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Author: admin, 26.07.2014. Category: Ring In The Ears

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. A very recent development is the capability to do screening audiometry on one's own cellphone.
The core method of pure tone audiometry is to present a series of tones in one ear, close to threshold (the loudness that the person can just barely detect), and keep dropping the intensity in 10 db steps until the person stops responding - -raising their hand or pushing a button. There are a few places where human input is needed because there are sometimes few decisions to make during hearing testing.
Of course, there are many far more complex decisions and thought processes that can potentially present in persons with hearing disorders.
For the most part, there is rarely a reason to do bone conduction if the air conduction audiogram is normal. Bone conduction testing in persons with hearing loss should be done with masking (see below) to prevent sound from the stimulated side from going over to the good side.
Practically, electrical devices (such as digital audiometers or CD players) will never drift in frequency or volume.
On the other hand, mechanical devices (such as headphones, and insert headphones in particular) nearly always break down over time.


As a result, these auralizations are only a very rough approximation to the sound perceptions of people who have hearing impairments. 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. Hopefully, in the next 10 years or so, most of the testing may be done by the public as software is becoming available to test hearing on smartphones and similar devices.
This is just a part of the entire human auditory range, which extends between 20 and 20,000 hz. Then the person testing the hearing goes back up in 5 db steps until the person starts responding again. The insert earphones have the advantage that they block out environmental noise, and they also have less of a tendency to be heard by the other ear. The reason to do this is to prevent sound from the side being tested from going over to the good side.
WRS has some limitations - - most of us don't communicate with monosyllabic speech, so a good score on the WRS may not necessarily correlated with good functional performance.
Every single part of the system that you use should be calibrated - -the electrical device that produces the sound, and the headphones or speakers that deliver the sound. Once their intensity is checked, formal electrical calibrations are more likely to cause trouble (i.e. This is not a severe hearing loss and ordinarily very little benefit would be obtained from a hearing aid. We think the most promising avenue is exploring more home testing -- we think smartphones with appropriate software, could hugely improve accessibility of hearing testing. 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. This will free up the audiologists to handle the difficult cases and give them more time to help people select hearing aids.
This will probably drastically change how hearing testing is done as one can now test hearing right away. Neverthless, most audiometers are designed so that they cannot go as low or high as most good stero systems. There are special symbols for the conditions underwhich the hearing test is done (see below). Their main disadvantage is that they are a little trickier to use (one has to insert them properly), and also that they give wrong readings in persons who have perforations of their ear drums. 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. When an otologist and audiologist or technicianwork together as a team, the otologist should tell the audiologist or technician whether or not bone is needed even if hearing is normal.
Of course your CD player's volume should be calibrated so that the volume of words presented is identical to the volume from your audiometer. Poor performance overestimates everyday communication impairment for patients with high frequency hearing loss. So there is a conflict between the financial needs of one's hearing equipment vendor and patient care.
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. 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. 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.
This is called a mixed hearing loss and has a portion that is conductive and a portion that is sensorineural.



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