[an error occurred while processing this directive]

Table of Contents

 

INTRODUCTION: AUDIOLOGICAL MANAGEMENT 5

I. AUDIOMETRIC TECHNICIAN REQUIREMENTS 7

A. Definition of Audiometric Technician 9

B. Duties of the Audiometric Technician 9

C. Initial Audiometric Technician Training 9

Level 1-Pure Tone Sweep Screening Certification 11

Level 2-Pure Tone Threshold Screening Certification 13

Level 3-Tympanometry Screening Certification 15

Level 4-Infant/Toddler Hearing Screening Certification 17

D. Initial Certification 18

E. Renewal of Audiometric Technician Certificates 18

F. Certification as an Audiometric Technician is not designed to: 18

II. HEARING SCREENING ENVIRONMENT 19

A. Acoustic Environment Criteria 21

B. Suggestions for Meeting Screening Site Criteria 22

III. CARE AND HANDLING OF THE AUDIOMETER 23

A. Recognizing Common Audiometric Problems 25

B. Transport of the Audiometer 26

C. Biological Check of the Audiometer 27

IV. OTOSCOPIC INSPECTION 29

A. Conditions Affecting Screening Results 31

B. Performing an Otoscopic Inspection 31

C. Observation of the External Auditory Canal and Tympanic Membrane 32

D. Otoscopic Referral Criteria 33

V. SWEEP SCREENING PROCEDURES 35

A. Population to Screen 37

B. Screening Checklist 37

C. Administering Screening 37

D. Instructions to Students 38

E. Screening Procedures 38

G. Screening Quick Reference Cards 39

 

VI. THRESHOLD SCREENING PROCEDURES 41

A. Threshold Screening Preparations 43

B. Threshold Determination 43

C. Referral Criteria 44

D. Screening Young or Difficult to Test Students 44

E. Common Errors in Audiometry 44

F. Parent Notification Requirements 44

VII. HEARING AID MANAGEMENT 47

A. Regulations Pertaining to Hearing Aid Monitoring 49

B. Daily Listening Checks 49

C. Cleaning the Earmold 50

D. Listening Check for Ear Level Hearing Aids 50

E. Listening Check for Conventional Body Worn Aids 50

F. Troubleshooting Hearing Aid Problems 51

G. Types of Aids 53

VIII. TYMPANOMETRY SCREENING 57

A. Population to Screen 59

B. Parameters of Tympanometry Screening 60

C. Reliability of Test Results 62

D. Special Considerations 62

E. Steps to Conducting Tympanometry 62

F. Tympanogram Interpretation 63

G. Referral Criteria Based on Otoscopy, Pure Tone Screening, and Tympanometry 64

IX. EARLY CHILDHOOD SCREENING 67

A. Play Audiometry Screening Procedures 69

B. Otoscopy Review 70

C. Tympanometry Review 70

D. Tympanometry Screening Procedures 71

E. Hearing Screening Report Form 71

F. Tympanometry Screening Procedures 71

G. Completing the Hearing Screening Report Form - Tympanometry 72

 

 

X. INFANT/TODDLER HEARING SCREENING 75

A. Impact of Hearing Loss on Infants and Toddlers 77

B. Equipment and Supply Needs 78

C. Infant/Toddler Screening Protocol 79

1. High Risk Indicator Checklist

High Risk Indicator Checklist Form

Explanation of High Risk Indicators

Completing High Risk Indicator Checklist

2. Developmental Scales

Developmental Scales Form

Completing the Developmental Scales Form

D. Completing the Hearing Screening Report-Birth through 2 80

1. Hearing Screening Report Form

Reporting and Referral Criteria Flowchart

E. Explanations of High Risk Indicators 83

F. Completing the High Risk Indicators Checklist 86

G. Developmental Scales 87

H. Completing the Developmental Scales Form 91

I. Completing the Hearing Screening Report - Birth Through Two Form 91

J. Reporting and Referral Criteria 95

XI. GLOSSARY 97

XII. REFERENCES 107

XIII. APPENDICES 113

A. Anatomy of the Ear 114

B. Tympanogram Examples 115

C. Audiometric Technician Certificates 117

D. Hearing Screening Law 119

I. Child Find Screening and Evaluation

II. Educational Audiologists Roles and Certification Requirements

III. School Audiologist Certification Requirements

IV. Licensure Statutes for Speech Language Pathologists and Audiologists

 

 

 

 

INTRODUCTION

AUDIOLOGICAL MANAGEMENT

This document is a set of guidelines for training audiometric technicians in the State of Kansas. It may be used as a guide for audiologists conducting hearing screening certification workshops. Because the sense of hearing is a major mediator for learning and communication, it is imperative that measures be taken to identify students with hearing loss in order to circumvent potential academic and communication difficulties caused by unidentified hearing loss.

Audiological management in the educational setting is a broad term encompassing numerous activities relative to hearing conservation. It not only includes the hearing screening and diagnostic assessment, but also the provision of habilitative/rehabilitative services to those students identified as having hearing problems. Audiology, as a profession, has traditionally provided services through speech and hearing clinics, at universities, or in conjunction with medical practices. With the implementation of Public Law 94-142, audiology has become "school-centered." The primary goal of habilitation/rehabilitation for deaf and hard of hearing (D/HH) students is the optimal use of residual hearing. Audiological management requires that the audiologist be available to the student as part of the educational support team.

There are three types of hearing losses: conductive, sensorineural, and mixed. Each of the three types of hearing losses deprive the student of receiving auditory input which can result in communication and learning problems. The hearing loss may involve both medical and audiological management. From an educational standpoint, it is important to realize that many of the effects of hearing loss can be remediated with early identification and intervention. A hearing loss can adversely affect a student’s speech and language development, auditory perceptual skills, and academic achievement. In addition, hearing loss and communication difficulties can lead to social isolation and may have an impact on vocational choices.

School-centered audiology programs serve preschool through high school aged students. These programs can develop effective parent/infant and integrated preschool programs. For the older student, good hearing conservation and counseling programs are both part of the audiological management services in schools. Designed well, school-centered audiology programs can complement hearing screening programs which are required by the State but not always delivered in educational settings.

The hearing screening technician helps to advance the quality and delivery of audiological services to our children. It is incumbent upon the technician to be well trained, efficient, and effective provider of screening and support services. A hearing screening technician must have state-of-the-art technical screening skills matched with professional sensitivity to work with children, colleagues, and family members.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I.

AUDIOMETRIC TECHNICIAN

REQUIREMENTS

 

 

I. AUDIOMETRIC TECHNICIAN REQUIREMENTS

A. Definition of Audiometric Technician

A technician shall be defined as any person certified by an audiologist to do hearing screening. This includes administer tests, and assess the initial findings as to the health and function of the outer, middle, and inner ear. The level of competency shall be designated by the level of certificate held by the person assigned. Any person assigned to do audiological screening shall be required to hold the appropriate level of certification.

B. Duties of the Audiometric Technician

1. Complete the prescribed training as specified by Student Support Services of the Kansas State Department of Education (KSDE).

Hearing screening is mandated in K.S.A. 72-1204. In compliance with the Mandatory Hearing Screening Act, every individual assigned by the LEA to conduct hearing screening shall be competent in the use of a calibrated audiometer. Kansas State Department of Education (KSDE) and Kansas Department of Health and Environment (KDHE), shall review and assure competency of persons assigned by the LEA to conduct hearing screening as prescribed in K.S.A. 72-1204, and any amendment to this statute (K.A.R. 91-12-53 (a)). Assessment of audiometric technicians will be made at least once every two years. Certificates will be awarded to those participants who master screening competencies.

2. Administer individual pure-tone air conduction sweep screenings. (Level 1)

3. Administer otoscopic and pure-tone air conduction threshold screenings to all students who do not pass the sweep screening. (Level 2)

4. Administer tympanometry screening and play audiometry techniques. (Level 3)

5. Administer auditory screenings for infants and toddlers. (Level 4)

6. Report any unusual or difficult screening situations (noise, disturbances, school personnel problems, etc.) to the audiologist or supervisor/coordinator of the screening program.

7. Assume the responsibility for compiling records/reports as directed locally and by KSDE.

8. Observe policies and procedures of the LEA and KSDE.

9. Refer any questions about specific hearing screening results to the audiologist or coordinator of the program. Diagnostic and prognostic interpretations are the responsibility of the audiologist or medical professional.

10. Perform only the duties of an audiometric technician in compliance with the standards established by the LEA and KSDE.

C. Initial Audiometric Technician Training

The LEA may use a variety of training alternatives depending on teaching personnel, geographic location, level(s) of training needed, etc. Training must be conducted by an audiologist. It is recommended that audiometric technicians allow adequate time to establish competency at each level before seeking training at additional levels. The number of participants at each training session will be limited. Questions regarding training and educational materials can be directed to , KSDE, KDHE, or your local school audiologist.

Districts can contract with LEAs, Cooperatives, Regional Service Centers, universities who currently employ audiologists, or accredited private-practice audiologists for training. These training alternatives shall be arranged among the parties involved based on availability, work load of audiologist, location, scheduling, and fees.

 

Level 1 Pure Tone Sweep Screening Certification

For Level 1 only, minimal course content shall consist of three hours of instruction and three hours of practicum. Any person certified at Level 1 is certified to perform sweep screening with appropriate supervision. Annual renewal is required and must consist of at least three hours of instruction and demonstration of skills. Course content should include the following:

Course Content For Audiometric Technician Level 1

Topic Suggested Time

Introduction 15 minutes

State Law

Rationale - early identification

Frequency of screenings

Reporting to parents

Who is screened

Ethics - responsibilities and obligations

Local education plan requirements

Anatomy, Physiology, and Disorders of Hearing 45 minutes

Three parts of the ear - outer, middle, inner ear

General anatomy and function of each

Three types of hearing loss

Air conduction vs. bone conduction

Causes of hearing loss

Common disorders

Hearing conservation

The Audiometer 30 minutes

Parts of machine and operation

Definition and use of dB and Hz

Care of audiometer

Troubleshooting audiometer/biological check

Calibration

Maintenance

Hearing Screening Procedures 30 minutes

Screening environment

Earphone placement

Positioning of student

Equipment/material needs

Sweep Screening 30 minutes

Instructions to student

Tips on screening

Record keeping

Failure criteria

Common Errors In Audiometric Screening 15 minutes

Referral Sources 15 minutes

Practicum - sweep screening 3 hours

Each participant must have three clock hours of hands-on practicum with school age students. Direct supervision is required, not to exceed eight participants per instructor. Practicum must include practice in sweep screening and record keeping.

 

Competencies For Audiometric Technician - Level 1:

Be able to explain the hearing screening law and the rationale for mandatory hearing screening.

Be able to describe the basic anatomy and physiology of the ear.

Identify general behaviors, signs, and symptoms of hearing loss.

Exhibit ability to work with students and to explain the hearing screening process and results.

Perform biological check of audiometer and determine if audiometer is working properly.

Perform air conduction sweep screening.

Determine if there is a need for referral. Record and maintain results accurately.

Level 2 Pure Tone Threshold Screening Certification

For Level 2 the minimum shall be 6 clock hours of course content and six clock hours of practicum. People certified at Level 2 are qualified to conduct audiometric sweep screening and threshold screening. Certification at Level 2 is valid for two years. (Successful completion of the Level 2 workshop will certify the participant at both Level 1 and 2). Course content should include the following:

Course Content For Audiometric Technician - Level 2

Topic Suggested Time

Introduction 15 minutes

State Law

Rationale - early identification

Frequency of screenings

Reporting to parents

Who is screened

Ethics

Local education plan requirements

Anatomy and Physiology 45 minutes

Three parts of the ear - outer, middle, inner ear

General anatomy and function of each

Sound - physiology/basic acoustics

Disorders of Hearing 45 minutes

Three types of hearing loss

Air conduction vs. bone conduction

Causes of hearing loss

Common disorders

Hearing conservation

The Audiometer 30 minutes

Parts of machine and operation

Definition and use of dB and Hz

Care of audiometer

Troubleshooting audiometer/biological check

Calibration

Maintenance

Hearing Screening Procedures 30 minutes

Screening environment

Earphone placement

Positioning of student

Equipment/material needs

Sweep Screening 30 minutes

Instructions to student

Tips on screening

Record keeping

Failure criteria

Threshold Screening 30 minutes

Instructions to student

Threshold screening process (Tips on screening)

Behavioral observations

Audiogram/Record keeping

Pass/Fail/Referral criteria

Otoscopy 30 minutes

Common Errors In Audiometric Screening 15 minutes

 

Level 2 Pure Tone Threshold Screening Certification (continued)

Audiogram Interpretation 30 minutes

Case history

Degree of loss

Effect of degrees of loss on speech and language

Classroom modifications for deaf or hard of hearing students

Referral Sources 15 minutes

Hearing Aid Checks 30 minutes

Rationale

Law

Procedure

Hearing Conservation 15 minutes

Practicum (sweep and threshold screening) 6 hours

Each participant must have six clock hours of hands-on practicum with students. Direct supervision is required; maximum of one instructor supervising eight participants. Practicum must include practice in sweep and threshold screening, completing audiograms, record keeping and determining appropriate referrals.

Competencies For Audiometric Technician - Level 2

• Be able to explain the hearing screening law and the rationale for mandatory hearing screening.

• Be able to describe the basic anatomy and physiology of the ear.

• Identify general behaviors, signs, and symptoms of hearing loss.

• Perform otoscopic inspection.

• Exhibit ability to work with students and to explain the hearing screening process and results.

• Perform biological (listening) check of audiometer and determine if audiometer is working properly.

• Perform air conduction sweep screening and threshold screenings.

• Prepare audiograms and determine if there is a need for referral. Record and maintain results accurately.

• Discuss and explain hearing loss identified through threshold screening and the need for appropriate follow-up.

• Perform daily listening checks of hearing aids and auditory trainers.

Level 3 Tympanometry Screening Certification

The Level 3 applicant must first complete Level 1 and 2 certification. Level 3 certification is valid for two years. The minimum course content will consist of six clock hours of instruction and six clock hours of practicum to total 12 clock hours. Course content should include:

Course Content For Audiometric Technician - Level 3

Topic Suggested Time

Introduction 15 minutes

State Law

Rationale

Procedure

Anatomy and Physiology/Disorders 60 minutes

General anatomy and physiology

Common middle ear disorders

Program Development 30 minutes

Background rationale

Equipment/Supply needs

Personnel training requirements

Review Level 1 & 2 Competencies

Screening Rationale 60 minutes

Otitis media

Occurrence/prevalence of otitis media

High risk populations

Symptoms of otitis media

Effect on speech, language, cognition, etc.

Management of otitis media

Other conditions

Otoscopy 30 minutes

Screening Procedures and Results 105 minutes

Types of tympanograms

Who to screen

Procedures

Operation of tympanometer

Reliability

Play Audiometry 30 minutes

Fun response techniques

Conditioning/reinforcing responses

Instructions to student

Screening procedures

Reporting/Referral Criteria 30 minutes

Practicum for Audiometric Technician - Level 3 6 hours

Each participant must have six clock hours of hands-on practicum with children from two age groups; age six months to five and above age five. Direct supervision is required, not to exceed eight (8) participants per instructor. Practicum must include practice in recordkeeping, otoscopy, and tympanometry screening, interpreting tympanograms and determining appropriate referrals.

Level 3 Tympanometry Screening Certification (continued)

Competencies For Audiometric Technician - Level 3

• Be able to explain the purpose and rationale for including tympanometry in screening protocol.

• Be able to demonstrate skill in operation of tympanometer.

• Be able to describe measurement parameters used in tympanometry and give normal ranges for each.

• Demonstrate skill in performing otoscopic inspections and in performing tympanometry screenings.

• Demonstrate application of pass/fail and referral criteria when interpreting tympanograms.

• Recognize valid and invalid screening parameters.

• Demonstrate knowledge of symptoms related to various stages of otitis media and possible consequences of otitis media on development/educational progress.

• Be familiar with other middle ear disorders and current trends in medical care.

• Perform play audiometry

Level 4 Infant/Toddler Hearing Screening Certification

The Level 4 applicant must first complete Level 1, 2, and 3 certification. Certification for Level 4 is valid for two years. The minimum course content will consist of six clock hours of instruction. (No practicum is required). Course content should include:

Course Content For Audiometric Technician Level 4

Topic Suggested Time

Introduction 30 minutes

Audiometric Technician training

Need for early identification

Screening environment

Equipment and supply needs

Difficult to test students

Review Levels 1,2, & 3 Competencies

Infant/Toddler Hearing Screening 90 minutes

Birth/Case history

High risk registry

Normal development

Developmental scales

Otoscopy

Tympanometry

Flow charts

Risk Indicator Information. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 minutes

Auditory Development. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 minutes

Screening Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 minutes

Hearing Assessment Report/Record Keeping 60 minutes

Hearing screening report

Failure criteria

Referral criteria

Referral Procedures. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 minutes

Written Competency Test. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 minutes

Competencies for Audiometric Technician Level 4:

• Be able to explain need for early identification.

• Be able to describe the various components of infant/toddler hearing screening protocol and the use and importance of each.

• Be able to identify and explain factors which place an infant/toddler at high risk for hearing loss.

• Be able to discuss normal auditory development and the use of developmental scales.

• Perform paper screening.

• Exhibit ability to explain hearing screening results.

• Determine if there is a need for referral to an audiologist or physician based on hearing screening results.

• Keep accurate screening records.

D. Initial Certification

Initial Certification training for Levels 2, 3 and 4 must have the following components for each level:

1. Minimum of six clock hours of instruction

2. Minimum of six clock hours of practicum with the exception of Level 4

3. Written test (mastery must be demonstrated by a minimum score of 80%).

4. Practical skills checklist.

5. Course evaluation.

E. Renewal of Audiometric Technician Certificate

1. Level 1:Annual renewal required. Persons holding this level are qualified to do only audiometric SWEEP screenings. Renewal shall be yearly and include no less than six clock hours of instruction and practicum. Content of renewal shall be based on performance competencies of the applicant as determined by the instructor.

2. Recertification for Level 2, 3 and 4 shall include:

a. Lecture

b. Demonstration of screenings

c. Written test (mastery demonstrated by a score of 80% or higher).

d. Course evaluation.

Level 2: Renewals shall be for no more than two years. Renewal shall be no less than six clock hours of instruction and/or practicum with satisfactory demonstration of knowledge and practical skills. (Although it is not recommended, at times circumstances will warrant an audiologist to extend the renewal for up to four (4) years. Justification should be provided by the audiologist.)

Level 3: Renewal shall be no more than two years. Renewal shall be no less than six clock hours of instruction and/or practicum with satisfactory demonstration of knowledge and practical skills.

Level 4: Renewal shall be no more than two years. Renewal shall be no less than six clock hours of instruction and/or practicum with satisfactory demonstration of knowledge and practical skills.

Note: Renewal of any certificate shall be at the highest level of certification. Satisfactory completion of recertification training renews all levels of certification held. When a higher level of certification is acquired lower levels held are automatically renewed.

F. Certification as an Audiometric Technician is not designed to:

< Prepare the audiometric technician to train other technicians.

< Prepare the audiometric technician to diagnose hearing problems or interpret audiograms or tympanograms

< Prepare the audiometric technician to work without proper supervision.

< Prepare the audiometric technician to become an audiologist.

< Prepare the audiometric technician to do industrial testing.

< Prepare the audiometric technician to administer hearing screenings other than those defined in these guidelines.

 

 

 

 

 

 

 

 

 

 

 

 

 

II.

HEARING SCREENING ENVIRONMENT

 

II. HEARING SCREENING ENVIRONMENT

A. Acoustic Environment Criteria (American National Standards Institute,(ANSI)

When it is the responsibility of an agency to provide hearing screening for students, it is also the responsibility of the agency to provide a suitable screening environment. A sound-level meter and a frequency analyzer in the screening environment may be used to measure the noise level in the technical prep, physical education areas, or other high noise environments.

Finding a suitable acoustic environment is a very important part of the screening program. Frequently, school environments are sufficiently quiet for screening above 1000 Hz, but not quiet enough for accurate screening at 500 Hz and 1000 Hz. For that reason, the screening site must be evaluated yearly or before screening is conducted. Analysis of the ambient noise level should be conducted by someone experienced in noise measurements with the following:

1. Sound-pressure-level measurements are to be taken with a sound-level meter, or its equivalent, and a frequency analyzer. (Sound-level meter must meet the requirements of ANSI S1.4-1971).

2. The sound is to be measured in one-third or full octave bands that include the audiometric test frequency (500, 1000, 2000, 3000, 4000, 6000 Hz).

3. Measurements are to be taken with a sound-level meter microphone where the subject's head would be positioned.

4. Measurements of ambient noise are to be made with the same number of people in the room as in a test situation.

5. Measurements of ambient noise are to be made under the same noise level conditions (i.e., air conditioning/ventilation system running, typewriting, bells, footsteps, traffic noise occurring) as will exist when audiometric testing is being conducted.

If each of the sound-pressure-levels is less than the level stated in Table 1, the ambient noise level should not interfere with pure-tone screening procedures.

Table 1. MAXIMUM ALLOWABLE AMBIENT NOISE DURING SCREENING*

Maximum allowable sound pressure levels in decibels for ambient noise during screening audiometry using TDH-39 headsets encased in MX-41/AR cushions.

Test tone: Frequency (Hz)

500

1000

2000

4000

Octave band levels: ears covered with earphone mounted in MS-41/AR cushion (ANSI-53.1-1977)

 

21.5

 

29.5

 

34.5

 

42.5

Screening level (dB HL)

20.0

20.0

20.0

20.0

Maximum allowable SPL for ambient noise

41.5

49.5

54.5

62.0

* Maximum levels for ambient noise in sound pressure level will change with headsets other than TDH-39. See ANSI S3.6-1969 (American National Standards Specifications for Audiometers) and ANSI S3.1-1977 (Criteria for Permissible Ambient Noise During Audiometric Testing) to determine appropriate levels.

6. Listen to each frequency to be screened and be sure tone can be heard at 20 dB HL or below by someone with "normal" hearing. Check daily or more often as needed.

7. If screening cannot be conducted at 20 dB HL because of noise, DO NOT SCREEN.

 

B. Suggestions for Meeting Screening Site Criteria

1. If ambient noise exceeds the value given in Table 1, the noise level will effectively mask the reference threshold level. This will cause pure tone threshold levels to be inaccurate. Possible solutions to this problem would include:

a. Selection of an alternate screening site

b. Modification of the existing screening environment Examples:

• Cover floor with carpet

• Apply absorptive acoustical treatment to walls and ceiling

• Place baffles in ventilation systems

• Position ballast for fluorescent lamps outside the test room

c. Use of a completely enclosed screening room Examples:

• Small single wall booth - thin walls, 1000 lbs.

• Single wall sound room - one 4" thick wall

• Double wall sound room - two isolated 4 inch thick walls

2. When selecting a screening site, avoid the following:

a. Location near an air conditioning/heating unit.

b. Interference of typewriter/printer, clock, pop machine, and copier noise. If possible, unplug any of these items prior to screening.

c. Screening sites near a gymnasium, construction site, bathroom, lawn mowing, or where heavy traffic noise is heard.

d. Interference of florescent lighting. If sunlight provides adequate lighting and the room lighting system is noisy, room lights may need to be turned off during screening.

 

 

 

 

 

 

 

 

 

 

III.

CARE AND HANDLING

OF THE AUDIOMETER

 

 

III. CARE AND HANDLING OF THE AUDIOMETER

A. Recognizing Common Audiometer Problems

A properly serviced and calibrated instrument is important to the reliability of test results. During the time between periodic service it is helpful to use a few simple procedures which allow the recognition of equipment problems or the need for repair.

1. Earphone

a. Check cords:

• Set attenuator at 50 dB or higher.

• Set frequency at 2000 Hz.

While listening to tone, flex the cord on the phone at the connections (at earphone and audiometer). If a scratchy noise is heard or tone cuts out, replace cord. If one earphone seems to have a lower output than the other across frequencies for a given attenuator setting, you may need a new cord. This problem may be caused by the cord having a high resistance. Exchange earphones at the audiometer. If the low level earphone remains low, it could indicate a damaged earphone.

• Check electrical cord and headphone cords for breaks or static. Never bend or twist cords.

b. Check for Hum in Earphones:

• Set frequency at 1000 Hz.

• Set attenuator to 90 dB (signal on) and listen for noise or hum. Interrupt signal and listen for noise.

• Decrease attenuator to 60 dB (signal on) and listen for noise. Interrupt signal and listen for noise.

• Decrease attenuator to its lowest setting and listen for noise (signal on). Interrupt signal and listen for noise.

c. An audiometer may develop a tone in the quiet earphone. Check for tone:

• Select a person who is known to have normal hearing.

• Apply a signal to the right phone.

• Disconnect the right phone from the audiometer. If a two-room installation is used disconnect from the wall.

• Rotate frequency switch through all frequency settings while subject listens for tone in the quiet (left) earphone.

• Use the same procedure for left phone. If there is any sound in the quiet earphone, it will interfere with testing, particularly in unilateral losses.

There should not be any hum or extraneous noise at any of the above settings with the tone on or off. It is possible that some audiometers will have noise present at the 90 dB setting with the tone off; however, this noise should disappear at the 60 dB setting. If it does not disappear or if noise is heard at any other setting, the instrument needs service.

2. Noise in Attenuator

Attenuators may become noisy from dirt deposits and lack of lubrication and should be cleaned periodically by a qualified person. The noise may be apparent only when changing he attenuator setting while the tone is being presented and, may be prevented by not changing the attenuator while the tone is on.

3. Noise in Frequency Switch

Scratchy noises or clicks may develop in the frequency switch. To prevent this noise from being presented through the headphones, do not change the frequency dial setting when the tone is on.

 

4. Attenuation at Low Levels

It is important that the signal be checked at attenuator settings of zero (0 dB) and below. Sometimes the signal in the phone will drop to about 10 dB above zero and then remain constant or sometimes increase slightly when the attenuator is turned below this point. This condition will normally exist between 1000 and 4000 Hz.

To check for this problem, you must use a person with a threshold of zero dB or better since they must be able to detect a decrease as the attenuator is moved from 10 dB to 5 dB or below. Ability to hear at both levels may not be sufficient.

5. Calibration

a. Regardless of how often your audiometer is serviced, it is advisable to run audiograms on local office personnel regularly to verify its calibration. Listen to each frequency tone and be sure tone can be heard at least at 0 dB by someone with "normal" hearing.

b. If there is a difference of intensity level between the two phones at some frequencies, the audiometer will probably be out of calibration due to a change in the earphone sensitivity. A difference in intensity level at all frequencies would ordinarily indicate circuit problems with the audiometer. In either case, the audiometer should be checked by a qualified service person.

c. All dials and tone interrupter should turn freely and quietly; if not, repair is needed. Never force dials or tone interrupter.

d. In most cases, a signed and dated sticker will be affixed somewhere on the

audiometer to indicate the date of the last calibration or calibration check.

6. Fit of the Headset

The fit of the headset affects the limit on low level measurements when the ambient noise level is high. Always check the following:

a. Examine the cushions on the earphones. They should be reasonably resilient and free of cracks. If not, they should be replaced. Refer to an authorized service person to determine the possible effect on calibration.

b. Always shape the headband so that the cushion edges touch when they are hanging from the storage hook. Spring steel headbands can be shaped by grasping the headband and twisting into a tight circle.

c. Headphones and band may be cleaned with antiseptic solution.

7. Sound Room Jack Panel

a. Check to see that all plugs are inserted completely and that they are not or bent.

b. Clean and tighten the jacks periodically. Earphone output may drop when plugged through the jack panel even though there is no drop when directly connected to the audiometer.

B. Transport of the Audiometer

1. The audiometer is a sensitive instrument. Follow these rules while transporting:

a. Place the audiometer on the car seat and secure it with a seat belt, or place it on a foam rubber pad on the car floor when transporting.

b. Do not expose audiometer to extreme heat or cold.

c. Avoid bumping or dropping the audiometer.

d. The audiometer calibration must be checked once a year.

 

C. Biological Check of Audiometer

1. A daily biological check of the audiometer should be conducted. The technician must know own hearing threshold level in order to accurately perform this check. Suggested guidelines:

 

Check

Problem

The audiometer is in need of repair...

Press interrupter bar and elicit tone

Acoustic click? (one ear)

 

if a "click" is heard

Present a 70 dB HL continuous tone through one phone

Cross talk?

 

if the tone can be heard in the opposite phone

Present a 2000 Hz tone at 90, decrease intensity in 5-10 dB steps

Linearity of attenuator? (one ear)

 

if the tones do not get steadily weaker

Present 1000 Hz tone at 20, 15, 10, 5 dB HL

Low intensity function of the attenuator? (one ear)

 

if the tone is not presented at the intensity levels expected

Present a 50 dB HL continuous tone through each phone

Cords, connections to phones?

 

if static, crackling sound, cutting off and on is heard

Present a 60 dB HL continuous tone - run through octaves and half octaves

Frequencies? (one ear)

 

if the frequencies do not sound like what is expected

Switch signal from one phone to the other

Signal equal in intensity (matched ear phones)?

if the signals are not equal in intensity

 

An annual acoustic calibration check of every audiometer should be conducted by a qualified person.

 

REMEMBER: DUST IS NOISE! Keep your audiometer covered when not in use!!

 

 

 

 

 

 

 

 

 

 

 

 

 

IV.

OTOSCOPIC INSPECTION

 

 

IV. OTOSCOPIC INSPECTION

A. Conditions Affecting Screening Results

1. Conduct an otoscopic inspection prior to threshold or immittance screening.

a. Conditions that might affect audiometric and immittance screening results:

• Collapse of the ear canal, impacted cerumen, foreign objects in the canal, or perforation of the tympanic membrane.

• The occurrence of pathologies, such as fungus infection, and edema, may not cause abnormal audiometric results, but should receive prompt medical attention.

• Wax is not a problem unless it is completely occluding the canal.

• Variations in color, inability to observe normal landmarks, drainage from ear, or significant deviations from normal tympanic membrane appearance should alert screening personnel to encourage examination by a physician.

These conditions can often be seen and must be taken into account when interpreting screening results. NEVER try to remove foreign objects or wax from the ear. Refer the student to a physician.

b. In immittance measurements, otoscopy can help to determine the correct ear probe size and positioning of the probe so that it is directed toward the tympanic membrane.

B. Performing An Otoscopic Inspection

1. Inspect the pinna and the area around the pinna for abnormalities. Unusual skin coloration of the pinna or mastoid area, drainage, and unusual appearance of the external ear should be noted and brought to the attention of a physician.

2. Select the largest speculum that will fit comfortably into the ear canal. A small speculum may not provide enough illumination to see the tympanic membrane. A speculum that fits snugly into the canal permits a larger area of the tympanic membrane to be visualized and assists in straightening out the ear canal.

3. Grip the otoscope at the top of the handle near the light source for better control. By inverting the otoscope handle so that it is above the pinna, the speculum can be directed upward with the handle moving away from the student’s head.

4. Always rest the hand holding the otoscope lightly against the student’s temple. This will help prevent the speculum from being accidentally inserted deeper into the canal by a sudden movement of the student’s head.

5. The student’s ear canal and examiner’s eye should be parallel.

6. Pull back the pinna with the hand not holding the otoscope to straighten the canal. Because of the upward curvature of the canal in the infant and small child, the examiner must grasp the lower portion of the pinna and pull the ear down and backward to straighten the canal. An older child’s canal has changed to assume more of an adult position, therefore, the pinna should be pulled up and back to straighten the canal.

7. Place an appropriate size speculum into the ear canal at a comfortable depth without touching the canal wall with the tip.

8. When observing through the otoscope, the examiner’s eye should be about one inch from the otoscope lens.

9. Look for ear canal or tympanic membrane abnormalities.

 

C. Observation of the External Auditory Canal and Tympanic Membrane

1. Normally the tympanic membrane is shiny, pearly white, and semi-transparent. However, the color of the tympanic membrane may vary from person to person.

2. Comparing the person’s tympanic membranes to each other may be helpful.

3. An effort should be made to look beyond the exterior surface in order to notice the presence of subtle landmarks within the middle ear. The long process of the malleus (manubrium) should extend to approximately the center of the tympanic membrane.

4. Some students may have ventilation tubes. They vary in color and resemble the end of a spool. They may be in various positions in the tympanic membrane. Occasionally the tube may be observed laying in the ear canal.

FIGURE A: An anatomical comparison of adult and child's ear. Note that the ear canal of the adult is larger, longer, and straighter than that of a child.

 

 

FIGURE B -For otoscopic examination of child's ear, pull ear down and back to straighten ear canal.

D. Otoscopic Referral Criteria

1. Structural defects of ear, head, or neck such as abnormal position or structure of the external ear, absence of pinna, atresia of canal, malpositioned pinna, or preauricular pits and tags (unless physician is previously aware) are observed;

2. Ear canal abnormalities such as inflammation, bleeding, impacted cerumen, tumors, foreign bodies in ear canal are observed;

3. Tympanic membrane abnormalities such as perforation, inflammation, or severe retraction of the tympanic membrane are observed;

4. Other abnormalities such as perforations, effusion, edema, bleeding, drainage, redness, blisters, cholesteotoma, neoplasm, debris or dermititis are observed.

 

 

 

 

 

 

 

 

 

 

 

 

 

V.

SWEEP SCREENING PROCEDURES

 

 

V. SWEEP SCREENING PROCEDURES

The audiometric sweep screening is designed to identify persons whose hearing is within normal limits. This procedure is important and should be administered carefully in order to avoid passing anyone with hearing sensitivity outside of normal limits. Before beginning any audiometric procedure, make sure that the screening environment meets criteria for maximum allowable noise level.

A. Populations to Screen

1. Annual screening of all students through age 8 or grade 2. *

2. Students 9 years old or above or 3rd grade should be screened at least once every three years (screening at least every two years is recommended).

3. Screen every student during the first year of admission to a new school.

4. Annual screening of all students who are at high risk for hearing loss, have failed the screening in the previous year or who have been identified as having a hearing loss.

5. Screen students upon request or referral from an educator, administrator, parent, or physician.

6. Screen any student returning to school following an extended illness.

7. A screen must be conducted within 12 months prior to a comprehensive evaluation.

8. Students referred for medical care during a previous screening should be rescreened.

* Tympanometry is a required component of the screening protocol for children between the ages of 6 months and 5 years (not in Kindergarten). Tympanometry is recommended as part of the screening for all students through age 8.

B. Screening Check List

1. If a sound treated room is not available, screen in an area which complies with the maximum ambient noise level outlined in the section on Acoustic Environment Criteria - Table 1.

2. Place an audiometer on a table large enough for writing space.

3. Use appropriately sized chairs.

4. The audiometer has been acoustically calibrated within the past year.

5. Perform biological check. Check earphones for noise, tone production, poor connections, etc.

C. Administering Screening

1. Listen to each frequency to be screened and be sure tone can be heard at 20 dB HL or below by someone with "normal" hearing. Check daily or more often as needed.

2. If screening cannot be conducted at 20 dB HL because of noise, DO NOT SCREEN.

3. Present the tone for approximately one to two seconds. A tone may be presented more than once at each frequency.

4. Vary the time interval between tone presentations.

5. Avoid presenting a pattern of tone presentations.

6. Do not look at the student when a tone is presented.

7. Avoid clicking the tone interrupter switch.

8. Do not let the student see the front of the audiometer during screening.

9. Be sure the student cannot watch your movements in mirror reflections or windows.

10. Seat the student in position facing away from other people in the room.

11. Be sure earphones are properly placed over the ear canals.

12. Position earphone cords behind the student to prevent noise resulting from contact.

 

D. Instructions to Students

1. Give instructions before earphones are placed on the ears.

2. Make instructions as simple as possible.

3. Allow questions before the screening.

4. Instruct the student to respond to every stimulus. The technician should understand that some students take longer to respond than others.

5. Instruct the student to remain very quiet during screening.

6. Instructions to Students:

"You will hear a tone. Every time you hear the tone, raise your hand high. When the tone stops, put your hand down quickly. Raise your hand every time you hear a tone, even if the tones are different. You may raise either hand during the screening. Any questions before we begin?; "

7. Glasses, hair ribbons, headbands, clips, etc. should be removed.

8. The student may raise either hand during screening.

9. Make sure the student being screened is not holding their breath or chewing gum or candy.

E. Screening Procedure

1. Seat the student facing away from the audiometer so that half of the student 's face may be observed.

2. Place the earphones on the student, red: right, blue: left. If drainage or bleeding from the ear is observed when putting on the ear phones, do not screen the student and immediately make an appropriate medical referral.

3. Set the audiometer frequency dial at 1000 Hz, and the intensity dial at 40 dB HL. Present one tone for identification purposes only.

4. Set intensity dial at 20 dB HL and present tone at 1000 Hz.

5. For children ages 2 1/2 to 5 not in Kindergarten, use the following screening patterns:

Right ear - 1000, 2000, 4000 Hz; Left ear - 4000, 2000, 1000 Hz. Tympanometry screening is required.

6. For children Kindergarten through 8 years of age or in 2nd grade screen the following frequencies in each ear:

500, 1000, 2000, 4000 Hz. Tympanometry is optional. If tympanometry is administered, 500 Hz can be dropped from pure tone screening.

7. For children nine years old or 3rd grade and above screen the following frequencies in each ear: 1000, 2000, 4000, 6000 Hz. To identify high frequency noise-induced hearing loss in this population, 6000 Hz is included. Screening at 500 Hz is optional.

8. Record if student passes or needs a recheck. If the student does not respond to any one tone at 20 dB HL, rescreen in not more than 2-4 weeks.

9. Administer a threshold screening during the second screening if the student does not respond to all tones at 20 dB HL.

 

 

 

Screening Quick Reference Cards

 

 

 

 

Procedure for Screening Children age 21/2 through age 8 (2nd grade)

1. Set audiometer-Right ear-1000 Hz-40 dB HL (Identification tone).

2. Reset to 20 dB HL - (Screening level).

3. Right ear-1000, 2000, 4000 Hz

Left ear-4000, 2000, 1000, 500 Hz*

Right ear-500, 1000 Hz

4. Student must hear every tone at 20 dB HL to pass. If the student does not

hear a tone, it may be repeated.

* When tympanometry screening is conducted, 500 Hz does not have to be screened.

Tympanometry screening is required for all children six months to age 5; optional

for students above age 5.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Procedure for Screening Students age 9 and above

(or 3rd grade and above)

1. Set audiometer-Right ear-1000 Hz-40 dB HL (Identification tone).

2. Reset to 20 dB HL - (Screening level).

3. Right ear-1000, 2000, 4000, 6000 Hz; Left ear-6000, 4000, 2000, 1000 Hz

(Return to right ear)

4. Student must hear every tone at 20 dB HL to pass. If the student does not

hear a tone, it may be repeated.

 

 

 

 

 

 

 

 

 

 

 

 

 

VI.

THRESHOLD SCREENING

PROCEDURES

 

 

VI. THRESHOLD SCREENING PROCEDURES

Threshold screening seeks to establish the hearing sensitivity of students across multiple frequencies up to 80 dB HL , where as sweep screening is used to establish the hearing sensitivity of students at the 20 dB HL. Information from this screening helps determine the need for further referral to insure students receive the hearing intervention they require. Before beginning any audiometric procedure, make sure the testing environment meets criteria for maximum allowable noise level.

A. Threshold Screening Preparations

1. Complete an otoscopic inspection after failure of the second screening. Threshold screening should not be started until an otoscopic examination has been completed. If drainage from ear is noted, refer to a physician. Do not screen.

2. Seat the student facing away from the dials of the audiometer, but so that their face may be observed.

3. Instructions to Students

"You will hear a tone. Every time you hear the tone, raise your hand high. When the tone stops, put your hand down quickly. Raise your hand every time you hear a tone, even if the tones are different. You may raise either hand during the screening. Any questions before we begin?; "

4. Make sure the earphones are properly placed

a. Diaphragm of the phone should be directly over the ear canal.

b. The earphones should be adjusted correctly with cords behind student.

c. Check that the pressure of the earphone does not collapse the canal or close it off.

d. The earphone need not cover the entire ear.

e. Remove the student’s glasses, hair ribbons, head bands, and barrettes. They interfere with placement of earphones.

5. Have student remove gum.

B. Threshold Determination

1. The procedure for determining threshold is the same for all frequencies. Present a tone at 1000 Hz at 40dB HL (in the better ear) to allow for easy identification of the tone. If child responds, decrease intensity by 10dB until no response is obtained. Increase intensity by 5 dB until a response is obtained. Once a response is obtained, decrease intensity by 10dB until no response is obtained. Increase intensity by 5 dB until a response is obtained. This " down 10-up-5" pattern is repeated until the child’s hearing threshold level is identified. Threshold is defined as the faintest tone that can be heard at least 50% of the time and is established after several threshold responses, usually 2 out of 4 presentations. If for any frequency, a response is not obtained at 40dB HL, increase the intensity in 20dB steps until a response is obtained. Do not exceed an 80 dB HL presentation level. When a response is obtained, follow "down 10-up-5" procedure detailed above. If no response is obtained at 80dB HL record "NR" or appropriate arrow on audiogram for the frequency being tested.

2. After the threshold for 1000 Hz has been established in the better ear, the

procedure is repeated for 2000, 4000, 6000, 500 Hz, in that order. The thresholds

for the same frequencies are then obtained for the second ear.

3. Screening in the second ear may begin with the last frequency used to screen the

first ear. It is not always necessary to start again with 1000 Hz.

4. Screening may be terminated after thresholds have been obtained for all five

frequencies in each ear. Thresholds may be obtained for additional frequencies

as needed.

5. If there is a difference of more than 30 dB in adjacent frequencies, screen the

intermediate frequency (750, 1500, or 3000 Hz). When the threshold at 6000 Hz is

35 dB HL or poorer, screen 8000 Hz.

 

C. Referral Criteria

A more extensive evaluation is recommended if either of the following criteria are met:

1. There is a hearing loss of 25 dB HL or greater at 500, 1000, or 2000 Hz in either ear. If using tympanometry as a part of a student's screening battery, see "VIII. Tympanometry Screening" for referral criteria.

2. There is a hearing loss of 35 dB HL or greater at 4000 or 6000 Hz in either ear. If a student does not pass the sweep screening at 4000 and/or 6000 Hz at 20 dB HL, but does not meet referral criteria, the parent should be notified the student did not pass the hearing screening, yet a referral for further evaluation is not indicated. However, the student should be considered "high risk" for high frequency hearing loss and screened the next year.

ASHA (1985). Guidelines for Identification Audiometry. ASHA, Vol. 27, 49-53.

D. Screening For Young Or Difficult To Test Students

Threshold screening is very tiring for a child. Fatigue and all of its manifestations must be taken into account during a screening because it will affect the reliability and validity of the screening. If the student shows any indication of tiring, alter the frequency sequence. The altered sequence should include 1000 Hz, 2000 Hz, and 500 Hz in both ears. It is better to have reliable measures for the 500 Hz, 1000 Hz, 2000 Hz (the speech range) than to have a complete test of all frequencies with questionable accuracy. Continue threshold testing for 4000 Hz and 6000 Hz for both ears if the student's attention span is maintained. Switch to a pulsed or warble tone if a student suddenly begins to respond inconsistently at 4000 Hz or 6000 Hz and tinnitus is suspected.

E. Common Errors In Audiometry

1. Extended evaluation time may cause fatigue.

2. Rushed screening process.

3. Inaccurate or unclear directions to the student.

4. Student in direct view of the audiometer control panel or the motions of the operator.

5. Earphone on the wrong ear.

6. Technician giving visual cues.

7. Presenting tone presentation longer than two seconds.

8. Presenting the tone in a rhythmic manner.

9. Failure to note change in ambient noise levels during screening procedures.

10. Unnecessary talking during screening.

F. Parent Notification Requirements

The results of all hearing screening must be reported to the parents. This report can be delayed until after rescreening.

K.S.A. 72-1205(d) states "...all tests shall be performed by a person competent in the use of a calibrated audiometer and who has been designated by the board of education which provides the basic hearing screening. The results of the test and, if necessary, the desirability of examinations by a qualified physician shall be reported to the parents or guardians of such students... "

 

CAUTION:

Passing a sweep or threshold screening does not rule out the possibility of an auditory problem. Frequently, students are referred for hearing screening because they demonstrate behavior in the classroom that suggests their hearing is not normal. Students may have difficulty following directions; understanding the teacher when background noise is present; or with reading, spelling, speech, or language development. Audiometric screening assesses only basic auditory sensitivity. Hearing screening personnel should recognize the need to suggest evaluation by trained personnel. DO NOT ignore the classroom teacher's observations. Realize that sweep screening evaluates only one part of the hearing system and that special testing may be needed in order to determine the source of the student's difficulty.

 

 

 

 

 

 

 

 

 

 

 

VII.

HEARING AID MANAGEMENT

 

 

VII. HEARING AID MANAGEMENT

It is very important that each D/HH student have properly selected and well-maintained hearing aid(s). Hearing aids amplify sound, but cannot restore hearing to normal. A hearing aid helps the student to respond to sound that might otherwise go undetected. Hearing aids cannot improve auditory reception beyond the residual discrimination capacity of the ear, nor do they typically prevent or contribute to further hearing loss.

A. Regulations Pertaining to Hearing Aid Monitoring

Regular and frequent monitoring of the hearing aid is crucial to a student's ability to benefit from the educational experience. The hearing aid check can be done quickly and easily on a daily basis. Daily checks are recommended. Procedures for monitoring the function of a cochlear implant shall be determined by parents and school personnel.

It is the parent’s right to request that school personnel not examine their student's hearing aid. Such requests should be respected, but carefully documented in the student's permanent records.

K.A.R. 91-12-53(c) requires:

1. Each Local Education Agency (LEA) shall maintain a list of all who wear hearing aids.

2. Each LEA shall adopt procedures for the regular monitoring of the functioning of all hearing aids. Those procedures shall meet the following requirements.

a. The aids shall be checked not less than once each week.

b. Personnel shall be designated and trained to provide the listening check in each school building where a child wearing a hearing aid is enrolled. The check may be done by that child's regular or special education teacher or by a paraprofessional, or a LEA designee.

c. Until a child has completed the fourth grade, the hearing aid shall be checked by the person designated by the LEA in accordance with the preceding paragraph. Children in the fifth and subsequent grades may check their own hearing aids under the supervision of the person designated by the LEA.

d. The hearing aid of each child shall be checked by an audiologist or hearing aid dealer not less than once each year.

B. Daily Listening Check

The individual designated to provide daily hearing aid listening checks should be equipped with a battery tester and a hearing aid stethoscope. These items will provide general assessment of the functioning of a hearing aid. The LEA will provide inservice on the hearing aid battery testing and listening for acceptable hearing aid output. SAMPLE FORM:

NAME _______________________________ LE AID ____________________________

Make/ Model

Authorization _________________________ RE AID ____________________________

Make/ Model

Mo. _____

Yr. _____

Day of Mo. _____

Aid

Satisfactory (x)

Aid Not

Satisfactory (x)

EXPLANATORY REMARKS:

For example: battery dead, cord broken, earmold missing, aid left at home, aid in for repairs, etc.

Mon.

     

Tues.

     

Wed.

     

Thurs.

     

Fri.

     

 

C. Cleaning The Earmold

Clean the earmold periodically. This can be done by removing it from the hearing aid and washing it in mild soapy water. After rinsing, the earmold canal and tubing should be dried thoroughly. The earmold can be reattached to the hearing aid when it is completely dry.

D. Listening Check For Ear Level Hearing Aids

1. Test battery for appropriate voltage. Replace battery if charge is below one volt. Check appearance of the battery terminals to see if they are clean, and if necessary, clean them with an eraser.

2. Insert battery into hearing aid. Make sure positive and negative terminals are placed correctly.

3. Check plastic tubing on the earmold for possible stiffness, pinholes, or cracks.

4. In order to listen to the hearing aid, connect a hearing aid stethoscope to the canal portion of the earmold.

5. Set switches correctly for intended use ("On/Off switch in "on" position, "MTO" set to "M", or "MO" set to "M").

6. With ear level aids, place your thumb firmly over the opening of the ear mold. If whistling comes from the case, the aid should be checked by an audiologist or the hearing aid dealer.

7. Turn the hearing aid on and hold it approximately six inches from your mouth. Turn the volume up gradually to a comfortable setting as you speak in a normal voice. Listen for clarity and distortion when saying the following sounds: "ah," "oo," "ee," "sh," "s." Listen for scratchiness or dead spots while changing the volume control.

8. Listen for problems while talking into the hearing aid: weak or intermittent signal, distortion, or unusual noise from the signal.

9. Check the earmold for cleanliness.

10. Gently tap the case on all sides and listen for a reduction of power or break in the signal. Check the condition of the hearing aid case.

11. If the hearing aid is not functioning properly, notify the teacher, parent, and/or audiologist.

E. Listening Check For Conventional Body Worn Units

1. Test battery for appropriate voltage. Replace battery if charge is below one volt. Check appearance of the battery terminals to see if they are clean, and if necessary, clean them with an eraser.

2. Insert battery into hearing aid. Make sure positive and negative terminals are placed correctly.

3. In order to listen to the hearing aid, connect a hearing aid stethoscope to the canal portion of the earmold.

4. Set switches correctly for intended use ("On/Off switch in "on" position, "MTO" set to "M", or "MO" set to "M").

5. Turn the hearing aid on and hold it approximately six inches from your mouth. Turn the volume up gradually to a comfortable setting as you speak in a normal voice. Listen for clarity and distortion when saying the following sounds: "ah," "oo," "ee," "sh," "s." Listen for scratchiness or dead spots while changing the volume control.

6. Roll the cord back and forth between your fingers to check for "cut-outs." Check the firmness of cord connections.

7. Listen for problems while talking into the hearing aid: weak or intermittent signal, distortion, or unusual noise from the signal.

8. Turn the aid off (switch to "off" position, turn volume completely down, or open battery compartment) and remove stethoscope from ears. Place your thumb firmly over the opening in the receiver and turn the hearing aid back "on." Turn the volume to maximum. Listen for a soft whistling sound from the hearing aid case. If whistling is heard, the aid should be checked by an audiologist or hearing aid dealer.

9. Check the earmold for cleanliness.

10. If the hearing aid is not functioning properly, notify the teacher, parent, and/or audiologist.

F. Troubleshooting Hearing Aid Problems

If the battery, tubing, earmold, cord and earphone all appear satisfactory, but the aid does not function properly, factory or repair service will be necessary. Arrange for service through an audiologist or a hearing aid dispenser. Attempts at do-it-yourself repairs could void the warranty and cause serious damage.

Hearing aids are delicate electronic devices and should be handled carefully. They should not be exposed to moisture or extreme heat. Alcohol, solvents, or cleaning fluids should not be used to clean the hearing aid or earmold.

 

 

 

 

 

 

 

 

Solving Minor Hearing Aid Problems

Hearing Aid Problem

Cause

Solution

Hearing Aid is Dead

Dead battery

Replace battery

 

Battery inserted incorrectly

 

Install battery correctly

 

Aid/earmold holes plugged with wax or debris

 

Remove wax or debris carefully

 

Aid damp or wet

 

Air blow to dry

 

Switch in wrong position

 

Correct position

 

Bent or twisted tube

 

Straighten tube

     

Hearing aid sound is distorted/weak

Battery almost dead

Replace battery

 

Earmold hole plugged

 

Remove wax/dirt

 

Volume control turned too high

 

Turn down volume

 

Microphone opening covered or dirty

 

Remove dirt or uncover

 

Earmold damp

 

Dry with air blower

 

Tube bent or twisted

 

Straighten tube

     

Hearing aid goes on and off, or fades

Battery almost dead

Replace battery

 

Battery dirty

Rub pencil eraser over battery contact side

 

Aid/tubing damp

Dry with air blower

     

Hearing aid produces feedback

(squealing or whistling)

 

Aid/mold not inserted correctly

Remove and reinsert

 

Mold does not fit

 

May need new impression

 

Hole or crack in tube

 

See audiologist

 

Microphone covered

Check if hair or hat covers opening

 

 

Volume control too high

Turn volume down but not below normal setting

 

Child’s ear canal blocked

 

Refer to physician

 

 

G. Hearing Aid Types

Personal hearing aids are available in four basic types. The type most frequently worn by D/HH students is the behind-the-ear aid. The basic components include: microphone, volume control, function switch, battery compartment, battery, tubing and earmold (see below). The function switch markings will resemble one of the following:

1. Behind the ear -

O - off

T - telephone position (external

microphone off)

M - external microphone (normal setting)

 

O - off

I - external microphone

(normal setting)

S - noise suppression setting

   

 

 

The body aid is worn by some students who have a profound hearing loss. It is generally worn in a pouch of a hearing aid garment or harness. The sound is routed through a cord to a receiver or miniature earphone that is held in place by an earmold. See diagram below.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Some students with milder losses use the in-the-ear type of hearing aid. The components of this type of aid are in a shell resembling an earmold. This type of hearing aid is worn within the ear canal.

In-The-Ear Hearing Aid Canal Hearing Aid

 

In certain situations, an FM auditory trainer may be used with hearing impaired students. These systems use a receiver that looks similar to a body aid which may connect to the student's personal hearing aid. The auditory trainer receives and amplifies an FM radio signal transmitted by a microphone worn by the teacher. This system helps to minimize background noise and provides a clearer reception of the teacher's voice than a standard hearing aid. Operation and care of the auditory trainer are the same as those for a body aid. Most auditory trainers use chargers rather than conventional batteries. Instruction in the care and maintenance of an auditory trainer system will be provided by the Local Educational Audiologist and/or the audiologist from the Kansas School for the Deaf who administers the State classroom auditory trainer program.

Troubleshooting an Auditory Trainer

A. If there is no sound coming from the student FM receiver:

1. turn the power on

2. turn the teacher microphone/transmitter on

3. turn the environmental microphones on

4. recharge the teacher microphone/transmitter batteries

5. recharge the student FM receiver batteries

6. clean the students earmolds

7. plug the transducer cords into the phone jacks

8. plug the proper color-coded RO into the student FM receiver

B. Weak sound coming from the student FM receiver:

1. clean the student's earmolds

2. recharge the student FM receiver batteries

3. recharge the teacher microphone/transmitter batteries

C. Whistling sound while the student FM receiver is worn:

1. check to see that the student's earmolds are properly fitted in the ears

2. be sure the student's earmolds and ears are free of wax

 

 

D. No FM reception

1. turn on the power

2. turn on the teacher microphone/ transmitter

3. try an RO from an FM receiver that is working

4. is the cord plugged into correct location

5. recharge the teacher microphone/transmitter

6. recharge the student FM receiver

TEACHER STUDENT RESULT

Power Mic Power

OFF OFF OFF Silence

OFF ON ON Room & self

ON ON ON Teacher, room

& self

ON OFF ON Teacher

 

 

 

 

 

 

 

 

 

 

 

 

 

VIII.

TYMPANOMETRY SCREENING

 

VIII. TYMPANOMETRY SCREENING

Tympanometry measures the compliance or mobility of the tympanic membrane as a function of varied air pressure in the ear canal. Tympanometry is valuable in the detection of medically related conditions of the ear. These conditions may include fluid build-up in the middle ear and other abnormalities which influence the parameters measured by tympanometry. The information obtained by conducting tympanometry screening is beneficial in assessing the auditory system. Pure tone hearing screening alone may not provide enough information for making referrals.

The pure tone hearing screening addresses how well the student hears the tones which are presented. It is one factor which helps detect medical hearing disorders. The addition of tympanometry to the hearing screening protocol compliments the overall objectives of a hearing screening program which are:

l Detection of possible hearing losses that might require medical treatment;

l Detection of hearing losses which are currently or may affect a student's academic, communication, and social skills, and;

l Detection of permanent sensorineural hearing losses to ensure that students can get early amplification and rehabilitation.

Tympanometry screening is most effective when combined with pure tone screening. Tympanometry has served to identify conditions of the ear that may be missed by audiometric screening alone. It is important to remember that tympanometry is a screening process to identify possible disorders, and is not to be used as a diagnostic tool. Tympanometry screening is required as a part of the hearing screening for all students six months through 5 years of age (not in kindergarten).

The benefit of including tympanometry in the screening protocol is that it is an objective measure that does not require a behavioral response. It is quick, accurate, easy to administer, and creates little, if any discomfort to the student. It can be conducted reliably on children beginning at 6 months of age. Therefore, tympanometry allows the audiologist and audiometric technician to identify accurately those children who may need medical treatment for hearing disorders. The American Academy of Pediatrics states that there is "growing evidence of a correlation between middle ear disease with hearing impairment and delays in the development of speech, language and cognitive skills." This is important because otitis media, (middle ear infection) is the second most common early childhood disease. It is second only to the common cold. In order to adequately identify those students who need medical treatment, tympanometry must be included in the screening protocol.

A. Population To Screen

General hearing screening guidelines can be found in previous sections of this document. The following describes how tympanometry is incorporated into a comprehensive hearing screening program:

1. Age Variable

Students age 6 months to 5 years of age (not in Kindergarten) should be screened using otoscopy, paper or pure tone screening, and tympanometry.

Students in Kindergarten through high school should be screened using otoscopy and pure tone screening. Tympanometry is optional but strongly encouraged for students through grade two.

2. Pure tone Screening Variable

Frequencies selected for pure tone screening vary according to the use of tympanometry. See "V. Sweep Screening Procedures, E. Screening Procedures."

B. Parameters Of Tympanometry Screening

Tympanometry is a test which can be used to identify possible disorders of the middle ear. It serves to identify conditions of the ear which may be missed by audiometric screening alone. Two components of tympanometry are considered in interpreting results and making referrals. The parameters are:

1. Physical Volume (Part of Referral Criteria)

The physical volume is the amount of air measured in the space between the probe tip of the tympanometer and the tympanic membrane. It can be called physical volume, volume, absolute volume. Physical volume is measured in milliliter (ml) or cubic centimeters (cc). The "normal range" of mobility for a particular instrument should be determined by reading the manual and using the values recommended by the manufacturer. In general, physical volumes between .3ml and 2.0ml are considered normal ranges for most instruments.

There is a large variance in normative values for physical volume measurements. A borderline range for students could be considered as being between 1.5ml and 2.0ml. Many adults will have physical volume measurements of greater than 2.0ml. The size of the ear canal, as well as the amount of cerumen (ear wax) present, should be taken into account when determining the need for referral.

Volume measurements below .3ml may indicate the probe is placed against the side of the ear canal or against cerumen in the ear canal. Occasionally, the ear canal may be completely occluded by cerumen and a low volume measurement may indicate the size of the ear canal from the probe tip to the cerumen.

Volume measurements above 2.0ml indicate that the cavity being measured is larger than the ear canal volume. If there is a patent (open) PE tube in the tympanic membrane or if there is a perforation of the tympanic membrane, a large physical volume measurement may be obtained. The reason for a large physical measurement should be considered when determining need for referral.

It is helpful to compare the volume of both ears to check validity of the measurements. Most students will have ear canal volumes that are roughly equal in both ears and the measurement should fall within the normal range of .3ml and 2.0ml.

Physical Volume Values Chart

 

Value

Interpretation

 

.3 to 2.0 ml

Normal

 

< .3ml

Abnormally small

 

> 2.0 ml

Abnormally large

 

2. Mobility or Compliance of the Middle Ear System

(Part of Referral Criteria)

A normal middle ear system has a tympanic membrane and attached ossicular chain which vibrate easily allowing the transmission of sound energy to the inner ear by converting the sound waves to mechanical motion.

In tympanometry, the freedom of movement (mobility or compliance) of the tympanic membrane and ossicular chain is assessed by measuring the amount of energy necessary to move them. On the tympanogram, it is represented by the height of the peak and is expressed in milliliters.

Some conditions of the middle ear cause the mobility of all or part of the middle ear system to be reduced. Other conditions may allow excessive motion. Extremely low or extremely high mobility may indicate a condition which needs further attention.

A compliance peak from .2 to 1.8ml is within the normal range (check owner's manual for equipment specific criteria).

A compliance measurement of less than .2ml indicates the middle ear is stiffer than normal.

A compliance measurement of greater than 1.8ml indicates a hyperflaccid tympanic membrane. A value greater than 3.0ml may indicate a disarticulated ossicular chain. High compliance measurements are not considered a factor in referral criteria unless hearing loss is present.

Compliance Measurements*

 

Value

Interpretation

 

.2 to 1.8ml

Normal

 

< .2ml

Abnormal

 

> 1.8 ml

Abnormal

*Check owner's manual for equipment specific criteria.

There are three additional components which can be measured on some instruments, but are not used as factors in referral criteria. These parameters include: Middle ear pressure (Tympanometric peak pressure), Acoustic reflexes (AR) and Gradient.

3. Middle Ear Pressure **

In a normal middle ear system, the Eustachian tube will open allowing air to more in to and out of the middle ear cavity. This keeps air pressure behind the tympanic membrane roughly equal to the atmospheric or ambient air pressure in the ear canal. If the Eustachian tube does not function normally, a negative or occasionally a positive pressure may develop in the middle ear. The results are expressed in daPa (deca Pascals) or mm H2O (millimeters water pressure). Most tympanometers measure values from -300daPa, some express even greater negative values.

Middle ear pressure has not been shown to be a viable parameter in determining middle ear pathology because the middle ear is a dynamic structure. It is reasonable to expect fairly large swings in middle ear pressure throughout a typical day. Consequently, one single measurement (such as would be taken during a screening) may not be reliable.

4. Acoustic Reflex**

Acoustic reflex (AR) testing involves the objective measurement of the contraction of a small muscle within the middle ear in response to a loud sound. Recent research has indicated that the efficacy of acoustic reflex measurement for detecting middle-ear disorders is limited for screening purposes, however AR testing may be used as part of a full audiological evaluation.

5. Gradient or Tympanic Width**

Gradient measures are used to describe the shape of the tympanogram in the vicinity of the peak. Commonly, gradient measures are calculated by determining the pressure interval corresponding to a 50% reduction in peak immittance. Normative data and measurement standards have not yet been established for determining gradient. In addition, many tympanometers currently in use do not provide gradient data.

** Middle ear pressure, Acoustic reflex, and Gradient are not used in this screening protocol.

 

C. Reliability Of Test Results

Under most conditions, tympanometry provides reliable information regarding middle ear function. However, there are factors which affect the reliability and validity of test results. Individuals conducting tympanometry should be aware of these factors in order to obtain accurate information.

1. Tympanometry screening should not be administered to students under the age of 6 months.

A high incidence of false negative results (i.e., normal tympanometric results found in infants with middle ear effusion) have been obtained from tympanometry conducted on newborn infants. The reason for this is the highly compliant nature of the external auditory canal wall in infants. As such, the normal tympanogram may be a compliance measure of the external auditory canal rather than the tympanic membrane.

2. Tympanometry should not be administered to students who have had middle ear surgery (other than myringotomy and PE tubes) within the past six months unless requested by a physician.

Middle ear surgeries may include cholesteatoma removal, tympanoplasty, canaloplasty, etc. Tympanometry can provide valuable data on the patency of tubes shortly after the surgical procedure.

3. Tympanometry should not be administered to students who fail otoscopy.

D. Special Considerations

1. Middle ear functioning is a dynamic, non-static, system. Fluctuations in negative pressure measurements will often be observed. This is not clinically significant for determining the need for referral.

2. If a flat tympanogram is obtained (compliance of .2ml or less), always repeat the tympanogram. This will minimize inaccurate results based on improper probe placement. Referrals should be made on results which can be replicated. When tympanograms are repeated, physical volume measurements should be monitored to ensure that the probe tip is properly placed and is not against the canal wall, or in excessive cerumen, etc.

3. If a perforation or patent PE tube is present and the eustachian tube is open, an airtight seal may not be obtainable. Do not keep trying to get a probe tip seal.

E. Steps For Conducting Tympanometry

1. Equipment

In order to conduct Level 3 hearing screening, the following equipment is needed:

a. Acoustic Immittance Bridge (Tympanometer) and tips

Minimum pressure range of -300 to +150 mm H2O

Minimum compliance scale of at least 3.0 ml.

b. Otoscope and specula

c. Pure tone Audiometer

d. Other, depending on age of students

2. Procedure

a. Turn on machine.

b. Check Calibration. Many of the newer tympanometers will check the calibration automatically each time they are turned on. Older units require you to manually check the calibration by measuring the size of the volume using a specified probe tip. Read your operating manual to determine which procedure to use on your unit. This is only a calibration check. It does not take the place of full electroacoustic calibration which is required annually.

 

c. Otoscopic examination. (See section IV Otoscopic Inspection). Cerumen that completely occludes the ear canal will interfere with the test. If the cerumen does not completely occlude the canal, a reliable tympanogram can be obtained. While doing the otoscopic exam, note the size and shape of the ear canal to determine the appropriate size probe tip.

d. Place appropriate size probe tip on probe. As a rule, it is better to have a probe tip that is too large than too small.

e. Place against ear canal for seal. Most new units obtain a seal rather easily. However, when just beginning tympanometry screening, you may find this difficult. Sometimes, it is helpful to use a twisting motion to rotate the probe back and forth to fit into the ear canal.

The seal must be obtained in the ear canal, not against the walls of the ear canal itself. You will know if you have achieved a good seal when beginning the tympanogram. If there is a leak, the test will not be completed. If you are against the canal wall or the probe tip is blocked by wax or an object, you will know by the physical volume reading. If this measurement is extremely small, remove the probe, inspect it for blockage, and clean it if necessary. Reposition the probe tip in the ear canal and test again. A different sized probe tip may be required.

f. Maintain seal until test is completed (typically less than 10 seconds). Hold the probe steady once a seal is obtained. Remove after the test is completed.

g. Remove probe and print the results if needed. Some tympanometers do not give you a choice. They automatically print after each test. It is not necessary to print out tympanograms that are normal.

h. Always repeat the tympanogram if it appears abnormal. Even though the reliability of tympanograms is quite good, run the tympanogram again to check the reliability of the results.

i. Clean probe tip for each student. Use alcohol, alcohol prep pads, or clean with an antiseptic after each use. If cleaning the probe tip while on the tympanometer, hold the tip down so any excess moisture moves away from the probe assembly.

F. TYMPANOGRAM INTERPRETATION

(See Appendix B for additional tympanogram examples)

 

TYMPANOGRAM

COMPLIANCE

PHYSICAL

VOLUME

POSSIBLE CAUSE

 

Peak is present

Compliance within normal limits (.2 - 2.0ml)

Normal*

.3 - 2.0ml

Normal tympanic membrane

 

No peak

Low compliance < .2ml

Small

< 0.3ml

May suggest blockage of external ear canal with wax or other object

 

No peak

Low compliance < .2ml

Normal

May suggest fluid filled middle ear, otitis media or retracted tympanic membrane

 

No peak

Low compliance < .2ml

Large

> 2.0

May suggest perforation or patent ventilation tube

*For normal ears, physical volume is sometimes greater than 2.0ml; look at the size of the ear canal.

 

 

 

 

REFERRAL CRITERIA BASED ON OTOSCOPY, PURE TONE SCREENING AND TYMPANOMETRY

 

 

 

 

 

 

 

OTOSCOPY

PURE TONE HEARING

TYMPANOMETRY

RECOMMENDATIONS

Pass

 

Pass

Normal

Routine screening or as concerns arise

Pass

Pass

Abnormal

Rule out: PE tubes, perforation, equipment errors. Repeat tympanogram in 2-4 weeks and if failed refer to physician. Repeat hearing test if tympanogram is normal at rescreen. Follow annually if hearing remains normal.

 

Fail

 

Pass or Fail

Normal or Abnormal

Refer to physician

Pass

Fail

Abnormal

Repeat hearing test and tympanogram in 2 weeks, if both are failed, refer to physician and audiologist..

 

Pass

 

Fail

Normal

Refer to audiologist

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IX.

EARLY CHILDHOOD SCREENING

 

 

IX. EARLY CHILDHOOD SCREENING

The purpose of play audiometry is to incorporate a "fun" response technique with traditional pure tone hearing screening procedures in order to maintain a child's attention long enough to complete the task. This "fun" technique may also be useful in screening difficult-to-test children.

Play audiometry is a reliable operant conditioning procedure for screening the hearing of children ages 2 1/2 to 5 years. In play audiometry a child is rewarded for an appropriate response to a tone presentation which results in an increase in the occurrence of the response. Any task which requires a behavioral response such as putting a cotton ball in a can, putting a ring on a spindle, dropping a block in a box, connecting snap-lock beads etc. can be used. Consistent responses may be obtained with children age 2 1/2 to 5 years, although many children under age 3 years may not respond consistently to play audiometry. This may be due to these younger children not wearing the earphones or not understanding the task.

Reinforcement may be given in many different ways. For screening tests the reinforcement will usually be verbal or physical. Verbal reinforcement such as "Good!, "You're doing a nice job" or physical reinforcement, such as applause or a pat on the back may be effective. If verbal or physical reinforcement is used, it should be given for each response throughout the screening.

A. Play Audiometry Screening Procedures

1. If the child is 2 1/2 to 5 years old, play audiometry should be used. The pure tones 1000, 2000, and 4000 Hz should be presented at 20 dB HL. Use the presentation technique learned for school age screening in previous sections with the following modifications:

• Keep instructions simple. Show the child how to respond appropriately. For example, a block or cotton ball may be dropped in bucket when a tone is heard.

• Be generous with verbal and physical reinforcement. Continue presenting tones until independent responses are obtained. Remember it's a game to the child, not a test.

• If the child is restless or unhappy and you suspect you may not be able to complete all frequencies, try to obtain reliable screening results at 1 or 2 frequencies in each ear, usually 1000 and 4000 Hz.

2. If a child under 2 1/2 years old can successfully be conditioned for play audiometry, it can be used.

3. It may be helpful to use two screeners for play audiometry, one screener may present the stimulus while the other conditions, observes responses, and provides reinforcement.

4. Once conditioning is established, place the earphones on the child and present a 1000 Hz tone at 40dB HL (identification tone) in the right ear. If no response is obtained try the left ear. If a response is obtained, decrease the intensity to 20dB HL and continue the test at 1000, 2000 and 4000 Hz in each ear.

5. You may alternate frequencies and ears if needed to maintain consistent responses.

6. During the screening, continue to provide positive reinforcement for each response. Avoid using verbal cues such as "Did you hear that?". If a verbal cue is used always repeat the presentation without a verbal cue to be sure the response is valid.

7. Avoid giving visual cues - such as looking at the child or leaning forward as you present the tone. Arm, shoulder and hand movements should not be visible to the child.

8. If a tone presented at the screening level of 20 dB does not elicit a response, present the tone again at 40dB HL. If you obtain a response, decrease the intensity to 20 dB HL and present the tone again. If no response is obtained, the child probably did not hear the tone.

9. Some children have trouble generalizing the task to the opposite ear. If they fail to respond when you change ears, you may have to prompt the child or recondition the task.

10. Some children respond to the "offset" of the pure tone rather than the onset. If the child consistently responds to the "offset" this can be counted as a conditioned response.

11. If you fail to get a response to a tone, move quickly to another frequency. The child must be kept involved. Children will not sit for long periods of time and will rapidly lose interest in the task.

12. Vary the presentation pattern of the tones.

 

B. Completing the Hearing Screening Report Form - Pure Tone

1. When a response is obtained record a "+" for that frequency on the Hearing Screening Report. If no response is obtained mark it with a "" or "NR" for no response.

2. If the child responds to all 6 stimuli at 20 dB HL check "PASS" on the Hearing Screening Report. If the child fails to respond to any of the tones at 20dB HL, check "FAIL" on the Hearing Screening Report.

C. Otoscopy Review

(For detailed information regarding otoscopy see “IV. Otoscopic Inspection”)

An otoscopic inspection is a critically important part of any hearing screening, particularly for the child age birth to 5 years. As many children may be fearful/resistant to otoscopic inspection, the screener may prefer to conduct only a cursory examination for drainage from the ears, prior to conducting the behavioral hearing screening. A thorough otoscopic examination should be conducted following behavioral screening.

Conditions that might affect audiometric and tympanometric screening results can often be seen and must be taken into account when interpreting screening results. These conditions include: collapse of the ear canal, impacted cerumen, foreign objects in the canal, and perforations of the tympanic membrane. Frequently, the occurrence of other pathologies will be observed but may not cause abnormal audiometric results. The observation of problems should be referred for prompt medical attention.

1. Inspect the pinna and the area around the pinna for abnormalities. Unusual coloration of the pinna or mastoid should be noted and brought to the attention of a physician.

2. Select the largest speculum that will fit comfortably in the ear canal. A small speculum positioned in a large canal may not provide enough illumination from the otoscope to permit visualization of the tympanic membrane. A speculum that fits snugly into the canal permits a larger area of the tympanic membrane to be visible and assists in straightening out the ear canal.

3. Grip the otoscope towards the top of the handle, near the light source, for better control.

4. Pull back the pinna with the hand not holding the otoscope to straighten the canal. Because of the upward curvature of the canal in the infant and small child, the examiner must grasp the lower portion of the auricle and retract the ear downward and backward to straighten the canal.

5. As the child gets older, the canal changes to assume more of an adult position; therefore, the pinna should be pulled up and back to straighten the canal.

 

6. Because young children can be "squirmy," it is best to examine the child's ear canal and tympanic membrane in the following manner:

a. Have parent hold child in lap with head secured against parent’s shoulder.

b. Hold the otoscope with the handle extending upward toward the top of the child's head. Always rest the fingers or the heel of the hand holding the otoscope against the child's temple. This will help prevent the speculum from being accidentally inserted deeper into the canal by a sudden movement of the child's head.

7. By inverting the otoscope handle so that it is above the pinna, the speculum can be directed upward with the handle moving away from the child's ear.

8. Place the speculum in the ear canal 1/4 to 1/2 inch without touching the canal wall with the tip of the speculum.

9. When observing through the otoscope, the examiner's eye should be about one inch from the magnifying lens.

D. Completing the Hearing Screening Report Form - Otoscopy

1. On the Hearing Screening Report under "Otoscopy," record any abnormalities observed as a result of the cursory otoscopic examination of each ear. The presence of ventilation tubes should be noted.

2. If a structural defect of the head, neck, ear, or abnormality of the ear canal or tympanic membrane is observed, under "Otoscopy," check "fail."

3. If no abnormalities were observed for either ear, under "Otoscopy," check "pass."

E. Tympanometry Review

(For detailed information regarding tympanometry screening procedures, see "VIII. Tympanometry Screening.")

In order to identify middle ear disorders, tympanometry must be included in the comprehensive hearing screening of infants and toddlers. The specific guidelines for tympanometry are addressed in chapter VIII Tympanometry Screening. The tympanometric protocol must include:

1. A cursory (unaided eye) visual inspection should be included, as well as an otoscopic examination.

2. Tympanometry measurements include compliance, ear canal volume, and tympanometric peak pressure.

3. Referral criteria is based only on compliance and ear canal volume.

Tympanometry should not be conducted for infants under six months of age or if the child failed the otoscopic screening.

F. Tympanometry Screening Procedures

l. Check calibration of tympanometer.

2. Perform thorough otoscopic examination.

3. Select appropriate sized probe tip and place on probe assembly.

4. Place probe tip against ear canal for seal.

5. Watch probe/tympanometer signals to assure that tympanogram is being obtained.

6. Remove probe and print tympanogram.

7. If tympanogram is different from what was expected, repeat. Tympanograms should also be repeated to verify their reliability, particularly when a medical referral is being made.

8. Clean probe tip for next child with antiseptic solution.

 

G. Completing the Hearing Screening Report Form - Tympanometry

1. On the Hearing Screening Report, under "Tympanometry," record the physical volume measurement for each ear. If a tube is present, indicate whether or not the tube is patent by marking "YES" or "NO" and the tympanogram results obtained by recording a check mark under "normal" or "flat" for each ear.

2. See chapter VIII Tympanometry Screening for pass/fail and referral criteria. If results meet pass criteria, under "Tympanometry," check "PASS." If results meet failure criteria, under "Tympanometry," check "FAIL."

3. Circle appropriate referral direction.

Initial Screening

Rescreening

HEARING SCREENING REPORT

 

Child’s Name: Date of Screening:

D.O.B.: Phone:

Parent’s Name: Address:

City/State/Zip: Screened By:

 

PURE TONE SCREENING CHECK (3 ): q PASS q FAIL

RIGHT EAR LEFT EAR

500 Hz* (Required if in Kindergarten, 1st or 2nd grade and tymanometry is not administered)

1000 Hz (Required)

2000 Hz (Required)

4000 Hz (Required)

6000 Hz* (Required if in 3rd grade [age 9] or above)

NOTE: + indicates the child heard the 20 dB HL tone

- indicates the child did not hear the 20 dB HL tone

(ALL + = PASS; ANY - = FAIL)

 

OTOSCOPY CHECK (3 ): q PASS q FAIL

Right Ear:

Left Ear:

 

TYMPANOMETRY SCREENING CHECK (3 ): q PASS q FAIL

PHYSICAL VOLUME

 

Tube Patent?

   

Normal

Flat

Right Ear:

 

Yes

No

       
           

Right

   

Left Ear:

 

Yes

No

       
           

Left

   

Referral: Cleared for Rescreen Medical Referral Medical & Audiological Audiological

Hearing in 4 weeks & Rescreen Referral Referral

Notes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

X.

INFANT/TODDLER HEARING

SCREENING

 

 

X. INFANT/TODDLER HEARING SCREENING

This section was developed as a guide for establishing an effective hearing screening program for the identification of hearing loss for children aged birth to 5. In addition, children in this age group receiving special education services according to an IEP or IFSP must be screened at least annually. The techniques described herein are also useful in screening difficult-to-test students.

Those involved in providing hearing screening services to school-age children (traditionally K-12) are now responsible for providing hearing screening services to children as young as newborns. The Kansas State Board of Education formally recognized the need for audiometric technicians to receive advanced training and be certified to conduct hearing screening (PL 99-457) birth through 5 years of age. Reliable responses to sound stimuli are difficult to judge for this group. Ideally, all infant/toddler screening should be administered by an audiologist, however, this is not practical. For this reason, behavioral audiometry is not conducted by an audiometric technician; rather, a paper screening that includes case history information and a developmental scale checklist is used. When in doubt, REFER!

A. Impact of Hearing Loss on Infants and Toddlers

A moderate, severe, or profound hearing loss has a significant impact on cognitive, psychosocial, and speech and language development of children. The effect of a slight or mild hearing loss is more subtle but may also cause significant developmental delay. The value of early identification cannot be over emphasized.

Since the 1940's (WW II Era), there has been a heightened awareness of the need to identify and habilitate persons with hearing loss. With each passing decade, the need to lower the age of identification has been more fully recognized. Many successful intervention strategies for dealing with hearing loss are available once these students are identified.

In the early to mid '70's, tympanometry (screening of middle ear function) became an established component of hearing screening protocol for students. The impact of middle ear disease on development has received extensive research attention since the '70's.

The impact of hearing loss on speech and language development and on academic achievement has been well documented (Allen, 1986; Osberger, 1986; Moeller, Osberger and Eccarius, 1986). To minimize these debilitating effects, the development of early identification and intervention strategies (both medical and educational) is critical. In 1982, the Joint Committee on Infant Hearing developed a position statement which included seven criteria for identifying infants at risk for hearing impairment. In 1990, this list was expanded to include 10 high risk criteria for neonates (aged birth - 28 days) and a separate listing of eight high risk criteria for infants (aged 29 days - 2 years). In 1994, the Joint Committee on Infant Hearing further revised the high risk indicators by including delayed-onset hearing loss indicators.

A major goal of a newborn screening program is to identify newborns who have congenital hearing losses serious enough to delay their speech and language development. Such early identification will make it possible for medical or educational habilitation at an age early enough to take advantage of the critical periods for the development of auditory function. Birth to age two has been widely recognized as a critical period for speech and language development. Obviously, the hearing status of an infant has a direct relationship to development of these skills.

A D/HH infant can receive language input through a hearing aid if the infant has sufficient residual hearing or through visual and manual language inputs if totally deaf (Downs, 1971). Placement in an appropriate therapy program is mandatory for the deaf or hard of hearing infant just as soon as the loss is identified. Many centers throughout the state have home-based intervention programs for the deaf or hard of hearing infant aged birth through two years. Home correspondence courses in auditory, visual, and manual language training procedures are also available. This kind of early intervention gives D/HH infants the opportunity to use their residual hearing to develop optimal language skills.

The 1990 session of the Kansas Legislature enacted K.S.A. 65-1,149, The Early Identification of Hearing-Impaired and High Risk Infants. This law establishes a program wherein hospitals must screen newborns at risk for hearing loss, and provide referral information for follow-up hearing evaluation to parents of those infants identified as high risk. The referral sources are audiologists, ear, nose, and throat physicians (ENT's), and neurologists. It is possible that the audiometric technician will be the first person to see the student for screening, since the primary health care provider (e.g. physician, local health department) receives notification of the infant’s status of high risk for hearing loss. It is recommended that the infant's follow-up hearing evaluation occur within three months of being identified as high risk for hearing loss. For those infants who are not high risk for hearing loss, routine periodic hearing screening is recommended.

Diagnosis of hearing loss frequently does not take place until after a student demonstrates significant delay in speech and language. The importance of the early identification of hearing loss, and ensuing early intervention, is emphasized by the following goal for the nation: "Reduce the average age at which children with significant hearing loss are identified to no more than l2 months.'' The NIH Consensus Conference statement on Early Identification of Hearing Loss in Infants and Young Children (1993) recommended universal screening for all newborns. It is hoped that the high risk screening program, in combination with hearing screening programs through local education agencies, local health departments, and physicians' offices, will help Kansas meet that goal. The Joint Committee on Infant Hearing recommends that, optimally, infants with hearing loss should be diagnosed and their habilitation begun by six months of age.

In Kansas, we must develop a hearing screening program for the early identification and expedient referral of infants who require audiologic and/or medical evaluation and management.

B. Equipment and Supply Needs

In order to conduct hearing screening for children birth through 2 years of age, the following equipment/materials are needed:

• Pure Tone Audiometer

• Otoscope & Specula

• Tympanometer & Probe Tips

• Blocks/box

• Antiseptic solution

• Infant/Toddler forms

Note: If you do not have the specified equipment, you can not adequately perform a hearing screening for children birth through two.

 

C. Infant/Toddler Screening Protocol

With very young children, special needs, or difficult to test children, conventional audiometric techniques are seldom an appropriate evaluative procedure.. The following is a battery of screening procedures for the identification of hearing loss in children birth through 2 years of age, and difficult to test children above the age of 3. In addition, any child receiving early childhood special education services should be screened at least annually using the paper screen or play audiometry (when the child is developmentally ready), tympanometry and otoscopy. The screening protocol includes:

Paper Screening (or play audiometry, when possible)

Otoscopy

Tympanometry (if older than 6 months)

The Paper Screen is comprised of two screening protocols: the High Risk Indicator Checklist and the Developmental Scales. The paper screening examines children historically and developmentally by using information from sources other than direct contact with the child. Even though the information obtained in this manner does not confirm the absence or presence of hearing loss, it does alert screeners to the increased possibility of hearing loss.

The paper screening is the first facet of the screening procedure. Both the High Risk Indicator Checklist and the Developmental Scales should be completed for all children age birth through 2. If failure criteria is met on either assessment, the child should be referred to an audiologist.

 

 

D. High Risk Indicators

The High Risk Indicator Checklist incorporates the high risk criteria developed by the 1994 Joint Committee on Infant Hearing. It is vital to obtain complete and accurate information of the student’s prenatal and natal history and early childhood development in order to determine if factors associated with hearing loss are present.

The Committee outlined the indicators associated with sensorineural and/or conductive hearing loss in three categories: 1) Birth - 28 days, 2) 29 days - two years who experience or develop conditions that require testing, and 3) 29 days - three years who require periodic monitoring of hearing. The Committee recommended that the case history should include:

•Parent/care giver concern:

Hearing, speech and language, and/or developmental delays.

•Prenatal history:

Length of pregnancy (gestational age of the infant)

Prenatal infection (cytomegalovirus, rubella, syphilis, herpes, toxoplasmosis)

Alcohol and/or drug abuse, and medications

Rh factor

•Neonatal history (birth to 29 days):

Birth weight (significant if less than 3.3 lbs. or 1500 grams)

Craniofacial anomalies

Abnormalities of the ear (pinna and canal)

Hyperbilirubinemia (requiring exchange transfusion)

Low APGAR scores (0-4 at one minute/0-6 at five minutes)

Ototoxic mediations

Breathing difficulties (requiring mechanical ventilation five days or longer)

Neonatal infections (especially bacterial meningitis)

Stigmata or indications of a syndrome associated with hearing loss

•Infants and childhood history (29 days and older), in addition to the above:

Development of bacterial meningitis, cytomegalovirus (CMV), or Beta strep

Skull fracture or head trauma associated with loss of consciousness

Stigmata or indications of a syndrome associated with hearing loss

(including Neurofibromatosis Type II)

Neurodegenerative disorders

Ototoxic medications

History of recurrent or persistent otitis media

Family history of hereditary childhood hearing loss

Infant/child’s developmental performance of hearing and speech/language

If appropriate, behavioral concerns and school performance

The items included as indicators are factors which have been identified as potential causes of hearing loss. The child is at greater risk for an auditory impairment as one or more positive responses are found. As stated earlier, studies have shown that between 50 and 75 percent of deaf/ hard of hearing children were positive on at least one of the Committee’s indicators. (Elssmann, Matkin, & Sabo, 1987; Feinmesser & Tell, 1976; Stein, Clark, & Kraus, 1983). The identification of indicators is an essential component of a comprehensive screening program particularly for children ages birth through 2.

HIGH RISK INDICATOR CHECKLIST

CHILD'S NAME: DOB:

PARENT'S NAME: PHONE:

ADDRESS: DATE:

SCREENED BY:

What was your child's birth weight? Was child premature? By how many weeks?

Has child had chronic middle ear infections? *

Were tubes placed? When?

Has your child been tested or screened for hearing? By whom and what were you told?

HIGH RISK INDICATORS (Please mark an X in the appropriate column)

YES NO

___ ___ 1. Do you have a concern about your child's hearing or speech and language

development?

List concerns:

___ ___ * 2. Have any relatives had a permanent hearing loss before the age of 5?

Explain:

___ ___ * 3. Was child exposed to any of the following during mother's pregnancy?

Check (3 ) all those that apply: o toxoplasmosis o syphilis o rubella

o cytomegalovirus o herpes

o other (name unknown)

___ ___ 4 Was your child in the Newborn Intensive Care Unit (NICU) for 4 days or more?

___ ___ 5. Does child have any abnormal features for the outer ear, mouth, nose, neck or head?

Explain:

___ ___ 6. Was child's birth weight less than 3.3 pounds (1500 grams)?

___ ___ 7. Were blood transfusions considered or performed for jaundice (high billirubin levels)?

___ ___ 8. Has the child ever been given the following medications? Please check (3 ) that apply:

o gentamicin o tobramycin o kanamycin

o streptomycin o loop diuretics in combination with the above?

___ ___ 9. Has child ever had bacterial meningitis? At what age?

___ ___ 10. Did child have an APGAR score of 0-4 at 1 minute or 0-6 at 5 minutes?

___ ___ 11. Was child placed on breathing machine (mechanical ventilation) for 10 days or more?

___ ___ 12. Has your child been diagnosed as having any syndromes associated with hearing loss (such as; Down’s, Usher’s, Waardenburg’s, etc.)?

Explain:

___ ___ 13. Has child ever had a skull fracture?

___ ___ *14. Has child been diagnosed as having Neurofibromatosis Type II or other

neurodegenerative disorders? * Explain:

* Indicates need for screening every 6 months up to age 3, and at appropriate intervals thereafter.

Pass = All NO responses Check ( 3 ) one: q Pass

Fail = One or more YES responses q Fail

 

E. Explanations of High Risk Indicators

All of the high risk indicators have been shown to potentially impact hearing abilities in young children. A brief description and explanation of the indicators are provided below in order to ensure that accurate and pertinent information is obtained from each parent or care giver.

1. Do you have a concern about your child’s hearing or speech and language development?

It is important that hearing loss is identified as early as possible to prevent speech, language, and developmental delays. Most parents are reliable reporters of their children’s development. The National Institute of Health Consensus Statement on Early Identification of Hearing Loss in Infants and Young Children (1993) stated that as many as 70 percent of D/HH infants and children are identified because of parental concern.

2. Have any relatives had a permanent hearing loss before the age of 5?

This question is aimed at identification of hereditary (genetic) hearing loss from both maternal and paternal family members, living or deceased, when known. A family history of hearing loss is not necessary for the cause to be a genetic defect. Hearing loss that is genetic is most often sensorineural. It is important to ensure the hearing loss was not acquired (such as those resulting from meningitis, noise exposure, chemotherapy, or the aging process). Acquired hearing losses are not inherited from one generation to the next. The type of loss which is inherited is typically present at a very young age. Semi-annual screenings are recommended because hereditary hearing loss may have delayed onset.

3. Was your student exposed to any of the following during pregnancy: toxoplasmosis, cytomegalovirus, syphilis, herpes, rubella?

The presence of these infectious agents have been linked to hearing loss. The majority of infections in pregnant women involve the upper respiratory and gastrointestinal tract and are not known to cause hearing loss. However, a few infectious agents are contracted by the mother during pregnancy and may cross the placental barrier and invade fetal tissue. Severe infections, especially those occurring in the first trimester, can be related to hearing loss since this is when the auditory system develops. Many infections go unrecognized due to the lack of clinical symptoms in the mother. Semi-annual screenings are recommended due to the potential of delayed onset sensorineural hearing loss.

a. Toxoplasmosis is caused by a protozoan parasite and the infection is usually asymptomatic in the mother. The incidence of intrauterine toxoplasmosis averages one case per 750 deliveries in the US. Infection during the first trimester appears most likely to adversely affect the fetus. Central nervous system involvement, as well as mental retardation, seizures, and ocular disease are frequently seen.

b. Syphilis is the only bacterial infectious agent known to be capable of infecting the fetus. Congenital syphilis may become apparent in the first 2 years of life, or between the ages of 8 to 20 years. Hearing loss is sensorineural and may be sudden, progressive or fluctuating. Early onset hearing loss caused by syphilis may be reversible with early detection and prompt treatment.

c. Rubella (German measles) occurring within the first trimester of pregnancy poses a serious risk to the developing fetus. The risk is reportedly as high as 50 percent for the first month and 10-15 percent for the third month. In addition to hearing loss, other anomalies include heart disorder, low birth weight, mental retardation and vision loss. When hearing loss occurs, 50 percent have bilateral severe to profound loss. In milder cases, the hearing loss may be progressive.

d. Cytomegalovirus (CMV) is a virus in the herpes group and is the leading cause of fetal viral infection in the US. It accounts for over 4000 cases of sensorineural hearing loss per year. The infection is most often asymptomatic in the mother. CMV can cause sensorineural hearing loss which varies in severity. The hearing loss may have a delayed onset, may be unilateral, and is often progressive. Central nervous system disabilities occur in 10-15 percent of all CMV births. No safe vaccination against CMV is available.

e. Herpes, either systemic or simplex 1 or 2, is in the same family as the CMV virus. Herpes may cause severe to profound sensorineural hearing loss.

f. Other, viral infections may include polio virus, varicella, measles, and mumps.

4. Was your child in the Newborn Intensive Care Unit (NICU) for 4 days or more?

Infants admitted to a NICU are at risk for potential difficulties, both physical and mental. Hearing is one area which may be effected.

5. Does your child have any abnormal features of the outer ear, mouth, nose, neck, or head?

Abnormalities of the head and neck may be an indication of the presence of a hearing loss. Abnormalities such as cleft lip or cleft palate, shortened neck, webbed neck, and abnormal head circumference are a few indicators of possible problems. Malformation of the ears may include atresia, low set ears, skin tags, and preauricular pits. These abnormalities are often syndromatic.

6. Was your child’s birth weight less than 3.3 pounds (1500 grams)?

Infants with low birth weight are at increased risk for both sensorineural and conductive hearing loss.

7. Were blood transfusions considered or performed for jaundice (high Billirubin levels)?

Jaundice is a condition which occurs when there is too much by product from the liver in the blood which eventually results in high billirubin levels. Too much billirubin (hyperbilirubinemia) is ototoxic and may cause hearing loss. Premature infants, and infants with low birth weight, are at greater risk for high billirubin levels. Hearing loss is the most common and often the only permanent clinical sign of high billirubin levels. Low billirubin levels (slight jaundice) typically do not affect hearing.

8. Has your child ever been given the following medications? Gentamicin, tobramycin, kanamycin, streptomycin, or loop diuretics in combination with the above?

Ototoxicity is a chemical reaction of various prescription drugs which cause sensorineural hearing loss. The loss is usually bilateral and symmetrical and may or may not be reversible.

Factors Which Increase Ototoxic Affects:

a. An increase in the drug serum level

b. A decrease in renal function

c. Administration of more than one ototoxic drug simultaneously or consecutively

d. An increase in the daily dosage of ototoxic drugs for an extended period of time.

9. Has your child ever had bacterial meningitis? At what age?

Type B, Hemophilus Influenza carries the greatest incidence of hearing loss. Bacterial meningitis is the leading cause of acquired deafness in infancy and childhood. Incidence of hearing loss ranges from 5-30%. Most occurrences result in bilateral, symmetrical, sensorineural hearing loss which is severe, 30% have profound loss. Other origins of meningitis may be due to congenital anomalies of the ear such as fistulas or inner ear defects. The age at which meningitis occurs significantly impacts rehabilitative needs; the younger the student, the greater the impact on speech and language acquisition.

10. Did your child have an APGAR score of 0-4 at 1 minute or 0-6 at 5 minutes?

An APGAR score is a numerical measure of physical health of newborn infants derived from evaluating heart rate, muscle tone, respiratory effort, skin color, response to stimulus, and other physiological indicators. The attending physician assigns the score at intervals of 1 minute and 5 minutes. An infant is at risk for hearing loss when APGAR scores are low.

11. Was the child placed on a breathing machine (mechanical ventilator) for 5 days or more?

Infants who require prolonged use of mechanical ventilation are at risk for hearing loss due to possible oxygen deprivation which may adversely affect the cochlea. In addition, high noise levels from the equipment has been considered a possible source of hearing loss.

12. Has your student been diagnosed as having any syndromes associated with hearing loss (such as Down’s, Usher’s, Waardenburg, etc.)?

There are literally hundreds of syndromes associated with hearing loss and are far too numerous to list in this document. Many of the syndromes are associated with observable physical anomalies of the head, neck and ear which frequently result in conductive hearing loss. A few examples are:

 

No Associated Abnormalities

 

Musculoskeletal

 

Renal

 

Nervous System

Dominant progressive

Recessive congenital

X-linked

Goldenhar

Crouzon

Treacher-Collins

Klippel-Feil

Alport

Branchio-oto-renal

Neurofibromatosis

Noonan

 

Skin System

Ear Abnormalities

Eye Disease

Metabolic and Other

Fragile X

Waardenburg

Pili Torti

Atresia

Low set ears

Skin Tags

Preauricular pits

Usher’s

Mobius

Hurler syndrome

Hunter syndrome

Jervell Lange-Nielsen

Trisomy 13, 18, and

21(Down)

13. Has your child ever had a skull fracture?

Skull fractures may affect hearing due to the potential damage to either the cochlea or middle ear resulting in sensorineural or conductive hearing loss. Conductive hearing loss occurs as a result of perforation of the tympanic membrane, bleeding, and/or disruption of the ossicular chain. Sensorineural loss may occur due to damage or obliteration of the temporal bone housing the inner ear.

14. Has the child been diagnosed as having Neurofibromatosis Type II or other neurodegenerative disorder?

Neurofibromatosis Type II, (NF 2), is an inherited tumor syndrome. If this disorder has been diagnosed, semi-annual hearing screenings are recommended because of the potential for progressive loss as tumors grow.

F. Completing the High Risk Indicators Checklist

The High Risk Indicators Checklist asks for identifying information as well as for information regarding birth weight, prematurity, and history of middle ear infections. If the answer to any one indicator is "YES," the child must be referred to an audiologist for evaluation.

1. When beginning a child’s hearing screening, the parent/caregiver should complete the identifying information requested, and respond to the questions regarding birth history and middle ear problems. The audiometric technician should complete the remainder of the screening form by asking the parent/caregiver each question. Responses should be marked either "YES" or "NO." The audiometric technician should define terminology and provide clarification of questions to obtain accurate information.

Note that the presence of chronic middle ear infections * and questions regarding history of family hearing loss ( #2), in utero infection ( #3), and neurodegenerative disorders (#14), are indicators of delayed onset hearing loss. If any of these indicators are present hearing screening every 6 months to age 3 is recommended.

2. If on the High Risk Indicators Checklist, all indicators are marker "NO," then check PASS at the bottom of the form. If one or more indicators are marked "YES," then FAIL should be checked at the bottom of the form.

3. Complete the Hearing Screening Report Form - Birth Through Two Years by circling "PASS" or "FAIL" under "Paper Screen-High Risk Indicators," and explain what was failed under "Comments" at the bottom of the form.

4. Finally, in determining "Date of Rescreen," consider the indicators suggesting delayed onset hearing loss to determine the need for annual or semi-annual rescreen dates.

*Chronic history of ear infections is defined as three or more bouts of otitis media within a twelve month period, or one episode of otitis media lasting two months, or having had PE tubes inserted.

 

G. Developmental Scales

The Developmental Scales, as part of a screening battery, use information typically obtained from the child’s parents or primary care giver. The scales are a means of examining a child’s speech, language, and auditory development by identifying the presence of specific behaviors typically observed in normal hearing children of similar age. The absence of one or more of these behaviors may signify an auditory deficit.

Developmental scales for children ages birth through two allow the screener to determine if a child has age appropriate skills relative to hearing, language, and speech development. Each age category contains several items. If the answer to any one of the items is "no," the screener should be alerted to the possibility of hearing loss in the student. If two of the items are answered "no," the student must be referred to an audiologist for evaluation.

If the child being screened is younger than 2 years of age and was born prematurely, use the child's adjusted age to determine the appropriate age category to be completed on the Developmental Scales form (adjusted age is the age of the child with premature factors considered). To calculate adjusted age, take the chronological age of the infant and subtract the number of weeks that the infant was premature from the child's chronological age.

For example, if the infant was born on December 1, 1990 and was 8 weeks premature and was screened on June 1, 1991, the adjusted age for the infant would be 4 months and the "birth to 4 months" age category would be used.

Child's age: 6 months

Premature: -2 months (8 weeks)

Adjusted age: 4 months

This adjustment is made only for infants younger than 2 years old. No adjustment is made for children 2 and older.

 

 

DEVELOPMENTAL SCALES

Please check questions in the appropriate age category - use adjusted age.

Does your child:

YES NO Birth to 4 months

___ ___ startle or cry to loud noises?

___ ___ awaken to loud sounds?

___ ___ respond to a familiar voice?

___ ___ stop crying when talked to?

___ ___ stop moving when a new sound is made?

4 to 8 months

___ ___ stir or awaken when sleeping quietly and someone talks or makes a loud noise?

___ ___ try to turn head toward an interesting sound or when name is called?

___ ___ listen to a soft musical toy, bell or rattle?

___ ___ cry when exposed to a sudden or loud sound?

___ ___ make several different babbling sounds?

8 to 12 months

___ ___ respond in some way to the direction "no?"

___ ___ react to name when called?

___ ___ turn head toward the side where a sound is coming from?

___ ___ stir or awaken when sleeping quietly and someone talks or makes a loud sound?

___ ___ try to imitate you if you make familiar sounds?

___ ___ use variety of different consonants and vowels when babbling? (variegated babbling*)

12 to 18 months

___ ___ say "mama" or "dada" and imitate many words you say?

___ ___ react to name when called?

___ ___ respond to requests such as "come here" and "do you want more?'

___ ___ turn head to look in the direction where the sound came from when an interesting sound is presented?

___ ___ wake up when there is a loud sound?

18 to 24 months

___ ___ try to sing?

___ ___ point to several different body parts?

___ ___ respond to simple commands such as "put the ball in the box?"

___ ___ speak at least 20 words?

___ ___ request by name items such as milk or cookies?

2 to 5 years

___ ___ point to a picture if you say "Where's the _____________ ?"

___ ___ talk in short sentences?

___ ___ notice most sounds?

___ ___ listen to TV or radio at same loudness level as other family members?

___ ___ hear you when you call child's name from another room?

(*Variegated babbling is defined as non-repetitive babbling using several consonant and vowel combinations, such as "itika", "dabata", or "omada". It is quite different from common babbling, such as "dada" , "mama", or "baba")

PASS = none or only one NO response Check ( 3 ) one: r PASS

FAIL = two or more No responses r FAIL

 

H. Completing the Developmental Scales form

After computing the child’s age (if applicable), circle the appropriate age category on the Developmental Scales Form. The parent/caregiver should then respond to each of the questions in the circled category, and the form should be completed by checking "YES" or "NO." If, on the Developmental Scales Form, none or only one of the questions are marked "NO," then check "PASS" at the bottom of the form. If two or more are marked "NO" on the Developmental Scales Form, check "FAIL" at the bottom of the form.

1. Complete the Hearing Screening Report Form-Birth Through Two by circiling "PASS" or "FAIL" under the "Paper Screen-Developmental Scales."

2. Explain what was failed in the "Comment" section under the corresponding screening number on the Report.

I. Completing the Hearing Screening Report - Birth Through Two form

If this is an initial screening for the child, complete the column under "Screen #1." Additional columns are provided for rescreening results. Both High Risk Indicators and the Developmental Scales must have "PASS" circled in order for the child to pass the Paper Screen. The child fails the screen if either paper screen is circled as "FAIL."

1. If the child fails the paper screen, the child must be referred to an audiologist for evaluation.

2. If the child passes the Paper Screen, complete an otoscopic examination and tympanometry screening (if older than 6 months).

3. Complete otoscopy section on the Hearing Screening Report-Birth Through Two Form by circling "PASS" or "FAIL" for each ear. (Refer to otoscopy section for criteria).

4. Complete tympanometry section on the Hearing Screening Report - Birth Through Two form by recording the information requested for each ear.

Tympanogram Normal or Flat (circle one)

Tube Present? Yes or No (circle one)

Record Physical Volume (write in volume measurement)

Circle "PASS" or "FAIL" for each ear. (Refer to tympanometry section for criteria).

5. Circle appropriate referral direction. (Refer to the reporting and Referral Criteria sheet and/or the Flow Chart)

6. Record the date of the next recommended screening (annually, six months, or 2-4 weeks).

 

 

HEARING SCREENING REPORT - Birth Through Two Years

Child’s Name: Date of Screening:

D.O.B.: Phone:

Parent’s Name: Address:

City/State/Zip: Screened By:

 

 

Screen #1

Screen #2

Screen #3

Screen #4

Date of (Re)Screen:

       

Age of child:

       
       

1. Paper Screen

High Risk Indicators

Developmental Scales

(Circle One)

Pass Fail

Pass Fail

Pass Fail

Pass Fail

Pass Fail

Pass Fail

Pass Fail

Pass Fail

2. Otoscopy

Right Ear

Left Ear

 

Pass Fail

Pass Fail

Pass Fail

Pass Fail

Pass Fail

Pass Fail

Pass Fail

Pass Fail

3. Tympanometry(if >6 Mo.)

Right Ear: (circle or write)

Tympanogram:

Tube present?:

Physical Volume:

 

 

Normal Flat

Yes No

P.V. ________

Pass Fail

 

 

 

Normal Flat

Yes No

P.V. ________

Pass Fail

 

 

Normal Flat

Yes No

P.V. ________

Pass Fail

 

 

Normal Flat

Yes No

P.V. ________

Pass Fail

Left Ear: (circle or write)

Tympanogram:

Tube present?:

Physical Volume:

 

Normal Flat

Yes No

P.V. ________

Pass Fail

 

 

Normal Flat

Yes No

P.V. ________

Pass Fail

 

Normal Flat

Yes No

P.V. ________

Pass Fail

 

Normal Flat

Yes No

P.V. ________

Pass Fail

REFERRAL: (Circle One)

 

 

 

*Annual rescreen recommended

Passed*

Rescreen 2-4 wks.

Med. Ref./Rescreen

Med. & Aud. Ref.

Aud. Ref.

Passed*

Rescreen 2-4 wks.

Med. Ref./Rescreen

Med. & Aud. Ref.

Aud. Ref.

Passed*

Rescreen 2-4 wks.

Med. Ref./Rescreen

Med. & Aud. Ref.

Aud. Ref.

Passed*

Rescreen 2-4 wks.

Med. Ref./Rescreen

Med. & Aud. Ref.

Aud. Ref.

Comments:

       

1#

   

Screened By:

 
     

Date of Rescreen:

 
         

2#

   

Screened By:

 
     

Date of Rescreen:

 
         

3#

   

Screened By:

 
     

Date of Rescreen:

 
         

4#

   

Screened By:

 
     

Date of Rescreen:

 
         

Page 2

HEARING SCREENING REPORT - Birth Through Two Years

Child’s Name: Date of Screening:

D.O.B.: Phone:

Parent’s Name: Address:

City/State/Zip: Screened By:

 

 

Screen #5

Screen #6

Screen #7

Screen #8

Date of (Re)Screen:

       

Age of child:

       
       

1. Paper Screen

High Risk Indicators

Developmental Scales

(Circle One)

Pass Fail

Pass Fail

Pass Fail

Pass Fail

Pass Fail

Pass Fail

Pass Fail

Pass Fail

2. Otoscopy

Right Ear

Left Ear

 

Pass Fail

Pass Fail

Pass Fail

Pass Fail

Pass Fail

Pass Fail

Pass Fail

Pass Fail

3. Tympanometry(if >6 Mo.)

Right Ear: (circle or write)

Tympanogram:

Tube present?:

Physical Volume:

 

 

Normal Flat

Yes No

P.V. ________

Pass Fail

 

 

 

Normal Flat

Yes No

P.V. ________

Pass Fail

 

 

Normal Flat

Yes No

P.V. ________

Pass Fail

 

 

Normal Flat

Yes No

P.V. ________

Pass Fail

Left Ear: (circle or write)

Tympanogram:

Tube present?:

Physical Volume:

Normal Flat

Yes No

P.V. ________

Pass Fail

 

Normal Flat

Yes No

P.V. ________

Pass Fail

Normal Flat

Yes No

P.V. ________

Pass Fail

Normal Flat

Yes No

P.V. ________

Pass Fail

REFERRAL: (Circle One)

 

 

 

*Annual rescreen recommended

Passed*

Rescreen 2-4 wks.

Med. Ref./Rescreen

Med. & Aud. Ref.

Aud. Ref.

Passed*

Rescreen 2-4 wks.

Med. Ref./Rescreen

Med. & Aud. Ref.

Aud. Ref.

Passed*

Rescreen 2-4 wks.

Med. Ref./Rescreen

Med. & Aud. Ref.

Aud. Ref.

Passed*

Rescreen 2-4 wks.

Med. Ref./Rescreen

Med. & Aud. Ref.

Aud. Ref.

Comments:

       

5#

   

Screened By:

 
     

Date of Rescreen:

 
         

6#

   

Screened By:

 
     

Date of Rescreen:

 
         

7#

   

Screened By:

 
     

Date of Rescreen:

 
         

8#

   

Screened By:

 
     

Date of Rescreen:

 
         

 

J. Reporting and Referral Criteria

1. Hearing Screening Results

Once your screening battery is completed, there are five possible outcomes to determine if the infant/child passes or if referral is needed.

The five possible outcomes are:

a. Annual hearing screening* is recommended when:

The infant/toddler passes the paper screen, tympanometry and otoscopy.

* Semi-annual screenings are recommended if delayed-onset indicators are present. These indicators include chronic otitis media, family history of hearing loss, in utero infection, and neurodegenerative disorders.

b. Rescreen in 2-4 weeks is recommended when:

Tympanometry is failed on the initial screening and there is no history of otitis media, and otoscopy is passed and paper screen is passed.

c. Medical referral-rescreen in 2-4 weeks is recommended when:

The child fails otoscopy and the paper screen is passed.

d. Medical and audiological referral is recommended when:

•. The child fails tympanometry and has a history of otitis media but does not receive medical management.

• Upon rescreening, the child continues to fail otoscopy and/or tympanometry.

e. Audiological evaluation is recommended when:

• The child fails either the High Risk Indicators Checklist or the Developmental Scales.

• The child is uncooperative and/or validity of results is questionable.

High risk children should be screened diligently for middle ear disease. In addition, these children are at risk for hearing loss which may have a delayed onset. If delayed onset indicators are present, semi-annual screenings are recommended.

Because of the limitations of any screening protocol, passing this screening does not rule out the possibility of some forms of hearing loss. Once conditioned responses are able to be obtained, such as those obtained through play audiometry, a child can be more positively cleared for hearing. For this reason, play audiometry should be attempted with most children age 2 1/2 and older; however, success will vary depending upon the developmental readiness of each child. If successful conditioned responses are obtained, Level 2 and 3 protocols are applicable.

 

 

 

 

 

 

 

 

 

 

 

XI.

GLOSSARY

 

 

 

Acoustic Admittance:

The ease of flow of energy transmission through a system.

Acoustic Environment:

Listening surroundings.

Acoustic Immittance:

Measurement of the sound wave admitted by the tympanic membrane and the middle ear system.

Acoustic Millimho(mmho):

The unit of acoustic admittance; 1 mmho = 1.04 H20.

Acoustic Reflex:

The objective measurement of the contraction of a small muscle within the middle war in response to a loud sound.

Acoustics:

The science of sound including its production, transmission, and effects.

Acquired Deafness:

Hearing loss not present at birth but developed in an individual as a result of environmental factors (severe illness, head trauma, noise exposure, etc.)

Acute Otitis Media: Active inflammation and/or infection of the middle ear space of recent onset or repeated occurrence, often bulging tympanic membrane and/or evidence of pus, discoloration or discharge through a perforation. Usually resulting from infection of fluid within middle ear space which in turn causes eustachian tube dysfunction, develops over a short period of time and either resolves (either spontaneously or with medical treatment) or progresses to otitis media with effusion or a chronic condition.

Adjusted Age:

The premature (less than 40 weeks gestation) child’s chronological age is modified to reflect the prematurity. Age is adjusted for prematurity until the child reaches a chronological age of 2 years.

Admittance:

See Acoustic Admittance.

Air Bone Gap:

The difference in decibels (at a specified frequency) between the hearing threshold level for air conduction and for bone conduction.

Air Conduction:

Process by which sound waves normally reach the inner ear, i.e., via the external canal, tympanic membrane, and ossicular chain.

Ambient Noise:

Surrounding noise from all directions encompassing a combination of sources (i.e., lighting, Htg/AC systems, people moving about, use of equipment/facilities, etc.).

APGAR:

A quantitative estimate of the condition of an infant 1 minute and 5 minutes after birth, derived by assigning 0-2 points each to the quality of heart rate, respiration, color, muscle tone and response to stimulation. The score is expressed as the sum of these points (maximum = 10).

Atresia of External Canal:

A collapsing or closing of the outer ear canal.

Atresia:

A closure of the ear canal.

Attenuation:

Weakening or reduction of sound energy. Thus, a sound which is attenuated by 10 decibels has been made 10 decibels weaker (less intense).

Audiogram:

A graph which shows hearing threshold level for pure tones at each test frequency.

Audiology:

The science of measurement and interpretation of normal and impaired hearing.

Audiologist:

A specialist in audiology who administers audiometric tests, conducts hearing aid evaluation and contributes to the rehabilitative needs of hearing impaired individuals.

Audiometer:

An electronic instrument for measuring hearing threshold levels with pure tones or speech.

Audiometric Technician:

An individual certified by the Kansas State Board of education to perform audiometric sweep screening and impedance screening according to level of certification.

Audiometric Zero (or “0” dB hearing level):

A set of values representing average hearing threshold for healthy young adult ears.

Auditory Brainstem Response (ABR):

An electronic method of making an objective measurement of the auditory pathway response to acoustic stimuli. (a.k.a. BAER, BAEP, EP)

Auditory Training:

A method used to teach individuals with loss of hearing to take full advantage of the sound clues that are still available to them through the use of residual hearing: usually used in conjunction with a hearing aid that provides the appropriate amplification of sound.

Auricle (Pinna):

The most visible part of the ears, is an ovoid-formed, skin-covered fibrocartilaginous plate that is attached to the head. The auricle is believed to be most useful in gathering and localizing of sound.

Auropalpebral Reflex:

Rapid and distinct closing of the eyelids, or twitch of the eye, resulting from a sudden sound stimulus. It is said to be closely related to the stapedius muscle reflex in the middle ear.

Behavioral Observation Audiometry (BOA):

Observation of responses to auditory stimuli (i.e., change in breathing, limb movement, grimacing, turning head toward sound stimuli).

Biological Check:

A daily listening check of the audiometer using the audiometric technician’s own hearing sensitivity as a reference for proper function.

Bone Conduction:

The process by which sound is conducted to the inner ear through the cranial bones. Bone conduction threshold is a direct measure of the sensorineural components of the hearing mechanism, relatively unaffected by the condition of the conductive mechanism.

Bone Conduction Vibrator:

An electromechanical transducer used with an audiometer to measure bone conduction thresholds. The device is held against the mastoid process by a flexible metal headband.

Bullous Myringitis:

A large blister or blisters within or beneath the epideral layer of the tympanic membrane.

Calibration:

The electroacoustical or psychoacoustic determination that an audiometer is performing properly in terms of its acoustic output, attenuation linearity, frequency accuracy, harmonic distortion, etc.

Cerumen:

Wax, secreted in the outer portion of the external auditory canal that keeps out foreign objects and keeps skin in the canal and tympanic membrane moist.

Cholesteatoma:

A cyst (collection of Keratinizing squamous epithelium) that invades the middle ear, mastoid bone and sometimes the external ear canal; it frequently originates from a perforation in Shrapnell’s membrane (pars flaccid) of the tympanic membrane; also called keratoma.

Chronic Otitis Media:

Condition persists beyond the normal period of time, often relatively little pain is present.

Cochlea:

A coiled spiral, tapered bony tube of about 2 3/4 turns located in the inner ear. It contains the receptor organs essential to hearing.

Cochlear Implant:

An electrode which is placed in the cochlea and attached to the coil under the skin near the ear. An additional unit is placed on the outside of the body. This device provides the ability to hear to people who cannot benefit from conventional aids. However, the ability to hear has a quality different from natural, unaided hearing.

Compliance:

The reverse of stiffness. A measurement of how mobile the tympanic membrane and the middle ear system is at a given time.

Conductive Hearing Loss:

Produced by pathologies of the external and/or the middle ear. The audiogram in such a loss is characterized by normal bone conduction thresholds, but depressed air conduction (sometimes referred to as the “air-bone “ gap).

Cross-Over (Contra Lateralization):

Occurs during a hearing test when a tone delivered to one ear is carried either around or through the head in sufficient intensity to stimulate the opposite ear.

Cytomegalovirus (CMV):

A member of the group of DNA viruses, closely related to the herpes viruses, which may cause progressive hearing loss.

Decibel (dB):

A unit used to measure the relative loudness of sounds; 0 dB re 0.0002 dynes/cm2 is considered to be the faintest sound that can be heard by a normal hearing person; 140 dB (sound Pressure Level):-a pressure 10 million times as great a 0 dB SPL decibel is considered to be the pain threshold of the normal ear.

Dermatitis:

Inflammation of the skin.

Developmental Scales:

A graded series of performances used in rating individual development.

Tympanic membrane:

Called the tympanic membrane. It is a membrane that separates the outer and middle ears.

Effusion:

Fluid collected in a body cavity (i.e., middle ear cavity).

Eustachian Tube:

A canal that connects the middle ear with the back of the throat. It supplies air to the middle ear and serves to equalize the air pressure on the two sides of the tympanic membrane.

Exogenous:

Originating outside of the body.

External Auditory Meatus (or ear canal):

The canal that conducts sound vibrations from the auricle to the tympanic membrane.

Free Field:

Unbounded area or an area in which boundaries have little effect on sound pressure waves.

Frequency:

The rate of repetition of the cycles of s sound wave. The unit is called hertz (Hz); but it has been called, until recently, cycles per second (cps). The frequency of a tone largely determines pitch.

Glue Ear:

Thickened purulent fluid in the middle ear cavity.

Gradient:

A change in the value of static admittance relative to the tympanometric width. Gradient measures are sued to describe the shape of the tympanogram in the vicinity of the peak.

Habilitation:

Education of the deaf or hard of hearing to function better in society.

Habituate:

Becoming accustomed to a sound or noise to the degree that it is ignored.

Hair Cells:

The sensory receptor cells for hearing. They are ciliated epithelial cells located within the cochlea at the organ of the Corti.

Hearing Aid:

A compact device used to amplify sound.

Hearing Level (HL):

The difference in decibels between the threshold for that sound and the corresponding normal threshold or audiometric zero.

Hearing Impaired:

Deaf and Hard-of-Hearing

Deaf: Those in whom the sense of hearing is nonfunctional for the ordinary purposes of life.

Congenitally Deaf: Those who are born deaf.

Adventitiously Deaf: Those who were born with normal hearing, but acquired a severe or profound hearing loss.

Hard-of-Hearing: The sense of hearing, although defective, is functional with or without amplification.

Hereditary Hearing Loss:

Hearing loss resulting from inherited characteristics.

Hertz (Hz):

The unit of frequency (formerly called cycles per second).

High Risk Registry (HRR):

1) Broadly speaking, a roll or record of the names of newborns who may possibly have disabilities as the result of birth hazards; (e.g., anoxia, hypertoxia, parental blood incompatibilities.

2) a list of diseases, syndromes, and defects that may cause disabilities in the newborn.

Immittance:

An audiological term to describe measurements made of tympanic membrane impedance, compliance, or admittance.

Immittance Measurements:

The term used to describe the acoustic immittance test battery of tympanometry, compliance, and acoustic reflex. It measures the function and integrity of the middle ear system.

Impedance:

The opposition to sound at the surface of the tympanic membrane. It is comprised of frictional resistance and stiffness influenced by frequency.

Infant State:

The status of an infant characterized by a particular condition/set of behaviors.

Intensity:

The amount of energy in a sound. The intensity of a sound is perceived by the ear as its loudness. The noise of a jet engine is a high intensity sound and to the ear it seems very loud. A whisper is a low intensity sound and it seems very weak as it is heard. Intensity is measured in decibels (dB).

Inter-Observer Agreement:

Agreement of two or more persons that a change in an infant’s behavior (response) occurred.

Inter-StimulusInterval (ISI):

The period of time occurring between presentation of two stimuli.

Jaundice:

Yellowness of the skin, mucous membranes, and secretions, due to hyperbilirubinemia (sometimes seen in premature newborns).

Keratoma:

See Cholesteatoma.

Local Education Agency (LEA):

The educational organization responsible for providing services in a given area.

Localization:

Determination of the source of a sound made possible partly by the difference in loudness and partly by the difference in time of reception by the two ears.

Meningitis:

An inflammation of the membranes of the brain and spinal cord.

Middle Ear:

An air-filled cavity bordered by and including the tympanic membrane, ossicles, and Eustachian Tube and ending at the cochlea (inner ear).

Middle Ear Effusion:

An accumulation of fluid (liquid) in the middle ear.

Minimal Response Level (MRL):

The lowest level at which a stimulus elicits a change in the state of an infant.

Moro Reflex:

A physical startle reaction to a stimulus in which the newborn tends to withdraw to the position in which it was carried in the womb.

Myringotomy:

Small incision of the tympanic membrane to allow drainage of fluid from the middle ear.

Neomembrane:

A scar on the tympanic membrane; the scarred region may be thinner and have a higher admittance than the normal tympanic membrane.

Neoplasm:

An aberrant new growth of abnormal cells or tissues; a tumor.

Non-Suppurative Otitis Media:

Characterized by the presence of uninfected fluid in the middle ear cavity.

Occlusion:

A closing or shutting off of the external ear canal.

Octave:

The interval between two tones which are separated by a frequency ratio of 2:1.

Operant Conditioning:

Training a response to a stimuli which can be recognized by its affect on the child.

Ossicles:

The three small bones in the middle ear, i.e., the malleus (hammer), the incus (anvil), and the stapes (stirrup). The bones transmit sound vibrations from the tympanic membrane to the cochlea.

Ossicular Fixation:

Fixation of the malleus and/or the incus, frequently caused by tympanosclerosis, a complication of chronic otitis media.

Otitis Externa:

Inflammation of the external ear.

Otitis Media:

Generically, the inflammation of the middle ear cavity, synonymous with ear infection.

Otitis Media with Effusion:

Inflammation of the middle ear accompanied by an accumulation of fluid (liquid).

Otolaryngologist:

A physician who specializes in disorders of the ear, nose, and throat.

Otologist:

A medical doctor whose specialty is the science of the ear, its diseases, structure, and function.

Otosclerosis:

A genetic abnormality of the temporal bone, frequently causing fixation of the stapes and conductive hearing loss.

Otoscope:

A flashlight-like device with a funnel-like speculum on the end, designed for visualization of the tympanic membrane.

Otoscopy:

Visual inspection of the ear canal and tympanic membrane by means of an otoscope.

Paper Screening:

A questionnaire format for separating children into different groups.

Patent:

Open, unobstructed, not closed.

Pediatric Free Field Audiometry:

The quantitative and qualitative evaluation of a child’s hearing by use of an instrument which produces a calibrated stimulus in a room in which sound waves originate from a speaker.

Physical Volume Test:

A test involved in immittance measuring the size of the cavity, determines if tube is patent, possible tympanic membrane perforation, wax, normal volume, etc.

Pinna:

The external ear.

Pitch: The attribute of auditory sensation in terms of which sounds may be ordered on a scale extending from low to high. P{itch depends primarily upon the frequency of the sound stimulus, but it also depends upon the sound pressure and wave form of the stimulus.

Presbycusis:

The loss of hearing associated with aging.

Pressure Equalization Tubes (P.E. Tubes):

Tubes placed in the tympanic membrane to equalize air pressure in the middle ear cavity with air pressure outside the head.

Probe Ear:

Describes the ear in which the probe tip is inserted.

Pure Tone:

A sound wave of a single frequency component whose sound sensation is characterized by its singleness of pitch.

Purulent:

A festering, forming or discharging pus.

Recessive Deafness(hereditary):

Characterizing a genetic trait causing hearing loss which is not expressed in the presence of a dominant trait.

Recruitment:

A large increase in the perceived loudness of a signal produced by a relatively small increase in intensity above threshold.

Recurrent Otitis Media:

When infection occurs repeatedly over a defined period of six months or a year.

Residual Hearing:

The range of useful hearing above the threshold of sensitivity.

Resonance:

A vibrating air column, string, membrane, rod, or an electric circuit (oscillator) is excited by a small energy source at or near the same frequency of the mechanical or electrical system.

Rubella:

An acute, benign, viral, contagious disease of children characterized by fever and rash.. Associated with fetal abnormalities when maternal infection occurs in the first trimester. of a pregnancy.

Screening Audiogram:

Any audiogram which is used to identify individuals whose thresholds lie below a given level from those whose thresholds lie above the same level.

Screening Thresholds:

A pure tone audiometric technique used by an audiometric technician to identify the faintest intensity level of a given frequency that a person can detect on fifty percent of a number of trials. Tones above the threshold are audible; those below are inaudible.

Secretory Otitis Media:

Also called mucoid otitis media, glue-like consistency caused by chronic inflammation and by mucous production in the lining of the middle ear space, usually follows an acute infection.

Sensorineural Hearing Loss:

Hearing loss resulting from a pathological condition in the inner ear or along the nerve pathway from the inner ear to the brain stem. The audiogram in such a loss is characterized by depressed air conduction and bone conduction thresholds of generally equal amounts.

Serous Otitis Media:

Otitis media with effusion, indicates presence of thin watery, clear fluid seen relatively early in eustachian tube dysfunction.

Sound:

An oscillation in pressure or molecular vibration in an elastic medium (air, water, metals, etc.) which results in transmission of vibratory energy in a wave-like manner. It is also the auditory sensation evoked by such an oscillation.

Sound Field:

A bounded area specially designed to allow for optimal listening conditions.

Sound Level Meter:

An instrument designed for the measurement of sounds in decibels calibrated to the standard reference level (0.0002 dynes/cm2 or 20/N/m2). Frequency weighting networks allow measurements to be made which approximate the loudness level of a noise.

Sound Pressure:

The average difference between the air pressure that occurs during sound transmission and the ambient air pressure.

Sound Pressure Level (SPL):

Level state in decibels which is a ratio or measured sound pressure reference to specific point, maximum and minimum sound pressure levels a person can detect. The decibel level based on a physical reference (0 dB = 0.0002 dynes/cm2).

Speech Pathology:

The study and treatment of functional and organic speech defects.

Speech Frequencies:

A range extending from below 100 Hz to over 10,000 Hz. although the most significant range includes 300 Hz to 4000 Hz. Within this range, 500, 1000, and 2000 Hz are used audiometrically to predict the hearing threshold for speech.

Static Admittance:

The admittance of the middle ear at the air pressure corresponding to the tympanometric peak. It is calculated by subtracting the admittance of the ear canal from the admittance at the tympanometric peak. The MicroTymp estimates static admittance by subtracting the admittance at 200 daPa from the peak admittance.

Static Compliance:

Measurement of the tympanic membrane and the middle ear in its resting or static state. Compliance refers to mobility.

Stenosis:

An abnormal narrowing, as of the external auditory canal.

Suppurative Otitis Media: (See Acute Otitis Media)

Supra-Threshold Response:

Above the lower limit of a stimulus capable of evoking a response.

Sweep Screening:

An audiometric technique to identify those individuals whose thresholds do not fall within the normal limits of hearing from those individuals whose thresholds fall at or within the limits of normal hearing; using pure tone as a stimuli.

Temporary Threshold Shift (TTS):

A change of hearing threshold primarily due to exposure to high intensity noise which recovers in 48 to 72 hours. Any loss which remains after this period is termed permanent threshold shift (PTS).

Threshold of Hearing:

The lowest intensity of sound that is capable of evoking an auditory sensation in a specified fraction of trials (usually 50% or more).

Tinnitus:

The ringing sensation in the ear(s) which generally follows an exposure to hazardous noise but may be due to numerous other causes.

Tympanic Membrane (Ear Drum):

Cone-shaped semi-transparent membrane that separates the external auditory meatus from the middle ear cavity and transmits sound vibrations to the ossicules.

Tympanogram:

A graphic representation of a pressure compliance function of the middle ear.

Tympanometer/ Bridge:

The instrument used to make acoustic immittance measurements.

Tympanometric Gradient:

A measure of the shape of the tympanogram in the region of the tympanometric peak. The MicroTymp calculates the gradient by determining the pressure interval corresponding to a 50% reduction in admittance on either side of the peak. Also called the tympanometric width.

Tympanometric Width:

See Tympanometric Gradient.

Tympanometric Peak Pressure:

The value of ear canal pressure at which the tympanometric peak occurs.

Tympanometry:

The measurement of the ability of the ear drum and ossicular chain to transmit sound pressure waves. An intact tympanic membrane is subjected to air pressure changes to determine its stiffness (impedance) and compliance (admittance). The results may be charted on a tympanogram.

Tympanoplasty:

Surgery involving the tympanic membrane.

Tympanosclerosis:

A complication of otitis media that is characterized by sclerotic regions involving the tympanic membrane, ossicles, and middle ear mucosa. Tympanosclerosis increases the stiffness of the middle ear system.

Tympanostomy Tubes:

Very small polyurethane tubes inserted in the tympanic membrane to provide ventilation to the middle ear. (See Pressure Equalization Tubes.

Ventilation Tubes: (See Pressure Equalization Tubes.

Vibrotactile:

Using the sense of touch to detect or interpret sound.

Visual Reinforcement Audiometry (VRA):

The quantitative and qualitative evaluation of hearing by conditioning the desired response with visual rewards.

Volume Velocity:

The volume of air that passes through a plane per unit time.

Warble Tone:

A tone resulting from rapid modulations of frequency within fixed limits around basic pure tone frequency.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

XII.

REFERENCES

 

 

 

References

*(1993). Congenital cytomegalovirus infection and neonatal auditory screening. Journal of Pediatrics, 123 (5), 779-782.

*(1993). Hearing loss in very prettier and very low birthweight infants at the age of 5 years in a nationwide cohort," International Journal of Pediatric Otorhinolaryngology, 26 (1), 11-28.

American Speech and Hearing Association. (May, 1985). Guidelines for Identification Audiometry., pp. 49-53.

American Speech and Hearing Association. (March, 1989). Guidelines:Audiologic screening of newborn infants who are at risk of hearing impairment. pp. I-9 to I-16.

American Speech and Hearing Association. (1990). Guidelines for screening for hearing impairments and middle ear disorders. ASHA, 32, (Suppl. 2), 17-24.

American Speech and Hearing Association. (1991). Guidelines for the audiological assessment of children from birth through 36 months of age. ASHA, 33, (Suppl 5), 37-43.

American Speech-Language-Hearing Association. (1991). The use of FM amplification instruments for infants and preschool children with hearing impairment. ASHA, 33, (Suppl. 5), 1-2.

American Speech/Language/Hearing Association. (1994, December). The joint committee on infant hearing:1994 position statement,", ASHA, 36, 38-41.

Ballot, D. E., Rothberg, A.D., & Katz, B. J. (1992). Speech and hearing problems in a high risk population .South African Medical Journal, 82, 23-26.

*Bergman, I. Hirsch, R. P., Fria, T.J., Shapiro, S.M., Holzman, I., & Painter, M.J. (19 ). Cause of hearing loss in the high-risk premature infant. Journal of Pediatrics, 106, 95-101.

Boison, K. (1986). The need for hearing conservation in our (jos municipality) public schools: Brief research report. International Journal of Rehabilitation Research, 9(1), 60-63.

Brown, M., & Collar, M. (1982, September-October). Effects of prior preparation on the preschooler's vision and hearing screening preparation by parents in the home. American Journal of Maternal Child Nursing, 7 (5), 323-328.

Brummett, R.E. (1981). Ototoxicity resulting from the combined administration of potent diuretics and other agents. Scandinavian Audiology, Suppl 14, 215-224

Cloherty, J.P., & Stark, A.R. (1991). Manual of neonatal care:Joint program in neonatology (3rd ed.). Harvard Medical School, Beth Isreal Hospital, Brigham and Womens Hospital, Childrens Hospital Boston, MA: Little Brown & Company.

Dodge, P., Davis, H., Feigin, R., Homes, S., Kaplan, S., Jubeliere, D., Stechenberg, B. &Hirsch, S (1984). Prospective Evaluation of hearing loss as a sequela of acute bacterial meningitis. New England Journal of Medicine,.311, 869-874

.

Eichwald, J. & Mahoney, T (1993). Apgar scores in the identification of sensorineural hearing loss. American Academy of Audiology, 4, 133-138.

Environmental Protection Agency . (1979). School Hearing Test Program. (Brief No. 141). Office of Noise Abatement and Control, Washington, D.C.

Fritsch, M.H. & Sommer, A.S (1991). Handbook of congenital and early onset hearing loss. New York: Igaku-Shoin Medical Publishers.

Gannon, M. (1988, May). Which children fail hearing tests? Midwife Health, Visitor and Community Nurse,.24 (5), 184-188.

Garrity, J. & Mengle, H. (1983). Early identification of hearing loss:Practices and procedures. American Annals of the Deaf, 128 (2), 99-106.

Heath, R. et al (1987). Hearing dysfunction hawaiian preschoolers: Its relation to educational achievement and family characteristics. Kamehameha Schools/Berniece Pauahi Bishop Estate.

Hughes, J.G. & Griffith, J.F (1984). Synopsis of pediatrics. St. Louis, MO: C.V. Mosby Company.

Jackson, C. (1983, November 18-21). Use of microcomputers for school hearing screening and evaluation records. Paper presented at the Annual Convention of the American Speech/Language/Hearing Association, Cincinnati, Ohio.

Jacobson, G.P., Burtka, M., Wharton, J.A., Newman, C.W., Shepherd, N., & Turner, R. (1990). Infant hearing screening 1984-1989: The henry ford hospital experience. The Henry Ford Hospital Medical Journal, 38, 39-43.

Mandell, C. & Johnson, R. (1984). Screening for otitis media: Issues and procedural recommendations. Journal of the Division for Early Childhood,.8(1), 86-93.

McDermott , J. (1982, October). Immittance screening for aural problems in school children. Journal of School Health, 52 (8), 462-468.

*Naulty, C.M., Weiss, I.P. & Herer , (19 ). Progressive sensorineural hearing loss in survivors of persistent fetal circulation. Ear and Hearing, 7, 74-77.

*Nield, T.A., Schrier, S., Ramos, A.D., Platzker, A. & Warburton, D. (19 ). Unexpected hearing loss in high-risk infants. Pediatrics, 78, 417-422.

Northern, J. & Downs, M. (1991). Hearing in children (4th ed. ). Baltimore MD: Williams & Wilkins.

*Northern, J. and Hayes, D, (1994). Universal screening for infant hearing impairment: Necessary, beneficial and justifiable. Audiology Today - American Academy of Audiology, 6(2),

O’Mara, L., Isaacs, S., & Chambers, l. (1992, September-October). Follow-up of participants in a preschool hearing screening program in child care centers. Canadian Journal of Public Health, 83, (5), 375-378.

Robarts, J. (1985, April 15-19). Impedance in school screening programs. Paper presented at the Annual Convention of the Council for Exceptional Children, Anaheim, CA.

*Robinson, D. et al (1988, August). Infant tympanometry: Differential results by race. Journal of Speech & Hearing Disorders, 53 (3), 341-346.

Sande, M., Smith, A., & Root, R, (1985). Contemporary issues in infectious diseases volume 3, bacterial meningitis. New York: Churchill Livingstone.

Scahill, L, Jekel, J., & Schilling, L. (1991, February). Screening child psychiatric patients for communication disorders: A pilot study. Archives of Psychiatric Nursing, 7 (1), 31-37.

*Shimizu, H, (1992). Childhood hearing impairment:Issues and thoughts on diagnostic approaches. American Auditory Society Bulletin, 17(1),

Smeltzer, C.D. (1993,November). Primary care screening and evaluation of hearing loss. Nurse Practitioner: American Journal of Primary Health Care, 18 (8), 50-55.

State, K. (1988, September-October). Improving hearing screening programs in the elementary school. School Nurse, 4 (3), 16-19.

Vietze, P. & Vaughn,Jr., H, (1988). Early identification of infants with developmental disabilities. Philadelphia, PA: Grune & Stratton.

White, K., & Mauk, G. (1993). Early identification of hearing impaired children: Expanding and redefining best practices:Final report. Utah State University, Logan, Department of Psychology, .

Wisconsin State Department of Public Instruction. (1983). Wisconsin hearing conservation program: A guide for nurses, parents & schools, Madison, Division for Handicapped Children and Pupil Service.

Wisconsin State Department of Public Instruction. (1988). The 1985-1986 wisconsin school district hearing screening survey (Bulletin # 8441). Madison, Bureau for Children with Physical Needs.

Wynne, M., Molloy, T., & Bloom, B, (1992, June). The high risk Register for hearing loss in kansas: Some preliminary data. Kansas Medicine, 198-202.

 

*Indicates references with missing information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

APPENDICES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Materials included in the Appendix are examples only, except Hearing Screening Law, and are not intended to be used as official state documents nor does the Kansas State Board of Education, Special Education Outcomes Team, endorse any referenced documents.

 

 

APPENDIX

B

Tympanogram Examples

Normal Tympanometry Values

Compliance 0.2 to 1.8 ml

Pressure -175 to +25 daPa

Volume 0.3 to 2.0 ml

Reflex present

NORMAL TYMPANOGRAM

(Type A)

 

 

 

 

AIR PRESSURE

Compliance 0.4 ml

Pressure -10 daPa

Volume 1.3 ml

1.5

 

 

 

 

 

-400 -200 0 +200

 

ABNORMAL TYMPANOGRAM - possible otitis media, fluid in the ears, wax impaction

(Type B)

 

 

 

 

AIR PRESSURE

Compliance 0.1 ml

Pressure NO PEAK

Volume 0.2 ml

1.5

 

 

 

 

 

-400 -200 0 +200

 

ABNORMAL TYMPANOGRAM - possible Eustachian tube dysfunction, incipient or resolving

(Type C) otitis media

 

 

 

 

AIR PRESSURE

Compliance 0.5 ml

Pressure -250 daPa

Volume 0.5 ml

1.5

 

 

 

 

 

-400 -200 0 +200

 

 

ABNORMAL TYMPANOGRAM - stiff middle ear, thickened tympanic membrane, scarred tympanic membrane or

(Type As) otosclerosis

 

 

 

 

 

AIR PRESSURE

Compliance 0.2 ml

Pressure 10 daPa

Volume 1.6 ml

1.5

 

 

 

 

 

-400 -200 0 +200

 

ABNORMAL TYMPANOGRAM - flaccid tympanic membrane, ossicular disarticulation

(Type Ad)

 

 

 

 

AIR PRESSURE

Compliance 1.85 ml

Pressure -10

Volume 1.4 ml

1.5

 

 

 

 

 

-400 -200 0 +200

 

ABNORMAL TYMPANOGRAM - perforated tympanic membrane, tube in tympanic membrane and open

(Type B)

 

 

 

 

 

AIR PRESSURE

Compliance 0.2 ml

Pressure no peak

Volume 5.0 ml

 

 

 

ABNORMAL TYMPANOGRAM - tube in place but occluded, middle ear status is normal at this time

 

 

 

 

 

AIR PRESSURE

Compliance 0.4 ml

Pressure 0 daPa

Volume 1.3 ml

 

 

 

 

APPENDIX

C

AUDIOMETRIC TECHNICIAN CERTIFICATES

 

SAMPLE Level 1 Audiometric Technician Approval Certificate

 

Audiometric Technician Approval Level I

This is to certify that _________________________________________, Soc. Sec. No. ___________________, has satisfied the requirements of the Kansas State Board of Education, Kansas Department of Health and Environment and the certified audiologist whose name appears on this document for approval as an audiometric technician. The above named person has met the requirements for Level 1 certification and is qualified to perform pure tone air conduction sweep screenings as outlined in KSA 1969 Supplement 72-1204-1206 Mandatory Hearing Screening and qualifies the employing agency as meeting state requirements in compliance with said law.

This approval is valid from ____________________ until ___________________.

(month/day/year) (month/day/year)

Renewal of the Level 1 certificate is required annually.

 

_____________________________________

(Name)

Audiologist

 

 

 

 

 

SAMPLE Level 2 Audiometric Technician Approval Certificate

 

 

Audiometric Technician Approval Level II

This is to certify that ___________________________________________, Soc. Sec. No. ___________________, has satisfied the requirements of the Kansas State Board of Education, Kansas Department of Health and Environment and the certified audiologist whose name appears on this document for approval as an audiometric technician, meeting the requirements for Level 2 certification. The above named person is qualified to perform otoscopic inspection and pure tone air conduction sweep and threshold screenings as outlined in KSA 1969 Supplement 72-1204-1206 Mandatory Hearing Screening and qualifies the employing agency as meeting state requirements in compliance with said law.

This approval is valid from ____________________ until ____________________.

(month/day/year) (month/day/year)

Renewal of Level 2 certification is required every two years.

_____________________________________

(Name)

Audiologist

 

 

 

SAMPLE Level 3 Audiometric Technician Approval Certificate

 

 

Audiometric Technician Approval Level III

This is to certify that _________________________________________, Soc. Sec. No. ___________________, has satisfied the requirements of the Kansas State Board of Education, Kansas Department of Health and Environment and the certified audiologist whose name appears on this document for approval as an audiometric technician. The above named person has met the requirements for Level 3 certification and is qualified to perform otoscopic inspections, perform pure tone air conduction sweep and threshold screenings and tympanometry screenings as outlined in KSA 1969 Supplement 72-1204-1206 Mandatory Hearing Screening and qualifies the employing agency as meeting state requirements in compliance with said law.

This approval is valid from ____________________ until ____________________.

(month/day/year) (month/day/year)

Renewal of Level 3 certification is required every two years.

 

_____________________________________

(Name)

Audiologist

 

 

 

 

 

SAMPLE Level 4 Audiometric Technician Approval Certificate

 

 

Audiometric Technician Approval Level IV

This is to certify that ___________________________________________, Soc. Sec. No. ___________________, has satisfied the requirements of the Kansas State Board of Education, Kansas Department of Health and Environment and the certified audiologist whose name appears on this document for approval as an audiometric technician, meeting the requirements for Level 4 certification. The above named person is qualified to perform otoscopic inspection, pure-tone air conduction sweep and threshold screenings, tympanometry screenings, and to administer hearing screening procedures for infants and toddlers as outlined in KSA 1969 Supplement 72-1204-1206 Mandatory Hearing Screening and qualifies the employing agency as meeting state requirements in compliance with said law.

This approval is valid from ____________________ until ____________________.

(month/day/year) (month/day/year)

Renewal of Level 4 certification is required every two years.

 

_____________________________________

(Name)

Audiologist

APPENDIX

D

HEARING SCREENING LAW

I. 91-12-40. Child find, screening and evaluation

(a) Child find. Each local education agency shall implement on-going procedures, including screening, preassessment and comprehensive evaluation, to identify children with disabilities, age birth through 21 years, within its jurisdiction. Public notice of these procedures shall be given at least annually.

(b) Screening

(1) Screening is the first phase in the identification of exceptional children and shall not be used as a basis for placement or programming.

(2) Each local education agency shall develop and implement written screening procedures to identify children ages birth through 21 years who may need special education.

(3) Screening procedures for children under the age of five years shall be made available at least monthly and shall use age-appropriate instruments, measures, and techniques for all of the following:

(A) Hearing screening, including testing of middle ear function and behavioral audiometry;

(B) vision screening, including behavioral and observational signs of vision problems in addition to basic vision screening; and

(C) developmental screening which does not depend entirely on interview information, group tests, or intelligence testing. This screening shall include: communication skills; gross and fine motor skills; cognition; social and emotional adjustment; and self-help skills.

(4) Screening procedures for children ages five through 21 years shall include:

(A) Mandatory hearing and vision screening; and

(B) age-appropriate assessments designed to identify possible physical, intellectual, social or emotional language or perceptual deviations.

(c) Preassessment.

(1) No child enrolled in regular education shall be evaluated or identified as exceptional until a building level team has:

(A) Documented that the child has been presented with learning experiences which are appropriate for the child's age and ability levels;

(B) documented that the child's potential for learning has not been achieved in that regular education environment; and

(C) completed a record of the dates the preassessment team met, the names and positions of preassessment team members, and the team recommendations.

(2) If the parent of a child requests a comprehensive evaluation of the child before the preassessment is completed, the preassessment may continue, but the comprehensive evaluation shall be initiated no more than 45 school days from the date of the request for evaluation:

(3) A referral for a comprehensive evaluation shall be made whenever screening or preassessment indicates a child may be exceptional. In addition, the 90 day notice from an infant and toddler program under Part H of the federal Individuals with Disabilities Education Act shall constitute a referral for a comprehensive evaluation.

(d) Comprehensive evaluation. No child shall be placed in special education prior to the completion of a comprehensive evaluation. The following procedures shall be implemented:

(1) All evaluation procedures shall be nondiscriminatory as prescribed in K.S.A. 72-963.

(A) When any child is from a home in which English is not the principal language, the local education agency shall determine the language best understood by the child. The comprehensive evaluation or access to special education services shall not be postponed solely because that child cannot communicate effectively in English.

(B) If any child has sensory, motor, or speaking impairments, tests shall assess whatever factor the test purports to measure rather than reflect that child's impaired communication skills.

(2) The comprehensive evaluation shall be conducted by a multidisciplinary team or group of persons, including at least one teacher or other specialist with knowledge in the area of suspected disability, and at least one person qualified to conduct individual diagnostic examination of children. No child shall be placed in special education on the basis of a single evaluation procedure, instrument or measure.

(3) If any child is suspected of having specific learning disabilities, the provisions of K.A.R. 91-12-58 shall be followed.

(4) Each test or other evaluation material used as a part of any comprehensive evaluation shall have been validated for the specific purpose for which the test or other material is used and shall be administered in conformance with the instructions provided by the producer of the test or material.

(5) Each test used as a part of any comprehensive evaluation shall be administered by a professional holding current certification or licensure to administer and interpret that test. Public school psychological evaluations shall be carried out only by an approved school psychologist certified by the Kansas state department of education or by an appropriately trained psychologist licensed by the Kansas behavioral sciences regulatory board and reported to the Kansas state department of education.

(6) Each student shall be assessed in all areas related to the suspected exceptionality including, where appropriate, health, vision, hearing, social and emotional status, general intelligence, educational performance, communicative status, motor abilities, and vocational skills. For children who have a speech impairment as their only apparent exceptionality, a qualified speech and language clinician shall evaluate those children using procedures that are appropriate for the diagnosis and appraisal of speech and language disorders. The speech and language clinician shall verify the absence of learning or behavioral problems through a preassessment, and through examination of the child's records or conferences with parents and teachers, or both. If referral for an additional evaluation by other professionals is not indicated, the comprehensive examination may then be considered to be complete.

(7) After any child has been assessed in all areas related to a suspected disability, that child's evaluation team shall meet to determine whether the evaluation results indicate that the child meets eligibility criteria for special education services. The child's parents shall have the opportunity to attend this meeting or to have their opinions expressed by a designated representative or member of the team. If an evaluation team recommends a child for special education services, the evaluation results shall be made available for use in developing the individualized education program. In no case shall the decision to place a child in special education be made solely by one person, even though this person may have considered the data collected by all members of the evaluation team.

(8) Each comprehensive evaluation shall be completed within 40 school days following the written referral. (Authorized by and implementing K.S.A. 72-963; effective May 1, 1983; amended May 1, 1984; amended, T-88-40, Oct. 27, 1987; amended May 1, 1988; amended July 1, 1990; amended June 1, 1993.)

II. Educational Audiologists Role and Certification Requirements

Educational Audiologist Duties and Responsibilities

A school audiologist is a specialist who provides and coordinates services to the auditorily disabled including detection of the problem and management of audiologic habilitative procedures. These duties and responsibilities include:

(1) Coordinate and manage the screening programs for the total public school population. Teams of nurses, school aides, and selected volunteers should be used in the annual district-wide or school-wide sweep screenings.

(2) Ensure the calibration of screening audiometers.

(3) Conduct comprehensive audiological evaluations (which may include air conduction, bone conduction, immittance and speech audiometry) for those students failing sweep and threshold screenings.

(4) Provide, at least annually, an audiological evaluation for children with known hearing losses.

(5) Annually, complete electracoustic evaluation and specification checks of the amplification devices (classroom and personal) used by D/HH students within each Local Education Agency (LEA).

(6) Provide consultant services related to the needs of the D/HH student to teachers, administrators, and parents.

(7) Provide data indicating the number of children receiving audiological diagnostic services, number of children indirectly served by parent and/or teacher counseling, and type and frequency of service provided through local hearing screening programs according to the requirements of the LEA or State Education Agency (SEA).

(8) Maintain records for all students with known hearing losses, preschool through school age, for the duration of the hearing loss or until the pupil reaches 21 years of age.

(9) Develop and maintain liaisons with community agencies that provide services complimentary to the school’s audiometric services.

(10) Develop pupil referral procedures and cooperative service agreements with local speech-language-hearing centers, medical facilities, hearing aid dispensers, and other community agencies which provide related services.

(11) Consult with school administrators and educators regarding the selection and purchase of auditory training equipment, and be responsible for its care.

(12) Participate in admission, placement, and programming procedures as appropriate to each student and as cont with procedures se t forth by State regulations (i.e., IEP advisement, school-based committtees).

(13) Serve as a resource person in parent guidanceand counseling programs, providing information on hearing loss, audiograms, hearing aids, acoustic environments and auditory training activities for home programs.

(14) Ensure the daily monitoring of aids by providing teachers with an annual orientation and/or inservice in hearing aid "trouble shooting" if they have D/HH students who wear amplification.

(15) Coordinate school-wide efforts to assist all students in the care and protection of their hearing.

A full-time (FTE) audiologist on staff is recommended for LEA’s having an average daily mmbership (ADM) of 10,000, one additional audiologist is needed for 10,000- 20,000 ADM, two additional audiologists for 20,000 -30,000 ADM, etc. For educational agencies with ADM head counts of less than 10,000:

(1) grouping of LEAs is recommended for sharing an audiologist on staff; or

(2) contracting for some or all audiology services with already existing facilities in the community; or

(3) utilizing local resources (civic clubs, provate donations, and so on) to construct and equip an audiological suite, and contracting for an audiologist’s services within the LEA for the amount of time needed to train audiometrists, supervise screening, complete evaluations, and provide follow-up services.

For LEAs having larger populations of students with hearing losses, one additional audiologist is needed for very

seventh-five (75) D/HH students. Constant and consistent audiological management is necessary

 

III. 91-1-137a. School Audiologist Certification Requirements

(a) Each applicant for a school audiologist endorsement at the preschool, elementary, middle or secondary level shall have earned a graduate degree in communication disorders with emphasis in audiology, shall have completed a state-approved program in audiology, and shall be recommended by a teacher education institution.

(b) Approved programs shall require students to complete a course of study allowing the students to:

(1) Acquire knowledge of normal and abnormal development of speech, language, and hearing. The course study shall allow students to acquire the ability to:

(A) Identify and explain the normal sequence of speech, language, and hearing development and criteria for identification of abnormal speech, language or hearing development; and

(B) identify and explain basic anatomy, neurology, and physiology of the normal and pathologic communicative mechanism.

(2) Acquire knowledge of laws and standards of regular and special education. The course of study shall allow students to acquire the ability to:

(A) Explain the mandates and standards of federal, state and local laws and the procedures for due process safeguards as they pertain to hearing disorders; and

(B) explain the philosophy and principle of public education.

(3) Acquire the ability to plan, implement, and supervise an efficient and effective hearing screening program. The course of study shall allow students to acquire the ability to:

(A) Select, explain, and utilize materials, equipment and procedures for screening which are appropriate to the age and setting; and

(B) record and interpret screening results, and make appropriate decisions for diagnostic testing.

(4) Acquire the ability to comprehensively evaluate hearing problems. The course of study shall allow students to acquire the ability to:

(A) Identify and select diagnostic instrument and procedures that are appropriate for age level and setting;

(B) administer and interpret tests of pure-tone audiometry and speech audiometry using appropriate masking;

(C) administer and interpret tests of middle ear function of acoustic immitance;

(D) administer and interpret an appropriate battery of special auditory tests for pseudohypoacousis, central auditory processing abilities, and site-of-lesion;

(E) administer an efficient battery of tests for the determination of need for amplification or appropriateness of existing amplification and for making necessary recommendations;

(F) administer an appropriate battery of tests for the purpose of recommending or fitting hearing aid devices;

(G) communicate diagnostic results to parents, teachers, and other appropriate professionals; and

(H) make appropriate referrals as needed.

(5) Acquire the ability to plan and conduct effective habilitation/rehabilitation sessions for individuals with hearing disorders. The course of study shall allow students to acquire the ability to:

(A) Provide appropriate information to be included in an Individual Education Plan during participation in a multidisciplinary team conference;

(B) select, utilize, and place in sequence materials appropriate to age and skill level;

(C) plan and implement programs of speech, reading and auditory training;

(D) make appropriate management decisions based upon regular assessment of individual performance and progress;

(E) evaluate the acoustical effectiveness of a classroom;

(F) communicate goals and techniques to parents, teachers, and other appropriate professionals; and

(G) coordinate a hearing aid and auditory trainer monitoring program involving parents, teachers, and other appropriate professionals.

(6) Acquire the ability to function in the roles of educator, evaluator, resource person, consultant and referral source. The course of study shall allow students to acquire the ability to:

(A) Interact professionally with parents and other professionals including paraprofessionals;

(B) explain the manner in which audiology services fit into the school setting and community;

(C) present organized oral, written, and visual materials which convey ideas to students, parents, colleagues, and others;

(D) provide preventive information on ear protection to students, parents, and teachers;

(E) conduct an assessment of strengths and weaknesses for a given district's hearing identification and conservation program; and

(F) conduct a self-assessment of performance and continued professional growth and development..

(c) This regulation shall take effect on and after May 1, 1987. (Authorized by, and implementing, Kans. Const. Art. 6, Sect. 2(a); effective May 1, 1985)

IV. 65-6501 et seq. Licensure Statutes For Speech Pathologists and Audiologists

65-6501. Definitions. As used in this act, the following words and phrases shall have the meanings respectively ascribed to them in this section:

"Secretary" means the secretary of health and environment.

"Speech-language pathology" means the application of principles, methods and procedures related to the development and disorders of human communication. Disorders include any and all conditions, whether of organic or inorganic origin, that impede the normal process of human communication including disorders and related disorders of speech, articulation, fluency, voice, verbal and written language, auditory comprehension, cognition/communication, and oral pharyngeal or laryngeal sensorimotor competencies, or both. Speech-language pathology does not mean diagnosis or treatment of medical conditions as defined by K.S.A. 65-2869 and amendments thereto.

"Practice of speech-language pathology" means:

(a) Rendering or offering to render to individuals or groups of individuals who have or are suspected of having disorders of communication, any service in speech-language pathology including prevention, identification, evaluation, consultation, habilitation and rehabilitation;

(b) determining the need for personal augmentative communication systems, recommending such systems and providing training in utilization of such systems; and

(c) planning, directing, conducting or supervising such services.

"Speech-language pathologist" means a person who engages in the practice of speech-language pathology and who meets the qualifications set forth in this act.

"Audiology" means the application of principles, methods and procedures related to hearing and the disorders of hearing and to related language and speech disorders. Disorders include any and all conditions, whether of organic or inorganic origin, peripheral or central, that impede the normal process of human communication including, but not limited to, disorders of auditory sensitivity, acuity, function or processing. Audiology does not mean diagnosis or treatment of medical conditions as defined by K . S . A. 65-2869 and amendments thereto.

"Practice of audiology" means:

(a) Rendering or offering to render to individuals or groups of individuals who have or are suspected of having disorders of hearing, any service in audiology, including prevention, identification, evaluation, consultation and habilitation or rehabilitation (other than hearing aid or other assistive listening device dispensing);

(b) participating in hearing conservation;

(c) providing auditory training and speech reading;

(d) conducting tests of vestibular function;

(e) evaluating tinnitus; and

(f) planning, directing, conducting or supervising services.

"Audiologist" means any person who engages in the practice of audiology and who meets the qualifications set forth in this act.

"Speech-language pathology assistant" means an individual who meets minimum qualifications established by the secretary which are less than those established by this act as necessary for licensing as a speech-language pathologist; does not act independently; and works under the direction and supervision of a speech-language pathologist licensed under this act.

"Audiology assistant" means an individual who meets minimum qualifications established by the secretary which are less than those established by this act as necessary for licensing as an audiologist, does not act independently; and works under the direction and supervision of an audiologist licensed under this act.

History: L. 1991, ch. 177, § 1; Jan. 1, 1992.

65-6502. Speech-language pathology and audiology board established; duties; composition; appointment of members.

(a) There is hereby established a speech-language pathology and audiology board. Such board shall be advisory to the secretary of health and environment in all matters concerning standards rules and regulations and all matters relating to this act.

(b) The board shall be composed of five persons appointed by the secretary who have been residents of this state for at least two years. Two members shall be licensed, or initially eligible for licensure, as speech-language pathologists; one member shall be licensed, or initially eligible for licensure, as an audiologist; one member shall be a person licensed to practice medicine and surgery; and one member shall be a member of the general public who is not a health care provider. The secretary may make appointments from a list submitted by professional organizations representing speech pathologists and audiologists.

(c) Members of the board attending meetings of such board or attending a subcommittee meeting thereof authorized by such board shall be paid amounts provided in subsection (e) of K.S.A. 75-3223 and amendments thereto.

(d) Board members shall be appointed for a term of two years and until their successors are appointed and qualified, except that of the initial appointments, which shall be made within 60 days after the effective date of this act, two members first appointed, as specified by the secretary, shall serve on the board for terms of one year and thereafter, upon expiration of such one-year terms, successors shall be appointed in the same manner as the original appointments. The chairperson of the board shall be elected annually from among the members of the board. Whenever a vacancy occurs on the board by reason other than the expiration of a term of office, the secretary shall appoint a successor of like qualifications for the remainder of the term. No person shall be appointed to serve more than two successive two-year terms.

(e) Appointments to fill vacancies shall be made in the same manner as original appointments for the portion of the term. The secretary may terminate the appointment of any member for cause which in the opinion of the secretary reasonably justifies such termination.

History: L. 1991, ch. 177, § 2; Jan. 1, 1992.

65-6503. Duties of secretary of health and environment. The secretary shall:

(a) Issue to each person who has met the education and training requirements listed in K.S.A. 1991 Supp. 65-6505 and amendments thereto and such other reasonable qualifications as may be established by rules and regulations promulgated by the secretary, the appropriate license as a speech-language pathologist or audiologist;

(b) establish by rules and regulations the methods and procedures for examination of candidates for licensure;

(c) appoint employees necessary to administer this act and fix their compensation within the limits of appropriations made for that purpose;

(d) keep a record of the board's proceedings and a register of all applicants for and recipients of licenses; and

(e) make all such reasonable rules and regulations as deemed necessary to carry out and enforce the provisions of this act.

History: L. 1991, ch. 177, § 3; Jan. 1, 1992.

65-6504. Unlawful acts and representations; persons licensed under act not authorized to engage in dispensing and fitting hearing aids and not engaged in practice of healing arts.

(a) On or after September 1, 1992, it shall be unlawful for any person to engage in the practice of speech-language pathology or audiology in the state of Kansas unless such person has been issued a valid license pursuant to this act or is specifically exempted from the provisions of this act. It shall be unlawful for any person to hold oneself out to the public as a "speech pathologist," "speech therapist," "speech correctionist," "speech clinician," "language pathologist," "voice therapist," "voice pathologist," "logopedist," "communicologist," "aphasiologist," "phoniatrist," "audiologist," "audiometrist," "hearing therapist," "hearing clinician," "hearing aid audiologist," or any variation, unless such person is licensed under this act as a speech-language pathologist or audiologist.

(b) No person licensed under this act shall be authorized to engage in the practice of dispensing and fitting hearing aids as defined under K.S.A. 14-5807 and amendments thereto unless such person is also licensed or holds a certificate of endorsement under the hearing aid act to engage in the practice of dispensing and fitting hearing aids.

(c) Persons licensed under this act to engage in the practice of speech-language pathology or audiology shall not be deemed to be engaged in the practice of the healing arts when practicing under and in accordance with this act.

History: L. 1991, ch. 177, § 4; Jan. 1, 1992.

65-6505. Qualifications for licensure. Speech-language pathologists or audiologists shall meet the following qualifications for licensure under this act:

(a) Possess at least a master's degree or equivalent in speech-language pathology or audiology from an educational institution with standards consistent with those of the state Universities of Kansas approved by the secretary which consists of a course of study consistent with the standards of the state universities of Kansas approved by the secretary pursuant to the rules and regulations;

(b) complete supervised clinical practicum experiences from an educational institution or its cooperating programs the content of which shall be approved by the secretary and shall be consistent with the standards of the state universities of Kansas and delineated in the rules and regulations;

(c) complete a postgraduate professional experience as approved by the secretary pursuant to the rules and regulations; and

(d) pass an examination in speech-language pathology or audiology approved by the secretary.

History: L. 1991, ch. 177, § 5; Jan. 1, 1992.

65-6506. Application for licensure; expiration and renewal; fees; reinstatement of lapsed license; licensure without examination; licensure by another jurisdiction; temporary license.

(a) Any applicant for licensure shall submit an application to the secretary upon the forms prescribed and furnished by the secretary and shall pay appropriate fees as established by the secretary, including examination fees if required. All licenses shall expire after two years and may be renewed by submitting an application, showing proof of completing required continuing education and paying a renewal fee to be established and collected by the secretary.

(b) At least 30 days before the expiration of the license, the secretary shall notify the licensee of the expiration by mail addressed to the licensee’s last place of residence as noted upon the office records. If the licensee fails to submit an application and fee by the date of the expiration of the license, the licensee shall be given a second notice that the license has expired and the license may only be renewed if the application, renewal fee, and late renewal fee are received by the secretary with the thirty-day period following the date of expiration and, if both fees are not received within the thirty-day period, the license shall be considered to have lapsed for failure to renew and shall be reissued only after the applicant has been reinstated under subsection (c).

(c) Any licensee who allows the licensee’s license to lapse by failing to renew as herein provided may be reinstated upon payment of the renewal fee and the reinstatement fee, and upon submitting evidence of satisfactory completion of any applicable continuing education requirements established by the secretary. The secretary shall adopt rules and regulations establishing appropriate continuing education requirements for reinstatement of persons whose licenses have lapsed for failure to renew.

(d) Upon due application and payment of a licensure fee as established by the secretary within one year subsequent to September 1, 1992, the secretary may waive the examination and grant a license to any applicant so long as the applicant: (1) Has met the educational, supervised clinical practicum experiences and postgraduate professional experience set forth in this act on or before September 1, 1992; or (2) has a master's degree or equivalent in speech-language pathology or audiology and has been actively engaged in the practice of speech-language pathology or audiology for at least two years of the last four years immediately preceding September 1, 1992; or (3) holds a current teaching certificate by the Kansas department of education as a speech-language pathologist or audiologist on the effective date of this act; or (4) has a bachelor's degree in speech-language pathology or audiology and has been actively engaged in the practice of speech-language pathology or audiology for at least three years of the last four years immediately preceding September 1, 1992.

(e) The secretary, upon application and payment of the fee fixed by the secretary, may issue a license as a speech-language pathologist or audiologist to any person who holds a valid license or its equivalent issued to such person by another state or country if the requirements for the licensure of the speech-language pathologist or audiologist under which such license or equivalent was issued are equivalent to or exceed the standards of this act.

(f) The secretary, upon application and payment of the temporary licensure fee, and submission of evidence of successful completion of the education and supervised clinical pracπticum experiences, may issue a temporary license, which shall expire 12 months from the date of issuance. The temporary license may be renewed for one period not to exceed 12 months by appeal to the secretary if the applicant has failed the examination or failed to complete the postgraduate professional experience.

History: L. 1991, ch. 177, § 6; Jan. 1, 1992.

65-6507. Contracts to obtain information about courses of study and clinical practicum experience. The secretary may contract with investigative agencies, commissions or consultants to assist the secretary in obtaining information about courses of study and supervised clinical practicum experiences to be approved by the secretary under K.S.A. 1991 Supp. 65-6505 and amendments thereto.

History: L. 1991, ch. 177, § 7; Jan. 1, 1992.

65-6508. Denial, revocation, suspension or limitation of license; grounds. The secretary shall deny, revoke, suspend or limit the license provided for in this act for any of the following reasons:

(a) Making a false statement on an application for a license, or any other document required by the secretary;

(b) engaging or attempting to engage, or representing oneself as so entitled, to perform procedures not authorized in the license;

(c) demonstrating incompetence or making consistent negligent errors in tests or procedures;

(d) engaging in dishonorable, unethical or unprofessional conduct of a character likely to deceive, defraud or harm the public;

(e) providing professional services while mentally incompetent, under the influence of alcohol or narcotic or controlled substance that is in excess of therapeutic amounts or without valid medical indication

(f) violating or aiding and abetting in a violation of any provisions of this act or any of the rules or regulations adopted under this act.

History: L. 1991, ch. 177, § 8; Jan. 1, 1992.

65-6509. Administrative proceedings; judicial review. Proceedings under this act shall be conducted in accordance with the Kansas administrative procedure act. Judicial review and civil enforcement of agency actions under this act shall be in accordance with the act for judicial review and civil enforcement of agency actions.

History: L. 1991, ch. 177, § 9; Jan. 1, 1992.

65-6510. Penalty for violation of act. Any person who violates any of the provisions of this act shall be guilty of a class C misdemeanor and each day in violation of this act shall be considered a separate offense.

History: L. 1991, ch. 177, § 10; Jan. 1, 1992.

65-6511. Act not applicable to certain persons. The provisions of this act shall not apply to:

(a) Personnel employed by the United States government;

(b) health care providers as defined by K.S.A. 1990 Supp. 65-4921 and amendments thereto or exempt licensees under the Kansas healing arts act who are providing services within the lawful scope of their authority so long as they do not hold themselves out to the public by a title set forth in K.S.A. 1991 Supp. 65-6504 and amendments thereto;

(c) persons duly credentialed by this state as a teacher of the deaf and hard of hearing who are providing services within the lawful scope of their authority so long as they do not hold themselves out to the public by a title set forth in K.S.A. 1991 Supp. 65-6504 and amendments thereto;

(d) the activities and services of persons pursuing a course of study leading to a degree in speech-language pathology or audiology at a college or university provided that: (1) These activities and services constitute a part of the organized course of study at that institution; (2) such persons are designated by a title such as intern, trainee, student, or by other such title clearly indicating the status appropriate to their level of education; and (3) such persons work under the supervision of a person licensed by this state to practice speech-language pathology or audiology.

(e) an employee or other person under the supervision of a person licensed to practice medicine and surgery in this state so long as such persons do not hold themselves out to the public by a title set forth in K.S.A. 1991 Supp. 65-6504 and amendments thereto; or

(f) persons licensed or holding a certificate of endorsement to engage in the practice of dispensing and fitting hearing aids under the hearing aid act when practicing under and in accordance with the hearing aid act so long as such persons do not hold themselves out to the public by a title set forth in K.S.A. 1991 Supp. 65-6504 and amendments thereto.

History: L. 1991, ch. 177, § 11; Jan. 1, 1992.

65-6512. Fees. The secretary shall fix by rules and regulations the licensure fee, temporary licensure fee, renewal fee, late renewal fee, reinstatement fee, and examination fee, if necessary, under this act. Such fees shall be fixed in an amount to cover the costs of administering the provisions of the act. The secretary shall remit all monies received from fees, charges or penalties under this act to the state treasurer at least monthly. Upon receipt of each such remittance, the state treasurer shall deposit the entire amount thereof in the state treasury and credit the same to the state general fund.

History: L. 1991, ch. 177, § 12; Jan. 1, 1992.