Post on 03-Jul-2020
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HAAP Workshop #4LESSONS 13 - 16
Learning Objectives Identify the parts of an otoscope
Demonstrate visual inspections of the ear canal using appropriate techniques
Perform correct bracing for otoscopy, probe tube insertion, otoblock placement, and impression making.
Identify the parts of an audiometer, and demonstrate and discuss the use of each component
Draw an audiogram and explain how it is used to record hearing levels
Categorize hearing levels by degree of hearing loss
Explain how audiometric data are used by the physician and by the hearing aid specialist
Relate threshold on the “Average Auditory Area of a Normal Ear” from Lesson 4 Psychoacoustics to audiometric zero
Compare and contrast the different audiometric transducers
Describe the daily biological check and compare this with electroacoustic calibration
Instruct the patient/client on the listening task and response mode
Demonstrate proper placement of air conduction transducers
Demonstrate proper placement of the bone oscillator
Accurately determine thresholds
Document accurately the pure tone air conduction and bone conduction thresholds for each ear
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Lesson 13 – Otoscopy & Bracing
Otoscopy
visual examination of the auditory canal and the eardrum with an otoscope.
The act of using an otoscope to perform a visual examination of the pinna, mastoid process, ear canal, and tympanic membrane.
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The Otoscope
“A device that is specifically designed to provide illuminated magnification of the ear canal and tympanic membrane, and as such, allows you to see what you need to see in order to do your job” (Bankaitis, 2011).
Types of Otoscopes:
Full-Size
Video
Pocket Otoscopes
Designed to be carried in the pocket of a lab coat.
Smaller and Lighter than full sized otoscopes.
Most use disposable batteries that are in the handle of the otoscope.
Limitation - does not offer interchangeable parts, unable to upgrade technology
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Full-Size Otoscopes
Interchangeable heads and handles
Welch Allyn’s “interlocking tool” technology
Allows for the use of new technology as it is developed
Rechargeable batteries
Video Otoscopes
Interfaces with a monitor or screen
Image is transmitted directly from the otoscope to the video output
Advantage – projection of the TM in a larger manner, offering a more detailed view of the structures
Ability to capture and print images
Direction matters
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Parts of the Otoscope
Handles/Batteries
Head
Light Source
On/Off Switch
Otoscope Handles & Batteries
Power Source for Otoscope
Holds batteries
Wall Plug for rechargeable options
Batteries:
NiCd (Nickel Cadmium)
Memory Effect
Heavy
Nickel Metal
Approx. 30% more capacity than NiCad
Lithium Ion
Highest capacity
Retain charge approx. 2 times
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Otoscope Heads Standard or Diagnostic
Wide angle-viewing lens
Usually 2.2 times magnification
MacroView
Twice the field of view
Approx. 30% more magnification than Standard heads
Focus
Speculum ejection
Pneumatic
Designed to allow observation of TM movement
Allows for a insufflator bulb to introduce puffs of air into the ear
Operating
Open-System design
Removal of speculum allows for insertion of instruments into the ear canal
Video
No eyepiece
Cable to connect to monitor
Otoscope Light Sources Light source is in the form of a bulb
Incandescent
Old school light bulb
Short life span
Fade in strength over time
Halogen
Bulb is filled with a halogen gas
Run hotter than incandescent
Xenon
Generate electrical discharge between two electrodes
LED
White in color
Not pure white, more of a whitish-blue color
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Otoscope Light Technology
Fiber Optic
Light is directed into the ear canal from the otoscope head via fiber optic cables.
Allows light to reach destination in a highly concentrated manner.
Enhanced quality of light and improved visibility and clarity.
Non-Fiber Optic
Illumination of ear canal by directing the light emitted by the bulb directly from the otoscope head into the ear canal.
Bulb will be visible through the eye piece.
Otoscope On/Off Switch
Generally on the handle.
Slider
Push and Rotate
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Why do we perform otoscopy?
Otoscopy will reveal if there are any conditions that require medical referral; If found STOP the process and make the referral
To inspect the ear canal for any obvious inflammation, growths, foreign objects, or excessive cerumen.
Inspect the back of the pinna as well for any evidence of surgery that may not be reported on the case history - look for any sores or lesions on the pinna itself, since it must be held while examining the ear canal
Verify that the ear canal is clear and the TM is healthy
Note any unusual landmarks, visible cartilage movement, etc.
When do we perform otoscopy? Before hearing test
When preparing to make an ear impression
Immediately after removing an ear impression and re-inspect the ear
Use to verify real ear probe tube placement (end should be 3-5mm from TM)
Before fitting hearing instruments
At follow-up visits
Annual retest
Use to see SNs, debris in receiver and/or mics
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Infection Control for OtoscopyWhat equipment and parts of myself will touch my client?
Otoscope
Specula
Hands
For all equipment that will be coming into contact with the client: use a germicidal wipe (such as the Sani-Cloth) to wipe down your otoscope and specula.
Remember to allow the equipment to Air Dry!
Be mindful of the possibility of cross contamination. Always use a new speculum for each ear.
Infection Control for Otoscopy
Hand Washing:
Apply liquid hand soap
Rub hands together thoroughly for at least 20 seconds
including the areas
Between fingers
Backs of hands
Fingernails
Rinse with water
Dry hands with disposable paper towel.
Hand sanitizer is accepted as “hand washing”
Apply appropriate amount of degermer (Approx. a quarter size amount)
Rub hands together as when washing hands
Rub until hands are dry
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Infection Control for Otoscopy
Hand Washing
Hand Washing
Don Gloves Clean Otoscope Remove Gloves
Don Gloves Perform Otoscopy
Otoscopy – Safe Support Techniques
Safe Support or Bridge and Brace techniques are an important part of member safety.
Costco Hearing Aid Centers has a culture of Best Practices
IHS Clinical Practice Guideline: Bridge-and-Brace Technique for Patient Safety
https://www.ihsinfo.org/IhsV2/professional-development/pdf/2017/IHS%20Clinical%20Practice%20Guideline%20on%20Bridge-and-Brace%20Technique.pdf
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Otoscopy – Safe Support Techniques
Performing Otoscopy
Step 1: Non-tool hand is used to pull up and back on the pinna to straighten the canal and improve view of the canal and TM
Step 2: Tool hand braces head or completes a bridge to non-tool hand
Step 3: Speculum attached to otoscope approaches and then enters ear canal
Step 4: Verify that the ear canal (Scratches, blood, redness, and excessive wetness are all signs of an abnormality) and the TM is healthy (pearly gray & cone of light)
Step 5: Remove first speculum and place clean speculum on otoscope
Step 6: Repeat steps above for 2nd ear.
(Picture made without gloves to better show bracing.)
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Anatomy & Characteristics of the Ear
Before looking into the ear, it is important to carefully
look at the outer ear (Pinna) and the mastoid process
behind the ear.
Signs of previous surgery or other malformation should
be noted.
Anatomy & Characteristics of the Ear
Once you have evaluated the pinna and mastoid process you
will place your otoscope into the client’s ear and evaluate
the ear canal.
The ear canal should be smooth and pinkish in
appearance.
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Otoscopy – Abnormal Ear Canals
Fungal Infection Exostosis Foreign Object
Cerumen Cerumen
Anatomy & Characteristics of the Ear
Once you have evaluated the ear canal it is time to evaluate the TM.
The TM should be light gray and shiny. The cone of light should be clearly visible
on the bottom half.
Note the other landmarks present such as the malleus and annular (tympanic) ring.
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Otoscopy – Abnormal TM’s
Perforation PE Tube
Otitis Media Cholesteatoma
Following Otoscopy
Step 1: Remove 2nd speculum from otoscope and dispose
Step 2: Remove and dispose of gloves
Step 3: Clean hands with soap and water or hand sanitizer
Step 4: Share otoscopy findings with the member: professional and do not diagnose
“Your ear canal is clear and I can see all of your ear drum.”
“There appears to be a build-up of wax in your ear canals and I will not be able conduct your hearing test until it is removed.”
Step 5: Make medical referral based on otoscopy as needed
Abnormality? Foreign Body? Obstruction?
Refer???
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Lesson 14Introduction to Audiometric Evaluation
Audiometric Evaluation
A painless, noninvasive test to measure a person’s ability to hear different sounds, pitches, or frequencies.
Pure Tone Audiometry measures the softest sounds that a person can hear.
Word recognition or Speech discrimination assesses a person's ability to understand speech.
(Lockhart, 2016)
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Audiometric Evaluation
Two ways sound travels to the cochlea:
Air Conduction
Acoustic energy from the atmosphere through the ear canal, middle ear, and to the inner ear
Bone Conduction
Bypasses the middle ear and stimulates the inner ear through vibrations
The Measurement of Hearing
The purpose of an audiometric evaluation is to measure an individual’s hearing levels at discrete frequencies and also with speech as a stimulus.
The procedure measures the sensitivity of a person’s hearing.
Results are compared that of the average normal hearing individual.
Information is displayed on an Audiogram
Application of Data:
Referrals
Hearing Management Program
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The Audiogram
Pure Tone Air and Bone Conduction thresholds are recorded on a graph called an audiogram.
The Y-axis represents intensity in decibels hearing level (dB HL).
The X-axis represents the frequency in Hertz (Hz).
Low to High 125 Hz to 8K Hz
The Audiogram
Octave
A mathematical doubling of frequency.
250 Hz to 500 Hz is an octave.
Inter-octave (Half-octaves)
500 Hz to 750 Hz
Note that an inter-octave to an inter-octave makes an octave.
1K dividing line
High & Low Freq.
Normal Hearing
20 dB HL and below
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Audiometric Zero
Audiometric Zero = 0 dB HL
Softest intensity the average individual can detect
The softest intensity in dB SPL is different at each freq.
Normalization
The process of converting the dB SPL in a normal-hearing population to 0 dB HL.
Straight lines rather than curves.
Audiometric Symbols
Indicate Test Ear (TE) transducer used and if masking was employed.
The appropriate symbol is placed on the audiogram at the intersection of the frequency tested and the intensity in dB HL.
Thresholds are the measured intensity at which the member responds to 50% of the stimulus presentations.
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Degrees of Hearing Loss
Terms to be clearly defined for proper understanding and communication of audiometric results:
Normal Hearing (0 to 20 dB HL) – Intensity range defined as normal audibility
Mild Hearing Loss (20 – 40 dB HL)
Moderate Hearing Loss (40 – 70 dB HL)
Severe Hearing Loss (70 – 90 dB HL)
Profound Hearing Loss (90 dB HL and greater)
Elevated Hearing Thresholds – thresholds that are worse than the normal range or that are worse than previously tested.
The Test Environment
Best performed in a sound controlled environment.
In every environment, take precautions to ensure that the test area is as quiet as possible.
Turn off and/or remove any competing sound sources to optimize the validity of your test results.
Ambient noise can be measured with a sound level meter.
Typical ambient noise level allowed for hearing testing is 55 dB SPL or less.
Most critical for BC testing
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Audiometer
An audiometer is the tool used to measure hearing.
Computer-based or free standing
Audiometer
It is your responsibility to be completely familiar with the options and functions of every control/switch on your audiometer.
Consult the manufacturer’s user manual.
Job Aids on the Intranet
Aurical – The Cube.
Common Features/Functions:
Transducers:
Insert Earphones
Supra-aural Earphones (and/or Circumaural earphones)
Bone Conduction Oscillator
Sound field Speakers
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Audiometer Common Features/Functions:
Transducer Selectors:
Selects the appropriate transducer
Right/Left/Both Ears
Freq. Selector
Interrupter Switch:
Stimulus Type Selector:
Pure Tones
Warble Tones
Pulsed or Continuous tones
Masking Noise
Narrow Band Noise
Speech Nosie
Microphone
Speech Inputs:
CD
WAV Files
Audiometer
Common Features/Functions:
Intensity Control (Attenuator)
A VU Meter:
To calibrate recorded speech
Monitored Live Voice Testing
Talk-Over system
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Electroacoustic Calibration
Audiometric equipment must be calibrated at least once a year.
Calibration measures the performance of the audiometer and compares that to a prevailing, recognized electroacoustic standard.
Ensures accuracy of test signals in terms of freq. and intensity.
Each transducer must be calibrated to the audiometer it is used on.
Test environments should be calibrated as well to ensure that they meet ambient noise standards.
Daily Biological Check
Despite the fact that your audiometer is calibrated annually, it is important to verify on a daily basis the function of the various components of the audiometer.
This should be documented
Turn on audiometer and wait one minute.
Listen to the signal at different settings through each transducer.
Check the power, attenuator, earphone, and bone vibrator cords for signs of wear or cracking.
Listen to a signal through the transducer and move the cord around – defective cords will produce static or the tone will be intermittent.
Check the audiometer controls to be certain they are functioning properly.
Listen for audible mechanical clicks through the earphone when the controls are manipulated.
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Daily Biological Check
Listen to the output at both a moderate (60 dB HL) level and one below the threshold of hearing.
If clicks are present – member may respond to those rather than the tone.
Listen for static at high intensity levels, both when a stimulus signal is present and when it is absent.
Static or buzzing at levels below 60 dB HL should not be audible.
Listen to the signal while moving from maximum to minimal levels to ensure the smooth transition from one intensity level to the next.
Move through the frequencies and listen for distinct changes from one to another.
Be aware of your own thresholds to ensure the output is accurate.
If threshold appears to be erroneous, the output levels should be checked electronically.
Daily Biological Check
If the member reports other irregularities, or if audiometric data irregularities are observed, stop the test and immediately perform a biological check of the equipment.
Replace defective equipment when needed.
IS Service Desk – 425-313-8001
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Daily Biological Check
Play 1K Hz Calibration tone of speech stimulus
Verify that the intensity is to 0 dB or green on VU meter
If not at 0 dB adjust sensitivity of stimulus so that the calibration tone is at 0 dB.
Tympanometry (more in Lesson 23)
Measures middle ear function
Measured with a tympanometer
Results are displayed on a graph
Normal Middle Ear Function = sensory/neural hearing loss
Abnormal Middle Ear Function = related to the presence of an air-bone gap
Acoustic Reflex
Measures the activity of the stapedius muscle in response to sound
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Lesson 15Pure Tone Air Conduction Audiometry
Audiometric Evaluation
Is dependent on accurate threshold
determination
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Audiometric Symbols
Uniform World Wide
Color Code:
Red = Right
Blue = Left
Symbol placed at the intersection of freq. and intensity that represents the threshold
If there is No Response at the intensity limit of the audiometer – use the appropriate symbol with a downward-pointing arrow to indicate that the tone was not heard
For PT UCL’s this will indicate that the member did not respond that the tone was uncomfortable
Connect the symbols with a straight line for each ear
AC Threshold Determination
Threshold determination is a precise procedure that has validity, reliability, and is standardized among all hearing healthcare professionals.
The procedure is valid in that hearing sensitivity is measured.
The extremely high test/retest reliability results from employing a consistent procedure that is globally endorsed and through the use of equipment that meets calibration standards.
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Purposes & Procedures for PT AC Testing
What is the purpose of performing Pure Tone Air Conduction?
To determine the softest sound a member can hear 50% of the time.
What is the procedure for performing Pure Tone Air Conduction testing?
Hughson-Westlake Ascending/Descending Technique
5 dB increases in presentation level / 10 dB decreases in presentation level .
Ascend = increases (louder sound) Descend = decreases (softer sound)
Why insert earphones are recommended?
Improved interaural attenuation relative to supra- and circumaural earphones
Better isolation from ambient noise
Improved infection control (disposable, one time use tips)
Better comfort than supra- and circumaural earphones
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Member Instructions
Instructions Matter!!!!!
Member Instructions
“You and I are going to measure the softest sounds that you can hear. Every time you hear beeping tones, push the response button. Respond no matter how soft or far away the tones become. There will be a pause or break, then the beeping tones will start new again. Push the button each time you hear the beeping tones start new again. We’ll start with your right (or left) ear. Do you have any questions?”
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AC Threshold Determination1. Follow appropriate equipment sanitizing and infection control guidelines.
2. Instruct the member
3. Place the AC transducer in the ear canal (over the pinna if headphones) and check for proper placement
4. Present 1000 Hz tone at 40 dB. If no response, increase in 20 dB steps until there is a response. Each tone should be presented about 2 seconds. Vary your timing.
5. Once there is a response, descend in 10 dB steps until there is no longer a response.
6. Increase intensity level in 5 dB steps until there is a response (ascending technique)
7. Continue ascending/descending technique until the member responds to 2 out of 4 opportunities to respond at the lowest presentation level on the ascending runs.
8. Record the threshold on the audiogram using the appropriate symbol
9. Test all frequencies using this technique
10. Repeat procedure for the other ear.
*It is important to vary the time between presentations*
Obtaining Threshold - Example #1
Start the presentation level at 40 dB.
If client does not respond, increase to 60 dB and present again.
When client responds, decrease the presentation level by 10 dB
Continue this until the client does not respond.
At the point that the client does not respond, increase the presentation level in 5 dB steps until they respond again.
Once they respond again repeat the ascend 5 dB/ descend 10 dB “bracketing” until they get 2 out of 4 responses at the same lowest intensity level.
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Obtaining Threshold - Example #2
Start the presentation level at 40 dB.
If client does not respond, increase to 60 dB and present again.
When client responds, decrease the presentation level by 10 dB
Continue this until the client does not respond.
At the point that the client does not respond, increase the presentation level in 5 dB steps until they respond again.
Once they respond again repeat the ascend 5 dB/ descend 10 dB “bracketing” until they get 2 out of 4 responses at the lowest intensity level on the ascending runs
What if they never respond?
Is the equipment working??? Do they understand the task?
If there is no response (NR) at the intensity limit of the equipment for that frequency use the appropriate symbol with a downward-pointing arrow to indicate that you tested this intensity but the tone was not heard.
Lines are used to connect thresholds (that are heard). Do not connect symbols that indicate no response (NR).
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Test Frequencies
Always start with 1000 Hz first, then remaining test frequencies.
1000, 1500, 2000, 3000, 4000, 6000, 8000, 1000, 500, 250 Hz
Best Practice & Costco: 250, 500, (750), 1000, 1500, 2000, 3000, 4000, 6000, 8000 Hz
Inter-octaves must be tested when there is a difference of 20 dB or greater between adjacent octaves.
Retesting 1K Hz is essential to establishing response consistency and threshold reliability. The threshold must be +/-5 dB of the initial threshold at 1K Hz.
If not, stop testing, re-instruct the member, and restart the test (retest everything that’s been tested).
May need to also verify transducer placement.
Lesson 16Pure Tone Bone Conduction Audiometry
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AC Testing vs. BC testing
The difference is the mode of transmission of the stimuli to the inner ear and the transducer used.
Threshold determination is the SAME!
BC Testing
Bypasses the outer and middle ears and tests the cochlea directly by vibrating the skull.
There is no detectable difference in the sound quality or clarity for stimuli delivered by AC or by BC.
Presentation Order:
Same as for AC
1K, 2K, 3K, 4K, 500 Hz
Audiometer limits for BC testing will be lower than for AC
Output level produced by the bone oscillator may result in a tactile sensation (vibrotactile response) at high intensity levels.
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Placement of BC Oscillator
The BC Oscillator is slightly concave or has a raised circle on the side lying against the skull.
The headband applies pressure to the oscillator holding it firmly against the most prominent point on the mastoid, the raised bone behind the ear.
A loose headband results in inaccurate thresholds.
The member must not hold the oscillator in place
Must NOT touch the pinna
Vibrations will be set up in the ear canal that will result in invalid threshold measurements.
Member must remove glasses prior to oscillator placement.
Placement of BC Oscillator
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Member Instructions
Instructions Matter!!!!!
Member Instructions
“You and I are going to repeat the hearing measurement using a different device, but you’ll still be hearing beeping tones. As before, push the button every time you hear the beeping tones. No matter how soft or far away the beeping tones sound. We’ll start with your right (or left) ear. Do you have any questions?”
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BC Threshold Determination1. Follow appropriate equipment sanitizing and infection control guidelines
2. Instruct the member
3. Place the BC oscillator on the most prominent area of the mastoid bone behind the pinna and check for proper placement
4. Present a 1000 Hz tone at a level 20 dB (10 dB ok too) louder than the AC threshold of the better hearing ear (explained further in Lesson 18). If NR increase in 20 dB increments until there is a response.
5. Once there is a response, descend in 10 dB steps until there is no longer a response.
6. Increase intensity level in 5 dB steps until there is a response (ascending technique)
7. Continue ascending/descending technique until the member responds to 2 out of 4 opportunities to respond at the lowest presentation level on the ascending runs.
8. Record the threshold on the audiogram using the appropriate symbol with the open side close to but not in contact with the vertical frequency line
9. Test all frequencies using this technique
10. Repeat procedure for the other ear.
More about BC thresholds Physiologically BC thresholds cannot be worse than AC thresholds...but it
happens.
Check placement of BC oscillator
Additional ambient noise in room
Might be due to thickness of skull, damage to part of skull that restricts proper vibration, or excess fat covering the bones of the skull
What to do? ALWAYS record the measured threshold - don’t assume they are identical to AC thresholds.
Masking is needed if the BC is better than the AC threshold by 15 dB or more (Lesson 18)
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Bone Conduction:Do I Need to Test the Second Ear?
When is testing of the second ear needed?
When there is a difference of 15 dB or more between the measured BC thresholds of the TE and the measured AC thresholds of the Non-TE.
Only the freq. with the gap must be tested.
All second ear BC scores must be masked (Lesson 18).
Bone Conduction:Do I Need to Test the Second Ear?
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Bone Conduction:Do I Need to Test the Second Ear?
Bone Conduction:Do I Need to Test the Second Ear?
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Bone Conduction:Do I Need to Test the Second Ear?
Bone Conduction:Do I Need to Test the Second Ear?
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Bone Conduction:Do I Need to Test the Second Ear?
Bone Conduction:Do I Need to Test the Second Ear?
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Resources ADC Diagnostix 5111N 2.5v Pocket Otoscope. (n.d.). Retrieved October 24, 2017, from
https://www.floridamedicalequipment.com/products/adc-diagnostix-5111n-2-5v-pocket-otoscope
Anatomy Atlases: Anatomy of First Aid: A Case Study Approach: The External Ear. (n.d.). Retrieved October 30, 2017, from http://www.anatomyatlases.org/firstaid/Otoscopy.shtml
Bankaitis, A. U. (2011, May 9). Otoscopes A. U. Bankaitis. Retrieved October 24, 2017, from https://www.audiologyonline.com/articles/otoscopes-833https://www.merriam-webster.com/medical/otoscopy
Cholesteatoma and mastoid surgery JW Fairley Consultant ENT Surgeon Kent UK. (n.d.). Retrieved October 30, 2017, from http://entkent.com/cholesteatoma-and-mastoid-surgery/
Clinical Practice Guideline Bridge-and-Brace Technique for Patient Safety. (2015). Retrieved October 30, 2017, from https://www.ihsinfo.org/IhsV2/professional-development/pdf/2017/IHS%20Clinical%20Practice%20Guideline%20on%20Bridge-and-Brace%20Technique.pdf
Degrees of Hearing Loss. (n.d.). Retrieved October 30, 2017, from http://hearinghealthcare.ie/degrees-hearing-loss/
Lockhart, MA, CCC-A, S. (Ed.). (2016, February). Hearing (audiometry) test. Retrieved October 30, 2017, from http://www.mayfieldclinic.com/PE-hearing.htm
Oaktree Products. (n.d.). Retrieved October 24, 2017, from https://www.oaktreeproducts.com/welch-allyn-3-5v-halogen-diagnostic-otoscope-complete-set-25020c
Otoscopy Medical Definition. (n.d.). Retrieved October 24, 2017, from https://www.merriam-webster.com/medical/otoscopy
Video otoscope for quality counseling and care. (n.d.). Retrieved October 24, 2017, from http://www.otometrics.com/solutions/hearing-aid-fitting-system-aurical/video-otoscope-aurical-otocam