Donald Goldberg, Sharon Sandridge, Cynthia Gensur, and Craig Newman
BEST PRACTICES IN PEDIATRIC AUDIOLOGY:
THE CLEVELAND CLINIC MODEL
Abstract
The purpose of this poster presentation is to share
the Cleveland Clinic’s “Pediatric Audiology Best
Practices” algorithm for the evaluation and
management of infants and children who are deaf
or hard of hearing. Our model reflects best current
practices of comprehensive audiologic testing
(including ABR, ASSR, OAE, immittance, and
behavioral audiologic assessment); early
amplification strategies (including fitting,
verification, and validation); and decision steps for
cochlear implant (CI) candidacy and follow-up
programming. Following identification, infants
may be enrolled into auditory-based intervention.
The algorithm decisions are team-based with input
from audiology, speech-language pathology, and
otology.
Hearing Implant Program
Peter Weber, M.D.Donald Goldberg, Ph.D.
Cochlear Implant Specialist
Michael Scott, Au.D.
Hillcrest Audiologists
Nancy Adamson, M.A. Amy Aylward, Au.D.
Main Campus Audiologists
Melissa Drabo, Au.D. Janet Fraser, M.S. Tonya Nussbaum, M.S.Cynthia Gensur, Au.D.
Coordinator, Pediatric
Audiology
Craig Newman, Ph.D.
Section Head
Audiology
Sharon Sandridge, Ph.D.
Director, Clinical Services
Its ALL About
Learning to Listen!
Other Cleveland Clinic
Audiology-SLP Services
Auditory-Verbal Therapy
Auditory-Based Therapy
Communication Evaluations
Assistive Listening/Alerting Devices (ALD)
Demonstration Room
TrakAid - Hearing Aid Data
Management System
TrakCI – Cochlear Implant Data
Management System
Tinnitus Management Support Group Sessions
Adult Audiologic Rehabilitation –
Hearing Aid Support Group
Adult Audiologic Rehabilitation –
Cochlear Implant Support Group
Acronym Key
ABR = Auditory Brainstem Response
ASSR = Auditory Steady State Response
DP-OAE = Distortion Product-Otoacoustic Emissions
SNHL = Sensorineural Hearing Loss
ABR click thresholds
IF NORMAL (as defined as 20 dBnHL thresholds) do following tests:
* Screening ASSR air conduction or 250 Hz tone burst ABR
* Tympanometry using age-appropriate frequency
* DP-OAEs
RESULTS:
If normal – See Treatment Plan A1
If abnormal – See Treatment Plan A2
IF ABNORMAL (defined as prolongation of all waves I-V that are
parallel to the normal Latency-Intensity Function) do the following
tests:
* ASSR air conduction
* ASSR bone conduction
* Tympanometry using age-appropriate frequency
RESULTS:
If results suggest conductive hearing loss – See Treatment Plan B
If results suggest mixed hearing loss – See Treatment Plan C
IF ABNORMAL (defined as prolongation or absence of wave V) do the
following tests:
* ASSR air conduction
* Screening ASSR bone conduction
* DP-OAEs
* Tympanometry using age-appropriate frequency
RESULTS:
If results suggest mild to moderately-severe SNHL
– See Treatment Plan D
If results suggest severe to profound SNHL
– See Treatment Plan E
If results suggest profound SNHL/deaf
– See Treatment Plan F
IF ABNORMAL (defined by the presence of a cochlear microphonic
and abnormal/absence of wave III-V) do the following tests:
* DP-OAEs
* Tympanometry using age-appropriate frequency
* Ipsilateral acoustic reflexes
RESULTS:
If results suggest auditory neuropathy (AN)
– See Treatment Plan G
Co-Directors HIP
Diagnostic Plan Treatment Plans
Treatment Plan A1: Confirmed normal hearing sensitivity
* Retest hearing using age-appropriate behavioral audiometry
by 12 months of age
* Retest hearing using age-appropriate behavioral audiometry every 6
months if infant is at risk for progressive hearing loss until 3 years of age
* Retest hearing using age-appropriate behavioral audiometry if
parental concerns arise
Treatment Plan A2: Probability for hearing loss is low
* Repeat testing within 4 to 6 weeks
Treatment Plan B: Confirmed conductive hearing loss
* Otologic management and repeat
audiometric/electrophysiologic testing following resolution
of conductive pathology
* Audiologic management if conductive pathology cannot be
resolved medically/surgically:
• Sensory device (e.g., Baha™, hearing aids, FM devices)
assessment, fitting, and follow-up
• Closely monitor speech and language development
• Enrollment in Early Intervention Program1, if needed
Treatment Plan C: Confirmed mixed hearing loss
* Otologic management and repeat
audiometric/electrophysiologic testing following resolution of
conductive pathology
* Audiologic management for SNHL
• Sensory device (e.g., hearing aids, FM devices)
assessment, fitting, and follow-up
* Communication Evaluation2 to assess developmental status
* Enrollment in Early Intervention Program1
Treatment Plan D: Confirmed mild to moderately-severe SNHL
* Otologic work-up and management
* Audiologic management for SNHL
• Selection of sensory devices (e.g., hearing aids, FM
devices) assessment, fitting, and verification
• Follow-up every 3-6 months as needed
* Communication Evaluation2 to assess developmental status
* Enrollment in Early Intervention Program1
* Closely monitor speech and language development
Treatment Plan E: Confirmed severe to profound SNHL
* Otologic work-up and management
* Audiologic management for SNHL
• Hearing aids/FM devices provided on a loaner basis
for pre-implant trial (trial period will be dependent
upon age of identification and development of
auditory/speech/language)
• Selection of sensory devices (e.g., hearing aids,
FM devices) assessment, fitting, and verification
• Follow-up every 3-6 months as needed
* Communication Evaluation2 to assess developmental status
* Enrollment in Early Intervention Program1
* Cochlear Implant Evaluation3 initial appointment
* Closely monitor auditory, speech, language development
with hearing aids/FM devices (proceed with implantation
evaluation if child is not making acceptable
auditory/speech/language development)
* Cochlear implant intervention4, if child
receives cochlear implant/s
Treatment Plan F: Confirmed profound SNHL to deaf
* Otologic work-up and management
* Audiologic management for SNHL (fast-tracked for cochlear
implant consideration)
• Hearing aids/FM devices provided on a loaner basis
for pre-implant trial (trial period will be dependent
upon age of identification and development of
auditory/speech/language)
• Selection of sensory devices (e.g., hearing aids,
FM devices) assessment, fitting, and verification
• Follow-up every 3-6 months as needed
* Communication Evaluation2 to assess developmental status
* Enrollment in Early Intervention Program1
* Cochlear Implant Evaluation3 initial appointment
* Closely monitor auditory, speech, language development
with hearing aids/FM devices (proceed with implantation
evaluation if child is not making acceptable
auditory/speech/language development)
* Cochlear implant intervention4, if child
receives cochlear implant/s
Treatment Plan G: Confirmed auditory neuropathy/dysynchrony
* Otologic work-up and management
* Audiologic management for AN
• Hearing aids/FM devices provided on a loaner basis to
determine if amplification is beneficial.
• Selection of sensory devices (e.g., hearing aids,
FM devices) assessment, fitting, and verification
• Follow-up every 3-6 months as needed
* Communication Evaluation2 to assess developmental status
* Enrollment in Early Intervention Program1
* Cochlear Implant Evaluation3 initial appointment
* Closely monitor auditory, speech, language development with
hearing aids/FM devices (proceed with implantation evaluation
if child is not making acceptable auditory/speech/language
development)
* Cochlear implant intervention4, if child receives cochlear implant/s
If child is less than 12 months of age:
Repeat auditory electrophysiologic testing at age 12 months to
determine if AN has resolved.
If resolution of AN:
• Discontinue use of amplification
• Closely monitor auditory/speech/language development
If no resolution of AN and development of auditory/speech/
language is not age-appropriate:
• Cochlear Implant Evaluation3
• Cochlear implant intervention4
• Enrollment in Early Intervention Program
If child is over 12 months of age:
If development of auditory/speech/language is not
age-appropriate:
* Cochlear Implant Evaluation3
* Cochlear implant intervention4
* Enrollment in Early Intervention Program
1Early Intervention Program at Cleveland Clinic
Hearing Implant Program
• Monitor speech/phonetic repertoire
• Monitor receptive/expressive language
development (e.g., SKI-HI LDS, REEL-3,
MacArthur Inventories, Minnesota/CDI)
• Monitor auditory development
2Communication Evaluation
• Case history
• Auditory functioning
• Speech/oral-motor
• Receptive/expressive language skills
• Referrals to developmental pediatrics,
OT, PT, psychology, social work, as needed
3Cochlear Implant Evaluation
• Candidacy – both medical/surgical and
audiologic
• Aided testing with appropriately fit hearing
aids/FM system
• Device selection: manufacturer/processor,
unilateral versus bilateral
(simultaneous versus sequential)
4Cochlear Implant Intervention
• Initial activation performed 2-weeks
post-surgery
• Follow-up monitoring of CI MAPping
• Serial CI audiogram at 3-6 month intervals
• Serial speech perception measures at
3-6 month intervals
• Serial outcome measures at 3-6 month intervals
(e.g., IT-MAIS; MAIS; LittlEars)