The Role of the Audiologist in Life Care Planning (I)

Audiology, an autonomous profession that encompasses both health care and educational professional areas of practice, is involved with the study of hearing and balance and their related disorders. The audiologist is the independent hearing health care professional who provides com­prehensive diagnostic and habilitative/rehabilitative services for all areas of auditory, vestibular, and related disorders. These services are provided to individuals across the entire age span from birth through adulthood, which is in concert with the goals of a life care plan; to individuals from diverse language, ethnic, cultural, and socioeconomic backgrounds; and to individuals who have multiple disabilities (ASHA, Spring 1996).

Within life care planning, the audiologist should be involved in pediatric and adult rehabilitation efforts when clients experience decreased hearing sensitivity, auditory processing problems, auditory neuropathy (auditory dys-synchrony), or balance problems. Clients may experience auditory deficits, due to genetic or natural aging factors, ear disease, brain injury, auditory processing dysfunction, environmental noise exposure, or reactions to medications that are ototoxic or vestibulotoxic.

Life care planners seeking information on current audiology preferred practices, technical papers, position statements, reimbursement codes, standards, and certification and licensure (Appendix 10.1) will find the American Speech-Language-Hearing Association (ASHA) web- portal (www.professional.asha .org or www.asha.org) the most comprehensive site for peer- reviewed documentation of practice issues and currency of reimbursement codes. The ASHA Code of Ethics (ASHA, 2003), revised January 1, 2003; scope of practice (ASHA, Spring 2004); preferred practice patterns for the profession of audiology (ASHA, 2006); Joint Audiology Committee Clinical Practice (1999) statements and algorithms; and current reimbursement code funding are documents (ASHA, 2007) of significant interest to life care planners seeking best practices information and quality hearing health care for their clients. The information is also available on the ASHA webportal.

Services provided by audiologists include the ability to

¦     Test and diagnose hearing and balance disorders

¦     Select, fit, and dispense hearing aids and assistive devices

¦     Provide audiologic/aural (re)habilitation services

¦     Educate consumers and professionals on prevention of hearing loss

¦     Participate in hearing conservation programs to help prevent workplace-related and recre­ational hearing loss

¦     Consult for federal, state, and local agencies in reducing community noise

¦     Conduct research

Audiology services are available in the following work settings:

¦     Colleg es and universities

¦     Public and private schools

¦     Hospitals

¦     Community-based hearing and speech centers

¦     State and local health departments

¦     Private practices

¦     Rehabilitation centers

¦     Nursing care facilities

¦     Industry

¦     State and federal governmental agencies

¦     Military

Audiology can be categorized by either the setting in which one practices or the population one serves. Bess and Humes (1995) identified the following specialty areas in which audiologists generally practice (see Figure 10.1). The pediatric audiologist concentrates on the audiologic management of children of all ages. The pediatric audiologist is often employed in a children’s hospital or a health care facility primarily serving children. The medical audiologist works with patients of all ages and is more concerned with establishing the site and cause of a hearing or balance problem. Medical audiologists are typically employed in hospitals as part of either a hearing and speech department or a department of otolaryngology (i.e., ear, nose, and throat). Some audiologists who work in a medical environment perform intraoperative monitoring, which involves monitoring central and peripheral nerve function during surgical procedures. The rehabilitative/dispensing audiologist focuses on the management of children or adults with hearing impairment. Rehabilitative audiologists are often in private practice and may specialize in the direct dispensing of hearing aids in addition to offering other audiologic rehabilitation services. Rehabilitative audiologists are also employed by a variety of health care facilities (e.g., hospitals and nursing homes). The industrial audiologist provides consultative hearing conservation services to companies whose workers are exposed to high noise levels. The industrial audiologist may be in private practice or work on a part-time basis. The forensic audiologist serves as an expert witness in legal issues related to hearing and balance. The forensic audiologist may serve as an expert witness for the plaintiff or defense in compensation cases and may also serve as a consultant in community or environmental noise issues. Finally, the educational audiologist serves children in the schools and is employed or contracted by the educational system. Many audiologists, not just those in academic environments, engage in basic and applied research that is not only essential to understanding human auditory function but also necessary in order to develop testing materials and procedures and improved amplification systems.

When referring a patient to an audiologist for a basic audiologic assessment, one may expect cer­tain basic procedures to be conducted to quantify and qualify hearing loss on the basis of responses to acoustic stimuli and to screen for other associated communication disorders. These include a pure tone hearing test (ASHA, 1978), speech audiometry (ASHA, 1988), and acoustic immit- tance (ASHA, 1991b) procedures accomplished in accordance with American National Standards

Institute standards (ANSI, 1981, 1986, 1987, 1991, 1992, 1996) and under Centers for Disease Control (CDC) standard health care precautions guidelines (CDC, 1988; U.S. Department of Labor, 1998). Of course, the basic audiologic procedures may be modified depending on the age or level of cooperation of the patient.

The clinical process for a basic audiologic evaluation includes the following (ASHA, 1999):

¦     A case history

¦     Otoscopic evaluation

¦     External ear canal examination and cerumen management, if necessary

¦     Assessment, which includes:

-       Air conduction and bone conduction threshold measures with appropriate masking (pure tone testing)

-       Speech recognition thresholds or speech awareness thresholds with appropriate masking

-       Word recognition (speech discrimination) measures with appropriate masking

-       Acoustic immittance testing (tympanometry, static compliance, and acoustic reflex measures)

-       Other procedures, which include, but are not limited to, otoacoustic emissions screening, speech and language screening, communication inventories, and screening for APDs and other related auditory disorders

The external ear canal examination is performed to remove debris from the ear canal to allow the audiologist to perform the assessment or to perform rehabilitative or hearing aid procedures. The need for cerumen (ear wax) management is required when there is an accumulation of debris that would preclude the audiologist from obtaining valid and reliable assessment results and, in many cases, improve auditory sensitivity. Established procedures include the following (ASHA, 1991a; Roeser & Crandell, 1991; Ballachandra & Peers, 1992):

¦     Mechanical removal

¦     Irrigation

¦     Suction

It should be noted that in some states, cerumen management is not within the scope of practice of audiologists. Reimbursement for the service varies by state and region and also from third-party payers.

An audiologist using a calibrated electronic device called an audiometer measures hearing. An audiogram is a graphic representation of hearing. It relates intensity (loudness) as a function of frequency (pitch). Frequency, measured in hertz (Hz), is plotted along the abscissa, and intensity, measured in decibels (dB), is plotted along the ordinate.

A person wears earphones and the audiologist presents tones at varying frequencies and inten­sities for each ear. When the individual hears the tone, she responds by raising her hand. When the tone is heard at the lowest intensity level two out of three times, the audiologist records this inten­sity level for each frequency on the audiogram. This level is called threshold. Thresholds for the left ear are plotted with a blue X and thresholds for the right ear are plotted with a red 0. Normal hearing is considered to be between —10 and +15 dB HL. Hearing level (HL) is the number of decibels relative to normal hearing, which is 0 dB HL on the audiogram. The example audiogram indicates normal hearing in the left ear and a hearing loss in the right ear.

The area enclosed by the two wavy lines is called the speech banana. This area represents the frequencies and intensities of spoken English and assists the audiologist in explaining how a hear­ing loss may affect a person’s ability to understand speech. In the example audiogram, the person will not be able to hear speech sounds above 1000 Hz in the right ear because his thresholds are out of the speech banana. Were this person to have this degree of hearing loss in both ears, he may be expected to have difficulty understanding high-frequency speech sounds such as s, f th, p, t, k, sh, and ch, for example. In addition, he may be expected to have considerable difficulty under­standing conversational speech in the presence of background noise, such as in a cafeteria.

Audiograms are very important because they can indicate whether a person has a hearing loss and also the type and degree of loss she has. There are three principal types of hearing loss directly associated with the peripheral auditory mechanism: conductive (a problem in the outer or middle ear), sensorineural (a problem in the inner ear or the eighth cranial nerve, which carries the auditory signals to the brain), and mixed conductive and sensorineural loss. Other nonperipheral auditory deficits may include auditory processing disorders and an auditory neuropathy (auditory dys-synchrony).

A second part of the basic testing includes speech audiometry where the audiologist evaluates how well a person can hear and understand speech. Speech audiometry consists of speech thresh­old and word recognition (understanding) or speech discrimination testing. Speech threshold testing determines how soft a speech sound a person can recognize, whereas word recognition testing tells the audiologist what percentage of conversational speech is correctly understood at a particular intensity level. One method of obtaining a word recognition/speech discrimination score is called the articulation gain function (Figure 10.4) (or performance intensity/phonetic balance function). This method assures that the patient’s maximum score possible will be identi­fied (ASHA, 1988).

Most people understand conversational speech maximally at approximately 40 dB above their speech threshold. The evaluator starts by presenting the speech level at 40 dB above the patient’s speech threshold and reading a list of 50 single-syllable words with the person instructed to repeat back each word.

The percentage correct score at 40 dB above a person’s threshold is then plotted. If 100% correct is not achieved, the test is repeated using a similar list of words at 50 dB above the person’s threshold, and that score is plotted. This procedure is repeated until the person’s best score is obtained. The score in the example graph indicates that the person will understand speech 90% of the time as long as it is 60 dB above threshold.

Acoustic immittance, sometimes referred to as acoustic impedance, measures the mobility of the middle ear system. The middle ear is basically a vibratory system consisting of the eardrum and the three middle ear bones: the malleus, incus, and stapes. The middle ear is responsible for taking acoustic energy (sound) and transferring it via mechanical energy from the outer ear to the fluids in the inner ear. The functioning of the middle ear affects the way people hear. Tympanometry is a measure of the mobility of the middle ear (compliance) as a function of middle ear pressure, measured in dekapascals (daPa). The results are displayed on a graph called a tympanogram (Figure 10.5), and interpretation of these results can help indicate the site of the lesion or what is causing a hearing loss (ASHA, 1991b).

An electroacoustic immittance meter is used to measure the middle ear function. A plug is inserted into the ear canal, and the instrument takes the measurements and graphs the information.

There are five basic types of tympanograms:

Middle ear pressure is between +100 and 150 daPa. Compliance is normal.Middle ear pressure is normal.Middle ear pressure is normal.Middle ear pressure cannot be measured due to fluid.Middle ear pressure is reduced.Middle ear pressure (daPa) Type B

Middle ear pressure (daPa)

Type CMiddle ear pressure (daPa)

Although these procedures are typically conducted during an audiologic evaluation, they may be modified to meet the special needs of children and other difficult-to-test patients. For patients who cannot or will not tolerate earphones, test signals (tones and speech) can be presented through loudspeakers strategically placed within the sound-attenuated test booth. The patient will either look toward the sound or be taught to place a peg in a board, ring on a peg, block in a box, and so on, in response to the sound. At that moment, the patient’s positive response behavior will be reinforced. Successive trials will enable the audiologist to establish threshold or an acceptable estimate of hearing level.

Pediatric audiologic assessment is usually conducted on infants and young children (under 5 years of age) (ASHA, 1993) and other individuals whose developmental levels preclude the use of standard adult audiologic assessment procedures. The assessment typically requires an audiolo­gist skilled in pediatric assessment and will involve multiple office visits. The clinical process is essentially the same as that for a basic audiologic assessment prior to attempting to obtain test results. The assessment may include one or more assessment tools (acoustic immittance measures, audiologic (re)habilitation and education needs assessment, otoacoustic emissions (OAE), electro- physiologic assessment, and other developmentally appropriate behavioral procedures). Behavioral testing measures include the following:

¦    Visual Reinforcement Audiometry (VRA)

¦     Conditioned Play Audiometry

¦     Tangible Reinforcement Operant Conditioning Audiometry (TROCA)

¦    Visual Reinforcement Operant Conditioning Audiometry (VROCA)

¦     Behavioral Observation Audiometry (BOA)

¦     Prenatal Causes of Hearing Loss

Prenatal causes refer to adverse effects on the cochlea during embryological and fetal development, resulting in congenital hearing loss. Development of the external, middle, and inner ear takes place between the fourth and eighth weeks of gestation. Some infants have hereditary factors that put them at risk for hearing loss. Genetic abnormalities such as a variety of sensorimotor impairments; difficulty with balance and coordination; mental retar­dation; musculoskeletal anomalies; thyroid disorders; abnormal skin pigmentation; visual disorders; cleft palate; and skull, facial, and external ear deformities may accompany the hearing loss. Combinations of these various disorders are referred to as syndromes, and a combination of genetic and in utero environmental factors is referred to as multifactorial genetic consideration.

Teratogens are environmental agents that result in malformations and anomalies of specific organs and systems that are undergoing rapid development in the embryo or fetus. Exposure to teratogens may result in maj or congenital anomalies. Some of these teratogens and infectious diseases are drugs (alcohol, cocaine, cigarette smoke), congenital HIV and AIDs, rubella, cytomegalovirus (CMV), herpes simplex-type virus, toxoplasmosis, congenital syphilis, and thalidomide (the most notorious teratogen in history). Table 10.1 summarizes categories of risk factors for hearing loss in infants and young children.

Family history of childhood hearing loss Congenital infections (TORCH)*

Craniofacial anomalies

Low birth weight (less than 3.5 lbs or 1.6 Kg)

Hyperbilirubinemia requiring blood exchange

Bacterial meningitis

Asphyxia

Ototoxic medication

Mechanical ventilation of more than 10 days Syndromes that include hearing loss

Note: *TORCH is an acronym describing congenital perinatal infections, including toxoplasmosis, other infections (like syphilis), rubella, CMV, and herpes simplex

Many children are born with significant hearing impairments but are not identified and provided appropriate intervention (Folge, 2008). These children lose their ability to acquire fundamental speech, language, cognition, and social skills required for later schooling and success in society. Early intervention is needed for them to develop communication skills on par with their normal hearing peers (Hayes & Northern, 1997; Vaughn, 2005). Hearing screening may be a luxury in many nations, but it is becoming increasingly important in nations with the resources to provide the procedures. Hayes and Northern (1997) stated that the prevalence of significant hearing disorders in newborns may be as high as 6 in every 1000 live births. Simmons, McFarland, and Jones (1980) found hearing loss in 1 out of 50 infants who had been discharged from neonatal intensive care units. Infants with low Apgar scores are considered at risk for hearing impairments. Some newborns may pass a hearing screening and still be at high risk for hearing loss, therefore it is important to perform regular follow-up hearing screenings for at least several months (Mann, Cuttler, & Campbell, 2001). Readers are referred to Table 10.2.

ASHA has a model bill for states, called the Early Hearing Detection and Intervention (EHDI) advocacy campaign, designed to help states reduce the number of infants lost to follow-up after hearing screening, expand early intervention services, and promote culturally sensitive family support programs.

Launched in 1999, ASHA’s Phase I EHDI campaign, developed in 2000 and revised in 2004, focused on federal seed grants and state legislation to expand universal newborn screening and other policies to build the infrastructure to support state EHDI programs. Since then, the number of infants screened for hearing loss has increased from 20% to 92% nationwide. Although not all states mandate hearing screening for all newborns, all states have a hearing screening program in place.

1. An illness or condition requiring admission of 48 hours or greater to a NICU.

2. Stigmata or other findings associated with a syndrome known to include sensorineural or conductive hearing loss.

3. Family history of permanent childhood sensorineural hearing loss.

4. Craniofacial anomalies, including morphological anomalies of the pinna and ear canal.

5. In-utero infection such as cytomegalovirus, herpes, toxoplasmosis, or rubella.

29 days to 24 months

1. All of the above, plus the following.

2. Parent or caregiver concern regarding hearing, speech, language, developmental delay, or a combination of these.

3. Postnatal infections associated with sensorineural hearing loss, including bacterial meningitis.

4. Recurrent or persistent otitis media with effusion for at least 3 months.

5. Neonatal indicators—specifically, hyperbilirubinemia at a serum level requiring blood exchange transfusion, persistent pulmonary hypertension of the newborn associated with mechanical ventilation, and conditions requiring the use of extracorporal membrane oxygenation.

6. Syndromes associated with progressive hearing loss such as neurofibromatosis, osteoporosis, and Usher’s syndrome.

7. Neurodegenerative disorders such as Hunter’s syndrome, kyphosis, gargoylism, or sensorimotor neuropathies such as Friedreich’s ataxia and Charcot-Marie-Tooth syndrome.

8. Recurrent or persistent otitis media with effusion for at least 3 months.

9. Head trauma.

The Phase II advocacy campaign builds on the principles of the 2007 Joint Committee on Infant Hearing (JCIH) Statement and the Early Hearing Detection and Intervention Act of 2007 (H.R. 1198 and S.N. 1069). ASHA’s goal is to have the federal EHDI legislation passed in 2009.

The EHDI model bill focuses on follow-up services. It calls for an enhanced tracking system to monitor newborns and infants with hearing loss. It also provides the following:

¦     A broad range of early intervention services, including family support programs

¦     Comprehensive insurance coverage for intervention services and devices for children with hearing loss

¦     Coverage for children with mild, moderate, and unilateral hearing loss

Although the majority of infants are screened for hearing loss, almost 60% of infants who do not pass the screening are lost to follow-up, either because they do not receive follow-up services or because their follow-up is not tracked effectively. In addition, services recommended in Phase II—early intervention services, family support programs, and devices—are either not provided or

not covered by health plans. ASHA’s model legislation addresses that gap by calling for improved tracking systems and by mandating insurance coverage for early intervention services, family support programs, and devices.

The model legislation is structured so that states can adapt it to fit their needs and availability of resources. Some states, such as Rhode Island and Virginia, already mandate coverage for early intervention services, and at least nine states mandate hearing aid coverage for children.

One important aspect of the Phase II follow-up and early intervention services requires states to mandate that family information and support are timely, culturally competent, and family cen­tered. Phase II stipulates that families receive unbiased information and are offered the full range of early intervention services and treatment options available for children with hearing loss.

At press time of the third edition of this text, the following update on EDHI is available. New state laws are on the books in Maine and Tennessee that enhance early hearing detection and intervention (EHDI) efforts, reflecting a national trend to improve EHDI programs.

Maine’s governor approved legislation on April 17, 2008, to help ensure that newborns with suspected or confirmed hearing loss receive the necessary follow-up care in a timely manner from qualified professionals. The legislation implements the recommendations of a working group that studied the effectiveness and timeliness of early identification and intervention for children with hearing loss.

The new law requires a hospital or birthing center to schedule a newborn whose screening result is “refer” for a follow-up audiology appointment. Parental approval is necessary. The appointment must be scheduled prior to discharge, and the hospital or center must notify the newborn’s pri­mary care provider in writing of the screening result and appointment prior to discharge. In addi­tion, the Maine Department of Health and Human Services’ Newborn Hearing Program must report to a joint standing committee of the legislature about barriers to access to audiologists for the continued evaluation of hearing loss in newborns.

Tennessee’s governor signed legislation on April 21, 2008, to enhance the state’s newborn hearing screening program by mandating hearing screenings and follow-up care for all newborns. Claire’s Law requires that every newborn infant in Tennessee be screened for hearing loss before discharge from the hospital, unless the child’s parents object on religious grounds. For children born outside of a hospital setting, or in a hospital that does not provide screening, the attending health care professional must refer the child to the Department of Health or to an appropri­ate provider for a hearing screening. In addition, any medical or audiologic provider performing follow-up tests must report the results. Children who do not pass the hearing screening test are then referred to the Tennessee Early Intervention System (TEIS) of the Department of Education for follow-up. Children who have been identified with hearing loss or are at high risk for hearing loss must also be referred to the TEIS. Finally, the law requires certain insurance plans to cover hearing screenings.

Perinatal causes of hearing loss are those that occur during the birth process. Infants who must be admitted to neonatal intensive care units (NICUs) are 20 times more likely to have hearing prob­lems than infants in normal newborn nurseries (Simmons et al., 1980). Hearing loss in infants who were in NICUs is often associated with the identifiable disorders that caused the need for the NICU or treatment for the disorders. Respiratory distress syndrome (RDS/hyaline membrane disease) is the most common respiratory disease in premature infants. Infants with RDS receive treatment by invasive procedures such as intubation and suctioning, putting them at an additional
risk of infections. If infants become septic (generalized infection), general treatment is with anti­biotics with potential ototoxic properties, placing them at a higher risk for hearing loss.

Congenital heart disease (CHD) is among the most common birth defects, affecting as many as 1 in 100 newborns (Fogle, 2008), and may exhibit cyanosis, respiratory distress, congestive heart failure, or a combination of these. In addition, these infants frequently exhibit failure-to- thrive and feeding problems. CHD is often associated with syndromes such as growth deficiencies, mental retardation, Down syndrome, and external ear anomalies. Again, ototoxic drugs may be needed to fight the infections.

Central nervous system disorders may have hearing loss as one component of the disorder, including cerebral hemorrhage, hydrocephalus, hypoxic encephalopathy, and neonatal seizures. Any individual who experiences hypoxia may have compromised neurological status and hearing abilities.

Postnatal causes of cochlear hearing loss are factors occurring after birth. These include bacterial meningitis, measles, mumps, chicken pox, influenza, and viral pneumonia. Most viral-producing hearing losses are bilateral, except for mumps. The body’s natural reaction to infection is elevation of temperature; however, when fever becomes excessive, cellular damage can occur, including cells of the cochlea. Treatments may warrant ototoxic antibiotics. Diabetes mellitus and kidney disease have been implicated in sensorineural hearing loss, as have head traumas, which cause both neuro­logical disorders and hearing loss (Fogle, 2008). Table 10.1 lists some of the risk factors for hearing loss in infants and young children.

In older children (and adults), one of the most preventable is noise-induced hearing loss. Most people will have reduced hearing as they grow older (especially after the age of 60); however, there are things individuals can do to try to preserve their hearing. Noise-induced hearing loss, once called “blacksmith’s deafness” from the continual clanging of metal on metal, dates back hundreds of years. During World War II it received much more attention because of the heavy artillery used in the war. Acoustic trauma from a single exposure may cause permanent hearing loss. Gradual hearing loss from repeated exposure to excessive sound can damage or destroy the delicate hair cells in the cochlea. Hearing conservation programs and hearing research programs (ASHA 2006) have developed public education campaigns to alert people, especially adolescents and teenagers, to the damage caused to hearing with loud music. Wearing ear plugs or ear muffs to help block the loud sounds or music, limiting the time of an iPod session with breaks to allow your hearing to rest, and keeping the volume reduced are just a few suggestions included in a hearing conservation program. Table 10.3 shows the readers the decibel levels of some of the most com­mon environmental sounds, and Table 10.4 lists the decibel levels of some musical instruments as well as some types of music. Table 10.5 shows the noise exposure of sound in decibels for certain periods of time that may create hearing risk.

Many infants and children have repeated ear infections requiring pressure-equalizing (PE) tubes. The surgical procedure is called a myringotomy, performed with a small surgical incision into the tympanic membrane to relieve pressure and release fluid or pus from the middle ear. A small suction device may be inserted through the incision to delicately suction out the fluid and pus. Antibiotics are given before and continued afterward to manage infection (Mosby, 2006).

Source: Adapted from Northern, J. L. & Downs , M. P. Hearing in Children (5th ed.). Baltimore, MD: Lippincott Williams & Wilkins, 2002; Van Bereijk, W., Pierce, J., & David, E., Science, 131, 219-220, 1960; and American Industrial Hygiene Association, 2007.

 Source: Adapted from HeadWize, www.headwise .com/articles /hearing_art.htm.

Following the myringotomy and cleaning of the middle ear, the otolaryngologist may insert a PE tube through the incision in the tympanic membrane. The tube is plastic, tiny, and hollow with a flange on each end that prevents the tube from falling into the middle ear or falling out of the tympanic membrane prematurely. The tube allows direct ventilation of the middle ear and

Note: When 2 or more periods of noise exposure occur, the combined effect should be considered rather than the individual effect of each. Exposure to impulse or impact noise should not exceed 140 dB peak sound pressure level.

functions as an artificial Eustachian tube to maintain normal middle ear pressure. The tube may remain in place from several weeks to several months, after which time it extrudes (pushes out) naturally into the external auditory canal, usually without the child noticing. Newer-designed tubes may remain in place indefinitely.

The Role of the Audiologist in Life Care Planning (II)

Myth: Hearing aids restore hearing to normal just as an eyeglass prescription can restore vision to 20/20.

Fact: Hearing aids do not restore hearing to normal. Just as eyeglasses do not cure vision problems, hearing aids do not cure hearing loss. Like eyeglasses, hearing aids provide benefit and improvement. They can improve hearing and listening abilities, and they can substantially improve quality of life.

Any individual who subjectively reports and audiometrically demonstrates hearing loss of a degree that interferes with communication should be considered for fitting with amplification. The clinical process is initially the same as that for a basic audiologic assessment. The complete audiologic assessment and needs assessment is necessary to initiate a treatment plan that may include amplification. The process of the hearing aid selection in conjunction with determination of the treatment plan is necessary prior to initiating the selection regimen.

The patient must be counseled to include an explanation of the potential benefits and limita­tions associated with personal amplification. The fitting of a personal amplification system and verification of its appropriateness for the communication needs of the patient, family, and care­giver are necessary requisites. There must be validation of the benefit to and satisfaction of the patient, family, and caregiver. In many cases it is necessary to demonstrate a support system is in place to assist in maximizing the use and maintenance of the personal amplification system. The clinical decision-making process is based on professional judgment and individual patient char­acteristics that may significantly influence the nature and course of the selection and fitting pro­cess. The process may vary by audiologist and may vary based on the patient needs, cooperation, comprehension, and process setting. The procedures listed in the following require the completion of an audiologic assessment within the prior 6 months. (Most audiologists will require their own assessment at the time of the hearing aid selection process.)

The audiologic clinical process may include, but is not necessarily limited to, the following (ASHA, 1998, 1999) (the components are not designed to be all-inclusive):

¦     Recent history of auditory function

¦    Appropriate physical examination (e.g., otoscopy)

¦     Cerumen (ear wax) management

¦     Sprathreshold loudness measurements

¦     Ear impressions

¦     Hearing aid selection procedure

¦     Hearing aid performance verification in 2 cc coupler and in the real ear for quality control

¦     Individual or group orientation to amplification

¦     Unaided/aided communication inventory

¦     Individual or group hearing aid follow-up

¦     Qualitative assessment of amplification

¦     Measurement of satisfaction and benefit

¦     Unaided and aided speech recognition measures

Hearing aids differ in design, size, the amount of amplification, ease of handling, volume con­trol, and the availability of special features. But they do have similar components, which include

¦    A microphone to pick up sound

¦    Amplifier circuitry to make the sound louder

¦    A receiver (miniature loudspeaker) to deliver the amplified sound into the ear

¦     Batteries to power the electronic parts

Some hearing aids also have ear molds (earpieces) to direct the flow of sound into the ear and enhance sound quality.

In-the-canal (ITC) and completely-in-the-canal (CIC) aids are contained in a tiny case that fits partly or completely into the ear canal. They are the smallest aids available and offer cosmetic and some listening advantages.

All parts of in-the-ear (ITE) aids are contained in a shell that fills in the outer part of the ear. These aids are larger than canal aids and, for some people, may be easier to handle than smaller aids.

All parts of behind-the-ear (BTE) aids are contained in a small plastic case that rests behind the ear; the case is connected to an ear mold by a piece of clear tubing. This style is often chosen for young children for safety and growth reasons.

Contralateral Routing of Signal (CROS) hearing aids are used for patients with one unaidable ear, due to the severity of loss, and one normal hearing ear on the contralateral side. A microphone is placed at the ear level of the “bad” side and the signal picked up by this microphone is “routed” (either through a hardwire or an FM transmitter) to the receiver in the ear level hearing aid on the “good” or normal ear. If the better ear also has a hearing loss, the arrangement is called BICROS, indicating that a microphone and an amplifier are also placed on the side of the better ear.

Bone-Anchored Hearing Aids (BAHA) as a part of advanced technology should also be considered as an alternative option to a traditional CROSS hearing aid for patients with profound unilateral hearing loss and, of course, patients with bilateral atresia (missing ear canal). The majority of hearing aids sold today are canal hearing aids and ITE hearing aids.

There are also special hearing aids built to handle very specific types of hearing losses such as aids that can be built into glasses for individuals who need that type of fitting. There are hearing aids available that can accommodate virtually any kind of hearing loss.

Hearing aids are distinguished by their technology or circuitry. In the early days, hearing aid technology involved vacuum tubes and large, heavy batteries. Today, there are microchips, computerization, and digitized sound processing used in hearing aid design.

¦     Conventional analog hearing aids are designed with a particular frequency response based on your audiogram. The audiologist tells the manufacturer what settings to install. Although there are some adjustments, the aid essentially amplifies all sounds (speech and noise) in the same way. This technology is the least expensive, and it can be appropriate for many different types of hearing loss.

¦     Analog programmable hearing aids have a microchip that allows the aid to have settings programmed for different listening environments such as quiet conversation in your home, noisy situations like a restaurant, or large areas like a theater. The audiologist uses a com­puter to program the hearing aid for different listening situations depending on the individual hearing loss profile, speech understanding, and range of tolerance for louder sounds.

¦     Some aids can store several programs. As the listening environment changes, a wearer can change the hearing aid settings by pushing a button on the hearing aid or by using a remote control to switch channels. The aid can be reprogrammed by the audiologist if hearing or hearing needs change. These aids are more expensive than conventional analog hear­ing aids, but generally have a longer life span and may provide better hearing in different listening situations.

¦     Digital programmable hearing aids have all the features of analog programmable aids but use digitized sound processing to convert sound waves into digital signals. A computer chip in the aid analyzes the signals of your environment to determine if the sound is noise or speech and then makes modifications to provide a clear, amplified distortion-free signal. Digital hearing aids are usually self-adjusting. The digital processing allows for more flex­ibility in programming the aid so that the sound it transmits matches a specific pattern of hearing loss. This digital technology is the most expensive, but it allows for improvement in programmability, greater precision in fitting, management of loudness discomfort, control of acoustic feedback (whistling sounds), and noise reduction.

Many hearing aids have optional features that can be built in to assist in different communication situations. Some options are

¦     Directional microphone. Some hearing aids have a switch to activate a directional microphone that responds to sound coming from a specific direction, as occurs in a face-to-face conversa­tion. A patient can switch from the normal nondirectional (omnidirectional) setting, which picks up sound almost equally from any direction, to focus on a sound coming from in front. When the directional microphone is activated, sound coming from behind is reduced.

¦     Telephone switch. Some hearing aids are made with an induction coil inside. You can switch from the normal microphone “on” setting to a “T” setting to hear better on the telephone. (All wired telephones produced today must be hearing aid compatible.) In the T setting, environment sounds are eliminated, and the patient only picks up sound from the telephone. Furthermore, he can talk without his hearing aid “whistling” because the microphone of the hearing aid is turned off.

¦     The T setting can also be used in theaters, auditoriums, houses of worship, and so on, that have induction loop or FM installations. The sound of the talker, who can be a distance away, is amplified significantly more than any background noises. Some hearing aids have a combination M (microphone)/T (telephone) switch so that while listening with an induction loop, the wearers can still hear nearby conversation.

¦     Direct audio input. Some hearing aids have a direct-audio-input capability that allows them to plug in a remote microphone or an FM assistive listening system, connect directly to a TV, or connect with other devices such as a computer, CD player, tape player, radio, and so on (www.asha .org/hearing/rehab/hearing_aids.cfm).

Federal and state regulations may require a medical evaluation and clearance from a licensed physician prior to hearing aid purchase.

Advances in digital signal processing in recent years have opened the way for digital hearing aids to become the standard of current audiologic practice. The current emphasis for research and development is on specific features such as directional technology and digital noise reduction to maximize speech understanding and sound quality. The introduction of digital noise reduc­tion (DNR) has provided greater ease of listening for many hearing-impaired individuals based on subjective measures. The challenge remains to develop algorithms that separate speech from noise. Notable technological developments are also being made in the field of implantable hearing devices. Apart from the more commonly employed cochlear implant technology, there has also been growth in the use of middle ear implants and, more recently, bone-anchored hearing aids suitable for single-sided hearing loss.

Auditory processing disorders (APDs) is the current terminology for what was referred to in earlier literature as central auditory processing disorders (CAPDs). With current research and improved diagnostic tools, we now know that not all APDs can be related to a central origin. An APD assessment helps to define the functional status of the central auditory nervous system (CANS) and central auditory processes.

The assessment is indicated for individuals of all ages who have symptoms or complaints of hearing difficulty with documented normal peripheral auditory function, have a central nervous system (CNS) disorder potentially affecting the central auditory system, or have learning problems possibly related to the auditory difficulties. The APD assessment requires a team approach and is to be conducted with other audiologic, speech, and language tests, as well as neuropsychological tests, to evaluate the overall communication behavior, including spoken language processing and production, and educational achievement of the individual (ASHA, 1999).

ASHA (1996) in the American Journal of Audiology defined (central) APDs as a problem in one or more of six areas:

Sound localization and lateralization (knowing where in space a sound source is located) Auditory discrimination (usually with reference to speech, but the ability to tell that one sound is different from another)Auditory pattern recognition (musical rhythms are one example of an auditory pattern) Temporal aspects of audition (auditory processing relies on making fine discriminations of timing changes in auditory input, especially differences in timing by the way input comes through one ear as opposed to the other)Auditory performance decrements with competing acoustic signals (listening in noise) Auditory performance decrements with degraded acoustic signals (listening to sounds that are muffled, missing information, or for some reason not clear—the best example is trying to listen to speech taking place on the other side of a wall; the wall filters or blocks out cer­tain parts of the speech signal, but a typical listener can often understand the conversation)

The interpretation of results is derived for multiple tests; there is no single test to determine the presence of an APD. The APD battery of tests may involve a series of appointments over a period of time. The test results will be measured against age-appropriate norms and knowledge of the CANS in normal and disordered states. The procedures in an APD battery should be viewed as separate entities for purposes of service delivery and reimbursement.

The clinical process is as follows:

¦     Appropriate communication, medical, and educational history is taken.

¦     Assessment is typically part of an intradisciplinary (audiology and speech-language pathology) approach.

¦     Assessment of peripheral hearing sensitivity to assure normal hearing sensitivity.

¦     Patient is prepared for behavioral and electrophysiologic assessment of the CANS.

¦     Typ es of central auditory behavioral tests include

-       Tests of temporal processes

-       Tests of dichotic listening

-       Low redundancy monaural speech tests

-       Tests of binaural interaction

Central auditory electrophysiologic tests include

¦     Auditory brain stem response (ABR)

¦     Middle latency evoked response (MLR)

¦     N1 and P2 (late potentials) responses (P300)

¦     Mismatched negativity (MMN)

¦     Middle ear reflex

¦     Crossed suppression of otoacoustic emissions

The comprehensive rehabilitation of and management of APDs may include interventions directed to acoustic signal enhancement, improvement of language and cognitive capacities, skills develop­ment, use of compensatory strategies, employment of listening strategies, and improvement of the listening environment (ASHA, 1990, 1996). Management (treatment) is conducted to improve auditory processing, listening, spoken language processing, and the overall communication process. Improvements in auditory processing and listening can benefit learning and daily living activities.

APD management is recommended when there is a likelihood of improving communication behavior in any age group. Any individual who is documented to have an APD after comple­tion of the APD test battery, and who is impaired or compromised on the basis of the results, is a candidate for management (treatment). Generalization of skills and strategies is enhanced by extending practice to the natural environment through collaboration among key professionals (ASHA, 1999).

The clinical process may be, but is not limited to, the following (ASHA, 1999):

¦     A treatment plan is formulated based on the patient’s complaints, symptoms, history, central auditory test results, and functional performance deficits.

¦     Treatment may be conducted in an intradisciplinary (audiology and speech-language pathology) and interdisciplinary manner.

¦     The treatment plan should incorporate several major approaches:

-      Auditory training and stimulation

-       Communication and educational strategies

-       Metalinguistic and metacognitive skills and strategies

-      Assistive listening devices

-       Acoustic enhancement and environmental modifications of the listening environment

Tinnitus, more commonly spoken of as ringing in the ear or head noise, has been experienced by almost everyone at one time or another. It is defined as the perception of sound in the head when no external sound is present. In addition to ringing, head noises have been described as hissing, roaring, pulsing, whooshing, chirping, whistling, and clicking. Ringing and head noises can occur in one ear or both ears and can be perceived to be occurring inside or outside the ear. Tinnitus can accompany hearing loss. It can exist independent of a hearing loss.

Tinnitus cannot be measured objectively. Rather, the audiologist relies on information provided in describing the tinnitus. The audiologist will ask questions like

¦     Which ear is involved? Right? Left? Both?

¦     Is the ringing constant? Do you notice it more at certain times of the day?

¦     Can you describe the sound or the ringing?

¦     Do es the sound have a pitch to it? High pitch? Low pitch?

¦     How loud does it seem? Does it seem loud or soft?

¦     Do es the sound change or fluctuate?

¦     Do you notice conditions that make the tinnitus worse (e.g., when drinking caffeinated beverages, when taking particular medicines, or after exposure to noise)?

¦     Do es the tinnitus affect your sleep? Your work? Your ability to concentrate?

¦     How annoying is it? Extremely so? Not terribly bothersome?

Knowing the cause of tinnitus is a relief, instead of having to live with the uncertainty of the condition. When tinnitus is demystified, stress level (which can make tinnitus worse) is frequently reduced, and there is a feeling of greater control.

The most effective treatment for tinnitus is to eliminate the underlying cause. Because tinnitus can be a symptom of a treatable medical condition, medical or surgical treatment can take place to correct the tinnitus.

Unfortunately, in many cases the cause of tinnitus cannot be identified, or medical or surgical treat­ment is not the appropriate course of action. In these cases, the tinnitus itself may need to be treated.

Drug therapy, vitamin therapy, biofeedback, hypnosis, electrical stimulation, relaxation therapy, counseling, habituation therapies, and tinnitus maskers are among many forms of management available. Audiologists and otolaryngologists routinely collaborate in identifying the cause and providing treatment. A treatment that is useful and successful for one person may not be appropri­ate for another.

Nonmedical management of tinnitus has traditionally involved masking or covering up the patient’s internally produced head noises with externally generated sound. This can take the form of enhanced environmental sound provided by traditional hearing aids, since most patients with handicapping tinnitus also have hearing loss. If there is no hearing loss, or if hearing aid use is not appropriate, a tinnitus instrument, similar in appearance to a hearing aid, can be used to provide a masking sound. The particulars of the masking sound used will vary according to information provided by the patient, such as the loudness, pitch, and quality of the tinnitus. More recent treatment protocols for tinnitus involve habituation to rather than covering up of the tinnitus. This is known as Tinnitus Retraining Therapy (Jastreboff, 1990). This treatment approach involves directive counseling designed to remove negative associations attached to the tinnitus. Sound therapy is also used, but not to cover up the tinnitus. Instead an emotionally neutral sound, such as white noise, is paired with the tinnitus in order to facilitate habituation. Tinnitus Retraining Therapy takes 12 to 18 months, but its proponents cite significant relief from annoying tinnitus in over 80% of patients treated (Jastreboff, 1996).

The scope of practice of audiologists is described in the following and should demonstrate the breadth and depth of knowledge and skill audiologists possess.

American Speech-Language-Hearing Association (ASHA) Audiology Scope of Practice

The practice of audiology includes the following (ASHA, 2004):

¦     Activities that identify, assess, diagnose, manage, and interpret test results related to disor­ders of human hearing, balance, and other neural systems

¦     Otoscopic examination and external ear canal management for removal of cerumen in order to evaluate hearing or balance, make ear impressions, fit hearing protection or prosthetic devices, and monitor the continuous use of hearing aids

¦     Conducting an interpretation of behavioral, electroacoustic, or electrophysiologic methods used to assess hearing, balance, and neural system function

¦     Evaluation and management of children and adults with central APDs

¦     Supervision and conducting of newborn hearing screening programs

¦     Measurement and interpretation of sensory and motor-evoked potentials, electromyography, and other electrodiagnostic tests for purposes of neurophysiologic intraoperative monitoring and cranial nerve assessment

¦     Provision of hearing care by selecting, evaluating, fitting, facilitating adjustment to, and dispensing prosthetic devices for hearing loss, including hearing aids, sensory aids, hearing assistive devices, alerting and telecommunication systems, and captioning devices

¦     Assessment of candidacy of persons with hearing loss for cochlear implants and provision of fitting, programming, and audiological rehabilitation to optimize device use

¦     Provision of audiological rehabilitation, including speech reading, communication manage­ment, language development, auditory skill development, and counseling for psychosocial adjustment to hearing loss for persons with hearing loss and their families and caregivers

¦     Consultation with educators as members of interdisciplinary teams about communication management, educational implications of hearing loss, educational programming, classroom acoustics, and large-area amplification systems for children with hearing loss

¦     Prevention of hearing loss and conservation of hearing function by designing, implementing, and coordinating occupational, school, and community hearing conservation and identification programs

¦     Consultation and provision of rehabilitation to persons with balance disorders using habituation, exercise therapy, and balance retraining

¦     Designing and conducting basic and applied audiologic research to increase the knowledge base, to develop new methods and programs, and to determine the efficacy of assessment and treatment paradigms; dissemination of research findings to other professionals and to the public

¦     Education and administration in audiology graduate and professional education programs

¦     Measurement of functional outcomes, consumer satisfaction, effectiveness, efficiency, and cost—benefit of practices and programs to maintain and improve the quality of audiological services

¦     Administration and supervision of professional and technical personnel who provide support functions to the practice of audiology

¦     Screening of speech-language, use of sign language (e.g., American Sign Language and cued speech), and other factors affecting communication function for the purposes of an audiologic evaluation or initial identification of individuals with other communication disorders

¦     Consultation about accessibility for persons with hearing loss in public and private buildings, programs, and services

¦     Assessment and nonmedical management of tinnitus using biofeedback, masking, hearing aids, education, and counseling

¦     Consultation to individuals, public and private agencies, and governmental bodies, or as an expert witness regarding legal interpretations of audiology findings, effects of hearing loss and balance system disorders, and relevant noise-related considerations

¦     Case management and service as a liaison for the consumer, family, and agencies in order to monitor audiologic status and management and to make recommendations about educational and vocational programming

¦     Consultation with industry on the development of products and instrumentation related to the measurement and management of auditory or balance function

¦     Participation in the development of professional and technical standards

As health professionals concerned with the welfare of the patients they serve, audiologists must possess certain credentials to practice audiology. These credentials signify a specific level of edu­cation and competence that serve to protect consumers. Certification and licensure are the two most common credentials possessed by audiologists. Table 10.6 delineates the characteristics of certification and licensure.

In order to be certified by ASHA and licensed/registered/certified by a particular state regulatory board or agency to practice audiology, one must possess a doctoral degree earned from an accredited college or university audiology graduate (doctoral) program (note: this requirement is relatively new, so one may encounter audiologists who do not possess doctoral degrees). College and university graduate audiology programs seek accreditation from the Council on Academic Accreditation of the American Speech-Language-Hearing Association. This ensures that graduates of these programs are eligible for the certificate of clinical compe­tence (CCC) issued by the Council for Clinical Certification of ASHA. The U.S. Department of Education and the Council on Recognition of Postsecondary Accreditation have approved ASHA as a credentialing agency. The standard on which the certificate of clinical compe­tence in audiology (CCC-A) is based has served as the foundation for most states’ licensing laws. ASHA’s national certification standards have undergone costly scientific tests of valid­ity (ASHA, 2004b). ASHA-certified audiologists possess specific knowledge and competen­cies and must pass a national examination as well as maintain currency through continuing education.

Grants recognition to practitioners who have met certain qualificationsProtects the public’s life, health, safety, or economic well-beingRestricts the use of the designated title to individuals who choose to meet the qualificationsRestricts scope of practice so that it is illegal for unlicensed individuals to provide the servicesFormal education, experience, personal characteristics, and completion of examinationMay piggy back on qualifications required for certificationDeveloped and approved by members of the associationDeveloped by regulatory body and approved according to the state’s Administrative Procedure Act• Rescind membership• Rescind certification • Admonishment• License revocation• Monetary fine• Restrictions on practice• Incarceration• License suspensionCertifying entity may sponsor continuing education opportunities for members; may be required for recertificationMay be required for licensees to renewSource: ASHA State Policy Division 10/10/95-aew

Additionally, most states require audiologists to be licensed, registered, or certified in order to practice audiology in that particular state. Each state’s licensing or regulatory board has specific educational and competency requirements, which are assessed through examination. Renewal of state credentials usually requires maintenance of currency through continuing education.

Referrals to audiologists can be made directly by contacting the office, center, hospital, or facil­ity in which the audiologist is employed. ASHA, at (301) 897-5700; the American Academy of Audiology, at (703) 790-8466; or a state speech-language-hearing association can provide the names of audiologists practicing in specific geographic areas. ASHA maintains a referral source (PROSERV) on its consumer website at www.asha .org.

It is important and helpful to be aware of the types of test procedures and terminology used by audiologists. This will assist the case manager in making appropriate referrals and in conversing knowledgeably with the audiologist. The following is some of the test procedures and terminology used by audiologists.

Conductive: Abnormalities of the outer or middle ear Sensorineural: Abnormalities of the inner ear Mixed: Combination of conductive and sensorineural Central: Abnormalities of the central auditory nervous system

Behavioral Observation Audiometry (BOA): Controlled observation of responses (i.e., changes in behavior such as quieting, arousal from sleep, eye shift, eye widening, eyebrow raising, body movement, and head turn) to acoustic stimuli Visual Reinforcement Audiometry (VRA): Reinforcement with lighted toys when the child turns toward the sound source Conditioned Play Audiometry (CPA): Conditioning the child to respond to the stimulus through game playing

Conventional Audiometry: Hand-raising or button-pushing response to stimulus Auditory Evoked Potentials (AEPs): Measurement of changes in electrical activity of the auditory nervous system in response to acoustic stimuli Otoacoustic Emissions (OAEs): Measurement of sound generated by motion of the outer hair cells

(Central) Auditory Processing Evaluation (APDs): Assessment of the central auditory system to process complex auditory stimuli

Soundfield: Testing via loudspeakers; does not allow a unilateral or asymmetrical hearing loss to be ruled out

Air Conduction: Testing via earphones; allows each ear to be evaluated in isolation Bone Conduction: Testing via a bone vibrator; directly stimulates better cochlea function

Frequency-Specific Information: Absolute vs. minimum response

Speech Awareness Threshold (SAT): Lowest intensity level at which there is awareness of speech Speech Reception Threshold (SRT): Lowest intensity level at which a spondee word can be repeated 50% of the time Word Recognition Ability: Percentage of monosyllabic words repeated correctly when presented at a comfortable listening level Acoustic Immittance: Previously explained

Tympanometry: Measurement of the mobility of the tympanic membrane/middle ear system as a function of varying degrees of air pressure in the external ear canal

Static Compliance: Mobility of the tympanic membrane/middle ear system Equivalent Volume: Ear canal volume

Acoustic Reflex Measurements: Observation of the contraction of the muscles of the middle ear in response to loud sounds

Outcomes of audiology services may be measured to determine treatment effectiveness, efficiency, cost—benefit analysis, and consumer satisfaction. Specific outcome data may assist consumers to make decisions about audiology service delivery. The following list describes the types of outcomes that consumers may expect to receive from an audiologist:

¦     Interpretation of otoscopic examination for appropriate management or referral

¦     Identification of populations and individuals with or at risk for hearing loss or related audi­tory disorders:

-       With normal hearing or no related auditory disorders

-       With communication disorders associated with hearing loss

-       With or at risk of balance disorders, and tinnitus

¦     Professional interpretation of the results of audiological findings

¦     Referrals to other professions, agencies, or consumer organizations

¦     Counseling for personal adjustment and discussion of the effects of hearing loss and the potential benefits to be gained from audiological rehabilitation and sensory aids, including hearing and tactile aids, hearing assistive devices, cochlear implants, captioning devices, and signal/warning devices

¦     Counseling regarding the effects of balance system dysfunction

¦     Selection, monitoring, dispensing, and maintenance of hearing aids and large-area amplifi­cation systems

¦     Development of culturally appropriate, audiologic, rehabilitative management plans, including, when appropriate:

-       Fitting and dispensing recommendations, and educating the consumer and family/ caregivers in the use of and adjustment to sensory aids, hearing assistive devices, alerting systems, and captioning devices

-       Counseling relating to psychosocial aspects of hearing loss and processes to enhance communication competence

-       Skills training and consultation concerning environmental modifications to facilitate development of receptive and expressive communication

-       Evaluation and modification of the audiologic management plan

¦     Preparation of a report summarizing findings, interpretation, recommendations, and audio­logic management plan

¦     Consultation in development of an individualized education program (IEP) for school-age children or an individualized family service plan (IFSP) for children from birth to 36 months of age

¦     Provision of in-service programs for personnel and advising school districts in planning educational programs and accessibility for students with hearing loss

¦     Planning, development, implementation, and evaluation of hearing conservation programs

Life care planners and other individuals should be aware of the impact that hearing loss can have on communication. Generally speaking, a conductive (outer or middle ear) hearing loss, which cannot be medically remediated, can be adequately benefited through amplification. It must be cautioned that young children commonly experience conductive hearing loss due to ear and upper respiratory infections. Although these episodes are usually self-limiting or respond to medical intervention when necessary, some children persist with conductive hearing loss, which may affect their speech and language development. These children should be referred to an audiologist as well as a speech-language pathologist.

An individual with a sensorineural (inner ear) hearing loss, however, can be expected to experi­ence some degree of difficulty understanding speech, particularly when the listening environment is less than ideal. This means that when a person with a sensorineural hearing loss is greater than 3 to 4 feet from the source of the sound or when there is noise in the background (there almost always is some noise in the background), that person will likely misunderstand some of what is being said. This is because the pattern of hearing with a sensorineural hearing loss is typically worse in the high frequencies or pitches and better in the low frequencies or pitches. In order to understand speech clearly, we must hear all the pitches equally well. The vowels are generally low in pitch (and loud) compared to consonants, which are high in pitch (and soft).

A properly fitted hearing aid can be extremely beneficial. However, it is important for all to rec­ognize that even with appropriate amplification, individuals with sensorineural hearing loss might still have difficulty understanding what is being said, particularly with noise in the background.

How to Communicate with People Who Are Hard of Hearing

The following suggestions are examples of effective strategies for communicating with individuals with hearing impairment:

¦     Positioning:

-       Be sure the light, whether natural or artificial, falls on your face. Do not stand with the sun to your back or in front of a window.

-       If you are aware that the hard-of-hearing person has a better ear, stand or sit on that side.

-       Avoid background noise to the extent possible.

¦     Method:

-       Get the person’s attention before you start talking. You may need to touch the person to attract attention.

-       Speak to the hard-of-hearing person from an ideal distance of 3 to 6 feet in face-to-face visual contact.

-       Speak as clearly as possible in a natural way.

-       Speak more slowly to the hard-of-hearing person. Pausing between sentences will assist the listener.

-       Do not shout. Shouting often results in distortion of speech and it displays a negative visual signal to the listener. Do not drop your voice at the end of the sentence.

-       If the person does not understand what you said, rephrase it.

-       When changing the subject, indicate the new topic with a word or two or a phrase.

¦    Physical:

-       Do not obscure your mouth with your hands. Do not chew or smoke while talking.

-       Facial expressions and lip movements are important clues to the hard-of-hearing person. Feelings are more often expressed by nonverbal communication than through words.

¦    Attitude:

-       Do not become impatient.

-       Stay positive and relaxed.

-      Never talk about a hard-of-hearing person in his presence. Talk to them, not about them.

-      Ask what you can do to facilitate communication.

How to Communicate with People Who Are Deaf

The following is a list of suggestions for communicating with someone who is deaf.

¦     DO be facially expressive when communicating.

¦     DO NOT break eye contact when communicating with people who are deaf. Lack of eye contact is considered rude when communicating with a visually oriented person.

¦     DO get the attention of a person who is deaf by tapping the shoulder.

¦     DO NOT take offense at direct questions regarding qualifications or personal life. Direct questions between one person who is deaf and another person who is deaf are culturally quite common and can spill over into interactions with hearing people with no attempt to be rude.

¦     DO be conscious of hearing-loss terminology. Within the culture of the deaf, the norm is profound deafness and a mild hearing loss may mean “hard of hearing” to the person who is deaf.

¦    While a person who is deaf is signing, DO NOT touch her hands.

¦     DO define individuals who are deaf by their abilities, rather than their disabilities.

¦     DO NOT talk with another hearing person in the presence of a person who is deaf without signing or ensuring a clear line of sight for speech reading. Just as those with acquired hear­ing loss may be suspicious when they do not understand what others are saying, so may indi­viduals who are deaf. Use sign language, written communication, or ensure the individual who is deaf can speech read (lip read) what is said.

¦     DO attempt to use sign language with an individual who is deaf. Any attempt is appreciated, but if you are not fluent, the services of an interpreter should be obtained.

¦     DO NOT use the term oral as it implies oral ideologies (oralists). Rather, use the term spoken English or spoken communication. Similarly, communication training may be preferred to aural rehabilitation because the former implies improvements in aspects of communica­tion, such as written communication, that are not aurally based.

The following are some suggestions for troubleshooting minor hearing aid difficulties. If the problem is not resolved, the hearing aid may require factory repair and should be returned to an audiologist or hearing instrument specialist (preferably the same who dispensed the aid).

Hearing aid dead:

Assure aid turned on.

Assure battery inserted correctly.

Try new battery.

Clean battery contacts with pencil eraser.

Assure earmold not clogged with wax (BTE aid).

Assure receiver port not clogged with wax (ITE aid).

Hearing aid weak:

Replace battery.

Clean receiver port (ITE aid).

Clean earmold tip.

Assure microphone port not occluded (ITE aid).

Aid distorted:

Replace battery.

Clean receiver port (ITE aid).

Aid whistles:

Assure tight fit of earmold (BTE) or ITE aid.

Assure ear canal free of cerumen.

Causes, Tests, and Remedies

Cause: Dead or rundown battery. Test: Substitute new battery. Remedy: Replace worn-out battery.Cause: Battery reversed in holder so that positive end is where negative end should be. Test: Examine. Remedy: Insert battery correctly.Cause: Poor contacts at cord receptacle of battery holder due to dirty pins or springs. Test: With hearing aid turned on, wiggle plugs in receptacles and withdraw and reinsert each plug and the battery. Remedy: Rub accessible contacts briskly with lead pencil eraser, then wipe with clean cloth moistened with dry-cleaning liquid. Inaccessible contacts usually can be cleaned with a broom straw dipped in cleaning fluid.Cause: Internal break or near-break inside receiver cord. Test: While listening, flex all parts of cords by running fingers along entire length and wiggle cords at terminals. Intermittent or raspy sounds indicate broken wires. Remedy: Replace cords with new ones. Worn ones cannot be repaired satisfactorily.Cause: Plugs not fully or firmly inserted in receptacles. Test: While listening, withdraw and firmly reinsert each plug in turn. Remedy: Insert correctly.Cause: Ear tip not properly seated in ear. Test: With the fingers, press the receiver firmly into the ear and twist back and forth slightly to make sure that the ear tip is properly positioned. Remedy: Position correctly.Cause: Ear tip plugged with wax or with drop of water from cleaning. Test: Examine ear tip visually and blow through it to determine whether passage is open. Remedy: Disconnect ear tip from receiver, then wash ear tip in lukewarm water and soap, using pipe cleaner or long- bristle brush to reach down into the canal. Rinse with clear water and dry. A dry pipe cleaner may be used to dry out the canal; blowing through the canal will remove surplus water.Cause: Insufficient pressure of bone receiver on mastoid. Test: While listening, press the bone receiver more tightly against the head with the fingers. Remedy: Bend the receiver headband to provide greater pressure. Your audiologist who is more skilled in maintaining conformation with the head preferably does this.

. 10. Cause: Receiver close to wall or other sound-reflecting surfaces. Test: Examine. Remedy: Avoid sitting with the fitted side of the head near a wall or other surfaces. Such surfaces tend to reflect the sound from the receiver so that it is more readily picked up by the microphone, thus causing whistling.

Cause: Microphone worn too close to receiver. Test: Try moving instrument to provide wider separation between it and the receiver. Remedy: Avoid wearing microphone and receiver on same side of body or close together.Cause: Plastic tubing not firmly seated at hearing aid or ear tip ends, or tubing so sharply bent as to block the passage of sound through it. Test: Examine and check for tightness at ends. Remedy: Push tubing ends firmly onto nubs. See that there is no kink or sharp bend. Replace the tubing if necessary.

Certain characteristic behaviors by children should alert parents and teachers to be concerned

about their hearing. Some of the signs are

¦     Often misunderstands what is said

¦     Constantly requests that information be repeated

¦     Has difficulty following oral instructions

¦     Gives inconsistent responses to auditory stimuli

¦     Turns up the volume of the television, radio, or stereo

¦     Gives slow or delayed response to verbal stimuli

¦     Has poor auditory attention

¦     Has poor auditory memory (span and sequence)

¦     Is easily distracted

¦     Has difficulty listening in the presence of background noise

¦     Has poor receptive and expressive language

¦     Has difficulty with phonics and speech sound discrimination

¦     Learns poorly through the auditory channel

¦     Has reading, spelling, and other learning problems

¦     Exhibits behavior problems

¦     Says “Huh?” or “What?” frequently

Some common indicators associated with hearing loss include

¦     Family history of hearing loss

¦    In utero infection (e.g., cytomegalovirus, rubella, syphilis, or toxoplasmosis)

¦     Craniofacial anomalies, including those with morphological abnormalities of the pinna and ear canal

¦     Birth weight less than 1500 grams (3.3 pounds)

¦     Hyperbilirubinemia at a serum level requiring exchange transfusion

¦     Ototoxic medications, including, but not limited to, chemotherapeutic agents, or aminogly­cosides used in multiple courses or in combination with loop diuretics

¦     Bacterial meningitis and other infections associated with sensorineural hearing loss

¦     Severe depression at birth with Apgar scores of 0 to 4 at 1 minute or 0 to 6 at 5 minutes

¦     Prolonged mechanical ventilation 5 days or longer (e.g., persistent pulmonary hypertension)

¦     Stigmata or other findings associated with a syndrome known to include a sensorineural or conductive hearing loss

¦     Parent/caregiver concern regarding hearing, speech, language, or developmental delay

¦     Head trauma associated with loss of consciousness or skull fracture

¦     Recurrent or persistent otitis media with effusion for at least 3 months

¦    Neurofibromatosis type II and neurodegenerative disorders

¦    Anatomic deformities and other disorders, which affect eustachian tube, function

The cost of hearing aids varies from approximately $500 to $2500 per instrument depending upon type and options. A single behind-the-ear instrument may be as little as $500, while a digital instrument will typically cost $2100 to $2500. Middle ear implantable instruments may run $25,000, plus $5000 per year for technical support. Many patients with disabilities may need manufacturer support to ensure they are capable of operating the volume control and other instru­ment options. Digital hearing aids often have an external control much like a television remote control. Care must be given to ensure appropriate fitting and follow-up services. Pitfalls that must be avoided are indiscriminate fitting of patients with amplification not appropriate for their loss and insufficient follow-up and audiologic/aural rehabilitation.

¦    A hearing aid should be effective for 3 to 5 years before replacement is necessary. It is wise to purchase replacement and repair warranties.

¦    A standard factory warranty will be 1 to 2 years.

¦     Battery costs may vary depending on the severity of the hearing loss and the power required of the hearing aid. A package of six batteries will cost $4 to $5. The average life expectancy for a battery is approximately 10 days to 2 weeks when the instrument is worn during wak­ing hours. If an instrument is out of warranty, the cost of repair is approximately $150 to include a 1-year warranty.

Children under 21 are entitled to mandatory hearing services, including hearing aids, under Medicaid. Hearing aid coverage for adults is optional and varies from state to state. A list of state Medicaid office contacts can be found at http://cms.hhs .gov/medicaid/tollfree.asp.

Although Medicare does not pay for hearing devices in fee-for-service plans, hearing aids may be covered by Medicare+Choice plans, such as health maintenance organizations. The Centers for Medicare and Medicaid Services (CMS) clarified in 2001 that Medicare carriers should pay for diagnostic audiologic tests regardless of a hearing aid recommendation.

Obviously, people with the financial resources to pay privately for these devices and services will be able to obtain what they need. However, most rely upon alternative funding and specific issues are mentioned in the following:

¦     Medicaid: States must cover hearing aids for children through the Early and Periodic Screening, Diagnosis, and Treatment Program. Coverage for adults is optional and rarely included in a state plan.

¦     Medicare: Medicare does not cover hearing aids or tests related to hearing aids. Social health maintenance organizations (SHMOs) are part of a demonstration project that includes some long-term care. All SHMOs cover hearing aids. As risk HMOs enter the Medicare market, many are providing partial coverage of hearing aids. For example, the Medicare HMO might cover $500 of a hearing aid. Some states and regional third-party payers allow balance billing—check in your state and with your dispensing audiologist.

¦     Private Health Plans: Most do not cover hearing aids unless there is a labor union contract such as the United Automobile Workers (UAW), which covers the costs related to one hear­ing aid every 3 years. The benefit is not limited to automobile workers but is found in many contracts negotiated by the UAW. Another example of a union contract is the California Public Employees Retirement System, which offers a hearing benefit to retirees enrolled in Medicare managed care plans. Some private plans such as Blue Cross and Blue Shield may cover a hearing aid if the need is related to an accident or illness.

Please refer to the Audiology SuperBill for current (2008) procedural codes and V codes (ASHA, 2008).

Cochlear devices have been implanted in nearly 10,000 children and adults who are profoundly hearing impaired or deaf due to genetic factors, ototoxic drugs, meningitis, rubella, and head trauma. A criterion for candidacy (Table 10.7) primarily requires that the auditory nerve must not be destroyed. General guidelines include the following:

¦     Be at least 1 year of age (with anticipation of even younger in near future).

¦     Have severe to profound bilateral sensorineural deafness.

¦     Demonstrate no significant benefit from traditional amplification.

¦     Have strong family support.

¦     Have no medical contraindications to surgery.

¦     For children, have a supportive school system.

¦     For adults, have appropriate expectations.

¦     Have the ability to pay for the device and services—the total cost of an implant in 2008 was more than $60,000, not including replacements (see example case in the following).

battery2008 to lifeSonic Alert: 1x only. Silent Call: every 10 years.Sonic Alert: $260 with 1-yr warranty. Silent Call: $540 with vibrating unit and 2-yr warranty. Door knock signaler with light2008 to lifeEvery 10 years.$65.00 for package. Portable smoke detector2008 to lifeEvery 10 years.$175. Allowance for batteries, lightbulbs, etc.2008 to lifeBatteries: monthly.

Bulbs: yearly depending on use.$50 per year (estimate). Baby cry alerter (assumes child)Estimate 20321x (assumes child).Sonic Alert: $40 (may also be used as smoke detector). Replacement cords and batteries for implant device$1000 to lifeEvery 3 months for two cords at $10 each. One time per year for 2 pack batteries at $10/per year.$90 per year.AreaRecommendationDatesFrequencyExpected Cost Replacement

headset2010 (after 3-year warranty to life)Project 3-4 upgrades over life.$500 every 3 years. Upgrade external processor20231 x.$6000. Silent Call or Sleep Alert charger unit2008Every 10 years.$110. Service contract for external speech processor and headset (internal device has a 99-year warranty)2008 to lifeEvery 2 years.$750 for 2 years (after 3-yr manufacturer warranty expires).EducationPublic school2008 to 2022School year.$0 provided under IDEA.

Weekly to 2022.

As needed.$0 with school counselor. $150 per hour privately. $0 should be paid by vocational rehabilitation.

 Notes: (a) TTY unit uses regular phone lines; however, units are unable to distinguish between incoming TTY call or voice calls. A separate phone line dedicated to TTY calls may be appropriate. Cost for additional phone line installation is estimated between $100 and $110 plus monthly charge of $35. Does not include long-distance charges that are usually higher due to length of time to transmit written words rather than spoken words. Cost cannot be projected. Internet access cost is $25/month.

(b) No provision for technology advances.

(c) Economist to determine present value.