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turn tone up at same time to a known audible level 

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VRA 3
- Respond state rest,
Ear: left
Transducer ; Insertphone
threshold 1khz at 20db, 4khz 30db, 500hz 45db

mark X on the audiogram to represent the threshold

VRA 1
.Give instruction that explain the procedure and reinforcers used,tell  the parents to avoid cueing.Firstly, get the child’s audibility. Condition the child by presenting the audible warble tone at 1KHz together with the reinforcer. Repeat the conditioning until child used to it. Perform testing to confirm the conditioning by obtaining at least 2 consistent responses before descending.  Find the threshold by descend 20dB. Get at least 2 out of 3 ascending response as threshold after descend 10dB and ascend 5dB. Present at 20-30dB lounder from adjacent threshold to test at new frequency. Lastly,record the result.

VRA 2

Firstly make sure interact and build good relationship with patient. Optimize child’s response state. Distract the child from random head turn Keep the child attention to the towards distractor. Condition the child by presenting audible warble tone at 1Khz together with the reinforcer. Use some social reinforcement to encourage the prompt responses from the child to avoid boring. Make sure the reinforcement should be effective and attractive. Repeat until child used to it.

BOA 3
Developmental age  : 6 months (MRLs obtained =35-45dbA)
Response state   : active
Interpretation
1.The MRLs is appropriate
2.Tympanogram -type A (normal Peak YTM, TPP and ECV)
3. Normal APR
•Suggestion: No worse than a mild hearing loss in the better ear, possibly normal
•Management: VRA at 7-8 months

BOA
Developmental age: 3 months (MRL= out of expected)
Response state: sleepy and passive
Interpretation
1.tympanogram-type A suggesting normal middle ear function
2.present APR

- Suggestion:the child may have no worse than moderate to severe hearing loss in the better ear most likely have normal hearing.

Management:  VRA at 7-8 month

BOA 1
Developmental age: 5 months (MRL elevated)
Interpretation

1.the response which is head turn appropriate with the age
2.tympanogram- type B with normal ECV
3.bsent APR
suggestion:there is likely to have conductive hearing loss due to middle ear effusion.
Management
1.refer to ENT or GP
2.further assessment like Air conduction and Bone conduction ABR to determine type of Hearing loss
3.test again after 3 month with VRA.

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Akmal Abdul Wafiy Bin Mohd Thani (1418305)

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Akmal Abdul Wafiy Bin Mohd Thani (1418305)

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BOA

Interprete the following BOA and tympanometry results. Include in your answer suggestion of the hearing status and management. (5 months)
INTERPRETATION:
1. Elevated MRL.
2. No APR observed.
3. Type B Tympanogram with normal ECV.
4. Suggest that there is likely to have conductive hearing loss due to OME.

HEARING STATUS AND MANAGEMENT:
1. Conduct ABR testing.
2. Refer to ENT.
3. Retest after 3 months with VRA.

Interprete the following BOA and tympanometry results. Include in your answer suggestion of the hearing status and management. (3 months)
INTERPRETATION:
1. Elevated MRL at some frequency may be due to poor response state.
2. Present of APR (normal).
3. Type A tympanogram suggesting normal hearing.

HEARING STATUS AND MANAGEMENT:
1. Hearing review for VRA at 7-8 months.

Interprete the following BOA and tympanometry results. Include in your answer suggestion of the hearing status and management. (6 months)
INTERPRETATION:
1. Normal MRL (in expected range)
2. Present of APR (normal)
3. Type A tympanogram suggesting normal hearing.

HEARING STATUS AND MANAGEMENT:
1. Hearing review for VRA at 7-8 months.
2. Refer child to ENT.

VRA

Outline the procedure of VRA
1.          Instruction - audiologist will give instruction and explain the procedure of the test to the parent.
2.          Audibility check - to know the appropriate initial presentation of tone is present to the child to make sure it is audible to the child
3.          Conditioning - the child will be train to response toward the narrow band or warble tone  present in the present of reinforcer.
4.          Attempt testing – the attempt is done to see if the child is conditioned or not and need the get at least 2 consistent response
5.          Threshold seeking-  the threshold will descend by 20dB, if no response, ascend by 5 dB and descend 10 dB for threshold seek.
6.          VRA worksheet - the result will be recorded in the VRA worksheet.

Outline the process you would use to teach a child to do VRA
1.      The distractor must create rapport with the child during the history taking with the parent.
2.      Condition the child to turn toward the sound which come with the reinforcer.
3.      Distract the child to look at the front when there is no sound by using the toys
4.      Give effective social reinforcement to encourage the child when they do it correct.
5.      Prevent from letting the child touch the toys.

Interprete the following VRA results and explain how you are going to plot your answer in the audiogram.
1 kHz – 20db
4 kHz – 30 db
500 Hz – 45 db
The result shows consistency during 1khz and 4khz but there is many questionable respond at 500hz which most likely due to restless and tired toward the end of the test which make the kid less attention toward the sound.

*Mark X at 1KHz & 4KHz indicate threshold of the child, however at 500Hz plot MRL due to a lot questionable responses of the child on that day.

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BOA 1

Interprete the following BOA and tympanometry results.

1)     Developmental Age: 5 months (expected MRLs 40-50)

2)     Response State: Awake and calm

3)     Result:
-elevated MRLs

-tympanograms: type B with normal ECV suggested middle ear effusion

-APR absent

4)     Suggest: likely conductive hearing loss

5)     Management:
-refer to GP/ENT

-air and BC ABR

-review VRA at age 7-8 months

BOA 2

Interprete the following BOA and tympanometry results.

1)    Developmental Age : 3 months (expected MRLs 50-70)

2)    Response State: Sleepy and tired

3)    Result:
-elevated MRLs that maybe because of the baby’s response state.

-tympanograms: type A

-normal APR

4)    Suggest: no worse than a mild hearing loss in the better ear, possibly normal

5)    Management: VRA at 7-8 monts

BOA 3

Interprete the following BOA and tympanometry results.

1)    Developmental Age : 6 months (expected MRLs 40-50)

2)    Response State: Active

3)    Result:
-appropriated MRLs

-tympanogram: type A

-normal APR

4)    Suggest: no worse than a mild hearing loss in the better ear, possibly normal

5)     Management: VRA at 7-8 monts

VRA 1

Outline the procedure of VRA

1)    Positioned patient

2)    Give instruction to the caregiver

3)    Make audibility check at (1KHz, 60dBHL, FF, WT)

4)    Conditioning at least twice (NB/WT+reinforcer)

5)    Attempt testing until obtain at least 2 independent responses before testing

6)    Threshold seek by descending 20 dB and then up 5 dB and down 10 dB for     threshold seeking

7)    Record the result on VRA worksheet

VRA 2

Outline the process to teach a child to do VRA.

1)    Establish a rapport with the child

2)    Optimize the response state of the child

3)    Use conditioning method to train the child to turn to the reinforcer together with presenting an audible 1KHz warble tone

4)    Make sure the stimulus is perceptible or audible

5)    Distract the child with suitable toys

6)    Encourage prompt responses using social reinforcement

7)    Reinforcement must be effective for the child

8)    Make sure the child have the ability to perform appropriate response

9)    Repeat until the child understands what to do

VRA 3

Interpret following results and explain how to plot in audiogram.

1) Response state: Calm but restless and tired towards the end of the testing

2) Tranducer used: Insertphone on the left ear

3) Threshold:  500 Hz = 45dB

1 KHz = 20dB

4 KHz = 30dB

(mark ‘X’ on the audiogram)

4) Interpretation: the child may has lost of conditioning because of the poor response state

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BOA 1

Interpretation

Response state: Awake and calm

Developmental age: 5 months

-the response which is head turn appropriate with the age

-there is elevated MRL

-tympanogram type B with normal ECV

-absent APR

-this could suggest that there is likely to have conductive hearing loss due to middle ear effusion.

Management

-refer to ENT or GP

-do further assessment like Air conduction and Bone conduction ABR

-do test again after 3 month with VRA.

BOA

Interpretation

Developmental age: 3 months

Response state: sleepy and tired

-the response is appropriate based on the developmental age

-the MRL is out of expected due poor the response state

-the tympanogram is type A suggesting normal middle ear function

-present APR

-the result suggesting the child may have no worse than moderate to severe hearing loss in the better ear most likely have normal hearing.

Management:

-do VRA at 7-8 months.

BOA 3

Interpretation

Developmental age: 6 months

Response state: active

-the response is appropriate due to the developmental age

-the MRL is in the expected range

-APR present

-tymp type C which suggesting Eustachian tube dysfunction

-the result suggesting the child may have no worse than mild hearing lose and most likely to have normal hearing but based on tympanometry the child may have a flu or have problem with the Eustachian tube.

Management

-refer child to ENT

-Review VRA at 7-8 months.

.VRA 1

Outline procedure of VRA

1.          Instruction- audiologist will give instruction and explain the procedure of the test to the parent.

2.          Audibility check- the initial presentation of tone is present to the child to make sure it is audible to the child

3.          Conditioning- the child will be train to response toward the sound present in the present of reinforce.

4.          Attempt testing – the attempt is done to see if the child is conditioned or not and need the get at least 2 response

5.          Threshold seeking-  the threshold will descend by 20dB, if no response, ascend by 5 dB and descend 10 dB for threshold seek, threshold is plotted if there is 2 out of 3 ascending response..

6.          VRA worksheet- the result will be record in the VRA worksheet as a proof of response.

VRA 2

1.      First, the distractor must create rapport with the child during the history taking with the parent.

2.      Before the testing start, both tester and distractor need to cooperate in order to teach the child

3.      Condition the child to turn toward the sound which come with the reinforcer.

4.      Distract the child to look at the front when there is no sound by using the toys

5.      Prevent the child from habit of look to the reinforce without the toys

6.      Give social reinforcement

7.      Prevent from letting the child touch the toys

VRA 3

Interpretation

The result is consistent during 1khz and 4khz but there is many questionable respond at 500hz which most likely due to restless and tired toward the end of the test which make the kid less attention toward the sound. From the threshold seeking, the child might have no worse than mild hearing loss but most likely to have normal hearing due the response state.

Threshold for 500hz need to take the MRL only as there is too many questionable response.

1 kHz – 20db

4 kHz – 30 db

500 Hz – 45 db

*X is plotted on the audiogram.

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VRA 1

Procedure of VRA are:

1. INSTRUCTION

Explain to the child caregiver or mother on the procedure of the test and reinforces given to the child when the child respond.

2. AUDIBILITY CHECK

Present appropriate initial presentation level (in example 60dB at 1 kHz) as initial conditioning level in order to seek suitable audible initial presentation for the child.

3. CONDITIONING

Present an audible 1 KHz warble tone and reinforcer at the same time and train the child to look at the puppet when there is a sound and repeat until child understands what to do.

4. ATTEMPT TESTING

Obtain at least 2 consistent responses from conditioning. Then start to attempt testing by presenting at the same intensity and wait for a response. Immediately reward the child with reinforcer when a clear head turn is seen.

5. THRESHOLD SEEKING

Start threshold seeking when 2 consistent attempt testing is obtain by presenting at the same intensity and wait for a response.Descend 20 dB when there is a response. Always immediately reward appropriate responses with reinforcer. When there is no response, ascend by 5 dB until another response is observed and descend 10 dB when there is a respond. 2 out of 3 ascending is accepted as threshold.

6. VRA WORKSHEET

Result are record in VRA worksheet as a proof of response.

VRA 2

Process to teach child to do VRA

1.     Know the response state of the child on that day

2.     Rapport with the child while history taking with  the mother

3.     Choose suitable toys and reinforcers to be given to the child

4.     Present sound and reinforce at the same time

5.     Ask child to turn to the toy when sound is heard

6.     Repeat until 2 consistent clear head turn in obtain

7.     Present sound, wait child to turn and if there is a response present the reinforce immediately

8.     Distractor give social reinforcement on child response

VRA 3

Response State: Calm but restless and tired towards the end of the testing

Tranducer used: Insertphone on the left ear

Test ear : Left ear

Threshold obtain at :

1 kHz : 20dB

4 kHz : 30dB

500 Hz : 45dB

BOA

EXPECTED MRLS for 3 months is: 50-70 dbA

INTERPRETATION :

MRL : Elevated MRLS

1)      Elevated MRLs could due to the poor response state of the child

2)      Tympanometry type A with normal ECV

3)      NormalAPR

4)       Management :

- Review VRA at age 7-8 months

BOA 1

EXPECTED MRLS for 5 months is: 40-50 dbA

INTERPRETATION :

MRL : Elevated MRLS

1)      Tympanometry type B with normal ECV suggesting Otitis Media Effusion

2)      Absent APR

3)      Likely conductive hearing loss

4)      Management :

-Refer to ENT

-Conduct ABR

BOA 3

EXPECTED MRLS for 6 months is: 30-40 dbA

INTERPRETATION :

MRL : Normal MRLS

1)      Tympanometry type A

2)      Normal APR

3)      Management :

- VRA at age 7-8 months

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MUHAMMAD ZUL FAHMI BIN SHAIDATUL NOR AZHAR 1410901

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MUHAMMAD ZUL FAHMI BIN SHAIDATUL NOR AZHAR 1410901

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VRA

1.       Outline the procedure of VRA

-Give instruction to the caregiver (emphasize to caregiver not to lean their child and dont give any clue)

-Do audibility check at 1 kHz at 60 dB using warble tone (only do it once)

-Conditioning. Present narrow band or warble tone together with reinforcer (do it at least two times or more)

-Attempt testing with correct order of frequency (child must response two times)

Headphone/ Insertphone: 1K (R) > 4K (R) > 4K (L) > 1K (L) > 500 (L) > 500 (R) >2K (R) > 2K (L)

Free Field: 1K > 4K > 2K > 500

-Threshold seeking (descend 20 dB and up 5 dB, down 10 dB)

- write response in VRA worksheet

2.       Outline the process you would use to teach a child to do VRA

-Tester should condition the child by presenting the tone and reinforcer at the same time

-Distractor need to teach the child to turn to the sound when it present

-Use toys that is suitable to distract and play with the child during testing

-Give effective social reinforcement to encourage the child when they do it correct

-Repeat until child know and understand what to do

3.    Interprete the following VRA results and explain how you are going to plot your answer in the audiogram.

1kHz – 20 dB, 4kHz- 30 dB, 500 Hz – 45 dB (questionable response at 500 Hz)

Threshold is out of normal range for low frequency

BOA

1.       Interprete the following BOA and tympanometry results. Include in your answer suggestion of the hearing status and management.  (5 months)

INTERPRETATION: Elevated MRL, No APR observed, suggest SNHL, Type B Tympanogram with normal ECV suggesting OME

HEARING STATUS AND MANAGEMENT: conduct ABR testing and refer to ENT

2.    Interprete the following BOA and tympanometry results. Include in your answer suggestion of the hearing status and management. (3 months)

INTERPRETATION: Elevated MRL at some frequency and ear, may be due to poor response state, normal APR, Type A tympanogram suggesting normal hearing

HEARING STATUS AND MANAGEMENT: hearing review for VRA at 6-7months

3.       Interprete the following BOA and tympanometry results. Include in your answer suggestion of the hearing status and management. (6 months)

INTERPRETATION: normal MRL, normal APR, Type A tympanogram suggesting normal hearing

HEARING STATUS AND MANAGEMENT : hearing review for VRA at 7-8 months

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BOA 1

Expected MRL : 40 – 50 dBA

Interpretation:

BOA – Elevated MRLs, absent APR

Tym – Type B with normal ECV

Suggestion:

Likely conductive hearing loss

Management:

Refer to ENT, conduct ABR, review VRA at age 7-8 months

BOA

Expected MRL : 50 – 70 dBA

Interpretation:

BOA – Elevated MRLs (might be due to bad response state), normal APR

Tym – Type A

Suggestion:

No worse than a mild hearing loss in the better ear, possibly normal hearing

Management:

VRA at age 7-8 months

BOA 3

Expected MRL : 30 – 50 dBA

Interpretation:

BOA – Appropriate MRLs, normal APR

Tym – Type A

Suggestion:

No worse than a mild hearing loss in the better ear, possibly normal hearing

Management:

VRA at age 7-8 months

VRA 1

1.      Give instruction towards parents about the test procedure.

2.      Perform audibility check on patient by giving 1kHz stimulus at 60dB.

3.      Condition the patient to turn at the reinforcer when he hears the stimulus.

4.      Attempt testing to comfirm that the patient is already conditioned.

5.      Start threshold seeking of that patient.

6.      Record the result on VRA worksheet.

VRA 2

1.      The distractor must first build a rapport with the patient.

2.      Manipulate the patient’s response state.

3.      Start conditioning by giving stimulus and reinforcer simultaneously.

4.      Encourage patient to turn toward reinforcer when there is the stimulus.

5.      Give social reinforcement.

6.      Repeat several time until we are sure that the patient knows what to do.

VRA 3

Interpretation:

- Might have mild hearing loss at 4kHz.

- At 500Hz, shows MRL because of bad response state and there’s a lot of questionable responses.

Result (mark X at audiogram):

1kHz : 20dB

4kHz : 30dB

500Hz : 35dB

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BOA

Developmental age: 3Month       Expected MRL: 50-70dB         Response state: tired
Actual MRL: 50-70dB (elevated)
Tymp: Type A ( normal)
APR: Normal
Suggestion: Possibly normal
Management: VRA during 6 month

*MRL may elevated due to the poor response state of the child during the test is being taken

BOA 1

Developmental age: 5 Month         Expected MRL: 40-50dBA    Response state:awake
Actual MRL: 60-70dBA (elevated)
Tymp: Type B (ME effusion)
APR: No response
Suggestion: Conductive Hearing Loss
Management: Refer to ENT, ABR, Review VRA at age 7 Month

BOA 3

Dev age: 6 Month           Expected MRL:40dBA                             Response state: active
Actual MRL: 35-45dBA (appropiate)
Tymp: Type A (normal)
APR: Normal
Suggestion: Possibly normal
Management: VRA at age 7-8 months

VRA 1

Procedure VRA:
1) Give appropiate instruction to the caregiver of the child
2) Do the audibility check to get the audible initial presentation level of the child
3) Start conditioning: Presenting proper frequency and level of warble tone paired together with the reinforcer (simultaneously)
4) Attempt testing at least getting 2 responses once the condition is good
5) Seek for the threshold and prevent from presenting the stimulus too long inn order to avoid false positive.
6) Plot result in the VRA sheet

VRA 2

Process to teach child to do VRA:
1) Optimize response state of the child
2) Establish a rapport with the child
3) Use conditioning method to train child to turn to the reinforcer for every sound that he/she heard
4) Distract child with suitable toys
5) Avoid habituation
6) Apply trouble shooting during the test
7) Encourage prompt response using social reinforcement

VRA 3

Respose state: calm, restless and tired towards the end of testing
Transducer: insertphone
Test ear: left

Threshold:
1kHz : 20dB
4kHz:  30dB
500Hz:   45dB

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VRA 1

Outline procedure of VRA:

1.     Give appropriate instruction to caregiver.

2.     Establish audibility check to know an audible initial presentation level of child.

(Initial presentation: 1 kHz, Warble Tone, at 60dbHL, free field)

3.     Conditioning- train child by presenting an audible 1 kHz warble tone and reinforce paired together.

4.     Attempt testing - present tone and wait for child response, obtain at least 2 independent responses before testing.

5.     Threshold seeking-  descend in 20 dB then,  up 5dB and down 10 dB for threshold seek

6.     Record the result in VRA worksheet.

VRA 2

Outline the process used to teach child to do VRA:

·        Our aim is to teach child to turn head to look for sound.

·        We train them by presenting an audible 1 kHz warble tone and reinforce paired together.

·        In response to a correct head turn, visual reinforce in the form of animated toys will be shown to child.

·        We are encouraged to use social reinforcement in order to get maximal response from child.

·        When sound is not presented, child will play with the distractor in order to keep child attention to look front and to avoid random head turn.

·        Repeat until child understands what to do.

·        The process is called conditioning.

VRA 3

·        At frequency 1 kHz and 4 kHz, we manage to get threshold from child.

·        For 1 kHz, the threshold is 20 dB while for 4 kHz, the threshold is 30 dB.

·        At 500 Hz, the response is MRL because the child starts to get tired in the end of testing (not in good response state). There is also a lot of questionable response establish.

·        Indicate that at 500 Hz we get 45 dB as MRL.

·        Reliability- not so good at 500 Hz.

·        Test on left ear- so, plot X on audiogram.

BOA

Age: 3 months, expected MRL= 50-70 dbA

Result :

·        Elevated MRL

·        Tympanogram- Type A (normal)

·        APR- normal

Suggest- No worse than a mild hearing loss in better ear, possibly normal. SNHL can’t be ruled out.

MRL could be normal (within expected range) but during the test, the child is not in a good response state which is the child is sleepy and tired. Poor response state may affect the result obtained. We can get the best response when the child is awake and calm.

Management- VRA at 7-8 months

BOA 1

Age: 5 month, expected MRL (40-50 dbA)

Result :

•           Elevated MRL

•           Tympanogram- Type B with normal ECV suggest middle ear effusion

•           APR- no response

Suggest- conductive hearing loss, SNHL can’t be ruled out

Management- refer to ENT, Air and BC ABR, review VRA at age 7-8 months.

BOA 3

Age: 6 months, expected MR (30-40 dbA)

Result :

•           Elevated MRL

•           Tympanogram- Type A (normal)

•           APR- normal

Suggest- No worse than a mild hearing loss in better ear, possibly normal. SNHL can’t be ruled out.

MRL could be normal (within expected range) but during the test, the child is not in a good response state which is the child is active. Poor response state may affect the result obtained. We can get the best response when the child is awake and calm.

Management- VRA at 7-8 months

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LYDIA FARHANA BINTI MUSTAFAR RAMDZUAN 1412242

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LYDIA FARHANA BINTI MUSTAFAR RAMDZUAN 1412242

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BOA 1

Baby: 5 months old

Result

MRL: Elevated MRL
Tymp: Type B with normal ECV
APR: Absent APR

Suggest: It may suggest that the baby has conductive component and suggest to have conductive hearing loss

Management:

- Refer ENT
- Air and BC ABR at age 7-8 months
- Review VRA at age 7-8 months

BOA 2

Baby: 3 months old

Results

MRL: Elevated MRL
Tymp: Type A
APR: Normal APR

Suggest: It may suggest that the baby has SNHL but due to poor response state, a significant SNHL cannot be rule out.

Management:

-         VRA at age 6-7 months

-         ABR/ASSR/OAE for diagnosis

BOA 3

Baby: 6 months old

Results

MRL: Normal MRL
Tymp: Type A
APR: Normal APR

Suggest: It may suggest that the baby has no worse than a mild hearing loss in the better ear, possibly normal.

Management:

-         VRA at 9-10 months

VRA 1

Procedure of VRA

1.       Give instruction to the parents/caregivers about what are we going to do and ask them to give cooperation for the test.

2.       Do audibility check as it is done to know the appropriate initial presentation level for the initial conditioning to be audible for the child.

3.       Do conditioning by training the child at an audible 1kHz warble tone and reinforcer paired together. Repeat until the child understands what to do.

4.       As conditioning has been confirmed, attempt testing by presenting the tone at the same intensity and wait for a response.

5.       Do threshold seeking by descending 20dB. If there is no response ascends by 5dB until another response is observed. Use increase 5dB and down 10dB step to find the threshold. 2 out of 3 ascending is accepted as threshold.

6.      Record the test result on the VRA worksheet as it is the proof of response.

VRA 2

1.       Look at the state of the child on that day.

2.       Establish relationship with child.

3.       Interact with child to build rapport with the child.

4.       Distracts to control visual scanning and random head turning.

5.       Teach them to look at the toys when the tone is presented during conditioning.

6.       Repeat until the child is understand what to do on the test.

7.       Continues distraction during sound presentation to avoid cueing.

8.      Reward them with reinforcer, approval and encouragement when the childe give appropriate responses.

VRA 3

Response state : Calm but restless and tired towards the end of the testing

Tranducer used: Insertphone

Ear: Left ear

Results:

1kHz: 20dB
4kHz: 30dB
500Hz: 45dB

*mark X on the audiogram

Interpretation: The baby is good at conditioning and test at first. But, due to poor state of the baby at the end of the testing, the result is questionable especially at 500Hz.

*Audiogram for VRA 3

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VRA 3

1. Identify the threshold for each frequency tested. For VRA, the frequency tested was at 1kHz, 4kHz and 500Hz. If have ample time then only we tested at 2kHz.

-At 1 kHz, the threshold is at 20dB

-At 4 kHz, the threshold increased to 30dB

-At 500Hz, the threshold become 45dB. This is due to tiredness of the patient during the end of the testing.

2. Mark “X” on the audiogram to show the threshold of the patient.

VRA 2

1. Seat the child comfortably on a lap of the caregiver.

2. Face the child forward, the distractor should keep the child does not turn their head randomly to avoid getting the questionable response.

3. Start testing the child by doing the audibility check which present the sound above its threshold to see the response.

4.  After that, start with conditioning method which pairing the sound with the VRA toy to condition the child to respond whenever there is sound presented.

4. Start testing at 1kHz and when you get a response, make the sound softer. Keep making the sound softer until there are no more responses. Then start making the sounds louder until you see the response again(threshold seeking method).

5. Responses should be observed 2 out of 3 presentation before it is considered a response.

6. Continue testing at 4kHz and 500Hz, if the child is in good response state and have ample time,can continue testing at 2kHz.

7. Mark on the audiogram the result of the test.

VRA 1

1.      Before starting the test, give instruction to the caregiver about the purpose of your testing and what they should do.

2.      Start with audibility check by presenting warble tone,1kHz,60dB

3.      Then procede with the conditioning at least 2 response obtained. Present the tone with the reinforcer together.

4.      After we get a good conditioning, start with attempt testing by presenting the tone and wait for the child’s response.

5.      Use threshold seeking method to find the threshold by descend 10dB and increase 5dB if the child do not respond.

6.      Plot the child result on the VRA worksheet.

BOA 3

INTERPRETATION:

MRL: Appropriate ( expected MRL for 6 month baby is 40-50dBA).Obtained MRL ( 35-45dBA)

Tympanogram: Type A normal ECV, TPP, Peak Ytm.

APR: Present (100 eye blinks)

Suggest: no worse than mild hearing loss in the better ear, possibly normal.

Management: VRA at 7-8 months.

BOA

INTERPRETATION:

MRL: Appropriate ( expected MRL for 3 month baby is 50-70dBA). The obtained MRL is 70-75dBA which exceed the expected MRL by  5dBA. This maybe due to the poor response state of the child on that day.

Tympanogram: Type A with normal ECV, TPP, Peak Ytm.

APR: Present (90 eye blinks)

Suggest: no worse than mild hearing loss in the better ear, possibly normal.

Management: VRA at 7-8 months.

BOA 1

INTERPRETATION:

MRL: Elevated ( expected MRL for5 month baby is 40-50 dBA). But the obtained MRL for that day is worse than that ( 60-70 dBA )

Tympanogram: Type B with normal ECV.

APR: Absent (No respond at 105 dBA)

Suggest: Likely conductive hearing loss

Management: Refer to GP/ ENT,  Air and bone conduction ABR,  review VRA at 7-8 months.

# data[].attributes.body
BOA 1

5months, awake and calm
expected MRL : 40-50 dBA

INTERPRETATION
-Elevated MRL
-Abnormal APR
-Tympanometry : normal ECV (type B)

Suggest: possible middle ear effusion

-Refer to ENT as soon as possible
-Review VRA at the age between 6 months until 2.5 years old

BOA

3months, sleepy and tired
expected MRL : 50-70 dBA

INTERPRETATION
-Elevated MRL
-Normal APR
-Tympanometry : Type A (normal)

Suggest: Possible Sensorineural Hearing Loss

MX
-Do OAE, ABR & ASSR for further diagnosis
-Review VRA at the age of 6months

BOA 3

6months, active
expected MRL : 40-50 dBA

INTERPRETATION
-Normal MRL
-Normal APR
-Tympanometry : Type A (normal)

Suggest : No worse than a mild hearing loss in the better ear, possibly normal.

MX
-Review VRA at 7 to 8

VRA 1

1. History taking - ask & observe if the child has a good neck support or not and also good vision

2. Position the child at the calibrated spot

3. Give instruction to the parents

4. Check audibility (Observe the response of the child without giving any reinforcement)

5. Conditioning (Present tone & reinforcer simultaneously)

6. Attempt testing

7. Threshold seeking

8. VRA worksheet (To validate the response & as a proof of the response)

VRA 2
1. Make rapport with the child
2. Conditioning (teach to look at the toys when there is tone)
3. Use less interesting toys if possible in order to avoid the child from being distracted
4. But, if the child is lost of attention or bored, show the toys that he/she likes but do not let him/her touch it.
5.Praise the child when he/she does it well in the testing.

VRA 3
Response state : Calm but restless & tired towards the end of the testing
Transducer used : Insertphone on the left ear

Threshold:

1kHz - 20 dB
4kHz - 30 dB
500 Hz - 45 dB (there is questionable response)

Mark 'X' on the audiogram as the left ear is tested.

# data[].attributes.body
PROCEDURE OF VRA
1.Give explanation on how the testing will be conducted .Instruction is given to the child's parent or guardian.
2.Establish the child's audibility in order to know the appropriate initial presentation level.
3.Condition the child by pairing 1kHz warble tone and reinforcer.Repeat until the child understand what to do.
4.Attempt testing after conditioning is confirmed by obtaining at least 2 consistent response.Present at the same intensity level and observe the response.
5.Seek for threshold by descending 20dB until there is no response and ascend 5dB until there is response.Descend by 10 dB and ascend by 5 dB.
6.Take the threshold when there is 2 out 3 ascending response.
7.Do VRA worksheet to establish valid response.

PROCESS
1.Establish relationship with the child
2.The distractor should keep the child's attention to the front
3.Choose toys that interest the child
4.Condition the child until the child understands what to do

BOA 1
Elevated MRLs
Absent APR
Type B tympanogram with normal ECV
Suggestive conductive hearing loss
Management : refer to ENT/AP , AIR and BC ABR , Review VRA at 7 to 8 month

BOA
Elevated MRLs
normal APR
Type A typmpanogram with normal ECV
Suggestion : Result may be due to response state , hearing possibly normal
Management : VRA at 6-7 month

BOA 3
Appropriate MRLs
normal APR
Type A tympanogram with normal ECV
Suggestion : normal hearing or no worse than mild hearing loss
Management : 8-9 months

VRA 3
Left ear
Threshold at 500 Hz : 45 dB
Threshold at 1kHz : 20 dB
Thresold at 4khz : 30 dB

# data[].attributes.body
BOA

- Elevated MRL
- Type A indicates normal compliance and normal middle ear pressure
- Normal APR
- Suggest no worse than a middle hearing loss in better ear, possibly normal
- Management:  VRA at 7-8 months

BOA 1

- Elevated MRL
- Type B, suggestive of middle ear effusion
- Absent APR
- Suggest likely conductive hearing loss associated with ME effusion
- Management:  refer ENT, air and BC ABR, review VRA at age 7-8 months

BOA 3:

- Elevated MRL
- Type A indicates normal compliance and normal middle ear pressure
- Normal APR
- Suggest normal hearing
- Management: VRA at 7-8 months

VRA 1

1) Explain the procedure and reinforces to the parents and told them to avoid cueing
2) Establish audibility to know appropriate initial presentation level as initial              conditioning level must be audible to child
3) Condition the child by train child. Presenting an audible 1kHZ warble tone and reinforcer paired together
4) Attempt testing by confirm conditioning before descending by obtaining at least 2 consistent responses
5) Seek for threshold by descend by 20dB and present tone 2 to 3 seconds
6) Fulfill the VRA worksheet

VRA 2

1) Conditioning the child first by establish the rapport
2) Train the child to response toward the 1 kHZ of warble tone with paired reinforcer together
3)  Repeat the action until the child understand what he needs to do
4) The distracter needs to keep child get attention to the front and manipulate
children's response state
5) Distracts to control visual scanning and random head turning
6) Keep conditioning until the child have ability to elicit the response

VRA 3

1)  1kHZ:  20 dB
2)  2kHZ:  30 dB
3)  500HZ:45 dB

# data[].attributes.body
BOA 1

Elevated MRL
Type B tympanogram with normal ECV
Absent APR
Suggestion : Conductive hearing loss associated with middle ear effusion
Management : Refer to ENT, Air and BC ABR, Review VRA at 7-8 months

BOA

Elevated MRL
Type A tympanogram
Normal APR
Suggestion : no worse than mild hearing loss, due to child's poor response state
Management : VRA at 7-8 months

BOA 3

Appropriate MRL
Type A tympanogram
Normal APR
Suggestion : possibly normal hearing
Management : VRA at 7-8 months

VRA 1

1. Give an intsruction to the caregiver of the child. Explain the procedure and reinforcers. Caregiver also must avoid give a cue during the test.

2. do the audibility check to know the appropriate initial presentation level. (1KHz,Warble tone, 60 dbHL,Free Field).

3. do the conditioning. present the warble tone simultaneously with reinforcer. the distractor have to train the child to look the reinforce when hear the sound. do the conditioning until the child able to give appropriate response.

4. co firm the conditioning by start the attempt testing. present the tone and wait for child's response. get at least 2 independent responses before testing. if no independent response obtained, do the conditioning again.

5. start the threshold seeking. descend by 20 dB when the child give a response. (increase 5 dB when no response, decrease 10 dB when there is a response).

6. get the threshold and record in VRA worksheet.

VRA 2

1. distractor establish relationship with the child
2. interacts with the child during the test
3. optimize the response state of the child
4. choose appropriate toys for distraction.
5. do the troubleshooting when the child gives questionable response.

VRA 3

interpretation :

1KHz : 20 dBHL
4KHz : 30 dBHL
500 Hz : 45 dBHL

1kHz and 4kHz are threshold because 2 out of 3 responses on ascend is achieved.
500Hz is MRL because the child not in a good response state and presence of many questionable responses.

# data[].attributes.body
VRA 3

Interprete the following VRA results and explain how you are going to plot your answer in the audiogram.

- Response State : Calm but restless and tired towards the end of the testing

- Tranducer used: Insertphone on the left ear

1kHz                  4kHz                 500  Hz
60 C C C √ √        40 √                  60 √

40 √
30 √ √              45 √ √
25 √ x x           40 x ? x
20 √ √                20 x x x             35 ? x ? √ ? √
30 x
25 ? x

ANSWER:

I khz : threshold at 20 dbHL

4khz: threshold at 30 dbHL

500hz : MRL at 45dbHL

*1khz & 4khz are threshold because there is no response at below this level and always a response at above this level. At that frequency, there also has good response state.

*500hz is MRL due to the results shows a lots of questionable responses and the child is not good response state.

VRA 2

Outline the process you would use to teach a child to do VRA.

1)     Undergo conditioning process with the child

2)     By establish the relationship with the child.

3)     Train the child to response towards the sound that present at 1khz warble tone and reinforce paired together.

4)     Repeat until child understands what to do.

5)     The distracter need to keep attention of the child to the front.

6)      Keep conditioning until the child have the ability to elicit the response.

VRA 1

Outline the procedure of VRA.

1)     Give the appropriate instructions to the parents about what are going to do for this test.

2)     Do the audibility check by presenting the stimulus at 1khz at 60 db.

3)     Conditioning can proceed if the child give response during audibility check by training the child gives appropriate response while presenting an audible 1khz warble tone and reinforce paired together.

4)     Attempt testing at least 2 consistent responses after the conditioning achieved.

5)     Threshold seeking by descending 20 db until there is no response and ascend by 5db. if there is response descend by 10 db and ascending again by 5 db until 2 out of 3 ascending is accepted.

6)     Establish the VRA worksheet to proof the responses at behind audiogram sheet.

BOA 3

Interprete the following BOA and tympanometry results. Include in your answer suggestion of the hearing status and management.

|   Developmental  Age : 6 months  Response State : Active
|   Stimulus          |   R (dBA)                |   L (dBA)
|   Man. Rattle     |   40 Head Turn     |   35 Head Turn
|   “mmm”            |  45 Head Turn     |   45 Head Turn
|   “sh”                |   40 Head Turn      |   45 Head Turn
|   Drum              |  100 Eye Blinks

|                 |  SC  (ml) |   MEP  (dapa) |   ECV  (CM3)
|   Right     |   0.4       |   -150              |  0.7
|   Left       |   0.5       |   -120            |   0.6

Interpretations:

Appropriate MRLs :

Type A tympanogram with normal ECV, TPP (dapa) and peak ytm.

Normal APR

Suggest:

No worse than a mild hearing loss in the better ear, possibly normal.

Management:

VRA at 7-8 months

BOA

Interprete the following BOA and tympanometry results. Include in your answer suggestion of the hearing status and management.

|   Developmental  Age : 3 months  Response State : Sleepy and tired
|   Stimulus     |   R (dBA)       |   L (dBA)
|   Man. Rattle|   70 Startle     |  75 leg jerks
|   “mmm”       |   75 leg jerks  |   70 Startle
|   “sh”             |  75 Startle      |   75 leg jerks
|   Drum          |   90 Eye Blinks

|             |  SC  (ml)     |   MEP  (dapa)     |  ECV  (CM3)
|   Right   |   1.4           |   20                    |   0.7
|   Left     |   1.5           |   35                    |   0.6

Interpretations:

Appropriate MRLs

Type A tympanogram with normal ECV, TPP, peak ytm

Normal APR

Suggest:

No worse than a mild hearing hearing loss in the better ear, possibly normal.

Management:

VRA at 7-8 months

BOA 1

Interprete the following BOA and tympanometry results. Include in your answer suggestion of the hearing status and management.

|   Developmental  Age : 5 months  Response State : Awake and calm
|   Stimulus          |   R (dBA)                |   L (dBA)
|   Man. Rattle     |   60 Head Turn     |   65 Head Turn
|   “mmm”            |  70 Head Turn     |   70 Head Turn
|   “sh”                 |   65 Head Turn     |   60 Head Turn
|   Drum             |   105 No response

|                |  SC  (ml) |   MEP  (dapa) |   ECV  (CM3)
|   Right      |   NP        |   NP              |   0.4
|   Left        |   NP        |   NP               |   0.5

Interpretations:

Elevated MRLs

Type B tympanogram wth normal ECV suggested middle ear effusion

Absent APR

Suggest:

likely conductive hearing loss.

Management:

Refer to GP/ ENT,

Air and BC

Review VRA at age 7-8 months

# data[].attributes.body
VRA 1
1) Give instruction to the caregiver of the child by explaining on the procedure and reinforcers.

2) Establish audibility by applying audibility check in order to know the appropriate initial presentation which is need to be audible to the child.

3) Start conditioning the child by presenting an audible warble tone and reinforces paired together.

4) Attempt testing once the child is fully conditioned.

5) Threshold seeking by presenting the stimulus not too long in order to avoid false positive. Descend the stimulus by 20dB  step and ascend by 5dB step until the threshold is obtained.

6) Plot the result in VRA worksheet.

VRA 2
1) Establish relationship and interact with child.

2) Optimize child's response state.

3) Condition the child to turn to the reinforcer as they heard the stimulus.

4) Distract the child with suitable toys in order to make sure they didn't looking at the reinforcer even the stimulus is not presented.

5) Troubleshoot once child gives questionable response, loses conditioning and stop responding.

VRA 3
Response state : Calm but restless and tired towards the end of the  testing
Transducer : Insertphone
Test ear : Left

Result :
500Hz = 45dBHL
1kHz = 20dBHL
4kHz = 30dBHL

- The child has poor response state at the end of the testing that might affect the MRLs.
- 'X' is marked on the audiogram since the test ear is left ear.

BOA 1
Developmental age : 5 months
Response state : Awake and calm
Expected MRLs : 40-50dBA

Interpretation :
- Elevated MRLs
- Type B tympanogram
- Absent APR

Suggestion : Possible conductive problem suggesting conductive hearing loss

Management :
- Refer to GP/ENT
- Air and BC ABR
- Review VRA at age 7-8 months

BOA
Developmental age : 3 months
Response state : Sleepy and tired
Expected MRLs : 50-70dBA

Interpretation :
- Elevated MRLs that might due to poor response state of the child
- Type A tympanogram
- Normal APR

Suggestion : No worse hearing than a mild hearing loss in the better ear, possibly normal

Management :  VRA at age 7-8 months

BOA 3
Developmental age : 6 months
Response state : Active
Expected MRLs : 30-50dBA

Interpretation :
- Appropriate MRLs
- Type A tympanogram
- Normal APR

Suggestion :  No worse hearing than a mild hearing loss in the better ear, possibly normal

Management :  VRA at age 7-8 months

# data[].attributes.body
VRA

1. Give the instruction that explaining the procedure to parents on how the reinforcer (puppet) was used. Remind the parent not to give any cues while doing tests.

2. Test the child’s audible level so that the child able to be condition with audible intensity.

3. Start to condition the child by presenting the audible warble tone at 1KHz together with the reinforcer. Repeat the conditioning until child understands how to do it which minimum condition is 2 times.

4.  While to attempt testing, tell distracter so that there is no confusion and no longer conditioning the child. Attempt seeking is successful when there is 2 times consistence ascending times before descending.

5.  Seek the threshold by descend 20dB at first from the initial presentation which is 60dB. At least 2 out of 3 ascending response as threshold after descend 10dB and ascend 5dB. Present at 20-30dB lounder than adjacent threshold to test at new frequency.

6. Record the result using VRA worksheet as a proof of responses.

VRA 2

1.      Interact and build rapport with the child.

2.      try to optimum the child’s response state.

3.      Distract the child from random head turn and visual scanning.

4.      Keep the child attention to the front to the toys.

5.      Train the child by presenting audible warble tone at 1Khz together with the reinforcer.

6.      Use social reinforcement to encourage the prompt responses.

7.      Make sure the reinforcement should be effective for the child.

8.      Repeat until child reflex involuntary when hear sound and what to do.

VRA  3

Response state : calm but restless and tired toward the end of testing.

Transducer : insertphone

Ear : left

Result :

500Hz - 45 dBHL

1000 Hz - 20 dBHL

2000 Hz - 30 dBHL

the child has a poor response state toward the end of testing which then might affect the MRL on that day.

*Mark X at 1KHz & 4KHz indicate threshold of the child, however at 500Hz plot MRL due to a lot questionable responses of the child at the day.

BOA 3

Interpret the following BOA and tympanometry results. Suggest the hearing status and management

Developmental age  : 6 months (expected MRLs = 40dbA)

Response state   : active

The MRLs is appropriate

Tympanogram type A with normal Peak YTM, TPP and ECV

Normal APR = (100 Eye blinks)

Suggestion: No worse than a mild hearing loss in the better ear, possibly normal or sensorineural HL

Management: VRA at 7-8 months

5) BOA 2

Interpret the following BOA and tympanometry results. Suggest the hearing status and management

Developmental age : 3 months (expected MRLs = 50-70 dbA)

Response state  : sleepy and tired

Interpretation

The result obtained has exceeded the expected MRLs but by considering the child’s response state, the result is reliable

This finding may be due to child’s poor response state

Tympanogram type A with normal Peak YTM, TPP and ECV

Normal APR = (90 Eye blinks)

Suggestion: No worse than a mild hearing loss in the better ear, possibly normal or have SNHL

•Management: VRA at 7-8 months

6) BOA 1

Interpret the following BOA and tympanometry results. Suggest the hearing status and management

Developmental age  : 5 months (expected MRLs = 40-50dbA : MRLs obtained =60-70dbA)

Response state  : awake and calm

Interpretation

The result obtained has elevated MRLs

Tympanogram type B with 0.4 ECV and 0.5 ECV

Absent APR = (105 no response)

Suggestion: Possible conductive problem suggesting conductive HL and SNHL due to no reflex.

Management: Refer to ENT/GP, Air and BC ABR/ Review VRA at age 7-8 months

Do ABR

# data[].attributes.body
BOA

-Elevated MRL
-Tympanometry shows normal
-Present of APR

Suggest: Not worse than mild hearing loss in better ear.
Management: VRA 7-8 month

BOA 1

-Elevated MRL
-Tympanometry shows abnormal result
-Absent APR

Suggest: Likely to have conductive hearing loss
Management: Refer to ENT
Air and Bone ABR
Review VRA at the age 7-8 month

BOA 3

-Appropriate MRL
-Tympanometry is abnormal
-Present of APR

Suggest: Likely to have conductive hearing loss
Management: Refer ENT

VRA 1

1. Instruction
-Give instruction to the parent what we are going to do. Which is we will teach the child to turn the head to the puppet when there is sound stimulus. Parent should not do anything and cueing must be avoided.

2. Audibility check
-Test to check the sound is audible or not using NB noise, Warble, Rattle with initial presentation at 1kHz at 60dB.
-If no response, increase intensity level and try to another frequency.
-If clear head turn, reinforce immediately.
-If behaviour response, proceed with conditioning and no reinforcement.

3. Conditioning
-Tone + reinforcer paired together
-Repeat until the child understand what to do.

4. Attempt testing
-Conditioning must be confirmed with at least 2 consistent responses before descending.

5. Threshold seeking
-Descend 20dB
-Always reward appropriate response. Give reinforcement.
-If no response, ascend 5dB until another response observed. Descend 10dB and ascend 5dB for threshold seeking. 2 out of 3 ascending is accepted as the threshold.

6. VRA worksheet
-Noted the response to establish valid response.

VRA 2

-Always give the reinforcement to the child.
-Build a good relationship with the child.

VRA 3

-Plot the audiogram as:
1k Hz the MRL is 20dB
4k Hz is 30 dB
5k Hz is 45dB

The MRL of the child is not worse than mild hearing loss. However, there is excessive false positive  responses at 500Hz.

# data[].attributes.body
VRA 1

OUTLINE THE PROCEDURE OF VRA

1.      Instruction- the audiologist will explain on the procedure, reinforcers  and tell parents what they should or should not do before start the testing

2.      Audibility check- present appropriate initial presentation level as initial conditioning level must be audible to child. Initial presentation usually is at 1kHz at 60 dB.

3.      Conditioning- It is to train child by presenting an audible 1kHz warble tone and reinforce pair together until the child understand what to do.

4.      Attempt testing - present tone and wait for child’s response. Obtain at least 2 independent response before testing.

5.      Threshold seeking-  descend 20dB, if no response, ascend by 5 dB and descend 10 dB for threshold seek.2 out of 3 ascending is considered as threshold.

6.      VRA worksheet- record the result on VRA worksheet to establish valid response.

VRA 2- Outline the process you would use to teach a child to do VRA

1.      The distractor must build good interaction with child.

2.      Optimize the good response state of child such as grab their attention to distraction and not to play.

3.      Avoid cueing by giving continues distraction during sound presentation.

4.      Keeps child’s attention to front.

5.      Present the audible 1khz warble tone and reinforce paired together until the child fully conditioned.

6.      Stimulus must be interesting and audible.

7.      Repeat until child understand what to do and able to elicit appropriate response.

VRA 3 -  interprete VRA result and how to plot in audiogram.

Interpretation

The child is having normal hearing at the 1kHz and mild hearing loss at higher and lower frequency at left ear.  This finding may be due to poor response states towards the end of the testing.

Threshold in audiogram

1kHz -20

4kHz – 30

500Hz – 45

The (x) symbol is plotted in audiogram to indicate the left ear is being tested.

BOA 1- interprete Boa and tympanometry result. Include suggestion of hearing status and management.

BOA  result and tympanometry (5month):

The MRLs is elevated, the auropalpebral reflex (APR) is absent. Tympanogram is type B  suggesting middle ear disorder which cause conductive hearing loss at both ears.

Management

-Refer to ENT for the middle ear disorder

-Conduct objective test,OAE and ABR.

- review VRA at age 7-8

BOA – interprete BOA and tympanometry. Include suggestion of hearing status and management.

BOA and tympanometry result (3months):

Baby give consistent response to a range of stimuli at elevated levels. However, the auropalpebral reflex (APR) is normal. This finding may be due to poor response state of the baby. Tympanogram shows type A suggesting normal middle ear function. Thus, it suggest no worse than a mild hearing loss in better ear, possibly normal.

Management

Review VRA at 7-8 months.

BOA 3. - BOA – interprete BOA and tympanometry. Include suggestion of hearing status and management.

BOA and tympanometry result (6months):

Baby give consistent responses to a range of stimuli at level in range 40-50 which is appropriate MRLs. The auropalpebral reflex is normal .these result suggest no worse than a mild hearing loss in better ear. however, tympanogram shows type C suggesting Eustachian tube dysfunction.

Management.

Refer the baby to ENT .

# data[].attributes.body
(VRA1)
1-Instruction: explain the procedure     to patient
2-Audibility check: present the initial     tone at 60db,1kHz
3-Conditioning: pair stimulus with         reinforcer
4-Attemp testing: after conditioning     had been confirmed do attempt         testing at the same intensity n             frequency
5-Threshold seeking: descend by           20db n atleast 2 consistent                   response
6-Vra worksheet: mark to establish       valid respond

(VRA2)

1-determine the child response state
2-tester/distractor build rapport w the child
3-choose appropriate toys
4-do effective conditioning
5-give reinforcement
6-vary the tone/frequency/interval to avoid habituation

(VRA3)
Response state:calm but restless n tired toward the end of testing
Transducers:insertphone
Ear:left

Result:
500Hz – 45dbHL
1kHz – 20dbHL
4kHz –30dbHL
To plot on the audiogram mark (X) at the threshold for each F

(BOA1)

Elevated MRL and no response on APR with type B tympanogram w normal ECV

The patient likely to have conductive hearing loss
Mx: VRA (6-8months) ,refer to ENT

(BOA2)

Elevated MRL due to poor response state and normal APR with type A tympanogram
This suggest no worse than mild hearing loss on better ear
Mx: VRA (6-8months)

(BOA3)

Appropriate MRL and normal APR with type A tympanogram
This suggest no worse than mild hearing loss on better ear
Mx:review VRA at 7-8months

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NURSAKINAH BINTI ABDUL GHANI                        1417652

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NURSAKINAH BINTI ABDUL GHANI                        1417652

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VRA 1
Outline the procedure of VRA

1.     Give the instruction to the caregiver about the procedures and reinforcers.

2.     Make the audibility check to know the appropriate initial presentation level as initial conditioning level.

3.     Start to condition the child by presenting warble tone together with the reinforce.

4.     Attempt testing in order to confirm the conditioning by obtaining at least 2 responses.

5.     Seek the threshold by descending 20 dB. If there is no response, ascend 5 dB and descend 10 dB. Avoid presenting the stimulus for long duration.

6.     Plot the result in the VRA sheet.

VRA 2
Outline the process you would use to teach a child to do VRA

1. Distractor need to make a rapport with the child.

2. Train the child to turn to the toys when he / she heard the sound.

3. Use the suitable toys depending on the response state of the child.

4. Always give the appropriate encouragement or prompt response.

VRA 3
Interpret following results and explain how to plot in audiogram

-         Good response state in the beginning but at the end of testing, the child’s response state is poor due to restless and tired.

-         Transducer used is insertphone on the left ear.

-          Threshold :
1KHz    = 20dB
4KHz    = 30dB
500HZ  = 45dB
*mark X on the audiogram

BOA 1
Interpret the following BOA and tympanometry results. Suggest the hearing status and its management.

Developmental age : 5 months
Response state        : Awake and calm

Expected MRLs     : 40-50 dBA

Interpretation
• The result obtained is elevated MRLs
• Tympanogram is type B with normal ECV

• Has absent APR

•Suggestion:

May be middle ear effusion and possibly conductive hearing loss.

•Management:

Refer to ENT or GP, make ABR testing and review VRA at age 7-8 months

BOA
Interpret the following BOA and tympanometry results. Suggest the hearing status and its management.

Developmental age  : 3 months

Response state         : Sleepy and tired

Expected MRLs      : 50-70 dB

Interpretation
• The result obtained is elevated MRLs due to poor response state of the child but the result is

still reliable.
• Tympanogram is type A with normal middle ear function.

• Has normal APR.

• Suggestion:

No worse than a mild hearing loss in the better ear, possibly normal.

• Management:

Review VRA at 6-7 months

BOA 3
Interpret the following BOA and tympanometry results. Suggest the hearing status and its management

Developmental age  : 6 months

Response state         : Active

Expected MRLs      : 30-40 dB

Interpretation
•• The result obtained is elevated MRLs due to poor response state of the child but the result is

still reliable. The MRLs is appropriate.
• Tympanogram is type A with normal middle ear function.

• Has normal APR.

• Suggestion:

No worse than a mild hearing loss in the better ear, possibly normal.

• Management:

Review VRA at 6-7 months

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BOA

Developmental age: 3 months

Response state:  Sleepy and tired

Expected MRLs: 50 – 70dBA

Interpretation:

-Elevated MRLs

-Type A tympanogram with normal middle ear function

-Normal APR

Suggestion: probably normal hearing or no worse than mild hearing loss although the                       MRLs is elevated  that might be due to poor response state (sleepy and                             tired).

Management: Review for VRA at 6-7 months.

BOA 1

Developmental age: 5 months

Response state:  Awake and calm.

Expected MRLs: 40 - 50dBA

Interpretation:

-Elevated MRLs

-Type B tympanogram with normal ECV.

-Absent of APR

Suggestion: Suggest middle ear effusion probably with conductive hearing loss.

Management:

- Refer to ENT/GP

-Review for VRA at 7-8 months

-ABR for diagnosis

BOA 3

Developmental age: 6 months

Response state:  Active

Expected MRLs: 30 - 40dBA

Interpretation:

-Elevated MRLs

-Type A tympanogram with normal middle ear function.

-Normal APR

Suggestion: probably normal hearing or no worse than mild hearing loss although the                        MRLs is elevated  that might be due to poor response state (active).

Management: Review VRA at 8-9 months.

VRA 1

1) Give the instruction and explain the procedure and reinforcers regarding the test to the parents.

2) Establish the audibility check so that the appropriate initial presentation level will be presented to the child and to make sure the stimulus is audible during the conditioning.

3) Teach the child to response by presenting an audible warble tone at 1 kHz frequency and paired together with the reinforcer.

4) Attempt testing when the child is fully conditioned by presenting the stimulus at the same intensity level for at least 2 consistent responses.

5) Start for the threshold seeking by descend 20dB at first and if there is no response, use the 5dB up and 10dB down steps,2 out of 3 ascending is accepted as the threshold.

6) Record the result in the VRA sheet.

VRA 2

1) Train the child by presenting an audible 1 kHz warble tone and paired together with the reinforcer.

2) Use the social reinforcement as a way to encourage prompt responses.

3) The step is repeated until the child understands what to do and the have ability to elicit appropriate response.

VRA 3

Response state: Calm but restless and tired towards the end of the testing.

Transducer used: Insertphone on the left ear

Interpretation: The child has good response state at the start of the testing and become poorer towards the end of the testing. The conditioning is easily established but it decrease through the testing process. The responses are reliable.

Result:

|   Frequency     |   Threshold
|   500Hz               |   45dBHL
|   1000Hz            |   20dBHL
|   4000Hz             |   30dBHL

-Mark ‘X’ on the audiogram to show the left ear is being tested.

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VRA 1 Outline the procedure of VRA.

1.      Positioned patient.

2.      Give instruction.

3.      Make audibility check.

4.      Conditioning.

5.      Attempt testing until obtain at least 2 independent responses before testing.

6.      Threshold seek by descending 20 dB and then up 5 dB and down 10 dB for      threshold seeking.

7.      Record the result on VRA worksheet.

VRA 2 Outline the process to teach a child to do VRA.

Conditioning process will be used to teach a child to do VRA. The child will be trained by presenting an audible 1 kHz warble tone and reinforcer together. Then, social reinforcement will be given in order to encourage prompt responses. The conditioning process will be repeated until the child understands what to do. Conditioning can be achieved by less than eight trials and even less for younger children.

VRA 3 Interprete VRA results and explanation on how to plot result on audiogram.

-         Response state: good at initial but poor toward the end of testing.

-         Easy to be conditioned, only 3 times.

-         Threshold at 500 Hz is 45 dB.

-         Threshold at 1kHz is 20 dB.

-         Threshold at 4kHz is 30 dB.

-         Then, plot the value of thresholds as stated above as ‘X’ on the audiogram at the 500 Hz, 1kHz and 4kHz since it is left ear.

BOA 3 months.

-         Elevated MRL due to poor response state.

-         Tympanograms Type A, suggested normal middle ear function.

-         Normal APR.

-         Suggests: no worse than a mild hearing loss in the better ear, possibly normal.

-         Management: review VRA at age 6-7 months.

BOA 5 months.

-         Elevated MRL.

-         Tympanogram Type B with normal ear canal volume (ECV), suggested middle ear effusion.

-         Absent APR.

-         Suggests: middle ear effusion probably with conductive hearing loss.

-         Management: refer GP/ENT, do ABR, review VRA at age 7-8 months.

BOA 6 months.

-         Elevated MRL.

-         Tympanogram Type A with normal middle ear condition.

-         Normal APR.

-         Suggests: no worse than a mild hearing loss in the better ear, possibly normal.

-         Management: review VRA at age 8-9 months.

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VRA 1

1.       Give instruction that explain the procedure and reinforcers used, politely ask the parents to avoid cueing.

2.       Get the child’s audibility to have the appropiate initial presentation level as the conditiong stimulus should be audible.

3.        Train the child by presenting the audible warble tone at 1KHz together with the reinforcer. Repeat the conditioning until child understands how to do it.

4.       Attempt testing to confirm the conditioning by obtaining at least 2 consistent responses before descending.

5.       Seek the threshold by descend 20dB at first. Get at least 2 out of 3 ascending response as threshold after descend 10dB and ascend 5dB. Present at 20-30dB lounder than adjacent threshold to test at new frequency.

6.       Record the result using vra worksheet as a proof of responses.

VRA 2

1.      Interact and build relationship with the child.

2.      Optimize child’s response state.

3.      Distract the child from random head turn and visual scanning.

4.      Keep the child attention to the front.

5.      Train the child by presenting audible warble tone at 1Khz together with the reinforcer.

6.      Use social reinforcement to encourage the prompt responses.

7.      Make sure the reinforcement should be effective for the child.

8.      Repeat until child understand what to do.

VRA 3

Response state : calm but restless and tired toward the end of testing.

Transducer : insertphone

Ear : left

Result :

500Hz - 45 dBHL

1000 Hz - 20 dBHL

2000 Hz - 30 dBHL

-the child has a poor response state toward the end of testing that might affect the MRL.

BOA 1

Response state : awake and calm.

Result :

-         Elevated MRL

-          type B tympanogram with normal ECV

-         Absent APR

Suggestion : likely conductive hearing loss.

Management :

-         Review VRA at 7-8 months

-         Refer to ENT

-         ABR

BOA 2

Response state : tired and sleepy.

Result :

-         Elevated MRL

-          type A tympanogram

-         Normal APR

Suggestion : no worse than mild hearing loss at better ear, possibly normal although the MRL elevated  due to poor response state.

Management : VRA at 6-7 months.

BOA 3

Response state : active.

Result :

-         Elevated MRL

-          type A tympanogram

-         Normal APR

Suggestion : possibly normal and no worse than mild hearing loss on better ear.

Management : VRA at 8-9 months.

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ZAHIRATUL NADYAH BINTI ZURAIDY (1414678)

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ZAHIRATUL NADYAH BINTI ZURAIDY (1414678)

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BOA 1

Developmental age : 5 months
Response state : Awake and calm
Expected MRLs : 40-50 dBA

Interpretation:
- Elevated MRLs
- Type B tympanogram with normal ECV
- Absent APR

Suggestion:
- presence of conductive component in ear, possibly middle ear effusion
- likely to be conductive hearing loss

Management:
- refer to ENT doctor
- air and BC ABR
- review VRA at 7-8 months

BOA

Developmental age : 3 months
Response state : Sleepy and tired
Expected MRLs : 50-70 dBA

Interpretation:
- Elevated MRLs
- Type A tympanogram
- normal APR

Suggestion:
- may due to child's poor response state
- no worse than a mild hearing loss a least in better ear, possibly normal hearing

Management:
- VRA at 7-8 months

BOA 3

Developmental age : 6 months
Response state : Active
Expected MRLs : 30-50 dBA

Interpretation:
- appropriate MRLs
- Type A tympanogram
- normal APR

Suggestion:
- no worse than a mild hearing loss at least in better ear, possibly normal hearing

Management:
- VRA at 7-8 months

VRA 1

1. Explain on instruction for the procedures and reinforcers to the parents.
2. Establish audibility to know the appropriate initial presentation level to the child
3. Condition the child by presenting an audible warbled tone at the frequency and reinforcer being paired together
4. Attempt testing after the child has been fully conditioned by descending the intensity level and obtaining at least two consistent responses
5. Seek for threshold by using the 5-dB up and 10-dB down steps, 2 out of 3 ascending consistent responses are considered as threshold
6. Record the result in VRA worksheet

VRA 2

1. Establish rapport with child
2. Optimize child's response state
3. Train child to turn to the reinforcer for each sound heard by the child
4. Distract the child from keep looking at the reinforcer when the sound is not presented
5. Troubleshoot immediately when the child gives questionable responses, stops responding or loses conditioning

VRA 3

Response state : Calm but restless and tired towards the end of testing
Transducer : Insertphone on the left ear

Interpretation :
Threshold at 1kHz : 20 dB
Threshold at 4kHz : 30 dB
Threshold at 500Hz : 45 dB

- could be affected by the child's response state; child has lost conditioning
- may be has mild hearing loss at the left ear

Audiogram:
- mark "X" on the audiogram

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QUIZ 1 : PAEDIATRIC

1) VRA 3
Interpret following results and explain how to plot in audiogram

Response state   : calm but restless and tired towards the end of testing
Transducer : insertphone
Test ear : left

Threshold :
1KHz    = 20dB
4KHz    = 30dB
500HZ  = 45dB
*mark X on the audiogram

2) VRA 2
Outline the process you would use to teach a child to do VRA

1. Optimize the response state of the child
2. Establish a rapport with the child
3. Use conditioning method to train the child to turn to the reinforcer  for every sound the child heard
4. Distract the child with suitable  toys
5. Avoid habituation
6. Can apply troubleshooting during the test
7. Encourage prompt responses using social reinforcement

3) VRA 1
Outline the procedure of VRA

1. Giving an appropriate instruction to the caregiver of the child

2. Applying the audibility check to identify the suitable and audible initial presentation level of the child

3. Start conditioning by presenting a proper frequency and level of warble tone paired together with the reinforcer

4. Attempt testing at least by obtaining 2 responses once the conditioning is good enough

5. Seek for threshold and prevent from presenting the stimulus too long to avoid false positives. Descend stimulus to 10dB and ascend 5 dB until threshold is obtained

6. Plot the result in the VRA sheet

4) BOA 3
Interpret the following BOA and tympanometry results. Suggest the hearing status and management

Developmental age  : 6 months (expected MRLs = 40dbA : MRLs obtained =35-45dbA)
Response state   : active

Interpretation
•The MRLs is appropriate
•Tympanogram type A with normal Peak YTM, TPP and ECV
•Normal APR = (100 Eye blinks)
•Suggestion: No worse than a mild hearing loss in the better ear, possibly normal
•Management: VRA at 7-8 months

5) BOA
Interpret the following BOA and tympanometry results. Suggest the hearing status and management

Developmental age : 3 months (expected MRLs = 50-70 dbA : MRLs obtained =70-75 dbA)
Response state  : sleepy and tired

Interpretation
•The result obtained has exceeded the expected MRLs but by considering the child’s response state, the result is reliable
•This finding may be due to child’s poor response state
•Tympanogram type A with normal Peak YTM, TPP and ECV
•Normal APR = (90 Eye blinks)
•Suggestion: No worse than a mild hearing loss in the better ear, possibly normal
•Management: VRA at 7-8 months

6) BOA 1
Interpret the following BOA and tympanometry results. Suggest the hearing status and management

Developmental age  : 5 months (expected MRLs = 40-50dbA : MRLs obtained =60-70dbA)
Response state  : awake and calm

Interpretation
•The result obtained has exceeded the expected MRLs  (elevated MRLs)
•Tympanogram type B with 0.4 ECV and 0.5 ECV
•Absent APR = (105 no response)
•Suggestion: Possible conductive problem suggesting conductive HL
•Management: Refer to ENT/GP, Air and BC ABR/ Review VRA at age 7-8 months

*audiogram for VRA 3

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Assalammualaikum all,

Below are the questions for BOA and VRA. Please answer the question as if you are answering an exam question.

Please answer the question by 3rd March. I'll comment on Friday 4th March and make the padlet public until 7th of March. Please make use of all the info in this padlet.

I'll comment on the answer and how your style of answering. Hopefully it will benefit you tremendously.

Thank you and good luck!!!

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Interprete the following VRA results and explain how you are going to plot your answer in the audiogram.

- Response State : Calm but restless and tired towards the end of the testing

- Tranducer used: Insertphone on the left ear

1kHz                    4kHz                   500  Hz
60 C C C √ √        40 √                    60 √

40 √
30 √ √                45 √ √
25 √ x x             40 x ? x
20 √ √                  20 x x x             35 ? x ? √ ? √
30 x
25 ? x

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Outline the process you would use to teach a child to do VRA.

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Outline the procedure of VRA.

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Interprete the following BOA and tympanometry results. Include in your answer suggestion of the hearing status and management.

|   Developmental  Age : 6 months  Response  State : Active
|   Stimulus          |   R (dBA)                |   L (dBA)
|   Man. Rattle     |   40 Head Turn     |   35 Head Turn
|   “mmm”            |   45 Head Turn     |   45 Head Turn
|   “sh”                  |   40 Head Turn      |   45 Head Turn
|   Drum              |   100 Eye Blinks

|                 |   SC  (ml) |   MEP  (dapa) |   ECV  (CM3)
|   Right     |   0.4         |   -150              |   0.7
|   Left       |   0.5         |   -120              |   0.6

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Interprete the following BOA and tympanometry results. Include in your answer suggestion of the hearing status and management.

|   Developmental  Age : 3 months  Response  State : Sleepy and tired
|   Stimulus     |   R (dBA)         |   L (dBA)
|   Man. Rattle|   70 Startle     |   75 leg jerks
|   “mmm”       |   75 leg jerks  |   70 Startle
|   “sh”             |   75 Startle      |   75 leg jerks
|   Drum          |   90 Eye Blinks

|             |   SC  (ml)     |   MEP  (dapa)     |   ECV  (CM3)
|   Right   |   1.4             |   20                      |   0.7
|   Left     |   1.5             |   35                      |   0.6

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Interprete the following BOA and tympanometry results. Include in your answer suggestion of the hearing status and management.

|   Developmental  Age : 5 months  Response  State : Awake and calm
|   Stimulus          |   R (dBA)                |   L (dBA)
|   Man. Rattle     |   60 Head Turn     |   65 Head Turn
|   “mmm”            |   70 Head Turn     |   70 Head Turn
|   “sh”                   |   65 Head Turn     |   60 Head Turn
|   Drum               |   105 No response

|                |   SC  (ml) |   MEP  (dapa) |   ECV  (CM3)
|   Right      |   NP          |   NP                |   0.4
|   Left        |   NP          |   NP                 |   0.5