It is becoming clear that most hearing losses have a genetic component, if not a complete genetic basis. As of December 2011, 10 states require an Associate’s Degree to be a hearing aid dispenser, another 31 require a high school diploma or GED, and the remaining 9 are silent on the minimum education required. There may be state-to-state variation in whether an audiologic evaluation performed by a hearing aid dispenser can be used by the VR Counselor except to establish eligibility.
If an individual has a conductive hearing loss it is possible that surgery will improve the situation or even cure the problem, depending on its exact nature.
This therapy will consist of listening to speech sounds with the hearing device, learning how the sounds may be slightly different than with no hearing loss. For example, speech in noise testing isn’t always completed by the audiologist, but that information is critical for understanding functional limitations. It sometimes displays otorhinolaryngological symptoms because of the relatively high incidence of secretory otitis media and hyperacusis, which may be present in up to 95% of patients. There are two common variants: (1) acute otitis media (AOM) and (2) otitis media with effusion (OME). There is decreased movement of the eardrum on pneumatic otoscopy (insufflation of air into the ear canal).
Mastoiditis -- Patients with acute mastoiditis present with fever, ear pain, and a protruding auricle. Some patients hear 0 dB, but reaching the threshold of hearing usually requires louder test signals.
This is a consequence of the normal aging process and may vary widely from patient to patient. Type B demonstrates very poor compliance at any frequency, suggestive of a tympanic membrane (TM) immobilized by fluid in the middle ear or a TM perforation (no peak). Skull base osteomyelitis occurs most often in patients who are diabetic or immunocompromised.
Rotatory chair testing is the “gold standard” for diagnosing bilateral vestibular weakness. Turning the head quickly or into a certain position, causes this free- floating material to move the endolymph in the inner ear, stimulating the vestibular division of the eighth cranial nerve. This question can help the audiologist establish the origin of the hearing loss, although  that cannot always be determined. If a patient reports dizziness the audiologist will most often include a physician referral for that patient in the recommendations. Audiologists are interested in determining how easily sound travels through the middle ear to the cochlea, the end organ of hearing because that helps them figure out if someone has a hearing loss, as well as how much and what type of hearing loss they may have. Type C might also be seen in a person with upper respiratory challenges, such as someone with allergies. Some people think this reflex is there to help protect their ears from loud sounds; it may protect them a little, but in general the reflex happens too slowly to prevent that loud sound from getting to the cochlea. The process looks complicated, but basically sound travels through the system in the usual way: ear canal through the middle ear to the cochlea and up the nerves. However, one discovery that was theorized around 1948 and proven in 1978 is a phenomenon called otoacoustic emissions, or ‘OAEs’. This entire process is ‘hearing,’ but if the cochlea isn’t working well, the information that gets to the brain cannot be comprehended.
The squares represent the measure of noise present in the room when the emissions were measured.
The audiologist is seated outside the room behind an audiometer (as seen below in the photo).
When considering that the frequency range of human hearing, in the absence of hearing loss, is from 20 Hz to 20,000 Hz and every frequency in between, a pure tone hearing test does not give audiologists very much information.
Using their results we can split the pitch range into 2 pieces at 1500 Hz; 35% of speech information is in the lower half, between 20-1500 Hz, and 65% of speech information is above 1500 Hz.
This testing is called air conduction pure tone testing because the sound is conducted through the air into the ear canal and the middle ear to the inner ear, as in everyday life.
The tones sent to the ear through the bone conductor do not travel through the ear in the normal way.


Sometimes if one ear is much worse than the other the audiologist has to send a noise (static) to the better ear to keep it busy while they are testing the worse ear. An audiologist decides whether a hearing loss is conductive or sensorineural by looking at the relationship between the air conducted and bone conducted thresholds.
This value is then compared to the scale in the table below, and the degree of hearing loss is assigned according to the pure tone average.
The volume increases until the final sentence, when the speech and background noise are the same volume. This speech in noise measure is used during the counseling process to quantify how difficult it is for the client to understand speech in noise, compared to someone without hearing loss.
Most states have grandfathered audiologists who have a master’s degree but not an AuD degree.
Based on test results and case history information, the audiologist may recommend that the client and the client’s family seek genetic counseling. In contrast, the surgeon may need to operate on the 8th cranial nerve (the vestibuloacoustic nerve) and sever the nerve completely, thus wiping out hearing and balance information from that ear.
The present paper describes a case of WS associated with bilateral conductive hearing loss which was not related to secretory otitis media. Ears Otitis media Hearing loss Otitis externa Vertigo Nose Sinusitis Allergic rhinitis Epistaxis Throat Strep.
Common bacteria that cause acute OM in children are Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Meningitis With increasing antibiotic resistance, especially Streptococcus pneumoniae, these complications may again become more common.
Type C represents a tympanogram in which the compliance of the membrane is greatest at a point where the pressure in the canal is 200 mm of water below that of atmospheric pressure (peak shifted to the left). The patient is slowly spun in a rotating chair and dizzinessis is measured with optokinetic testing and a fixation test.
The Dix-Hallpike test is performed with the patient’s head rotated 45? toward the right ear, and the neck slightly extended with the chin pointed slightly upward. The patient will usually awaken with room-spinning vertigo that will gradually become less intense over 24–48 hours. Tinnitus in and of itself can be problematic; however, and determining how bothersome it is for a particular patient is necessary for appropriate management. When this situation occurs, the person can experience an earache, or otitis media, which is what many children experience, particularly in the winter months. A Type C tympanogram may or may not have hearing loss accompanying it, but even if not, the person may feel stopped up and sound can be muffled. The audiologist plays out a series of tones and the client is told to raise their hand, say ‘yes’ or push a button whenever they hear a tone, even if the tone is very faint and they are not sure they even heard it. However, audiologists can develop an overall picture of the person’s hearing sensitivity in the various frequency ranges of low (250-500), middle (1000-3000) and high (4000-8000) pitch ranges.
This is important because most individuals with hearing loss first lose high frequency information, which can impact the understanding of speech even though it may not affect the loudness of speech. Instead, the bone conductor makes the skull vibrate and those vibrations are carried directly to the inner ear, bypassing the outer and middle ears. In those cases the symbols used change and squares are used for the left ear, triangles for the right. If the bone symbols are normal but the air symbols are poorer than 25 dB HL, that person has a conductive hearing loss. While describing a hearing loss based on a single loudness level may be convenient, it often does not capture the difficulty that listener may have in day-to-day listening situations. After, he became an audiologist and university professor spending his career educating audiologists and trying to help audiologists understand the difficulties people with hearing loss can have.
During this test the volume is changed such that the person will clearly hear some of the words but will not be able to understand others when they are very soft, which is normal. Best audiology practices say that this list of words should be presented from a recording, although that may not occur in every clinic.
In recognition of this fact, many audiologists are now using some kind of speech in noise testing to supplement the basic evaluation, particularly for individuals who will be fit with hearing aids. Another use is after hearing aid fitting to document improved speech understanding in noise when listening in a noisy background. Whether the individual and family pursue the counseling option is, of course, a private decision.
A brief overview, by state, of various regulations for hearing aid dispensers may be found here. The reader is referred to the How section of this training for more in-depth information about all the help a VR counselor can provide. Requesting these specific types of information will help audiologists understand the information VR counselors need to best help the client. In healthy children older than two years of age who present with less severe symptoms, observation for 48 hours may be considered.
This suggests inefficient eustachian tube function with persistent negative pressure in the middle ear. The diagnosis is strongly suggested by a history of diabetes mellitus, severe otalgia, cranial neuropathies, and characteristic EAC findings. Moving platform posturography is a method of quantifying balance, but should not be used alone to diagnose vestibular disorders.
Medical therapy with vestibular suppressants is ineffective because the episodes of vertigo are so fleeting, and should be discouraged.
Otitis media often leads to reduced sound transmission through the middle ear, resulting in temporary hearing loss that resolves when the fluid drains out. As with most Type B tympanograms the hearing loss is temporary and hearing returns to normal when the underlying medical condition clears up. The softest sound that a person responds to at least 50 percent of the time is called the pure tone threshold. These divisions of frequency have served us well and will continue to do so because the low pitches are where much of the energy of the vowel sounds is and also energy in noises (such as air conditioners, groups of people talking). People with low frequency loss complain that speech is too soft, but they often can understand the speech better than individuals with a high frequency loss.
The result of word recognition testing is the percentage the individual repeated correctly.
Both of these certifications as well as most state licensure agencies require continuing education credits for audiologists. Often, the outcome of a genetic evaluation will have little impact on audiologic care, unless a condition is identified in which it is suspected that the hearing loss will worsen over time. During the audiogram, independent thresholds are determined for each ear for both air conduction (conductive hearing) and bone conduction (sensorineural hearing). It is most useful in quantifying balance improvement (or worsening) following treatment for a particular problem, and can help identify the functional dizzy patient.
Once the vertigo and the nystagmus provoked by the Dix-Hallpike test cease, the patient’s head is rotated about the rostral-caudal body axis until the left ear is down (panel B). If all the symbols are located close together on the audiogram and are poorer than 25 dB HL, that person has a sensorineural hearing loss. A second function of the SRT is as a comparison to the results of pure tone testing; the pure tone average and the SRT should agree within 5-10 dB. Most audiologists will count a word as incorrect if the person misses even one sound in the word.
In this situation, foreknowledge of that possibility would allow for future planning to manage the hearing loss appropriately. Treatment of the hyperacusis by acoustic training, instead, yielded excellent, long-lasting remission of the symptoms.
ECOG is not really a test of the vestibular system, but is a useful test of hearing in the evaluation of Meniere’s disease.
Instead, the bone conductor makes the skull vibrate and those vibrations are carried directly to the inner ear, by passing the outer and middle ears.
However, it is possible that a person has this gap with the bone thresholds poorer than 25 dB HL and the air thresholds even poorer.
For the most part audiologists will present 25 words to each ear, so the score listed will reflect the fact that each word is worth 4 percent of the total presented. The test is a variant of brainstem audio-evoked response and, if possible, should be performed during active Meniere’s attacks. This is called a mixed hearing loss and has a portion that is conductive and a portion that is sensorineural.
With the head kept turned toward the left shoulder, the patient is rought into the seated position (panel D).
Once the patient is upright, the head is tilted so that the chin is pointed slightly downward.



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