Presentation on theme: "Antonia Brancia Maxon, Ph.D. Texas ENT Specialists, P.A."— Presentation transcript:
1 Antonia Brancia Maxon, Ph.D. Texas ENT Specialists, P.A. Screening, Diagnosis and Early Intervention: The Pediatric Audiologist’s RoleAntonia Brancia Maxon, Ph.D.NECHEARKaren M. Ditty, M.S.Texas ENT Specialists, P.A.NCHAM
2 Timely and Appropriate Diagnosis of Hearing Loss Benchmarks (JCIH, 2000)Newborns screened by 1 monthInfants with hearing loss identified by 3 monthsAmplification use begins within 1 month of diagnosisInfants enrolled in family-centered early intervention by 6 monthsOngoing Audiological management - not to exceed 3 month intervalsProfessionals are knowledgeable
3 Newborns screened by 1 month Currently approximately 86% of all newborns in the United States have their hearing screened at birthThe number of infants referred for diagnostic audiological evaluations has dramatically increased .
4 Infants with hearing loss diagnosed by 3 months Progress has been madeTesting site may influence age of diagnosisGeographic access to services may influence age of diagnosis
5 Impediments to Lowering Diagnostic Age Audiologists lack experience with very young infants and are uncomfortable making the final diagnosis.Facilities do not have the equipment needed to assess very young infants.Audiologists are not familiar with clinical protocols necessary for making accurate diagnosis with very young infants.Inadequate number of audiologists with pediatric expertise
6 Aids to Lowering the Age of Diagnosis Although there are no national protocols or standards many states have guidelines for their audiologists.These guidelines can be obtained via the following link on the NCHAM website:NCHAM audiology trainingPediatric DiagnosticsPediatric Amplification FittingFor many audiologists, ABR test protocols for the adult population are well known and accepted. However, when addressing infants, protocols and practices need to be revised. Eventually, standardized infant protocols will be developed and will become widely accepted. Let’s look at this particular benchmark that JCIH set up and discuss what is the appropriate infant diagnostic test battery
7 Pediatric Audiologist Have the appropriate audiological equipment and protocols for testing newborns and young infants.Can evaluate a child’s hearing within a short period of time after being contacted for an appointment.Specializes in working with infants and young children.Wants to work with infants and young children.Has worked with Part C program in their state
8 Pediatric Audiologist Is familiar with the procedures of the Part C system, including IFSP development and procedures for acquiring hearing aids or assistive technology.If dispenses hearing aids:can make earmolds,has loaner hearing aids availableprovides hearing aids on a trial basishas resources to repair hearing aids quickly
9 Pediatric Audiologist Is willing to review the test results of the audiological evaluation face to face with the family, respecting the Cultural Differences of family units.Is willing to provide a comprehensive written report with a copy of the test findings in a timely manner.
10 Pediatric Diagnostic Test Battery Comprehensive Case HistoryFrequency-Specific Auditory Brainstem ResponseHigh Frequency Probe Tone TympanometryTransient and/or Distortion Product Otoacoustic EmissionsBehavioral AudiometryReferralsSo you fit the criteria and know you could be that Pediatric Audiologist we need What about equipment?
11 Frequency-Specific ABR Accuracy of pure tone threshold estimates with tone burst ABRHigh correlation (>.94) for infants and older children (Stapells, et al, 1995)90% of ABR thresholds within 20 dB of PT thresholds with most within 10 dBaudiometric configuration does not affect accuracy of match (Oates and Stapells, 1998)
12 Pediatric ABRAir conduction measures should be done with insert earphones - can affect latencyBone conduction measures are needed to rule out conductive loss or find conductive component.Without BC will extend time until diagnosis
13 Pediatric ABR-Sedation Who and When4 months to 5 yearsOptionsconscious sedativemild general anesthesiaMonitoringadministered and managed by nursemonitor O2, HR and BPcrash cart and suction available(J. Hall, 2001)
14 Pediatric ABR-Sedation Negative outcomes associated withoverdoses, drug interactionsnon-trained personnelinjuries to facility (administered at home)drugs with long half-lives (chloral hydrate, pentobarbital)(J. Hall, 2001)
15 Pediatric Immittance Measures Provide information about middle ear status to add to BC informationMay be affected by conditions in very young infant’s ears - highly compliantUse of high frequency probe tone (800 Hz or greater) increases reliability and accuracy in young infants.
16 Infants and young children with normal hearing have robust Pediatric Evoked OAEsInfants and young children with normal hearing have robusttransient evoked otoacoustic emissions (TEOAE)distortion product otoacoustic emissions (DPOAE)TEOAEs and DPOAEs and easily measured in infants and children.
17 Middle Ear Effects on OAEs Middle ear effusion mayobliterate emissioneliminate low frequency componentNegative middle ear pressure mayreduce amplitude, particularly in high frequencies
18 OAE Summary OAEs are objective evidence of healthy cochlear function The vast majority of hearing impairment in the low-risk population is a result of malfunction of the cochlear / outer hair cell system, the most sensitive and vulnerable part of the hearing mechanism tested by OAEs.OAEs provide meaningful information when Retrocochlear and/or auditory neuropathy are a concern.
19 Behavioral Response Audiometry Provides information about how an infant or young child uses hearingBehavioral observation techniques can be used to give functional informationonly suprathreshold information is obtainedwill get better responses to speech than tonesCan look at amplification benefit
20 Amplification Assessment and Fitting Initiate amplification process immediately after diagnosis.Includes medical clearanceIncludes earmolds - overnight mailing to get within 1 weekDoes not require exhaustive audiological data
21 Pediatric amplification fitting Ability to conduct real-ear measuresScheduling flexibility and immediacyExperience with functional measures of benefit
22 Basic Audiological Information Used to Fit Amplification Hearing SensitivityABR frequency specific information - low, mid and high frequencyIndividual ear measures: insert phonesMiddle Ear StatusTympanometry - high frequencyBC to rule out conductive loss
23 Basic Audiological Information Used to Fit Amplification Cochlear statusABR intensity-latency functionOAEsBehavioral Responsestarget audiogramspeech awareness
24 Prescriptive Approach to Hearing Aid Fitting Prescriptive methods designed to consider earmolds and person’s own ear canal, etc.,Select targets (gain, output)real ear measurescoupler measures
25 Real Ear to Coupler Difference Procedure (RECD) The infant’s ear is smaller than an adult earMore SPL for same input compared to adultDifferences can be as large as dBMany hearing-aid fitting algorithms do not take these differences into account.RECD affects estimates of:ThresholdReal-ear gain and output
26 RECDAfter the RECD is obtained, all hearing aid testing can be done in the test boxRECD values are entered into the hearing aid fitting program to provide a more accurate estimate of real-ear aided gain and outputThe RECD will change as the child grows. A good rule of thumb is to obtain a new RECD when a new earmold is needed
27 Prescriptive Approach to Hearing Aid Fitting Desired Sensation Level - DSL (Seewald, et al, 1996)Uses minimal audiometric dataReal ear measuresAdjustments for pediatric earsUsed to determine target gain and output settings
28 DSL GoalProvide children with amplified speech that is audible, comfortable, and undistorted across broadest relevant frequency range possible.Infant acquiring language has access to speech of othersInfant acquiring language has access to own speech
29 Speech Sounds Range from softest to loudest speech sound = 30 dB Low frequencies carry suprasegmental, vowel, and voicing information.High frequencies carry consonant, perceptual, and linguistic cues.
30 Referral to and Enrollment in Early Intervention Know established Part C guidelines in stateKnow child eligibility criteriaautomatic enrollment - diagnosed conditionsignificant developmental delayKnow state guidelines for selecting a program
31 Enrollment in Early Intervention Develop Individualized Family Service Plan (IFSP)All servicesspeech and language developmentauditory developmentassistive technologyGoals and objectivesTimelines
32 Components of IFSP for I/T with Hearing Loss Amplification provisionparent educationAudiological monitoringDevelopment of auditory skillsCommunication developmentlistening skills - speech perceptionspeech productionlanguage developmentMonitoring middle ear status
33 Status of EHDI Programs: Early Intervention State Coordinators estimate:Only 53% of infants with hearing loss are enrolled in EI programs before 6 months of ageOnly 31% of states have adequate range of choices for EI programs
34 Barriers to Early Intervention 30-40% of children with hearing loss demonstrate additional disabilities that may affect communication and related development.Families who live in under-served areas may have less accessibility, fewer professional resources, deaf or hard of hearing role models, or sign language interpreters available to assist them.A growing number of children with hearing loss in the United States are from families that are non-native English Speaking.JCIH 2000
35 Some babies are born listeners.. If we:use the elements of an effective EHDI programuse the JCIH 2000 Benchmarksuse appropriate diagnostic protocols and proceduresrefer to early interventionare active participants in early intervention