Audiology Basics: Otoscopy, Hearing Screening & Amplification Overview
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Audiology Basics –
Otoscopy, Hearing Screening,
and Amplification
Arkansas Children’s Hospital
EARS Team
June 2018
Today’s Presenters
Jessica Newman, Au.D., CCC-A
Arkansas Children's Hospital – EARS Team
Darby Jackson, Au.D., CCC-A
Arkansas Children’s Hospital – EARS Team
Learner Outcomes
Perform a hearing screening
Complete basic troubleshooting for various types of
amplification
Recognize otoscopic findings which deem a referral
Perform otoscopy
Pure-Tone Testing
Protocol Summary
Pure Tone Screening
Rescreening (if did not pass 1
st
screen)
Referral
Follow-up
Reporting
Who to Screen
•
Students in grades Pre-K, K, 1, 2, 4, 6, 8 & transfer
students
•
Special education students & teacher referrals
Who NOT to Screen
Students who wear hearing aids, who have cochlear
implants or have documented hearing loss (by an
audiologist/MD) should NOT be screened
Remember To: Request documentation of a current
audiogram (should have annual hearing exam results
on file)
When to Screen
NOT
the first week of school
Children entering school for the first time
Need time to adjust to school environment
BUT you do not want to wait too long if a child DOES have hearing
loss
Don
’
t wait too long
Cold and Flu season
Need time for follow-up
Preparing for Screens
Know your equipment (Audiometer Controls)
Power (on/off)
Ear indicator (right/left)
Intensity selector (dB; e.g. 20 dB HL)
Frequency selector (Hz; e.g. 4000 Hz)
Signal selector (use continuous or pulsed tone only)
Presentation function (how you present the tone)
Annual Calibration (Summertime)
Headphone Placement
•
Place the headphones on student (red on right ear; blue on left ear)
•
Hair behind ears
•
Remove large earrings
•
May want to remove glasses
•
Diaphragm of headphones over ear canal
•
A
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u
s
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h
e
a
d
b
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f
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,
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f
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t
•
Head band on top of head is preferred
How to Screen
Instruct student for the task (e.g. raise hand when they
hear the beep)
Condition the student to the task (i.e. present a tone in
one ear at one frequency ABOVE the screening level –
example: 50 dB)
Once the student is conditioned – start the screening
protocol @ 20 dB HL
Screening/Rescreening Protocol
Right Ear
1000 Hz
20 dB
2000 Hz
20 dB
4000 Hz
20 dB
Left Ear
1000 Hz
20 dB
2000 Hz
20 dB
4000 Hz
20 dB
NOTE: Need to obtain 2 responses in each ear at each frequency for a
pass
Pass/Fail Criteria
Student must pass all frequencies in an ear for that
ear to be classified as a
“
pass
”
If a student does not pass ALL frequencies in each
ear, he/she should be re-screened in 2-4 weeks
25 dB is NOT a PASS!
Tips and Tricks for
Performing Hearing
Screenings
Do’s
DO find a quiet room
DO screen at 20 dB HL
DO present tone for at least 3 seconds
DO use pulsed tones if possible
Don’ts
Don
’
t require students to raise right or left hand
Don
’
t get into a pattern with your presentation of the tone
Don
’
t give visual cues-position audiometer controls out of
view
Don’ts
Don
’
t screen ear with known hearing loss
Don
’
t switch the headphones from one audiometer to
another. This changes the calibration for your machine. If
you have to get your headphones repaired or replaced,
your audiometer has to be re-calibrated
Play Audiometry
Use with students who are difficult-to-test, who are
developmentally delayed, or who are non-English speaking
Use a play task (drop blocks in a bucket)
Teach child the task at an elevated intensity level (e.g. 50
dB HL)
Make sure child can do on his own before you attempt
screening at 20 dB HL
Video Examples
Hearing Screening (Standard)
https://www.youtube.com/watch?v=r0EBvmz6x0A&list=PLStceB-
WlntRlSi7FXtKloLGlVUDtieKW&index=17&t=0s
Hearing Screening (Play Audiometry)
https://www.youtube.com/watch?v=_jBAYxeZw54&t=0s&list=PLStce
B-WlntRlSi7FXtKloLGlVUDtieKW&index=15
Hearing Screening (Difficult to Test)
https://www.youtube.com/watch?v=mfp6lI3bIcE&list=PLStceB-
WlntRlSi7FXtKloLGlVUDtieKW&index=16&t=0s
Referral
Refer immediately if you observe physical abnormalities that are not
documented in the student
’
s file
May immediately refer if child does not pass and there is serious concern
regarding hearing or speech/language development
Referral to EARS audiologist
Refer to MD or Audiologist if fails rescreen
Refer to MD or Audiologist if child passes, but there is concern regarding
hearing
Follow-Up
•
Send letter, referral form, and a list of appropriate professionals to
the parent/guardian (make sure school nurse contact info is on
referral form)
•
If no response from parent/guardian in 2 weeks, follow-up with a
phone call or personal contact
•
Review information received from examining professional
•
Rescreen after medical treatment if indicated
•
Collaborate with special education personnel if indicated
Basic Troubleshooting
for Various Types of
Amplification
Amplification
Hearing Aids
Cochlear Implants
Bone Anchored Implants/Softband (BAHA/BAI)
Troubleshooting – Hearing Aids
Hearing Aid Stethoscope
Daily Listening Checks
Batteries
Wipe down the earmold with an alcohol swab
Clean any debris from the earmold using a cleaning tool.
Visually inspect the earmold tubing for signs of moisture
(earmold blower)
Updates to HA technology: Rechargeable batteries and smart phone
programming
Troubleshooting – Cochlear
Implants
Batteries
Listening Earphones
LING 6
Visual inspection of cables
Troubleshooting – BAHA/BAI
Batteries/Power
Make sure the front cover is securely in place.
Check that the abutment is clean and clear of any debris and that the
device is correctly attached.
Ensure the softband is snuggly fit around
the head (loose handbands will lead to feedback).
BAHA/BAI Updates
Cochlear Baha Attract
Cochlear SoundArc
Video Demonstrations
Troubleshooting Hearing Aids
https://www.youtube.com/watch?v=UNQ8ue3Iz8M&list=PLStceB-
WlntRlSi7FXtKloLGlVUDtieKW&index=7&t=0s
Troubleshooting Cochlear Implants
https://www.youtube.com/watch?v=dvJgHe4Zna4&index=24&list=PL
StceB-WlntRlSi7FXtKloLGlVUDtieKW&t=0s
Troubleshooting BAHA/BAI
https://www.youtube.com/watch?v=Z0Ic3ZtQW5g&index=12&list=PL
StceB-WlntRlSi7FXtKloLGlVUDtieKW&t=0s
OTOSCOPY
What is Otoscopy?
Visual inspection of the outer portion of the ear and
make note of any abnormalities
Inspection of the external ear canal
Visualization of the tympanic membrane (eardrum)
https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935406§ion=Key_Issues
Outer Ear Anatomy
L
a
b
e
l
s
27 = Pinna or auricle
29 = External
auditory meatus or
ear canal
31 = Tympanic
membrane or eardrum
Visual Inspection of Outer Ear
Externally (*Without the otoscope)
Atresia: Closure of the ear canal
Stenosis: Narrowing of the ear canal
Anotia: Absence of pinna/auricle
Microtia: Congenitally, abnormally small pinna/auricle
Microtia and Atresia
http://www.atresiarepair.com/education-ear.html
Visual Inspection of Outer Ear
Externally (*without the otoscope)
Inspect the pinna and the area around it to note any
abnormalities
Position of the ears (set or tilt)
Tenderness
Redness or edema
Dermatitis
Ear Tag/Pit
Signs of drainage
Foul odor
Wax build up
Outer Ear Abnormalities
https://www.denochearing.com/wp-content/uploads/2016/01/oe5.jpg
http://printer-friendly.adam.com/content.aspx?productId=117&pid=1&gid=003304&c_custid=802
Visual Inspection of the Ear Canal
Tools Needed:
•
Otoscope
•
Specula
Image:
http://www.wms.co.uk/sharedimages/Zoom/W53203_2.jpg
http://www.insufflatorbulb.com/images/fiberoptic_otoscope_halogen.jpg
Steps for Completing Otoscopy
1.
Choose the largest speculum that will allow you to
see into the child’s ear canal and turn on otoscope.
2.
Check the ear canal for blockages or foreign bodies.
3.
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.
6
Steps for Completing Otoscopy
(continued)
4.
Brace your hand against the child’s head using your
fingers or the heel of your hand to prevent trauma
when the child moves.
5.
Straighten the ear canal for best viewing.
In children less than three years of age, grasp the earlobe and
gently pull down and out (speculum upward).
In children three and older, grasp the pinna and gently pull up and
back to straighten the canal (speculum downward and forward).
Normal Appearance of
Ear Canal and Eardrum
Little or no wax build up
Cone of light
Translucency of eardrum
Malleus/Umbo
http://i.pinimg.com/736x/b3/43/73/b3437373720788e8be7ca5ad303ed0cc.jpg
Otoscopic Exam
Internally (*with the otoscope)
Inspect the ear canal and tympanic membrane (eardrum)
Note presence or absence of normal tympanic membrane
landmarks.
Ear Canal
Drainage, wax buildup, foreign bodies, redness of the ear canal, and other
abnormalities
Tympanic membrane (eardrum)
Tympanosclerosis (scarring), fluid/otitis media, TM perforation, pressure
equalization (PE) tube
Drainage
https://www.treatcurefast.com/ear/ear-drainage-smelly-
clear-discharge-pus-blood-draining-from-ear/
Wax Impaction
Foreign Body
https://www.youtube.com/watch?v=B-YIszlMU_s
http://doctorimanrozali.blogspot.com/
2011/02/osce-ent.html
Fluid/Otitis Media (OM)
http://www.drmkotb.com/EN/index.php?page=students&case=&A=1&B=3&C=4
http://www.drrahmatorlummc.com/serousotitismedia.htm
TM (eardrum) Perforation
http://sydneyentclinic.com/sean-flanagan/patient-resources/hearing-
loss/tympanic-membrane-perforation/
https://app1.unmc.edu/medicine/heywood/otology/unit5-tympanic-
membrane-perforations.cfm
PE Tube
http://www.earcentergreensboro.com/medical-education/ear_tubes.php
http://www.entusa.com/ear_photographs_html/ear_tube_p
erforation-1.htm
Tympanosclerosis
https://www.mommaaddict.com/7-undesirable-ear-tube-complications/tympanosclerosis/
Referrals
Outer Ear Abnormality
Untreated Drainage
Wax Blockage
Foreign Body
Untreated Fluid/OM
Eardrum Perforation
PE tube lying in canal
Practice Otoscopy!
Questions/Comments?
Jessica Newman, Au.D., CCC-A
Arkansas Children's Hospital – EARS Team
NewmanJL@archildrens.org
Darby Jackson, Au.D., CCC-A
Arkansas Children’s Hospital – EARS Team
JacksonDL2@archildrens.org
References
http://www.asha.org/aud/Facts-about-Pediatric-Hearing-Loss.htm
https://www.phonak.com/us/en/support/children-and-parents/troubleshooting.html
https://www.oticon.com/support
http://www.arkansased.gov/divisions/learning-services/school-health-services/school-
nursing/health-screenings-in-schools
http://www.asha.org/content.aspx?id=10737451142
http://www.hearingloss.org/content/basic-facts-about-hearing-loss
nursing/health-
screenings-in-schools
http://www.asha.org/content.aspx?id=10737451142
http://www.hearingloss.org/content/basic-facts-about-hearing-loss
References
Bamford, J., Fortnum, H., Bristow, K., Smith, J., Vamvakas, G., Davies, L., Taylor, R.,
Watkin, P., Fonseca, S., Davis, A., & Hind, S. (2007). Current practice, accuracy,
effectiveness, and cost-effectiveness of the school-entry hearing screen. Health
Technology Assessment, 11(32), 1-168.
Centers for Disease Control and Prevention (CDC). (2010). Identifying infants with
hearing loss - United States, 1999-2007. Morbidity and Mortality Weekly Report, 59(8),
220-223.
https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5908a2.htm
National Institute on Deafness and Other Communication Disorders. (2007). NIDCD
outcomes research in children and hearing loss, statistical report: Prevalence of
hearing loss in U.S. children. Retrieved February 6, 2014, from
http://www.nidcd.nih.gov/
health/statistics/Pages/begins.aspx
References
Fitzpatrick, E. M., Whittingham, J., & Durieux-Smith, A. (2014). Mild bilateral and
unilateral hearing loss in childhood: A 20-year view of hearing characteristics, and
audiologic practices before and after newborn hearing screening. Ear and hearing,
35(1), 10-18.
http://www.asha.org/Practice-Portal/Professional-Issues/Childhood-Hearing-
Screening/
EARS YouTube Channel:
http://tinyurl.com/EARSVideosPlaylist
EARS HEARSAY Newsletter:
https://tinyurl.com/EARSHearSayNewletters
EARS Resources:
https://tinyurl.com/EARSPD12-07-17
References
Katz, Jack (2002). Handbook of Clinical Audiology – Fifth Edition. Lippincott Williams
& Wilkins.
Roeser, R., Valente, M. & Hosford-Dunn, H. (2007). Audiology Diagnosis – Second
Edition. Thieme Medical Publishers.
http://www.health.state.mn.us/divs/cfh/topic/hearingscreening/content/downloads/tymp
manual.pdf
Learn about audiology basics including otoscopy, hearing screening, and amplification. Find out about the learner outcomes, pure-tone testing protocols, who to screen, who not to screen, when to screen, and how to prepare for screenings. Get insights into the essential aspects of audiometry controls and equipment. Enhance your knowledge to perform a hearing screening, troubleshoot amplification issues, recognize otoscopic findings for referrals, and conduct otoscopy effectively.
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Presentation Transcript
Audiology Basics Otoscopy, Hearing Screening, and Amplification Arkansas Children s Hospital EARS Team June 2018
Todays Presenters Jessica Newman, Au.D., CCC-A Arkansas Children's Hospital EARS Team NewmanJL@archildrens.org Darby Jackson, Au.D., CCC-A Arkansas Children s Hospital EARS Team JacksonDL2@archildrens.org
Learner Outcomes Perform a hearing screening Complete basic troubleshooting for various types of amplification Recognize otoscopic findings which deem a referral Perform otoscopy
Protocol Summary Pure Tone Screening Rescreening (if did not pass 1stscreen) Referral Follow-up Reporting
Who to Screen Students in grades Pre-K, K, 1, 2, 4, 6, 8 & transfer students Special education students & teacher referrals
Who NOT to Screen Students who wear hearing aids, who have cochlear implants or have documented hearing loss (by an audiologist/MD) should NOT be screened Remember To: Request documentation of a current audiogram (should have annual hearing exam results on file)
When to Screen NOT the first week of school Children entering school for the first time Need time to adjust to school environment BUT you do not want to wait too long if a child DOES have hearing loss Don t wait too long Cold and Flu season Need time for follow-up
Preparing for Screens Know your equipment (Audiometer Controls) Power (on/off) Ear indicator (right/left) Intensity selector (dB; e.g. 20 dB HL) Frequency selector (Hz; e.g. 4000 Hz) Signal selector (use continuous or pulsed tone only) Presentation function (how you present the tone) Annual Calibration (Summertime)
Headphone Placement Place the headphones on student (red on right ear; blue on left ear) Hair behind ears Remove large earrings May want to remove glasses Diaphragm of headphones over ear canal Adjust head band for snug, even fit Head band on top of head is preferred
How to Screen Instruct student for the task (e.g. raise hand when they hear the beep) Condition the student to the task (i.e. present a tone in one ear at one frequency ABOVE the screening level example: 50 dB) Once the student is conditioned start the screening protocol @ 20 dB HL
Screening/Rescreening Protocol Right Ear 1000 Hz 2000 Hz 4000 Hz 1000 Hz 2000 Hz 4000 Hz 20 dB 20 dB 20 dB 20 dB 20 dB 20 dB Left Ear NOTE: Need to obtain 2 responses in each ear at each frequency for a pass
Pass/Fail Criteria Student must pass all frequencies in an ear for that ear to be classified as a pass If a student does not pass ALL frequencies in each ear, he/she should be re-screened in 2-4 weeks 25 dB is NOT a PASS!
Tips and Tricks for Performing Hearing Screenings
Dos DO find a quiet room DO screen at 20 dB HL DO present tone for at least 3 seconds DO use pulsed tones if possible
Donts Don t require students to raise right or left hand Don t get into a pattern with your presentation of the tone Don t give visual cues-position audiometer controls out of view
Donts Don t screen ear with known hearing loss Don t switch the headphones from one audiometer to another. This changes the calibration for your machine. If you have to get your headphones repaired or replaced, your audiometer has to be re-calibrated
Play Audiometry Use with students who are difficult-to-test, who are developmentally delayed, or who are non-English speaking Use a play task (drop blocks in a bucket) Teach child the task at an elevated intensity level (e.g. 50 dB HL) Make sure child can do on his own before you attempt screening at 20 dB HL
Video Examples Hearing Screening (Standard) https://www.youtube.com/watch?v=r0EBvmz6x0A&list=PLStceB- WlntRlSi7FXtKloLGlVUDtieKW&index=17&t=0s Hearing Screening (Play Audiometry) https://www.youtube.com/watch?v=_jBAYxeZw54&t=0s&list=PLStce B-WlntRlSi7FXtKloLGlVUDtieKW&index=15 Hearing Screening (Difficult to Test) https://www.youtube.com/watch?v=mfp6lI3bIcE&list=PLStceB- WlntRlSi7FXtKloLGlVUDtieKW&index=16&t=0s
Referral Refer immediately if you observe physical abnormalities that are not documented in the student s file May immediately refer if child does not pass and there is serious concern regarding hearing or speech/language development Referral to EARS audiologist Refer to MD or Audiologist if fails rescreen Refer to MD or Audiologist if child passes, but there is concern regarding hearing
Follow-Up Send letter, referral form, and a list of appropriate professionals to the parent/guardian (make sure school nurse contact info is on referral form) If no response from parent/guardian in 2 weeks, follow-up with a phone call or personal contact Review information received from examining professional Rescreen after medical treatment if indicated Collaborate with special education personnel if indicated
Basic Troubleshooting for Various Types of Amplification
Amplification Hearing Aids Cochlear Implants Bone Anchored Implants/Softband (BAHA/BAI) Baha diagram
Troubleshooting Hearing Aids Hearing Aid Stethoscope Daily Listening Checks Batteries Wipe down the earmold with an alcohol swab Clean any debris from the earmold using a cleaning tool. Visually inspect the earmold tubing for signs of moisture (earmold blower) Updates to HA technology: Rechargeable batteries and smart phone programming
Troubleshooting Cochlear Implants Batteries Listening Earphones LING 6 Visual inspection of cables
Troubleshooting BAHA/BAI Batteries/Power Make sure the front cover is securely in place. Check that the abutment is clean and clear of any debris and that the device is correctly attached. Ensure the softband is snuggly fit around the head (loose handbands will lead to feedback). Baha diagram
BAHA/BAI Updates Cochlear Baha Attract Cochlear SoundArc
Video Demonstrations Troubleshooting Hearing Aids https://www.youtube.com/watch?v=UNQ8ue3Iz8M&list=PLStceB- WlntRlSi7FXtKloLGlVUDtieKW&index=7&t=0s Troubleshooting Cochlear Implants https://www.youtube.com/watch?v=dvJgHe4Zna4&index=24&list=PL StceB-WlntRlSi7FXtKloLGlVUDtieKW&t=0s Troubleshooting BAHA/BAI https://www.youtube.com/watch?v=Z0Ic3ZtQW5g&index=12&list=PL StceB-WlntRlSi7FXtKloLGlVUDtieKW&t=0s
What is Otoscopy? Visual inspection of the outer portion of the ear and make note of any abnormalities Inspection of the external ear canal Visualization of the tympanic membrane (eardrum) https://www.asha.org/PRPSpecificTopic.aspx?folderid=8589935406§ion=Key_Issues
Outer Ear Anatomy Labels Labels 27 = Pinna or auricle 29 = External auditory meatus or ear canal 31 = Tympanic membrane or eardrum
Visual Inspection of Outer Ear Externally (*Without the otoscope) Atresia: Closure of the ear canal Stenosis: Narrowing of the ear canal Anotia: Absence of pinna/auricle Microtia: Congenitally, abnormally small pinna/auricle
Microtia and Atresia http://www.atresiarepair.com/education-ear.html
Visual Inspection of Outer Ear Externally (*without the otoscope) Inspect the pinna and the area around it to note any abnormalities Position of the ears (set or tilt) Ear Tag/Pit Tenderness Signs of drainage Redness or edema Foul odor Dermatitis Wax build up
Outer Ear Abnormalities https://www.denochearing.com/wp-content/uploads/2016/01/oe5.jpg http://printer-friendly.adam.com/content.aspx?productId=117&pid=1&gid=003304&c_custid=802
Visual Inspection of the Ear Canal Tools Needed: Otoscope Specula Image: http://www.wms.co.uk/sharedimages/Zoom/W53203_2.jpg http://www.insufflatorbulb.com/images/fiberoptic_otoscope_halogen.jpg
Steps for Completing Otoscopy 1. Choose the largest speculum that will allow you to see into the child s ear canal and turn on otoscope. 2. Check the ear canal for blockages or foreign bodies. 3. Hold the otoscope in your dominant hand with the thumb and first two fingers close to the otoscope head, and the power base up, much like holding a pencil. 6
Steps for Completing Otoscopy (continued) 4. Brace your hand against the child s head using your fingers or the heel of your hand to prevent trauma when the child moves. 5. Straighten the ear canal for best viewing. In children less than three years of age, grasp the earlobe and gently pull down and out (speculum upward). In children three and older, grasp the pinna and gently pull up and back to straighten the canal (speculum downward and forward).
Normal Appearance of Ear Canal and Eardrum Little or no wax build up Cone of light Translucency of eardrum Malleus/Umbo http://i.pinimg.com/736x/b3/43/73/b3437373720788e8be7ca5ad303ed0cc.jpg
Otoscopic Exam Internally (*with the otoscope) Inspect the ear canal and tympanic membrane (eardrum) Note presence or absence of normal tympanic membrane landmarks. Ear Canal Drainage, wax buildup, foreign bodies, redness of the ear canal, and other abnormalities Tympanic membrane (eardrum) Tympanosclerosis (scarring), fluid/otitis media, TM perforation, pressure equalization (PE) tube
Drainage https://www.treatcurefast.com/ear/ear-drainage-smelly- clear-discharge-pus-blood-draining-from-ear/
Foreign Body https://www.youtube.com/watch?v=B-YIszlMU_s http://doctorimanrozali.blogspot.com/ 2011/02/osce-ent.html
Fluid/Otitis Media (OM) http://www.drmkotb.com/EN/index.php?page=students&case=&A=1&B=3&C=4 http://www.drrahmatorlummc.com/serousotitismedia.htm
TM (eardrum) Perforation http://sydneyentclinic.com/sean-flanagan/patient-resources/hearing- loss/tympanic-membrane-perforation/ https://app1.unmc.edu/medicine/heywood/otology/unit5-tympanic- membrane-perforations.cfm
PE Tube http://www.entusa.com/ear_photographs_html/ear_tube_p erforation-1.htm http://www.earcentergreensboro.com/medical-education/ear_tubes.php
Tympanosclerosis https://www.mommaaddict.com/7-undesirable-ear-tube-complications/tympanosclerosis/
Referrals Outer Ear Abnormality Untreated Drainage Wax Blockage Foreign Body Untreated Fluid/OM Eardrum Perforation PE tube lying in canal
