Welcoming Some New Additions Kelly A. Baroch, Au.D. Infant Hearing - PowerPoint PPT Presentation

Diagnostic ABR: Welcoming Some New Additions Kelly A. Baroch, Au.D. Infant Hearing and Inpatient Program Coordinator Cincinnati Children’s Division of Audiology

Cincinnati Children’s Caring for children from all 50 states and over 57 countries

Five Outpatient Clinics Offering Diagnostic ABR Over 850 outpatient annually

Cincinnati Children’s

32 Surgical Suites Over 1300 inpatient ABRs last fiscal year

Challenges of Diagnostic ABR • Accuracy • Speed • Quality Control • Consistency

Efficiency in Diagnosis • The goal should be to achieve a complete assessment within one test session. – What information do you need to answer the question or establish a baseline for monitoring? • Reducing test time: – speeds the access to amplification, – allows more infants to be seen by each clinic – reduces repeat and missed appointments – LTF!!!!! – reduces parental anxiety while waiting for results – saves health care $$$ and much more. • Early access to amplification is KNOWN to improve the communication outcomes of children with hearing loss. • There may be no more important outcome than to expedite early intervention. • Detection of hearing loss, degree and type, as quickly and as early as possible. (For all ABRs!!!! Outpatient, Inpatient, OR)

Diagnostic ABR at CCHMC – Where We’re Headed ABR QI at CCHMC 2011 2015 2017 ABRs Reviewed 764 660* 660* Incomplete ABR at Initial Evaluation 26% 11% 5% (200) (73) (33) *Random sample of five ABRs per ABR audiologist per month • 2011-2015 • Overhaul of ABR technology at all locations • Education!!! (focused on technology, BC ABR, infant sleep state) • 2015-2017 • Revised protocol • Education!!! (focused on protocol training, transition to 2 channel ABR, BC testing/masking In addition, anesthesia time studies on GA ABR cases show that, with equipment and protocol changes, ABR test time decreased from an average of 45 to 37 minutes.

A little bird told us…( chirp,chirp)

What We Know About Clicks and Tonebursts: • Clicks and tonebursts (TBs) used in ABR haven’t changed much since the 1980’s. • The auditory evoked response relies on the rapid “synchronous” firing of the auditory nerve to generate a tiny electrical signal which can be averaged and recorded. • Requires a very brief stimulus to ensure neural synchrony and a well defined waveform. • Narrow band stimuli have a longer duration which “smears” the ABR, especially at low frequencies.

History of Chirps • First described in the literature by Shore & Nuttal in 1985 • In 2007, the CE Chirp was introduced by Elberling and Don, later developed narrow band CE Chirp (frequency specific). • CE Chirp attempts to overcome the temporal smearing by compensating for the cochlear travelling wave delay. Lower frequencies are presented before higher frequencies so all frequencies arrive at their optimal response position on the basilar membrane simultaneously – improved synchronized firing – larger response amplitudes.

Ferm et al 2013 • 30 babies (42 ears) for each study • Tested with tone pips and NB CE Chirps at 1000 Hz and 4000 Hz • Wave V amplitudes with chirps were significantly increased when compared to tone bursts at 4KHz and 1KHz – 64% • Wave V amplitudes with chirps were significantly increased when compared to tone bursts at 2KHz and 500 Hz – 52% and 31% respectively. • Proposed that the ABR nHL threshold to eHL correction for NB CE-Chirps should be approximately 5 dB less than the corrections for tone pips at 500 Hz, 1KHz, 2KHz, 4 KHz

Chirp/Toneburst Ratio Infants Firm et al 2013 Rodriguez & Lewis VF Chirp CE Chirp 2013 (Currently in CE Chirp Development) 4KHz 1.58 1.62 1.30 2KHz 1.52 1.48 1.44 1KHz 1.60 1.43 1.48 500 Hz 1.31 1.31 1.55 N=52 ears

Stuart & Cobb 2014 • Identification of wave V can occur with a smaller number of sweeps which can reduce test time (Stuart & Cobb 2014)

Observations • Larger amplitudes seen with infants • Larger amplitudes more pronounced in low frequencies • Larger amplitudes in low frequencies in children with middle ear disease • Benefits of chirp stimuli not consistent in all ears • Consistent with toneburst thresholds(-5dB)

Case 1: 4000 Hz Chirp vs Toneburst 5 week old Normal tympanogram Present DPOAEs

Case 1: 2000 Hz Chirp vs Tone Burst

1000 Hz Chirp vs Toneburst

Case 2: 1000 Hz Chirp vs Toneburst 6 year old Developmental Delay History of chronic middle ear disease Patent PE tubes

Case 2: 500 Hz Chirp vs Toneburst

500 Hz Chirp vs Toneburst ?

500 Hz Chirp vs Toneburst 3 year old Status post PE tube placement

Putting It All Together 4 KHz 20 dBnHL 2 KHz 20 dBnHL 1 KHz 25 dBnHL 500 Hz 35 dBnHL 500 Hz 25 dBnHL 500 Hz 30 dBnHL

Coming Soon….

Monitoring for Late Onset Progressive Hearing Loss • Ototoxicity • CMV • ECMO • Syndromes associated with HL • Hidden Hearing Loss

The Need for High Frequency Tone Bursts Oncology Population • Childhood cancer rates on the rise • More infants/toddlers who need to be monitored by ABR for ototoxicity • Children with neuroblastoma, hepatoblastoma, retinoblastoma, germ cell tumors, osteosarcoma, medulloblastoma, and other brain tumors are routinely treated with cisplatin, and/or carboplatin.

The Need for High Frequency Tone Bursts • Although often underappreciated, even hearing loss restricted to high frequency ranges (4,000- 8,000 Hz) can have a significant impact on language development, verbal abilities, and reasoning skills in young children.This is of particular concern with patients treated in early childhood for embryonal malignancies because the ototoxic effects are concurrent with the developmental period in which the process of acquiring speech and language skills is so critical. Gurney and Bass 2012

SIOP Boston Grading Scale

6000 and 8000 Hz Tone Bursts

Adults 4KHz BT 4KHz TB CF 6KHz BT 6KHt TB CF 8 KHz BT 8 KHz TB CF Ear 1 5 15 -10 5 15 -10 15 20 -5 Ear 2 5 20 -15 5 15 -10 15 20 -5 Ear 3 0 10 -10 0 5 -5 10 10 0 Ear 4 0 10 -10 0 5 -5 10 10 0 Ear 5 5 15 -10 5 15 -10 15 20 -5 Ear 6 0 15 -15 10 20 -10 20 30 -10 Ear 7 5 15 -10 5 5 0 10 15 -5 Ear 8 10 15 -5 10 15 -5 10 15 -5 Ear 9 5 10 -5 10 20 -10 15 25 -10 Ear 10 10 15 -5 10 15 -5 10 15 -5 Children 4KHz TB CF* 6KHz TB CF* 8 KHz TB CF* *Corrected Ear 1 20 -10 15 -5 10 0 Ear 2 20 -10 10 0 10 0 Ear 3 15 -5 20 -10 15 -5 Ear 4 20 -10 5 0 10 0 Ear 5 20 -10 10 0 15 -5 Ear 6 20 -10 10 0 10 0 Ear 7 20 -10 5 -5 15 -5 Ear 8 20 -10 5 -5 10 0 Ear 9 15 -5 10 -10 15 -5 Ear 10 15 -5 10 -10 10 0

4 yo with pilocystic astrocytoma (cisplatin and carboplatin)

2 y.o. PNET tumor (cisplatin and high dose carboplatin)

Questions and Discussion Kelly.Baroch@cchmc.org 513-659-2022