Adult Case History Questionnaire
What brings you in today/How can I help you?
Do you have any noises/tinnitus in your ears?
Do you have any dizziness or balance issues?
Have you ever been or are you currently exposed to loud noises?
• Occupational
• loud machinery, factory, military
• Recreational
• Do you fire guns?
Family History of Hearing loss
• Pregnancy
Previous surgeries?
• Cause?
Previous hearing test?
Medications?
Anything else that you’d like to add before we begin testing?
- 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
Family History of Hearing loss
• Pregnancy
Previous surgeries?
• Cause?
Previous hearing test?
- Results
Medications?
- Ototoxic?
Anything else that you’d like to add before we begin testing?
- ?
Results Flowchart
Comprehensive audiometry threshold evaluation and speech recognition
Otoscopy
Immitance
Pure Tone Thresholds
Word Recognition Thresholds
Otoacoustic Emissions - Test the functional integrity of the cochlear outer hair cells
ABR - Functional diagnostic of the integrity of the brainstem; DAN, PAN, CN, SOC, IC; SUGGESTS AUDITORY NERVE OR BRAINSTEM PATHOLOGY
- 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
- A - Normal
- 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)
- 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?
- Standard stimulus rate
Recommendations
Conductive Pathology
Retrocochlear Pathology
Auditory Neuropathy
Vestibular Problems
Hearing Protection
Types of Amplification
- 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