Anatomy & Phys.
Outer Ear/Ear Canal: Which of the following are true?
a. the outer ears function is to funnel sound into the external auditory canal
b. the lateral portion of the ear canal contains apocrine and sebaceous glands
c. the lateral 1/3rds is made out of cartilage and medial 2/3rds is osseous
d. the lateral 1/3rd is osseous while the medial 2/3rds is made out of cartilage
True are: A, B and C.
You have 5 vestibular organs; what are they?
Which ones are innervated by the superior branch of the nerve? Which by the inferior?
What does ampullofugal and ampullopedal refer to?
Utricle, Saccule, HSCC, PSCC and ASCC.
SVN: HSCC, ASCC, Utricle
IVN: Saccule, PSCC
Ampullofugal means the fluid flows away from the ampulla when excited. Ampullopedal measn the fluid flows toward the ampulla when excited.
*remember lead ear always excites.
Peds Foundation:
Embryology- Put the following developments in order and label what week they occur in: ossicles ossify & full HC's are apparent, cochlea begins to develop & heart starts beating, cochlea's 2.5 turns complete, Haircells becoming apparent, ME muscles are present/incus and malleus are cartilage
What is TORCH? What does each letter stand for?
Cochlea/Heart @ Wk 5, ME muscles present, Incus/Malleus are cartilage @ Wk 8,
Cochlea's 2.5 turns complete @ Wk 9
HC's begin developing @ Wk 11
Ossicles ossify and full HCs are apparent @ Wk 16-21
Torch is a group os diseases that can effect a baby in utero. T: toxoplasmosis, O:other infections like syphillis, varicells and mumps and HIV, R: rubella, C: CMV, H: herpes.
Components of a CI: label EXTERNAL vs INTERNAL
magnet, receiver coil, microphone, electronic package, intracochlear electrode array, speech processor BTE, 2 ground extracochlear electrodes
Intracochlear Electrode Array: MED-EL, Advanced Bionics, Cochlear
a. 16 contacts, 2 ground electrodes
b. 22 contacts, 2 grounds
c. 12 pairs, 2 grounds
EXT: microphone, BTE speech processor
INT: magnet, receiver coil, electronic package, intracochlear array, ground electrodes
a. AB
b. cochlear
c. med-el
Pathophys:
What is otomycosis?
What is winklers disease and how do we treat it?
T/F: Otitis Media is considered acute if it occured within the last 3 weeks and chronic if its been 3 months or longer. T/F: Mucopurulent effusion is thin, watery and retracts the pocket of the TM. T/F: Mucoid effusion is sticky, viscous and has a yellow tint. T/F: Chronic OM can lead to ossicular damage or mastoiditis if left untreated.
Match otoxicity: outer hair cells, inner hair cells, stria vascularis
a. dieurtics damage this area
b. this area is susceptible to damage from antibiotics
c. this area is at risk when someone is taking analgesics
What is more common with MS, hearing loss or vertigo?
Otomycosis is a fungal infection, spores & filaments fill canal. skin flakes occlude the canal. Winklers Disease is a bump/nodule and if it gets painful or swells we remove it.
True. Acute < 3 wks, Chronic > 3 months.
false. serous effusion is thin, watery and retracts.
true. true.
Otoxicity: A. Stria Vascularis B. IHC C. OHC
MS: vertigo! HL is not common.
Genetics: match term and definition
Mendels Principle of Segregation, Priniciple of Random Assortment, Transcription Factor, consanguity, mitochondrial inheritance, digenic inheritance, multifactorial inheritance
a. gene inherited from mom
b. increases risk for autosomal recessive disorders
c. embryo receives half moms genes and half dads
d. genes located in 2 locations create a phenotype
e. the interaction between genes and the environment
f. protein that controls transcription
g. production of new combo's of genes, each gamete is different
a. mitochondrial inheritance
b. consanguity
c. mendels principle of segregation
d. digenic inheritance
e. mulifactorial inheritance
f. transcription factor
g. random assortment
TM & Tympanic Cavity:
What are the three layers of that make up the TM? What do we call the ring that goes along the outer edge of the TM?
What do we call the roof of the tympanic cavity? What is the anterior wall made out of? And what anatomical structure sits on the anterior wall? What 4 things "sit" in the medial wall? Which two ossicles take up "space" in the epitympanic recess?
Cutaneous, Fibrous & Serous.
Annulus.
Roof: Tegmen Tympani
Ant. Wall: Temporal Bone, Eustachian tube
Medial Wall: Oval window, Round window, promontory of the cochlea and the prominence of the CNVII canal.
Epitympanic Recess: head of the malleus and bulk of the incus
What are the four divisions of the vestibular nuclei? Which two are prodominantly responsible for the VOR?
What do we call the "fast phase" of a nystagmus? Whats the "slow phase"?
What are some "clues" that the pathology is central in origin?
Lateral, Inferior, Medial & Superior. Medial & superior responsible for VOR.
fast: saccade, slow: smooth pursuit
the nystagmus will change directions, nystagmus doesnt follow a pattern and does not improve with fixation.
Peds Assessment:
What is the main goal of "EDHI"? What is the prefered timeline (think 1-3-6)? What are three advantages of the early ID of a HL?
When would you use a 1k Hz tone for a tymp? What are 3 advantages of using wide-band immittance testing over a 1k Hz tymp?
EDHI systems are comprehensive, coordinated, timely and available [services] to all infants. Screening by 1 month, rescreen by 3 months, intervene by 6 months.
Advantages: increases success with HA outcomes, better speech perception and language development and costs less versus later id.
1k Hz used from 2 weeks old to 5 months. WBI has frequency specific information, distinguish between mass and stiffness disorders and can be used to track MEE re-occurence.
Put the following steps in order:
a. output from each band pass filter is rectified and low passfiltered to extract envelope
b. auditory nerve delivers signal to brain
c. microphone picks up signal
d. acoustic signal is bandpass filtered
e. intracochlear electrode array delivers pulses to electrodes one at a time
f. envelope is the basis for modulation train for biphasic current pulses
c. Mic picks up
d. signal is bandpass filtered
a. low pass filtered to extract envelope
biphasic current pulses
e. electrode array one at a time
b. signal to brain
Pathophys:
What is the difference between a syndromic and non-snydromic hearing loss?
Match Syndrome with Characteristics: Pendred, Downs, Treacher Collins, Apert, Ushers, Waardenburg, Jervell-Lange Nielson
a. primarily heart disease, AU profound SNHL
b. U shaped high hz SNHL
c. fused fingers, toes and stapes; AU flat CHL
d. AU SNHL, retinitis pigmentosa
e. AU conductive or mixed HL
f. dental, auricular and ossicular malformations. atresia common. common to have high hz snhl.
g. absent or defective organ of corti, dystopia canthorum
What do the letters in CHARGE stand for? What is the typical HL?
syndromic: other systems in the body are affected
non-syndromic: issue is primarily in the aud system
Match: A. Jervell-Lange Nielsen
B. Pendred C. Apert D. Usher's
E. Down Syndrome F. Treacher-Collins
G. Waardenburg
Colobama Heart A:blocked nasal
Retardation Genital/Urinary Ear
HL ranges from WNL to Profound.
Vestibular Math: You've just completed calorics on a patient. RC: 40, RW: 50, LC: 15, LW: 8.
Calculate the unilateral weakness and directional preponderance.
When you move on to oculomotors, completing some gaze testing, with eyes center and lights off you get 15. At center with lights on you get 25.
Calculate the fixation index. What does this information indicate about the pathology?
UW: (40+50)-(15+8)/113= 67/113=.59x100=59%
DP: (40+8)-(50+15)/113=-17/113=15%
Left Unilateral Weakness, WNL DP.
F.Index: 15/25=60%
Abnormal Fixation Index, indicative of a central finding
Name the 6 ligaments and 2 muscles that are present in the middle ear space.
What are the three canals named inside the cochlea? What are the fluids inside them called? Which one if HIGH in potassium?
True or False: The OHC's of the cochlea send the auditory signal to the brain, the IHC's amplify that signal.
Superior, Lateral & Anterior Malleolar.
Annular Ligament. Posterior & Superior ligaments of the Incus. Stapedius & Tensor Tympani.
Scale tympani, Scala Vestibuli, Scale Media.
Endolymph, Cortilymph & Perilymph.
K+= Endolymph
False. OHC's amplify input on the way to the IHC's, IHC's send signal to the brain.
Posturography:
in what way are positions 2 and 5 similar?
In what ways are 1 and 4 similar?
In what ways are 3 and 6 similar?
In what ways are postions 1-3 similar?
what about 4-6?
2 & 5: eyes are closed.
1 & 4: eyes are open, visual field is fixed
3 & 6: eyes are open, visual field is swayed
1, 2 & 3: the platform is fixed.
4, 5 & 6: platform is swayed.
Peds Assess:
What are 2 methods of obtaining threshold data from a pediatric patient? What are the age ranges for both? When would you do WRS with a kiddo? What are a few ways you can modify testing?
VRA (5 months-2 years) CPA (2.5 yrs-6)
WRS- when the child can repeat the words back.
Modify by using childs name, list/repeat body parts and take any repeatable response.
Hearing aids: define the following terms.
compression
expansion
attack time
release time
binaural summation
binaural squelch
input
output
gain
compression: more gain for soft sounds, less gain for louder sounds. keep soft audible, loud comfortable.
expansion: decrease soft sound gain to reduce environmental noises
attack time: time the aid takes to decrease gain once the input has gone over the knee point
release time: time the aid takes to increase gain when input falls below the knee point
binaural summation: both ears added together, sound doesnt need to be as loud
binaural squelch: using both ears to block out background noise and focus on desired signal
input: the SPL going into the HA mic
output: the amplified sound coming out of the receiver
Diff DX:
Pt 1. Pt has unilateral CHL. They note vertigo and the ability to hear their eyes move. What do you think they might have?
Pt 2. Female who is 8 months pregnant. C/O hearing declined, she has a AU CHL. There is no smell or pain. What do you think she has? What test results would you expect?
Pt 3. C/o pulsatile tinnitus. Otoscopy reveals a reddish-blue tint behind the TM. What ME pathology might it be?
1. SSCD!
2. Otosclerosis. Otoscopy-might see mass behind TM. Tymps- might be affected depending on size of mass, As typical. Audio would have Carharts notch.
3. Glomus Tumor!
Cochlear Implants: in terms of loudness, what is the "c-lvl", "m-lvl" and "mcl"? Which company uses which?
What is WNL impedance levels for a circuit?
What qualifies as a short circuit? What qualifies as an open circuit?
Match: ADRO, whisper setting, volume control, beam/zoom, mic sensitivity, autosensitivity control
a. aggressive directional mic designed to improve SNR by attenuating signals from side and rear
b. widens the IDR to 45 dB
c. acts on individual channels by reducing gain to maintain comfort in channels where "noise" is detected
d. affects the range of acoustic SPLs that activate CI processor
e. automatically adjusts mic sensitivity, affects all channels evenly
f. affects c-level but not t-level or IDR
c-lvl is when the stimulus lvl is loud but not uncomfortable, used by Cochlear. m level is the most comfortable level but output may exceed the level. M lvl is used by Advanced Bionics. MCL is loud but not uncomfortable, level will not exceed. Used by Med-El.
WNL: 500 to 10k ohms.
short: 0 to 10 ohms
open: greater then 20k/30k ohms
a. beam/zoom
b. whisper setting
c. ADRO
d. mic sens.
e. autosen. control
f. volume control
What are the 3 ways the auditory system overcomes acoustic impedance?
What are the 3 evoked potentials created within the auditory system and where are they generated?
What is the purpose of the stapedial reflex?
Area Ratio Transformation: TM is 17.2x bigger then the Oval window. Ossicular Lever action: the fulcrum of the bones. Catenary Lever Action: the buckling of the TM.
Cochlear Microphonic: generated by OHC's
Summating Potential: fluid around HC's changes in charge. Action Potential: neural firing (generated by nerve)
Protection from NIHL & our own voices. volume control. preserve speech intelligibility and increase SNR by seperating sounds.
How do you know if a VEMP is abnormal?
What is a "WNL" threshold for a VEMP? What are the latencies?
Whats the difference between an "overt" and "covert" response on a vHIT test?
response is absent, abnormally low thresholds, asymmetry between ears
threshold: 80-110. Latency cVemp > 17.5; oVemp > 13 msecs abnormal.
overt: easily seen corrective saccades, indicates acute injury. covert: hidden corrective saccade, indicates a compensated injury
Peds Intervention: Fill in the blank.
(high/low) ______ hz's contains speech power, the vowels. _____ hz's contain speech information, the consonants.
(place/manner/voicing) _____ is whether the vocal folds are on or off. _____ carries the consonant identity. _____ is the configuration of the articulators.
(pragmatic/synthetic/analytic/eclectic) Methods of auditory training include _____ which trains the child to adjust for communication variables like context and complexity. _____ which focuses on the small pieces and builds to the bigger one, like working from phonemes to words. _____ is a more global approach, stresses syntax and overall meaning. And finally _____ which is a combo of some or all methods.
Low, High.
Voicing, Place, Manner.
Pragmatic/Analytic/Synthetic/Eclectic
Assess 2: Matching
REUR, REAR, REOR, REIG
a. occluded response, SPL w/HA in but turned off
b. aided response, what we use when speech mapping
c. unaided response, unoccluded EAC at given input. converts dBHL into dBSPL.
d. insertion gain, amount of gain provided by HA alone. calculated by subtracting REUR from REAR
What are two main uses for RECD?
What is a clinical test that can be used to identify a cochlear dead region?
a. REOR
b. REAR
c. REUR
d. REIG
RECD allows for fitting a HA while PT isnt present. Correct the conversion of HL to SPL in REM box for individuals unique acoustics
Cochlear dead region- ten test (threshold equalizing noise)
Diff Dx:
Test Results: Asymmetric SNHL AS. Poor SRT and WRS AS. Abnormal ABR. C/O Unilateral tinnitus in AS, disequilibrium and facial numbness.
What does your Pt have?
What is the gold standard for assessing your hunch?
What are the 3 surgical options?
Match. NF1 v. NF2
a. cafe au lait spots
b. seizures common
c. AU schwannomas
d. lisch nodules
e. patients can become deaf, blind and quadriplegic
Vestibular Schwannoma. Gadolinium MRI scan.
Mid. Fossa Cranioectomy, Retrosigmoid, Translabyrinth.
a. NF1
b. NF2
c. NF2
d. NF1
e. NF2
Tinnitus/Hyperacusis:
What are the four classifications of tinnitus?
What is somatosensory tinnitus?
You have a patient who c/o pulsatile tinnitus that betas in rhythm with their heart. They were recently Dx with a glomus tumor. Is there tinnitus primary or secondary? objective or subjective? Is it arterial, venous or arteriovenous in etiology?
What are the 4 classifications of hyperacusis?
define misophonia. define phonophobia.
Subjective, Objective, Primary & Secondary
Somatosensory tinnitus is when the perceived characteristics of the tinnitus change with head/neck movements, eye/jaw movements, muscle contractions and pressure at trigger points.
Secondary: Tinnitus bc of the tumor. Objective: tumor "creating" noise in body. Arteriovenous etiology.
Hyperacusis: loudness, annoyance, fear and pain.
misophonia is the dislike of certain sounds regardless of their volume. phonophobia is the fear that non-damaging levels of sound will make conditions worse
Put the central auditory pathway in order: lateral lemniscus, inferior colliculus, superior olivary complex, ipsilateral cochlear nucleus, cochlea/CNVIII, medial geniculate body, cerebral lobes.
Which lobe is the auditory cortex in?
What do we call the "highway" that sends information from the IPSI SOC to the CONTRA SOC?
What are the three subsections of the cochlear nucleus? Which portion is responsible for temporal resolution? Which does spectral information and complex signal analysis?
Cochlea/CNVIII, IPSI CN, SOC, Lateral Lemniscus, Inferior Colliculus, MGB, Cerebral lobes
Temporal lobe. Lateral lemniscus.
Anterior, posterior and dorsal.
Anterior: temporal resolution, Dorsal: spectral info & complex signal analysis.
Name a test that assesses....
the saccule ______, the utricle _______, the VSR _______, HSCC _____ & ____ & ______, PSCC ______ & ______, ASCC _______, oculomotors (for determining central path.) _____ & ______ & _____ & _______. VOR (unilateral vs AU) _____ & _____ & _______.
saccule: cVEMP.
utricle: oVEMP.
VSR: posturography.
HSCC: rotary chair, calorics, vHIT (head left to right)
PSCC: dix hallpike, vHIT (head back left to right)
ASCC: vHIT (head front right to left)
Oculomotor: saccades, OPK's, Smooth pursuit, gaze testing.
VOR: positionals, head turn test, head shake test
Peds Intervention:
What is "SPICE"? What are the goals for SPICE?
Communication Oppurtunities; Which of the following are TRUE?
a. Cued speech is made up of 8 handshapes and 4 locations. Kiddos utilize cued speech with speech, speech reading and audition.
b. The auditory-verbal approach allows for the use of gestures and lip reading.
c. The auditory-oral approach encourages the use of ASL.
d. Total communication uses any modality to present the child with as much as possible and see what works best for them.
e. At any time our patient and their family can choose to switch communication approaches and we should make that known to them!
Speech Perception Instructional Curriculm and Evaluation. Goals are the 4 levels of speech perception: detection, suprasegmental (intonation) perception, vowel & consonant perception and connected speech.
True: A! D! E!!!
False: B! (no gestures and no lip reading) C! (ASL frowned upon)
Implantables:
WHat localization cues are the primary cues used by AU CI user? pitch, timing, level or binaural summation?
What does the acronym FAT stand for? When might you want to use FAT?
If T and C lvls are set correctly, the sound field audiogram for a CI user will be....?
A patient comes to see you for a CI eval. they are 16 years old with CAPD, active MEE and absent ART's. Which of these factors is exclusionary? inclusionary? and not relevant?
Interaural level cues
Frequency Allocation Table; default in software & when 2 electrodes are shorted
flat 15 to 30 db HL from 250-6k Hz
Inclusionary: age (older then 1)
Exclusionary: CAPD and MEE
not relevant: Absent ART's
Diff Dx:
Which of the following are dominant? recessive?
x-linked?
a. ushers
b. connexin 26
c. alport
d. waardenburg
What is tone decay? What is PB max/Rollover?
T/F: The alternating AU loudness balance test is a test of recruitment.
T/F: The Short increment sensitivity index or 'sisi' looks at the ear with the SNHL and tests to see if it can detect small changes in intensity.
a. recessive
b. recessive
c. x linked
d. dominant
Both tests of retrocochlear pathologies. Tone decay tests how long the stapedius can remain contracted. Rollover is when WRS get worse when i turn the volume up.
True! True too!
Remember when Dr. Hanks asked us to define inverse square law and critical distance? Well, what are they?
Psychoacoustics: What is suppression? What is adaptation?
Dichotic vs Diotic: what is the difference?
Inverse Square Law: double the distance, the SPL decreases by 6 dB and continues for each halving of the distance. Critical distance is the distance when reverberation interferes with the original signal.
Suppression is the reduction of a response to one tone caused by the introduction of a second tone at a nearby hz. Adaptation is when the nerve firing decreases rapidly with continued stimulation.
Both listening with two ears, diotic is identical sounds while dichotic is 2 sounds