Transcript Audiology Advocacy - National Center for Hearing Assessment and

Audiology Advocacy
Audiologists responsibility to EHDI
Mary Beth Brinson, Au.D.
Stephanie Disney, M.S. CCC-A
Presentation Points
 Historical Perspective
Survey comparisons
Audiological services comparison
 Pediatric Audiology Crisis
Professional Organizations and Plans
Au.D. solutions
 Case Studies
 Problem solving and discussion
Historical Perspective
 In 2000, Kentucky
audiologists were
surveyed about
pediatric audiology
protocols, equipment
availability, training
needs and resources,
and community
collaboration
 54% of those surveyed
responded (41/75)
Access to services by age
Based on 2000 survey
100
90
80
70
60
% testing 50
40
30
20
10
0
95
78
84
5
0
6
12
test age in months
36
Test Protocol
Based on 2000 survey
100
90
80
70
60
% testing 50
40
30
20
10
0
97
95
Pure
tone
HA
90
75
24
Tymp
OAE
ABR
Test Protocol
Training Needs
Based on 2000 survey
50
45
40
35
30
%
25
interested
20
15
10
5
0
50
None
28
30
28
OAE
CI
ABR
Training requested
EI Training
Based on 2000 survey
63
52
50
Training requested
Integration
Community
Resources
Language
Stim
13
None
70
60
50
%
40
interested 30
20
10
0
Distribution of Audiologists
Pediatric Audiology Crisis
 Paradise and Bess (1994) article: Predicted
inability to provide quality follow-up from
UNHS due to high numbers
 Speculated that there were not enough
qualified professionals
High Risk Registry vs. UNHS
 High risk registry: misses estimated 50% of
permanent childhood hearing loss
 Crisis is that theoretically we have doubled
the babies entering the system
 Where are the additional qualified providers?
JCIH 2000
EHDI
GUIDELINES
8
PRINCIPLES
Audiology Test Battery
Includes physiological measures
Includes developmental appropriate
behavioral techniques
Measures that assess integrity of the
auditory system
Estimate for each ear type, degree and
configuration of hearing loss
JCIH Guidelines
(6 through 36 months)






Family and child history
Behavioral Response Audiometry (CPA,
VRA)*
Otoacoustic emissions
Acoustic emittance measures
Speech detection and recognition
measures*
Electrophysiologic (ABR) testing: at least
once*
*requires special adaptations for pediatrics
JCIH Guidelines
(0 through 6 months)
 Family and child history*
 Frequency specific electrophysiological test
(ABR or ASSR)/Bone conduction*
 Otoacoustic emissions
 Middle ear function test/ ART*
 Behavioral Observation Audiometry*
*Requires special adaptations for pediatrics
“Adequate confirmation of an
infant’s hearing status cannot
be obtained from a single test
measure. A battery crosschecks findings of both
physiological and behavioral
measures.”
JCIH
Confirmation of
Hearing Loss: Benchmarks
 Comprehensive services coordinated between the
medical home, family and related professionals
with expertise in hearing loss.
 Audiologic and medical evaluations before 3
months of age or 3 months after discharge for
NICU infants
 Infants with diagnosed hearing loss receive and
otologic evaluation
 The medical and audiologic evaluation process
perceived as positive and supportive
Clinical Doctorate?
Percent of Audiologist who hold an Au.D. by State
June 2004
1-4%
5-9%
10-14%
15-19%
20-24%
19-25%
Training?
 Total number of NCHAM training workshops completed: 14
 Total number of audiologists trained: 299
 Areas workshops located:
2002 Florida
2003 Iowa, San Diego, Redondo Beach, Oakland,
Chicago (CA had a separate grant)
2004 Salt Lake City, Boston, Redondo Beach, Boise
Philadelphia,Redondo Beach, San Mateo, New Orleans
2005 Next one scheduled is in New Mexico
Credentialing?
 Still being developed……
 Doesn’t address today’s needs
Case Studies
Case Study 1
Risk factors include:
Sepsis
Ototoxic Medications
Prematurity
Notched
tymp due
to crying?
Behavioral
explanation, no cross
check?
Multi
system evaluation?
No Cross Check
Parental report of cessation
of babbling at 11 months
RECHECK in 6 months?
A cross check
now?
Is this matching
results to middle
ear measures?
Post op tubes –
Behavorial excuse for
hearing loss?
Questionable
microphonic
Questionable
microphonic
Audiological Findings
 Severe to Profound Bilateral SNHL
 Functional PE tubes
 Recommend immediate amplification
-There are no OAE’s and a lack of systemic
evaluation and cross check battery
Ear specific?
Fit with powerful
Phonak Sonoforte 2
P3AZ HA
Cross check?
OAE’s?
Pre Cochlear Implant Evaluation
? OAE
Audiological
Recommendations
 Re-program hearing aid to new hearing loss
-Only obtained thresholds at 500, 2K
 Re-evaluate with behavorial testing in 3
months
-Parents report child has no speech
-No physiologic measures planned
90 dB
85 dB
Middle ear evaluatedTympanometry
Cochlear function evaluated- OAE
Neural track evaluated- ABR
Frequency Specific information
Audiological
Recommendations
 Diagnosis- Auditory Neuropathy
 Discontinue current amplification
 Consider mild gain aid
 Proceed with Cochlear Implant Evaluation
Identified with a hearing loss so late in the critical
language learning period, she is at a disadvantage
in the language learning process
Late age of identification and
upcoming use of Cochlear
Implant……………..
Stephanie:
Sorry I haven’t followed up with you sooner, but it has been crazy!!! I
got your phone message and wanted to follow up with you. You were
right about the Neuropathy. Sue Windmill made the diagnosis in
April!!! We consulted with Dr. Linda Hood at LSU, and Vanderbilt
agreed to do the implant surgery!!! She was implanted on April 28th
and switch on was May 26th. She has been in AV therapy since that
time, and seems to be coming along. We have a very long way to
go, and are uncertain about the full outcome at this point? I have
been on the LSU website, but would love to get more information on
AN if I can? Any suggestions where I might find research or other
resources?
Thank you again for helping us get a diagnosis. If you had not
helped us, we would still be searching for the answer.
I can’t thank you enough.
Sincerely,
Christy Adkins
A different take on 1-3-6
 6 Audiologists
 3 Centers in 2 states
 1 Late Diagnosis
Case Studies
Case Study 2
Case 1: TM
 Male
 Born August 2004
 Failed UNHS bilaterally
 No reported risk factors
 Normal pregnancy and birth
Case 1:T.M.
 UNHS follow-up 8/21/04
 ABR
 Results…
ABR 1Results: T.M.
Right ear:
60dB
ABR 1Results: T.M.
Left
ear:
60dB
Artifact
90
Sweep
2000
Tympanogram 1: T.M.
Tymps
@
226Hz
@
4 weeks
Inappropriate
test settings
OAE 1: T.M.
Interpretation of
st
1 ABR
 Actual hearing could not be determined due
to child’s awake state
 Middle ear dysfunction right ear, normal left
 Audiologist not confident in findings


Attributed hearing loss results to high artifact
Scheduled retest at 2 months of age
ABR 2: T.M.
Left
ear:
35dB
ABR 2: T.M.
Right ear:
50dB
ABR 2: Results
 Borderline normal hearing left
 Possible mild hearing loss right
 Again, awake state interfered with tests
 Recommendation: Sedated ABR due to high
artifact and for second opinion**
ABR 3: T.M.
 Different facility
 Under sedation
 December 2004
 Child is 5 months old
ABR 3: T.M.
ABR 3: T.M.
 Bilateral moderate sensory hearing loss
 Earmold impressions made
 Early intervention referral made
Problems: T.M.
 3 ABRs performed, 4 months for diagnosis
 High Artifact? < 10%
 3rd ABR with sedation: unnecessary?
 2 1/2 hour trip to other facility
 Parents now travel for hearing aid appts.
Possible Remedies
 Correct tests were performed according to
JCIH
 More education in modifications for neonates
 More experienced mentor to lend support
 Additional pediatric testing training (locally
and nationally available)
Not everything that is faced can be
changed, but nothing can be changed until
it is faced -James Baldwin