1 Audiology for School Based ProfessionalsNancy Gillispie, Au.D. CCC-A, F.A.A.A.

2 Agenda Overview of the State Guidelines Otoscopy TympanometryPure Tone Screening Hearing Aid Basics

3 West Virginia Council of School NursesReference WV § Code Requires a compulsory pre-enrollment screening for children entering public school for the first time in the state. An audiologist, speech pathologist or support personnel under the supervision of an audiologist should complete the screenings. RESA audiologists have developed screening guidelines in accordance with ASHA recommendations (1997). Audiometers and Tympanometers must meet ANSI requirements. Requires 25dB response at 500Hz and 20dB response at 1000 Hz, 2000 Hz, and 4000 Hz. Results are pass or refer Failure to pass this criteria results as a referral to an audiologist or physician. Results should be sent to the family as soon as possible. Results must be tracked The guidelines and referral preferences should be established with an audiologist or other professionals prior to initiating screenings in your county.

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5 Otoscopy The purpose of an otoscopic examination is to describe normal and abnormal physical findings in the referral process.

6 Otoscopy The otoscopic exam is to ensure that the ear canals are free of any obvious problems prior to performing tympanometry, administering hearing tests, and fitting hearing protection. One should be able to identify or rule out disorders of the Outer Ear and Middle Ear disorders involving the eardrum. Please note that viewing the tympanic membrane/eardrum through the otoscope provides information about condition of Middle Ear. However, main purpose of otoscopy is to rule out disorders of the Outer Ear

7 Otoscopy

8 Otoscopy 1. Observe proper hygiene 2. Select a speculum of proper sizewash hands or use gloves note any bodily fluid or secretion 2. Select a speculum of proper size larger size ensures a good view 3. Lock speculum into place 4. Change/discard the speculum after each patient

9 Successful Outcomes Require #1 Otoscope placement #2 Eye placementOtoscopy Successful Outcomes Require #1 Otoscope placement #2 Eye placement

10 Otoscopy Grip otoscope firmly and comfortably with the handleThe hand holding the otoscope should have the pinky extended Grasp upper edge of the ear (helix) with the opposite hand Pull pinna gently upward & back to straighten the ear canal Examine the pinna and concha area while inserting lighted otoscope past the first canal bend Rest your fingers against the patient’s head to avoid injury if patient moves suddenly

11 Otoscopy NOW put your eye up to the otoscope eyepieceExamine the ENTIRE canal and tympanic membrane SLOWLY move the otoscope if needed to see all of the canal and eardrum Dispose speculum and turn off otoscope light Should you be satisfied with a partial viewing? – NO! NO discomfort to the patient if properly conducted If discomfort is experienced, note this in the referral

12 Otoscopy We are NOT to diagnose or label a problem or pathology. However, it is OK to describe what you see – for example … a. “your ear canal appears very swollen” b. “there is too much wax to see the eardrum” c. “your eardrum looks very red” d. “there is a yellowish wetness in your ear” e. “I need to refer you to your family physician/pediatrician”

13 Otoscopy The goal of the examination is to make sure the ear canal is clear of debris or conditions as part of the hearing screening protocol.

14 Otoscopy

15 Otoscopy Ideally, otoscopy should be done before any testing to rule out outer ear disorders/abnormalities. However, otoscopy is not typical practice, particularly when testing more than one person at a time.

16 Otoscopy

20 Cerumen (Wax) Filled CanalOtoscopy Cerumen (Wax) Filled Canal

23 Abnormal Findings – Bead in the CanalOtoscopy Abnormal Findings – Bead in the Canal

26 Pressure Equalization TubeOtoscopy Pressure Equalization Tube

28 Permanent Pressure Equalization TubeOtoscopy Permanent Pressure Equalization Tube

30 Abnormal Findings – Otitis Externa – Inflamed EpitheliumOtoscopy Abnormal Findings – Otitis Externa – Inflamed Epithelium

31 Otomycosis – Fungal InfectionOtoscopy Otomycosis – Fungal Infection

32 Otomycosis – Fungal InfectionOtoscopy Otomycosis – Fungal Infection

35 Otoscopy Serous Otitis Media

37 Otoscopy Otitis Media

40 Tympanic Membrane Perforation with Current InfectionOtoscopy Tympanic Membrane Perforation with Current Infection

43 Retracted Tympanic Membrane - SevereOtoscopy Retracted Tympanic Membrane - Severe

44 Retracted Tympanic MembraneOtoscopy Retracted Tympanic Membrane

45 Tympanometry

46 Supports the Otoscopic Examination.Tympanometry Supports the Otoscopic Examination.

47 Tympanometry Based on physical principles and mathematical algorithms but conducting the test is fast and simple. Results indicate the flexibility or the stiffness of the eardrum and middle ear bones. The stiffness or flexibility of the eardrum is measured and consistently identifies if there is a middle ear disorder/disease present.

48 Tympanometry A soft tipped probe is inserted just inside the ear canal and seals it. A pump varies pressure against eardrum. Simultaneously a pure tone is sent into the ear (typically 240 Hz). Results are displayed in numerical form and in a graph called a tympanogram. NOTE: The equipment will not start the procedure if an acoustic seal is not obtained.

49 Tympanometry 1. Observe proper hygienewash hands or use gloves note any bodily fluid or secretion 2. Select a probe tip of proper size 3. Ensure the probe tip is placed correctly 4. Change/discard/clean the tip after each patient

50 Tympanometry Grip the probe comfortably by the handleThe hand holding the handle should have the pinky extended to avoid injury if the patient moves suddenly Grasp upper edge of the ear (helix)with the opposite hand Pull pinna gently upward & back to straighten the ear canal Insert the probe into the canal and release the helix to relax the canal Press the button on the equipment to begin if it is not an automatic system If an acoustic seal is not obtained, ensure the probe tip is fitting well in the canal (change probe tip if needed) and repeat the previous steps

51 Tympanometry Ear Canal Volume (EVC or Equivalent Ear Canal Volume)Note first during the examination Vary and are age dependent Should be similar between ears Measures the volume from the probe tip to the tympanic membrane

52 Volumes below ranges are indicative of debris in the ear canal.Tympanometry Ear Canal Volume Children (3 years to 5 years) 0.3 to 1.0 Adults to 1.5 Volumes below ranges are indicative of debris in the ear canal. Volumes larger than the ranges are indicative of perforations or PE tubes if an acoustic seal is obtained.

53 Tympanometry – Type A “Mountain” Peak placement Horizontal Vertical -150 to to 1.8 NORMAL TYMPANOGRAM “TYPE A” Tympanometer displays and prints a graph with measurement values. a. horizontal axis/line indicates amount of pressure inside middle ear cavity b. vertical axis/line indicates amount of movement or flexibility of the eardrum c. often there will be a shaded box or outline to indicate normal range Normal tympanogram – referred to as Type A – will show an inverted “V” or mountain within the normal ranges. The peak of the inverted “V” or mountain must be within the numerical ranges indicated (on the slide) in terms of height (eardrum movement or vertical axis) and horizontal placement (negative or positive middle ear pressure). 4. OHC Technician needs to be able to recognize the pattern or configuration to determine if tympanogram is normal or abnormal (middle ear pathology) (NEXT SLIDE) Display uses “box” or shaded area to show normal range

54 Variations of Type A TympanogramsTympanometry – Type A Variations of Type A Tympanograms Peak Horizontal -150 to +50 Vertical 0.2 to 1.8 VARIATIONS OF NORMAL TYPE A People have different shapes and sizes of ear canals and middle ear bones. As in all health situations, there is a range of normal function. Type A tympanogram can vary – tall, short, skewed left or right of “0”. HOWEVER Peak must always be within normal range values for both horizontal and vertical axis / dimensions OR within shaded box or area indicating normal range (NEXT SLIDE)

55 You cannot identify Normal Hearing Acuity.Tympanometry – Type A Identifies: Normal Eardrum Movement Normal Middle Ear Pressure Normal Middle Ear Functioning Normal Eustachian Tube Functioning Normal Outer and Middle Ear INTERPRETATION – TYPE A A Type A tympanogram indicates normal eardrum movement and middle ear pressure. 2. A Type A tympanogram indicates that Eustachian tube is functionally normally. THEREFORE (CLICK) Patient/employee has a normal outer and middle ears which means there is no conductive hearing Loss. That means any hearing loss --- STS – is due to inner ear problems. (NEXT SLIDE) You cannot identify Normal Hearing Acuity.

56 Flat or poorly defined peak Absent or poorly definedTympanometry – Type B Flat or poorly defined peak Peak Placement Absent or poorly defined Horizontal Vertical > < 0.2 ABNORMAL TYMPANOGRAM “TYPE B” There are several patterns of tympanograms that indicate abnormal middle ear function. OHC Technician needs to recognize two major types of abnormal tympanograms. Type B tympanogram has little shape, is flat OR may have a poorly defined, very rounded peak typically placed far to the left in negative pressure area. (NEXT SLIDE)

57 Tympanometry – Type B Identifies:Minimal or Absent Eardrum Movement Confirms Outer and/or Middle Ear Dysfunction such as: Ear canal occlusion Eustachian Tube dysfunction Otitis Media or Middle Ear Effusion INTERPRETATION - TYPE B 1. Type B tympanogram is abnormal 2. Type B indicates that eardrum movement is minimal or totally absent 3. Type B means that there is an outer and/or middle ear problem (CLICK) Abnormal conditions that would result in a Type B tympanogram include --- a. ear canal is occluded – cerumen, foreign body, disease, etc. b. Eustachian Tube is not functioning normally so that eardrum is sucked into the middle ear space due to negative pressure or vacuum within the middle ear space (Eustachian tube is not able to ventilate middle ear space with fresh air). c. otitis media or middle ear effusion – middle ear cavity is full of infectious material or clear fluid because the Eustachian Tube is swollen shut, creating a perfect environment for bacteria/virus to have a party. d. eardrum has a significant perforation. 5. Typically , a low frequency hearing loss will be present with a Type B tympanogram – usually a mild hearing loss, not more than dB HL. ADDITIONAL NOTE: A mnemonic device is Type “B” = “blah” or “blocked” (something is preventing eardrum from moving). (NEXT SLIDE) Results are typically indicative of a Mild Hearing Loss in the LOW Frequencies.

58 Clearly defined Peak to the LeftTympanometry - Type C Clearly defined Peak to the Left Peak Placement Horizontal Vertical > to 1.8 ABNORMAL TYMPANOGRAM “TYPE C” Second major type of tympanogram that the OHC Technician needs to recognize is the Type C tympanogram. Type C tympanogram has a clearly defined peak that is skewed to the left Height or eardrum movement often is normal – but it always has negative middle ear pressure outside normal range (NEXT SLIDE)

59 Tympanometry - Type C Identifies: Negative Middle Ear PressureAbnormal Eustachian Tube Functioning Etiologies Include: Recent Cold and/or Congestion Sinus Infection Upper Respiratory Infection Allergies ABNORMAL TYMPANOGRAM “TYPE C” Second major type of tympanogram that the OHC Technician needs to recognize is the Type C tympanogram. Type C tympanogram has a clearly defined peak that is skewed to the left Height or eardrum movement often is normal – but it always has negative middle ear pressure outside normal range (NEXT SLIDE)

60 Tympanometry over 10-14 day periodRequest a RETEST for follow-up tympanogram Otitis Media or Middle Ear Effusion onset to resolution can be tracked via Tympanogram progress Type C >> Type B >> Type C >> Type A over day period

61 Otoscopy & TympanometryEar Canals clear and free of obvious problems such as discharge, masses, impacted cerumen, foreign bodies, inflammation Tympanic membrane appearance is translucent, pearly gray, healthy in color Eardrum landmarks to note include the cone of light from center to membrane edge and shadow of the first middle ear bone attached to the center Cerumen is normal unless occludes view of TM > 50% and a warning can be made to parents regarding Q-Tip use and the damming effect.

62 Otoscopy & Tympanometry ReferralPain or discomfort is reported Drainage is visible Perforation is visible Tympanic membrane is bulging Ear canal is blocked by cerumen or foreign body Complaint of sudden severe hearing loss with tinnitus and/or dizziness When in doubt

63 Pure Tone Screening Set Up should be in the quietest area available and not shared with another professional completing other tasks such as speech screenings simultaneously. Complete a listening check to ensure that the equipment is working and the stimuli can be heard by you or a normal hearing listener without distortion. Make sure that the headphones are free from frayed wires and broken cushions. Instruction should fit the student. This can be based upon the introduction and question/answer period prior to the pure tone portion of the screening. Make the task something other than raising the hand each time you hear the beeps.

64 Pure Tone Screening Set the audiometer to a loudness level louder than the minimum requirement of 20 dB and at a pulsed signal if this is an option. Extend the headband larger than needed for the student. Use both hands to bring headphones over the head and place the cushions on the ears. Pull the headband taut but comfortable to fit the head. Ask the student if the headphones are comfortable and adjust if necessary.

65 Pure Tone Screening Present the pulsed pure tone at 1000 Hz at least at 40dB to illustrate the sensation in which they are listening and note the student‘s response. Reinstruction might be necessary. Give positive reinforcement especially during this point in the screening. Make the decision at this point to continue with the screening or practice once again.

66 Pure Tone Screening Once the presentation of the pulsed stimulus begins at 20dB at 1000 Hz, continue thru 2000 Hz and 4000 Hz for each ear. If the environment supports testing at 500 Hz based upon the listening check, continue with this frequency at 25dB. Some professionals support not screening 500 Hz based upon the completion of tympanometry. If a child does not respond to all frequencies, go back and double check them prior to completion of the process.

67 Pure Tone Screening Be careful not to cue the student to respond by our own Hand gestures Eye movements Reactions to their responses Observation of the equipment

68 Results The results are simply pass or refer. Results should be communicated to the family as soon as possible with the appropriate plan of action outlined. Track the results in a manner that works for your county and school, which might include but not limited to WVEIS.

69 Putting It Together

70 Putting It Together Reduced Ear Canal Volume

75 Goals To effectively establish screening protocols and referral processes To identify hearing impairments among school aged children to eliminate any barriers to academic success

76 Target Population Approximately 3 in 100 in the school-age population have a mild hearing loss. (Bess et al., 1998)

77 Target Population Joint Committee on Infant Hearing identifies a target population of permanent bilateral or unilateral, sensory or conductive, hearing loss that averages dB HL or more in the frequency region important for speech recognition (approx Hz) and a non-target population of children with hearing losses < 30 dB HL A study of 86,000 infants within the newborn hearing screening project resulted in 4% of the group failing OAEs and passing A-ABR. Of that population 77% of those had permanent hearing loss of mild severity (PTA < 40 dB) 57% had unilateral hearing loss Of those with a hearing loss 86% were sensorineural

78 Why is this important? The fatigue scores reported herein indicated more fatigue experienced by children with hearing loss than children with cancer, rheumatoid arthritis, diabetes, and obesity (Varni et. Al, 2002; 2004; 2009; 2010) What are the contributing stressors to this population? • Listening conditions? • Listening effort? • Lack of early or aggressive intervention? • Lack of effective amplification? • Concomitant otitis media and other ear conditions?

79 Hearing Aids Assistance/Support for the student within the schools vary among professionals. The school should be quipped with extra batteries, listening scope, and possibly a cleaning kit. A daily listening check should be completed daily and recorded on the designated form provided by the county. Training amongst professionals with the actual hearing aid instrument is strongly recommended based upon the availability of diverse devices.

80 ? QUESTIONS ?