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ASK THE EXPERTS

Our team of audiology experts have decades of experience in the field. They are here to answer your questions to help you grow in your profession! Check out our entire collection of Ask the Experts below.

THREE LEVELS OF LEARNING

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    INTRODUCTORY

  • gsi-advance-intermediate-education

    INTERMEDIATE

  • gsi-advance-advanced-education

    ADVANCED

All of our learning opportunities can be categorized into one of three levels of learning: Introductory, Intermediate, and Advanced. One of the three icons displayed below will be displayed on each resource to quickly identify the straightforwardness to complexity of the content. ADVANCE provides a variety of content designed to suit all audiologists' needs.

WHAT ARE THE DIFFERENCES BETWEEN SYNCHRONOUS AND ASYNCHRONOUS MODELS IN TELEAUDIOLOGY OPTIONS?

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Teleaudiology is gaining significant momentum in today’s ever-changing world. There are a couple of driving factors:

  • Aging population
  •  Not enough audiologists
  • Geographic challenges
  • Patient load

There are two main ways to perform teleaudiology. Synchronous, or live face-to-face, is the most common form of teleaudiology. This is typically what people think of when they imagine telemedicine. It requires a video connection between the audiologist and the patient. A technician or an audiology assistant is required at the patient site to be the audiologist's “hands”. It's truly just like a live appointment in the sense that the audiologist is present and running the appointment. The equipment used for synchronous teleaudiology must be PC based and paired with a two-way video stream. The audiologist controls the equipment from their office while the patient and the technician are in a different location. Audiometry, hearing aid fittings, and counseling can be formed this way. If your technician is trained appropriately, you may also utilize video otoscopy and REM.

The second way to perform teleaudiology is asynchronous, or Store-and-Forward. The audiologist does not need to be present for the appointment because the patient "runs" the program to obtain basic air/bone/speech information. The setup is with a GSI audiometer and a computer with GSI AMTAS teleaudiology software loaded on it. AMTAS was developed by Dr. Bob Margolis from University of Minnesota and has been validated and researched extensively. A technician or medical assistant puts the headphones and bone oscillator (forehead placement) on the patient and then begins the software program. AMTAS uses a modified Hughson-Westlake method to obtain thresholds and then a closed set speech test that is based on the thresholds. At the end of the evaluation, a report is generated with up to nine quality indicators that give the audiologist who is interpreting the results a clear idea of what the patient was "doing" during the test. AMTAS tells you how many false positives there were (there are catch trials). It does a test-retest at 1kHz in both ears, reports any masking dilemmas, and does a quality check when it establishes each threshold by bumping the intensity up by 5 dB and looking for a response.

The patient performs the automated test and the results are "stored and forwarded" to the audiologist for interpretation. The benefits of this model is it increases access. You don't have to wait for a schedule to clear for basic diagnostic audiometry. The audiologist will get the results of the initial testing and make decisions based on the data. GSI has seen this implemented in several ways. ENT clinics and VA Medical Centers use AMTAS for walk-in appointments and annual evaluations. AMTAS is being implemented to gather basic data so that audiologists can perform more tasks that require their attention like tymps/reflexes, OAEs, counseling, and more. Dr. Margolis developed this program when he realized that his audiologists and students were spending up to 40% of their time on basic pure tone testing and this wasn't the best use of their knowledge or time.

FURTHER INFORMATION
GSI AMTAS Overview Video 
GSI AMTAS Website
Audiology Online course - Teleaudiology: Improving Access to Hearing Healthcare

HOW DO YOU PERFORM AUTOMATED SPEECH AUDIOMETRY FOR TELEAUDIOLOGY WITH GSI AMTAS?

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Because the patient is directing the test independently with a software program, speech testing on AMTAS is a closed set task. Before the speech test begins, there is a speech specific set of instructions. These instructions may be reviewed by video or text and indicate that the patient will listen for a word and then select the word that they heard from the group of words displayed on the screen. They must select a word; they cannot repeat the audio or go back.

Speech Recognition Threshold (SRT) testing is obtained using a closed set of spondaic words and is very similar to manual audiometry. The SRT presentation starts at a level the patient can hear and gets softer and softer until the speech threshold is obtained. After SRT is obtained, the software moves into Word Recognition Score (WRS) using a closed set of NU-6 words. Because this is a closed set test, the presentation level is not “Most Comfortable Level (MCL)” or “40 dB above SRT.” MCL and other comfortable dB levels for WRS testing in a closed set task are too easy. Every patient would get 100% and that would not add value to the automated test.

The default presentation level of the WRS testing is 22 dB above the reference level based on either SRT or PTA. The reference is specified in the configuration application. Due to the low presentation level of the WRS, it is common to get scores that are not 100%. If the score is 88%, that is considered excellent and AMTAS moves to the next part of the evaluation. If the score is less than 88%, AMTAS increases the dB presentation level to 28 dB above the reference and repeats the WRS. The patient still may not get a score of 100%, but it gives the audiologist who is interpreting the test an opportunity to observe PIPB increase. This adds diagnostic value to the automated speech testing. It is also possible to specify a fixed dB level for WRS testing. However, with a fixed level, the words are presented only one time regardless of the score. Speech WRS testing will not be performed under the following circumstances:

A. SRT is greater than 68 dB
B. PTA is greater than 68 dB
C. A fixed value WRS presentation level is greater than 80 dB

When used in combination with the audiogram and the quality indicators provided in the audiologist report, automated speech audiometry provides the interpreting audiologist valuable information to make decisions on the most appropriate next step in the patient treatment plan.

WHAT GSI EQUIPMENT IS TELEPRACTICE FRIENDLY?

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GSI AMTAS is telehealth friendly. AMTAS Pro is a software that is used with a GSI audiometer and AMTAS Flex is a software that is used with a tablet and calibrated headphones. AMTAS is designed to perform an automated test so the patient can come in, a technician can set them up for the evaluation, and the patient can go through the audiometric evaluation. AMTAS Pro provides diagnostic air conduction, bone conduction, and speech testing with masking and AMTAS Flex provides air conduction thresholds and basic screening audiometry. These results are reviewed later by an audiologist to determine if follow up testing is required.

CAN I CHANGE PROTOCOLS ON MY NOVUS NEWBORN HEARING SCREENING DEVICE?

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The GSI Novus™ is a handheld, comprehensive newborn hearing screening instrument. The Novus features a touch screen display and user-friendly software in a compact hardware design. Novus may be configured with AABR, OAE, or both which allows for seamless two stage infant screening. When the Novus was initially released, there was only one protocol option each for AABR, DPOAE, and TEOAE. With the latest update to HearSIM, support for multiple protocols for all test modalities is included. The original protocols will be the default protocols that will come loaded on the device from the factory.

Summary of Default Protocols
The AABR protocol utilizes a fast rate auditory brainstem response (ABR) algorithm with a rate of 88/sec left ear and 92.5/sec right ear. The varying rates allow for simultaneous ear testing, which reduces overall test time, with the maximum being three minutes. Once the passing criteria has been met, the device will abort testing, and a passing result is usually achieved within 30 seconds. The stimulus is CE-Chirp® at 35 dB nHL and the device will provide a Pass, Fail, or Incomplete result. This protocol has been optimized for the infant ear and should only be utilized on infants under six months of age.

With DPOAE, L1/L2 are established at 65/55 dB SPL with the F2/F1 ratio equal to 1.22. Test frequencies include 5000, 4000, 3000, and 2000 Hz. To achieve a pass, 3/4 tested frequencies must record a SNR of 6 dB with a minimum amplitude of -5 dB. As with AABR, the device will abort testing once the passing criteria has been met. The maximum testing time for DPOAE is one minute and this protocol is appropriate for any age.

During TEOAE, an 83 dB click stimulus is analyzed in different frequency bands that center around 1400, 2000, 2800, and 4000 Hz. Similar to DPOAE, 3/4 frequencies with a SNR of at least 4 dB and minimum amplitude of -5 dB are needed for a passing result. While this protocol is appropriate for any age, it has been optimized for the infant ear. Maximum testing time is 60 seconds.

Both OAE protocols give only a Pass, Fail, or Incomplete result.

Newly Added Protocols for All Modalities
Newly added protocols for AABR include the CE-Chirp stimulus at varying intensities. The default will remain at 35 dB nHL, but now 30, 40, and 45 dB nHL are also available. In addition, a traditional Click Stimulus at 30, 35, 40, and 45 dB nHL can be selected. No other options will be available to change, and the device will still only function as a screening device, providing only a Pass, Fail, or Incomplete result.

For DPOAE, the default will be 2000 - 5000 Hz range, with three additional protocols added. 1.5 - 4k Hz will have the same passing criteria as the default protocol, and will include F2 frequencies of 4000, 3000, 2000, and 1500 k Hz. A 1.5 - 6k Hz protocol will consider five F2 frequencies (6000, 4000, 3000, 2000, 1500 Hz) with 3/5 needed for a pass, along with a minimum of 6 dB SNR and -5 dB amplitude. A 6-frequency protocol was also added between 1.5 - 5k Hz (6000, 4000, 3000, 2000, 1500 Hz) and will require 3/6 for a pass along with a 7 dB SNR and -5 minimum amplitude.

There are two new TEOAE protocols that both consider the same four center frequencies of 1400, 2000, 2800, and 4000 Hz with a click (non-linear) stimulus. The first variation measures at 83 dB peSPL and requires 2/4 passing criteria for each frequency band with a 6 dB minimum SNR and 0 dB SPL amplitude. The second measures at 80 dB peSPL and 3/4 passing frequencies with a minimum of 4 dB SNR and -5 dB amplitude. Both will have a maximum test time of one minute.

New protocols can be loaded onto the Novus with the companion HearSIM software with software version 2.1 and above.

Learn more by viewing our tutorial video: https://www.youtube.com/watch?v=kt-fD7lG0y4&list=PLf-QVux8dOsBPP-8NGoZ8YRQZbe_1TI6E&index=15

WHY IS THE CE-CHIRP SO BENEFICIAL FOR THRESHOLD ESTIMATION?

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For over 30 years, threshold estimation in very young or difficult to test patients has been accomplished with Auditory Brainstem Response (ABR). The ABR is an onset response, a large number of neurons must fire at the same time to elicit the response. To ensure this synchronous firing, a short duration stimulus is used. The two most common short duration stimuli are the click and the tone pip.

The traditional click stimulus is a 100 µs electrical pulse that has a frequency range of approximately 100 - 10,000 Hz. The broadband nature of the click provides stimulation of a large portion of the cochlea, which causes a large number of neurons to fire simultaneously. The resulting AEP provides information on the neural synchrony of the auditory nerve. The tone pip (also called tone burst) stimulus assists in the evaluation of frequency-specific performance of the auditory system. The frequency-specific stimulus is achieved by presenting a sine wave for a brief duration. The tone pip stimulus is based on the number of cycles presented. Typically, the rise and fall times of the stimuli are 2 cycles and the plateau is either 1 or 0 cycles. With this approach, the duration of the stimulus varies with frequency, but the energy content of stimulus is consistent for each frequency.

The ABR response to click and tone pip stimuli is highly efficient and results in a clear, repeatable waveform. However, the ABR is limited by the cochlea’s traveling wave. It takes time for a signal to travel from the high to low frequency regions of the cochlea.

The goal of overcoming the traveling wave delay in ABR is not a new concept. Research on this subject dates back over 20 years. An ideal approach to solve the traveling wave delay in the ABR was introduced by Claus Eberling and others. The CE-Chirp is a broad-band stimulus designed to enhance Wave V of the ABR through adjustment of the stimulus frequency composition. This adjustment counteracts the temporal dispersion of the travelling wave inherent in the cochlea by presenting lower frequency energy before higher frequency energy. The CE-Chirp stimulus adjustment maintains the same frequency content of the click. The frequency timing, however, maximizes the response of the cochlea, increasing the synchronous neural firings of the auditory pathway. CE-Chirp Octave Bands are frequency specific short duration stimuli derived from the CE-Chirp stimulus providing more robust frequency specific threshold estimation. The ABR response to the CE-Chirp stimulus has been demonstrated to be 1.5 to 2 times greater in amplitude than the ABR amplitude to click stimuli in normal hearing subjects.

CE-Chirp stimuli are ideal stimuli for electrophysiological threshold estimation. Threshold estimation can be difficult to achieve in a single appointment such as when testing infants and young children. The CE-Chirp and the CE-Chirp Octave Band stimuli have been demonstrated to generate a repeatable and reliable Wave V response that is larger in amplitude than the Wave V elicited by traditional click and tone-pip stimuli. The robust responses are often generated with fewer averages which shorten the time of the evaluation. Additionally, the use of CE-Chirp Octave Band stimuli provides robust and fast frequency-specific threshold estimation for a more thorough evaluation. Although clinical studies are not yet available for neurophysiologic diagnostic evaluation, threshold estimation is an immediate and effective use for the CE-Chirp stimuli.

HOW DO I TRANSFER RESULTS FROM THE CORTI IF I DON'T HAVE GSI SUITE?

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In addition to GSI Suite, the GSI Corti comes with the Data Manager software. The Corti Data Manager software is very easy to use and allows you to maintain all OAE tests in one location. After installing the software on your computer, connect the Corti using the micro USB cable and select results. The OAE tests stored on the Corti will then be transferred into the software. From there you’re able to add the patient name, birth date, and case history information and complete the OAE report. On the other hand, if all you need is a basic PDF then the auto print function is ideal. As soon as you connect the Corti, a PDF is generated and saved.

WHO BENEFITS FROM GSI AMTAS?

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GSI AMTAS, or Automated Method for Testing Auditory Sensitivity, is designed to increase the efficiency by automating a basic diagnostic evaluation. Any audiologist in a busy ENT office, where they may have multiple doctors with patients at the same time, will benefit from AMTAS. You can use AMTAS to obtain basic diagnostic audiometric information with one patient, while doing a middle ear evaluation, OAEs, or counseling with another patient. AMTAS is great for any audiologist who wants to obtain basic information during an open house at their private practice. AMTAS frees us up to spend more time building rapport with patients and doing other audiometric tests that add overall value.

WHAT IS THE ARLT SPECIAL TEST?

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The ARLT, or Acoustic Reflect Latency Test, is a simple clinical procedure that can be a sensitive indicator in distinguishing cochlear from retro cochlear lesions. The acoustic reflex latency is the time interval between the onset of an acoustic stimulus and the onset of a stapedius muscle contraction. What we’re measuring is the efficiency of the neural auditory system. And we know anything that affects the efficiency of the neural pathways will affect the latency measurement. Research has indicated that prolonged latency with retro cochlear disorders will be indicated with the ARLT. Although there are not norms, comparing the interaural latencies can provide valuable information to support the differential diagnosis. The ARLT can help provide information on the most appropriate next step in diagnosis and treatment and provide more diagnostic information with a less invasive or less uncomfortable evaluation.

WHAT ARE THE COMPONENTS OF ADMITTANCE AND WHEN SHOULD THEY BE USED CLINICALLY?

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Background
Middle ear testing has been a standard component in audiometric evaluations for many years. It is performed regularly to objectively document the compliance of the middle ear system, monitor chronic middle ear fluid, evaluate Eustachian tube function, and used in combination with the audiogram to develop a complete picture of a patient’s hearing. In the majority of cases, using the total admittance (Y) obtained with the 226 Hz probe tone provides sufficient information for basic diagnosis. This is the fastest way to “confirm” a normal middle ear system. However, when a more critical look at the middle ear is required, higher frequency probe tones and individual admittance components can provide detailed information.

What are the components of admittance?
Middle ear testing has been described as evaluating the impedance of the ear. Impedance refers to the opposition of the flow of energy. In other words, if energy (sound) is introduced to a system (ear), how much of the energy is blocked or impeded. Impedance is not a practical measurement for an office setting, so the commercial impedance bridges are actually measuring admittance which is the inverse of impedance. Admittance is measuring the ease at which energy (sound) flows through the system (ear). Admittance (Y) is a measurement taken at the plane of the tympanic membrane and is made up of two components: susceptance (B) and conductance (G).

Susceptance (B) is referred to as the “stiffness” of the middle ear system and refers to the relationship between the springy parts and the mass of the middle ear. In other words, this is the way the ligaments, tendons, and muscles work with the bones in the middle ear to transmit sound. Typical middle ear testing at 226 Hz probe tone provides very predictable and reliable results using the total admittance (Y). There is no need to separate the individual components because the total admittance (Y) is equal to the susceptance (B) at that probe tone. Research has shown that when using the 226 Hz probe tone, the springy portion of the susceptance is transmitting the sound through the system.

The ear is a machine with working parts, and therefore there will be a natural amount of energy lost. Conductance (G) refers to the loss of energy due to friction in the system.

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What is the difference between probe tones?
As the frequency of a stimulus is increased and gets closer to the resonance frequency of the ear, there is a natural evolution of the morphology of the tympanogram. These changes in the tympanogram are expected and follow a general rule. Sound is being transmitted be the springy portion of the ear with a low frequency probe tone (226 Hz) and the resulting tympanogram will by the typical type A. As you move to a mid-frequency probe tone (such as 678 or 1000 Hz), the mass portion of susceptance is more involved with sound transmission and the resulting tympanogram will develop multiple peaks or notches. At the resonance frequency of the ear, the tympanogram will have multiple peaks and is described as an inverted W. When using a high frequency probe tone that is above resonance frequency, the tympanogram will continue to evolve into a V shape (opposite of 226 Hz) because the mass portion of susceptance is transmitting the sound.

When is it appropriate to use different probe tones?
For basic diagnosis of middle ear function, the 226 Hz probe tone is completely appropriate. When a more detailed look at the individual components of the middle ear is required, 678 Hz should be the “go to” probe tone frequency. Tympanometry with 678 Hz is typically performed when the audiologic results don’t add up. Examples of when to use 678 Hz probe tone tympanometry are:

1. Presence of an air-bone gap with a normal 226 Hz tympanogram.
2. Abnormally steep gradient (suspected disarticulation).
3. Patient complaints are consistent with middle ear pathology that is not detected with a basic tympanogram.

The 1000 Hz probe tone is utilized for the basic evaluation of the infant ear because the middle ear structure in patients under 6 months of age is different than that of patients over 6 months of age. The infant ear is mass dominated and has a lower resonance frequency which can create complex morphology and notching when using a low frequency probe tone. The 1000 Hz probe tone is far away from the resonance frequency of the infant ear and will result in more predictable morphology that is consistent with common middle ear pathologies for the infant patient population.

Interpreting results when using different probe tones
When using probe tones other than 226 Hz, susceptance and conductance should be viewed simultaneously. Baseline, or compensated, is not used. The shape of the tympanogram is classified by the number of peaks, or extremum, that are present in B and G. There are four normal classification types: 1B1G, 3B1G, 3B3G, and 5B3G. Examples of normal B/G tympanograms are shown below. Tympanograms are considered abnormal if there are too many peaks or if the peaks are too wide. See examples below of abnormal B/G tympanograms. These results often help distinguish between ossicular discontinuities and other disorders – even when no abnormality is present on the 226 Hz tympanogram.

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For 1000 Hz probe tones, refer to normative data and look for any discernable peak. 

HOW CAN I LOAD RECORDED SPEECH ON MY GSI AUDIOMETER?

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How can I load recorded speech on my GSI Audiometer? The AudioStar Pro and Pello include over 100 widely used recorded wordlists. Below, you will find the list of the included CDs on the AudioStar Pro and Pello audiometers:

Basic Auditory Evaluation - Adult
Spondee - A and B
NU6 list 1a - 4a
W-22 list 1a - 4a

Basic Auditory Evaluation - Child
Spondee Child
PBK lists 1a - 3a

Spanish Auditory Speech List
2 lists for SRT (Tri syllable)
4 lists for WRS (Two syllable)

VA CDs 1, 2, and 4
https://chs.asu.edu/programs/schools/department-speech-and-hearing-science/audio-cds-speech-audiometry

The AudioStar Pro includes the following Special Tests* on every instrument and the Pello includes the following Special Tests with the Speech Plus License:
QuickSIN
BKB-SIN
AZ Bio Sentences
AZ Bio Sentences Pediatric
*Additionally, the TEN Test is integrated into every AudioStar Pro.

In order to add additional CDs to your audiometer, GSI must extract the tracks from the CD and convert them to XML .WAV files. The original CD that you wish to be extracted as well as the score sheet (or script) with the lists of words on each track will need to be mailed to GSI along with the letter of ownership document. The letter of ownership states that the CD is your media and you are allowing GSI to change the format of it. Additionally, the document requests information about the audiometer to be loaded with the new .WAV files to ensure the proper format is delivered. This process takes 4 - 6 weeks to complete so if it is a CD that you use frequently, it is recommended that you make a copy to keep in your office for use during the time it is processing at GSI. When the extraction process is complete, GSI will send a USB drive with the new files for you to load on your instrument.

CAN THE GSI CORTI TEST PATIENTS WITH PE TUBES?

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Yes. The Corti can easily test patients with PE tubes. To do so, the probe check needs to be disabled. The Corti runs a probe check that begins automatically after testing is initiated. The probe check display shows a cone, larger at the left and tapering toward the right, representing the ear canal volume from very large (blue area) to very small (orange area). The vertical white bar indicates the measured ear canal volume and probe fit stability.

If the measured ear canal volume is in the normal range for testing and the vertical bar is stable in the gray portion of the cone, it will turn green, the device will calibrate, and testing will be initialized:

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If the ear canal volume is too large for the test to begin, the probe is not in the ear, or there is a large leak, the ear seal indicator will move to the left in the blue part of the cone.

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In patients with patent PE tubes, the probe check will not pass, no matter how well the probe is positioned in the ear canal. To complete testing, the probe check needs to be bypassed. This is accomplished by first inserting the probe with appropriate ear tip into the ear canal and obtaining a proper seal. To disable AutoStart at the main menu, select the ear to be tested by holding down the RIGHT or LEFT arrow key for three seconds until the green “ready” light turns off. Once the key is released, the Corti will calibrate and test as before. The appropriate in-the-ear stimulus intensity levels are applied to ears with PE tubes.

How Reliable is Automated Audiometry?

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The results of AMTAS are data driven and evidence based. They are then used to calculate the overall accuracy and a number of other important markers that will basically give the audiologist an image of how the patient was acting during the test. It is important that you are familiar with these.

The Quality Indicators that are most impressive to audiologists and ENTs are as follows: Predicted Average Absolute Difference, Time Per Trial, False Alarm Rate, and QC Fail.

Predicted Accuracy - Overall Quality - Good, Fair, Poor – based on the quality indicators.
Predicted Average Absolute Difference – Difference between automated and manual thresholds based on a study where five expert audiologists tested patients manually and compared the results to AMTAS evaluations – based on research.
Masker Alerts - These indicate thresholds where masking may have been too high or low. 
Time Per Trial - Measures the average time from stimulus to patient response.
False Alarm Rate – The number of times patient responded with no stimulus presented is divided by number of trials when no stimulus was presented. When there is a false alarm, AMTAS displays a message to alert the patient that he responded yes when there was not a tone presented. 
Average Test-Retest Difference – Displays the average difference between 1 KHz test and retest in the right and left ears.
Quality Check Fail Rate – When threshold is established, AMTAS presents a stimulus that is 5 dB above threshold. The patient should hear this tone. QC fail indicated the number of times patient did not respond to stimulus above threshold divided by the number of measured thresholds. If this is high, it can indicate malingering or that the patient is not a good candidate for AMTAS.
Number of Air/Bone Gap > 35 dB – This is the number of air/bone gaps that exceed 35 dB.
Number of Air/Bone Gap < -10 dB – This is the number of air/bone gaps that are less than 10 db

If the data and research is not convincing enough, patient care situations can help:

- If an ENT cannot find an audiologist but he has a patient that requires audiometric testing, he must end the appointment, send the patient across town to the audiologist he refers to, and then wait for the patient to come back. This adds a level of complexity that is inconvenient. The patient must then make an appointment, go to the appointment (pay the copay), and then make and go to a follow up appointment (copay again) with the ENT. If that office had AMTAS, they would still likely refer to audiology, but they would be able to complete the patient’s appointment more efficiently. 

- If an audiologist is supporting an ENT clinic and has several patients who need audiometry at the same time, the patients will have to wait until the audiologist completes testing with the previous patients before they can be seen. This can add up to a long time in a waiting room for a hearing test. If that audiologist had AMTAS, one patient could be working through a basic air/bone/speech while other patients were undergoing middle ear testing, OAEs, or counseling.

- If a busy clinic has AMTAS, a walk-in patient with sudden hearing loss can be tested immediately and worked into the schedule for immediate treatment.

- A satellite office where an audiologist is not available every day can see more patients and be more effective by using AMTAS.

The biggest drawback to AMTAS (from an audiologist or ENT perspective) is the billing. Currently, there is not a billing code in place for this evaluation. GSI believes that in the next couple of years that will change. In the meantime, the small amount of money that is reimbursed for the air/bone/speech is made up for by the time and other testing that can be performed by the audiologist.

GSI AMTAS is a powerful automated audiometry tool that can benefit a clinic in many ways. For more information, visit www.grason-stadler.com to learn what AMTAS can do for you!

What Are the Differences Between a 2 Channel and 1.5 Channel Audiometer?

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There a few major differences between a two-channel and a one-and-a-half-channel audiometer.  Most of us have experience using a two-channel audiometer like the AudioStar Pro™ (or the GSI 61™) with mirror controls for channel one and channel two.  With a two-channel audiometer, you are able to use channel one to conduct speech audiometry, while you have tone stimulus routed through channel two.  It is also possible to route stimuli from both channels into the same ear for seamless pediatric testing. Both channels have the ability to present and route stimuli to any ear and transducer that is available. Two-channel audiometers are considered type one audiometers and are the industry standard for clinical testing and research.     

With its full routing flexibility, array of sound field options and multiple transducer capabilities, the AudioStar Pro is the answer for complete clinical testing of all age ranges.  Typical practice/test types include hospitals, the VA, those that conduct pediatric and CAPD testing, universities and research facilities, cochlear implant centers and private practices.    

Pello™, GSI’s one-and-a-half channel audiometer, is considered a type two audiometer.  With Pello, channel one becomes the primary stimulus channel and channel two is dedicated as the masking channel.  Channel two routing will always be opposite to channel one, with a few very specific exceptions.  Those exceptions include the Stenger test, and dichotic tests (numbers, words, sentences) found on internal word play lists or external media devices such as CDs.  

Pello is an adaptable audiometer with 4 different license options to consider.  The standard license allows for standard audiometric testing (air, bone, and speech). A license for additional speech testing capabilities, including the Quick SIN and BKB SIN, is available with “Speech Plus.”  Automatic scoring features are also available with this license. Fine frequency testing is available out to 20kHz with the “High Frequency” License, and the TEN test, pediatric noise and classic auditory tests (ABLB, SISI, tone decay) are included with the Special Tests License. Licenses can be selected based on current needs, and additional licenses may be added in the future should your testing protocols change. 

Pello has a significantly smaller footprint than the Audiostar Pro, and easier portability.  It is geared more for testing adult populations, and will typically be used in satellite clinics or private practices with emphasis on dispensing amplification.   For audiologists who test Pediatric populations, Cochlear Implant patients, and CAPD, the AudioStar Pro would be the preferred option over the Pello.

Both of these audiometers are designed smart and built strong. A complete comparison chart is available here.

How Can I Set Up an Automatic Testing Protocol with the GSI TympStar Pro?

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GSI’s Tympstar Pro™ is a powerful and flexible clinical middle-ear analyzer.  Using the included configuration application (config app) can help save time by allowing multiple diagnostic and screening protocols to be created for each testing preference (examiner or patient type).   With the latest software updates to the TympStar Pro (V1.1) and accompanying config app, users will find setting up the custom protocols intuitive and easy to navigate. 

The TympStar Pro comes loaded with default parameters for automated screening and diagnostic tympanometry.  The screening protocol includes a 226Hz tympanogram and Ipsilateral reflex screening (pass / fail) at 1khz.  Additionally, there are two factory auto-sequence diagnostic protocols loaded into the TympStar Pro. Auto Sequence is initialized from the tymp test type screen and includes a tympanogram, Ipsilateral and Contralateral reflex thresholds at 5, 1, 2 and 4K, as well as Reflex Decay at 5 and 1khz.  These protocols are based on CPT codes and cannot be directly modified; however, you are able to copy them and use them as a template for creating your own custom protocols. Each practitioner can modify the protocols to preferred specifications and easily access individual preferences on the device by pressing the “Examiners” button, and then using the touch screen to select the appropriate protocol.

Customizing the TympStar Pro gives the audiologist a consistent “jumping off” point for evaluations; however, we all know things don’t always move along according to plan.  At any point in the evaluation, the examiner is able to take full manual control of the TympStar Pro and modify the parameters or sequence to accommodate individual testing needs.  With GSI’s TympStar Pro, testing and analysis of the middle-ear is efficient and precise.  From integrated and custom protocols, to advanced automatic functionality, evaluations will be quick and accurate. For more TympStar Pro tips and tricks, check out the webinar, Customizing to Enhance Efficiency with GSI TympStar Pro

How Can I Tailor Reports Based on My Testing and My Referral Sources?

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Audiologists work with a variety of referral sources; everything from ENT’s, pediatricians, general practitioners to a wide array of specialty physicians.  Tailoring a report that meets each of the different protocols and referral source preferences can be a time consuming task, and sometimes hard to keep straight.  GSI Suite™ is designed to help manage test and patient data, and can save you time and help keep your reports organized. 

Suite can be used as a stand-alone software or as a module of NOAH and communicates directly with GSI’s audiometers (AudioStar Pro™, Pello™, GSI 39™, GSI 61™), middle ear analyzers (TympStar Pro™, TympStar Classic™, GSI 39), and OAE devices (Corti™). This allows you to consolidate the results of all tests you do into a patient’s electronic file.  Suite will also allow you to pull audiometric and tympanometric data from non-GSI equipment, as long as it communicates with the public databases in NOAH.  Once you have all of your test data transferred to the patient file, you can use one of 20+ GSI designed report templates, or use our powerful report writing tool to customize a report specifically for the types of tests in your protocol, or specific to the needs of your referral source.  Suite lets you organize those reports into a favorites list so that the ones you use most often will be the easiest to access quickly.  You can also use Suite to help cut down on the time it takes to write comments with a tool to manage predefined comments.  Once you have completed the report using Suite, you can save to PDF, JPEG, TIFF or XPS to email, or attach to an EMR.

Suite is powerful tool that can be customized to meet the many reporting demands that come with a busy audiology office.  To find out more, check out our webinar, Get Creative with GSI Suite.

I HAVE AN AUDIOLOGY PRACTICE THAT PRIMARILY DISPENSES HEARING AIDS, HOW CAN AMTAS FLEX HELP MY PRACTICE GROW?

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AMTAS Flex, GSI’s self-directed screening and air conduction threshold audiometer, has multiple intended uses for a dispensing audiology practice.  In general, AMTAS Flex could be used for everything from community outreach efforts, annual audiometric testing, open houses, and walk-ins. The system itself consists of a windows based tablet, which is perfect for data management and NOAH integration, and a set of calibrated Radio Ear DD 450 headphones that are commonly used for extended high frequency testing. This makes the system lightweight and very portable.

COMMUNITY OUTREACH
Many independent practices develop relationships with assisted living organizations and nursing homes to coordinate things like “lunch and learns”, regular on-site hearing aid cleanings, and consultative services. Often times, free hearing screenings at regular intervals are offered where the practitioner spends a couple of hours testing residents' hearing and then advising them. With AMTAS Flex, it is possible to coordinate with the activity director to have the tablet available for a few days in a quiet room where residents could come in to take a quick hearing test at their leisure. The software uses a headphone check (to make sure the transducers are on the appropriate ear), and then instructs that patient on how to take the test with either a video or text instructions on screen. AMTAS Flex can be configured to have identifying demographics entered prior to taking the test. This allows the practitioner to connect with that resident about the results and the follow up services that are recommended. Additionally, AMTAS has an option for tests results to pop up after the test for the patient to review. It has accompanying text to help explain the audiogram and insight into their results in particular. Since AMTAS Flex runs in “kiosk mode”, at the end of test, and after results are displayed (if it is configured to include it), it will return to the start screen. It will not be possible to quit the program or get into the tablet operating system without a user name and password. Results can be printed off as a PDF (a patient report and practitioner report are available), or results can integrated into GSI suite for reporting. AMTAS Flex can also be used at places like health fairs, at bedside in hospitals, in a patient’s home, and in schools. Obviously, this is by no means an exhaustive list. AMTAS Flex can go anywhere!

OFFICE USE
There are numerous applications for AMTAS Flex in outreach efforts, and it has just as many possibilities in the office. Many independent offices are located in areas that have a lot of foot traffic and regularly have people who stop in simply because they happened to walk by. Unfortunately, they don’t always stop by when someone is immediately able to see them. Office staff can be trained to get people started on AMTAS, which can buy time for the practitioner to finish up with their current appointment and possibly squeeze the walk-in patient into the schedule so no opportunities are missed. If you have a satellite office that has front office staff, you can capture threshold or screening test data when the practitioner is not physically there. AMTAS Flex can also come in handy for up to date audiogram testing for current patients. At an annual visit, the patient could use AMTAS Flex while the practitioner checks and cleans their hearing aids, cutting down on time testing, and leaving more time for adjustments and additional counseling. AMTAS Flex can also be used for things like open houses. When targeted marketing is used to encourage people with potential hearing loss to come in and have their hearing tested, there are always those with normal hearing that stop in who are just curious about their hearing status. Starting everyone with a quick self screen can help sort out the normal hearing folks, allowing the practitioner to focus more time and effort on those with hearing loss.

AMTAS Flex is a powerful tool for a private practice, and can be deployed in a variety of creative ways. For more information visit www.grason-stadler.com and find out what AMTAS can do for you! 

DOES THE GSI TYMPSTAR PRO PERFORM EUSTACHIAN TUBE TESTING?

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Yes. Since the TympStar Pro was introduced, it has been capable of assessing Eustachian tube function for both intact and perforated tympanic membranes, with a work-around for performing patulous testing. With the release of TympStar Pro version 1.2, a patulous Eustachian tube test has been added as its own individual protocol with options to customize testing conditions.

Eustachian tube function can be assessed for the intact TM by obtaining a seal and running a series of three pressure sweeps with the patient drinking water between them. The TympStar Pro guides the user through the test sequence with on-screen instructions. A comparison is then made between the three peaks recorded to determine if there is a difference of 15-20 or more daPa between any of them to establish normal function. 

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Cases where the tympanogram tracings are nearly identical would be consistent with Eustachian tube dysfunction.

In cases where a patent PE tube or perforation of the TM has been verified, Eustachian tube function can be established by navigating to the ETF-Perforated test protocol. In this test, pressure is now graphed on the y axis, with time on the x axis. Options for recording out to 60 seconds are available in the test setting menu. As with the intact protocol, the TympStar Pro guides the user through the testing sequence. Pressure is established and the patient is instructed to drink water at intervals, while watching for a tracing that looks like a set of stairs to establish normal function.

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If the pressure was unchanged during recording it would be consistent with abnormal Eustachian tube function. 

With the recent release of firmware version 1.2, the TympStar Pro now has a dedicated test protocol for patulous Eustachian tube testing. Prior to V1.2, TympStar Pro users would navigate to reflex decay testing with contralateral stimulus selected and assess waveform morphology as the patient did a variety of respiration exercises. The contralateral probe is unplugged and/or not placed in the patient’s ear during testing, while the probe is used to establish a seal and record deflections at the level of the TM.

With this new dedicated test protocol, users will have the ability to record deflections under a variety of test conditions including Breathing Normal, Holding Breath, Breathing with one Nostril Closed, and Forced Respirations. These conditions can be customized using the TympStar Pro Configuration Application to suit individual preferences. Up to eight tracings can be recorded, with the ability to record more than one tracing under the same testing condition. Time base options extend out to 60 seconds in 15 second intervals.

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Normal function is confirmed by very little change in deflection while the patient is performing the desired respiration during recording.  

A rhythmic series of deflections recorded during forced respirations for example, as pictured below, would be consistent with a patulous Eustachian tube.

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IS THERE A QUICK WAY TO ASSESS SPEECH-IN-NOISE FOR CHILDREN?

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The BKB-SIN is integrated on the GSI AudioStar Pro and the GSI Pello (with the Speech Plus license). The BKB-SIN is a speech-in-noise test very similar to the QuickSIN. Normative data was collected on normal hearing adults and children, using a 70 dBHl presentation level, presented binaurally. A 50 dBHL presentation level was used on patients with cochlear implants. To perform the test, press the “More” button and select “BKB-SIN”. On the display menu, select the age range of your patient to access the appropriate normative dataset. The age ranges are 5-6, 7-10, 11-14, and 15 & up (for adults). Present the sentences and score in the same way as QuickSIN. Store the results to obtain the SNR lost. The BKB-SIN can be administered to adults that might have difficulty with the longer sentences used with the QuickSIN.