- 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     

                 

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.

 

 

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.

 

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.

 

 

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 

 

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.

 

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.

 

 

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.

 

-         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.

-         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.

-         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.

                     

          

  

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.

 

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

 

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.

 

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.

 

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.

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.

 

   ���

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.

 
 

-         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 

 

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 .

 

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 

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                    

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     

 

Appropriate MRLs : 

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

Normal APR 

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

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     

 

Appropriate MRLs

Type A tympanogram with normal ECV, TPP, peak ytm

Normal APR

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

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     

 

Elevated MRLs

Type B tympanogram wth normal ECV suggested middle ear effusion

Absent APR

likely conductive hearing loss. 

Refer to GP/ ENT, 

Air and BC 

Review VRA at age 7-8 months

  

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.

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. 

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.  

Baby: 5 months old

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 

 

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. 

-         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. 

-         VRA at 9-10 months

 

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.

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.  

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

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

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

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

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

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.

 

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.
 

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

1.       Outline the procedure of VRA

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

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

BOA

 

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

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

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

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

 

 

 

 

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.

 

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.

 

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.

 

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

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.

 

 

 

 

  

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

 

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

 

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

 

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

 

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

 

 
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.