Bone-Conduction Hearing Aids PDF

SepOct2012
The magazine of, by, and for audiologists
Bone Conduction
Hearing Devices:
Solving the Puzzle
Pediatric Vestibular Evaluation

Improving Clinical Care for Patients
Electronic Practice Management Tools
Published by the American Academy of Audiology | www.audiology.org

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Contents
SepOct2012
Volume 24 No 5
16
Bone Conduction Hearing Devices: Solving the Puzzle With the trend continuing
toward implantable treatment options for hearing loss, the audiology profession
is tasked with the responsibility of establishing evidence-based practices for the
management of these technologies.
By Hillary Snapp
28 Pediatric Vestibular Evaluation/Balance Assessment At minimum, audiologists in
pediatric hospitals need to have the clinical skills to effectively identify children
requiring vestibular/alance assessment.
By Ashleigh J. Callahan, Norman J. Lass, Susan E. Reed, and Meredith C. Willis
38 Improving Clinical Care for Pediatric Vestibular Patients 2012 Marion Downs
lecturer Dr. Linda Luxon spoke with AT about the developments in and challenges
of diagnosis and treatment of pediatric patients with vestibular disorders.
By David Fabry
48 Electronic Practice Management Tools and Resources The information age of the
Internet and social media continues to flourish. This proliferation of information
and easy access from anyone possessing a computer has led to a bevy of practice
management resources available within seconds, just by using a search engine.
By Brenna Carroll
Departments
8 President’s Message It’s All About Awareness By Deborah L. Carlson
10 Executive Update On the Move By Cheryl Kreider Carey
12 Know-How Draw Awareness to Your Practice By Brenna Carroll and

Melanie Duldulao
15 Calendar Academy and Other Audiology-Related Deadlines
15 the web page What's New on the Academy's Web Site
53 CSI: Audiology The Case of Encephalopathy By Emily Nairn,

Virginia Ramachandran, and Brad A. Stach
58 Moment of Science The Medical Olivocochlear Relfex By Skyler G. Jennings

and Judy R. Dubno
62 Coding and Reimbursement 2013 Proposed Medicare Fee Schedule Rule

By Sharmila Sandhu
64 Compliance PQRS: Participate Sooner By Debbie Abel
68 Foundation Update Widex Grant Supports New Tinnitus Lectureship |

State Audiology Organizations: Funding Opportunities |
SAA Special Olympics Healthy Hearing Grants
71 SAA Spotlight SAA Across the USA! By Ally Costlow
73 ABA The Importance of Verifying Professional Expertise

By John Coverstone
75 ACAE Corner Silos Are Great for Storing Corn, But… By Lisa Hunter
Academy News
77 Washington Watch Academy Board Approves Three New Public Policy
Resolutions By Melissa Sinden
78 Just Joined Welcome New Members of the Academy
78 News and Announcements Audiologic Guidelines for the Assessment of Hearing in Infants
and Young Children and Standards of Practice
Editorial Mission
The American Academy of Audiology publishes Audiology Today (AT) as a means of communicating information among its members
about all aspects of audiology and related topics.
AT provides comprehensive reporting on topics relevant to audiology, including clinical activities and hearing research, current events, news
items, professional issues, individual-institutional-organizational announcements, and other areas within the scope of practice of audiology.
Send article ideas, submissions, questions, and concerns to amiedema@audiology.org.
Information and statements published in Audiology Today are not official policy of the American Academy of Audiology unless so indicated.
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© Copyright 2012 by the American Academy of Audiology. All rights reserved.

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Otodynamics Audiology Systems
Board of Directors
President
Deborah L. Carlson, PhD
Univ. of TX–Medical Branch
Ctr. for Audiology & Sp. Path.
deb.carlson@utmb.edu
President-Elect
The American Academy of Audiology promotes quality hearing and balance care Bettie Borton, AuD
Doctors Hearing Clinic
by advancing the profession of audiology through leadership, advocacy, education, bchampion1@aol.com
public awareness, and support of research.
Past President
Therese Walden, AuD
Walter Reed National Military Medical
Center, Audiology and Speech Center
therese.walden@gmail.com
Content Editor Executive Editor Members-at-Large

Shilpi Banerjee, PhD
David Fabry, PhD | dfabry@audiology.org Amy Miedema, CAE | amiedema@audiology.org School of Audiology
Pacific University
shilpi@pacificu.edu
Editorial Advisors Managing Editor
Mindy Brudereck, AuD Joyanna Mills, CAE Patricia A. Gaffney, AuD
Department of Audiology
Paul Pessis, AuD Nova Southeastern University
Art Direction patricia.gaffney@yahoo.com
Christopher Spankovich, PhD
Suzi van der Sterre
Thomas Littman, PhD
Factoria Hearing Center Inc.
Editor Emeritus tom@facthear.net
Marketing Manager
Jerry Northern, PhD
Angela Ugoji Devin McCaslin, PhD
Vanderbilt Bill Wilkerson Center
devin.mccaslin@vanderbilt.edu
Editorial Assistant
Kevin Willmann Erin L. Miller, AuD
University of Akron
auderin@zoominternet.net
Web Manager
Richard A. Roberts, PhD
Marco Bovo
Alabama Hearing and Balance Associates, Inc.
rroberts@hearingandbalance.net
Advertising Sales
Eilene Rall, AuD
Heather Troast | heather.troast@theygsgroup.com | 800-501-9571 ext. 124 Children’s Hospital of Philadelphia
rall@email.chop.edu
Jennifer Shinn, PhD

Department of Otolaryngology
University of Kentucky
American Academy of Audiology Offices
jennifer.shinn@uky.edu
Main Office Capitol Hill Office
David Zapala, PhD
11730 Plaza America Drive, Suite 300 312 Massachusetts Avenue, NE Audiology Section-Mayo Clinic
Reston, VA 20190 Washington, DC 20002 zapala.david@mayo.edu
Phone: 800-AAA-2336 | Fax: 703-790-8631 Phone: 202-544-9334
Ex Officios
Cheryl Kreider Carey, CAE
Executive Director, American Academy
of Audiology
ccarey@audiology.org
American Academy of Audiology Management
Andrea Fowler
Executive Director Cheryl Kreider Carey, CAE | ccarey@audiology.org President, Student Academy of Audiology
afowlersaa@gmail.com
Deputy Executive Director Edward A. M. Sullivan | esullivan@audiology.org
Audiology Today (ISSN 1535-2609) is published bimonthly by
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President’s Message
It’s All About Awareness

Academy Initiatives, Activities, and Partnerships
We promote our profession and services

to the public during October with an expected increase in the short-
National Audiology Awareness age of health-care workers, present
and National Protect Your Hearing challenges as well as opportunities.
Month. These national designations We embrace both, as the Academy
provide an advantage as we join explores ways to extend the reach of
others in promoting healthy hearing our hearing and balance services and
and knowledge about who audiolo- at the same time increase recruit-
gists are and what we do. Our Public ment efforts into the profession.
Relations Committee has many pre- On the recruitment and rec-
made materials available under the ognition front, the Academy has
Publications and Resources section established a relationship with the
of the Academy Web site. PowerPoint National Association of Advisors for
presentations customized for vari- the Health Professions, Inc (NAAHP).
ous age groups and physicians, fact Attending the biennial convention
sheets, bookmarks, buckslips, and of health profession advisors this
press releases are just a few of the past June, the Academy has made approved the document in June. First
many items available for use. Beyond plans for attendance at the NAAHP cited in the July issue of AT E-News,
the activities that we plan in our own regional conferences over the coming the document can also be found on
settings, we should also use this time year. At the same time, we continue our Web site. I encourage you to refer
to increase member awareness of to expand our relationship with the to this document as you develop or
our Academy initiatives, activities, Hearing Loss Association of America update job descriptions or compe-
and the partnership opportunities (HLAA) because of their focus on tencies, or advocate for the role of
available to all in enhancing the rec- providing resources for people with audiologists in other purviews.
ognition of our profession. hearing loss and their families, as In our efforts to achieve recogni-
Our Preferred Futures were rolled well as raising public awareness tion by policymakers of the value
out in 2011 and sets the stage for of the need for prevention and of our full scope of practice, I am
how we want our profession to look treatment of hearing loss. We look pleased to report growing support
by 2017. The environmental scan forward to some unique opportu- for the Medicare Hearing Health Care
that led us to our Preferred Futures is nities in our evolving relationship Enhancement Act (HR 2140). A direct
already showing its value as we’ve with the Alexander Graham Bell access companion bill was intro-
seen a new form of service deliv- Association for the Deaf and Hard of duced in the Senate (S 3242) in May.
ery and a human research protocol Hearing given their principal focus Have you made contacts with your
related to stem cell treatment of on understanding childhood hear- representatives and senators to sup-
hearing loss. A number of trends ing loss and the importance of early port direct access legislation? What
and emerging issues were identi- diagnosis and intervention. about support for the Hearing Aid
fied as the scan reviewed changes One of the objectives in promot- Assistance Tax Credit Act (HR 1479
in sociodemographics, technology, ing exemplary standards in the and S 3242)?
environment, economic, and political provision of hearing and balance These are a sampling of the ongo-
(STEEP) areas that could impact our wellness is our new Standards of ing Academy initiatives related to
profession. Our aging and growing Practice. Following the peer review awareness and recognition of our
multicultural population, along with process, the board of directors profession. We thank our volunteer
8 Audiology Today | SepOct2012

President’s Message
leadership, committees, task forces, the impact of our services. Recruit individuals, that will advance the
and members who have shown sup- young students to our profession profession of audiology. Working
port on an individual basis for these and encourage them to visit your together, we will make a difference.
efforts. clinics to see what an audiologist
So what’s left to do on the does. Volunteer your services to the
awareness front? There are many Academy or state and local audiology
opportunities to participate in the organizations. Give to the American
awareness and recognition of our Academy of Audiology Foundation
profession on an individual basis. Tell (AAAF) and the PAC—no donations Deborah L. Carlson, PhD
your story on an ongoing basis, do are insignificant. The awareness President
what you can in October, and then opportunities are numerous and American Academy of Audiology
continue those efforts throughout the take varying amounts of time and
year. Take advantage of opportunities commitment on your part. Remember,
in your local communities to increase it is the targeted Academy efforts,
knowledge of our profession and as well as the collective efforts of
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SepOct2012 | Audiology Today 9

Executive Update
Your QR (Quick Read) on Where

the Academy Is Going (Literally)
… and Been
By Cher yl Kreider Carey, CA E, Execut ive Director, A mer ican Academy of Audiolog y
Date Headquarters Address Governed By Managed By

Nov 2012 11480 Commerce Park Drive, Ste. 220, Board of Directors (14) Professional Staff** (32)
Reston, VA
2002 11730 Plaza America Drive, Ste. 300, Board of Directors (13) Professional Staff* (19)
Reston, VA
1999 8300 Greensboro Drive, Ste. 750, Board of Directors (13) Professional Staff* (12)
McLean, VA
1993 Association Management Group, Board of Directors (14) Management Group
1735 North Lynn Street, Ste. 950,
Arlington, VA
1992 Georgetown University Medical Center, Exec. Committee (7) Volunteer Audiologists
2233 Wisconsin Avenue, NW, plus Board of and 1.5 Staff
Washington, DC Representatives (20)
1988 The Neurosensory Center of Houston, Executive Committee (7) Volunteer Audiologists
6501 Fannin, Ste. NA200, plus Advisory Board (24) and .5 Staff
Houston, TX
*Includes staffing for ABA **Includes staffing for ABA, AAAF, and SAA
In 1992, Tracy Kroner (the

Academy’s lone employee)
prepared for the 1993
Convention in Phoenix from
the Academy’s office at
Georgetown University. The
Georgetown audiologists came
by each evening to help stuff
folders, etc.
(Photo Credit: Brad Stach)

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Know-how
Make October the Month

to Draw Awareness to Your
Practice!
By Brenna Car roll and Melanie Duldulao
O
ctober is National Audiology Remember to smile, make eye download on the Academy Web site:
Awareness Month. This audi- contact, and invite people to visit www.audiology.org, search keyword
ology campaign provides a your table. An open disposition and "awareness."
natural opportunity to promote your relaxed body language will draw If public speaking leaves you feel-
practice while elevating the visibil- more visitors and facilitate con- ing shy, consider an unconventional
ity of the profession. Many creative versation (Durham, 2012). Portable approach to promotion by running a
liberties exist to take advantage of audiometers can be helpful in 5k on behalf of your practice. Many
this month-long awareness initia- providing a brief hearing screen- communities host 5k events, and
tive. Promotional campaigns can ing to highlight hearing limitations encourage corporate participants
range from small, social media-based and the benefit of a comprehensive and runners participating on behalf
information to large-scale, organized audiometric evaluation. Be sure to of an organization or cause. Brightly
events. Every opportunity to increase highlight the specific services you colored, customized t-shirts can
your visibility and the visibility of offer. If you specialize in hearing be created at low cost and can be
the profession enhances the growth conservation or provide pediatric customized to clearly state your com-
potential of your practice. services, let your patients know! pany and mission. Consider adding a
October falls conveniently in Other community educational clever, hearing-related slogan to the
the middle of the fall health-fair opportunities include visiting senior back of your t-shirt.
season. Contact your local conven- centers. Many senior centers host Offer a brief sale on assistive
tion center and inquire about table weekly or monthly sessions regard- listening devices for the month of
rates at upcoming health events. ing health information specifically October in celebration of National
Public health vendor tables are often related to this demographic. Many Audiology Awareness Month.
available at minimal cost. A day of seniors seek educational opportuni- Highlight accessories like Bluetooth
answering questions at a health fair ties containing material they find streaming devices, FM systems,
can result in increasing your referral relevant (Duay and Bryan, 2008). and pocket talkers during this
base. Clearly display your company Contact your local senior center and time. Advertise your sale on your
name and use bold colors on a offer your service as a hearing expert, company’s Web site and newslet-
contrasting background to create a and be prepared to provide a short ter. If you keep in contact with your
visually attractive and informative informational session and answer patients via e-mail, consider sending
display. Also be sure your company’s questions. Inquire about A/V support. an e-mail with the sale information.
branding and contact information is If a projection screen is available, Consider using social media such as
visible. Draw traffic to your table by PowerPoint presentations can pro- Facebook and Twitter to share the
providing small giveaways such as vide a strong forum to share your message of your offer. Add an audiol-
protective ear plugs or pens. You can message. Keep your presentation suc- ogy awareness banner to your Web
also consider raffling off a free pair cinct to avoid audience fatigue and site. A selection of Web site ads and
of custom earplugs and/or musician maximize retention. You can also banners can be downloaded from
monitors. Resist the urge to overfill ask the group to generate a list of the Academy Web page by following
your table with too much printed text, questions before the session to facili- links from Publications & Resources
and keep information clear and con- tate interactive discussion. Helpful to Consumer Information to National
cise in a bulleted format (Few, 2004). audiology awareness PowerPoint Audiology Awareness Month. Click
presentations are available for on the Web Tools link to view options.

Know-how
Use newsletters to your advan- referrals for your services. Providing References
tage and promote the profession. information about chronic medical
In addition to sharing information conditions associated with hearing Few S. (2004) Show Me the Numbers:
about current promotional offers, loss such as diabetes, chronic kidney Designing Tables and Graphs to
include an article in your company’s disease, and heart diseases associ- Enlighten. Oakland: Analytics Press.
newsletter to explain exactly what ated will educate medical providers
an audiologist is and highlight the about risk factors for hearing loss. Durham J. (2012) Business body language.
training and credentialing involved Research indicates that a physi- Work Etiquette (accessed on June 18,
to become a provider. This is a great cian recommendation is a strong 2012 from www.worketiquette.co.uk/
opportunity to share some informa- influencer in whether a patient business-body-language.html).
tion about yourself and colleagues pursues amplification (Academy,
with your clients. Be sure to include 1998). Share this information with Duay DL, Bryan VC. (2008) Learning later
your educational and training your local physicians! Use lunch-and- in life: what seniors want in a learning
background along with unique learns as an opportunity to explain experience. Ed Geron 34(12):1070–1086.
internships and experiences. the limitations of amplification and
Contact your local newspapers, the benefits of evidence-based prac- Thompson P. (2005) Power speaking: tips
radio stations, and news stations. tices like real-ear measurements to and tricks for presenting with confidence
Offer to compose an article about the provide objective verification on your and style. California CPA (accessed on
implications of hearing loss for your services. Make yourself memorable! June 18, 2012 from http://findarticles.
local newspaper in a health column. Dress professionally, be punctual com/p/articles/mi_m0ICC/is_9_73/
Fees are occasionally associated with and succinct, and remember to send ai_n15734259).
these columns; however, newspapers a personal thank-you note following
generally service several communi- the in-service. American Academy of Audiology (1998)
ties. This provides an opportunity to National Audiology Awareness 1997 marketing study. Audiol Today
share helpful information to those Month provides a plethora of oppor- 10(1):10–15.
with hearing loss while enhancing tunities to not only increase public
your visibility in your community. awareness about the profession
Many local cable stations have of audiology but also market your
free public access and community practice. Creative outreach events
service air time available to share can highlight your services and
information with the public. Keep increase the visibility of your prac-
the emphasis of the information tice. Consider celebrating October
evidenced based and scientific, and and National Audiology Awareness
include medical information and Month by engaging the public and
facts to engage your audience and sharing information about hearing
to foster your reputation as the and your practice.
local expert in hearing and balance-
related disorders (Thompson, 2005).
National Audiology Awareness Brenna Carroll, AuD, is a clinical
Month can also provide a great audiologist at Swedish Medical Group
opportunity to follow up on physician in Issaquah, Washington. Melanie
outreach with lunch-and-learn visits. Duldulao, AuD, is a clinical audiologist
Contact the office manager at local at Group Health Cooperative in Bellevue,
physician practices to schedule a Washington. They are both members of
lunch appointment. Keep your infor- the BEST Committee.
mation brief to maintain sensitivity
to the physician’s time and schedule.
Provide your contact information
and a brief, written description of the
services your offer and appropriate

THE BIG
NEWS IS
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The Web Page
Calendar
We asked. You answered.
Social Media Responses from the Audiology Community…
September 11
eAudiology Web Seminar
Coding and Reimbursement Series:
What event, statistic A middle ear
Understanding PQRS: A Step-by-
Step Approach to Recognition and
or experience left you implant surgery Reimbursement
flabbergasted when observation. www.eaudiology.org
—Ayi C.
learning about September 12
audiology and Honestly…when I eAudiology Web Seminar
Microphone Arrays and Their
hearing healthcare? realized just how
Applications for Hearing Aids
important hearing
www.eaudiology.org
health is, and how
many people do not
September 20–22
know about it! —Lily H.
Meeting
California Academy of Audiology
When I realized someone with barely a 13th Annual Conference
high school education was allowed to
www.caaud.org.
perform many of the same functions I
could in my state. —Ryan P. September 27–28
Meeting
Maryland Academy of Audiology
20th Annual Conference
www.maaudiology.org
October 4–7
Meeting
Scott Haug Foundation 28th Annual
Texas Hill Country Audiology Retreat
Latest Interviews on www.audiology.org www.scotthaug.org
The Patient's Freedom of Choice: Interview with Craig
Johnson, AuD
October 5–6
Meeting
Jewelry, CI Bling, and Partnerships: Interview with 13-Year-Old 20th Annual Conference on Management
Hard-of-Hearing Entrepreneur, Hayleigh Scott of the Tinnitus Patient
The University of Iowa
Consultative Selling Skills: www.healthcare.uiowa.edu/
Interview with Brian Taylor, AuD otolaryngology/tinnituscourse
October 12
Meeting
Translational Research: Applications to
Hearing Loss
Follow Like Connect
Evanston, IL
http://comm.soc.northwestern.edu/
knowles-hearing-center/symposium/
twitter.com/ facebook.com/ www.linkedin.com

AcademyofAuD audiology

Bone
Conduction
Hearing Solving
Devices: the
Puzzle By Hill a ry Sna pp
With the trend

continuing toward
implantable
treatment options
for hearing loss, the
audiology profession
is tasked with
the responsibility
of establishing
evidence-based
practices for the
management of
these technologies.

Bone Conduct ion Hear ing Dev ices: Solv ing t he Puzzle
hat is the evidence base for patient/device management, however, has limited the
bone conduction hearing application of these systems.
devices? Audiologists working Despite nearly 20 years of U.S. experience with BAIs,
with bone conduction hear- no general consensus exists among audiologists regarding
ing devices (BCHD) have long evaluation and candidacy, fitting measures, verifica-
been challenged by this question, or validating outcomes. The lack of evidence-based
tion. The earliest BCHDs included the conventional bone guidelines for the practice of fitting these devices often
conduction hearing aid and the transcranial CROS,1 but discourages clinicians from incorporating them into
dissatisfaction with comfort, sound quality, and output their practice. In reality, these devices are a viable treat-
yielded little acceptance of these devices. With the poten- ment option for many patients with conductive, mixed,
tial to overcome some of these obstacles, the Food and or profound unilateral sensorineural hearing loss who
Drug Administration (FDA) approval of bone anchored otherwise do not benefit from traditional amplification.
implants (BAIs) in 1996 opened the door for new and Numerous studies have demonstrated improved quality
exciting treatment options for patients with conductive of life in BAI patients,2-8 supporting their role as an accept-
and mixed hearing loss. Indications were later extended able intervention. This is evidenced by the recent surge
to include individuals with single-sided deafness (SSD) in in development of a variety of bone conduction hearing
2001; unpredictable outcomes and uncertainty regarding devices. Currently, the most widely used bone conduction
<20
Research Subjects
and
Development 9%
13%
Subjective
Report
12%
Other
13%
Review
Article
13%
Medical
Outcomes
40%
Figure 1. Studies excluded.

device is the percutaneous BAI on a titanium abutment

(Cochlear Corp., Denver, CO; Oticon Medical, Somerset,
NJ). Recent alternatives to this approach are the Sophono
Inc (Boulder, CO) transcutaneous BAI, and a noninvasive
dental bone conductor by Sonitus Inc (San Mateo, CA).
Even a cursory review of the literature clearly reveals
the limited evidence regarding audiological practice
(Figure 1). The majority of the research in BCHDs comes
from the medical community and primarily provides
evidence regarding safety and effectiveness of implant
systems. However, effectiveness is largely defined by
the minimal requirement of improved audibility for soft
inputs. There are very few studies from the audiology
community focused specifically on hearing outcomes.
To more accurately determine the evidence base
for bone conduction devices, a comprehensive review
of the literature is necessary. With the assumption
that questions regarding safety have been well studied
and accepted, this brief review focuses on the current
evidence base for audiological practices related to bone
conduction hearing devices.
Specifically, questions to be answered include
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What criteria exist for selecting the appropriate
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What are the accepted fitting practices? school, in your community,
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What are the appropriate verification and validation
methods?
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A PubMed search yielded 461 articles related to bone and information about audiology.
anchored hearing aids, bone anchored implants, and bone
conduction hearing devices. Abstracts of each article
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were reviewed for inclusion. Only human studies report-
ing behavioral and/or objective audiological outcomes
were included. Four hundred and thirty-nine articles
were excluded (Figure 1) resulting in 22 articles for further
at your school.
review.4-25 Visit www.studentacademyofaudiology.org
To date, few studies have examined the overall ben- for more information.
efits of bone conduction hearing devices. The majority of
the publications in this area comprised single case stud-
ies or were limited by small sample sizes (<20 subjects).
The literature search did not identify any randomized
controlled trials. In addition, the review revealed several
other limitations in the research methods. For example,
some studies included previously published data, and

there was a lack of homogeneity across studies with

considerable variability in both patient population and
study procedures making it difficult to compare effective-
ness, performance, patient outcomes, etc. (Table 1). These
discrepancies make it difficult to summarize the patient
outcomes, as well as the effectiveness of bone conduction
devices. Further, it has likely contributed to the lack of
accepted audiological guidelines.
Evaluation and Candidacy

Research directly related to evaluation methods or candi-
dacy guidelines is limited.21, 26-27 Considering the invasive
nature of most current bone conduction treatment options,
the importance of selecting appropriate candidates and
predicting patient outcomes is even more critical.
Audiometrical bone conduction thresholds are com-
Table 1. Representation of the Variation monly seen both clinically and in the literature as the
in Outcome Measures Used to Validate primary means of determining candidacy for BAIs.4, 9, 11-15
Effectiveness of Treatment Based on the hearing aid literature, sole reliance on the
audiogram alone has been determined as insufficient and
Outcome Measures Total Studies has been shown to be a poor predictor of patient benefit.28
Many studies have used functional gain measures as
Sound field thresholds 13 a means of validating device performance and patient
benefit. As such, some researchers have looked to such
measures as a means to pre-operatively predict outcomes,
Sound field speech reception 13
recommending testing sound field thresholds with the
thresholds
processor on a test band to predict post-operative gain.24
Reports of large intra- and inter-subject variability of
Word recognition scores in quiet 7 threshold responses as a result of skin impedance and
transcranial attenuation, raise questions regarding the
validity of this method. 24, 29-30 Because the variability
Word recognition scores in noise 9 increases with high frequency stimulation, this may be
more of an issue with the SSD population than the con-
ductive or mixed hearing loss patient for whom audibility
Signal-to-noise ratio loss 6 is the primary need. Nonetheless, the inherent limita-
tions of aided sound field thresholds31-34 make this an
unreliable and potentially invalid method of evaluation
Localization 4 on its own.22
At home test band trials26 are also recommended in
the literature as a pre-operative indicator of expected
Lateralization 1
benefit with BAIs. Interestingly, most subjective reports
suggest that the majority of BAI recipients are satisfied
Maximum phoneme score 3 and have improved quality of life.2-8 However, studies
reporting on test band trials indicate that only 34–50 per-
cent of patients chose to pursue surgery after the trial.26-27
Binaural masking level difference 1 Although it was reported that the primary indicator for
patients not choosing the surgery was that the device did
not meet their hearing needs, a clear underlying explana-
Gap discrimination 1 tion could not be identified.26-27 It is reasonable to presume
that those who do not experience good hearing outcomes

during the trial are less likely to experience optimal better predictor of benefit than verifying audibility of soft
benefit postoperatively; however, this is not an objective inputs in the sound booth. Conversely, the recommended
measure. Based on the reported variability with test band protocol is limited to a single noise condition, thereby
performance versus implant performance, this may not limiting the ability of the audiologist to accurately predict
be an accurate means of assessment. In addition to the performance in all listening environments. Further, this
questionable audibility for high frequencies, inherent protocol does not address the needs of the conductive or
issues such as variability with headband placement, feed- mixed hearing loss populations, including audibility for
back, and discomfort cannot be avoided. While the ability multiple inputs and consideration of a contributing senso-
of the patient to experience the implant preoperatively rineural hearing loss.
most certainly has its place in the evaluation process, it
must be well controlled and evidence based. Device Selection and Fitting
For individuals with SSD, it has been proposed The evidence presented in the literature regarding device
that using the test band clinically to measure aided vs. selection is also lacking. There is evidence to support
unaided signal-to-noise ratio (SNR) loss is a good predic- direct bone conduction as a means to provide improved
tor of postoperative benefit.21 This allows the patient audibility and patient satisfaction over transcutaneous
the opportunity to experience the device preoperatively, stimulation (i.e., the BCHA).4, 10-11 Additionally, a study
while providing some quantitative measure of speech found that in patients with an air bone gap greater than
audibility. Given that listening in noise is the primary 30 dB, BAIs outperform air conduction hearing aids and
complaint of patients with SSD, the authors argue that improve subjective satisfaction.40 Beyond this, recom-
this is a more appropriate assessment of needs and a mendations regarding which direct BCHD to use are based
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on output of the device and audiometric bone conduction were reported in the literature with considerable varia-
thresholds.35 This is likely due to the fact that, for the tion in test materials and procedures. Other limitations
most part, BCHDs have been reserved for use in patients included failure to report materials or procedures all
with normal cochlear function. together. Further, the majority of the studies included
Well established prescriptive methods have long been some qualitative measure (ultimately reporting signifi-
the standard for hearing aids. In a normal cochlea, we cant subjective benefit), but fail to report the tool used to
presume that normal loudness growth, frequency speci- measure outcomes.
ficity, neural tuning, and etc. are maintained. If the goal is Despite the observed variability, the clear trend is
to merely provide the normal cochlea access to sound, the to rely on sound field measures, primarily functional
need for gain prescriptions may not be as important. This gain, for validation of device performance. However, if
assumption, however, fails to consider the differences in best practice is to verify audibility across the speech
bone conducted versus air conducted sound, the impact frequencies for multiple inputs, the process must rely on
of the occlusion effect, the vibratory mechanics of the validated and objective verification measures.36-38 Pure
system, or the previously discussed variances in skin and tone threshold testing in the sound field only provides
transcranial attenuation. Further, this approach does not information for low level inputs and is complicated by
take into account compensation for a potential sensori- issues such as noise floor effects, inability to assess
neural component as seen in mixed hearing loss. With the output limiting characteristics, and poor frequency
differences in hearing impairment, it cannot be assumed resolution.31, 34 As a result, functional gain measures have
that a single device or programming strategy will work for been shown to be an inadequate assessment of device
all patients. The selection process must include an assess- performance and objective benefit.31, 33-34, 36
ment of needs and handicap, and considerations should For BCHDs, the means to objectively verify frequency
include features and output characteristics of the device. specific responses at the level of the functioning cochlea
The primary objective of the fitting process should are lacking. This limits the ability of clinicians to fine
ensure that speech is audible, clear, and comfortable. tune the sound processors to address the finite differ-
Looking to the hearing aid literature for guidance, we ences in frequency and intensity needs between patients.
acknowledge that certain guidelines must be followed As previously stated, it could be argued that this is less
to ensure the ethical practice of fitting hearing aids.36- important in the SSD and conductive population, as the
38
However, until appropriate measures for candidacy dynamic and adaptive capabilities of the normal cochlea
assessment can be identified, selection and fitting of do not require such fine-tuning. However, long-term
appropriate devices falls subject to the pitfalls of bone outcome data regarding potential complications with the
conduction measurement. While there are some recom- onset of age-related hearing loss have yet to be considered
mendations regarding fitting guidelines,35 these are based in the literature. Hearing aids have been the standard
on the assumption that percutaneous bone conduction of care for individuals with age-related hearing loss and
thresholds on the test band are an accurate reflection of have yet to reach impressive satisfaction levels. Ongoing
direct bone conduction responses. At present, selection MarkeTrak surveys indicate that even with advance-
and fitting methods for BCHDs lacks objectivity and sup- ments in digital products only 55 percent of hearing aid
portive evidence. users report being satisfied or very satisfied.39 The most
recent survey in 2010 shows that negative experiences are
Verification and Validation related to device performance in noise, comfort with loud
Considerable variation in design methodology was
observed for the reported verification and validation of
BCHDs in the literature review (Table 1). Only three stud-
ies directly address the topic of verification and validation
with only a single investigation of truly objective veri-
fication. 22-23, 25 The remaining studies most commonly “Bone Conduction and Transcranial
Attenuation” on the Academy Web site.
validated device performance and/or patient benefit
using posttreatment sound field measures and subjective Visit www.audiology.org and search
keywords “bone conduction” or use the
questionnaires. Of these, there was a lack of homogeneity
QR code to view the article on your mobile
among outcome measures used to determine effective- device.
ness. Ten different behavioral outcome measures (Table 1)

sounds, and ability to hear soft sounds. In contrast, satis-

faction rates are strongly associated with overall benefit
and sound quality.39
Currently hearing aids are objectively verified through
real ear probe microphone measures (REM).36 Despite
this, hearing aids have yet to be considered a globally
successful treatment option for patients with hearing
loss. Similar objective verification measures are not
currently available for BCHDs, and well-defined clini-
cal protocols are lacking, further limiting the potential
for long-term success. In 2010, Hodgetts and colleagues
investigated various methods for verifying BAI output.22
As previously demonstrated in the hearing aid literature,
they confirmed that aided threshold measurement in
the sound field is an inadequate form of validating BAI
performance.31-34 Attempts at using probe tube measures
were also unsuccessful. Ultimately, they suggested an
alternative in-situ method using a skull simulator and
The Pediatric
accelerometer to measure output of the device. This
method measures accelerations at the transducer versus Audiology Specialty
SPL at the eardrum in the real ear method. While promis-
ing, the high cost and limited availability of these systems
make it difficult to adopt clinically. Without frequency-
Certification (PASC)
and intensity-specific information to verify output of Advertise to colleagues, patients, and other
the BAI processor at the level of the functioning cochlea, health-care providers that you have obtained
addressing the individual listening and communication a high level of knowledge in pediatric
needs of these patients will continue to be a challenge. audiology and are a primary referral
Until a more feasible objective verification measure exists, destination for children with audio-vestibular
clinicians must rely on well-defined clinical protocols disorders and hearing loss.
that combine objective performance data with subjective
measures to validate posttreatment benefit.
Upcoming Exam
Conclusion April 7, 2013
The evidence supporting the use of BAI and related Anaheim, CA
devices remains largely subjective. Aside from this, a Application deadline is February 5, 2013.
critical mass of evidence for efficacy in evaluation, fit-
APPLY TODAY!
ting, and verification of these systems does not exist. The
rapid advancement in hearing technology has outpaced
research for BCHDs. Consequently, audiologists have
been left to fall back on outdated and disproved theories For further information,
of practice. Although we know better, we have continued
and to download an application,
without progress simply due to the lack of appropriate
alternative validation and verification measures.32 visit www.americanboardofaudiology.org.
For bone conduction technology, our practice remains
unacceptably behind. While many patients report success
with these devices, there are also patients who inexpli-
cably have less benefit or no benefit at all. With the trend
continuing toward implantable treatment options for
hearing loss, the audiology profession is tasked with the
responsibility of establishing evidence-based practices

for the management of these technologies. Without the 8. Christensen L, Richter GT, Dornhoffer JL, “Update on bone-
appropriate clinical tools to objectively verify device anchored hearing aids in pediatric patients with profound
performance, it can be expected that research will remain unilateral sensorineural hearing loss,” Arch Otolaryngol Head
limited. At this time, careful consideration should be Neck Surg Vol. 136, No. 2 (2010), pp. 175–177.
given to candidacy selection. Deficit-specific measures
should be incorporated into the evaluation process and 9. Håkansson B, Liden G, Tjellström A, et al., “Ten years
utilized to validate performance in the absence of objec- of experience with the Swedish bone-anchored hearing
tive verification tools. system,” Ann Otol Rhinol Laryngol Suppl Vol. 151 (1990), pp.
1–16.
Hillary Snapp, AuD, is a clinical audiologist and assistant 10. Mylanus EAM, Snik AFM, Jorritsma FF, et al., “Audiological
professor at the University of Miami in Miami, FL. results of the bone-anchored hearing aid HC200: multicenter
results,” Ann Otol Rhinol Laryngol Vol 103, No. 5 (1994), pp.
368–374.
Endnotes
11. Snik AD, Mylanus EA, Cremers CW, “Speech recognition
1. Hayes DE, Chen JM, “Bone-conduction amplification with with the bone-anchored hearing aid determined objectively
completely-in-the-canal hearing aids,” J Am Acad Audiol Vol. and subjectively,” Ear Nose Throat J Vol. 73, No. 2 (1994), pp.
9, No. 1 (1998), pp. 59–66. 115–117.
2. Dutt SN, McDermott A, Jelbert A, et al., “The Glasgow 12. Snik AF, Mylanus EA, Cremers CW, “The bone-anchored
benefit inventory in the evaluation of patient satisfaction hearing aid compared with conventional hearing aids,” Otol
with the bone-anchored hearing aid: quality of life issues,” J Clin North Am Vol. 28, No. 1 (1995), pp. 73–83.
Laryngol Otol Vol. 116 (2002), pp. 7–14.
13. Snik AF, Dreschler WA, Rinze AT, et al., “Short- and long-term
3. McDermott A, Dutt SN, Tziambazis E, et al., “Disability, results with implantable transcutaneous and percutaneous
handicap and benefit analysis with the bone-anchored bone-conduction devices,” Arch Otolaryngol Head Neck
hearing aid: the Glasgow hearing aid benefit and difference Surg Vol. 124 (1998), pp. 265–268.
profiles,” J Laryngol Otol Vol. 116 (2002), pp. 29–36.
14. Lustig LR, Arts AH, Brackmann DE, et al., “Hearing
4. Hakansson B, Carlsson, P, “The bone-anchored hearing aid: rehabilitation using the BAHA bone-anchored hearing aid:
principal design and audiometric results,” Ear Nose Throat results in 40 patients,” Otol Neurotol Vol. 22 (2001), pp.
J Vol. 73, No. 9 (1994), pp. 670–675. 328–334.
5. Powell RH, Burrell SP, Cooper HR, et al., “The Birmingham 15. Bosman AJ, Snik AD, van der Pouw CT, et al., “Audiometric
bone anchored hearing aid programme: paediatric experience evaluation of bilaterally fitted bone-anchored hearing aids,”
and results,” J Laryngol Otol Supplement (1996), pp. 21–29. Audio Vol. 40 (2001), pp. 158–167.
6. Cooper HR, Burrell SP, Powll RH, et al., “The Birmingham 16. Bance M, Able SM, Papsin BC, et al., “A comparison of the
bone anchored hearing aid programme: referrals, selection, audiometric performance of bone anchored hearing aids an
rehabilitation, philosophy, and adult results,” J Laryngol Otol air conduction hearing aids,” Otol Neurotol Vol. 23 (2002), pp.
Supplement (1996), pp. 21–29. 912–919.
7. Wazen JJ, Caruso M, Tjellstrom A, “Long-term results with 17. Hol MK, Bosman AJ, Snik AF, Mylanus EA, Cremers CW,
the titanium bone anchored hearing aid: the U.S. experience,” “Bone-anchored hearing aid in unilateral inner ear deafness: a
Am J Otol Vol. 19 (1998), pp. 737–741. study of 20 patients,” Audiol Neurotol Vol. 9, No. 5 (2004), pp.
274–281.

18. Hol MK, Bosan AJ, Snik AF, Mylanus EA, Cremers 21. Snapp HA, Fabry DA, Telischi FF, et al., “A clinical protocol for
CW, “Bone-anchored hearing aids in unilateral inner ear predicting outcomes with an implantable prosthetic device
deafness: an evaluation of audiometric and patient outcome (Baha) in patients with single-sided deafness,” J Am Acad
measurements,” Otol Neurotol Vol. 26, No. 5 (2005), pp. Audiol Vol. 21, No. 10 (2010), pp. 654–662.
999–1006.
22. Hodgetts WE, Hakansson BE, Hagler P, et al., “A comparison
19. Lin LM, Bowditch S, Anderson MJ, May B, Cox KM, Niparko of three approaches to verifying aided Baha output,” Int J
JK, “Amplification in the rehabilitation of unilateral deafness: Audiol Vol. 49, No. 4 (2010), pp. 286–295.
speech in noise and directional hearing effects with bone-
anchored hearing aid and contralateral routing of signal 23. Nicholson N, Christensen L, Dornhoffer J, et al., “Verification
amplification” Otol Neurotol Vol. 27 (2006), pp. 172–182. of speech spectrum audibility for pediatric baha softband
users with craniofacial anomalies,” Cleft Pal Cran J Vol. 48,
20. Wazen JJ, Van Ess MJ, Alameda J, Ortega C, Modisett M, No. 1 (2011), pp. 56–65.
Pinsky K, “The Baha system in patients with single-sided
deafness and contralateral hearing loss,” Otolaryngol Head 24. Heywood RL, Patel PM, Jonathan DA, “Comparison
Neck Surg Vol. 142, No. 4 (2010), pp. 554–559. of hearing thresholds obtained with baha preoperative
assessment tools and those obtained with the
osseointegrated implant,” Ear Nose Throat J Vol. 9, No. 5
(2011), pp. 21–27.
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Now Accepting Applications!
The American Academy of Audiology and the AAA Foundation are
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“grants program.”

25. Snapp HA, Angeli S, Telischi FF, et al., “Postoperative 36. American Academy of Audiology Task Force Committee
validation of bone-anchored implants in the single-sided (2007). Guidelines for the Audiologic Management of
deafness population,” Otol Neurotol Vol. 33, No. 3 (2012), pp. Adult Hearing Impairment. www.audiology.org/resources/
291–296. documentlibrary/documents/haguidelines.pdf.
26. Pennings RJE, Gulliver M, Morris DP, “The importance of an 37. American Speech-Language-Hearing Association Ad Hoc
extended preoperative trial of baha in unilateral sensorineural Committee on Hearing Aid Selection and Fitting, “Guidelines
hearing loss: a prospective cohort study,” Clin Otol Vol. 36, for hearing aid fitting for adults,” Am J Audiol Vol. 7, No. 1
No. 5 (2011), pp. 442–449. (1998), pp. 5–13.
27. Desmet J, Bousegta R, Hofkens A, et al., “Clinical need 38. Joint Audiology Committee, “Audiology Clinical Practice
for a baha trial in patients with single-sided sensorineural Algorithms and Statements,” Audiol Today, Special Issue,
deafness. Analysis of a baha database of 196 patients. Eur August 2000.
Arch Otorhinolaryingol Vol. 269, No. 3 (2012), pp. 799–805.
39. Kochkin S, “MarkeTrak VIII: Customer satisfaction with
28. Taylor B, “Speech-in noise tests: how and why to include hearing aids is slowly increasing,” Hear J Vol. 63, No. 1
them in your basic test battery,” Hear J Vol. 56, No. 1 (2003), (2010), pp. 11–19.
pp. 40–43.
40. Mylanus EA, van der Pauw AF, Cremers CW, Intraindividual
29. Håkansson B, Tjellström A, Rosenhall U, “Hearing thresholds comparison of the bone-anchored hearing aid and air
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30. Stenfelt S, “Transcranial attenuation of bone-conducted

sound when stimulation is at the mastoid and at the bone
conduction hearing aid position,” Otol Neurotol Vol. 33, No. 2
(2012), pp. 105–14.
31. Seewald RC, Hudson SP, Gagne JP, et al., “Comparison of

two methods for estimating the sensation level of amplified
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32. Seewald RC, Moodie KS, Sinclair ST, et al., “Traditional and
theoretical approaches to selecting amplification for infants
and young children,” In: Bess FH, Gravel JS, Tharpe AM, eds.
Amplification for Children with Auditory Deficits (Nashville:
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pp. 2–12.

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Pediatric
Vestibular
Evaluation/
Balance
Assessment:
Audiologists’ Perceived
Skills and Clinical
Practices
By ashleigh j. ca ll aha n, nor ma n j. l ass,
Susa n E. r eed, a nd Mer edith C. W illis
D
izziness can be associated
Many children with complaints of dizziness, vertigo, balance with disturbances in any
problems, and other associated symptoms are diagnosed of the three sensory sys-
tems—the visual, vestibular, and
with “unspecified dizziness,” leaving uncertainties about the
proprioceptive-somatosensory
prevalence and diagnostic accuracy of peripheral vestibular systems, which are used to maintain
lesions. Causes of childhood dizziness may be peripheral balance—or in the central nervous
system integration of these sensory
or central in origin, with migraine evidenced as the most inputs. An audiologic evaluation of
common cause. In order to effectively treat balance disorders the vestibular system and/or balance
in children, an extensive test battery is needed to determine assessment is warranted whenever
a patient, regardless of age, exhib-
the source of the imbalance. Although many respondents its nystagmus, subjective vertigo,
to our survey did report seeing patients with dizziness or abnormal gait, balance dysfunction,
or any other conditions suggesting
imbalance as a primary symptom, less than one quarter peripheral or central vestibulopathy
report employment in facilities currently conducting pediatric (American Speech-Language-Hearing
vestibular/balance assessment. At minimum, audiologists in Association [ASHA], 2006).
Many children with complaints of
pediatric hospitals need to have the clinical skills to effectively dizziness, vertigo, balance problems,
identify children requiring vestibular/balance assessment. and other associated symptoms are

diagnosed with “unspecified dizzi- Pediatric vestibular assessment and falls risk assessment (ASHA,
ness,” leaving uncertainties about the yields valuable information relating 2006). (See Table 1 for abbreviations
prevalence and diagnostic accuracy to diagnoses and management of of common vestibular evaluation and
of peripheral vestibular lesions children with vestibular dysfunc- balance assessment procedures used
(O’Reilly et al, 2010). Causes of child- tion, which may occur alone or in in the field of audiology.)
hood dizziness may be peripheral association with hearing impair- Depending on the age of the child,
or central in origin, with migraine ment or developmental disorders. many of these assessment proce-
evidenced as the most common Effective treatment of balance dures can be modified for pediatric
cause (Szirmai, 2010). Although bal- disorders in children requires an vestibular evaluation; however,
ance disorders may be less common extensive test battery to determine significant age effects have been
in children than adults, a wide range the source of the imbalance (Fife et found for rotational testing, CDP, and
of childhood peripheral etiologies al, 2000; Wiener-Vacher, 2008). The vestibular evoked myogenic poten-
have been reported including, but preferred practice patterns in audiol- tial (VEMP) evaluations (Ionescu et
not limited to, vestibular neuritis, ogy describe the audiologic balance al, 2006; Valente, 2007, 2011). In fact,
labyrinthitis, benign paroxysmal system evaluation as a detailed VEMPs have been studied in popula-
positional vertigo (BPPV), trauma of case history, bedside assessment, tions as young as preterm infants
the labyrinth, Ménière’s disease, and electronystagmography (ENG)/vide- (Erbek et al, 2009).
congenital inner ear malformations onystagmography (VNG), dynamic The American Academy of
(Wiener-Vacher, 2008; O’Reilly et al, visual acuity (DVA), rotational testing, Audiology (Academy) scope of
2010; Szirmai, 2010). computerized dynamic posturogra- practice in audiology includes the
phy (CDP), otolith function testing, diagnosis and management of

Pediat r ic Vest ibular Evaluat ion / Balance A ssessment
Table 1. Audiometric Abbreviations vestibular disorders without mention of age restriction

of Common Vestibular Evaluation and in either assessment or treatment of vestibular impair-
Balance Assessment Procedures ments (Academy, 2004). ASHA (2004) also includes
comprehensive diagnostic services as well as treatment/
Abbreviations Evaluation Procedures
rehabilitation of vestibular impairments for patients
CRM Canalith repositioning maneuver across the lifespan (from birth to adulthood). Although
CDP Computerized dynamic the role of the audiologist in vestibular/balance proce-
posturography dures is well defined by both the Academy and ASHA,
DVA Dynamic visual acuity only 37 percent of audiologists report providing any type
ENG Electronystagmography of vestibular assessment, and a mere 11 percent adminis-
ter vestibular rehabilitation (ASHA, 2008).
HSN Head shake nystagmus test
Despite the known benefits of balance assessment
MCT Motor control test in children, vestibular dysfunction remains potentially
SOT Sensory organization test underdiagnosed in this population (O’Reilly et al, 2010).
SHA Sinusoidal harmonic acceleration Formal vestibular assessment may not be conducted due
SVV Subjective visual vertical to a lack of recognition of the potential signs of a disor-
der, a limited understanding of the consequences of such
VEMP Vestibular evoked myogenic
disorders, and/or the inability to identify an appropriate
potential
vestibular test battery for specific age groups of children.
VST Velocity step test The aim of the current study was to examine pediat-
VNG Videonystagmography ric audiologists’ clinical practice of vestibular/balance
assessment in children along with the frequency of the
assessment and/or amount of referrals to other profes-
sionals. For those who perform vestibular evaluations in
Table 2. Respondents’ Reported Degrees, pediatric patients, test batteries were examined along
Age Ranges, and Years of Professional with modification for successful completion in young
Clinical Experience populations. The interest in continuing education in pedi-
atric vestibular assessment was also addressed.
Participants (n = 95)
Highest degree awarded Method
Master's degree 32.6% Targeted individuals in this nationwide survey were 438
AuD degree 62.1% audiologists employed in children’s hospitals or medi-
cal settings that primarily treat pediatric patients. The
PhD, EdD, or ScD degree 5.3%
participants were provided an explanation of the survey
Age ranges and a link to a Web-based survey via e-mail. The e-mail
20–30 years old 13.7% link to the survey was sent to potential subjects to assure
31–40 years old 52.6% the anonymity of all respondents. In addition, a follow-up
41–50 years old 23.2% e-mail was sent to each participant approximately one
month after the initial contact. If the participants had
51–60 years old 9.5%
already completed the survey, they were asked to disre-
61+ years old 1.1% gard the follow-up e-mail.
Professional clinical experience The e-mail request contained a link to a 32-item Web-
1–5 years 18.3% based author-constructed survey accessed through an
online program that securely collects and stores survey
6–10 years 26.9%
data. The participants were asked questions related to
11–20 years 36.6%
practices in pediatric vestibular evaluation and balance
21+ years 18.3% assessment. They were asked if their facility currently
conducts vestibular/balance assessment for children
and, if not, why not. Questions also examined reasons
for vestibular referral and to what professionals referrals

were made. In addition, perceptions of academic training

in pediatric vestibular assessment were also examined
along with respondents’ interest in continuing education
in pediatric vestibular assessment. For those conducting Equipment Unavailable
pediatric testing, the vestibular test batteries for various 100
ages were examined along with clinical modifications

for successful completion in young populations. The 80
Not Properly Trained
questionnaire also contained respondents’ demographic
information, including professional status, highest degree 60 Do Not Feel Ethically
Confident in Clinical Skills
PERCENT
awarded, year degree awarded, and place of employment.
All procedures are on file with and approved by the West Feel Children Are Unable
40 to Complete Testing
Virginia University Institutional Review Board for the
Feel Formal Assessment
Protection of Human Subjects (IRB). 20 Is Unnecessary
Results 0
A total of 107 audiologists from 29 states completed the
online survey, resulting in a response rate of 24.4 percent.
Figure 1. Reported reasons for not
A total of 95 respondents confirming current employment
in children’s hospitals or medical settings were included
performing pediatric vestibular
in subsequent data analysis. The majority of respondents evaluations and/or balance assessments.
hold the AuD degree (62.1 percent) and are between
31 and 40 years old (52.6 percent). Professional clinical
experience as an audiologist ranged from one to five
years (18.3 percent) to more than 20 years (18.3 percent).
Additional respondent information is included in Table 2.
While 24.2 percent report working in facilities that
currently conduct vestibular/balance assessment for
children, 75.8 percent do not. Of the respondents who are
not employed in a facility that conducts pediatric assess-
ments, 4.6 percent are currently initiating or constructing
laboratories. Participants were encouraged to select all
reasons that apply and/or to list “other” reasons for not
currently conducting vestibular/balance assessments
for children with potential vestibular/balance disorders
(Figure 1). For those working in a facility that does not
currently conduct vestibular/balance assessment for chil-
dren, the most common reason was that they do not have
vestibular/balance equipment available at their facility
(92.3 percent), followed by the fact that they do not feel
properly trained to perform pediatric vestibular/balance
assessment (60 percent) and they do not feel confident in
their clinical skills to ethically perform pediatric vestibu-
lar/balance assessment (37.5 percent). Participants were
also given an opportunity to provide an open response, in
which the following reasons for not conducting pediatric
assessment were listed: initiating or constructing a pedi-
atric vestibular lab (4.6 percent), making referrals to an
adult practice (4.6 percent), having no referrals/demand
(4.6 percent), only seeing newborn patients (3.1 percent),
and others (6.2 percent): only practice at rehabilitation

facility; more research needs to be conducted to increase vestibular/balance assessments. Other conditions initiating
“pediatric friendliness”; do not have otolaryngology referrals for vestibular evaluations and/or balance assess-
department; and currently not part of clinical practice. ments are available in Table 3. Other common reasons
When asked how many children are seen at their facil- for referral include developmental delays in gross motor
ity annually with dizziness or imbalance as a primary control (36.5 percent), cochlear implant candidates pre-
symptom, 50 percent see one to 50 children, 25 percent surgery (34.6 percent), and cochlear malformations, such as
see 51–100, and 25 percent see 101–150 children. A total Mondini deformity and cochlear hypoplasia (28.8 percent).
of 66.7 percent of respondents see approximately 1 to The majority of respondents make referrals to other audi-
50 children annually with dizziness or imbalance as a ologists who specialize in balance assessment (62 percent)
secondary or co-complaint with hearing loss, while the and to otolaryngologists (56.3 percent) (Figure 2).
remaining 33.3 percent report seeing more than 101 chil- When asked “How well do you feel your academic
dren annually with secondary balance problems. training (including clinical training and residency)
The majority reported referring patients with symp- prepared you to work with children having vestibular/bal-
toms of balance difficulty when standing or walking (71.2 ance disorders?” the majority of respondents (67 percent)
percent) and reported subjective vertigo (59.6 percent) for said “poor” (additional responses are displayed in Figure
3). When asked to rate their overall confidence level in
performing pediatric vestibular/balance assessment, the
majority (79 percent) indicated low (43.2 percent) or none
Table 3. Reported Conditions and (35.8 percent) (Figure 4). However, when asked to rank
Symptoms Leading to Referrals for their level of interest in receiving continuing education
Formal Vestibular Evaluations and/or in pediatric vestibular/balance assessment, the major-
Balance Assessments ity (56.4 percent) indicated high (23.4 percent) or medium
(33.0 percent) (Figure 5).
Reported Reasons for Referral Occurrence
The types of clinical evaluations used to assess ves-
Symptoms of balance difficulty when 71.2% tibular/balance disorders in children were then examined
standing or walking according to the 2012 American Academy of Pediatrics
Subjective vertigo 59.6% classification of pediatric age groups: infant (younger
Developmental delays in gross motor 36.5% than one year), early childhood (aged 1−4 years), late
control childhood (aged 5–11 years), and adolescent (aged 12–17
Cochlear implant candidates 34.6% years) (Figure 6). Of the 7.4 percent reporting performing
pre-surgery pediatric vestibular evaluations and balance assess-
Cochlear malformations (e.g., Mondini 28.8% ments, the most common clinical evaluation performed
deformity, cochlear hypoplasia) on infants was rotational testing (75 percent). For patients
in early childhood, head thrust/head impulse testing (75
Congenital severe to profound hearing 25.0%
percent), Romberg testing (75 percent), videonystagmogra-
loss
phy (VNG)/electronystagmography (ENG) (75 percent), and
Otitis media with persistent imbalance 25.0%
rotational testing (75 percent) were the most commonly
Cranial trauma 23.1% used tests in vestibular/balance assessment. VNG/ENG
Ophthalmological disorders 23.1% evaluations were performed 100 percent of the time on
CHARGE association 21.2% patients in late childhood to assess vestibular/balance
disorders, while head thrust/head impulse testing (75 per-
Post meningitic with hearing loss 19.2%
cent) and rotational testing (75 percent) were also often
Usher's syndrome 19.2% performed (Figure 6). The frequencies of tests chosen for
Cochlear implant candidates 15.4% children in late childhood were identical to those chosen
post-surgery for adolescents.
Waardenburg syndrome 15.4% Clinical practices used for children in vestibular evalu-
Pendred's syndrome 13.5% ations and balance assessments were also addressed,
including modifications to test environments, use of
Migraine headaches 13.5%
tasking stimuli, and preferred caloric irrigation types. In
Jervell and Lange-Nielsen syndrome 11.5%
order to effectively complete the pediatric vestibular/

100 100
Audiologists Specializing in
Balance Assessment
80 80
Otolaryngologist
Poor
Neurologist
60 60
Physical Therapist
PERCENT
PERCENT
Occupational Therapist
40 40
Pediatrician
Other* Average
20
Primary Care 20 Well
Physician Very Well
0 0
*Ophthalmologist, Cardiologist, Otologist, Referring physician, Neurodiagnostic PhD
Figure 2. Specialties in which audiologists Figure 3. Ratings of respondents’

indicate typically referring pediatric perception of their academic preparation
patients for vestibular evaluations and/or in assessment of children with
balance assessments. vestibular/balance disorders.
100 100
80 80
60 60
PERCENT
PERCENT
Low
40 None 40 Medium
Low
High
20 Medium 20 None
High
0 0
Figure 4. Ratings of respondents’ Figure 5. Ratings of respondents’

confidence in performing pediatric interest in attending continuing
vestibular evaluations and/or balance education in pediatric vestibular
assessments. evaluation and/or balance assessment.
100  > 1 year old 100 Animal or cartoon characters as visual stimuli
 1–4 years old Have child sit on parent's or caregiver's lap
 5–11 years old Pediatric-size goggles
80 80
Pediatric-size harness
Head Thrust/Head Impulse
Refer to equipment as space

Falls Risk Assessment
60 60
ship or carnival ride
Lights or stripes as
PERCENT
PERCENT
Rotational Testing
visual stimuli
Romberg Testing
40 40
Use of monothermal
warm screening
testing for calorics
VNG/ENG
20 20
VEMP
HSN
CDP
DVA
0 0
Figure 6. Specific types of vestibular Figure 7. Common modifications of

evaluations performed for age groups: vestibular evaluation and/or balance
infant (younger than 1 year), early assessment for children.
childhood (aged 1–4 years), and late
childhood (aged 5–11 years). SepOct2012 | Audiology Today 33
balance assessment, some common modifications to tra- laboratories; however, these facilities may serve as an
ditional adult test protocols included having the child sit example for other children’s hospitals or medical settings
on parent or caregiver lap (75 percent) and using animal or that primarily treat pediatric patients.
cartoon characters as visual stimuli (75 percent) (Figure 7). Practicing audiologists in pediatric hospitals mini-
Activities used to effectively task children during specific mally need to identify children who may benefit from
portions of respondents’ vestibular/balance assessments formal vestibular assessment, such as children with
included having children answer questions (100 percent), balance difficulty when standing and walking or reported
having children tell a story (100 percent), singing chil- subjective vertigo. To determine the need for addi-
dren’s songs (75 percent), and reciting nursery rhymes (25 tional evaluation, bedside screening procedures can be
percent). When the preferred type of stimuli used during performed without the use of expensive diagnostic equip-
pediatric caloric testing was examined, open loop water ment such as VNG/ENG, rotational chair, CDP, VEMPs, or
irrigators (75 percent) others. Continuing educa-
were preferred over air tion programs with a focus
irrigators (25 percent), and
none of the respondents Most respondents on identification of poten-
tial vestibular deficits
preferred closed loop along with hands-on train-
water irrigators (balloon reported feeling ing in bedside assessment
systems). may increase audiologists’
Discussion that their academic ability to refer for conven-

tional diagnostic pediatric
Although many respon- vestibular evaluations and
dents did report seeing programs provided balance assessments.
patients with dizziness or Referrals to other
imbalance as a primary
symptom, most of the
poor preparation for audiologists and otolar-
yngologists for children
working with children

surveyed audiologists with symptoms of balance
employed in children’s difficulty when standing
hospitals or medical or walking were common;
settings that primarily having a vestibular/ however, nearly a third
treat pediatric patients of the surveyed pediat-
do not perform vestibular
evaluations or balance
balance disorder. ric audiologists do not
refer patients with these
assessment. The respon- symptoms for formal
dents did not indicate that evaluations. For other
they felt that children symptoms and conditions
were incapable of completing vestibular assessments or referrals were much less likely. For example, only slightly
that vestibular assessments were unnecessary in this over half of respondents reported referring for subjective
population, yet many children did not receive formal vertigo, leading to the question: how many children with
assessments at their facility. The most common reason for complaints of “the sky turning” or “the world spinning”
not conducting formal evaluations in children was that are never evaluated for potential vestibular deficits? In
the facility does not have vestibular/balance equipment. addition, only approximately a third of pediatric audi-
Given that audiologists employed in pediatric hospitals ologists refer for developmental delays in gross motor
are likely to have access to young patients needing vestib- control. Without formal testing, vestibular disorders may
ular evaluations, such as those with hearing impairments go undiagnosed in these children; therefore, these chil-
or syndromes that may affect the vestibular system, dren may not be receiving treatment and/or rehabilitation
children’s hospitals should be encouraged to develop to aid in alleviating their symptoms.
pediatric vestibular testing facilities. Less than a quarter When referrals for children with hearing loss were
of respondents reported working in facilities that cur- examined, only a quarter of surveyed audiologists
rently conduct vestibular/balance assessment for children, reported referring children with congenital severe
and only a few are currently initiating or constructing to profound hearing loss for vestibular evaluation. It

remains unknown how many children with congenital example, the Academy’s eAudiology.org Web semi-
hearing loss and combined vestibular abnormalities only nars, AudiologyOnline.com e-Learning, the Nemours
receive services for the hearing component. Through Annual Training Course for Healthcare Professionals
early hearing detection and intervention (EHDI) programs, on Vestibular and Balance Disorders in the Pediatric
audiologists and other health-care professionals have Population, and opportunities through the Vestibular
identified early identification and treatment of hearing Disorders Association at vestibular.org).
loss in young children as an area of utmost importance Moreover, due to the extensive skill set required,
(Joint Committee on Infant Hearing, 2007); however, including but not limited to bedside examinations, ENG/
potential vestibular disorders and balance problems VNG evaluation, posturography, otolith function testing,
elicit little concern. Development of reliable vestibular and rotational testing, to comprehensively evaluate the
screening procedures would allow for early detection of vestibular system in children, audiologic specialties in
dysfunction and management of vestibular disorders. vestibular evaluation should be considered and encour-
Although many children with hearing loss may have aged within the profession (Zalewski, 2009). Recently
abnormalities isolated to the cochlea, “vestibular assess- the American Institute of Balance (AIB) began offer-
ment should be an integral part of the evaluation of ing certification in vestibular assessment or vestibular
children with sensorineural hearing impairment” (Raglan assessment and management for their workshop attend-
et al, 2009, p. 147). ees, including audiologists and physicians (http://dizzy.
The lack of referrals and low overall confidence levels com/education_without_boundaries.htm). Physical and
in performing pediatric vestibular/balance assessment occupational therapists may also apply for certification
may be attributed to the academic training in vestibular in vestibular rehabilitation through the AIB. As a result of
assessment. Most respondents reported feeling that their
academic programs provided poor preparation for work-
ing with children having vestibular/balance disorders. As
a result, a commonly reported reason for not performing
vestibular assessment in children is that respondents
do not feel properly trained. The graduate curricula in
audiology programs should be strengthened in the areas
of pediatric vestibular evaluation and balance assess-
ment. Academic programs are encouraged to review their
current vestibular/balance training curriculum to include
more extensive didactic instruction and clinical prepara-
tion in assessment of childhood vestibular dysfunction.
Continuing education in vestibular evaluation and
balance assessment may also be beneficial for many
practicing audiologists who have graduated from pro-
grams with minimal vestibular/balance coursework or
clinical practicum in pediatric assessment. Given the low
ratings for academic preparation, audiologists who intend
to perform pediatric vestibular/balance assessment and/
or rehabilitation must be certain to have obtained the
appropriate knowledge and skills to be fully competent
in providing these services (Academy, 2005). Additional
education and training may be required.
Audiology continuing education should continue
to focus on these areas to increase pediatric audiolo-
gists’ access to knowledge in vestibular evaluation and
balance assessment in children. For practicing audiolo-
gists and students, lectures and hands-on workshops
as well as live and recorded online training in pedi-
atric vestibular assessment are readily available (for

better training, pediatric audiologists may be able to pro- in the academic and clinical practicum curricula of AuD
vide a more comprehensive assessment for children with programs as well as in continuing education offerings
vestibular dysfunction and/or balance disorders. nationwide.
Interest in receiving continuing education in pediatric
vestibular/balance assessment was rated high or medium
by the majority of respondents, which is consistent with a Ashleigh J. Callahan, PhD, is an assistant professor, Norman
2008 Academy survey indicating that audiology students J. Lass, PhD, is professor, and Susan E. Reed, BS, is a
and recent audiology graduates expressed strong inter- graduate student, all in the Department of Speech Pathology
est in vestibular areas of audiology. Respondents ranked and Audiology at West Virginia University, in Morgantown,
further education in vestibular assessment/management West Virginia. Meredith C. Willis, BS, is a graduate student
third behind diagnostics and hearing aids, with more in the Department of Communication Disorders at Marshall
than 60 percent of respondents expressing interest in University in Huntington, West Virginia.
hands-on vestibular training at national conventions
(Academy, 2008). In a 2010 ASHA survey of certified
audiologists, nearly half expressed interest in vestibular References
disorders and treatment (25.3 percent reporting a 5, and
19.6 percent a 4, on a scale from 1 = “Not at all interested” American Academy of Audiology (Academy). (2004) Scope of
to 5 = “Very interested”). practice. www.audiology.org/resources/documentlibrary/pages/
Of the few reporting evaluation of children for ves- scopeofpractice.aspx.
tibular and balance dysfunction, depending on the age
of the patient, rotational testing, VNG/ENG evaluations, American Academy of Audiology (Academy). (2005) The
and head thrust/head impulse testing with modifications Audiologist's role in the diagnosis and treatment of vestibular
such as having the child sit on the parent or caregiver disorders. Audiol Today 17(1):17–19.
lap and using animal or cartoon characters as visual
stimuli were most common. Additionally, the most com- American Academy of Audiology (Academy). (2008) Doctoral
mon choices of tasking exercises during testing included students and recent graduates survey. www.audiology.org/
having children answer questions, tell a story, or sing education/students/saa/documents/studentsurveyresults.pdf
children’s songs. When performing caloric irrigations the (accessed January 28, 2010).
open loop method was preferred.
American Academy of Pediatrics. (2012) Coding for pediatric
Conclusion preventive care 2012. http://brightfutures.aap.org/pdfs/
Although most pediatric hospitals currently are not evalu- Coding%20PR%20F0809.pdf.
ating young children with potential vestibular/balance
disorders, the majority of respondents expressed interest American Speech-Language-Hearing Association (ASHA). (2004)
in receiving continuing education to increase knowledge Scope of practice in audiology. www.asha.org/policy.
in pediatric vestibular assessment. At minimum, practic-
ing audiologists in pediatric hospitals need to identify American Speech-Language-Hearing Association (ASHA). (2006)
children who could benefit from formal vestibular assess- Preferred practice patterns for the profession of audiology. 12.0
ment, and this identification requires increased emphasis balance system evaluation. www.asha.org/docs/html/PP2006-
00274.html#sec1.4.12.
American Speech-Language-Hearing Association (ASHA). (2008)

Also of Interest Audiology survey 2008. Summary report: number and type of
Position Statement on the Audiologist’s Role responses. Rockville, MD: American Speech-Language-Hearing
in the Diagnosis & Treatment of Vestibular Association.
Disorders
Visit www.audiology.org and search American Speech-Language-Hearing Association (ASHA). (2010)
keywords “vestibular position statement,” or Audiology survey 2010. Summary report: number and type of
use the QR code to view the article on your responses. Rockville, MD: American Speech-Language-Hearing
mobile device.
Association.

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assessment with Balance Quest normative data for children and
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See word-for-word captions of everything
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Advance for Audiologists, 11(6):16.
www.CapTel.com • 1-800-233-9130

Improving
Clinical Care
Interview with Dr. Linda Luxon By Dav id Fabry
David Fabry, PhD, content editor of AT and

member of the AAA Foundation board, had the
opportunity to speak with Dr. Luxon over the
summer about developments in and challenges
of diagnosis and treatment of pediatric
patients with vestibular disorders.
inda Luxon, CBE, BSc, FRCP, emeritus professor of Audiovestibular

Medicine at University College London, was the distinguished pre-
senter of the 2012 Marion Downs Lecture in Pediatric Audiology. Her
lecture, "The Dilemma of Dizziness in Children," was one of the
highlights of AudiologyNOW! 2012, in Boston, and was the eighth
presentation in this series of seminars on topics in pediatric audiology. The annual
Marion Downs Lecture is funded by the American Academy of Audiology Foundation,
with a grant from the Oticon Foundation.
Dr. Luxon trained in general internal medicine and neurology at St. Thomas’
Hospital and the National Hospital for Neurology and Neurosurgery, Queen Square,
London. She was appointed to staff at Queen Square in 1980 and to the chair of
Audiovestibular Medicine at the University of London, based at UCL, in 1991. Among
her many honors, Dr. Luxon has been elected president to the British Society of
Audiology; Section of Clinical Neuroscience, Royal Society of Medicine; International
Association of Physicians in Audiology; and European Federation of Audiological
Societies. She has been an invited lecturer in the United States, China, Thailand,
Korea, New Zealand, India, and throughout Europe. Her additional current activities
include being the Department of Health national clinical advisor in audiology and
vestibular disorders and officer at the Royal College of Physicians London.
Dr. Luxon’s main interest is improving clinical care for patients with hearing and
balance disorders with emphasis on teaching and research focused on vestibular

Improv ing Clinical Care: Inter v iew w it h Dr. Linda Luxon
disorders; noise-induced, genetic, and autoimmune hear- from vertigo or tinnitus. One quarter of those reported
ing loss; and central auditory processing disorders. David that symptoms were sufficiently severe to interrupt their
Fabry, PhD, content editor of AT and member of the AAA normal activity. There is an earlier Scottish study from
Foundation board, had the opportunity to speak with Dr. 2000 from Anoh-Tanon and his coworkers (Pediatr Neurol
Luxon over the summer about developments in and chal- 23(1):49–53) that looked at school children; this study
lenges of diagnosis and treatment of pediatric patients found that 18 percent had had one episode of dizziness
with vestibular disorders. or vertigo, and five percent of them had more than three
episodes of those symptoms in the last year.
There was a recent large study done by Humphriss
AT: Dr. Luxon, thank you for joining us today. and Hall from the UK in 2011 (Int Pediatr Otorhinolaryngol
There really aren’t a lot of people working in this 75(3):395–400) looking at just under 7,000 10-year-olds and
area, and there is keen interest in the topic of they reported the prevalence of rotatory vertigo to be just
pediatric vestibular disorders, both globally and under six percent. So, I think "dizziness" in children is
among American audiologists. The first question probably more common than people think, but the prob-
relates to the prevalence of dizziness in children. lem is that these children either get overlooked because
Luxon: There are a number of papers that report on the they are just thought to be messing around or the symp-
prevalence of vertigo and dizziness in children. There is toms are not thought to be important, or they go to see
a 2006 Finnish study by Niemensivu and her colleagues somebody that doesn’t really know much about dizziness.
(Pediatr Otolaryngol 70(2):259–265) with a study group In the United Kingdom, they would typically see a general
number of just under 1,000 in the general population practitioner (primary care), pediatrician or ENT, rather
that reported eight percent of 1–15 year-olds suffered than an audiologist, when a problem is first suspected.
Dick Danielson, chair of the AAA Foundation Board (left), and Don Schum, vice president, audiology and professional relations, Oticon, Inc. (right),
recognize Dr. Luxon as the presenter of the 2012 Marion Downs Lecture in Pediatric Audiology at AudiologyNOW! in Boston, MA.

The same would hold true in the United States. You have isolated one of the primary issues that
They would typically see a physician, specifically exists when there is a lack of coordinated care,
a primary care MD, pediatrician, or ENT. when children see many different providers and
Absolutely, but of course the problem is that except for the no one integrates the total picture.
ENT, the other doctors probably do not see these sorts of Yes, I think that is right. In a way, one of the most impor-
problems often. Furthermore, ENTs are better trained in tant things is to highlight which children might have a
middle and inner-ear disease than neurological causes problem. That is, focus on the groups that have a higher
such as migraine, so those children tend to get missed, prevalence than the rest of the population and concen-
or referred to psychologists and pediatric psychiatrists trate on them. Obviously, if you have bilateral profound
because people can’t find anything wrong. Because the auditory loss, a significant proportion of those children
symptoms are troublesome, but rarely life-threatening, will have vestibular loss. Certain groups are worth check-
they are often undiagnosed. In addition, what is reported ing for a vestibular abnormality, such as children with
in the literature is that because children go to various dis- syndromes, cranio-facial anomalies, or children who have
ciplines, no one speciality focuses on the real problem. I been inpatients in an intensive care unit.
think that is why the perception exists that children don’t
suffer from these symptoms.
AmericAn AcAdemy of Audiology
Share your experience and

new
knowledge with colleagues. educAtor
trAck
Submit proposals online at for 2013!
www.audiologynow.org.
Deadline for selected
submissions is October 10.
AnAheim, cA
April 3–6, 2013

That brings to mind a typical scenario for many spontaneously. If the parents are not well informed, they
pediatric cochlear implant centers that are might think that the child has nausea and is vomiting
working with patients who have, say, Mondini because they ate something or crawled around on the
malformation with enlarged vestibular aque- floor and stuck his dirty fingers in his mouth. If you see
ducts. The issue becomes when is it appropriate a child that has an auditory abnormality and you ask the
to explore additional vestibular evaluation for appropriate questions about development and balance,
diagnosis and treatment beyond the presence of you will frequently elicit a clue that indicates that you
the anatomical differences. need to look further.
Well right, but I think in all honesty, I would say that if
someone has the Mondini defect, obviously the parents or
the child should be quizzed about any possible symp- Yes, and I think that the challenge for many par-
toms that might suggest a vestibular abnormality. These ents is that their concerns are often dismissed by
include whether the child practitioners as being overly nervous or anxious,
and they are sometimes reluctant to bring up
1. uddenly stops functioning and hangs on to the furniture,
S issues with their physician.
2. Becomes terrified for no apparent reason, In the United Kingdom, this is often described as hav-
3. Suffers unexplained episodes of nausea and vomiting, ing a “Mommy Moment,” which is very unfair, because
4. Has episodes where he or she suddenly goes pale, or usually the parents turn out to be right. I suppose that an
5. Is not developing normally physically. example is clumsiness, which is hard to distinguish from
just the normal issues with learning to walk and becom-
Any of these symptoms should make you think ing stable. If there was any other indication, such as if
that you should investigate a bit further. It’s partly the there is a strong family history of migraine and the child
symptoms that they may have had, but, unless spe- has vomiting episodes or dizzy spells, then it makes sense
cifically asked, the parents may not recognize them to conduct further evaluation. The problem is, it is rarely
ever described as dizziness in children.
On that topic, many audiologists work in facilities

that do not have specialized equipment for pedi-
atric vestibular evaluation, so they would need to
refer to a tertiary clinical facility. Do you have a
recommended protocol for use with children that
is different from adult protocols?
Well, I wouldn’t say we use different techniques in
pediatric assessment, but the way we approach the child
is different. Certainly, for the examination we make it
more like play with flashing toys and sticking stickers on
them, rather than a pen to assess eye movements. In an
adult, we systematically work through the test battery,
and if the child is ten, and not upset, and you can do it, we
would complete our standard protocol: caloric responses,
eye-movement recordings, rotation testing, optokinetic
nystagmus, vestibular evoked responses (c-VEMP and
o-VEMP) and posturography. If, on the other hand, you
have a two-year-old child who is screaming, we would
use the history and what you found when you examined
them to determine which tests we might use. Do you get
an idea of dynamic visual degradation while doing the
dynamic visual acuity test, which uses pictures that get
smaller and smaller? Can the child identify them when

he is moving his head around? They don’t have to be able that we should always do, but VEMPs is a much more
to read; they just have to be able to say “house” or “cat” to pleasant test for little ones than running water in their
identify what is in the pictures. If we thought they had ears. Of course, VEMPs look at a different section of the
vestibular failure, we’d probably go straight to a rotational vestibular system. I think what we really have to get a
on the parent’s lap if the child was anxious. But if we handle on is the range of VEMPs abnormalities that are
suspected migraine, we’d probably look at caloric testing, associated with different pathologies. I just don’t think
because if that’s normal, and they have normal hearing that we know exactly how to interpret abnormal VEMPs
and suffer one or more of the symptoms listed previ- at the moment. I think that they are a great test, and sure
ously (e.g., dizzy/vomiting spell, unsteadiness or suddenly to come to the fore, but at the minute we’re still trying to
going pale), then it’s more like they have migraine and sort that out.
we would go down the path of antimigrainous therapy.
Rather than a “standard” protocol for specific age groups,
we try to gear diagnostics and treatment to the child. Yes, and the same goes for the United States.
Although a promising clinical measure for adults
and children, VEMPs have been viewed as some-
Do you see the applications for vestibular evoked what experimental until recently.
myogenic potentials (VEMPs) increasing for Well that’s right. There is still even some debate over
children? which parameter you measure. For a long time, we were
Yes, I do. It’s still in the early stages, though, so I don’t using latency. Recently, at the Barany Society, there was
really feel competent to say that it is definitely the test some talk about amplitude using the rectified voltage as a
The PAC is one of the most powerful tools

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much more meaningful tool. I’m not for a minute decry- Richard Gans published a recent paper in the
ing them; we certainly don’t consider them experimental January 2012 issue of AT that highlighted the
in the sense that we have to get ethics approval to use many tools available for equilibrium assess-
them, as we certainly do them routinely. But, I person- ment in infants, but he also made the case that
ally don’t feel hugely competent about interpreting them, low-tech equipment like a physioball ball may
despite having read the literature and doing them. That is, be used rather effectively with young children
when does “normal” truly exclude an abnormality? for assessing righting reflexes and equilibrium
responses.
I would entirely agree with that, and would suggest that
And if you don’t feel competent with the interpre- if an audiologist wants the ability to look at children with
tation, imagine the clinician who is only seeing balance disorders in their armamentarium, they would
this occasionally and just happens to have the go to a large facility, where they see many of children.
equipment at their disposal. It can become a little Frankly, I’m not sure any unit sees a lot of children with
like tea-leaf reading, in some respects. balance disorders, but an audiologist should attempt
Well that’s right, and I don’t think that we have the to find one where they see more than the norm, have
answer, but we must plod on. experience getting patient history, and conduct thorough
examinations of eye movements. An audiologist can
use teddy bears with flashing lights, or bigger toys to
What is the youngest patient on whom you have attract the child's attention to study pursuit and saccades,
used posturography? because you want to be able to identify an abnormal-
I think that it is difficult to use posturography on young ity. Can they pursue and make saccades normally in the
patients. I mean, we do use posturography, but we do it horizontal and vertical planes? Is there any nystagmus,
much more to guide rehabilitation physiotherapy than we with—and without—fixation? And, I recommend you
do diagnostically. I don’t think it is a useful diagnostic tool conduct a good positional test, because we have found
for children or adults. It’s very good for saying whether a little children with bangs to the head who have developed
person has visual dependent strategy, and can be helpful benign paroxysmal positional vertigo (BPPV) but have
for the physiotherapist directing therapy. never been taken to the hospital for evaluation.
Or, they might have seen a neurologist who has looked
at them, but hasn’t done a positional test, so nobody’s
That’s interesting, because I think that in the noticed the positional nystagmus, and that is all that
United States, posturography was all the rage, there is wrong with them. In summary, I would say,
but there has similarly been some controversy learning to undertake a really good examination in a unit
over whether it is more useful as a diagnostic or where they are looking at visual acuity with and without
rehabilitative test. Next question—what are the head movement is worth its weight in gold. Sometimes,
age effects on oculomotors? you’ve got to be able to do this with little or no test equip-
I’ll tell you who has done excellent work on this topic: ment, and for that reason, I would support Richard’s view
Sylvette Wiener-Vacher from Paris. I would refer people for clinical purposes. I’m not saying that the sophisticated
to her papers, because she’s got beautiful plots showing procedures aren’t necessary to help us develop our under-
the change in horizontal and vertical VOR with age. The standing of vestibular function, but that’s quite a different
trends in her paper clearly show age effects, but we don’t
clearly start measuring the phase and gain of the VOR
until around eight or ten years of age. We do the test and
look at the overall pattern, because nine times out of ten Also of Interest
what we are interested in is whether there is vestibular Dr. Luxon’s presentation, “The Dilemma of Dizziness in
failure or a marked asymmetry. Looking at the change in Children” (.15 CEUs), is now available as a free on-demand
VOR is totally interesting for research purposes; but in a Web seminar. Complimentary access of the 2012 Marion
diagnostic sense for children with disorders, I don’t think Downs Lecture in Pediatric Audiology is underwritten
by the American Academy of Audiology Foundation with
that this information is vital, as an audiologist is busy
funding from the Oticon Foundation. To register, visit
providing daily clinical service. www.eaudiology.org.

purpose than for the average audiologist who wants to Very good. One area that has gained a lot of
provide first-rate clinical service. recent attention in the United States is concus-
sion. Are there data to suggest that children with
repeated concussions are more prone to vestibu-
Absolutely. The pediatric audiologist who may lar pathology?
not be equipped for conducting vestibular evalu- I haven’t specifically looked to see if there are papers
ation may still have extensive experience with related to this topic in children, but in adults there are
behavioral observation and evaluation of young lots of papers in this area. That link is so difficult, not
children and their interaction with parents. least because people with mild head injuries often don’t
Exactly. And it’s the little things as well. When you are talk- seek treatment at a hospital, so the diagnosis of concus-
ing to the parents of a little child, observe him or her playing sion is under-reported. For example, teenagers often play
with the bricks and running around the room. Is she stable? sports, get a bang to the head and feel dizzy and off-bal-
Does she keep tipping over? Is she coordinated? Can she put ance, but never go to the hospital because they feel better
bricks on top of each other? Observe these details while the in a few days. Therefore, we often find that the major
child is playing, so you aren’t trying to get her to do any- group of patients studied are claimants going through
thing—you are just watching her activity. That also can give a legal case. Unfortunately, this patient group is almost
you clues. And, it helps you sort things out if you have a clear always confounded by compensation issues, and this
understanding of normal child development. skews the findings reported in the adult literature.
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Indeed. Causality is difficult to prove. Finally, if a child presents with acute vertigo or
Most studies report that the lifetime likelihood of getting dizziness, are there checklists or protocols that
a balance disorder is something on the order of 40 percent exist so clinicians ask the right questions?
of the population, so balance disorders are very common. Well, I would start by asking a battery of questions,
I know that in the adult literature, there were a handful including
of papers suggesting that Meniere’s disease may develop
after head trauma. If you have a car crash with head 1. W
ere the child born following a normal pregnancy and
trauma in 1978 and in 1980 you develop Meniere’s Disease, delivery?
there are some specialists who have suggested that the
two conditions are related, but I think this is open to 2. Has the child developled normally to date?
question. The same may exist for BPPV and head trauma.
It’s very hard to relate a head injury to a vestibular diag- 3. Has the child been hospitalized for any reason?
nosis; the two are temporally related.
4. Does the child have hearing loss?
Yes, and unless you suffer a basal skull fracture 5. Has the child had head trauma?
with associated hearing loss, it is often not that
clear. 6. Does the child have any ear pathology?
Yes, it is very difficult in adults, and more so in children.
7. Has the child taken ototoxic drugs?
Have you seen any relationship between hair cell 8. Does the child have positional nystagmus?
dysynchrony (auditory neuropathy) and vestibu-
lar neuropathy? 9. A
re there any psychogenic problems in the back-
Actually, yes, there are papers that clearly show an asso- ground that you should be considered?
ciation between the two. We have recently completed
a paper on the involvement of vestibular neuropathy 10. Is there a family history of migraine?
in various neuropathy, and we’ve looked at all types of
neurological neuropathies, including auditory neuropa- 11. Is the problem acute or chronic?
thy. Our paper has been submitted for publication to the
Journal of Vestibular Research. I think that it is worth having a whole set of questions,
or a decision tree that you can work through to try and
help you think through migraine, vestibular neuritis that
We’ll look forward to reading that. What are isn’t compensating, BPPV, or importantly a central neu-
questions that the average clinicians could ask rological disorder requiring a specialist opinion. I think
to become more confident in knowing when to that it is worth having a set of questions to help prevent
refer pediatric patients for additional testing? For missing things.
example, is it worthwhile to ask about motion
sickness from amusement parks or automobiles?
Yes, very many of the children who suffer motion sick- Is there a published checklist or decision tree?
ness will go on to develop migraine. Migrainous vertigo There was one published in 2003 by Ravid, Bienkowski,
is the most common condition that we see in children and Eviatar (Pediatric Neurology, 29:4, pp. 317-320). It is
who present with acute episodes of vomiting and associ- essential to validate the effectiveness of a questionnaire
ated vertigo or dizziness. And they tend to get better in and/or computer-assisted algorithm in screening children
adolescence, and then in adult life, they develop the more with dizziness or vertigo. I do not think this decision tree
characteristic headache, which may or may not have the is perfect, but it is certainly a good start.
accompanying visual/vestibular symptoms and other
neurological symptoms. There are many papers on this,
and the link is very strong. Is it specific to pediatrics?
Yes, it is specific to the pediatric population.

Great, sounds like it might be a tool that clini-

cians might want to consider. Any final thoughts?
Absolutely. I suppose that in addition to these measures,
the interested audiologist should consider gaining experi-
ence with
Leave a legacy to the next generation
1. Normal pediatric development, of audiology and ensure that your gift
supports healthy hearing programs in
2. Neuro-otology, that specifically includes exposure to the future.
neurology eye movement rather than ophthalmologi-
cal eye disorders alone, and
Your charitable trust, bequest, or
3. Children who have syndromes, whether that expo-
other estate gift will pay dividends for
sure is through medical genetics, ENTs, or some other years to come.
specialist.
For more information about the
I think that if you had a bit of exposure to all of those HearAfter Society, contact Kathleen
things, and certainly it is worth travelling to a facility where Devlin Culver at 703-226-1049 or
they have considerable experience integrating all of this kculver@audiology.org.
information and where they also do a lot of rehabilitation.
The audiologist would pick up valuable information because
there aren’t really a lot of courses in these areas yet.
Indeed, and this area is continuing to emerge, as

evidenced by the popularity of your session at
AudiologyNOW! 2012 in Boston.
Well, I hope that attendees found something useful in it.
I assure you they did! I think you have discussed

a lot of valuable information here. The sophisti-
cated equipment and tests are terrific, but a lot
of what you speak of involves asking the right
questions, behavioral observation, and just
being aware of the child’s relationship with his/
her surroundings. Thank you so much for taking
time to speak with us today.
Thank you for giving me the opportunity to spend time
with you.
David Fabry, PhD, is the content editor for Audiology Today

and the managing director of sales at Starkey.
Promoting philanthropy in support
of research, education, and public
awareness in audiology and
hearing science.
www.audiologyfoundation.org

Don’t
Reinvent
the
Wheel! A Guide to Electronic
Practice Management
Tools and Resources
By Br en na Ca r roll
Many practice management

tools are already available,
eliminating the need to
“reinvent the wheel.” It can
be challenging to narrow
online searches for tools and
resources most relevant to
maintaining and audiology
practice.

he information age of the Internet and social media
continues to flourish. This proliferation of information
and easy access from anyone possessing a computer has
led to a bevy of practice management resources avail-
able within seconds, just by using a search engine. With
such an explosion of innovation and resources, it can be
challenging to stay current on the latest resources avail-
able to assist you in your daily practice. Many online and
electronic resources are available at no cost or low cost.
Community outreach and provider introduction tem-
plate letters are available online. Facebook and blogging
sites provide opportunities to market your business and
provide technology updates and e-commerce opportuni-
ties directly to your consumers on a regular basis. With so
many online tools, the challenge becomes knowing how
to quickly and efficiently search for the resources you
need to maximize your efficiency.
Many marketing and outreach resources have already
been created, alleviating the audiologist of the burden of
“reinventing the wheel.” Visiting the Academy’s practice
resource page at www.audiology.org/practice/resources/
Pages/default.aspx provides a broad range of items
without the burden of parceling through information
that may not be relevant to an audiology practice from
the keyword search results of a large search engine. The
information on this Web page is assessed and updated
regularly. Physician outreach and private practice kits are
available, in addition to an audiology marketing guide.
The kits contain customizable introduction letters, and
separate hearing and audiology PowerPoint presentations
targeting physician and general public demographics. The
presentations can be customized to include your prac-
tice branding and contact information. The presentation
slides can be tailored to reflect information and services
offered by your practice.
Additional resources available at this site include
audiology promotional tools and posters, and brochures.
Downloadable images for May Is Better Hearing Month
can be added to the banner of your company’s Web
site. Nonmarketing practice management tools are also
available, including information on HIPAA and Medicare
updates.

Don't Reinvent t he Wheel!
Incorporate Social Media Facebook also provides an opportunity to share a

In addition to traditional referral source and outreach, bit about yourself with your consumers. Health-care
social media presents a new frontier of marketing and consumer research from BSM Consulting revealed that
patient interactions. According to a 2012 PriceWaterhouse patients like to know both the professional highlights
Coopers Health Research Institute poll of U.S. consumers, and “human” details about their providers and staff.
one-third reported using social media sites like Facebook, Information related to where a provider has lived, family
Twitter, YouTube, and online forums for health-related details, hobbies, and civic organization involvement is
matters. Four in 10 consumers report using social media appreciated and interesting to clients seeking your ser-
to find reviews of providers and treatments, and 41 vices (Walker, 2012).
percent reported that a negative review would impact A Facebook page can be used as an educational
their choice to see a specific provider (PriceWaterhouse resource for your patients. You can link your own
Coopers, 2012). Social media provides an opportunity to personal YouTube videos to your Facebook page with
allow potential patients and clients to find an audiologist vignettes answering frequently asked questions, and
and connect with that provider on a more regular basis. educational sessions about what to expect at a hearing
It also provides an opportunity to maintain an ongoing test, amplification consult, or VNG appointment. If you
relationship with existing patients and provide updates maintain an audiology blog, direct links on the Facebook
on new technologies. page can be provided to this information as well.
When using social media tools such as Facebook, it is Facebook also provides an opportunity to quickly share
imperative to respect patient privacy and HIPAA regula- information about specials and sales your office may
tions and use social media responsibly. The American be offering. Status updates provide a forum to quickly
Medical Association (AMA, 2012) has published guidelines disseminate information on new products and assistive
for professionalism regarding social media that is appli- listening devices and begin a dialogue with your consum-
cable across all medical and health settings. It should be ers. It is important to update your Facebook page regularly
noted that a HIPAA violation is considered sharing any to ensure regular feed communications with your fol-
information that a patient can identify themselves—even lowers. It can be helpful to designate a staff member to
if the interaction is positive. Seemingly innocent status provide an update on a regular weekly or biweekly basis.
updates such as, “fit a pair of bright red hearing aids on
a wonderful client last week” is considered a violation of Use Facebook E-Commerce
HIPAA regulations because the client will be able to iden- The world of e-commerce is moving to Facebook.
tify themselves based on the hearing aid description. It is E-commerce Facebook options (sometimes referred to as
safest to keep status updates focused on staff and practi- f-commerce to specifically designate use of the Facebook
tioners to avoid any inadvertent violations. Specifics on platform) provide StoreFront and Facebook e-Store
HIPPA can be found at the Academy’s practice resource options.
Web page provided earlier in this article. StoreFront is generally utilized when your practice’s
Creating a Facebook page for your practice is a simple Web site already supports online credit card payments.
means to promote your practice and provide updates to Via this option, items (like batteries, hearing aid wax
existing clients and consumers. Company Facebook pages guards and cleaning tools, and even assistive listening
can be built by the practice owner or staff. Online tutori- devices) are featured on a Facebook page with a “buy” or
als are available to assist with the construction of the “add to cart” button. Once the button is selected, users are
page and can be found quickly via online search engine. routed to the existing e-commerce site (usually the prac-
Suggestions for your Facebook page include prominently tice's Web site) to complete the transaction. StoreFront
displaying the phone number, location, and contact infor- options include the following:
mation of your establishment.

Don't Reinvent t he Wheel!
Miya Merchant e-commerce tool in addition to a destination for informa-

Beetailer tion and update.
Fliptabify
BigCommerce
ShopTab Brenna Carroll, AuD, is an audiologist at Swedish Medical
Group in Issaquah, Washington. She is also chair of the
Facebook e-Store options are designed to ease the Business Enhancement Strategies and Techniques (BEST)
commerce process by keeping users on Facebook to com- Committee of the American Academy of Audiology.
plete transactions. This is a great solution for practices
that do not currently support online payments via the
consumer section of a company Web site. Depending on References
the application utilized by the audiology practice, con-
sumers may be required to accept a permissions request American Medical Association (AMA). 2012 Annual Meeting.
before shopping is allowed. Some e-Store options include AMA policy: professionalism in the use of social media. www.
these: ama-assn.org/ama/pub/meeting/professionalism-social-media.
shtml (accessed on May 28, 2012).
8th Bridge
Miyoni PriceWaterhouseCoopers, LLC Health Research Institute.
Payvment (2012) Social media “likes” healthcare: from marketing to social
Intuit business. From PwC HRI Social Media Consumer Survey. www.
SimpleStore pwc.com/us/en/health-industries/publications/health-care-social-
TabJuice media.jhtm (accessed on May 28, 2012).
ShopIgniter
Walker A. (2012) Patient education: the informed patient is an
Conclusion involved patient. BSM Consulting. www.bsmconsulting.com/
Many practice management tools are already available, pdf_articles/PatientEducationInformedPatient.pdf (accessed on
eliminating the need to “reinvent the wheel.” It can be May 28, 2012).
challenging to narrow online searches for the tools and
resources most relevant to maintaining and audiology
practice. The Academy Web site provides practice man-
agement resources available to Academy members. This
information is relevant to a modern audiology practice
and regularly updated.
Social media, and in particular Facebook, provides an
opportunity to market to existing consumers, reach out to
new consumers, and provide hearing education. Facebook
can also be used to share information about audiolo-
gists and staff in a practice, creating a closer relationship
between the audiologist and the client. Facebook and
social media are ever evolving. Current trends include
adapting the company Facebook Web page into an

MeMbership
reNeWAls
NOw OpeN
Renew Online by
December 31, 2012,
and Receive a
Chance to win a free AudiologyNOW!® 2013 registration
Discount on an eAudiology Web seminar package
Discount on a learning lab at AudiologyNOW! 2013
Visit www.audiology.org to renew your membership today!

CSI: Audiology
The Case of Encephalopathy

Presenting as Hearing Loss
By Emily Na ir n, V irgini a Ramacha ndr a n, a nd Br ad A. Stach
Welcome back to an ongoing article series that diagnosis of “encephalitis” (inflam-

challenges the audiologist to identify a diagnosis mation of the brain).
for a case study based on a listing and explanation

Past Medical History
of the nonaudiology and audiology test battery. It is According to his family, prior to the
important to recognize that a hearing loss or a ves- onset of symptoms, the patient was
highly functioning and independent,
tibular issue may be a manifestation of a systemic
running two businesses and a small
illness. Being part of the diagnostic and treatment farm in his home country, where
“team” is a crucial role of the audiologist. Securing he had been living for the previous
three years. The patient’s family did
the definitive diagnosis is not only rewarding for the
report a vague description of some
audiologist but enhances patient hearing and bal- pre-existing hearing problems, but of
ance health care. a noticeably lesser degree than was
exhibited in the two months prior to
—Paul Pessis, Investigator-in-Chief admission. He had also experienced
a trauma earlier in life that blinded
CSI Reference Guide: Visit www.audiology.org and search keywords his right eye.
“CSI Reference Guide.”
Audiologic Findings
Case History confusion, gait problems, slurred Audiometric evaluation was per-
A 67-year-old male was seen in the speech, weight loss, emotional formed at his bedside. Otoscopy
emergency department, accom- lability, and eventually, hallucina- revealed normal external auditory
panied by his family. The patient tions. The patient’s family noticed a canals and tympanic membranes.
was unable to communicate and distinct progressive decline in hear- Pure-tone and speech audiometric
could not give his own case history ing ability during this time, with the results were unable to be obtained
information. patient talking loudly. due to the patient’s altered mental
It was reported that both the Due to the severity and progres- status.
patient and his wife developed flu- sion of symptoms, the patient’s Immittance results are shown in
like symptoms about two months daughter, who lives in the United Figure 1. They are consistent with
earlier. His wife recovered, but the States, flew to his home in Central normal middle-ear function bilater-
patient reportedly woke up one America, escorted her father back ally, characterized by normal Type A
morning shortly after contracting the to the United States, and brought tympanograms, and normal ipsilat-
illness and stated that he was having him immediately to the emergency eral (uncrossed) reflexes bilaterally.
“difficulty hearing.” At this time he department. Contralateral (crossed) reflexes were
also complained of a headache at the The treating physician reported elevated bilaterally.
back of his head and base of his neck. that the patient was “deaf” and was Distortion product otoacoustic
Over the course of the next two speaking loudly. At this time, the emissions, shown in Figure 2, were
months he began to experience patient was admitted with a working largely present bilaterally, consistent

CSI: Audiology
with normal cochlear outer hair hearing sensitivity loss bilaterally, Mitochondrial disease
cell function. Auditory brainstem but suspicion for central auditory
response testing was attempted dysfunction. Creutzfeldt-Jakob disease
using clicks at 95 dBnHL, but results
were not replicable bilaterally. ABR Differential Diagnosis Findings
results were deemed unreliable due
to patient movement. Paraneoplastic process CT scan was normal.
Although elevated, the presence of
acoustic reflexes rules out a periph- Slowly progressive dementia with A vast panel for autoimmune and
eral hearing loss greater than severe coincident hearing loss infectious etiologies was negative.
degree. In addition, the presence
of normal ipsilateral reflexes and Susac’s syndrome
otoacoustic emissions was consistent
with no more than a mild cochlear
hearing loss bilaterally.
Overall, the audiometric results
are consistent with normal cochlear
function, or a cochlear loss that
was no more than mild in degree.
No formal behavioral assessment
could be made regarding retroco-
chlear auditory function. However,
the presence of bilaterally elevated
contralateral acoustic reflexes is
suggestive of auditory disorder more
centrally. Informally, throughout his
hospital stay, each subsequent pro-
vider who interacted with the patient
described the patient as experienc-
ing “deafness,” even in the presence
of moments of otherwise apparent
lucidity.
Consider the Facts Figure 1. Tympanometry and acoustic reflex results.

The patient presents with: ECV = ear-canal volume; BBN = broad-band noise.
History of rapidly deteriorating
mental state, dementia, emo-
tional lability, slurred speech, and
ataxia;
History of rapidly progressing

hearing loss. Inability to interact
with health-care providers; inter-
preted by them as “deafness;” and
Acoustic reflex pattern and

distortion product otoacoustic Figure 2. Distortion-product otoacoustic emission
emissions pattern consistent () and noise floor () amplitudes as a function of F2
with no more than mild cochlear frequency, averaged over two samples.

CSI: Audiology
Ophthalmologic examination was become deformed, but once the This syndrome consists of a triad
normal on the left and could not prions become abnormal, they clump of symptoms that include encepha-
be evaluated on the right due to together and form spongelike areas lopathy, peripheral sensorineural
the pre-existing trauma. in the brain tissue, causing neuronal hearing loss, and retinal vasculitis
loss and damage. (Susac, 2004). The patient did possess
Behavioral health evaluation CJD is hereditary in about five to the first two symptoms, and while
indicated that mental status fluc- 10 percent of cases. It can be acquired retinal vasculitis was ruled out in the
tuated throughout his stay but, through exposure to infected brain left eye, the patient’s history of right
overall, continued to decline. Due tissues, which occurs in less than eye trauma precluded evaluation.
to excessive agitation, restraints one percent of cases. The most However, MRI did not show corpus
were required for the patient’s common form of CJD is “sporadic,” collosum changes characteristic of
safety. wherein the patient has no known Susac’s.
risk factors (National Institute of Mitochondrial diseases can also
Neurologic evaluation was posi- Neurological Disorders and Stroke, be present with encephalopathy and
tive for cerebellar dysfunction 2003). hearing loss but are extremely rare.
and startle myoclonus. While CJD cannot be diagnosed Results were ultimately consistent
definitively without brain biopsy or with CJD, despite the rarity of hear-
Multiple EEG studies showed autopsy, the presence of elevated ing loss as a presenting symptom.
slowing in the left hemisphere 14-3-3 protein (Sanchez-Juan, 2006)
and revealed a progression and the abnormalities found on MRI Treatment
from mild to moderate diffuse imaging (Tschampaa et al, 2003) are CJD is incurable and invariably fatal,
encephalopathy. pathognomonic for the disease. typically in a matter of months
Although there are a few iso- (Centers for Disease Control and
Sedated MRI with and without lated reports of hearing loss as a Prevention, 2010). The patient was
contrast showed cortical “ribbon- prominent symptom of CJD, it is placed on quetiapine—brand name
ing” in the both lateral temporal, not characteristic of the disease. Seroquel, a second generation anti-
parietal, and occipital lobes, Previous case reports have presented psychotic that has been shown to
worse on the left and FLAIR signal some conflicting information as far alleviate agitation in patients with
abnormalities of the bilateral as auditory electrophysiologic find- dementia. He was discharged 24
caudate, putamen, and posterior ings, with some being normal (Tobias days after initial hospitalization. At
thalami. et al, 1994; Bigelow et al, 1998), and that time, his daughter was seeking
others uninterpretable due to move- guardianship and would be caring for
Lumbar puncture cerebrospinal ment (Krishna and Bauer, 2004; Rene him at her home. Hospice care was
fluid analysis revealed elevated et al, 2007), which was the case with arranged.
14-3-3 proteins. our patient. When behavioral audio-
metric data were obtained, speech Conclusion
And the Diagnosis Is… audiometry performance was worse The overall impression of “deafness”
Creutzfeldt-Jakob disease than expected based on degree of in this patient and reports of progres-
hearing sensitivity loss (Tobias, et al, sively worsening hearing loss were
Discussion 1994; Bigelow et al, 1998; Krishna and instrumental in shaping the initial
Creutzfeldt-Jakob Disease (CJD) is a Bauer, 2004). diagnostic picture for the treating
prion disease. It is part of a family The hypothesis of paraneoplastic physicians. Hearing loss is character-
of diseases called “transmissible disease was ruled out with laboratory istic of Susac’s syndrome but rare in
spongiform encephalopathies.” testing, and the presence of other CJD, and this knowledge initially led
Prion proteins occur naturally in symptoms did not support a gen- the team to lean toward the former
the body’s cells and are harmless eral diagnosis of slowly progressive diagnosis, which has a very different
in their normal form. Prion disease dementia alone. prognosis and treatment strategy. In
occurs when these proteins become In considering hearing loss in the the end, audiologic evaluation results
deformed, “folded over,” or “crimped.” constellation of symptoms, Susac’s were only able to rule out extensive
It is unknown why the proteins syndrome was initially suspected. peripheral hearing loss, and we were

CSI: Audiology
unable to confirm or rule out the Virginia Ramachandran, AuD, is a Rene R, Campdelacreu J, Ferrer I, Escrig
existence of retrocochlear or cortical senior staff audiologist and Brad A. A, Povedano M, Gascón-Bayarri J, Moral
hearing loss. As we are well aware, Stach, PhD, is director of the Division of E. (2007) Familial Creutzfeldt-Jakob
the existence of peripheral senso- Audiology, both with the Department of Disease with E200K mutation presenting
rineural hearing loss in the older Otolaryngology—Head and Neck Surgery, with neurosensial hypoacusis. J Neurol
population is pervasive, so the pres- Henry Ford Hospital, Detroit, Michigan. Neurosurg Psychiatry 78:103–104.
ence of such in this patient would not
be diagnostically useful. However, Rennebohm R, Susac JO, Egan RA,
the absence of peripheral hearing References Daroff RB. (2010) Susac’s syndrome—
loss, while not ruling out Susac’s update. J Neurol Sci 299:86–91.
syndrome, can be helpful in the diag- Bigelow DC, Eisen MD, Yen DM, Saull
nostic equation, because it has been SC, Solomon D, Schmidt DE. (1998) Sanchez-Juan P, Green A, Ladogana A,
shown that the hearing loss charac- Otolaryngological manifestations Cuadrado-Corrales N, Sáanchez-Valle
teristic of this disorder is peripheral of Creutzfeldt-Jakob Disease. Arch R, Mitrováa E, Stoeck K, Sklaviadis
and not central (Rennebohm et al, Otolaryngol Head Neck Surg T, Kulczycki J, Hess K, Bodemer M,
2010). This case is illustrative of the 124(6):707–710. Slivarichová D, Saiz A, Calero M, Ingrosso
challenges inherent in diagnosing L, Knight R, Janssens AC, Duijn CM, Zerr
rare disorders in the face of abnor- Centers for Disease Control and I. (2006) CSF tests in the differential
mal presenting symptoms. The due Prevention. (2010) CJD (Creutzfeldt-Jakob diagnosis of Creutzfeldt-Jakob disease.
diligence that ultimately resulted disease, Classic). www.cdc.gov/ncidod/ Neurol 67(4):637–643.
in the determination of CJD demon- dvrd/cjd/ (accessed July 19, 2012).
strates the value that can be found Susac JO. (2004) Susac’s syndrome. Am
in a multidisciplinary approach to Krishna P, Bauer C. (2004) Hearing loss J Neuroradiol 25:351–352.
diagnosis. as the initial presentation of Creutzfeldt-
Jakob disease. Ear Nose Throat J Tobias E, Mann C, Bone I, de Silva R,
83(8):35, 538, 540. Ironside J. (1994) A case of Creutzfeldt-
Emily Nairn, AuD, is an audiology Jakob disease presenting with cortical
extern with the Division of Audiology, National Institute of Neurological deafness. J Neurol Neurosurg Psychiatry
Department of Otolaryngology—Head Disorders and Stroke. (2003) Creutzfeldt- 57(7):872–873.
and Neck Surgery, Henry Ford Hospital, Jakob Disease Fact Sheet. www.ninds.
Detroit, Michigan, and an AuD student nih.gov/disorders/cjd/detail_cjd.htm Tschampaa H, Múrtza P, Flackea S,
in the Department of Audiology, A.T. (accessed July 19, 2012). Pausb S, Schilda HH, Urbacha H. (2003)
Still University—Arizona School of Thalamic involvement in sporadic
Health Sciences. Creutzfeldt-Jakob disease: diffusion-
weighted MR imaging study. Am J
Neuroradiol 24(5):908–915.

OctOber Is
&
National Audiology Awareness Month
National Protect Your Hearing Month
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Moment of science
The Medial Olivocochlear

Reflex: Nature’s Automatic Gain
Control?
By Sk yler G. Jennings and Judy R. Dubno
A
s part of a standard medical based on the levels of the signals background noise and provide a more
exam, we are accustomed to reaching the cochlea. The idea that accurate representation of signals in
having our reflexes tested. gain reduction is beneficial may auditory nerve fibers (ANFs).
From tapping the knee with a rub- seem counterintuitive, as hearing The cochlea processes sound
ber mallet, to brushing the eye with aids are often provided to compen- intensity in a nonlinear fashion. As
a cotton swab, one thing remains sate for a loss of cochlear gain. As sound intensity increases, BM vibra-
certain: the presence of a reflex at an described later, gain adjustment tion increases at a progressively
appropriate strength is a hallmark may aid in separating speech from slower rate. Thus, a given change
of normal function. In audiology, the
most commonly measured reflex
is the middle-ear acoustic reflex;
however, in the family of auditory
reflexes, there is a more obscure and
somewhat clinically neglected sib-
ling: the medial olivocochlear (MOC)
reflex. Like other reflexes, the MOC
reflex involves the efferent neural
pathway, which sends signals from
the brain or brainstem to neurons
in the periphery. This reflex allows
the nervous system to modulate
how incoming sounds are processed
by the cochlea, which results in a
change in the neural representation
of sound traveling toward the brain
(for a review see Guinan, 2006). MOC
efferent fibers connect directly to
outer hair cells (OHCs), which amplify
soft sounds (i.e., provide “gain”) and
sharpen the tuning (or “frequency
selectivity”) of the basilar membrane
(BM). The primary function of the
MOC reflex is likely to reduce OHC
gain over the course of stimulation,
which is thought to improve speech
perception in noise (Guinan, 1996).
That is, in addition to providing
gain, a healthy cochlea dynamically
adjusts the amount of amplification

Moment of science
in sound intensity will result in speech and noise. The horizontal influence of saturation may pose a
a smaller change in BM vibration distance between the average speech problem for the neural representa-
when the intensity is relatively high; and noise levels is the acoustic tion of fluctuating signals, such
this relationship is often referred SNR, which is much larger than as speech, which have amplitude
to as “compression” or “compres- the vertical distance representing modulations on the order of 30–40 dB
sive nonlinearity” (for a review see the postcochlear SNR. Thus, from a (Olsen, 1988). Thus, for high speech
Oxenham and Bacon, 2003). Similar SNR perspective, BM compression levels, some ANFs may become
to compression circuits in hearing results in a reduction in the post- saturated and unable to accurately
aids, nonlinear processing in the cochlear SNR, which may impede represent the full extent of these
cochlea allows perception to occur communication. large fluctuations, similar to the
over a broad range of sound levels. A How does the auditory system effects of “peak clipping” in some
byproduct of cochlear compression is compensate for this change? Some hearing aids. Given that amplitude
that it may reduce the signal-to-noise studies suggest the MOC reflex may fluctuations in speech are thought
ratio (SNR) reaching the auditory be a key player in adjusting the to carry important cues (Shannon
nerve and the brain. When discuss- response of the cochlea to optimize et al, 1995), this saturation may be
ing SNR in this context, it is useful to the neural representation of sound detrimental to speech recognition.
distinguish between “acoustic” and (Kawase et al, 1993; Brown et al, 2010;
“postcochlear” SNRs. The acoustic Chintanpalli et al, 2012). When a
SNR refers to the difference (in dB) listener moves from a quiet to a noisy
between levels of speech and noise environment, the MOC reflex quickly
in the ear canal or in the free field. reduces cochlear gain. This results
The postcochlear SNR refers to this in an upward shift in the compres-
same level difference, but measured sion knee point (Plack et al, 2004), as
at the output of the cochlea and the illustrated in Figure 1B by the differ-
input to the auditory nerve. ence between the dashed gray line
When speech and noise are (the original gain) and solid black
compressed, the postcochlear SNR line (the new gain) and a substantial
may be poorer than the acoustic SNR, improvement in postcochlear SNR
which is illustrated in Figure 1A for (compare Figure 1B to Figure 1A). If
speech and noise processed at one the noise and speech levels increase
location along the cochlear duct. The (Figure 1C), the MOC reflex would
solid black line in Figure 1A shows further reduce the gain to maintain a
how the BM response at one cochlear favorable SNR. These basic examples
location increases with increas- illustrate how a normal MOC reflex
ing level of a tone presented at that can adjust cochlear gain to improve
region’s most sensitive frequency. or maintain a favorable SNR, which
This cochlear input/output func- may help extract speech from noise.
tion (similar to input/output curves This ability to adjust cochlear gain
of compression hearing aids) often may partially explain why individu-
exhibits compression at mid-to-high als with normal hearing (and normal
sound levels. That is, above ~35 dB cochlear function) are able to tolerate
in this example, the change in the higher noise levels while still main-
output (i.e., BM vibration) to a given taining good speech recognition.
change in the input (sound intensity) In addition to improving the
becomes progressively smaller with postcochlear SNR, the MOC reflex
increasing signal level. The average may assist in restoring the dynamic
speech and noise levels are displayed range of ANFs. The firing rate of an
as blue and red solid lines, and the individual ANF increases over a ~30 Figure 1. An illustration
shaded areas around these lines dB range before it saturates (i.e., is on how the MOC reflex
represent the fluctuations in the unable to fire at a faster rate). The may optimize the SNR.

Moment of science
The reduction in cochlear gain by the Skyler G. Jennings, AuD, PhD, is an Guinan JJ Jr. (2006) Olivocochlear
MOC reflex decreases the amplitude assistant professor in the Department of efferents: anatomy, physiology, function,
of signals arriving at the auditory Communication Sciences and Disorders and the measurement of efferent effects
nerve, which places signals within at the University of Utah, Salt Lake in humans. Ear Hear 27:589–607.
the dynamic range of ANFs and pro- City. Judy R. Dubno, PhD, is a professor
vides a more accurate representation in the Department of Otolaryngology- Kawase T, Delgutte B, Liberman MC.
of amplitude fluctuations. Head and Neck Surgery at the Medical (1993) Antimasking effects of the
Although currently speculative, University of South Carolina, Charleston. olivocochlear reflex. II. Enhancement of
the MOC reflex may partially explain auditory-nerve response to masked tones.
why individuals with cochlear hear- References J Neurophysiol 70:2533–2549.
ing loss have difficulty listening to
and understanding speech in noisy Brown GJ, Ferry RT, Meddis R. (2010) Maison SF, Liberman MC. (2000)
environments. Following damage A computer model of auditory efferent Predicting vulnerability to acoustic injury
to OHCs, the MOC reflex may be suppression: implications for the with a noninvasive assay of olivocochlear
less able to adaptively reduce gain, recognition of speech in noise. J Acoust reflex strength. J Neurosci 20:4701–4707.
which limits the expected improve- Soc Am 127:943–954.
ment in SNR. Reduced or absent Olsen WO. (1988) Average speech levels
MOC reflex activity may also be Chintanpalli A, Jennings SG, Heinz MG, and spectra in various speaking/listening
related to changes in tolerance for Strickland EA. (2012) Modeling the conditions: a summary of the Pearson,
everyday sounds (Collet et al, 1992) antimasking effects of the olivocochlear Bennett, and Fidell (1977) report. Am J
and to increased susceptibility to reflex in auditory-nerve responses to Audiol 7:21–25.
the damaging effects of high sound tones in sustained noise. J Assoc Res
levels (Maison and Liberman, 2000). Otolaryngol 13:219–235. Oxenham AO, Bacon SP. (2003) Cochlear
Given its potential significance to compression: perceptual measures and
audition, signal processing strate- Collet L, Veuillet E, Bene J, Morgon A. implications for normal and impaired
gies for hearing aids and cochlear (1992) Effects of contralateral white noise hearing. Ear Hear 24:352–366.
implants designed to restore the ben- on click-evoked emissions in normal and
eficial effects of the MOC reflex may sensorineural ears: towards an exploration Plack CJ, Drga V, Lopez-Poveda EA.
improve speech recognition in noise. of the medial olivocochlear system. (2004) Inferred basilar-membrane
Although it is unlikely that future Audiol 31:1–7. response functions for listeners with mild
audiologists will be tapping ears with to moderate sensorineural hearing loss. J
a rubber mallet, they may be using Guinan JJ Jr. (1996) Physiology of the Acoust Soc Am 115:1684–1695.
clever techniques to measure the olivocochlear efferents. In: Dallos P,
MOC reflex. With these techniques, Popper AN, Fay RR, eds. The Cochlea. Shannon RV, Zeng FG, Kamath V,
audiologists will be better prepared New York: Springer. Wygonski J, Ekelid M. (1995) Speech
to assess, treat, and counsel patients recognition with primarily temporal cues.
who may lack this important audi- Science 270:303–304.
tory reflex.

Inaugural SAA
Conference
Case Study Investigations
SAVE thE DAtE

April 3 in conjunction with AudiologyNOW!® 2013
Registration Opens November 1

This conference will focus on clinical decision-making in audiology, using
a case-study format. Participation will be open to audiology students
who are about to begin their externships.
Visit www.StudentAcademyofAudiology.org for more information

on the conference and the attendee selection process.
CODING AND REIMBURSEMENT
2013 Proposed Medicare Fee

Schedule Rule Released for
Comment
By Shar mila Sandhu
I
n July, the Centers for Medicare and a -27.0 percent update to the con-
and Medicaid Services (CMS) version factor, which would result in
issued a proposed rule for a conversion factor of about 24.71.
Medicare Part B services paid under The combined impact of CMS’
the Physician Fee Schedule in calen- proposed changes for audiology
dar year (CY) 2013. would result in a negative five per-
Academy staff and volunteers cent overall decrease in Medicare
analyzed the 765-page proposed rule reimbursement. As has been the
and its implications for audiology, political trend for the last several
and submitted comments to CMS years, Congress must intervene to measures and 14 measures CMS pro-
prior to the September 4, 2012, dead- prevent the reduction in reimburse- poses to retire.
line. A final rule, which will address ment caused by the flawed SGR, The Academy was disappointed
comments submitted in September, which impacts all Medicare provid- to learn that, of the 14 measures rec-
will be issued by November 1, 2012, ers. Please contact your member of ommended for retirement, two are
and will be effective for services per- Congress regarding this important audiology measures, specifically:
formed on or after January 1, 2013. issue by visiting the Academy’s
The following proposals have Legislative Action Center at http:// Referral for Otologic Evaluation
implications for audiologists. capwiz.com/audiology/home. for Patients with History of Active
Drainage from the Ear Within the
Sustainable Growth Physician Quality Previous 90 Days, and
Rate and Conversion Reporting System
Factor Qualified professionals, includ- Referral for Otologic Evaluation
Medicare reimbursement is calcu- ing audiologists, who satisfactorily for Patients with a History of
lated through a formula that consists, report on physician quality reporting Sudden or Rapidly Progressive
in part, of a conversion factor and system quality measures during 2013 Hearing Loss.
a sustainable growth rate (SGR). and 2014 will be eligible to receive
While CMS did not include a con- an incentive equal to 0.5 percent of CMS explains that the agency
version factor in the proposed rule, the total estimated Medicare Part is accepting the recommenda-
the agency did submit an estimate B allowed charges for all covered tions of the National Quality
of the SGR and conversion factor professional services furnished Forum’s (NQF) Measure Application
to the Medicare Payment Advisory during the applicable reporting Partnership (MAP) in its report,
Committee (MedPAC), which was period. In the proposed rule, CMS MAP Pre-Rulemaking Report: Input on
consistent with existing statute and recommended including a total of Measures under Consideration by HHS
would be applicable to Medicare 264 individual quality measures for for 2012 Rulemaking, which may be
payments for practitioners’ services reporting under the PQRS in 2013, viewed at www.qualityforum.org/
for CY 2013. CMS’s estimate included which includes 14 new proposed Setting_Priorities/Partnership/MAP_
a -18.9 percent sustained growth rate Final_Reports.aspx. The Academy’s

CODING AND REIMBURSEMENT
comment letter addressed the PQRS measure beginning in 2013 to same practitioner to a patient on the
removal of the above two measures avoid the payment adjustment. For same day. In the proposed rule, CMS
as part of the PQRS program and those who don't report on at least recommends extending this policy
defended inclusion of audiology mea- one measre in 2014, CMS proposes a to cardiovascular and ophthalmol-
sures in the program. deduction of two percent of reim- ogy diagnostic services. CMS is
CMS also states that, beginning bursement on all claims submitted also proceeding with applying the
in 2015, the PQRS program would for payment. current MPPR policy for outpatient
no longer be a voluntary incentive The Academy continues to therapy services and for imaging
program. In fact, CMS proposes that monitor the impact of “satisfac- services furnished in the same ses-
a payment adjustment of -1.5 percent tory reporting” on reimbursement sion by physicians in the same group
will be applied to eligible profession- for audiologists under PQRS and practice. While audiology codes are
als who fail to meet the satisfactory requested clarification in our com- not currently affected, the Academy
reporting criteria for 2013 PQRS ments to CMS regarding the payment continues to monitor the MPPR policy
claims defined by section 3002(b) of adjustment as applied to audiologists closely due to the potential for CMS
the Affordable Care Act (the health- with a very limited number of quality to apply such a reduction to audiol-
care reform bill). What this would measures on which to report. ogy codes in the future.
mean for audiologists is that, begin- Watch the Academy’s Web site for
ning on January 1, 2013, all claims Multiple Procedure updates regarding CMS’s response to
submitted to CMS will be reviewed Payment Reduction the Academy’s Medicare fee schedule
for satisfactory PQRS reporting, and Policy comments.
those deemed to fail to meet the In an effort to increase efficiency
criteria will only receive 98.5 percent in the Medicare program, CMS has
of the properly billed amount on been looking to identify areas in Sharmila Sandhu, Esq., is the director
submitted claims, an adjustment which to apply a multiple proce- of regulatory affairs for the American
which will not be made until 2015. dure payment reduction (MPPR) Academy of Audiology.
CMS is proposing that all eligible policy. The intent of this formula
professionals who bill services to is to reduce reimbursement on
Medicare must report on at least one multiple services provided by the

Compliance
PQRS—Participate Sooner to
Avoid Potential Assessments
Later
By Debbie Abel
F
or the past several years, the with a History of Sudden or Services paid under the Medicare
Centers for Medicare and Rapidly Progressing Hearing Loss Physician Fee Schedule is that of
Medicaid Services (CMS) has the 14 PQRS measures CMS recom-
been evaluating options to move Effective in January 2012, CMS mended for retirement, two are
away from a Medicare fee-for-service added a fourth measure on which audiology measures.
(FFS) model; FFS represents a pay- audiologists may report: To encourage reporting on the
ment model by which a practitioner four 2012 PQRS-eligible measures
is paid separately for each proce- 4. Measure: #261: Referral for for Medicare Part B–enrolled audi-
dure performed. With the probable Otologic Evaluation for Patients ologists, the Academy has created
transition from a FFS model, qual- with Acute or Chronic Dizziness an Easy Reference Guide (Table
ity outcome measures reporting is 1) to assist you with reporting on
likely to become a methodology for All those who successfully these four measures. This easy-to-
payment. One of these potential reported on PQRS measures received read table format contains for each
methodologies already in place for a two percent bonus for all allowable individual measure the approved
audiologists since 2010, the Physician Medicare claims in 2010. In 2011, this CPT, ICD-9 and modifier codes, as
Quality Reporting System (PQRS), bonus decreased to one percent, and required for reporting.
formerly the Physician Quality for 2012–2014, a 0.5 percent bonus is To show you how easy this can
Reporting Initiative (PQRI), allowed in effect. While this seems insignifi- be, let’s take measure #190 as an
Medicare Part B–enrolled audi- cant to many practices, it should not example and walk through the pro-
ologists to voluntarily report on the be ignored, as it provides profes- cess that you already complete on a
following three measures to qualify sional recognition within Medicare daily basis, with the exception of the
for a reporting bonus: for participating in quality of care last bullet:
measurement and reporting, and it
1. Measure #188: Referral for provides additional income. A Medicare beneficiary presents
Otologic Evaluation for Patients It is important to note that several to your office with the complaint
with Congenital or Traumatic changes to PQRS are on the near of a sudden hearing loss.
Deformity of the Ear horizon. In 2015, for those who did not
report on eligible measures in 2013, You perform CPT codes 92557
2. Measure #189: Referral for a 1.5 percent payment deduction on (comprehensive audiometry
Otologic Evaluation for Patients Medicare claims will be retained by threshold evaluation and speech
with a History of Active Drainage Medicare contractors. So, the adage recognition [92553 and 92556
From the Ear Within the Previous “sooner is better than later,” is certainly combined]) and 92570 (acoustic
90 Days applicable to filing your claims now, immittance testing, includes tym-
by merely adding a modifier to qualify panometry [impedance testing],
3. Measure #190: Referral for for the bonus. It is really that easy! acoustic reflex threshold testing,
Otologic Evaluation for Patients Another change noted in the 2013 and acoustic reflex decay testing).
proposed rule for Medicare Part B

Compliance
You choose to assign the ICD-9 The Easy Reference Guide, the future educational publications, so
diagnosis code 389.17, sensory CMS-designed toolkits for each stay tuned.
hearing loss, unilateral. measure, and other information can
be found on the Academy’s dedicated
The primary care physician PQRS page: www.audiology.org/prac- Debbie Abel, AuD, is the senior
referred this patient to you, but tice/PQRI/Pages/default.aspx. education specialist, business practices,
you are going to refer this patient Keep in mind that, as of the date for the American Academy of Audiology.
In 2015, for those who did not report on eligible

measures in 2013, there will be a 1.5 percent
disincentive on Medicare claims, which will be
retained by Medicare contractors.
to an otolaryngologist; therefore, of publication, the Academy was For questions related to the audiology
this modifier may be chosen and currently reviewing and analyz- measures and how to conduct claims-
placed in box 24 of the CMS-1500 ing the 765-page CY 2013 Medicare based reporting under PQRS, please
claim form: G8564: Patient was Physician Fee Schedule. Proposed contact Dr. Abel at dabel@audiology.org.
referred to a physician (preferably changes will be discussed during
a physician with training in dis- the eAudiology Web seminar and in
orders of the ear) for an otologic
evaluation.
figure 2, a sample CMS-1500 form,

Also of Interest
complete with the G modifiers, for a
nonaudiology procedure claim, may eAudiology Coding and Reimbursement Web seminar series:
be a helpful resource. While pub- Understanding PQRS—A Step-by-Step Approach to Recognition
and Reimbursement, September 11, 2012 (and on demand
lished in 2010, there have been no
afterward).
recent updates to this example.
Visit www.eaudiology.org or use the QR code to learn more and
register online using your mobile device.

Compliance
Department Title
Table 1. 2012 Physician Quality Reporting Systems (PQRS) Easy Reference Guide
Below are the CPT, ICD-9 and G-modifier codes required to report on each of the four eligible PQRS measures
for Medicare Part B enrolled audiologists. A measure is to be reported a minimum of once per reporting period
(January 1, 2012 to December 31, 2012) for all patients seen, regardless of age, as applicable to the measure’s
requirements. Until December 31, 2014, a .5% bonus will be given for all Medicare-eligible charges when report-
ing on these measures. For those who don’t report on eligible measures in 2013, a disincentive of -1.5% on
claims will be retained by Medicare contractors, beginning in 2015.
Measure #188: Referral for Otologic Evaluation for Patients with Congenital or Traumatic Deformity of
the Ear
CPT Codes ICD-9 Codes G-modifiers
92550, 92557, 380.00, 380.01, G8556: Referred to a physician (preferably a physician with training in
92567, 92568, 380.02, 380.03, disorders of the ear) for an otologic evaluation
92570, 92575 380.10, 380.30, G8557: Patient is not eligible for the referral for otologic evaluation-
380.31, 380.32, measure (e.g., for patients for whom an assessment of the congenital
380.39, 380.51, or traumatic deformity of the ear has been performed by a physician
380.81, 380.89, (preferably a physician with training in disorders of the ear) within the
380.9, 744.01, past six months, patients who are already under the care of a physician
744.02, 744.03, (preferably a physician with training in disorders of the ear) for congeni-
744.09 tal or traumatic deformity of the ear)
G8558: Not referred to a physician (preferably a physician with training
in disorders of the ear) for an otologic evaluation, reason not specified
Measure #189: Referral for Otologic Evaluation for Patients with a History of Active Drainage from the
Ear Within the Previous 90 Days
92550, 92557, 381.01, 382.00, G8560: Patient has a history of active drainage from the ear within the
92567, 92568, 382.01, 382.02, previous 90 days
92570, 92575 382.1, 382.2, 382.3, G8562: Patient does not have a history of active drainage from the ear
382.4, 382.9, within the previous 90 days
388.60, 388.61, G8559: Patient referred to a physician (preferably a physician with train-
388.69 ing in disorders of the ear) for an otologic evaluation
G8561: Patient is not eligible for referral for otologic evaluation for
patients with a history of active drainage measure (e.g., patients who
are already under the care of a physician for active ear drainage)
G8563: Patient not referred to a physician (preferably a physician with train-
ing in disorders of the ear) for an otologic evaluation, reason not specified
Measure #190: Referral for Otologic Evaluation for Patients with a History of Sudden or Rapidly
Progressing Hearing Loss
92550, 92557, 389.00, 389.01, G8565: Verification and documentation of sudden or rapidly progres-
92567, 92568, 389.02, 389.03, sive hearing loss
92570, 92575 389.04, 389.05, G8567: Patient does not have verification and documentation of sud-
389.06, 389.08, den or rapidly progressive hearing loss
389.10, 389.11, G8564: Patient was referred to a physician (preferably a physician with
389.12, 389.13, training in disorders of the ear) for an otologic evaluation
389.14, 389.15, G8566: Patient is not eligible for the “Referral for Otologic Evaluation
389.16, 389.17, for Sudden or Rapidly Progressive Hearing Loss” measure (e.g.,
389.18, 389.20, patients who are under current care of a physician for sudden or rapidly
389.21, 389.22, progressive hearing loss)
389.8, 389.9 G8568: Patient was not referred to a physician (preferably a physician
with training in disorders of the ear) for an otologic evaluation, reason
not specified

Department
Compliance
Title
Measure #261: Referral for Otologic Evaluation for Patients with Acute or Chronic Dizziness
92540, 92541, 780.4, 386.11 G8856: Referral to a physician for otologic evaluation performed
92542, 92543, G8857: Patient is not eligible for the referral for otologic evaluation
92544, 92545, measure (e.g., patients who are already under the care of a physician
92546, 92547, for acute or chronic dizziness)
92548, 92550, G8858: Referral to a physician for an otologic evaluation not performed,
92557, 92567, reason not specified
92568, 92570,
92575
For questions, contact Debbie Abel, AuD, senior education specialist, business practices at dabel@audiology.org.
Resources:
Academy’s dedicated PQRS Web page: www.audiology.org/practice/PQRI/Pages/default.aspx
The Centers for Medicare and Medicare’s webpage on PQRS: www.cms.gov/Medicare/Quality-Initiatives-
Patient-Assessment-Instruments/PQRS/index.html?redirect=/pqrs
Figure 1. Appendix D: CMS-1500 Claim Example

Widex Grant Supports

New Tinnitus Lectureship
R
ichard Danielson, chair of quality educational lectures that pro- annual conference. In addition, a
the AAA Foundation, recently vide audiologists with cutting-edge portion of the funding will also
announced that Widex has hearing science,” he said. “Widex is support free, online accessibility to
agreed to fund a new series of educa- delighted to fund the new Topics in the lecture for audiologists who are
tional lectureships that will provide Tinnitus lectureship since tinnitus unable to travel to convention.
audiologists with the most current management is an ongoing challenge Danielson also noted that
information on tinnitus diagnoses, for the hearing health community, Foundation leadership was reviewing
treatment, and research. The $70,000 and frequently a terribly debilitat- recent tinnitus research as it worked
educational grant will support the ing condition for our patients with to engage an exceptional presenter
Topics in Tinnitus lectures that will be tinnitus.” for the 2013 lecture. He added, “It
offered at AudiologyNOW! from 2013 As with the Foundation’s other really is an honor to work with Widex
through 2017. The generous grant endowed lectureships, this grant to bring one of the 'best and brightest'
will also underwrite on-demand will support the expenses associated experts in tinnitus to share expertise
accessibility of each lecture at with bringing renowned interna- with audiologists…and I thank the
eAudiology.org following each live tional speakers to the Academy’s Widex team for their generosity and
conference presentation.
“Since tinnitus frequently occurs
in patients with hearing loss, audi-
ologists are often on the front lines
of tinnitus management,” Danielson
stated. “This philanthropic gift from
Widex expands educational oppor-
tunities for audiologists as they seek
information on developments in tin-
nitus research and practical tools for
tinnitus treatment. We extend great
appreciation to our Widex colleagues
for this very generous funding.”
SØren Westermann, Widex A/S
executive vice president, spoke
about his company’s funding for
this new project while attending
AudiologyNOW! last spring. “Just as
the Widex name is synonymous with
quality hearing technology, the AAA
Foundation name is associated with
(Left to right) Foundation donors Bopanna Ballachanda and Melanie Herzfeld celebrate the new
lectureship funding with SØren Westermann, Widex A/S executive VP, and Francis Kuk, Widex VP
of clinical research and executive director of ORCA-USA, at the 2012 Happy Hour with a View.

vision in reinforcing the role of the and relief from this debilitating For more information on the 2013
audiologist as a primary resource for condition.” Topics in Tinnitus lecture, visit www.
tinnitus sufferers who seek informed audiologyfoundation.org.
diagnosis, quality treatment,
Donor Profile: Interview with an Audiology Philanthropist

Nöel Crosby
Web site (www.AuDBling.com), so audiologists can
Nöel, you’ve supported the AAA Foundation for purchase AuDBling products and know a portion of
several years now. Do you recall what inspired you to their purchase supports the SAA. I also am planning
make your first gift to the Foundation? other special promotions during the year which will be
Several years ago, I met SAA Board members Kari announced later.
Morgenstein, Ryan Bullock, and Chris Cox, who were
reaching out to companies interested in supporting In addition to being an audiologist and jewelry entre-
the new Student Academy of Audiology. I was so preneur, what else should we know about you?
impressed with them and all that they were doing! My husband, Michael, had always loved baseball, but
They inspired me to work with the Foundation to sup- I really had no interest in it. After our daughter left
port SAA programs. As the owner of a small company, for college, I had time to go to a few Tampa Bay Rays
AuDBling, it would have been a challenge for me to games, and I discovered that I love everything about
make a large gift, so I came up with the idea that I the sport. We recently decided to travel the country
could donate a percentage of my company’s merchan- every summer to visit other baseball stadiums, and
dise sales. have just returned from a two-week trip out West
where we went to three stadiums on our way to the
So has the AuDBling “cause marketing” campaign AG Bell convention. We had a blast…and now I guess
been a success? you could say I’m not only passionate about healthy
Through AuDBling, I sell cochlea-shaped jewelry, hearing but about baseball too!
T-shirts, and other hearing loss awareness products for
audiologists. For the last two years at AudiologyNOW! Are you interested in becoming an audiology philan-
I have donated five percent of my sales to the thropist? Visit www.audiologyfoundation.org or call
Foundation, earmarked for SAA programs. This has
800-222-2336, ext. 1049, for more information.
worked out really well because I am able to raise
money for SAA, and at the same time, I am able to
grow my business. It’s a real win-win.
What would you say to other audiologists who are

considering a gift to the Foundation?
It’s a great cause, and funding student programs
is an investment in the future of audiology. I would
challenge all audiologists to make a yearly gift to the
Foundation.
The Academy is celebrating its 25th anniversary in

2013, and as you know, the Foundation has some spe-
cial fund-raisers in the works. Is AuDBling planning
anything special to commemorate this milestone?
Yes! I am planning to participate in the 25th
Anniversary Dollar-a-Day initiative. And I’ll continue
to donate five percent of the AuDBling sales to
support student programs when audiologists use
Nöel and her husband, Michael, "represent" for the Tampa Bay Rays at
the “SAA25” discount coupon that’s available on my
Minute Maid Park in Houston, during their baseball road trip.

State Audiology Organizations: Receive Funding to Recruit

the Audiologists of Tomorrow
D
id you know that state science with an exciting new career path. basis through the March 15, 2013,
fairs are a great opportunity To facilitate nationwide involve- deadline. For resources on how to get
to introduce students to the ment of this recruitment initiative, involved in your local science fair or
audiology profession while recog- the Foundation is allocating funds to apply, visit www.audiology.org/
nizing research excellence in the to state audiology organizations resources/recruitment or www.audi-
hearing sciences? By volunteering to provide awards for middle/high ologyfoundation.org.
to judge at your local fair, you can school science fair participants.
present science-minded students Applications are accepted on a rolling
SAA Chapters: Apply Now for Special Olympics Healthy

Hearing Chapter Participation Grants
I
n 2010, the Student Academy
of Audiology (SAA) officially
announced its relationship
with the Special Olympics Healthy
Hearing (SOHH) program as a
national service project. The SAA
is encouraging university chapter
participation in SOHH programs
throughout the country to support
the goals of increasing the number
of student volunteers involved with
hearing screenings and improving
the audiological follow-up of athletes
after the games.
The AAA Foundation’s SAA
Chapter Participation Grants pro-
gram provides up to $250 for SAA
chapter members to serve as volun-
teers at local, regional, or state SOHH
events. These grants supplement
chapter fund-raising activities and
partially cover costs of travel and
supplies.
Applications are due October 1
and February 1 annually. For more
information and to apply, visit www.
audiologyfoundation.org.
Andrea Fowler (left) and Hilary Davis, the philanthropy chairs for the Vanderbilt University SAA
Chapter, volunteer at the Healthy Hearing check-out table at the Special Olympics Tennessee State
Basketball Tournament.

SAA spotlight
SAA Across the USA!

Movers and Shakers from the
East Coast to the West
By A lly Cost low
T
here are over 60 Student initiatives. Chelsea Blom, vice presi- characters questions about hear-
Academy of Audiology (SAA) dent of the UNL SAA, notes that her ing loss. Myths and misconceptions
chapters across the country, chapter supports Clinic with a Heart, about hearing loss are replaced with
each with a distinct membership that which is a free health clinic that pro- facts and sensitivity. These pup-
shapes how their chapter will vest vides services to individuals who are pet shows have been a hit in the
their efforts. One uniting charac- un- or under-insured by providing community.
teristic among chapters is the SAA free hearing screenings to children Community involvement has
spirit of service and advocacy for the and adults. Individuals who do not been a priority for the University of
varied populations that our profes- pass the screening are referred to Maryland, College Park’s SAA chapter.
sion serves. SAA chapters across the UNL SAA Sharing Clinic, which They have been involved in a number
the country have created a culture provides full diagnostic evaluations of activities and events both on and
of service and advocacy by getting for these individuals. off campus. In the fall of 2011, an
involved in a number of exciting Nationally, Nebraska is one of SAA representative collaborated
local, national, and international nine states participating in the with 200 other student leaders from
projects. Healthy Hearing 2.0 pilot proj- cultural to academic groups at UMD
Out West, the University of ect, which began in 2011. Special ONE, the campus-wide leadership
Nebraska–Lincoln (UNL) SAA Olympics Healthy Hearing (SOHH) conference. UMD SAA has since been
chapter has balanced supporting joined forces with Phonak’s Hear approached by a number of student
local, national, and international the World Foundation to provide groups, including the Homecoming
hearing aids to athletes who qualify Committee, that are interested in
through a screening process at collaborating with UMD’s SAA to
state, national, and international promote awareness and prevention
New Members games. Each year, UNL SAA pro- of noise-induced hearing loss.
of the Student vides screenings at the Nebraska

Games and in 2011, UNL SAA had the
UMD’s SAA made pathways
between the campus and the
Academy of opportunity to provide screenings at community by hosting a panel of
Audiology the International Special Olympics

Games in Greece. Go Huskers!
young adults from the Washington,
DC, chapter of the Hearing Loss
Laura Botts These are only a few of the Association of America (HLAA).
projects and initiatives that this Panelists openly and graciously
Cole Campbell
exemplary chapter has supported. shared their stories as young adults
Erin Campbell Other projects include UNL SAA
Shreemanti Chakrabarty going to local elementary schools
LeAnn Clements to promote hearing loss awareness
Mihwa Kim through “Kids on the Block” puppet
April LaBelle shows. Through a scripted dialogue,
children are educated about their
Alice Pinto
peers with hearing loss. Students
Lauren Roberts have the opportunity to ask the

SAA spotlight
Recent Grads!
Take the next step, with hearing loss. SAA members enjoyed hearing from
the group of young professionals who excel in careers
become a Fellow from engineering to education. SAA members hope to
Member make the panel an annual event to increase understand-

ing about the human aspect of hearing loss. Looking
forward, UMD’s SAA hopes to volunteer at the Special
Olympics of Maryland in June 2013 and to welcome
The Academy is invested in undergraduate associate members to their chapter this
fall.
helping the future of audiology The SAA chapters of the University of South Florida
(USF) has been making waves. USF SAA chapter member
and wants to offer you Alexandra Klein reports that the USF chapter traveled
to Beverly, Kentucky, in September 2011 to join Phonak’s
discounted Fellow membership Hear the World initiative. Students spent several days
at the Red Bird Mission in rural Appalachia performing
dues for the first two years hearing screenings for school-age children, making ear-
molds, and fitting new hearing aids to anxious first-time
following your graduation. users. Thanks to generous donations, Phonak hearing aid
fittings and repairs were provided at no cost to patients.
The community was incredibly grateful, and the experi-
ence was both educational and heartwarming for the
To learn more, visit www.audiology.org.
students. This was the third trip that USF has made to
Search key word UPGRADE. Beverly, Kentucky.
The USF SAA chapter has also been active on a
national scale. In March 2012, this chapter hosted an
advocacy campaign for direct access. Fifty-two letters
were sent to approximately 23 representatives in six dif-
ferent states asking representatives to support the bill,
which would allow audiologists to bill directly for their
services without prior referral. SAA members obtained
signatures from fellow students, faculty, family, and
friends.
While the last year was a year of growth and new
opportunities for SAA across the United States, this
upcoming year may be even more exciting.
Ally Costlow is a fourth-year student at the University of

Maryland and the chair of the SAA Media Committee. To
share your SAA chapter’s involvement, please contact Ally at
acostlow.saa@gmail.com.
Note: AAA Foundation funding is available to SAA Chapters

for SOHH activities. See page 70 for application information
and deadlines.

American Board of Audiology
The Importance of
Verifying the Professional
Knowledge of Audiologists
By John Coverstone
A
BA certification for audiolo- verifies professional experience to Specialty certification, currently
gists has been one of the top employers and provides consumers offered in cochlear implants and
issues in our profession with a method of identifying audiolo- pediatrics, requires a qualification
for at least the past 10 years. The gists with specialized knowledge in exam and higher degree of profes-
American Board of Audiology (ABA) a given area, thus increasing their sional practice and mentoring to
was founded in 1999 out of a desire confidence in the audiologist’s level achieve it. Specialty certifications are
for audiologists to have certification of expertise. created through an arduous process
practices that are completely under of professional practice analysis,
the auspices of audiologists (simi-
lar to the reasons for founding the
American Academy of Audiology
in 1988), elevate the commit-
ment of certified audiologists to
Board Certified in Audiology is a distinct

a higher educational and ethical
standard, are relevant specifically
to the profession of audiology,
and are a higher standard than professional credential administered
state licensure. Although there
are finite requirements imposed
to attain certification, this goal
exclusively by audiologists for
has been achieved through the
requirement of a greater num- audiologists. This voluntary certification
ber and higher level (Tier 1) of
continuing education courses,
as well as the requirement of
program is available to audiologists
adherence to a rigorous ethical
practices standard, and one that regardless of membership in any
is continually evolving to meet
the demands of modern audiology
practice. For these reasons, ABA
professional organization.
board certification is meaningful,
relevant, and able to withstand
scrutiny from inside and outside the
profession.
The standards for achieving
a specialty certification are even
higher. Specialty certification is the
hallmark of certification in most
professions. Specialty certification

American Board of Audiology
knowledge and skills rating, develop- change becomes increasingly less The ABA is pleased to
ment of professional requirements meaningful with every passing day.
announce the most
and standards that reflect a high level For this reason, it is essential to cer-
of achievement, and development of tification that we all, as a profession,
recent audiologists
an exam that is based on the highest continue to discuss, analyze, and who are Board
possible standards—namely those critique the certifications that are Certified in Audiology
imposed by the National Commission relevant to our professional practice. as of May 31, 2012.
for Certifying Agencies (NCCA), a Certification ultimately is not
Reem Alqahtani, AuD
globally recognized authority in certi- owned by the ABA, the ABA Board
Diana Anderson, AuD
fication practices. of Governors nor the subject matter
Jill T. Atwood, AuD
Certification represents a declara- experts. It is owned by the profession
Virginia B. Bailey, AuD
tion of an audiologist’s professional of audiology and everyone who is
Tricia R. Benjamin, AuD
competence. Many organizations in within this profession. Part of taking
Julie Bier, AuD
today’s competitive and challeng- ownership is to join the discussion
Chris R. Borders, AuD
ing economy have recognized their and add your expertise, insight, and
Becky L. Braun, AuD
workforce as their most valuable opinions to the continuing dialogue
John D. Burkart, AuD
asset. Likewise, individuals, whether about certification. There are multiple
Rachel Anne Cooper, AuD
employed or self-employed, know ways to do this: discuss certification
Margaret S. Dean, PhD
that now more than ever before they with colleagues, engage in informed
Jennifer Donath, AuD
must acquire and maintain more discussions within professional
Cheryl Edwards, AuD
comprehensive skill sets to ensure forums, attend courses about certi-
Kevin G. Flanagan, AuD
their own attractiveness and ability fication, or respond to surveys about
Douglas B. Garrison, AuD
in the workplace. certification or about the profession.
Amal Ghabril Awdeh, AuD
No matter how high the goals or When the greater body of audiologists
Susan M. Gibbons, AuD
achievements of any certification becomes actively engaged in the pro-
Heather M. Guy, AuD
program, it is vital that this not be cess of certification, the certifications
Deborah Hayes, PhD
a static process and that all audi- become stronger, more meaningful,
Walter F. Horan, AuD
ologists are aware of the dynamic and more relevant to professional
Jennine L Kelley, AuD
nature of certification. The staff and practice. Please, join us!
Debra A. LaPrete, AuD
board of the ABA are constantly dis-
Jennifer Lazzaro, AuD
cussing and reviewing requirements
Lesley Lee, AuD
and standards, at minimum every John Coverstone, AuD, is the chair of the
Jodi Little, AuD
five years as the profession changes. ABA Board of Governors.
Erin E. Maierle, AuD
Exams are constantly being reviewed
Cara Makuta, AuD
and questions revised, discarded, or
Esther V. McCormick, AuD
added as specialty practice areas
Rachel Lynne McNeal, AuD
change. A certification that does not
Kristin E. Musser, AuD
Jennifer M. Noetzel, AuD
Julie A. Norin, AuD
Amanda D. Pearson, AuD
Tacita Persad-Maharaj, AuD
Janice Leigh Richbourg, AuD
Heidi D. Roberts, AuD
Jeffrey G. Sirianni, AuD
Carolyn E. Thompson, AuD
Kimberly Throckmorton, AuD
Tressie L. Waldo, AuD
Crystal D. Wiggins, AuD
Alicia M. Winston, AuD

ACAE Corner
Silos Are Great for

Storing Corn, But… .
By Lisa Hunter
S
ilos are great for storing corn, relationship to the larger world of within the university can create aca-
but not so much as reposito- audiology. ACAE accredits programs demic silos and competition rather
ries of knowledge. Knowledge that develop the best and bright- than cooperation. So NSU set out to
is of little use if not shared, and in a est—students who choose to join find out how all stakeholders—from
field as rapidly changing as audiol- SAA. These students are our future— students, to faculty, to alumni, both
ogy, we must find new ways to break the next generation of audiologists on and off campus—perceived NSU’s
down the proverbial silos that exist who can bring new levels of exem- current reputation and future needs.
between science, education, and plary practice to our profession and The main point was to actively
clinical practice, so that research become board certified through engage all stakeholders in help-
findings can be put to the test by ABA. As professionals in the field, we ing to chart the university’s future.
clinicians and so that clinicians hope they will be inspired to give This process, known in business
can in turn inform researchers and back via the Foundation (AAAF) and as HumanSigma, is a methodology
educators about what really works in possibly provide input to or even that enables organizations to assess,
practice. become leaders themselves on the manage, and improve the employee-
This way of thinking—science to BOD. In giving back dollars, volunteer customer relationship. The same
practice, and practice back to science, efforts, and providing precepting, process can be employed in any orga-
is necessary to enrich and develop helps to fund education, training, nization, to seek and effectively use
any profession that genuinely and research within programs. Thus the collective intelligence and ideas
strives to be at the cutting edge. The the cycle completes and continues of those with a stake in the outcome.
Academy has taken a big leap toward to enrich the profession through ACAE is in the process of updating
silo smashing by bringing together active engagement in the future of standards for audiology accredita-
the "A4." These four groups are the: audiology. tion, and as part of this process, we
A recent article in Gallup are launching a survey of stakehold-
Accreditation Commission for Business Journal Online, titled ers. Who are stakeholders? If you are
Audiology Education (ACAE), “Transformational Change in reading this article, YOU are a stake-
Higher Education: Tearing Down holder and we want to hear from
Student Academy of Audiology Silos and Building a Brand at Nova you! Stakeholders include students,
(SAA), Southeastern University,” by Barbara teaching faculty and researchers, cli-
Packer-Muti and Robert Lockwood nicians, preceptors, consumers, and
American Board of Audiology (2012), describes how the silos that industry—anyone who has a stake in
(ABA), and helped to build Nova Southeastern hearing health care.
University (NSU), using the Harvard
American Academy of Audiology model of “every tub on its own
Foundation (AAAF). bottom,” were initially success-
ful, according to NSU President Ray
Depicted in a circular relation- Ferrero Jr., JD. However, this model
ship collaborating with the board of performance-based budgeting
of directors (BOD), these groups system that directs funding to the
can be thought of in terms of their best-performing schools and colleges

ACAE Corner
All of us have a vested interest program improvement in order to you—the reader and stakeholder—to
in, and will benefit from, continuous compete successfully for peer respect, respond to the ACAE stakeholder
improvements in program stan- research, and training funding, space, survey that will be sent to hear-
dards. Students obviously benefit, and equipment. Additionally, as ing health constituencies this fall.
and have much invested in tuition programs improve in quality and in Your participation will be extremely
and expenses, as well as years of reputation, they are able to attract important to ACAE as it revises its
study and practice. To compete for more qualified students. Industry new standards, and to the profession,
the best positions, students need to benefits from higher professional as it strives to enhance its reputa-
be educated and trained to the full standards since a cadre of highly tion as a leading health-care provider
breadth of practice, and to a suffi- educated practitioners is better able proponent in the United States and
cient depth to ensure they graduate to capitalize on advanced technol- globally.
with independent skills. Clinicians ogy and get below the surface of We hope that you will commit to
and preceptors benefit by having technology to truly meet not only the the future of our profession by recog-
a pool of highly qualified trainees technical side of patient needs but nizing your role in strengthening our
who arrive with a solid didactic also the human aspects—ultimately, educational programs. It is incum-
education to build on, and on whom to engage their patients in managing bent on all of us to thrive in this
they can depend in their practice their total hearing health-care needs. competitive health-care environment.
as future employees and colleagues. To accomplish all of the above Like a good partnership, we need to
Faculty and researchers benefit from points, we enthusiastically invite stand together, not huddle down in
silos, in support of our educational
programs and profession.
Lisa Hunter, PhD, is an associate

professor and scientific director, audiology,
at Cincinnati Children’s Hospital Medical
Center and chair of ACAE.
Donations to ACAE may be made at

www.acaeccred.org.
Reference
Packer-Muti B, Lockwood R. (2012)

Transformational Change in Higher
Education: Tearing Down Silos and
Building a Brand at Nova Southeastern
University. Gallup Business Journal
Online. http://businessjournal.gallup.com/
content/107596/transformational-change-
higher-education.aspx#1 (accessed July
25, 2012).

Washington Watch
Academy News
Academy Board Approves Three

New Public Policy Resolutions
By Melissa Sinden
T
he Academy’s Government Internet Hearing individual with hearing loss, a hear-
Relations Committee (GRC) Evaluations for the ing aid should not be programmed
has been hard at work in 2012 Purposes of Fitting and without a prior evaluation by an
researching and drafting public policy Dispensing Hearing Aids audiologist and that rehabilitative
resolutions (PPRs) on timely topics of Given recent initiatives centered on amplification services should always
interest to audiologists. The com- the use of Internet hearing evalua- be provided by, or supervised by, a
mittee generates topic ideas on their tions by insurance companies and licensed audiologist who is person-
monthly calls and establishes work other entities, the Academy’s ally involved in the care of a patient.
groups to examine the subject matter Government Relations Committee Furthermore, all 50 states have laws
and write the policy. After peer and took the opportunity to research governing the sale and distribution
subject matter expert review, the existing models and develop policy of hearing aids, designed to protect
resolutions are ultimately considered based on the findings. This resolution the hearing-impaired consumer.
by the Academy’s Board of Directors unequivocally resolves that hear- Additionally, the FDA recognizes
and either approved or amended ing evaluations are only one part of hearing aids as Class I medical
and re-reviewed by the GRC before an overall assessment necessary to devices and has therefore identi-
publishing. The three most recently make decisions about candidacy for fied the aforementioned "red flags,”
developed PPRs are outlined below. treatment of a hearing loss. It goes which indicate potentially serious
on to state that a hearing evaluation medical conditions only identifi-
Support Personnel in should be conducted in a controlled able through a comprehensive case
Audiology environment under the supervision history, physical examination, and
This resolution describes the impor- of an audiologist. thorough audiological examination.
tant role that a well-supervised The PPR references the American With regard to the latter two
audiologist assistant can play in National Standards Institute (ANSI) policies referenced, the GRC felt that
a practice setting. The Support requirements for audiometric tests it could not be overstated that an
Personnel in Audiology PPR high- as well as the U.S. Food and Drug amplification device is not the sole
lights the idea that audiologist Administration (FDA) criteria (“red form of treatment for hearing loss.
assistants can perform tasks that flags”). The resolution notes that Rather, the hearing aid is just one
do not require the skills of a licensed Internet hearing evaluations are not component in the overall treatment
audiologist, resulting in a cost- likely to detect conditions that could and management plan afforded to
effective and highly productive require medical evaluation prior the patient by the audiologist, and
patient experience. The resolu- to the fitting and the dispensing of the physician, when there are condi-
tion recognizes the education and hearing aids, as these conditions can- tions requiring medical intervention.
training that audiologists undergo not be evaluated without a thorough These PPRs and others are available
by virtue of their clinical exper- case history, a physical examina- on the Academy’s Web site at www.
tise, which makes them the most tion of the ear, and an appropriately audiology.org/advocacy/public
appropriate professionals to instruct performed diagnostic hearing policyresolutions.
and properly supervise audiologist evaluation.
assistants.
Mail Order/Internet Melissa Sinden is the senior director of
Ordering of Hearing Aids government relations for the American
This resolution asserts that to Academy of Audiology.
adequately meet the needs of an

Just Joined News and Announcements
Academy News
New Members Now Published on the Academy’s Web Site

of the American Audiologic Guidelines for the Assessment of
Academy of Hearing in Infants and Young Children
Audiology The American Academy of Audiology
supports early identification, assess-
most appropriate protocol will be
individualized for each child based
Ellin Becker, AuD ment, and intervention for all types on his or her developmental and/or
Kathy Bricker, MS of hearing loss in infants and young chronological age and other rel-
children to minimize deleterious evant factors. Thus, test procedures
Christine Chad, AuD
effects on speech, language, edu- needed to address this population
Gerald Chua, MEd cation, and social/psychological are diverse. The scope of practice and
Elaine Close, MS development. These clinical practice responsibility of the audiologist is to
guidelines describe recommended determine the appropriate test proce-
Judith Correll, MA
practices for this assessment of dures to use for each child.
Jennifer Dann, MS auditory function in children. The
Crystal Dvorak, AuD
Lori Frederick, MA
Standards of Practice for Audiology
The Standards of Practice for Audiology and consumers. These standards
Simone Fakhoury Garcia were developed to define acceptable reflect the values and priorities of
Tammy Gonzales, AuD standards of practice for services our profession and are continually
representing the Academy’s Scope of evaluated and revised to reflect the
Francis Gunther
Practice. This was developed to serve current state of the profession.
Abdul Hassan as a resource for both professionals
Bill Hodgetts, PhD
Visit www.audiology.org and search for these titles.
Leslie Hultberg, AuD
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SepOct2012

The magazine of, by, and for audiologists

Pediatric Vestibular Evaluation

Published by the American Academy of Audiology | www.audiology.org

Speech Guard technology is only found in Oticon instruments, including:

Intigai 10 Intiga RITE 10 Agil Chili SP 9 & 7

Speech Guard helps your patient

NEW Slim X-mini rIC

Call 888.984.7432. We’re Listening.

is tasked with the responsibility of establishing evidence-based practices for the

management of these technologies.

28 Pediatric Vestibular Evaluation/Balance Assessment At minimum, audiologists in

requiring vestibular/alance assessment.

By Ashleigh J. Callahan, Norman J. Lass, Susan E. Reed, and Meredith C. Willis

of diagnosis and treatment of pediatric patients with vestibular disorders.

Internet and social media continues to flourish. This proliferation of information

management resources available within seconds, just by using a search engine.

8 President’s Message It’s All About Awareness By Deborah L. Carlson

10 Executive Update On the Move By Cheryl Kreider Carey

12 Know-How Draw Awareness to Your Practice By Brenna Carroll and

15 Calendar Academy and Other Audiology-Related Deadlines

15 the web page What's New on the Academy's Web Site

53 CSI: Audiology The Case of Encephalopathy By Emily Nairn,

58 Moment of Science The Medical Olivocochlear Relfex By Skyler G. Jennings

62 Coding and Reimbursement 2013 Proposed Medicare Fee Schedule Rule

64 Compliance PQRS: Participate Sooner By Debbie Abel

68 Foundation Update Widex Grant Supports New Tinnitus Lectureship |

71 SAA Spotlight SAA Across the USA! By Ally Costlow

73 ABA The Importance of Verifying Professional Expertise

78 Just Joined Welcome New Members of the Academy

Send article ideas, submissions, questions, and concerns to amiedema@audiology.org.

Copyright and Permissions

© Copyright 2012 by the American Academy of Audiology. All rights reserved.

Otoport series Fast and accurate cochlear assessment

Content Editor Executive Editor Members-at-Large

Jennifer Shinn, PhD

HEARING AID RETAIL FINANCING

Contact us today! 800-533-0467

It’s All About Awareness

We promote our profession and services

8 Audiology Today | SepOct2012

SepOct2012 | Audiology Today 9

Your QR (Quick Read) on Where

Date Headquarters Address Governed By Managed By

In 1992, Tracy Kroner (the

(Photo Credit: Brad Stach)

10 Audiology Today | SepOct2012

He handles the toughest

Motion XCEL CIC

Make October the Month

12 Audiology Today | SepOct2012

SepOct2012 | Audiology Today 13

twitter.com/ facebook.com/ www.linkedin.com

SepOct2012 | Audiology Today 15

With the trend

SepOct2012 | Audiology Today 17

Figure 1. Studies excluded.

18 Audiology Today | SepOct2012

device is the percutaneous BAI on a titanium abutment

Start an SAA Chapter

SepOct2012 | Audiology Today 19

there was a lack of homogeneity across studies with

Evaluation and Candidacy

New Investigator Research Grant | Up to $10,000