Adult Case History Questionnaire

What brings you in today/How can I help you?

• How long has this been happening?
• Gradual or Sudden Profound or Diminished​
• Significant event around loss?
• One ear L or R or both ears?
• Constant or fluctuation?
• Difficulty in certain/specific situations?
• Quiet places?
• Background Noise?
• Speech?
• Aural pressure, fullness, pain (otalgia), drainage/fluid (otorrhea)?
• Falls
• Facial numbness?
• Numbness around your ear?
• Head trauma?
• Numbness around your ear after trauma?
• Hear voice while talking or chewing?
• Work Related?

Do you have any noises/tinnitus in your ears?

• One ear L or R or both ears
• What does it sound like? Roaring?
• Constant or intermittent
• Anything that triggers it? Weather?
• How bothersome is it on a scale from 1 to 10

Do you have any dizziness or balance issues?

• When did it start?
• Constant or intermittent
• Have you ever had a middle ear infection?
• Infections as a child?
• Was it treated?
• When was your last infection?

Have you ever been or are you currently exposed to loud noises?
• Occupational
• loud machinery, factory, military
• Recreational
• Do you fire guns?

• If yes, which hand
• Be on the lookout for noise induced hearing loss
• Concerts, motorcycles

• Do you wear hearing protection?

Family History of Hearing loss
• Pregnancy
Previous surgeries?
• Cause?

Previous hearing test?

• Results

Medications?

• Ototoxic?

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Anything else that you’d like to add before we begin testing?

• ​?

Results Flowchart

Comprehensive audiometry threshold evaluation and speech recognition

• Pure Tone Audiometry/Air Conduction Thresholds (AC)
• Bone Conduction Thresholds/Pure Tone (BC)
• Speech Audiometry Thresholds (WRS) with Speech Recognition Thresholds (SRT)

Otoscopy

• Clear external canals unilaterally/bilaterally?
  • Potentially conductive or SNHL
• Occluded canals unilaterally/bilaterally?
• Potentially conductive or SNHL​

Immitance

• Tympanometry
  • A - Normal
    • indication of SNHL
  • As - Flat/Shallow
    • indication of Conductive
  • Ad - Hypercompliant
    • Key is to see if ear canal volume is normal
    • Static admittance
    • Indication of perforation or disarticulation of ossicular chain
  • B
  • C
• Acoustic Reflex Thresholds - the neural integrity of the auditory eighth cranial nerve
  • Elevated or Absent
  • Ipsi or Contra
  • When ARTs are absent with sound present to one ear (ex, R/Ipsi, R/Contra) are consistent with right afferent portion of reflex arc missing and one ear is okay ipsilaterally (ex: L/Ipsi is okay, but L/Contra is not) 

Speech Reception Thresholds

• ​Normal levels
  • 15 Normal ability to receive speech
  • 35 Mild loss ability to receive speech
• In agreement with pure tone thresholds?
  • average 500Hz, 1000Hz and 2000Hz

Pure Tone Thresholds

• Limits of hearing

Word Recognition Thresholds

• Be sure to include masking
• Test for rollover P/I (performance intensity function)
• Pb Max Calculation of Pb Max - Min/Max
  • ​dividing the amount of rollover by the maximum score
  • max score 96%, minimum score 56% this is a rollover index of 0.42
  • 96-56/96 = 0.42; lower limit is 0.25-0.45
  • regardless, the difference between 96% and 56% in conjunction with these other signs is clearly indicative of rollover
• ​Therefore, start at a high level of 80dB HL
  • if the patients score is greater than 80% then significant rollover is ruled out 

Otoacoustic Emissions - Test the functional integrity of the cochlear outer hair cells

• Present and Robust?
  • Indication of intact outer hair cells
• Absent?
  • Is there a conductive component?
• The presence of symmetric OAEs in ears with asymmetric hearing is suggestive of retrocochlear disorder on a specific side

ABR - Functional diagnostic of the integrity of the brainstem; DAN, PAN, CN, SOC, IC; SUGGESTS AUDITORY NERVE OR BRAINSTEM PATHOLOGY

• Neurodiagnostic
  • ​Standard stimulus rate
    • Normal peak and interpeak latencies?
    • Delayed peak and interpeak latencies?
  • Use condensation, rarefaction and alternating click polarities and AVERAGE them
  • Look for repeatable response
  • Look for cochlear microphonic reversal
  • Look for the disappearance of the cochlear microphonic with tube clamping to rule out stimulus artifact
  • Look for grossly abnormal waves at a non-typical stimulus rate, say 11.1 clicks per second
  • replicable peaks?
  • Wave I to III interwave intervals
  • Wave III to V interwave interval
  • Wave I to V interwave interval
    • deviations from the norm?

Recommendations

Conductive Pathology

• Significant Air-Bone Gap can be ruled out by switching Headphones for Inserts

Retrocochlear Pathology

• Retrocochlear pathology should be suspected when a patient presents with asymmetrical hearing loss, unilateral tinnitus and unilateral aural fullness
• Word recognition scores may not be affected when an auditory lesion is present
• Acoustic Reflex decay is an important diagnostic tool in identifying retrocochlear lesions
• asymmetric symptomatology, asymmetric hearing sensitivity, absent ARTs with contralateral and ipsilateral signals presented to one side, rollover of the word recognition function and preservation of OAEs
• Look for an overall pattern of normal function in one ear and symptomatic in one ear (ex: Right Ear: asymmetric symptomatology, asymmetric hearing sensitivity hearing sensitivity, ARTs, WRSs and OAEs)
• 20% rule for rollover
  • over 20% is retrocochlear
  • less than 20% is cochlear
• Fun Fact: bilateral tumors are associated with Neurofibramatosis2

Auditory Neuropathy

• Pattern of findings (absent ARTs with the presence of DPOAEs) is commonly manifested in patients with auditory neuropathy spectrum disorder
  • DPOAEs should be absent with a given magnitude of hearing loss
  • Absence of ARTs to contralateral and ipsilateral stimulation with present DPOAEs are an important indicator for ABR testing
• ABR testing could confirm or deny the presence of nonorganic hearing loss versus ANSD
• Cochlear implant or BAHA? hearing aids may not help because it's not just an amplification thing! for kids it can work!
• ARTs absent, OAEs present, ABR waveforms being significantly degraded or absent, with CM activity
• hearing thresholds can range from within normal limits to a profound hearing loss that can fluctuate
• POOR SPEECH RECOGNITION, PARTICULARLY WHEN IN NOISY ENVIRONMENTS
• Most always have ANSD
• can be the inner hair cells, the inner hair cell/cochlear nerve fiber junctions and/or cochlear nerve fibers
• may want to refer to a neurologist
• auditory communication strategies

Vestibular Problems

• Comprehensive vestibular function testing would be indicated

Hearing Protection

• Include hearing protection in everything that you do

Types of Amplification

• Unilateral can use a bicross
• BAHA for bone stimulation
• Dexterity issues may need something to just insert in the ear without fine manipulation