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OTOACOUSTIC EMISSIONS

KUNNAMPALLIL GEJO JOHN BASLP,MASLP AUDIOLOGIST


KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Otoacoustic Emissions
Thomas Gold (1948)

Suggested active elements related to hair cells and feedback system could produce emissions

David Kemp (1978)

Demonstrated existence of evoked otoacoustic emissions


KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Anatomy of the ear

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Origins of Otoacoustic Emissions


The cochlea functions as a sensitive nonlinear, bio-mechanical amplifier Active cochlear processes known as the cochlear amplifier are responsible for high sensitivity, sharp tuning & wide dynamic range of the cochlea OAE are thought to be a by-product of this cochlear amplifier
KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Origins of Otoacoustic Emissions

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Physiologic Factors effecting Otoacoustic Emission Testing External ear

If the ear canal is blocked with cerumen or vernix, may not be able to record OAE even though it was produced by the cochlea .

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Physiologic Factors effecting Oto-acoustic Emission Testing Middle ear

must rule out middle ear dysfunction if OAE is abnormal negative pressure,retracted TM, excessive compliance of m.e. system, fixation of ossicles, otitis media The anatomy of the middle ear is helpful for inward propagation of sound only. There is about a 15 dB loss of intensity for outward propagation of sound in the normal ear.
KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Physiologic Factors effecting Oto-acoustic Emission Testing- Cochlea

The outer hair cells are the source of OAEs. Shearing effect causes receptor potentials to trigger ionic changes. The cells respond by lengthening and shortening at the frequency of the stimulus. This is what we record. Complete loss of OHC elevates threshold 4050 dB. OHC are susceptible to inflammation, ototoxicity, trauma, acoustic trauma. ototoxic drugs (Remember, this is a test of outer hair cell function only, some KUNNAMPALLIL GEJO JOHN, BASLP,MASLP ototoxic drugs affect only inner hair cells)

Physiologic Factors effecting Oto-acoustic Emission Testing Stria vascularis

provides energy to cochlea Decreased blood supply affects OHC motility. Some drugs (e.g. lasix) affect stria vascularis.

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Physiologic Factors effecting Oto-acoustic Emission Testing Efferent auditory system

Inhibitory system Stimulating the efferent fibers suppresses OHC activity. OAE may be larger in infants than adults because the efferent nervous system is not mature yet.

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Classes of Otoacoustic Emissions


Spontaneous
only occur in 50% of normals present more in women than in men can effect Evoked OAE since EOAE rides on SOAE Evoked observed in almost 100% of normals
KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Evoked Otoacoustic Emissions


Transient

produced by click or tone burst produced by continuous pure tone produced by 2 continuous pure tones
KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Stimulus frequency

Distortion product

Measurement Techniques
Measurement Techniques
Distortion Product Otoacoustic Emissions (DPOAE)

Bio -logic S ystems Co rp.

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

DPOAE/TEOAE

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

DPOAE measurement
Stimulus- two pure tones presented simultaneously producing intermodulary distortion F1 is the lower frequency (more apical). L1 is intensity of F1. F2 is the higher frequency (more basal). L2 is intensity of F2.

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Frequency F2;F1 Use a ratio which produces the highest amplitude of the DPOAE response e.g. F2/F1= 1.2 Measure the DPOAE at 2F1-F2. e.g. F1= 2,000, F2 =2,400 DP= 1,600 2(2,000) - 2,400=1,600 upper limits DPOAE: can test up to 10,000 Hz (F2) testing with F2 below 1,000 Hz is difficult due to physiological noise. Remember, DP is measured at a lower frequency than F2 KUNNAMPALLIL GEJO JOHN,
BASLP,MASLP

Intensity L2;L1

L1 and L2 must be at moderate intensity level Avoid high intensity (>70dB) which will cause false negative due to passive distortion of the BM best responses recorded when L2 is about 10 dB less than L1 recommendation: L1=65 dB, L2= 55 dB

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

DPOAE Analysis

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

DPOAE analysis
For an intensity ratio of F1=F2+10 dB, the response from the cochlea is generated at the F2. So, use F2 as horizontal axis on the DP gram For an intensity ratio of F1=F2, the response from the cochlea is generated near the geometric mean of F1 and F2 So, use geometric mean as horizontal axis on the DP gram.
KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

DPOAE analysis
DP should exceed noise floor by at least 6 dB to be valid. absolute value of normal DP varies by frequency (see normative data in OAE program) When comparing DPOAE to an audiogram, try to obtain F2 as close to audiometric frequency as possible, can use more points/octave.
KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

TEOAE collection
Collection

Stimulus- click Equal energy at all frequencies (1,500- 5,000)

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

TEOAE analysis
reproducability- related to TE-NF

overall by frequency band may set up pass refer criteria based on reproducability

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Beginning to test

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Test procedure Reduce noise in test area as much as possible. If possible, perform otoscopic exam (probably not possible in neonates). If patient is old enough to follow instructions, ask patient to remain quiet and still. Clip probe to patients clothing or other stationary object to cut down on noise. Insert probe in ear canal as deeply as possible (be careful not to canal probe). ...

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Test procedure(cont.)

do not need to test in sound booth, but environmental noise ldo not need to test in sound booth, but environmental noise levels should be as low as possible can test with patent PE tubes, helpful to have patient hold their breath during the test levels should be as low as possible can test with patent PE tubes, helpful to have patient hold their breath during the test
KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

New Patient File...

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Patient Information

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Reset hardware
(optional)

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Begin Collection

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Setup

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Select Protocol

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DPOAE Collection Setup Parameters

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DPOAE Advanced Setup Parameters

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

TEOAE Collection Parameters

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

TEOAE Advanced Collection Parameters

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

DPOAE display Setup

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TEOAE Display Parameters

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Open Patient Data File

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Right/Left Side by Side

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Superimposed

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Separate

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

File names
example 98J20D00
98= year J= 10th month (Oct.) 20= date D= distortion product otoacoustic emission

(T= Transient otoacoustic emissions)

00= first test done that day

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Reference data for DPOAE


Use normative data to analyze patients response Is the amplitude of the response within the normal region for that frequency?
There is a large degree of variability in amplitude even within the normal population Must use use same collection parameters when using a set of normative data. Use normative data collected on same type of equipment you are using
KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Viewing Scout Windows DPOAE

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Pass/ Refer

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Reference Data

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Analysis-Activate Display Setup

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Expanded Boys Town

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Expanded boys Town- normal


DP above the top lines suggests normal OAE function and therefor probably suggests normal hearing since so few impaired fall at or above the top lines

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Expanded Boys Town- abnormal


DP below the bottom lines suggests abnormal OAE function or inability to measure a response (middle ear) since so few normals have amplitude that low. i.e. DP approximately equal to NF

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Expanded Boys Town-indefinite


Between the 2 sets of lines, there are normals with low amplitude DP or hearing impaired with robust emissions. probably not worse than mild loss

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Transient Test Protocol

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TE Screen Protocol

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Practice

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Practice Information

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Troubleshooting
Confirm that actual stimulus intensities plotted are close to target stimulus intensities. If not, be sure probe is still in ear and tubes are attached between speaker and mike assemblies. Check spectrum of stimulus in ear to be sure that there are no large dips in ear canal acoustics. If there large dips in stimulus spectrum that the system cannot compensate for, try refitting probe in ear. if no sound or very low intensity sound is emitted from probe, clean probe by removing mike from back of probe and insert cleaning tool in mike port and 2 speaker ports
KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Factors to consider when interpreting OAE measurements


May fail OAE and be audiometrically normal. Can see the effect of excessive noise exposure in OAE even if not seen in the audiogram (early warning sign). May loose 20-30% of OHC and audiogram will be the same Cannot use audiogram normal cut off of 20dB when comparing to OAE since if audiometric threshold is 20dB, it is actually 4 standard deviations from zero

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Factors to consider when interpreting OAE measurements (cont.)...


Standing waves in ear canal can cause interference in DP of up to 20 dB, especially in high frequency (>7 kHz) Replicate- If questionable response is obtained, remove probe tip and replace it. If standing wave, responses will be out of synch OHCs are pre-neural structures, so it is possible to have no behavioral response to sound, no ABR and normal Otoacoustic emissions (auditory neuropathy). This is very rare, however.
KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Age/Gender
Neonates have larger OAEs till one year after birth At 30 weeks gestational age cochlea is mature (assuming normal development) Advancing age does not affect OAE (corrected for hearing loss) Gender a factor only for Transients or Spontaneous, but not Distortion Products but not Distortion Products(females stronger TEOAEs than KUNNAMPALLIL males) GEJO JOHN,
BASLP,MASLP

Applications
Neonatal hearing screening Preschool and school age hearing screening Ototoxicity Functional hearing loss Cochlear v.s. Retro-cochlear Monitoring noise exposure Tinnitus (confirms cochlear dysfunction)
KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

Neonatal hearing screening


Test at least 24 hours after birth, if possible, to prevent false positives due to vernix. If infant fails, re-test at least one more time before discharge If one ear fails, try to have baby lay so that the failed ear is facing up for a while to clear vernix before retest. Only need to retest failed ear OK to test while infant is nursing Baby may have middle ear effusion
KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

92587 Evoked Otoacoustic emissions, limited (single stimulus level, either transient and/or distortion products 92588 Evoked Otoacoustic emissions, comprehensive or diagnostic evaluation (comparison of transient and/ or distortion product Otoacoustic emissions at multiple levels and frequencies contact insurance companies to see what they reimburse in your area
KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

CPT codes

AuDX Hardware Options


AuDX I one protocol, not programmable 10 test memory, label printer AuDX II three protocols, programmable via software 50 test memory (option for 100 test memory) label printer option, AuDX link option Data Link option, HATS AuDX database option

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

AuDX Hardware Options(cont.)


AuDX Plus three protocols, programmable via software 50 test memory (option for 100 test memory) compatible with Scout OAE software for PC-based collection label printer option Data Link option, HATS AuDX database option
KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

AuDx Link

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Select file

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AuDX Link DP-gram

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AuDX Data link


To share information with OZ Sims program

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP

What should you do if you are having an equipment problem?


NO

YES

KUNNAMPALLIL GEJO JOHN, BASLP,MASLP