Diagnosis of Middle Ear Disorders Using Wideband Energy

Diagnosis of Middle Ear Disorders Using Wideband Energy CLINICAL DIAGNOSIS OF MIDDLE EAR DISORDERSÂ  USING WIDEBAND ENERGY REFLECTANCE A Doctoral Thesis Presented to The Graduate College of Missouri State University In Partial Fulfillment Of the Requirements for the Degree Copyright 2008 by [Alaaeldin Elsayed] CLINICAL DIAGNOSIS OF MIDDLE EAR DISORDERS USING WIDEBAND ENERGY REFLECTANCE Communication Sciences and Disorders ABSTRACT Accurate diagnosis of middle ear disorders in adults and children is a challenging task because of the complexity of disorders. Wideband energy reflectance (WBER) technique provides simplicity and accuracy in diagnosing middle ear disorders across wide frequency range. This research is expanding the studies of WBER to investigate the middle ear function in normal and pathological conditions of the middle ear in adults and children. Findings showed that WBER not only can distinguish abnormal from normal middle ear function but also can characterize different middle ear disorders in adults and children. Several specific WBER patterns were established in a variety of middle ear disorders among adults and children that will help in early diagnosis of such pathologies. The ER pattern was including significant higher ER in the children control group than the adult control group at 0.5 kHz and 1 kHz, abnormally high or shallower in otosclerotic ears, abnormally low in ears with TM perforati on and abnormally low ER with deep notch in ears with hypermobile TM. In presence of negative middle-ear pressure, elevated ER at ambient pressure is also expected. Results also showed that standard tympanometry was less sensitive in diagnosing middle ear disorders when compared to WBER especially in otosclerotic cases. Further studies are still required to validate the clinical use of ER in larger number of individuals with confirmed middle ear disorders. KEYWORDS: wideband energy reflectance, otosclerosis, otitis media with effusion, eustachian tube dysfunction, tympanometry. This abstract is approved as to form and content Wafaa Kaf, MD, MS, PhD Chairperson, Advisory Committee Missouri State Universit CLINICAL DIAGNOSIS OF MIDDLE EAR DISORDERS USING WIDEBAND ENERGY REFLECTANCETITLE OF THESIS By Alaaeldin Elsayed A Doctoral Thesis Submitted to the Graduate College Of Missouri State University In Partial Fulfillment of the Requirements For the Degree of Doctorate, Audiology ACKNOWLEDGEMENTS I would like to thank so many who encouraged me along this dissertation. First and foremost, I am thankful to God for all his blessings. I am very grateful to Dr. Neil DiSarno for all his support and kind caring throughout my graduate school education. Further, I am indeed grateful to Dr. Wafaa Kaf, my doctoral advisor, for her guidance, encouragement, and support throughout this work. In addition, I would like to show appreciation to my committee members for their helpful comments and direction for this dissertation. Special thanks also to the faculty and secretarial staff of the Department of Communication Science and Disorders. Thanks to Dr. Walid Albohy, and Dr. Ahmad Alhag for their help in collecting data for this study. Special thanks and appreciation for my wife Enass and my children Mohamed and Nada, your love and delightful spirits has kept me going forward. DEDICATION This work is dedicated To My dear parents, My beloved Enass, Mohamed, and Nada, Who made all of this possible, for their endless encouragement and patience. REVIEW OF THE LITERATURE Hearing mechanism and the middle ear Sound transmission. The hearing process includes the transmission of sound energy through the auditory canal to the tympanic membrane (TM). This sound energy results in vibration of the TM with an equal atmospheric pressure on both sides of the TM. The mechanical vibrations are, then, transmitted from the TM to the air-filled middle ear space and ossicles (malleus, incus and stapes), which further amplify the sound energy and transmit it, via oval window, to the fluid-filled inner ear. At the inner ear, the mechanical vibration is converted into electric waves and transmitted as nerve signals that are interpreted by the brain as sounds. Mechanical properties of middle ear. The middle ear is an air-filled cavity that connects the outer ear canal to the labyrinth of the inner ear. This connection is established through the middle ear ossicels-malleus, incus and stapes. The malleus is attached to the TM by its handle; the incus bone lies in the middle between the malleus and the stapes while the footplate of the stapes is attached to the oval window of the inner ear. The middle ear cavity is also connected to the nasopharyngeal cavity through the Eustachian tube (Musiek and Baran, 2007). The Eustachian tube is important in maintaining an equal pressure on both sides of the TM and ventilation of the middle ear cavity. The tube also drain the middle ear into the nasopharynx (Channell, 2008). Figure 1 demonstrates schematic representation of the anatomy of the ear. When the sound pressure moves the TM the mallus and incus consequently move together as one unit around a pivotal point. In doing so, both bones act as a lever; the lever arm formed by the manubrium of the malleus is slightly longer than that of the incus (about 1:1.3 ratio). In turn, the rotation of the long process of the incus around its pivotal point leads to the back and forth (piston-like) movement of the stapes footplate in the oval window of the inner ear. The movement of the stapes footplate is directly proportional to the frequency and amplitude of the sound waves. This route of sound transmission is called the ossicular route. Acoustic route is another way of transmitting sound waves directly from the TM and the oval window to the cochlea. The direct acoustic stimulation of the oval and round windows, by passing the ossicles (acoustic route), plays a part in sound transmission In normal ears both routs are functioning but the upper hand is for the ossicular route (Voss, Ro sowski, Merchant, and Peake, 2007). From the above information, it appears that the middle ear plays important role in the hearing process. The middle ear mainly helps to correct the impedance mismatching between the air-filled middle ear and the fluid-filled cochlea and to transform the acoustic energy at the TM into mechanical energy that will eventually be transferred to the inner ear. The Impedance matching function of the middle ear is carried out by three mechanisms: the lever action of the ossicles of the middle ear, the area difference between the TM and the area of the stapes footplate, and the buckling of the curved TM. An outcome of these mechanisms is that the vibration obtained from the large area of the TM is focused to the much smaller oval window of the inner ear (21:1 area ratio), resulting in a differential pressure between the oval window connected to scala vestibuli and the round window connected to the scala tympani. This pressure differential is critical in maximizing the flow of sound energy and activation of the cochlear structures (Cummings, 2004). Accordingly, middle ear disorders are expected to affect the normal transmission of sound, resulting in conductive hearing loss (discussed below). An illustration of the anatomical structure of External, Middle and Inner ear. Modified from Medline Plus Medical Encyclopedia: Ear anatomy. In addition to correcting the impedance mismatch between the air-filled middle ear and the fluid-filled cochlea, the middle ear also protects the inner ear from loud sound via the acoustic reflex. This mainly occurs as a result of reflex contraction of the two middle ear muscles, the tensor tympani and the stapedius, in response to loud sound leading to increased stiffness of the oscicular chain, and hence diminished sound transmission (Allen, Jeng, and Levitt, 2005). Given that the acoustic reflex mainly decreases the transmission of low frequency sounds thus, it improves speech discrimination in loud, low-frequency noisy environments. Unfortunately, the reflex does not protect the ear against impulsive sounds as gun shots due to prolonged latency in muscle contraction (Lynch, Peake, and Rosowski, 1994). Pathophysiology of middle ear disorders To further understand the pathology of middle ear disorders, it is important to consider the middle ear system as a vibrating mechanical system. Such a system is composed of three elements: mass, stiffness, and friction. When the mass and stiffness components are equal, so-called resonant frequency of the middle ear, it is expected that the amplitude of vibration of the middle ear is at maximum. On the other hand, when there is an increase in the mass without change in stiffness or friction the resonant frequency is lowered and the amplitude of vibration is lowered at frequencies above the resonant frequency. In contrast, when there is an increase in the stiffness component of the middle ear the resonant frequency increases and the magnitude of vibration reduces for frequencies below the resonant frequency (Roeser, Valente, and Hosford-Dunn, 2000). Middle Ear Disorders are a variable group of pathological conditions that includes, for example, middle ear infection (Otitis Media with Effusion: OME), chronic otitis media with perforation of the TM, Eustachian Tube Dysfunction (ETD), ossicular disruption or dislocation and or/ otosclerosis. Such middle ear disorders may lead to conductive hearing loss due to their effects on mass, stiffness, and/or friction elements of the normal middle ear. Perforated TM is induced by chronic otitis media or trauma to the ear. As a result, the normal structure and the function of the TM are altered. The degree of hearing loss is directly related to the size of the perforation (Voss et al., 2000) The perforation leads to equalization of pressure on both sides of the membrane which consequently leads to disturbance of the ossicular route and hearing loss (Voss et al., 2000). Normally the inward movement of the stapes is followed by an outward movement at the round window (push and pull mechanism). In the presence of TM perforation, this push and pull mechanism of the ossicles is disturbed and the sound waves energy reaching the oval window is reduced. Ossicular dislocation usually follows a violent trauma to head or as a consequence of chronic otitis media and/or cholesteatoma. Disarticulation of the incudostapedial joint due to traffic accident was the most common pathlogy of ossicular disruption(Yetiser s, 2008). With the exception disruption due to chronic otitis media, the dislocation of the ossicles may or may not be accompanied by TM rupture. The injury results in loss of the impedance matching mechanism of the middle ear and a conductive hearing loss of about 40-60 dB (Merchant, Ravicz, and Rosowski, 1997). Otosclerosis is a progressive disease of bone resorption and reformation that affects bones derived from the otic capsule. The etiology of the disease is not fully understood. The disease leads to osteodystrophy and fixation of the stapes in the oval window. Among the most accepted eatiological factors is genetic factors and viral infection. Otosclerosis is characterized clinically by progressive hearing loss, tinnitus and vertigo (Menger and Tange, 2003). Both conductive and sensory neural hearing loss has been reported in otosclerotic patients (Ramsay and Linthicum, 1994). Otosclerosis may affect the cochlea and other parts of the labyrinth as well (Menger and Tange, 2003). The resulting fixation of the footplate of the stapes leads to increased stiffness of the ossicular chain early in the disease. Increased stiffness of the middle ear affects the transmission of low frequency sounds. At later stages of the disease, the bone starts to grow adding a mass effect. This increase in ma ss of the middle ear affects the transmission of high frequency sounds as well (Shahnaz and Polka, 1997). More disorders include inflammatory conditions of the middle ear such as otitis media (OM) and media with effusion (OME), chronic otitis media, and cholesteatoma. OM usually results from upper respiratory infections or allergies that lead to obstruction of the Eustachian tube (Channell, 2008). As a consequence, negative pressure develops in the middle ear resulting in otalgia due to stretching of the TM and mild hearing loss due to the increased stiffness of middle ear transmitting mechanism. If the negative pressure inside the middle ear is not relieved, a transudate accumulates inside the middle ear. The condition is then called OME. The hearing is further affected by the mass- friction effect. The degree of hearing loss depends on the type and the amount of the transudate. The combination of fluid and pressure in the middle ear was found to reduce TM movement at the umbo by 17 dB over the auditory frequency range (Dai, Wood, and Gan, 2008). Middle ear function measures Tuning fork testing. The tuning fork testing is one of the traditionally used qualitative hearing tests. They are used to examine the conductive component of hearing loss (external or middle ear pathology). Several tests have been descried including: Rinne, Schwabach, Bing, and Weber tests. For Rinne test, the vibrating tuning fork is held against the skull, usually on the mastoid process bone behind the ear to cause vibrations through the bones of the skull and inner ear. To cause vibrations in the air next to the ear, the vibrating fork is then held next to, but not touching, the ear. In the test the patient is asked to determine if the sound heard through the bone is louder or that heard through the air. The results of the test are categorized as positive, negative, or equivocal. A negative Rinne test is indicated when the sound is heard louder by bone conduction than by air conduction which suggests a conductive component of the hearing loss. Although Rinne test was found to be highly specific in one study; the same author has suggested that it should be carried out only as a pack up test for pure tone audiometry in audiological evaluation of hearing loss (Browning and Swan, 1988; Thijs and Leffers, 1989). The Schwabach tuning fork test compares patients bone conduc tion to the normal examiner. Bing tuning fork tests determines the presence or absence of the occlusion effect. Weber tunning fork test determines the type of a unilateral hearing loss. While Rinne test compares air conduction to bone conduction in the same patient. Although the tuning fork testing is easy and reliable; it is still a subjective test that depends on the response of the patient and the degree of hearing loss. Additional drawbacks are that tuning fork testing is a qualitative and not a quantitative test, and does not diagnose the etiology of the conductive hearing loss. Pure-tone Audiometry. Pure-tone Audiometry is a behavioral test that measures hearing threshold. The test has been used to diagnose type and degree of hearing loss for more than one hundred years. During test setting, the patient is subjected to different tones to test the hearing mechanisms via air-conduction and bone conduction. Typically, the normal level of pure tone audiogram air and bone conduction will lie between 0-15 dB HL for children and 0-25 dB HL for adults. According to Northern and Downs (1991), the degree of hearing loss can be classified in adults as (0-25 dB HL) within normal limits, Mild (26-40 dB HL), Moderate (41- 55 dB HL), Moderate-Severe (56-70), Severe (71-90 dB HL) or Profound (91 + dB HL) hearing loss. In children it is classified as normal (0-15 dB HL), Slight (15-25 dB HL), Mild (25-30 dB HL), Moderate (30-50 dB HL), Severe (50-70 dB HL), Profound (70 + dB HL) hearing loss. This classification is applied to PTA of 500, 1000, and 2000 Hz (Roeser et al, 2000). Different types of hearing loss are interpreted by comparing air conduction thresholds to bone conduction thresholds. When the air conduction threshold elevated to a maximum around 60-70 dB HL in the presence of normal bone conduction threshold, this type of hearing loss is called conductive hearing loss. In sensorineural hearing loss the pure tone audiogram shows both air and bone conduction thresholds are elevated and with a 10 dB HL or less in between. Mixed hearing loss displays elevation in both air and bone conduction thresholds, but with the bone conduction threshold at better intensities than the air conduction by 10 dB HL or more. In both conductive and mixed hearing loss, the difference in air and bone conduction thresholds is called air-bone gap; and it represents the amount of conductive hearing loss present (Roeser et al, 2000). The use of pure-tone audiometry provides quantitative information regarding the degree and type of hearing loss. However, it does not diagnose the cause of hearing loss and cannot be used in infants, young children, and difficult-to-test subject. Mannina (1997) reported that the diagnosis of middle ear disorders in school-aged children is less efficient when using pure-tone audiometry alone. To improve the diagnosis of middle ear disorder, Yockel (2001) demonstrated that the addition of tympanometry to audiometry does improve the diagnosis of OME than using audiometry alone. Assessing Middle ear function is a very important step in early diagnosis and treatment of conductive hearing loss. Since the usually used subjective tests, the tuning-fork and pure tone audiometry, cannot identify the etiology of underlying middle ear disease, other objective measures such as acoustic immittance are needed for differential diagnosis and accurate diagnosis of specific middle ear disorders. Acoustic Immittance. Several objective measurements of middle ear function have been developed over the last four decades. Various anatomical structures of the middle ear represent complex network system that affects the sound presented to the ear. Not all the sound represented to the middle ear is delivered to the cochlea, but some of the power is absorbed by the bony structure of the middle ear (Zwislocki, 1982). Acoustic Immittance using tympanometry assess the middle ear status by measuring the transmitted sound energy to the middle ear. Acoustic Immittance provides objective information about the mechanical transfer function in the outer and middle ear. Acoustic Immittance is defined, as the velocity with which an objects moves in proportional to an applied force, while Acoustic Impedance (Za) is the opposition offered by middle ear and the TM to the flow of energy. Mathematically acoustic admittance (Ya) of a system is the reciprocal of impedance. Acoustic Immittance refers collectively to acoustic admittance, acoustic impedance or both (Tympanometry. ASHA Working Group on Aural Acoustic-Immittance Measurements Committee on Audiologic Evaluation, 1988). Investigators have found that abnormalities in the middle ear transmission might be reflected in the acoustic condition of the TM (Allen et al, 2005). Acoustic Immittance can be measured to single probe-tone frequency (single frequency tympanometry) or to series of multiple probe frequencies (multifrequency tympanometry). Single frequency tympanometry. Tympanometry is one of the earliest objective methods used to evaluate middle ear function. Tympanometry measures the acoustic immittance of the middle ear as a function of changing the air pressure in the ear canal. A single probe tone tympanometry is the conventional measure of middle ear function in response to low frequency probe tone, 226 Hz, under varying static air pressure. Evaluation of the acoustic immittance of normal and different middle ear disorders was done by Otto Metz, 1946, and confirmed later by Feldman, 1963 (Katz, 2009) In 1970, James Jerger began to incorporate immittance measurement into the routine audiological evaluation. Jerger classified tympanograms as type A, B, or C depending on the shape of the tympanogram (with or without peak) and location of the peak when present. Type A is the normal tympanogram with the peak at or near the atmospheric pressure (+25 to -100 daPa). Type A is further divided into subtypes Ad and As for high and low peaked type A tympanograms respectively (Feldman, 1976). Type B tympanogram has no peak and relates to middle ear effusion, infection with normal ear canal volume, or due to large TM perforation with large ear canal volume. Type C is a negatively shifted tympanogram that reflects Eustachian tube dysfunction, a precursor of serous OM, mostly evolved from type B (Katz, 2009). Since 1970, single frequency Tympanometry is the conventional clinical middle ear measure because it is a non-invasive, objective, and cheap indicator of many middle ear pathologies in children and adults. Unfortunately, low frequency probe tone tympanometry has high false negatives in infants younger than seven months (Holte, Margolis, and Cavanaugh, 1991). This is explained by the movement of the infants ear canal wall with pressure changes in the external ear canal due to immaturity of the bony part of the external auditory canal. In addition, tympanometry was found to be relatively insensitive to many lesions that affect the ossicular chain of the middle ear (Lilly, 1984). Furthermore, Keefe and Levi (1996) reported false positive tympanometry results compared to energy reflectance, a recent middle ear function measure. They found normal middle ear energy reflectance at higher frequencies in infants with flat low probe tone tympanometry. Multifrequency tympanometry. Multifrequency Tympanometry (MFT), which was first introduced by Colletti in 1976, measures middle ear impedance using multiple frequency probe tones ranging from 226-Hz to 500 Hz and up to 2000 Hz (Colletti,1976) . Similar to previous discussion about the three elements of the mechanical system of the middle ear, admittance of the middle ear has three components: stiffness (compliant susceptance), mass susceptance and conductance (resistance). A tympanometric pattern was developed by Vanhuyse and colleagues in 1975 that helped in interpreting the underlying middle ear pathology using MFT. The Vanhuyse tympanometric pattern is based on the assumption of the shapes and locations of reactance (X) and resistance (R) tympanograms. Using a conversion equation the model can predict the shapes of susceptance (B) and conductance (G) tympanograms. Vanhuyse et al proposed four normal patterns: 1B1G, 3B1G, 3B3G, and 5B3G as shown in Figure 2. 1B1G pattern is the normal tympanogram with a one susceptance (B) and one conductance (G) peak. It occurs when reactance (X) is negative and its absolute value is greater than resistance (R) at all pressure used (the ear stiffness is controlled). As the probe frequency increases the curve becomes more complex and notched. 3BIG model has three peaks of susceptance (B) and one conductance (G) peak. It represent negative reactance (X) with an absolute value greater than resistance (R) at low pressur e and smaller than resistance (R) at high pressure. The third model (3B3G) appears when the ear is mass-controlled. In 3B3G model the reactance is positive and less than resistance (X R) at low pressure and becoming negative at high pressure (Margolis, Saly, and Keefe, 1999). Figure 2. A graphic presentation of the model presented by Vanhuyse, Creten and Van Camp (1975). The resistance (R) , negative resistance (-R) and the reactance (X) tympanograms is shown in the upper left corner of each panel. Negative R is shown to compare the magnitude of the reactance X. The corresponding admittance (Y), (lower left corner), susceptance (B), (upper right corner) and conductance (G), (lower right corner) are also shown in each panel. Four patterns are presented and classified according to the number of extrema in the susceptance B and conductance G tympanograms. The pattern (1B1G) in panel one shows both susceptance and conductance have single extrema and reactance is negative. The pattern (3B1G) in panel two shows conductance G is single peaked with three extrema in susceptance B, reactance X is still negative but its absolute value is greater than resistance at high pressure. The pattern (3B3G) in panel three shows three extrema in susceptance B, conductance G, and admitta nce Y tympanograms, reactance Y is positive but less than resistance R . The pattern (5B3G) in panel four shows five extrema in susceptance B tympanogram and three extrema in conductance G, and admittance Y tympanograms, reactance Y is positive and greater than resistance R at low pressure. Because of the use of measuring middle ear function to several probe tone frequency, MFT is considered superior to single frequency tympanometry in detecting high impedance pathological conditions of the middle ear such as middle ear effusion, otosclerosis, and cholesteatoma. Such pathological conditions were not detected by conventional tympanometry (Colletti, 1976, Keefe and Levi, 1996, Shahnaz et al 2009). Several studies have shown that MFT has higher sensitivity and specificity in detecting middle ear pathologies such as TM mass or adhesions (Margolis, Schachern, and Fulton, 1998). Also, MFT is more sensitive than single frequency tympanometry in identifying normal and abnormal middle ear condition in neonates (Shahnaz, Miranda, and Polka, 2008). However, MFT is of limited clinical use for several reasons: long testing time, limited frequency range, and unreliable data above 1000 Hz (Allen et al, 2005). The use of wideband energy reflectance is shown to address the above limitat ions of MFT. Wideband energy reflectance. The wideband energy reflectance (WBER) is a new technique that has been introduced recently to evaluate middle ear dysfunction (Keefe, Ling, and Bulen, 1992). Simply the idea of WBER is that incident sound to the ear is transmitted through the ear canal and TM, some of this sound energy is absorbed through the middle ear and cochlea and part of it is reflected back (Figure 3). The energy reflectance (ER) is defined as the square magnitude of pressure reflectance ÂÂ ¦R(f) ÂÂ ¦2, which represents the ratio of the sound energy reflected from the TM to the incident sound energy at frequency (f). ER ratio ranges from one to zero (1.0 = all incident sound energy is reflected, and 0.0 = all sound energy is absorbed) (Allen et al, 2005). ER is an indicator of the middle ear power to transfer sound (Feeney, Grant, and Marryott, 2003). Energy reflectance (ER) measurers middle ear function over a wide band of frequencies (0.2- 8 kHz). ER is the ratio of the reflected energy (red arrow) to the incident energy (yellow arrow). When all incident sound energy is reflected back ER ratio equals one. When all incident sound energy is absorbed ER equals zero. Red arrow represents reflected sound energy; yellow arrow represents incident sound energy; green arrow represent absorbed sound energy. Modified from Medline Plus Medical Encyclopedia: Ear anatomy. WBER measures middle ear function using a chirp stimulus at 65 dB SPL over a wide frequency range, typically 0.2 to 8 kHz and at fixed ambient pressure (Feeney et al, 2003) . Normative data has shown that most incident acoustic power is reflected back to the ear canal (ER ratio closes to 1) at frequency range below 1 kHz or above 10 kHz that also show poor hearing threshold or at frequencies below 1 kHz and above 4 kHz (less efficient middle ear function) (Keefe, Bulen, Arehart, and Burns, 1993). More specifically, 50% of the acoustic power is transmitted to the middle ear between 1-5 kHz frequency range, indicating that the most effective middle ear transfer function (ER is at its lowest values, closer to one) occurs around 1-5 kHz (Allen et al, 2005; Keefe et al, 1993; Schairer, Ellison, Fitzpatrick, and Keefe, 2007). WBER has been used in measuring normal middle ear function and middle ear disorders using ambient pressure (Allen et al, 2005; Feeney et al, 2003; Shahnaz et al., 2009). In other studies the researchers used pressure to measure the acoustic stapedial reflex (Feeney and Sanford, 2005; Schairer et al, 2007). Development of the middle ear in infants was also investigated using WBER (Keefe and Abdala, 2007; Keefe e al, 1993; Keefe and Levi, 1996). Wideband energy reflectance in neonatal screening Keefe et al. (1993) and Keefe and Levi (1996) reported that the acoustic response properties of the external and middle ear varies significantly over the first 2 years of life. These changes, mostly physical changes, are responsible for the mass-dominant infants middle ear system with lower resonant frequency. The main components of this mass-dominant effect is the pars flaccida of the TM, ossicles, and perilymph in the cochlea (Van Camp, Margolis, Wilson, Creten, and Shanks, 1986). The mesenchyme in infants middle ear may add to the mass effect (Meyer, Jardine, and Deverson, 1997). This is completely in contrast to adults middle ear, which is a stiffness-dominant system at low frequency (Holte et al, 1991; Keefe and Levi, 1996). The TM, tendons and ligaments, the space between the mastoid and the middle ear cavity, and the viscosity of the perilymph and the mucous lining of the middle ear cavity constitute the stiffness component of the middle ear (Van Camp, Margolis, Wilson, Creten , and Shanks, 1986). Recently, Shahnaz (2008) have compared MFT and WBER findings between normal adults and normal-hearing neonates in the neonatal intensive care units (NICU), who passed the neonatal hearing screening test. The researcher found maximum absorption of the incident energy at narrower range of frequencies (1.2 2.7 kHz) in normal babies compared to adults (2.8 4.8 kHz) (Shahnaz, 2008; Shahnaz et al, 2008). This preliminary normative data from 49 neonatal ears reflects the potential diagnostic benefits of the WBER test in detecting middle ear effusion in neonates. Wideband energy reflectance in otosclerosis Although the main definitive diagnosis of Otosclerosis is during surgery, an accurate preoperative audiological diagnosis is very important indication for surgery. Still, pure-tone audiometry has its own limitations that prevent accurate diagnosis of otosclerosis. Also, standard 226 Hz tympanometry is usually within normal type A tympanogram in most otosclerotic patients (Jerger, Anthony, Jerger, and Mauldin, 1974). While multiple frequency tempanometry may be helpful in diagnosing otosclerosis, it adds little information to the diagnosis (Probst, 2007). On the other hand, the WBER responses in three ears of otosclerosis fell outside the 5th to 95th percentile of the normative data and presented a distinctive pattern for the disease (Feeney et al, 2003); which suggests that WEBR is a sensitive middle ear measure. In a recent study WBER was found to be helpful in distinguishing 28 otosclerotic ears from normal and/or other causes of conductive hearing loss. A significantly higher ER w as found in otosclerotic ears at frequency range of 0.4- 1 kHz as compared to normal ears. In the same study WBER was found to be more sensitive in diagnosing otosclerosis than the conventional 226 Hz tympanometry and the MFT (Shahnaz et al., 2009). Wideband energy reflectance in other middle ear pathology Hunter and colleagues (2008) found higher sensitivity of WBER in detecting otitis media in infants and children with cleft palate (Hunter, Bagger-Sjoback, and Lundberg, 2008). Feeney and colleagues in 2003 studied WBER at ambient pressure in 13 ears with different middle ear disorders and comparative normal. Different middle ear disorders were involved in this study included: four ears with OME, one ear with ossicular discontinuity, two ears with otosclerosis, two ears with hypermobile TM, two ears with perforated TM, and one participant with bilateral sensorineural hearing loss. The results suggested a distinctive WBE

Proposal Data Base

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Play Activity Assignment Essay

This assignment is called Play activity. It is deserving 30 % of the overall class of the faculty Early on Childhood Education. As portion of the assessment standard of this assignment I must finish a drama activity to a group o kids aged between 0-6 old ages. WORK PLACE I have been get downing to work in Creche X in Donnybrook country since two hebdomads ago ( as a full clip ) . I have been in a free test. so portion clip till they decided I can get down full clip. I work in Baby room. There are five kids at the minute. I love kids and I like being around them. I haven’t worked before with babes. so it was a challenge and a large duty for me and I was really happy for the opportunity given to me. Despite the fact I had no experience to work with babes. I learnt tonss of things in a short period of clip and I can state I still have to larn few more. It is a little but broad. but friendly and brilliantly foundling hospital. It is a full twenty-four hours care service from 7:30 boulder clay 6:00. They have a Baby room. Wobblers room. Toddler room and Montessori room. The Baby room has besides a fingerstall room with 4 beds. It is a lovely room plentifulness of playthings and books ( for babes ) . The foundling hospital has besides a changing room. an office. a kitchen and a big out-of-door garden. They provide breakfast and hot alimentary repasts. All of their staff ( six individuals ) are full trained and experienced. They are Garda vetted and First assistance trained. They use the Montessori and Highscope methods of drama and instruction. They have a unafraid entree. out-of-door safety surface. wheel chair accessible. day-to-day log kept for parents. When parents come to pick up their kids they must state a watchword or if they send person else to pick up their kid. they must name before and so to state a watchword every bit good. Duties * Sign the kids in and out * Keep daily record of each kid ( record book ) * Parents mark in and out * Changing diapers * Feeding kids * Playing with them ( sponge picture. manus print. activity gym. ball drama. drawing objects. mirror drama. face look. different sort of music. mussy drama. etc ) * Bring them to kip country * Verify so from tem to ten proceedingss * Write every twenty-four hours on a Care of Sheet the measure and the hours they had their bottles of milk. solids. how many clip diapers were changed. * Write down on the Cot Sheet that you verified the kids and they were safe at that minute * Answer the phone. * Hovering and mop every twenty-four hours the room * Fill out an accident study * Chat with parents about day’s activity * Medical consent and disposal signifier for medical specialties given to kids must be completed by the director. parent. staff and informant. * Take the temperature of kids that seem to be ill look intoing from 15 to 15 proceedingss and right down on the medical specialty book ; if the temperature is high we call the parents * Verify every forenoon and afternoon the temperature from icebox * Hover and wipe up all the foundling hospital one twenty-four hours a hebdomad ( when my bend comes ) PERSONAL PROFILE My name is Mihaela Serea. I’m from Romania and I came in Ireland in 2008. I have been get downing to work as a kid minder for two households. I took attention of a kid of four old ages old and one of three old ages old. The 2nd household merely moved in UK two months ago. so I decided to get down Fetac Level 5 in Childcare. In Romania I went to College for a period of 4 old ages Faculty of Letters. profile Romanian-English. During the college I completed the classs for the Department of Teaching in primary/secondary school. After the college I have done a maestro grade in Business Management for one twelvemonth and half. During my Master grade I had the chance to work in a kindergarten. I was afraid of taking attention of little kids. but it was a truly pleasant experience and I enjoyed it a batch. Some other classs completed: when I was in secondary school. I decided to make some classs within the country of computing machines. What I want to accomplish from this faculty Early on Childhood Education? It is a important period of kids at this age. so I want to research all the facets of a kid development. from safety and psychological science to physical. cognitive and emotional development. I want to assist kids to derive assurance in mundane undertakings. to guarantee that the drama is conforming to official wellness and safety criterions. It is a period when walking. speaking. vision of the universe and moral foundations are established. The early old ages of life are critical to the development of intelligence. personality and societal behaviour. I would wish to larn about kids demands and involvements. My alone merchandising points I enjoy learning. but in Rumanian linguistic communication because it will be easy to show myself. In English I loose myself. I forget the words. I don t know any longer what I want to state. it s hard. because in school we don’t communicate plenty. we merely learn to read. to compose. grammar. exercisings. When I was a kid I dreamed to be a instructor. All my narrative books have Markss on. I like painting. vocalizing. computing machines. I like to be informed. One twenty-four hours I believe I will hold my ain concern a foundling hospital. But first of all I need to work in a foundling hospital for more old ages to acquire more experience and to happen out everything I need to cognize approximately. I like kids really much. I will be a good director and I think it will be good money as good. if I provide a good service. Title of drama activity: Fall leaves Aim Autumn is a great clip to learn kids about foliages. I want to larn them through drama and geographic expedition of the nature and to acquire involved with it. Roll uping different foliages they learn different colourss. forms and constructions. Another purpose is to develop children’s creativeness by blending colourss. working in groups. Consultation with my supervisor When I take a group of kids out I have to be cognizant of their safety: planning. permission. supervising. conveyance. In my instance. I go into a park merely near by our location with a group of pre school kids. I spoke with my supervisor to give permission and a missive should be sent to all the parents/guardians of the kids. Co-operation with households is indispensable to guarantee the public assistance of the kids. The supervisor told me it s non necessary a conveyance. because it is merely two proceedingss off. We do non necessitate jammed repasts. merely some bottles of H2O. tissues. trim vesture. little first assistance kit. a charged Mobile phone and exigency contact Numberss. guaranting that the service’s insurance policy includes equal screen for excursions. I have to take attention of wellness. safety and hygiene of kids keeping a high criterion of attention which promotes the development of the kids. Children should be appropriately dressed for the excursion in fabrics which protect against the conditions. Children should non have on their best fabrics. Children’s vesture demands to let them freedom of motion so that they can take full advantage of all the chances offered on the excursion. I remembered to kids about route safety. Always we cross the route at safe points such as traffic visible radiations. I checked the topographic point in progress to be certain of the installations that are available and the country that may be a danger to kids. Benefits of my chosen subject: A survey of leaves/ fall opens up possibilities for larning in many content countries. Language Arts. Mathematics. Science. Social Studies. and Art all contribute to a unit on foliages. If there is entree to a park or resort area. the kids can travel on a foliage assemblage walk. When this isn’t possible. kids can be encouraged to garner foliages at place with their households and convey them in to the schoolroom. or instructors can supply the foliages. Leafs change colourss. normally from green to red. orange. xanthous and brown. Leafs can be found on trees. autumn to the land and we rake them. Children sort the foliages they collected by colour. size or type of foliage. Fall is a beautiful clip of twelvemonth. when the foliages change colour and autumn from the trees. Besides brushing them up and bagging them. see seting the fallen foliages to good usage. Children collect and turn them into leaf art. The motley foliages make beautiful trade undertakings. and the best portion is that they’re free. There are several types of trades you can make from foliages. The lone bound is your imaginativeness. Traveling out in the park they learn different types of animate beings. Besides kids learn about the season ‘’autumn’’ : season of the twelvemonth between summer and winter. enduring from the autumnal equinox to the winter solstice and from September to December ; period of adulthood verging on diminution. Five related subjects: 1. Leaf print 2. Hedge hogs 3. Colorss 4. Roll uping leaves 5. Autumn leaves Chosen activity: I have chosen an art activity to be completed with a group of 5 kids within a pre-school scene. Preparation: * I will speak with my supervisor in order to inform her about the background of the drama activity assignment * I will convey a photocopy of my program about this drama activity * During the meeting I ask her about some suggestions related to the drama activity and its educational content * I ask my supervisor if parents will give the permission to take the kids in the park * I will inquire my supervisor about a suited clip and location to finish the drama activity and what I may necessitate to acquire. * I wil seek to calculate out how long it may take to finish this activity * I will make a checklist in order to guarantee that all indispensable supplies are present during the drama * Equipment needed to finish the accomplishments presentation will be: baskets to roll up the foliages. gum. white documents. little and large paintbrushes. H2O based pigments. paper plates. paper tissues. wet rubs. and aprons. The pigment used will be non toxic. Execution: First of all the activity will be safe for the kids to set about. The park was at 5 proceedingss walking off from our location and it was a safe country. I gave them baskets to roll up the foliages from the park We spent 2 hours in the nature Wash hands Gather stuffs utilizing the checklist as a usher Set out an country permitted by the supervisor Put on the aprons on each kid I give to each kid a pigment coppices and paper home bases I showed them how to do the operation They cleaned up the muss Evaluation: As portion of my appraisal for the FETAC faculty: Early Childhood Education. I must finish one drama activity within a work topographic point puting. I tried to follow measure by step the program in order to finish the Play Activity ‘’Autumn leaves’’ . I spent about two hours in the park with kids. and so we came back. 1. How the accomplishments presentation went from my personal point of view 1. In my sentiment everything went really good and I was truly happy that I succeeded to finish it. The kids helped me a batch because they followed my verbal instructions. Before we have gone to the park. I gave them wood baskets to roll up the foliages. I provided all the stuffs they needed to cover with for publishing foliages on the documents. First of all I showed them how to make it. I took one of my ain foliages. I painted it and I put the painted side on the sheet of paper and gently press it with my custodies. After few seconds. I lifted the foliage. They could take small/big pigment coppices and colourss to utilize. I could see they tried to do the operation really good precisely as I showed it to them. TC1 and TC3 showed a large concentration. Despite of the fact that CT2 wanted to work on his ain. he mixed the colourss really nice. 2. How the accomplishments went presentation went from the child’s point of view The Play Activity ended really good. all kids have been happy about their creative activities. I put on their creative activities their names and I hanged them on a wire. They applauded/clapped their custodies and had large smilings on their faces. They showed a batch of concentration when they started to paint. 3. The last portion of the rating is really the development of kids through this drama activity as followers: P. I. L. E. S Physical Development: This was developed when all the kids collected foliages from the land and when they printed the foliages on the documents. In the park they collected foliages utilizing their fingers ( all right motor accomplishments ) . They moved from a topographic point to another. jumping and running about developing their gross motor accomplishments. ( Large musculuss: legs. organic structure motions ) . They held the paintbrushes ( all right motor accomplishments ) to publish the foliages. Intellectual: They counted how many leaves they had at the terminal and they sorted the foliages based on colourss and sizes ( Logical/math ) . They compared their foliages to see who has the largest 1 ( Concentration ) . Through art they developed their creativeness and look of their art when they put different colourss of foliages on documents. Children love to happen interesting molded foliages. T. C 4 remembered some names of the trees they learned in the schoolroom ( memory ) . T. C 1 pretended he is the kid of the jungle. Mowgly ( imaginativeness ) . T. C3 stick two documents side by side to do a bigger montage of foliages printed and T. C4 mixed the colourss of the foliages on the paper. ( creativeness ) . TC4 pretended he is a coney in the wood. so he started to leap like a coney. ( imaginativeness ) . Language: This was developed when kids understood my verbal instructions related to foliages ( roll uping them. numbering them. do comparings. painting the foliages so stick them for few seconds on the documents. etc ) . They learned new words related to and animate beings trees like maple. oak. squirrels. etc Emotional: This was developed when T. C1 expressed his felicity about detecting he found the largest foliage. T. C2 started to sing a vocal we have learned in the category. T. C4 started to shout because he falls down on the land. TC3 was angry because TC1 pushed him on a side merely to take his foliage he found on the land. They developed feelings associated with winning and losing. Social: This was developed when I brought them together in the park. in the nature. T. C1 was playing with the others. T. C3 collected foliages with T. C4. ( team work. the ability to work in groups. interaction with the others ) . When we were in the schoolroom I put them to work in braces of two. ( they learnt to portion the equipment. be patient. clean up the muss ) . Howard Gardner Kinesthetic: CT4 leaping like a coney. so he developed his gross musculuss ( legs ) . They played together. running. CT3 is really good at trade. he was making a great occupation lodging two documents side by side. and doing a bigger montage of different colourss. forms of foliage printed. Naturalist: CT2 was first-class at acknowledging the squirrels. They enjoyed being in nature. researching the nature. roll uping foliages. CT1 recognized some flowers. Interpersonal: CT3 seem to be a a natural leader enjoy learning the others how to paint the foliage and so to lodge them on the paper. I noticed CT3 is a closed friend to CT4. Intrapersonal: When I put them to work in groups of two. CT2 replied to me that he prefers working entirely. He showed a strong sense of independency in the park every bit good roll uping the foliages on his ain. ( He does a great occupation on his ain ) . Recommendations for alteration: I propose for the following clip when we go into a trip. we should take a larger topographic point with more attractive/educational musca volitanss for kids to see and we should take more kids and more staff. It will be more merriment. Impact on kids: Children enjoyed traveling out researching the natures. roll uping the foliages. They deal with forms. colourss. how they look combined. They loved to utilize different colourss to paint the foliages and they seemed really partisans about their work. At the terminal at the undertaking they were proud of their work. They learned to work in groups. Painting gives them the ability to portion their equipment. to clean up their muss. They learned to be patient. they learned new words. Personal acquisition: * I learned to finish a drama activity in a pre-school scene * I learnt to use theory to pattern * I improved to pass on with my supervisor and ask for advice sing my program activity.

Modern Technology, the Unseen Dangers Essay - 1514 Words

As time goes on, the world around us continues to change even more rapidly than it already has. All the time new gadgets and gizmos continue to be introduced to the market to satisfy the needs of the consumers. Social networking sites such as Facebook, Myspace, and Twitter allow people from all over the world to be connected. With the help of these social networking sites and cell phones people have become more easily accessible in the previous years than ever before. At first glance these modern technologies appear to be nothing but helpful conveniences that society has become accustomed to having , but as technology advances, our privacy continues to decrease without most people even realizing it. Cell Phones, everyone knows what a†¦show more content†¦This all seems like something you would find in a science fiction novel, but the possibilities of such things are happening right before our very eyes. 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