Role of an Audiologist

An audiologist is a health-care professional specializing in identifying, diagnosing, treating and monitoring disorders of the auditory and vestibular system portions of the ear. Audiologists are trained to diagnose, manage and/or treat hearing or balance problems. They dispense hearing aids and recommend and map cochlear implants. They counsel families through a new diagnosis of hearing loss in infants, and help teach coping and compensation skills to late-deafened adults. Audiologists have training in anatomy and physiology, hearing aids, cochlear implants, electrophysiology, acoustics, psychophysics, neurology, counselling and sign language.


Introduction
a) An audiologist is a health-care professional specializing in identifying, diagnosing, treating and monitoring disorders of the auditory and vestibular system portions of the ear.b) Audiologists are trained to diagnose, manage and/or treat hearing or balance problems.

c)
They dispense hearing aids and recommend and map cochlear implants.d) They counsel families through a new diagnosis of hearing loss in infants, and help teach coping and compensation skills to late-deafened adults.e) They also help design and implement personal and industrial hearing safety programs, newborn hearing screening programs, school hearing screening programs, and provide special fitting ear plugs and other hearing protection devices to help prevent hearing loss.

f)
In addition, many audiologists work as auditory scientists in a research capacity.
Audiologists have training in anatomy and physiology, hearing aids, cochlear implants, electrophysiology, acoustics, psychophysics, neurology, counselling and sign language.In a Neonatal and paediatric setup or in nursing homes an audiologist helps to identify and diagnose hearing impairment and possible speech delay soon after the birth of the infant.d) In such set up an audiologist closely works with the gynaecologist, the paediatrician and the NICU and PICU staff.e) Within the neonatal period the audiologist can identify and diagnose the possible hearing impairment.

f)
This would help in providing early intervention to the infant and thus improving the quality of life.
g) The mothers are counselled about the handicapping effects of the conditions and motivated for the intervention program.In addition to this, the audiologist can even counsel the parents of a high risk infant to monitor the possibilities of speech and language development delay.
h) With the improvement in the technology an infant can be screened soon after birth with the help of behaviour observation audiometry, Crib-O -Grams, with the help of a hand held audiometer designed specifically for the paediatrics and neonates, and also with the help of ABR and OAE screeners.

i)
In the absence of such equipment, use of simple instruments such as noise makers can indicate the loss but for detailed assessment the parents can be referred to a set up where it can be diagnosed in depth j) When the child grows old, usually when the child is not responding to sounds and is not speaking age appropriately, the parents usually come to the paediatricians for help, then the paediatrician is of maximum help to the parents as he or she would refer them to the audiologist.k) In a neurological set up l) The main focus of audiologist in neurological setup is differentially diagnosed cochlear versus retrocochlear disorder.m) So the audiologist has to be familiar with the symptoms and clinical manifestations of the disorders encountered.
n) An audiologist helps in identifying and diagnosing hearing loss caused due to a neurological disorder such as auditory neuropathy, central auditory processing disorders, Neoplasm and tumors, Brainstem encephalitis, Epilepsy, Demyelinating diseases, Hydrocephalus, Meningitis, Viral infections, Cerebrovascular disease, Cerebral palsy, Attention deficit hyperactive disorder (ADHD), Hyperacusis, Tinnitus, Parkinson's disease, Meniere's disease, Vestibular disorders.Presently, ABR has been the most important test in investigation of retrocochlear pathology.Pathology such as space occupying lesions, demylineating disorders, maturation delay, metabolic causes of coma, monitoring neural function during brain surgery and also correlation of various disorders of higher brain functions.Stacked ABR is an important tool in assessing acoustic tumour than the standard ABR.ii.CD player.

Instrumentation for hearing assessment in
iii.Parent and teachers questionnaires.
iv. Recorded speech materials and manuals for central auditory assessment.
The instrument used in a neurological setup needs have facilities to conduct these tests to arrive at diagnosis.Apart from clinical testing in a neurological setup, the audiologist also has a role in monitoring neural function during brain surgery, assessment of balance system and monitoring facial nerve.
Intra-operative Auditory Monitoring d) Target population.Patients undergoing surgery that place the auditory system at risk and those undergoing procedures for the relief of endolymphatic hydrops.These include hearing preservation procedures for removal of acoustic neuromas, vestibular nerve section, nerve decompression procedures, and endolymphatic procedures.e) Rationale.In the procedure that places the auditory system at risk; intraoperative auditory monitoring provides feedback to the surgeon regarding the status of the auditory function that can be useful in preserving hearing.In endolymphatic sac procedures for the patients with abnormal electrocochleography recording, intraoperative monitoring may be useful for detecting changes in cochlear function.Intraoperative auditory monitoring is performed by measuring the compound action potential (AP), summating potential (SP), and the auditory brainstem response (ABR).Patients who have symptoms of vertigo, disequilibrium, or imbalance due to an underlying disease condition.This might involve inner ear (Meniere's syndrome and labyrinthitis), the vestibular nerve (acoustic neuroma), cervical muscle and vertebrae, or the central nervous system (e.g.basilar artery migraine, demyelinating disease such as multiple sclerosis, neurodegenerative diseases, tumors and infracts). ii.
Patients who are receiving medications that might impair inner ear function.Ototoxic drugs include the aminoglycoside antibiotics and some diuretics when they are used in conjunction with other ototoxic medication.
iii.Patients who are recovering from inner ear or vestibular nerve surgery and continue to have symptoms of vertigo and dieequilibrium.The surgery might have been resection of an acoustic neuroma or a vestibular nerve section for intractable Meniere's disease.HallpikeManeuver.
The ENG and rotation test battery can identify avestibular deficit affecting eye movements and the vestibular-occular reflex (VOR) and determine whether there is a bilateral deficit or an asymmetry due to decreased function (or increased) on one side compared to the other side.In addition, it is useful for determining whether there is an occulomotor deficit which might involve central nervous system pathways in common with the vestibular system.Equipment required i.
Visual stimulus generator.
iv. Computer driven rotation chair.
Target population 1) Patients complaining of vertigo, disequilibrium, or imbalance.
2) Patients who are being followed to determine whether there is a progression of a disease state that affects the balance mechanisms or to differentiate among several subtypes of the disease condition.
3) Patient undergoing balance training or physical therapy.
4) Patients who are being evaluated for balance problems after head trauma.

b.
Rationale.The term posturography refers to the quantitative measurement of the body sway or center of force exerted at the feet while the patient stands on a platform.Dynamic refers to measurements taken while the platform is moving as well as it is stationary.Only body movement in the forward/backward plane will be considered.Since the DP evaluates the vestibule-spinal system and the function of vertical semicircular canals and Otolith organs, it complements the ENG and rotation test.
Dynamic Posturography provides unique information that can help identify whether postural instability is due to a deficit to use sensory information from the inner ear, eye, or the cutaneous receptors of the feet and the proprioceptors of the joints and muscles of the leg, or the combination of different sensory modalities.There might be a pattern of responses across the different DP test conditions that would suggest a specific disease condition.However, DP itself does not provide site of lesion, or laterality information.c.Equipment required.

i.
Equitest platform with visual surround.

Global Journal of Otolaryngology
ii.
Computerized data acquisition and display system that is integrated with the platform controller and force transducers.

iv. Genetics
Sometimes Audiologists are the first professionals to identify hearing loss caused by genetic transmission and syndromes that are likely to have hearing loss.
The audiologists refers their clients to the genetics' for a complete genetic test and gene analysis  xviii.An Air force Audiologist helps manage and develop hearing conservation programs as the personnels would be working in extreme noise conditions inherent with working around jets can cause hearing damage xix.Audiologist also helps in measuring noise levels at the runway and within the Air force station.They also provide HCP for those personnals working with the Aircraft machinery.Audiologist in a school setting ii.
In a school setting an audiologist Ideally, the educational audiologist should have primary responsibility for the identification of preschool and school age children with hearing loss and/or middle ear disease.
iii.The educational audiologist should coordinate the screening program.iv.They help in setting up of classroom amplification system and also help in the seating arrangement for the children in a classroom.

v.
The audiologist identifies CAPD, monitors children with speech and language delay caused by hearing impairment.
vi.One responsibility of the educational audiologist is to ensure that the hearing impaired child makes maximum use of this residual hearing.
vii.By integrating diagnostic information from speech and language assessments, the educational audiologist can determine a child's current level of performance and the rate at which communicative skills are being acquired viii.The audiologist plays a most important role in audiologic management of the hearing impaired child.
ix.The responsibilities in audiologic management include selection and evaluation of amplification, amplification maintenance, monitoring class-room noise, provision of habilitative activities, and parent counseling. x.
The educational audiologist must make sure that the characteristics of both the personal and classroom hearing aids of a child are comparable.
xi.The audiologist should provide the teacher and principal with a list of suggestions for classroom noise reduction.
xii.Auditory training, speech and language training, or visual communication training and may be provided by the educational audiologist.
xiii.The role of the educational audiologist is to coordinate these habilitative services and to interact with the child's teacher regarding specific areas in need of work or special concerns.
xiv.The audiologist's input should be evident in the individual education program (IEP) as it relates to such audiologic information as specific amplification needs, the amount and type of language and speech interventions required, the acoustic environment, parent and child counseling, and support systems for the classroom teacher.Conducting efficacy measurements to determine the need for and benefits from acoustical treatments and Global Journal of Otolaryngology modifications g) These areas of the activity are not necessarily the independent activities and may currently be within the work scope of some educational audiologists.For instance, advocacy and information resource functions are essentially pervasive across all areas of responsibility related to classroom acoustics.
h) The audiologist can provide useful information to facility planning and management teams, but it is collaborate with other professionals , and the skill set of an acoustical consultant or engineer also may be required.

i)
This is often the case when there is above the -ceiling plenum noise that needs to be managed using acoustic blankets or other available acoustical treatments.The audiologist can play a unique role in the promotion and marketing of good classroom acoustics.

j)
Collaborating with the other professionals will be more productive than launching a solo personal campaign to influence the change.k) Audiologist, architect, engineer, acoustical consultant and other members of social facility planning teams each offer a specific knowledge and skill set that will contribute to improving the classroom acoustics are perhaps the audiologist's greatest resource to be used to ensure acoustic access to information in the learning environment.

l)
The audiologist clearly not to provide long term support in resolving personal conflicts, which may manifest themselves as gilt or depression.Rather, counselling for the audiologist means helping client's fine ways to make practical adjustments in these situations to meet specific concerns.When science of gilt and depression are present, referral to a psychologist or other medical personal is appropriate.m) As non professional counsellors, one of our roles is to guide students through the acceptance stage of the grieving process, where we can promote an important component: a healthy self concept.
n) The social emotional aspects of hearing loss are critical to consider for students in the schools with hearing loss.Just as we ensure optimal listening and learning for students with hearing loss.o) Audiologist working with children in educational settings need to be aware of evaluating all aspects of how a student functions and these components are inter related, not just the audiogram.In a rural set up i.
Audiologists provide audiological (aural) rehabilitation to children and adults across the entire age span. ii.
Audiologists select, fit and dispense amplification systems such as hearing aids and related devices.
iii.Audiologists prevents hearing loss through the provision and fitting of hearing and consumer education.iv.Audiologists are involved in auditory and related research pertinent to the prevention, identification and management of hearing loss, tinnitus and balance system dysfunction.

v.
Audiologists serve as expert witnesses in litigation related to their areas of expertise.
vi. Audiologists provide services in private practice in medical settings such as hospitals and physician's officials; community hearing and speech centre's; managed care systems; industry; the military; home health, subacute rehabilitation, long term care and intermediate care facilities; and school systems.vii.Audiologists provide academic education in universities to students and practitioners in audiology, to medical and surgical students and residents and to other related professionals.Such education pertains to the identification, assessment and nonmedical management of auditory, balance and related disorders.

f)
Discussing with the surgeon regarding the choice of implantation in terms of its electrode array.g) Providing pre-operative counselling and post -operative counselling, training clinical audiologists to map the implant and its timely fine tuning.

h) Trouble shooting of the device i)
An audiologist works either as a clinical audiologist or works for special projects or research to provide evidence based practice.

j)
In a hearing aid company k) Assess the performance of a hearing aid l) Performs electro acoustic measures.m) Helps in marketing of the hearing aids and expands professional community.
n) It is the responsibility of the audiologist to take the time to perform, interpret and utilize the required tests for diagnostic and amplification and fitting purposes.
o) It is the responsibility of the audiologist to remain 'current' via reading the professional literature, studying, attending courses, earning CEUs and similar activities.
Maintaining competency and expertise regarding technology is the responsibility of the professional.
It is the responsibility of the audiologist to discuss, explore and demonstrate Assistive Listening Devices (ALDs) with every patient.ALDs aren't highly profitable when sold and they take a large amount of time to discuss, explore and demonstrate.Yet, ALDs can often make or break a patient's ability to function in a given environment.The satisfaction of knowing patients are communicating well is worth the extra time and effort.
It is the audiologist who offers the best value will garnish the greatest market share.Some manufacturing costs can be reduced (or eliminated) by highly skilled audiologists who are able to modify instruments in their office.Additionally, audiologists can help reduce or eliminate costs by taking consistently excellent ear impressions, picking flexible circuits, and packaging ear impressions carefully.The audiologist and the manufacturer, together, must take responsibility for the ultimate price of the instruments.ii.
The target group that has been provided such services includes: b.
Medical professionals: pediatrics, ENT doctors, family physicians, PHC doctors, Post graduate medical doctors.

c.
Paramedical professionals: Nurses and CBR workers.Head of schools, school teachers, social and health workers, anganwadi workers and different philanthropic organizations.
During these interactive programs the groups get guidelines on prevention, identification and management of the HI individuals.They are also given pamphlets and posters regarding prevention of HI.These orientation programs promote ear care and hearing conservation.

d.
Secondary prevention: Involves screening to identify individuals suspected to have hearing problems.This is done in order to identify, further diagnose and rehabilitate early screening is considered with respect to different target groups: i.
Screening is done by a team of specialist which includes an Audiologist and an ENT specialist.
Screening is usually recommended for: i.
Newborn babies: To identify at risk infants for HL as early as possible, because this is the critical age for speech and language development. ii.
School aged children: To identify any acquired / late onset hearing loss.To detect the presence of ME infection and to educate parents / educators about its future consequences (counseling).Also to promote early identification and rehabilitation of these children to prevent from deterioration of acquired speech.
iii.Noise induced hearing loss: This is one of the preventable causes for hearing loss.Through hearing conservation program the industrial employers are being educated regarding the ill effects of noise on hearing but also about the ill effects on the physical and mental health by conducting various workshop and orientation programs.Tertiary prevention: Involves rehabilitation of individuals identified as having HI.In young children it is required to help them acquire speech and language. b.
In individuals with acquired HL: Hearing is necessary to monitor his / her speech .HI will also affect an individual's education and job placement.
The impact of these hearing conservation problem helps to detect individuals with milder problems with unilateral hearing loss.ii.

Identification and Assessment
Conducting noise surveys & promoting hearing conservation to prevent NIHL.
iii.Develop national epidemiological databases and follow-up programs for communication disorders.iv.Provide information about the privileges, rights and sanctions existing for individuals with hearing impairment.
Audiologist as nonprofessional counsellor ii.
An audiologist cannot provide long term support in resolving personal conflicts, which may manifest themselves as guilt or depression.Rather, counselling for the audiologist means helping client's find ways to make practical adjustments in these situations to meet specific concerns.When signs of guilt and depression are present, referral to a psychologist or other medical personal is appropriate.a) As a non professional counsellors, one of our roles is to guide students through the acceptance stage of the grieving process, where we can promote an important component: a healthy self concept.
b) The social emotional aspects of hearing loss are critical to consider for students in the schools with hearing loss.Just as we ensure optimal listening and learning for students with hearing loss.

c)
Audiologist working with children in educational settings need to be aware of evaluating all aspects of how a student functions and these components are inter related, not just the audiogram.

f)
One of the important aspect of consideration in fitting Hearing Assistive Technology is social andemotional adjustment.The audiologist and support team must consider motivation, attention, fatigue, self image, self advocacy, social acceptance, classroom culture and family support to achieve a successful outcomes with HAT.

Future Directions
a) Educational audiologists provide comprehensive services to support students with hearing loss and/ or auditory processing difficulties in their learning environments.b) As an increasing percentage of these students receive their instruction in general education settings, school systems and educational audiologists will need to become more flexible in the way that support services are provided and funded.

c)
Additional resources and creative strategies to support and train general education teachers will need to be developed.While the professional practices outlined above are based on current mandates and reimbursement a) In a Hospital b) In a Neonatal and a Paediatric setupc) a neurological setup would include: a) Diagnostic audiometer b) Immittance audiometry with reflexometry c) Evoked potential Audiometry Global Journal of Otolaryngology d) Otoacoustic emission e) Vestibular assessment system A. Diagnostic audiometer.The audiometer in use has to be a single channel or a dual channel with option to administera) Pure tone audiometry b) Speech audiometry c) It also needs to have an option for special test such as i.Tone Decay Test (TDT) ii.Short increment Sensitivity Index (SISI) iii.Supra Threshold Adaptation Test (STAT) d) Tests for Central Auditory Processing Disorder B. Immittance audiometry and reflexomerty.A diagnostic immittance meter can be used with facility for reflexometry and Reflex Decay Test (RDT).Otoacoustic Emission Instrument.Otoacoustic emission instrument with facility for a) Transient Evoked Otoacoustic Emission.evoked response are -neurodiagnosis in adults or children, and other is estimation of hearing sensitivity, mostly in children and in difficult to test population.
b) Rationale.The term electronystagmography has been used for the set of tests including the following: of the spontaneous eye movements during maintained eye positions and f.
xi. Apart from the above mentioned set up, an audiologist is trained to treat hearing difficulties in the geriatric population xii.They are trained to diagnose, and extract information from the radiological reports.xiii.Audiologist in a Military set up xiv.Audiologists in the military set up are primarily recruited for the Hearing conservation Programme.xv.Conduct the full spectrum of diagnostics, including audiologic and vestibular evaluation, electrophysiology and hearing aid and cochlear implant services.xvi.Provide education, training, clinical support and program management.xvii.Engage in research-based practice as well as training and supervision of technicians, students and resident physicians.
xx.They also assess hearing and balance mechanism at the time of recruitment.xxi.They take care of the hearing of the personnel's families and those living within the Air Force Station.xxii.They Serve as the Hearing Conservation Program Manager for aviation, shipboard and artillery communities.xxiii.Perform auditory examinations on service personnel, their families and those in need across the globe.xxiv.Supervise, lead or conduct audiological research, whether measuring the auditory effects of humans not wearing proper ear protection or the long-term effects of sound on marine mammals.xxv.Provide hearing conservation certification for technical personnel so they know exactly how to protect their hearing xxvi.Perform routine and advanced auditory examinations.xxvii.Note any possible changes in hearing and instruct people on how to properly protect themselves from noise exposure.xxviii.Diagnose, evaluate and assess the impact of hearing loss on communication.xxix.Enhance communication ability through aural rehabilitative support.xxx.Ensure the auditory combat readiness of Fleet and Marine personnel.xxxi.Serve as consultant manager of Navy/Marine Corps Hearing Conservation Programs, demonstrating how crews' earplugs are inserted correctly and ensuring that cranial/earmuffs fit well and are in good condition.xxxii.Audiologist in an industrial set up xxxiii.Selecting suitable test areas for noise survey and audiometric tests xxxiv.Getting audiometric tests done xxxv.To formulate, administer and update the HCP xxxvi.Guidance and management on purchase of equipments or machinery related to industrial setup.xxxvii.Training and supervising the workers in proper use of EPDs xxxviii.Maintaining the effective records pertaining to HCPs xxxix.Participating in the selection of noise control procedures Global Journal of Otolaryngology xl.Decision to be made for the noise survey which includes industrial audiologists and acoustical engineer xli.Noise reduction should be handled by an acoustical engineer at various levels (source, transmission and listener).
xlii.The acoustical engineer plays important role in first two aspects while audiologist plays major role for noise control at the listener level xliii.Education of employee and the employer should be done regarding the noise survey and noise control procedure xliv.Education should include information on hearing aspects, effect of noise, HCP, EPDs, selection of EPDs, audiometric evaluation, consequences of hearing loss and difficulty in communication related to hearing impairment.xlv.The areas of noise hazards should be clearly marked and the employers working in these areas should be educated about the harmful effects of noise exposure.i) Noise survey: The main purposes of noise survey are a) To determine the risk area b) Level of attenuation required c) Audiologists or acoustical engineers making the noise survey should include details about the frequency composition, noise level and duration of noise exposure in these areas d) The impairment of speech communication that occurs during excessive noise exposure should be taken into consideration e) If the noise level can't be in order to restrict below Damage Risk Criteria (DRC) then the role of EPDs should be given emphasis for the employers or workers i.
xv. Audiologists who are employed by or contract with schools have unique opportunity to influence good classroom acoustics in their district or service area.Major areas of responsibility for the audiologist include: and other learning spaces d) Collaborating with the educational facility planning teams e) Ensuring access for the special population f) viii.Activities that identify, assess, diagnose, manage and interpret test results related to disorders of human hearing, balance and other neural systems.ix.In Forensic sciences and medico-legal cases x.Determining (investigating) the cause/effect features of hearing impairment claims.Consulting activities such as a) Evaluating the audibility of warning signals in collision cases; b) rating the efficacy of a hearing conservation program; c) measuring community noise sources; d) assessing product failure or misuse in product liability actions; e) malpractice actions; and f) Proactive efforts such as consultation on product development to reduce potential noise hazards.The legal issues in which an Audiologist plays important role are: a) Workers Compensation (NIHL, AT).b) Administrative Law (Environmental Noise) c) Constitutional Law (OSHA).Global Journal of Otolaryngologyd) Tort Law (injury, death, product liability).e) Criminal Matters (audibility, intelligibility).f) Professional Negligence (malpractice).B. In a cochlear implant company a) An Audiologist visits various hospitals on behalf of the company for developing the CI implantation procedures and for its promotions.b) Remote mapping of the implant, intraoperative mapping, performing NRT, Impedance testing and ART c) Inferring the radiological reports, providing detailed assessment to identify the candidate for the CI.d) Research and development of test materials exclusively for assessing cochlear implantees.e) Provide rehabilitative support and develop various rehabilitative strategies and spread its information among special educators, teachers, Auditory verbal therapists.
a) As a private practitioner b) An audiologist who is in private practice manages a clinical set up fully.fitting of appropriate hearing instrument, prepares ear mold, dispenses hearing aids to the clients directly e) Manages professional communication with hearing aid and companies dealing with the diagnostic instuments.f)Promoteshimself/herself in the market to gain referrals of the client.g) In urban areas C. Prevention Prevention of hearing loss primarily considered at 3 levels.a.Primary prevention: Aims to eliminate/ inhibition of the onset and development of the problem.Several activities considered for the same are: i.To educate general public on various causes of HI, aiming to prevent the occurrence of the problem.(openday / science day programs).
iv. Follow up programs to monitor the noise effects v. Orientation programs to the employees on use of ear protective devices vi.Orientation programs for elderly individuals: a) Do's and don'ts about the hearing loss.b) Systemic diseases and its contribution to hearing loss.vii.Camps.a.
d) An audiogram is only a small part of one's profile.Too often, audiologist immediately confirms what type of technology and accommodations are needed for a student solely from an audiogram.e) Frequently the recommendations are rejected by the clients because the time or consideration to involve the client in the discussion implications of hearing loss and the social, economical aspects of the hearing loss has been over looked.
In the ENT set upAudiologists and otorhinolaryngologists should go hand in hand for the best available medical care and treatment for hearing disorders.They complement each other in the assessment, diagnosis and treatment of ear and throat disorders.Audiologists are an integral part of an ENT practice.Audiologist identifies, diagnose and treat children and adult hearing complaints in case of cleft lip and palate as they are susceptible to conductive hearing loss.
d. Audiological practice in an ENT setup should, i. Help in diagnosing conductive hearing loss ii.Help in diagnosing sensorineural hearing loss iii.Hearing evaluation for patients with tinnitus and vertigo iv.Help in monitoring the benefit after surgical intervention v. Help in monitoring the success of drug therapy vi.Help in determining the appropriate treatment plans vii.Help in determining the candidacy for surgeries like cochlear implantation viii.Post surgical intervention after cochlear implantation, tympanoplasty etc. ix.Treatment of hearing loss with hearing aids which cannot be treated with any other medical techniques.