Spring 08 Week 12

An elderly male came in for a hearing aid check. He reported having problems with the dome of his Oticon Delta falling out of his ear when he opens his mouth wide or moved too much.
A retention wire was added to the right hearing aid to keep the receiver and dome in the ear canal. He practiced inserting his hearing aid with success.

He has normal sloping to severe sensorineural hearing loss in the right ear and a normal sloping to profound sensorineural hearing loss in the left ear. Hewas recently fit with an Oticon Delta 4000 in his right ear. Extremely poor speech discrimination in his left ear merited a monaural fitting. He received a10mm Delta dome, (size 3) and has expressed satisfaction with the new fit. He had previously been seen in the clinic for feedback problems; however, feedback has reportedly subsided with the new dome.

This was a perfect patient with little problems and great benefit from his hearing aids. After the session, he talked about how others should come to the clinic for amplification and for aural rehabilitation. I found an article that discussed another option for providing aural rehabilitation which includes peer-mentoring. This would allow the audiologist to provide assistance without being overwhelming and the peer would have some common experiences to share. This is a wonderful idea for those who do not have to meet AR competency requirements.

Shafer, D.N. (2005). Improving access for aural rehabilitation. ASHA Leader.

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=1&hid=3&sid=23ebca0f-e4c5-4b29-b448-44c4140450b7%40sessionmgr2

Spring 08 Week 11

A student was recruited to the clinic. He reported having sudden decreased hearing sensitivity in his left ear at the age of 8 years old. Before this time, he recalls having normal hearing (i.e. he could use the telephone on both ears with no hearing difficulties). He noted having recurrent ear infections as a child; however no correlation to his sudden decrease in hearing was noted. He reported excessive noise exposure from rifle shooting for many years. He is also presently a musician who attends concerts on a weekly to monthly basis. He does not wear hearing protection during these activities. Currently, he contributes his hearing loss to noise exposure. Specific information on the type, degree, or configuration of loss was unknown by the patient even after undergoing several previous hearing evaluations as a child. He only knows that a hearing loss is present.

Otoscopy revealed normal ear canals and present, intact tympanic membranes bilaterally.
Normal, type A, tympanograms were measured bilaterally. Acoustic reflex thresholds were normal for the right contralateral and ipsilateral reflex pathways; however, there were no responses for the left contralateral and ipsilateral reflexes. Air conduction thresholds for the right ear were within normal limits using insert headphones. The left ear displayed a severe sloping to profound sensorineural hearing loss. No responses were obtained for 500 Hz, 2000 Hz, and 8000 Hz. The air and bone conduction responses of the left ear for all frequencies tested were described as “felt not heard” from vibrotactile cues due to high intensity stimuli.
Speech recognition threshold (SRT) was 10dBHL and in good agreement with the pure tone average of the right ear. Word recognition for the right ear was 100% presented at 40 dB SL. SRT and word recognition could not be tested for the left ear due to audiometer intensity restrictions.

Distortion product otoacoustic emissions (DPOAEs) yielded passing values bilaterally, at least 3 dB above the noise floor, during a 750 Hz-8000 Hz diagnostic test. No significant response differences were seen between the two ears. These results suggest properly functioning outer hair cells in the cochlea bilaterally. No consistent otoacoustic suppression pattern was measured when testing the left ear. Normal suppression occurs when DPOAEs reduce 1 to 3 dB while presenting broadband noise at 15-30 dB SL to the non-test ear. However, otoacoustic suppression results may vary among normal patients.

The patient was asked to return for auditory evoked potential testing. ABRs and single and alternating polarities electrocochleography should be administered at that time. Noise exposure and hearing protection was also discussed.

Normal DPOAEs usually suggest hearing sensitivity of 40 dB HL or better. Contrarily, behavioral responses for the left ear resulted in a profound loss. A retrocochlear loss is suspected in the left ear due to the abnormal findings of acoustic reflex thresholds and extremely elevated behavioral in the presence of normal DPOAE results. Preliminary results are consistent with unilateral late onset auditory neuropathy; however, further testing, specifically auditory brainstem response (ABR) and electrocochleography (ECochG) are needed for a complete audiologic evaluation with site-of-lesion information and is needed to confirm this suspicion. ECochG results can also give information about the cochlear microphonic when single polarity is used.

I found a study (after much searching) for treatments addressing auditory neuropathy. This study asks two questions: Does noise present a particular problem for people with auditory neuropathy? Can clear speech and cochlear implants alleviate this problem? The results concluded that clear speech improved temporal properties which, in turn, helped improve speech recognition. Comparing acoustic to electrical stimuli merited cochlear implants as a treatment option for those with auditory neuropathy. In addition, the authors suggested the use of high quality hearing aids to help with speech recognition also.


Zeng, F. & Liu, S. (2006) Speech perception in individuals with auditory neuropathy. ASHA, 49.

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=1&hid=8&sid=640f8366-e105-4b8a-9cda-4c038216f6aa%40sessionmgr9

Spring 08 Week 10

An elderly male came in for a hearing aid check this week. He reported that his new left Widex Flash FL-X ITE hearing aid was no longer in working condition. He is an experienced hearing aid user, for approximately 15 years, and is currently in his 60 day trial period of bilateral Widex Flash FL-X in-the-ear (ITE) hearing aids. His right aid was recently returned to the manufacturer because it was causing irritation and redness in the helix area. At the current visit, the hearing aid has not been returned from the manufacturer. His previous hearing aids were bilateral analog MicroTech Cabello ITEs.

Upon visual inspection, an excessive amount of cerumen was found blocking the left hearing aid receiver. The wax guard was replaced and the hearing aid was subsequently found to have adequate amplification during the listening check. However, he had other concerns including the battery door configuration, the need for wax guard replacements, and the overall feel and look of the Widex Flash instruments. He then expressed interest in returning the Widex ITEs and purchasing MicroTech hearing aids (with advanced technology) due to his satisfaction with his old hearing aids. When information was elicited from MircoTech via phone call, a gradual merger of Starkey and MicroTech was revealed and some MicroTech instruments were no longer available. Therefore, a comparable Starkey mid-level product, Destiny 800, was recommended by the customer service representative.

He agreed to purchase bilateral Starkey Destiny 800 ITEs. A few special requests were noted on the order form which included no wax guards, a toggle volume control, a touchless t-coil, a 312 battery capability, a 3 year warranty, and a side-open battery door. The Widex instruments will be returned for a refund once the right aid returns from repair.

He seemed to be having difficulty with new technology and the cost of the new hearing aids which seems to be a trend with his purchasing history. So I found an article discussing perspectives on digital hearing aids and the history of hearing aids (which a certain professor would love!). This would be an excellent article to give to a patient who asks why hearing aids are so much more expensive now. Starting from WW II, the author goes through the advancements in amplification leading up to digital hearing aids.

Levitt, H. (2007). A historical perspective on digital hearing aids: How digital technology
has changed modern hearing aids. Trends in Amplication, 11.

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=1&hid=5&sid=9fdccebd-c228-4d6e-b399-233f48876fc4%40sessionmgr3

Spring 08 Week 9

An adult male came in to purchase musicians in-ear monitors with custom earmolds. He reported playing the keyboard in a band at his church. No hearing problems were reported. However, the right tympanic membrane has previously been ruptured twice. The last occurrence was approximately ten years ago. No other outstanding case history information was provided. Since he is exposed to noise often, a hearing evaluation was recommended and conducted.

Clear ear canals and visible, intact tympanic membranes were observed bilaterally. Redness was observed in the right ear canal. Normal, Type A tympanograms were measured bilaterally.
Otoacoustic emissions were not attempted due to the conductive component in behavioral testing. Puretone audiometry revealed a normal sloping to mild loss at 2000 Hz rising again to normal in the high frequencies in the right ear. The left ear had normal sloping to moderate loss at 4000 Hz rising to normal in higher frequencies. In both ears, the low frequencies showed a slight conductive component while the high frequencies were sensorineural. Pure tone averages were in good agreement with the speech recognition thresholds (SRT) bilaterally. SRT for the right and left ear was 30 dB HL. Word recognition testing was not completed at this time.

Musician custom earmolds were made. UM 56 ear pieces and UM 2 dual driver universal fit in-ear musicians’ monitors were ordered through Westone. He was recommended to return for annual evaluations or if changes in hearing are noticed. Due to a slight conductive component, an appointment with an otolaryngologist was recommended. The importance of hearing protection was also discussed.

I found a study that examined the impact that changing on-stage music and crowd noise levels during musical performance had on preferred listening levels and minimum acceptable listening levels across both floor and in-ear monitors. Participants for this study were 23- to 48-year-old musicians, with and without hearing loss, who had 10 years of experience. Preferred levels were found to be lower for floor monitors while acceptable levels were lower for in-ear monitors. However, there were no significant difference between the two kinds of monitors and both had acceptable levels according to OSHA. It was suggested by the authors for those patients at risk for noise exposure to use in-ear monitors to reduce other surrounding noises.

Federman, J. & Ricketts, T. (2008). Preferred and minimum acceptable listening levels for musicians while using floor and in-ear monitors. Journal of Speech, Language, and Hearing Research, 51, 147-159.

http://web.ebscohost.com/ehost/pdf?vid=1&hid=117&sid=e7290bc3-1ebb-49b1-96c7-03828271d116%40sessionmgr107

Spring 08 Week 8

A female recruit came in with the problems with hearing in noise, occasional tinnitus, and dizziness due to loud noise. She thinks she has a hearing loss but not a significant one. History consists of working in loud enviroments (i.e. bars, restaurants) and attending concerts frequently.

Otoscopy revealed normal, intact tympanic membranes and clear ear canals. Normal, type A, tympanograms were measured bilaterally. Audiometric findings were within normal limits. Speech audiometry revealed normal speech recognition thresholds and speech discrimination. A vestibular evaluation was not attempted at this time due to time restrictions. She was encouraged to return for further testing.

Since she had normal hearing, I thought that I would find an article that would pertain to the client but not currently. She has been a smoker for several years. This article discusses the increase risk of hearing loss due to smoking. The study showed that long-term smokers have a
higher risk of hearing loss at 3 and 4 kHz after noise exposure. Just one more reason to quit...

Wild, D.C., Brewster, M.J., & Banerjee, A.R. (2005) Noise-induced hearing loss is exacerbated by long-term smoking. Clinical Otolaryngology, 30, 517–520

http://web.ebscohost.com/ehost/pdf?vid=1&hid=104&sid=ce350299-0b60-4375-9fa4-f659dc06f0af%40sessionmgr104

Spring 08 Week 7

An adult female was recruited to the clinic for a hearing evaluation. She reported having problems hearing in noise and she talk excessively loud on the phone. No other problems were reported. Normal tympanic membranes and clear ear canals were observed bilaterally. Normal tympanograms were measured bilaterally. Pure tone audiometry revealed thresholds within normal limits. Distortion product otoacoustic emissions were also administered with normal responses in all frequencies. Overall test results revealed normal hearing :)

After discussing some irrevelant information after the hearing evaluation, it was discovered that the recruit was at risk for breast cancer due to familial issues. This reminded me of an interesting finding of how cerumen characteristics were compared to the risk of breast cancer. Japanese women do not have a high risk of breast cancer genetically. However, in a study conducted in California, Japanese women with breast cancer often had a wet-type cerumen. The authors suggest that the glands controlled by the apocrine system have a genetically determined variation that influences the susceptibility to breast cancer. The article is somewhat old but I did not have access to the newer ones.

Petrakis, N.L. (1971). Cerumen genetics and human breast cancer. Science, New Series, 173, No. 3994, 347-349.

http://www.jstor.org.www.libproxy.wvu.edu/stable/view/1732386

Spring 08 Week 6

This week I recruited a patient that described symptoms of Tullio's, which is dizziness due to loud sounds. He complained of feeling dizzy only at concerts. The patient has a high frequency ringing in both ears. Often the ringing causes problems with his sleeping patterns. He reported having many noisy hobbies including: playing in a band, power tools, and listening to music. No other abnormal history was accounted.

Otoscopy revealed normal ear canals and intact tympanic membranes bilaterally. Normal type A tympanograms were measured. Pure tone audiometry revealed hearing within normal limits bilaterally. SRTs were in agreement with PTA. Word recognition scores were 100% bilaterally.

An informal test for Tullio's was administered using a audiometer set to 90-100 dB HL and Frenzel lenses. The warble tones were played for about 2-4 seconds. During this time, the clinician was looking for nystagmus. However, the absence of nystagmus suggests that the patient does not have Tullio's at least with the presentation of only 2-4 seconds. He discussed how dizziness usually only occurs when he has been exposed to sounds for an extended period of time. For example, a rock concert will last about an hour with sounds reaching 140 dB HL. An article was found that discussed ways to test for Tullio's. This study used VEMPs (vestibular evoked myogenic potentials) which is the essential tool for testing Tullio's. The study examined 20 normal subjects, using a 500 Hz tonal stimulus of 105 dB HL, applied monoaurally. Each subject was studied under 4 different conditions: 1) head facing forwards, eyes open; 2) head facing forwards, eyes closed; 3) head rotated :90° to the right, eyes closed; and 4) head rotated :90° to the left, eyes closed. The results of the study suggest that the click-evoked
vestibulocollic reflex, can be considered a physiological Tullio phenomenon and VEMPs can be used for evaluation.

Russolo, M. (2002). Sound-evoked postural responses in normal subjects. Acta Otolaryngol, 122: 21–27

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=1&hid=114&sid=9de4686a-25e8-4e9a-9556-62a5954941a3%40sessionmgr104

Calorics were also performed for practice. The patient agreed to participate in the test. Both cool and warm calorics were administered bilaterally. Nystagmus was observed much sooner than expected (~ 15-25 seconds after first presenting). We usually see nystagmus after 30 seconds. Also, the patient had normal but robust responses. Although the patient had some unusual responses to calorics, everything was within normal limits.

Spring 08 Week 5

An elderly woman came in who was previously diagnosed with BPPV and was given Meclizine to help with her symptoms upon diagnosis. She has had recurring symptoms in the last two weeks. She reported symptoms of lightheadedness especially when she first wakes up and has fallen previously. The duration of symptoms vary. She also has tingling and a sharp pain on the left side of her face particularly her eye. However, these symptoms do not always occur with the dizziness. The client noted having glaucoma and high blood pressure. She is currently taking Celebrex, a diuretic, and blood pressure medicine. She reported no problems with hearing during her vestibular symptoms or any other time. The client was instructed to not take any medication before having her vestibular evaluation.

An article that was found gives typical responses and symptoms of BPPV. It included 59 patients, 19 men and 40 women, with benign paroxysmal positional vertigo (BPPV). The patients filled in a questionnaire concerning their symptoms, earlier diseases, accidents and tobacco and alcohol use. None of the patients had hearing loss. The mean duration of the vertigo attacks ranged from a few seconds to 5 min, and they were fairly mild. The attacks were perceived as more intense if vertigo was rotational or if it was accompanied by nausea. The vertigo attacks occurred in spells; patients had several attacks a week (23%) or during the course of 1 day (52%). The vertigo was rotational in 80% of patients, and 47% experienced a floating sensation.


Kentala, E. & Pyykko, I. (2000). Vertigo in Patients with Benign Paroxysmal Positional Vertigo. Acta Otolaryngology, 543, 20-22.

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=4&hid=15&sid=9a94e1ac-652f-424e-9d24-5f8185d7d5bf%40sessionmgr8

The Dix-Hallpike maneuver was performed to evaluate the presence or absence of nystagmus. Upon testing very strong rotary nystagmus was seen on the right side. Additionally, she reported feeling dizzy. These symptoms were positive for BPPV. No nystagmus was seen on the left side. Two rotations of the Epley maneuver were performed to the right side in order to successfully treat her BPPV. The client's results revealed positive signs of BPPV and the Epley was performed to reduce and treat the symptoms of BPPV. Reduction of symptoms and absent rotational nystagmus was observed during the second Dix-Hallpike maneuver. It was recommended that the client rest for a few days since the testing can cause some unsteadiness.

Spring 08 Week 4

A female student came to clinic to seek help for a fluctuating hearing loss. She describes her hearing as intermittent and fluctuating. Approximately four years ago, she had mononucleosis symptoms; however, test results were negative. She reports a constant feeling of aural fullness and tinnitus only with the decrease in hearing ability.

Clear ear canals and intact tympanic membranes were observed bilaterally. Normal, Type A tympanograms were measured. Pure tone thresholds using insert earphones were found to be within normal limits, less than 25 dB HL across all frequencies bilaterally. Speech recognition thresholds (SRT) were in excellent agreement with the pure tone averages. SRT scores were 5 dB bilaterally. Speech discrimination was 100% bilaterally. On the day of testing, her hearing is considered to be normal.

Although diagnosis can not be made just from the results, the patient described a case history that suggest multiple sclerosis. The report was sent to her primary care physician with a side note of fluctuating hearing loss is a symptom of MS. Which you can find a list of symptoms here:

http://www.nationalmssociety.org/about-multiple-sclerosis/symptoms/index.aspx

The article that I found tested one female with known MS. The participant was in later stages of MS and had more severe symptoms than that of the patient seen. However, it gives valuable information about the use of audiological assessment used for diagnosing MS. The participant had sudden bilateral sensorineural hearing loss and vertigo. She was tested with audiometry, AEPs, bithermal calorics, and MRI.

Young-Mi Oh et al. (2008). Sequential bilateral hearing loss in multiple sclerosis.
Annals of Otolarngology, 117: 186-191.

http://web.ebscohost.com/ehost/pdf?vid=1&hid=104&sid=ff919d2a-aafa-4afc-9cfe-7225021250c1%40sessionmgr107

Spring 08 Week 3

I saw an adult man who stated that he notices a hearing loss especially in his left ear with occasional tinnitus. A previous surgery for the removal of a neuroma of the pituitary gland was reported. However, he noted that his hearing loss did not coincide with the surgery. He also reported having served in the military and he target shoots annually.

Otoscopy revealed normal ear canals and tympanic membranes bilaterally. Immittance results were normal type A tympanograms bilaterally. Pure tone audiometry using insert earphones revealed a normal sloping at 1000 Hz to severe sensorineural hearing loss in the left ear. The right ear is normal sloping at 500 Hz to severe sensorineural hearing loss with an abnormal air-bone gap at 1000 Hz. Pure tone averages were in good agreement with the speech recognition thresholds of 30 dB in the right ear and 55 dB in the left ear. Speech discrimination was 84% in the right ear and 60% in the left ear. According to the results, the client has a sensorineural hearing loss bilaterally with an unexplained, unusual air-bone gap at 1000 Hz that was retested with active assistance of the supervisor.

After this finding, several other patients had strange masking responses in our clinic. When searching for an article about calibration and the effects on bone conduction scores, I found this article which discusses random and systematic errors made when performing BC audiometry. When two different sites were observed, bone conduction thresholds at 2 kHz revealed a notch or 'inflection'. The authors described, "part of the problem appears to be related to excessive air borne sound from the bone vibrator at these high frequencies. Regarding lower frequencies, several audiology professionals in the UK have expressed some concern about the accuracy of bone conduction at 1 kHz and 2 kHz". As a result, the authors suggest a complete review of technology of bone vibrators and also precise placement of the bone vibrators. This was a very strange finding since I've never heard of it. This may be a useful piece of information for all clinics.


O'Neill, G. et al. (2000). Systematic errors in bone conduction audiometry. Clinical Otolaryngology, 25, 357-369.

http://web.ebscohost.com/ehost/pdf?vid=1&hid=104&sid=3d17ea14-0ffe-465b-a833-cd2aaebebedf%40sessionmgr102

Spring 08 Week 2

A woman from the local group home came in for a hearing evaluation. The caregiver reported that the client had bilateral perforated tympanic membranes (TM), due to ear infections as a child, and a longstanding history of significant hearing loss. However, she can verbalize some words but chooses to do so with her mother only. A previous surgical attempt to repair the right TM was reportedly made but was unsuccessful. The caregiver also stated that she had a recent ear infection that was being treated with antibiotics. She has a history of mental retardation and seizure disorder.

Otoscopy revealed a perforated left TM. A potentially infected green substance was observed in both auditory canals. Immittance testing revealed flat, Type B, tympanograms bilaterally. The volume of the right ear was normal at 1.92 mL while the left ear was large at 2.76 mL. Visual reinforcement audiometry (VRA), using insert earphones, revealed fairly consistent behavioral responses to narrow band noise in the moderate to severe hearing loss range at 1000 and 2000 Hz. Additional testing could not be tested due to client noncompliance. Speech awareness thresholds were found for the right ear at 70 dB HL and for the left ear at 60 dB HL. Speech recognition thresholds could not be obtained. Otoacoustic emissions were not attempted due to abnormal Type B tympanograms bilaterally. Although specific thresholds could not be obtained, behavioral results revealed a bilateral moderate to severe hearing loss in the mid frequency range. Communication strategies were discussed with the caregiver.

I found an article that discussed the prevalence of viruses and bacteria after PE tubes were placed. In this instance, the patient had subsequent perforated tympanic membranes which allows more bacteria to build. In the study, at least 1 respiratory tract pathogen was noted in 76 children (96%). Bacteria were found in 73 cases (92%), and viruses were found in 55 (70%). In 52 patients (66%), both bacteria and viruses were found. Bacteria typical of AOM were detected in 86% of patients. Picornaviruses accounted for 60% of all viral findings.

Ruohola, A. et. al (2006) Microbiology of acute otitis media in children with tympanostomy tubes: Prevalences of bacteria and viruses. Clinical Infectious Diseases; 43.

http://web.ebscohost.com/ehost/pdf?vid=1&hid=104&sid=66bae850-ccf5-4eb8-9475-4aea16cc1f3a%40sessionmgr109

Spring 08 Week 1

I saw an elderly man this week who reported a gradual decline in hearing throughout his life. He reported noise exposure from power tools, construction, and hunting. In addition, he confirmed a personal and family history of diabetes. He is not currently a hearing aid user; however, the purpose of his visit was to determine hearing aid candidacy and discuss amplification options. The client's wife, a long time hearing aid user, accompanied him. Otoscopy revealed normal, clear ear canals and tympanic membranes bilaterally. Tympanometry revealed normal, Type A, tympanograms bilaterally. Pure tone audiometry revealed a mild sensorineural loss in the low frequencies sloping at 2000 Hz to a severe loss bilaterally. Fairly reliable responses were found for bone conduction testing due to inconsistencies in masked responses and client fatigue. Speech recognition thresholds (SRT) were found to be 45 dB HL, in both ears. Pure tone averages were in agreement with the SRT bilaterally. Speech discrimination testing, performed at 40 dB SL, resulted in 76% in the right ear and 52% in the left ear. According to the results, he displays a mild sloping to severe sensorineural hearing loss and is an excellent candidate for bilateral amplification. Several hearing aid options, including behind-the-ear (BTE) hearing aids, were discussed; however, he chose an in-the-ear (ITE) hearing aid comparable to his wife’s current aid. Ear impressions were made, Oticon Tego LP hearing aids were ordered, and a follow up appointment will be scheduled when the hearing aids arrive.

I found an article that discusses speech recognition assessments and their ability to measure objective and subjective outcome of wearing hearing aids. The SPIN, HINT, and QuickSin were administered to 21 hearing aid users. All tests were administered with and without hearing aids to see if the participants speech understanding improved. Subjective matter was measured using the Hearing Aid Performance Inventory. The results suggest a great benefit in speech recognition with all tests while using hearing aids. When comparing objective and subjective results, the HAPI ratings improved as the performance on the tests improved.

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=4&hid=15&sid=9a94e1ac-652f-424e-9d24-5f8185d7d5bf%40sessionmgr8

Mendel, L.L. (2007) Objective and Subjective Hearing Aid Assessment Outcome. American Journal of Audiology, 16

Hearing and Speech Evaluation after a Stroke

An elderly man came into the clinic for a speech diagnostic. He has recently had two strokes leaving one vocal fold paralyzed. The patient's vocal fold was left open and caused him to whisper. Automatically, I was thinking about speech testing and if he would be able to be evaluated. However, with just an increase in the talk back, I could hear him perfectly. His hearing was within normal limits and he seemed to do very well with all tasks, even raising his hand. Since the patient was taking many medications, he was dizzy and needed assistance while walking through the clinic.
The biggest concern for this patient was communication. A device was bought to amplify the patient's own voice. However, it was not specific enough to pick up his voice except for at very close proximity. Information was given and he was directed to the augmentative device person in the program. I found a list of tips on choosing augmentative devices here:

http://www.linc.org/ataugcom.html

And # 4 on the list was choosing a device with good speech quality...which is exactly what this patient needs. The list is very informal but gives good general and simple ideas.

Also, I found an article on the information that should be given to family members of a stroke patient. I thought that this article was important since the family is being relied on to take care of the individual and to help with therapy. The patient's daughter came with him to the clinic and showed great concern and attentiveness to all information. Basically, the article found that the patient and family members need three things from their health professionals: information, counseling, and accessibility.

Relatives of hospitalized stroke patients: their needs for information, counselling and accessibility. By: van der Smagt-Duijnstee, Miebet E., Hamers, Jan P.H., Abu-Saad, Huda Huijer, Zuidhof, Arjan, Journal of Advanced Nursing, 03092402, Feb2001, Vol. 33, Issue 3

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/detail?vid=1&hid=107&sid=fff35d66-ce82-4c19-9b67-0cc417fe6594%40sessionmgr107

Adult Student and Auditory Processing

A young adult female came in with complaints of having trouble at work and in classes with understanding speech. She did not believe that she had a hearing loss but was unsure the reason for the difficulties.
Hearing evaluation of tymps, otoscopy, audiometry, speech recognition, and word discrimination was administered. All results were within normal limits and in fact, discrim scores were 100% bilaterally.
For the auditory processing evaluation, the SCAN-A, SSW, and AFT-R were administered. The patient was very attentive and showed great effort to stay on task. The results for the SCAN and SSW were within normal limits. However, a temporal processing disorder was evident after presenting the AFT-R. Her mean ipi was greater than the second standard deviation based on her age.
The good news is that temporal processing disorders can be fixed with programs such as Fast ForWord. The bad news is that the patient has made it through the whole semester without assistance from the school. Hopefully, with correct diagnosis, the patient will get proper management skills to become a successful student.

The article that I found discusses the difference of temporal processing between young (18-40) and old adults (65-76) and also hearing and hearing impaired individuals. The results were consistent with what I expected. The young group had better thresholds and greater percentage correct. Also, the subjects with normal hearing did better than the hearing impaired subjects. These results are an additional piece of evidence for a good prognosis with the present patient. She is considered a young adult with normal hearing. Here is the article:

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/detail?vid=1&hid=101&sid=a0c1956f-addb-4a50-a895-10009397fcef%40sessionmgr106

Profile of auditory temporal processing in older listeners. By: Gordon-Salant S, Fitzgibbons PJ, Journal of Speech, Language & Hearing Research, 10924388, April 1, 1999, Vol. 42, Issue 2

Group Home Patient with Mental Retardation

I had a lady come in with mental retardation, vision problems, and a seizure disorder. She was very sweet but had limited speech and language so evaluation procedures were limited. No responses were observed when presented with pure tones in sound field. However, a speech awareness threshold was found within normal limits with speech stimuli including "hi", "how are you?", "are you ready?", and "come on, let's go". Also, otoacoustic emissions were present in all frequencies except for one that was very low freq. Since we see many patients from the group home with mental retardation, I found an article discussing general information for a physician when dealing with this type of patient. The article includes characteristics, types, diagnoses, and development. I especially found the evaluation and referrals section beneficial to our profession since this is a specialized group to assess. The importance of talking to the parent or caregiver was discussed. In my experience, the caregiver's information and opinions have been essential to testing the individual. Here is the article:

Daily, D., Ardinger, H.H., & Holmes, G.E. (2000). Identification and Evaluation of Mental Retardation. American Family Physician.

http://www.aafp.org/afp/20000215/1059.html

Follow-up to Orientation

The same elderly man from last week came in for a follow-up (this would be the third week in a row). He seemed to be in a better mind-frame in this session and participated without reluctance. I believe that his confidence is getting better which will help him accept his hearing loss. We worked on inserting the hearing aids again and also reprogrammed them because the patient said they were too loud.

Reprogramming included decreasing the gain in the lows and mids for loud sounds. After the change, the patient seemed to be happier. He also seems to need some time to adjust to the new hearing aids. His complaints included rustling of his clothes, an obnoxious laugher, and crowds of people talking too loud. However, these sounds have always been there but were not noticeable to him or they are annoying sounds no matter what level. Aural rehabilitation would be excellent for this patient but he does not seem interested in a weekly plan (even though he has been coming in weekly).

Since this patient has been having some problems, I went to the Widex (his hearing aids are Widex) and found their suggestions for first-time users. So here are some tips...
http://www.widex.com/is-bin/INTERSHOP.enfinity/WFS/Widex-COM-Site/en_GB/-/EUR/SVCPresentationPipeline-Start?Page=issite%3a%2f%2fWidex-COM-Site%2fWidexEnglishDic%2fDic%2f0_0_Index%2f0_0_1_IndexPages%2fAdviseForFirstTimeHearingAidUsers%2epage
The two tips that seemed most important for this patient were adjusting to new sounds and practice makes perfect.

In addition, I also read an article on hearing aid services and satisfaction because I was unsure if the problem was with me or him...which, most likely, it is both. I can not be with him everyday to make sure he is practicing so I'm not doing enough and he started out unmotivated. In this article, hearing aid users were asked to evaluate the service that they received when purchasing a hearing aid. I have seen this article before in class and possibly on someone else's blog. However, I never really noticed that the audiologists and hearing aid dealers were not giving the patient the opportunity for group aural rehabilitation. Also, communication strategies were also not top priority for the professionals to discuss with their patients. I believe that my patient needs both of these pieces of information. In fact, it was more important for me to discuss expectations, communication strategies, and aural rehab than how many programs the hearing aid had or how to change the wax guard. Here's the article:

http://www.hearingresearch.org/Dr.Ross/HAsatisfaction_consumers.htm

Stika, C.J. & Ross, M. (nd) Hearing Aid Services and Satisfaction: The Consumer Viewpoint.

Hearing Aid Orientation for New User

An elderly man came in for a hearing aid orientation and then the next week for a hearing aid check. Many factors effected the way the session went. His general health is not very good and he has been taking chemotherapy over the summer. His wife is the main person in his life and attended the appointment with him. However, she is also the only reason he purchased hearing aids to begin with since she is very opinionated (may be the best way to put it).

After introducing the concept of hearing aids, I showed how to insert the batteries, put on the hearing aids, and change the programs. The patient seemed reluctant to try these things for himself. Instead he would hand the instrument to his wife. Putting the hearing aids on was very difficult for the patient. He got very distraught and anxious to leave. Once he had the hearing aids in, he was out the door. Continuous reinstruction and patience was the key for this patient. The next session went much smoother. He actually put the hearing aids in himself several times. I believe that this patient needed to be seen more than others. He may have had some memory problems due to chemo treatments and because he is elderly. Also, he was not motivated or confident in the beginning. Once he realized that he could not break the hearing aids, he did much better.

The article that I've found is one that I believe someone else used for patient counseling. It is a very good article in this instance because it discusses normal, healthy patients. Just imagine the effects on someone who has other difficulties. Patients were tested to see how much they could remember right after a hearing aid orientation and then a month after. Around 75% was recognized overall after the orientation. I believe that you can't say important information enough. I used repetition to help me. I repeated instructions and I also scheduled for another appointment to reitterate the information. Do you think your patients remember what you say?? What's your method to help a patient insert their hearing aids??

Reese, J.L. & Hnath-Chisolm, T. (2005). Recognition of hearing aid orientation content by first-time users. American Journal of Audiology, 14 (1): 94.

http://aja.asha.org/cgi/reprint/14/1/94

Child with Little Expressive Language

A young boy came to the clinic as part of a speech diagnostic. The child had very little expressive language and was beginning the process of learning some signs. After trying many different stimuli, speech was used to ask where body parts were. The child responded to some by pointing. However, he began to fixate on his nose and started acting like a 'piggy'. Responses were inconsistent but were well within normal limits. Also, OAEs were performed successfully and were normal.

This patient was very energetic and playful. What little vocabulary he had was masked by articulation problems. In the article 'Communicative gestures in children with delayed onset of oral
expressive vocabulary', children with expressive language delays rely heavily on gestures and signs. This was apparent when the child walked in the clinic. He was pointing and handing things to his parents instantly. His nonverbal communication was also very good. He went from being happy to being bored to upset and every emotion was plain as day on his face.

Thai, D.J. & Tobias, S. (1992). Communicative Gestures in Children With Delayed Onset of Oral Expressive Vocabulary. Journal of Speech and Hearing Research, 35, 1281-1289.

http://jslhr.asha.org/cgi/reprint/35/6/1281

Testing Patient with Mental Retardation

I performed a hearing evaluation on an adult male with mental retardation. He also had some vision impairments that will hopefully improve after his cataract surgery within the month. Although very consistent with responses, the patient could not be tested using VRA and would he not allow anything near his ears. Warble tones and speech (patient's name) were used through sound field to elicit a response. The patient would respond by quieting or looking for his caregiver. Chronologically the patient was an adult but his cognitive age required the use of BOA. From the results, his hearing was determined to be normal.

In the article by Karikoski et al., the acuity of BOA in predicting hearing loss in children was evaluated. The results concluded that BOA was good for determining if there was a hearing loss or not. However, the degree of loss was not as easy to pinpoint especially for profound losses. In fact, BOA underestimated the loss when the actual loss was severe or profound.

Karikoski JO, Marttila TI, Jauhiainen T. Behavioural observation audiometry in testing young hearing-impaired children. Scand
Audiol 1998;27:183–7.

http://web.ebscohost.com.www.libproxy.wvu.edu/ehost/pdf?vid=1&hid=107&sid=b37f5c0e-0eb7-4fc7-b0d2-1331a6a0513b%40sessionmgr103