Best Practices in Audiology Consultations: Patient Interaction and Evaluation
ODYOMETRİ MESLEKİ İNGİLİZCE
ÖĞRETİM GÖREVLİSİ
RAMAZAN BAYRAM KARAKAYA
•
There are three primary tools used to create a
case history:
•
Interviews, questionnaires and the subjective,
objective
assessment and plan (SOAP) format.
These three tools are
often used in tandem,
but can certainly be used as preferred
by the
professional.
The audiologist must be aware of the warning
signs of dangerous and treatable medical and
surgical conditions
and should refer to the
appropriate professional when
“red flags” are
noticed.
Red flags include a sudden hearing
loss, ear
pain, draining or bleeding ears, unilateral
symptoms
of hearing loss or tinnitus, conductive
hearing loss, dizziness,
and other referral
criteria.
SCENARIO ONE
Review any/all assembled paperwork (chart, lab
notes, test
results, history, etc.) before meeting the
patient for the initial
consultation. Shake hands and
greet the patient, their
spouse, significant other,
family, and so on, and always
introduce yourself.
This is an amazingly simple protocol,
but it is often
overlooked, and when it is overlooked, it sets
an
unprofessional tone for the rest of the encounter. I
usually
say, “Good morning. My name is Dr. Beck,
I’m an audiologist.
Please come in Mr. Smith.”
SCENARIO ONE
•
After exchanging greetings and after sitting
down in the
office, inquire as to why the
patient scheduled today’s visit.
•
“Thanks for coming in today Mr. Smith. What
brings you
to the office?”
SCENARIO ONE
•
Mr. Smith: “I would like a comprehensive
audiometric evaluation
to confirm my bilateral
sensory/neural noise-induced
hearing loss
that my otolaryngologist diagnosed last week.
I
am very interested in acquiring two digital
hearing aids, and
by the way, I am wealthy and
do not have insurance. I pay
cash, and money
is no object. I want to hear everything as
best I
can.”
SCENARIO ONE
•
Because this patient has already been seen
and diagnosed
by the ear, nose, and throat
(ENT) specialist, the index
of suspicion for
some other disease process or a medical/
surgical issue is extremely low.
SCENARIO TWO
•
Mr. Smith: “Well doc, you know how it is. My
wife always
complains I have the TV up too
loud and it drives her outta
the room. I like to
be able to hear the darn thing so I keep it a
little loud. The same thing happens with the
car radio when
we’re driving to the store.
When she sets the volume, I just
hear noise
and can’t tell anything about what they’re
saying.
When I was a boy, I could hear a pin
drop from 40 paces.”
SCENARIO TWO
•
“I understand. How long have you been
playing the TV and
radio louder than your wife
likes it?”
SCENARIO TWO
•
“Let’s see, I started working at the steel
fabrication factory
14 years ago, and my son
was born 8 years ago . . . . so yeah,
it’s been at
least 8 or 10 years. When I let her set the
volume,
I can hear the voices, but I really can’t
understand what
they’re saying. That drives
me nuts. I told her and I’m telling
you too, I
ain’t gonna wear no hearing aids.”
SCENARIO TWO
•
Given the information presented in this scenario,
one
can make several, reasonable, assumptions.
We could assume
that Mr. Smith has a noise-
induced SNHL, likely impacting
4,000 Hz, and
because he cannot hear the consonant sounds
(high frequencies), he cannot clearly understand
the words spoken
to him. We might also assume
that Mr. Smith is not going
to wear hearing aids
and that there is little we can do to assist.
However, there are other options and protocols
to employ:
SCENARIO TWO
•
“Mr. Smith, have you had a hearing test before?”
•
“Not since the Army, back some 20 years ago.”
•
“Do both ears seem about the same, or is one ear
better than
the other?”
•
“The left ear is terrible—can’t hear thunder with
that one.”
•
“I see. Do you have any ear pain?”
•
“None at all. My ears feel fine.”
•
“Okay then. May I take a look?”
•
“Sure, help yourself.”
SCENARIO TWO
•
At this point, the audiologist has a rather low index of
suspicion for a tumor, such as an acoustic neuroma,
because
they occur in about 0.00001% of the population,
but a higher
index of suspicion for more likely possibilities,
including a
unilateral sudden sensory/neural loss that went
undiagnosed
(or maybe Mr. Smith works with his left ear
toward a loud
machine while wearing hearing protection
only in the right
ear, or perhaps he experienced head
trauma on the left or an
explosion near his left side during
boot camp; there are lots of
possibilities). The examination
of the pinna, concha, ear canal,
and tympanic membranes
is normal. The audiologist says,
“Okay, your ears look fine,”
and the interview continues to
determine which diagnosis
has the highest index of suspicion.
SCENARIO TWO
“Mr. Smith, let me make sure I understand . . .
the right ear is
the better ear and the left ear
has been bad for a long time.
Have you ever had
the left ear checked?”
SCENARIO TWO
“Yes. I had the doctor look at it a year or two
ago when it
went bad. He put me on antibiotics
and that was the end of
it. It didn’t get better
though, so I left it alone.
SCENARIO TWO
•
“Okay. What about drainage, anything coming out of
your ears?”
•
“No sir.”
•
“Any dizziness or spinning sensations?”
•
“Not any more. Well, maybe a little. When my left ear was
going
bad, I had some dizziness, but the doctor looked at it
and put me on
antibiotics, and the dizziness got better after
a while.”
•
“So the dizziness started and the left ear went bad all
about a year
or two ago?”
•
“That’s right.”
•
“Okay, very good. Are you on any medications?”
•
“Just a cholesterol pill and a baby aspirin, that’s about it.”
SCENARIO TWO
•
“Okay, and one last thing I’d like to ask you
before we do the
hearing test—do you have
any ringing or buzzing noises in
your ears?”
•
“Yeah, the darn left ear can’t hear anything,
but it sure makes
a racket. Kinda like a
“shhhhh” noise going on in there.
Keeps me
up at night sometimes.”
SCENARIO TWO
•
The audiologist does a comprehensive audiometric
evaluation and determines the following audiometric
profile:
•
Right ear:
Normal peripheral hearing. Tympanogram
normal (type A), ipsilateral reflexes within normal
limits
(WNL). Word recognition score (WRS) = 96%.
Speech
reception threshold (SRT) = 15 dB HL.
•
Left ear:
Flat 85 dB sensory/neural (SN) loss.
Tympanogram
normal (type A), ipsilateral reflexes
absent @105 dB
stimulus level. WRS = 8%, SRT = SAT
(speech awareness
threshold used because speech
understanding was extremely
poor) = 80 dB HL.
SCENARIO TWO
•
The index of suspicion for a left retrocochlear
disorder
is very high at this point. The case
history supports this possibility,
and the test
results indicate a possible retrocochlear
diagnosis for the left ear.
SCENARIO TWO
•
The audiologist refers the patient to an
otolaryngologist
(preferably an otologist or
neurotologist) based on the
high index of
suspicion for a retrocochlear hearing loss. The
otologist meets with and interviews the patient
and refers
the patient for a magnetic resonance
imaging (MRI) study
with contrast (gadolinium). A
3-cm vestibular schwannoma
(acoustic neuroma)
is diagnosed. Mr. Smith is scheduled
for surgery 3
weeks later, and the tumor is removed via the
translabyrinthine approach.
SCENARIO THREE
•
Mr. Smith: “Let’s see, I started working at this
really noisy
factory 14 years ago, and my son
was born 8 years ago . . .
so yeah, it’s been at
least 8 or 10 years. When my wife sets
the TV,
it sounds like everyone is mumbling; I can
hear the
voices, but I really can’t understand
what they’re saying.
That drives me nuts. I
told her and I’m telling you too, I
ain’t gonna
wear no hearing aids.”
Given the information presented above, one can
make several assumptions. We could assume Mr. Smith
has a noise-induced SNHL, impacting frequencies around
4,000 Hz, and because of the reduced amplitude and
distortion
affecting mostly the high-frequency consonant
sounds, he cannot clearly hear the words spoken to him.
We can also be comfortable in thinking that Mr. Smith is
not going to wear hearing aids, which reduces what we
can
do to assist him. However, there are other options
and protocols
to explore.
SCENARIO THREE
•
“Mr. Smith, have you had a hearing test before?”
•
“Not since the Army, back some 20 years ago.”
•
“Do both ears seem about the same, or is one ear
better than
the other?”
•
“They’re just about the same”
•
“I see. Any ear pain?”
•
“None at all. My ears feel fine.”
•
“That’s good. May I take a look?”
•
“Sure doc, knock yourself out.”
SCENARIO THREE
•
The pinna, concha, ear canal, and tympanic membranes
are
normal in appearance. The audiologist says, “Your ears
look
fine,” and the interview continues.
•
“Okay, what about drainage? Is there anything coming out
of
your ears?”
•
“No sir.”
•
“Any dizziness or spinning sensations”
•
“Nope.”
•
“Very good. Are you taking any medications?”
•
“Just a cholesterol pill and a baby aspirin, that’s about it.”
•
“The last question I’d like to ask you before we do the
hearing
test is do you have any ringing or buzzing noises in
your ears?”
•
“Yeah . . . maybe a little when it’s really quiet, nothing that
really
bothers me though.”
•
The audiologist does a comprehensive audiometric
evaluation
and determines the following
audiometric profile:
•
Right ear:
Moderate high-frequency sensory/neural
hearing loss. Tympanogram normal (type A),
ipsilateral
reflexes are within normal limits (WNL).
WRS = 96%.
SRT = 45 dB HL.
•
Left ear:
Moderate high-frequency sensory/neural
hearing
loss. Tympanogram normal (type A),
ipsilateral reflexes
are WNL. WRS = 92%. SRT = 45
dB HL.
•
“Mr. Smith, I’d like to review the results of today’s
tests with
you. Would you like to have your wife
join us while I review
the results?”
•
“Sure, that would be great. She’s in the waiting
room.”
•
“Hi Mrs. Smith, please join us while I review the
results of today’s
examination. This way, the two
of you will have the chance to
learn about the
results, and I can address your questions.”
Case 1/CASE HISTORY
•
Mr. Ang Kim, age 36, is being seen today after he failed
the
hearing screening at his company’s health fair. His
medical
history is generally unremarkable, though he
reports that
he is just getting over a sinus infection and
recently underwent
surgery for a slipped disc in his
back. You have back
to
back patients today and because
there is nothing remarkable
in his history you decide to
do a quick audiogram and
send him on his way. Results
from otoscopy, puretone, and
speech audiometry are
shown in Table 8.3 and Figure 8.2.
•
With subjective information alone this audiogram
could
indicate many things. For example, you may inaccurately
diagnose Mr. Kim with a collapsed ear canal, an
impacted cerumen plug, or a perforated tympanic
membrane
without additional tests to cross check your
findings.
Despite your busy schedule, you decide you need more
information to
make an accurate diagnosis, so you perform
objective testing to cross
check your subjective results. The
results from immittance testing and
OAE testing are shown
in Tables 8.4–8.6.
With this information, you
have several different tests
to confirm your finding of a conductive
hearing loss. The
Type B tympanogram in the right ear reveals normal
ear
canal volume but no mobility. The normal ear canal volume
suggests that the TM is not perforated and there is no cerumen
plug.
The pattern of the ARTs is consistent with a right
conductive pathology.
TEOAEs in the right ear are absent
which is expected with a conductive
pathology.
The combination of the subjective
and
objective test
results
correctly leads you to suspect otitis media with effusion
and would
require a referral for Mr. Kim to a physician.
In this case, you are able
to make an appropriate referral
based on the information you
obtained from a test battery
incorporating both objective and
subjective measures.
The content discusses essential tools in creating a case history, the importance of recognizing warning signs in audiology, and a scenario highlighting proper patient interaction during an audiometric evaluation. It emphasizes professionalism, thorough assessment, and referral protocols for audiologists.
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Presentation Transcript
ODYOMETR MESLEK NGLZCE RET M G REVL S RAMAZAN BAYRAM KARAKAYA
There are three primary tools used to create a case history: Interviews, questionnaires and the subjective, objective assessment and plan (SOAP) format. These three tools are often used in tandem, but can certainly be used as preferred by the professional.
The audiologist must be aware of the warning signs of dangerous and treatable medical and surgical conditions and should refer to the appropriate professional when red flags are noticed.
Red flags include a sudden hearing loss, ear pain, draining or bleeding ears, unilateral symptoms of hearing loss or tinnitus, conductive hearing loss, dizziness, and other referral criteria.
SCENARIO ONE Review any/all assembled paperwork (chart, lab notes, test results, history, etc.) before meeting the patient for the initial consultation. Shake hands and greet the patient, their spouse, significant other, family, and so on, and always introduce yourself. This is an amazingly simple protocol, but it is often overlooked, and when it is overlooked, it sets an unprofessional tone for the rest of the encounter. I usually say, Good morning. My name is Dr. Beck, I m an audiologist. Please come in Mr. Smith.
SCENARIO ONE After exchanging greetings and after sitting down in the office, inquire as to why the patient scheduled today s visit. Thanks for coming in today Mr. Smith. What brings you to the office?
SCENARIO ONE Mr. Smith: I would like a comprehensive audiometric evaluation to confirm my bilateral sensory/neural noise-induced hearing loss that my otolaryngologist diagnosed last week. I am very interested in acquiring two digital hearing aids, and by the way, I am wealthy and do not have insurance. I pay cash, and money is no object. I want to hear everything as best I can.
SCENARIO ONE Because this patient has already been seen and diagnosed by the ear, nose, and throat (ENT) specialist, the index of suspicion for some other disease process or a medical/ surgical issue is extremely low.
SCENARIO TWO Mr. Smith: Well doc, you know how it is. My wife always complains I have the TV up too loud and it drives her outta the room. I like to be able to hear the darn thing so I keep it a little loud. The same thing happens with the car radio when we re driving to the store. When she sets the volume, I just hear noise and can t tell anything about what they re saying. When I was a boy, I could hear a pin drop from 40 paces.
SCENARIO TWO I understand. How long have you been playing the TV and radio louder than your wife likes it?
SCENARIO TWO Let s see, I started working at the steel fabrication factory 14 years ago, and my son was born 8 years ago . . . . so yeah, it s been at least 8 or 10 years. When I let her set the volume, I can hear the voices, but I really can t understand what they re saying. That drives me nuts. I told her and I m telling you too, I ain t gonna wear no hearing aids.
SCENARIO TWO Given the information presented in this scenario, one can make several, reasonable, assumptions. We could assume that Mr. Smith has a noise- induced SNHL, likely impacting 4,000 Hz, and because he cannot hear the consonant sounds (high frequencies), he cannot clearly understand the words spoken to him. We might also assume that Mr. Smith is not going to wear hearing aids and that there is little we can do to assist. However, there are other options and protocols to employ:
SCENARIO TWO Mr. Smith, have you had a hearing test before? Not since the Army, back some 20 years ago. Do both ears seem about the same, or is one ear better than the other? The left ear is terrible can t hear thunder with that one. I see. Do you have any ear pain? None at all. My ears feel fine. Okay then. May I take a look? Sure, help yourself.
SCENARIO TWO At this point, the audiologist has a rather low index of suspicion for a tumor, such as an acoustic neuroma, because they occur in about 0.00001% of the population, but a higher index of suspicion for more likely possibilities, including a unilateral sudden sensory/neural loss that went undiagnosed (or maybe Mr. Smith works with his left ear toward a loud machine while wearing hearing protection only in the right ear, or perhaps he experienced head trauma on the left or an explosion near his left side during boot camp; there are lots of possibilities). The examination of the pinna, concha, ear canal, and tympanic membranes is normal. The audiologist says, Okay, your ears look fine, and the interview continues to determine which diagnosis has the highest index of suspicion.
SCENARIO TWO Mr. Smith, let me make sure I understand . . . the right ear is the better ear and the left ear has been bad for a long time. Have you ever had the left ear checked?
SCENARIO TWO Yes. I had the doctor look at it a year or two ago when it went bad. He put me on antibiotics and that was the end of it. It didn t get better though, so I left it alone.
SCENARIO TWO Okay. What about drainage, anything coming out of your ears? No sir. Any dizziness or spinning sensations? Not any more. Well, maybe a little. When my left ear was going bad, I had some dizziness, but the doctor looked at it and put me on antibiotics, and the dizziness got better after a while. So the dizziness started and the left ear went bad all about a year or two ago? That s right. Okay, very good. Are you on any medications? Just a cholesterol pill and a baby aspirin, that s about it.
SCENARIO TWO Okay, and one last thing I d like to ask you before we do the hearing test do you have any ringing or buzzing noises in your ears? Yeah, the darn left ear can t hear anything, but it sure makes a racket. Kinda like a shhhhh noise going on in there. Keeps me up at night sometimes.
SCENARIO TWO The audiologist does a comprehensive audiometric evaluation and determines the following audiometric profile: Right ear: Normal peripheral hearing. Tympanogram normal (type A), ipsilateral reflexes within normal limits (WNL). Word recognition score (WRS) = 96%. Speech reception threshold (SRT) = 15 dB HL. Left ear: Flat 85 dB sensory/neural (SN) loss. Tympanogram normal (type A), ipsilateral reflexes absent @105 dB stimulus level. WRS = 8%, SRT = SAT (speech awareness threshold used because speech understanding was extremely poor) = 80 dB HL.
SCENARIO TWO The index of suspicion for a left retrocochlear disorder is very high at this point. The case history supports this possibility, and the test results indicate a possible retrocochlear diagnosis for the left ear.
SCENARIO TWO The audiologist refers the patient to an otolaryngologist (preferably an otologist or neurotologist) based on the high index of suspicion for a retrocochlear hearing loss. The otologist meets with and interviews the patient and refers the patient for a magnetic resonance imaging (MRI) study with contrast (gadolinium). A 3-cm vestibular schwannoma (acoustic neuroma) is diagnosed. Mr. Smith is scheduled for surgery 3 weeks later, and the tumor is removed via the translabyrinthine approach.
SCENARIO THREE Mr. Smith: Let s see, I started working at this really noisy factory 14 years ago, and my son was born 8 years ago . . . so yeah, it s been at least 8 or 10 years. When my wife sets the TV, it sounds like everyone is mumbling; I can hear the voices, but I really can t understand what they re saying. That drives me nuts. I told her and I m telling you too, I ain t gonna wear no hearing aids.
Given the information presented above, one can make several assumptions. We could assume Mr. Smith has a noise-induced SNHL, impacting frequencies around 4,000 Hz, and because of the reduced amplitude and distortion affecting mostly the high-frequency consonant sounds, he cannot clearly hear the words spoken to him. We can also be comfortable in thinking that Mr. Smith is not going to wear hearing aids, which reduces what we can do to assist him. However, there are other options and protocols to explore.
SCENARIO THREE Mr. Smith, have you had a hearing test before? Not since the Army, back some 20 years ago. Do both ears seem about the same, or is one ear better than the other? They re just about the same I see. Any ear pain? None at all. My ears feel fine. That s good. May I take a look? Sure doc, knock yourself out.
SCENARIO THREE The pinna, concha, ear canal, and tympanic membranes are normal in appearance. The audiologist says, Your ears look fine, and the interview continues. Okay, what about drainage? Is there anything coming out of your ears? No sir. Any dizziness or spinning sensations Nope. Very good. Are you taking any medications? Just a cholesterol pill and a baby aspirin, that s about it. The last question I d like to ask you before we do the hearing test is do you have any ringing or buzzing noises in your ears? Yeah . . . maybe a little when it s really quiet, nothing that really bothers me though.
The audiologist does a comprehensive audiometric evaluation and determines the following audiometric profile: Right ear: Moderate high-frequency sensory/neural hearing loss. Tympanogram normal (type A), ipsilateral reflexes are within normal limits (WNL). WRS = 96%. SRT = 45 dB HL. Left ear: Moderate high-frequency sensory/neural hearing loss. Tympanogram normal (type A), ipsilateral reflexes are WNL. WRS = 92%. SRT = 45 dB HL.
Mr. Smith, Id like to review the results of todays tests with you. Would you like to have your wife join us while I review the results? Sure, that would be great. She s in the waiting room. Hi Mrs. Smith, please join us while I review the results of today s examination. This way, the two of you will have the chance to learn about the results, and I can address your questions.
Case 1/CASE HISTORY Mr. Ang Kim, age 36, is being seen today after he failed the hearing screening at his company s health fair. His medical history is generally unremarkable, though he reports that he is just getting over a sinus infection and recently underwent surgery for a slipped disc in his back. You have back to back patients today and because there is nothing remarkable in his history you decide to do a quick audiogram and send him on his way. Results from otoscopy, puretone, and speech audiometry are shown in Table 8.3 and Figure 8.2. With subjective information alone this audiogram could indicate many things. For example, you may inaccurately diagnose Mr. Kim with a collapsed ear canal, an impacted cerumen plug, or a perforated tympanic membrane without additional tests to cross check your findings.
Despite your busy schedule, you decide you need more information to make an accurate diagnosis, so you perform objective testing to cross check your subjective results. The results from immittance testing and OAE testing are shown in Tables 8.4 8.6. With this information, you have several different tests to confirm your finding of a conductive hearing loss. The Type B tympanogram in the right ear reveals normal ear canal volume but no mobility. The normal ear canal volume suggests that the TM is not perforated and there is no cerumen plug. The pattern of the ARTs is consistent with a right conductive pathology. TEOAEs in the right ear are absent which is expected with a conductive pathology. The combination of the subjective and objective test results correctly leads you to suspect otitis media with effusion and would require a referral for Mr. Kim to a physician. In this case, you are able to make an appropriate referral based on the information you obtained from a test battery incorporating both objective and subjective measures.
