1. Provider 10 minute Refresher Course June 2009

2. Special Instructions ●Be sure to put on Slide Show view ●Use your mouse to select your answers ●Click anywhere on the slide to advance to the next question ● Do not use the up/down arrows, space bar, or return key to advance ●You may find it useful to refer to your BSC Pocket Guide, Workbook and other training materials as necessary

3. What is the recommended time frame (in months) for newborns in terms of screening, diagnosis/amplification and early intervention? ●One, Three, SixOne, Three, Six ●Two, Four, SixTwo, Four, Six ●One, Six, TwelveOne, Six, Twelve

4. Sorry! That answer is incorrect!

5. Congratulations! You are correct! According to EDHI guidelines, the recommended time frame for a newborn is to be screened by 1 month, diagnosed and fit with amplification by 3 months and enrolled in appropriate early education by 6 months in order to keep apace with hearing peers.

6. Periodic hearing screening in the medical home is recommended to: ●Identify later onset hearing lossIdentify later onset hearing loss ●Identify progressive hearing lossIdentify progressive hearing loss ●Identify children who did not receive a hearing screening at birthIdentify children who did not receive a hearing screening at birth ●All of the aboveAll of the above

7. Partially Correct! That is one target goal of the BSC program but it is not the only goal. Please try again!

8. Congratulations! You are correct! The answer to this question is ALL OF THE ABOVE Because we need to catch children that fit into all of these categories.

9. According to the NEW periodicity intervals, BSC should be conducted at: ●2mos, 6mos, 12mos, 2 years & 3 years2mos, 6mos, 12mos, 2 years & 3 years ●Every 6 monthsEvery 6 months ●AnnuallyAnnually

10. Sorry! That answer is incorrect!

11. Congratulations! You are correct! The new protocol requires that BSC be conducted at set intervals corresponding to WCCs at 2m*, 6m, 12m, 2 yrs and 3 yrs. *The 2 month BSC is necessary if the child is not definitively known to have passed the newborn hearing screen and does not have risk factors for progressive hearing loss.

12. The three hearing screening procedures used as part of BSC are: ●OAE, ABR and Acoustic ReflexOAE, ABR and Acoustic Reflex ●OAE, Tympanometry and Acoustic ReflexOAE, Tympanometry and Acoustic Reflex ●OAE, Tympanometry and ABROAE, Tympanometry and ABR

13. Sorry! That answer is incorrect! The ABR (Auditory Brainstem Response) is not part of the BSC screening protocol. Automated ABR (AABR or ABAER) is often used to screen the hearing of newborns before they leave the NICU. Diagnostic ABR is frequently used by pediatric audiologists as an evaluative tool to comprehensively define presence, degree and type of hearing loss in infants, toddlers and young children. ABR records the response of the auditory (VIII th ) nerve to an auditory signal such as a click and a toneburst. ABR is used to determine cochlear sensitivity (degree of loss) as well as neural integrity (auditory neuropathy or retrocochlear pathology).

14. Congratulations! You are correct! FYI : The ABR (Auditory Brainstem Response) is not part of the BSC screening protocol. Automated ABR (AABR or ABAER) is often used to screen the hearing of newborns before they leave the NICU. Diagnostic ABR is frequently used by pediatric audiologists as an evaluative tool to comprehensively define presence, degree and type of hearing loss in infants, toddlers and young children. ABR records the response of the auditory (VIII th ) nerve to an auditory signal such as a click and a toneburst. ABR is used to determine cochlear sensitivity (degree of loss) as well as neural integrity (auditory neuropathy or retrocochlear pathology).

15. The PRIMARY purpose of Tympanometry is to: ●Determine whether there is cerumen in the earDetermine whether there is cerumen in the ear ●Determine whether a perforation is present in the TMDetermine whether a perforation is present in the TM ●Rule out middle ear pathologyRule out middle ear pathology

16. Sorry! That is not the best answer! It is rare for an ear to be completely obstructed with wax. Even if there is a tiny opening, it is usually possible to conduct the tymp screening.

17. Sorry! That is not the best answer! Although tympanometry is very helpful in determining the presence of a patent PE tube or eardrum perforation by showing a large ear canal volume (ECV) measurement (>1.0 in an infant or young child), this is not the primary purpose of tympanometry.

18. Congratulations! You are correct! Tympanometry is a very sensitive measure of the presence of middle ear fluid even when fluid cannot be visualized through otoscopy.

19. The OAE screening is a test of inner hair cell function ●TrueTrue ●FalseFalse

20. Sorry! The otoacoustic emission is a test of inner ear function, however the ‘echo’ is actually a product of the motility of the outer hair cells as they respond to a sound stimulus.

21. Congratulations! You are correct! The otoacoustic emission is a test of inner ear function, however the ‘echo’ is actually a product of the motility of the outer hair cells as they respond to a sound stimulus.

22. An absent acoustic reflex could result from: ● Auditory neuropathyAuditory neuropathy ● A severe to profound sensorineural (cochlear) hearing loss A severe to profound sensorineural (cochlear) hearing loss ●Middle ear or conductive pathologyMiddle ear or conductive pathology ●All of the aboveAll of the above

23. Partially Correct! True, but that is not the only answer. In fact all of these conditions could result in absence of the acoustic reflex.

24. Congratulations! All of these can result in absence of the acoustic reflex: ●In the case of Auditory Neuropathy, the VIII th nerve or synaptic junction between the nerve and inner hair cells is impaired. ●In severe to profound sensory hearing loss, the acoustic reflex is absent because sound cannot be made loud enough to activate it. ●In middle ear dysfunction, the middle ear pathology prohibits the measurement of the acoustic reflex. Careful study of reflex results IN CONJUNCTION WITH OAE AND TYMPANOMETRY is crucial in making appropriate screening referrals

25. In a patient less than 6 months old, the BSC protocol calls for ●OAE and High Frequency Tympanometry onlyOAE and High Frequency Tympanometry only ●OAE, High Frequency Tympanometry and Acoustic ReflexOAE, High Frequency Tympanometry and Acoustic Reflex ●OAE and Standard Tympanometry onlyOAE and Standard Tympanometry only

26. Sorry! The acoustic reflex is not reliable in children 0-6 months of age.

27. Sorry! Standard tympanometry cannot be used in babies 0-6 months, due to the extreme compliance of their ear canal walls.

28. Congratulations! You are correct! In order to measure eardrum, rather than ear canal compliance, a high frequency probe tone (1000 Hz) MUST be used in babies under 6 months of age. If a 1000 Hz probe tone is not used, middle ear effusion can be missed.

29. From the list below check any conditions that place an infant at risk for late onset, or progressive hearing loss ●Family history of hearing lossFamily history of hearing loss ●In utero infection such as CMVIn utero infection such as CMV ●NICU stay > 5 daysNICU stay > 5 days ●Aminoglycoside treatmentAminoglycoside treatment ●All of the above can result in progressive hearing lossAll of the above can result in progressive hearing loss

30. Partially Correct! That is one etiology of progressive or late onset hearing loss in young children. Please try again!

31. Congratulations! All of these are risk factors for progressive or late onset hearing loss.

32. According to BSC protocol, what action is recommended for a patient with the following results during their first BSC screening: Refer OAE, Refer Tymp, Absent Reflexes? STAT referral to JTC Audiology Rescreen in 3 monthsRescreen in 3 months ENT &Audiology referral

33. Sorry! This combination of results (OAE refer and flat tympanogram) is typical of middle ear disorder. It is best to initially follow this child medically for recovery from middle ear disorder before requiring a full hearing test. ENT and Audiology referrals would not be indicated until the 2 nd failed BSC.

34. Congratulations! According to BSC protocol, rescreening in 3 months is recommended, in order to allow sufficient time for the middle ear pathology to resolve.

35. NICU babies who fail the California Newborn Hearing Screening require ABR follow up at a certified outpatient infant hearing screening facility. ●TrueTrue ●FalseFalse

36. Sorry! According to California State guidelines, all NICU hearing screening fails must receive follow up ABR testing at a certified outpatient infant hearing screening facility, superseding any BSC screening they receive.

37. Congratulations! You are correct! It is important that BSC does not interfere with the established state- mandated procedures.

38. What action is recommended for a patient with the following results: OAE refer, Tymp Pass, reflex refer? ●STAT referral to JTC AudiologySTAT referral to JTC Audiology ●ENT referralENT referral ●Rescreen in 3 monthsRescreen in 3 months

39. Sorry! This combination of results (OAE refer and normal tympanogram) suggests a permanent sensory deficit. An immediate referral to audiology is recommended.

40. Congratulations! According to BSC protocol, an OAE refer and absent reflexes in the presence of a normal tympanogram would warrant immediate referral to audiology. This combination of results is strongly indicative of a permanent sensory (cochlear) deficit.

41. How would you interpret this tympanogram? Pass Refer Incomplete

42. Sorry! The compliance is less than 0.2ml, so this tymp is a refer, even though you can still see a small peak. Shallow tympanograms such as this are usually associated with the presence of middle ear fluid.

43. Congratulations! You are correct! Even though the gradient is within normal limits (less than 250daPa), the compliance is less than the 0.2ml cut-off. Shallow tympanograms such as this are usually associated with middle ear fluid.

44. How would you interpret this acoustic reflex screening? Present Absent Incomplete

45. Sorry! That answer is incorrect!

46. Congratulations! You are correct! The deflections on the print out are simply a result of the baby’s movement or crying. This test should be redone.

47. What would you recommend? Return for Routine BSC Additional BSC Tymp and reflex testing Refer for audio and speech AGE 2

48. Sorry! The BSC protocol calls for additional screening, since there are Risk Factors checked on the BSC questionnaire.

49. Congratulations! You are correct! The risk factors checked on the BSC questionnaire indicate the need for further tympanometry and acoustic reflex testing.

50. How would you interpret this tympanogram? Pass Refer Incomplete

51. Sorry! The gradient is greater than 250daPa, so this tymp is actually a refer, even though you can still see a small peak. Wide tympanograms such as this are usually associated with middle ear fluid.

52. Congratulations! You are correct! Even though the compliance is within normal limits the gradient is greater than the 250daPa cut-off. Wide tympanograms such as this are usually associated with middle ear fluid.

53. How would you interpret this Reflex tracing? Present Absent Incomplete

54. Sorry! That answer is incorrect!

55. Congratulations! You are correct!

56. How would you interpret this Reflex tracing? Present Absent Incomplete

57. The deflections circled are the response. The initial spikes are artifact Sorry! That answer is incorrect!

58. The deflections circled are the response. The initial spikes are artifact Congratulations! You are correct!

59. What would you do with this tympanogram? Pass Refer Incomplete/Retest

60. Sorry! Although the gradient and compliance readings are within normal limits, this tymp needs to be redone. The ‘blip’ on the otherwise flat tymp is confusing the issue, and is where those ‘normal’ numbers are derived from.

61. Congratulations! You are correct! Even though the compliance and gradient appear within normal limits the tympanogram is essentially flat, with just a ‘blip’ derived from the baby swallowing or moving.

62. Thank You for your participation in the Baby Sound Check ® Program Congratulations! You have successfully completed the BSC refresher course! Please click this link to send an email notifying BSC staff of your course completion and we will email you a certificate. smintz@jtc.org