Testing the hearing of children in the

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1 Testing the hearing of children in the ENT-Practice Dr. med. Thomas Wiesner Dep. of Phoniatrics and Pediatric Audiology Werner-Otto-Institut, Hamburg, Germany 1 Testing the hearing of children Every child is different, depending on: developmental age understanding instructions motor capabilities (like head control) attentiveness endurance motivation additional handicaps influence of the parents Sit down? Take a headphone? Raise your hand, if you hear? is a field of a thousand pitfalls, but correct results can be crucial for the child s development at any age 2 Picture: Reinhold Stehle, Alsheimer Str. 71, Guntersblum, / pixelio.de

2 Diagnostic options for testing the hearing of children Case history ENT- inspection Tympanometry OAE AEP acoustically evoked potentials BOA behavioral observation audiometry (unconditioned reactions) VRA visual reinforcement audiometry (conditioned reactions) Play audiometry Speech audiometry 3 Case history, ENT- inspection, Tympanometry You are the specialist! A very useful addition to the case history are special questionnaires (even as a hearing screening tool) But standard tympanometry with a probe tone of 226 Hz is misleading with babys 5 month old child Babys < 6 (8) month need a 1000Hz tympanometry 4

3 Otoacoustic emissions (A)-TEOAE, (A)-DPOAE An ideal diagnostic tool for children at any age! Quick Requiring only little cooperation No need to understand instructions Including middle ear and inner ear Ideal for a crosscheck of any subjective test results NHS great progress in the development of fully automated, reliable algorithms to analyze and interpret the test results, controlling: Probe fit, surrounding noise level, artifact rejection (DPOAE can automatically estimate a threshold < 50dB) 5 AEP for hearing screening : Click evoked A-ABR are sufficient (to check 2-4 khz) Automated statistical analyses at 35 db are available Some systems also provide automated ABR screening results for children > 6 month for finding the hearing threshold and as a basis for a hearing aid fitting: frequency specific AEPs are necessary: Tone-Burst-ABR, Notch-Noise-ABR, Chirp-ABR, ASSR the procedure and the interpretation of the test results need a lot of special experience essential for the assessment of hearing impaired babies 0-6 month 6

4 Behavioral Observation Audiometry and VRA with unconditioned and conditioned responses BOA 0-6 month crosscheck for any objective results no threshold VRA 6-18 month results near the hearing threshold + for each ear separately are achievable: highly attractive visual rewards like: animated toys, colorful bright impressive video cartoons child appropriate setting with a lightening that enhances the contrast of the visual rewards experienced staff Results in free field, insert phones, bone conductor 7 Age 0-6 month: Determining a frequency specific hearing threshold is a puzzel: OAE Click-ABR frequency specific AEP subjective reactions + tympanometry, stapedius reflexes, case history, 8

5 Play audiometry Conditioning can start at the age of 2/2½ y. play like activity, simple, less demanding on fine motor skills, motivation by a good relationship and by constantly praising the child Pitfalls: child does not understand, gets confused only rhythmic repetition of the play tast giving the wrong motivational clues standard play audiometry procedure needs experienced staff to yield reliable results or some technical help 9 FAST Frequency-specific Animal Sound Test Play audiometry - new options different animal symbols on the display represent different frequencyfiltered animal sounds the device presents an animal sound the child touches the corresponding animal symbol on the screen depending on the answer of the child the device increases and decreases the level of the test sounds 10

6 FAST Frequency-specific Animal Sound Test Play audiometry - new the device calculates by an adaptive procedure the hearing threshold of the child appropriate age 3½+ 11 MAGIC - Multiple-Choice Auditory Graphical Interactive Check Play audiometry - new options different animal symbols on the display represent different stimulus frequencies the child selects an animal symbol on the screen which will trigger an acoustic stimulus (beep) if the child is able to hear the sound it will touch the smiling animal symbol on the screen. 12

7 MAGIC - Multiple-Choice Auditory Graphical Interactive Check Play audiometry - new options the device calculates also a failure rate appropriate age 4+ depending on the answer of the child the device increases and decreases the level of the test sounds the device calculates by an adaptive procedure the hearing Th. threshold Wiesner, WOI, of the child 13 Matrix 3-word-sentence-test for children Speech audiometry new options Like the OLKISA (Oldenburger- Child-Sentence-Test) Identification of speech recognition threshold in noise and in quiet. Suitable also for profoundly hearing impaired people and cochlear implant users. Possibility of unlimited repetitions of measurements. Special speech simulating noise for best accuracy. No memorizing of test material possible. Adaptive level adjustment multiple languages available ( 14

8 AAST: Adaptive Auditory Speech Test Speech audiometry new options interactive PC-game like in multiple-choice form with n=6 alternatives child hears a spondee word and points to the picture (e.g.: airplane) redundancy comparable with short everyday sentences testing for: speech-threshold speech-in-noise (Signal-Noise-Ratio) adaptive procedure short test duration: less than 2 minutes multiple languages available 15 Conclusion The more limited the cooperation ability of a child is, the more you have to rely on: Experienced staff Optimized testing procedures Objective methods The less experienced your staff is, you have to rely on: automated devices providing a technically assisted testing procedure, controlling and documenting disturbances in the testing environment and analyzing the test results crosscheck of subjective results by automated objective methods Keep in mind: also any objective methods (especially the non-automated) have their limits and have to be seen as part of a more comprehensive test battery any hearing test of a child under suboptimal conditions may lead to more confusion then a reliable diagnosis and may cost valuable time before initializing therapeutic procedures 16

9 Conclusion For young children of 0-6 years, make use of reliable and time efficient methods: Case history + specialized questionnaires Outer ear and middle ear: inspection + tympanometry Objective methods: automated OAE and automated screening ABR Subjective methods: child appropriate devices with an automated and adaptive play audiometry algorithm and adaptive speech audiometry procedures With this test battery you will be able to rule out most permanent hearing losses for the great majority of your very young patients Any child, where the suspicion of a permanent hearing loss persists should be referred to a specialist in pediatric audiology without delay For children with a permanent hearing loss only a reliable frequency specific threshold is the basis for the correct diagnosis and a well-directed hearing aid fitting 17 Thank you for listening Thank you to the parents, the multi-professional team in Hamburg and the pediatric audiology working group in Germany 18

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