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Diagnostic audiology is the use of audiologic tests to determine the location of a problem in the auditory system and, in many cases, further insights about the disorder. Diagnostic audiology can be likened to crime shows you may watch on television. Each test serves as a clue that points toward a diagnosis of the patient’s hearing disorder. However, if individual tests (or clues) are examined without taking other evidence into consideration, a wrong conclusion might be made. For audiologists to make correct diagnoses, an audiologic test battery is used. A test battery is a series or combination of tests used to assess the auditory system. For most of the examples in this chapter, we will limit discussion of diagnostic audiology to tests that are commonly performed in an audiologic clinic, including puretone air-conduction and bone-conduction testing, speech testing, tympanometry, acoustic reflex thresholds (ARTs, also called middle-ear muscle reflexes [MEMRs]), and otoacoustic emissions (OAEs). These tests are discussed more fully in other chapters in this textbook and we refer you to these chapters for specific test procedures and norms (see Table 8.1); however, it is important to understand how to utilize these tests synergistically to arrive at an accurate diagnosis for each patient. Audiometric tests are used in conjunction with one another to help reinforce or, alternatively, rule out the diagnosis of a particular type of hearing loss or the site of lesion. The test battery is useful for determining some, but not all, auditory disorders.
诊断听力学是使用听力学测试来确定听觉系统中问题所在的位置，在许多情况下，进一步了解疾病。诊断听力学可以比作你可能在电视上看到的犯罪节目。每一项测试都是一条线索，指向对患者听力障碍的诊断。然而，如果在不考虑其他证据的情况下对个别测试（或线索）进行检查，可能会得出错误的结论。为使听力学家作出正确的诊断，使用了听力学测试组块。测试组块是一系列或组合的测试，用于评估听觉系统。对于这一章里大多数的例子，我们将把诊断听力学的讨论局限于听力学临床中常见的测试，包括纯音空气传导和骨传导测试、言语测试、鼓室测量、听觉反射阈值（ARTS，也称为中间值），耳肌反射（MEMS）和耳声发射（OAES）。这些测试在本教材的其他章节中进行了更全面的讨论，我们将向您介绍这些章节，以了解具体的测试程序和规范（见表8.1）；然而，重要的是要了解如何协同利用这些测试，以达到对每个病人的准确诊断。听力测试与其他测试一起使用，以帮助加强或排除对特定类型听力损失或病变部位的诊断。测试组块有助于对于确定部分但不是全部的听觉障碍。
Following a brief introduction to the cross-check principles employed by audiologists, this chapter will utilize a case study format. Finally, we will address the limitations of the test battery and discuss situations when referrals for other testing are indicated.
在简要介绍听力学家采用的交叉检验原则之后，本章将使用案例研究格式。最后，我们将讨论测试组块的局限性，并讨论被推荐的其他测试情况。
CROSS-CHECKING TEST RESULTS
交叉检验测试结果
The major reason that an audiologist uses a diagnostic battery is to be able to check the results of individual tests with each other. The idea that “the results of a single test are cross-checked by an independent test measure” is referred to as the cross-check principle (Jerger and Hayes, 1976, p. 614). Since the cross-check principle was first proposed, many manuscripts have revisited the concept as new diagnostic tests have been developed and different test batteries have been proposed to diagnose specific disorders. The goal of comparing the results of two or more tests is to increase the rate of correct identification of disorders (hit rate) and to decrease the rate of diagnosing a disorder when no disorder exists (false alarm rate) (Turner, 2003).
听力学家使用诊断组块的主要原因是能够相互检查单个测试的结果。“单次测试的结果通过独立的测试措施进行交叉检验”的观点被称为交叉检验原则（Jerger和Hayes，1976年，第614页）。自从交叉检验原则被首次提出以来，随着新的诊断测试的开发和不同的测试组块被提出来诊断特定的疾病，许多手稿重新审视了这一概念。比较两个或两个以上测试结果的目的是提高疾病的正确识别率（命中率），并在不存在疾病的情况下降低疾病的诊断率（误报率）（Turner，2003年）。
Cross-checks for Puretone Air Conduction
纯音空气传导的交叉检查
If you only obtained puretone air-conduction thresholds then you would not be able to accurately diagnose the type of hearing loss. Air-conduction audiometry is normally cross checked with bone-conduction audiometry or tympanometry to rule out a conductive component of the hearing loss. If a difference greater than 10 dB exists between the airconduction and bone-conduction thresholds at the same frequency, a conductive component is indicated. Similarly, air-conduction thresholds for an ear may be within normal limits; however, if a tympanogram for that ear falls outside of the norms for middle-ear pressure and compliance (e.g., Jerger Type B or Type C), a conductive component may be present. ARTs can reveal more information about the type of loss based on the pattern of responses obtained, thus serving as an additional cross-check for puretone air conduction.
如果您只获得纯音空气传导阈值，那么您将无法准确诊断听力损失的类型。空气传导测听术通常与骨传导测听术或鼓室测听术交叉检查，以排除听力损失的传导成分。如果在相同频率下，空气传导阈值和骨传导阈值之间存在大于10分贝的差异，则表明存在传导性因素。同样，耳朵的空气传导阈值可能在正常范围内；但是，如果该耳朵的鼓室图不符合中耳压力和顺应性规范（例如，Jerger B型或C型），则可能存在传导性因素。ARTS可以根据所获得的响应模式显示更多关于损失类型的信息，从而作为纯音空气传导的额外交叉检查。
Cross-checks for Puretone Audiometry
纯音测听交叉检查
When puretone audiometry (air- and bone-conduction testing) suggests a significant air–bone gap, tympanometry and ARTs can be used to reinforce the diagnosis of the conductive element and to contribute to a specific diagnosis. OAEs also can be used as a cross-check of puretone audiometry. OAEs are used to assess the health of the outer hair cells of the cochlea, but their measurement may be affected by disorders in the conductive pathway. An audiologist might use OAEs as a cross-check to aid in potentially ruling out a nonorganic hearing loss, to verify outer hair cell function and the degree of cochlear hearing loss, and to further assist with the diagnosis of conductive components, auditory neuropathy spectrum disorder (ANSD), and other retrocochlear disorders. In addition, ARTs have been used to cross check puretone audiometry (Jerger et al., 1974), although other objective tests, such as tone-burst–stimulated auditory brainstem response (ABR), are considered to be better procedures for estimating hearing thresholds. Acoustic reflexes can be used to help identify the presence of hearing loss in young children as well as in adults with language and/or cognitive issues that may reduce the validity and reliability of behavioral measures (Hall, 2010). Acoustic reflexes can also be used to determine site of lesion within the auditory pathway, specifically in differentiating between cochlear and retrocochlear pathologies.
当纯音听力测试（空气和骨传导测试）显示有明显的气骨间隙时，鼓室测量和ARTS可用于加强对传导元件的诊断，并有助于特定诊断。OAE也可以用作纯音测听的交叉检查。OAE用于评估耳蜗外毛细胞的健康状况，但其测量可能会受到传导通路紊乱的影响。听力学家可以使用OAE作为交叉检查，以帮助排除潜在的非器质性听力损失，验证外毛细胞功能和耳蜗听力损失程度，并进一步帮助诊断传导成分、听神经病频谱障碍（ANSD），以及其他耳蜗后疾病。此外，ARTS还被用于交叉检查纯音听力测试（Jerger等人，1974年），尽管其他客观测试，如短纯音刺激听觉脑干反应（ABR）被认为是评估听力阈值的更好方法。声音反射可用于帮助识别幼儿和成人中存在的听力损失，语言和/或认知问题可能会降低行为测量的有效性和可靠性（Hall，2010年）。听觉反射也可以用来确定听觉通路中的损伤部位，特别是在区分耳蜗和耳蜗后病理学方面。
Cross-check for Puretone Average
纯音平均值的交叉检查
A puretone average (PTA) is usually calculated as the average of the air-conduction thresholds at 500, 1,000, and 2,000 Hz for each ear. Normally, the PTA should agree with the speech recognition threshold (SRT), meaning that the PTA and SRT should be within 10 dB of one another in the same ear. One instance in which the audiometric thresholds may cause the PTA to be greater than the SRT by 10 dB is when the audiogram configuration is sharply sloping or sharply rising. In such instances, it is preferable to use a two-frequency PTA by averaging the two lowest (e.g., best) thresholds at 500, 1,000, and 2,000 Hz. The two-frequency PTA should then be in agreement with the SRT. Another instance in which the PTA and SRT may disagree is if a person is malingering or intentionally exaggerating a hearing loss. Outside of these special circumstances, we would expect SRTs and PTAs to be highly correlated (except when language or foreign language is a major factor). This allows us to use the SRT to validate the PTA (American Speech-Language-Hearing Association, 1988).
纯音平均值（PTA）通常计算为每只耳朵500、1000和2000赫兹的空气传导阈值的平均值。正常情况下，PTA应与语音识别阈值（SRT）一致，这意味着PTA和SRT应在同一耳朵中彼此之间的10分贝范围内。当听力图表现急剧倾斜或急剧上升时，听力阈值可能导致PTA大于SRT 10 dB。在这种情况下，最好通过在500、1000和2000 Hz下平均两个最低（例如，最佳）阈值来使用双频PTA。两个频率的PTA应与SRT一致。另一个PTA和SRT可能不同意的情况是，如果一个人在恶意或故意夸大听力损失。除这些特殊情况外，我们希望SRT和PTA高度相关（除非语言或外语是主要因素）。这允许我们使用SRT来验证PTA（美国语言听力协会，1988年）。
Considerations for Assessing Speech Understanding
评估言语理解的注意事项
One additional step that audiologists may take to address a patient’s complaint of not being able to understand speech in noisy environments is to administer a speech-in-noise test in addition to the word recognition testing in quiet. Although this is technically not a cross-check, the addition of a speech-in-noise test, especially with sentence stimuli, will provide a more realistic test environment to evaluate a common patient complaint. The puretone audiogram does not necessarily correlate with the amount of difficulty a listener will have in noise (Killion and Niquette, 2000). In addition, when word recognition testing is performed in quiet at a single speech presentation level, no guarantee exists that the test is measuring the patient’s maximum speech understanding (Wiley et al., 1995).
听力师在处理病人在嘈杂环境下听不懂说话的主诉时，可能采取的另一个步骤是，除了在安静的环境下进行单词识别测试外，还要进行语音噪声测试。虽然这在技术上不是一个交叉检查，但是添加一个语音噪声测试，特别是有句子刺激的，将提供一个更现实的测试环境来评估一个常见的病人诉求。纯音听力图并不一定与听者在噪音中的困难程度相关（Killion and Niquette, 2000）。此外，当单词识别测试在单一的语音表达水平上安静地进行时，并不能保证该测试能够测量患者最大的语音理解能力(Wiley et al.，1995)。
Cross-check Considerations for Pediatric Testing
儿科测试的交叉检查考虑因素
For children, it is imperative that the audiologist utilize the cross-check principle. The behavioral responses obtained via behavioral observation audiometry (BOA) or visual reinforcement audiometry (VRA) are considered to be accurate reflections of a child’s true thresholds when these tests are conducted carefully (Madell and Flexer, 2008). However, because children often do not respond as consistently or as quickly as adults, it is possible that a child’s behavioral responses may still be elevated compared to actual thresholds. As a result, the audiologist may judge the child’s responses as unreliable (Baldwin et al., 2010). Regardless of the judged reliability of such measures, audiologists should use objective tests such as OAEs and tympanometry as cross-checks for pediatric behavioral responses (Baldwin et al., 2010; Littman et al., 1998; Madell and Flexer, 2008). In addition, OAEs and acoustic reflexes have been shown to be good cross-checks for ABR in young children (Berlin et al., 2010; Stach et al., 1993). The Joint Committee on Infant Hearing Position Statement (JCIH; American Academy of Pediatrics, 2007) also recommends that electrophysiological measures be employed as a cross-check for behavioral response audiometry for children younger than 6 months chronological age. The statement further stresses the importance of obtaining behavioral thresholds as soon as possible using the most age-appropriate method “to cross check and augment physiologic findings” (American Academy of Pediatrics, 2007, p. 910).
对于儿童来说，听力学家必须利用交叉检查原则。通过行为观察测听（BOA）或视觉强化测听法（VRA）获得的行为反应被认为是这些测试仔细进行时儿童真实阈值的准确反映（Madell和Flexer, 2008）。然而，由于儿童的反应往往不像成年人那样一致或快速，因此，与实际阈值相比，儿童的行为反应仍有可能升高。因此，听力学家可能会判断孩子的反应是不可靠的（Baldwin et al.， 2010）。不管这些测量方法的判断可靠性如何，听力学家都应该使用客观测试，如OAEs和鼓室测压法，作为儿童行为反应的交叉检查（Baldwin et al.， 2010;Littman等，1998;Madell和Flexer, 2008）。此外，OAEs和声学反射已被证明是幼儿ABR的良好的交叉检查（柏林等，2010;Stach等，1993）。婴儿听力联合委员会立场声明（JCIH;美国儿科学会，2007年）也建议使用电生理测量作为6个月以下儿童行为反应测听的交叉检查。声明还强调了使用最适合年龄的方法“交叉检查和增强生理机能”尽快获得行为阈值的重要性（美国儿科学会，2007年，第910页）。
Electrophysiological Tests as Cross-checks
作为交叉检查的电生理测试
Although beyond the scope of this chapter, it should be noted that certain electrophysiological tests can be used to cross check behavioral measures, as well as to cross check each other and to help confirm diagnoses of certain disorders (Bachmann and Hall, 1998; Berlin et al., 2010; Gravel, 2002; Hall and Bondurant, 2009; Stapells, 2011). For example, Berlin et al. (2010) discussed the use of cross-checking test results to diagnose ANSD: “ . . . the presence of a [cochlear microphonic] or reversing waves at the beginning of the trace does NOT make a diagnosis of ANSD . . . without the cross-check of middle-ear muscle reflexes (MEMR), OAEs, and an ABR latency-intensity function” (p. 32). For further information about these tests, the reader is referred to the chapters that discuss electrophysiological tests in the text. Table 8.2 summarizes many of the cross-check tests that are used in audiology.
尽管超出了本章的范围，但应注意的是，某些电生理测试可用于交叉检查行为测量，相互交叉检查，并有助于确定某些疾病的诊断（Bachmann和Hall，1998年；Berlin等人，2010年；Gravel，2002年；Hall和Bondurant，2009年；Stapells，2011年）。例如，Berlin等人（2010）讨论了交叉检查测试结果在诊断ANSD中的应用：“…在跟踪开始处有[耳蜗微音]或反向波不能诊断为ANSD。…没有中耳肌肉反射（MEMR）、OAES和ABR潜伏期强度功能的交叉检查（第32页）。关于这些测试的更多信息，读者可以参考本文中讨论电生理测试的章节。表8.2总结了听力学中使用的许多交叉检查测试。
Order of Tests Administered
测试执行顺序
Although we acknowledge that there is considerable variability in test protocols across clinics, we recommend that testing begin with the objective tests unless contraindicated. At least two major advantages can be found for testing objective measures first. The first advantage is that the audiologist will have a good idea of the type and degree of hearing loss before beginning the subjective tests. The second advantage is the reduced risk for misdiagnosis of disorders such as ANSD and vestibular schwannoma, as well as failure to detect a patient who is malingering. One caveat needs to be discussed with conducting objective tests first. With rising costs of health care we need to be cautious that we are doing tests that are necessary. It is possible that, if the patient’s hearing is completely normal (with no listening complaints) or the patient is profoundly deaf (with previous documentation to support the initial diagnosis), tests such as OAEs and acoustic reflexes will be unlikely to add further information about the patient (but we would
recommend that everyone have tympanometry for the reasons previously discussed). We think that a nonorganic component is more likely to be present during subjective testing and may not be discovered until cross-checked with objective tests. For these reasons, we recommend objective testing first. A suggested testing order is shown in Figure 8.1. Nevertheless, it should be noted that some audiologists advocate giving puretone and speech tests first when the patient may be more alert and can actively respond to these tests and then relax during the objective tests.
尽管我们承认，不同诊所的测试方案存在相当大的差异，但我们建议测试从客观测试开始，除非有禁忌。首先测试目标度量至少有两个主要优点。第一个优点是，在开始主观测试之前，听力学家会对听力损失的类型和程度有很好的了解。第二个优点是减少了误诊ANSD和前庭神经鞘瘤等疾病的风险，以及未能发现病人装病。需要与进行客观测试讨论一个注意事项。随着医疗保健费用的不断上涨，我们需要谨慎地进行必要的测试。如果患者听力完全正常（无听力方面的主诉，或者患者严重失聪（以前的文档支持初步诊断），诸如OAES和声学反射等测试将不可能增加关于患者的进一步信息。（但我们会的基于前面讨论过的原因，建议每个人都做鼓室检查）。我们认为，非有机成分在主观测试中更可能存在，只有与客观测试交叉检查才能发现。出于这些原因，我们首先建议进行客观测试。建议的测试顺序如图8.1所示。然而，应该注意的是，一些听力学家提倡在患者可能更加警觉的时候，首先进行纯音和语音测试，并且能够积极应对这些测试，然后在客观测试中放松。
Beyond the Test Battery
测试组块以外
Although the use of a test battery is important, it is also vital for the audiologist to remember the case history and the patient complaints. In some ways, one may consider this patient-reported information to be a cross-check of the test battery itself. The case studies presented below demonstrate examples of diagnostic audiology in action.
尽管使用测试组块很重要，但对于听力师来说，记住病史和患者投诉也是至关重要的。在某些方面，人们可能认为这个患者报告的信息是对测试组块本身的交叉检查。下面的案例研究证明了诊断听力学的应用实例。
CASE STUDIES
案例研究
The importance of objective testing in conjunction with subjective tests can be seen through the use of case examples. The following cases are a range of examples that highlight the use and benefit of incorporating the cross-check principle into your clinical practice. The cases will be presented with a brief history and test results. A discussion of potential difficulties and challenges in interpreting the audiologic data is incorporated within each case. Although there is an ideal order to the test sequence as noted above, the order of tests often varies because of tester preference, patient complaint, age of patient, and so on. Therefore, the test order in the cases below varies to better represent what may be actually done in a clinical setting or what a student clinician may see from his/her supervisors. For the sake of simplicity, all of the cases represent testing with standard audiologic procedures on adults. As you read through each case, we encourage you to make a decision tree based on the order of tests presented in the case and then think about how you might decide to change the test order. It is important to review your clinical decision making periodically to ensure that your practice is evidence based.
客观测试和主观测试的重要性可以通过使用实例来看出。以下案例是一系列例子，突出了交叉检查原则在临床实践中的应用和益处。这些案例将提供简要的病史和测试结果。在每个案例中都包含了对解释听力数据的潜在差异和挑战的讨论。尽管如上所述，测试顺序是理想的，但由于测试人员的偏好、患者投诉、患者年龄等原因，测试顺序通常会有所不同。因此，以下案例中的测试顺序会有所不同，以更好地表示在临床环境中实际执行的操作，或学生临床医师从其导师那里看到的操作。为了简单起见，所有的病例都是用标准的听力学程序对成人进行测试。在您阅读每个案例时，我们鼓励您根据案例中提供的测试顺序制作决策树，然后考虑如何决定更改测试顺序。定期回顾你的临床决策很重要，以确保你的实践是基于证据的。
Case 1
案例1
CASE HISTORY
病史
Mr. Ang Kim, age 36, is being seen today after he failed the hearing screening at his company’s health fair. His medical history is generally unremarkable, though he reports that he is just getting over a sinus infection and recently underwent surgery for a slipped disc in his back. You have backto-back patients today and because there is nothing remarkable in his history you decide to do a quick audiogram and send him on his way. Results from otoscopy, puretone, and speech audiometry are shown in Table 8.3 and Figure 8.2.
现年36岁的金先生因未能通过公司体检中的听力筛查。他的病史一般都不起眼，尽管他说自己刚从鼻窦感染中恢复过来，最近因腰椎间盘突出而做了手术。你今天一个接一个的病人，因为他的病史没有什么特别的，你决定做一个快速的听力检查，然后送他回去。耳镜检查、纯音和言语测听结果如表8.3和图8.2所示。
With subjective information alone this audiogram could indicate many things. For example, you may inaccurately diagnose Mr. Kim with a collapsed ear canal, an impacted cerumen plug, or a perforated tympanic membrane without additional tests to cross check your findings. Despite your busy schedule, you decide you need more information to make an accurate diagnosis, so you perform objective testing to cross check your subjective results. The results from immittance testing and OAE testing are shown in Tables 8.4–8.6.
仅凭主观信息，这张听力图就能说明许多问题。例如，如果没有额外的测试来交叉检查你的发现，你可能会用耳道塌陷、耵聍堵塞或鼓膜穿孔来错误地诊断金正恩。尽管你的日程很忙，你还是决定需要更多的信息来做出准确的诊断，所以你会进行客观的测试来交叉检查你的主观结果。导容抗测试和OAE测试结果如表8.4-8.6所示。
With this information, you have several different tests to confirm your finding of a conductive hearing loss. The Type B tympanogram in the right ear reveals normal ear canal volume but no mobility. The normal ear canal volume suggests that the TM is not perforated and there is no cerumen plug. The pattern of the ARTs is consistent with a right conductive pathology. TEOAEs in the right ear are absent which is expected with a conductive pathology.
有了这些信息，你就有了几个不同的测试来验证你的传导性听力损失的发现。右耳B型鼓室图显示耳道容量正常，但无活动能力。正常耳道容积提示鼓膜未穿孔，也没有耵聍。ARTs的模式与正确的传导病理学是一致的。右耳未见TEOAEs，这是一种传导性病变。
The combination of the subjective and objective test results correctly leads you to suspect otitis media with effusion and would require a referral for Mr. Kim to a physician. In this case, you are able to make an appropriate referral based on the information you obtained from a test battery incorporating both objective and subjective measures.
主观和客观测试结果的结合正确地导致您怀疑分泌性中耳炎，需要将金先生转诊给医生。在这种情况下，您可以根据从包含客观和主观测量的测试组块中获得的信息进行适当的转诊。
Case 2
案例2
CASE HISTORY
病史
Mrs. Edith Jones, age 77, is being seen today for a hearing test. She does not perceive a listening difficulty but her husband was recently fit with hearing aids and insisted she have her hearing checked too. Her medical history is remarkable for high blood pressure and type 2 diabetes which are both controlled by medication.
现年77岁的伊迪丝·琼斯夫人今天正在接受听力测试。她没有感觉到听力障碍，但她的丈夫最近配戴了助听器，并坚持让她也检查一下听力。她的病史因高血压和2型糖尿病而引人注目，这两种疾病都是由药物控制的。
You conduct a basic audiometric evaluation on Mrs. Jones. Results for otoscopy are displayed in Table 8.7 and puretone and speech audiometry results are shown in Figure 8.3.
你对琼斯夫人做一个基本的听力评估。耳镜检查结果见表8.7，纯音和言语测听结果见图8.3。
If you decide not to proceed with further tests to cross check your results, you might diagnose this patient with normal hearing in the right ear and a mild conductive hearing loss in the left ear. You might then refer Mrs. Jones to an Ear Nose and Throat physician who would order more tests.
如果你决定不进行进一步的测试来交叉检查你的结果，你可能会诊断这个病人右耳听力正常，左耳轻度传导性听力丧失。然后你可以把琼斯太太介绍给耳鼻喉科的医生，他会安排更多的检查。
Instead, you decide to proceed and include additional tests in your battery that would provide a cross-check. We will review those results next (see Tables 8.8–8.10).
相反，您决定继续进行，并在您的组块中包含额外的测试，以提供交叉检查。接下来我们将回顾这些结果（见表8.8-8.10）。
These results suggest that Mrs. Jones has normal hearing that contradicts your puretone findings. Normal results on tympanometry, ARTs, and TEOAEs are not consistent with a mild conductive hearing loss. With this information you review the patient’s case history and puretone findings again and realize that the apparent conductive hearing loss in the right ear is likely the result of a collapsing ear canal. It is not uncommon for the pressure of the supra-aural headphones to cause the canal to collapse, particularly in older patients for whom the cartilage supporting the ear canal is soft. To confirm this finding you decide to retest Mrs. Jones with insert earphones. When you repeat your audiogram using the insert earphones, you measure Mrs. Jones’s rightear air-conduction thresholds at 5 or 10 dB HL for all frequencies tested. You are able to report to Mrs. Jones that her hearing appears to be normal!
这些结果表明琼斯夫人的听力正常，这与你的纯音听阈发现相矛盾。鼓室压力测量，ARTs和TEOAEs的正常结果和轻度传导性听力损失不一致。利用这些信息，您可以回顾患者的病史和纯音情况，并再次认识到，明显的传导性听力损失，在右耳可能是由于耳道坍塌。压耳式耳机的压力导致耳道塌陷的情况并不少见，尤其是对那些支持耳道的软骨较软的老年患者。为了证实这一发现，你决定用插入式耳机重新测试琼斯夫人的听力。当你用插入式耳机重复你的听力记录时，你测量琼斯夫人在所有频率，空气传导阈值均在5或10dBHL。你可以向琼斯太太报告她的听力似乎很正常！
Both cases 1 and 2 highlight the importance of using objective test results in conjunction with subjective test results to avoid misdiagnosis. Both audiograms revealed similar test results but very different actual diagnoses, which were only confirmed with the use of objective testing.
案例1和案例2都强调了将客观测试结果与主观测试结果结合使用以避免误诊的重要性。两种声像图的检测结果相似，但实际诊断有很大差异，只能通过客观检测加以证实。
Case 3
案例3
You receive the following case, accompanied by a patient-signed medical information release, via fax. A recently graduated audiologist at a practice across town just finished testing Mr. Smith and would like a second opinion.
您将通过传真收到以下病例，并附上患者签署的相关就诊信息。一个刚刚毕业的听力师在镇上的一个诊所里刚刚完成了对史密斯先生的测试，他想听听你的的意见。
CASE HISTORY
病史
Mr. Aaron Smith, 49, reports that he can no longer hear out of his left ear. He works in construction and reports that a transformer overloaded at his work site yesterday, resulting in a loud explosion which he believes caused his hearing loss. Mr. Smith reported that his hearing was normal prior to the explosion. He denies any aural fullness, tinnitus, or dizziness. His medical history is unremarkable and he denies any other injuries as a result of the explosion. Results of the audiologic testing are shown in Tables 8.11–8.13 and Figure 8.4.
49岁的亚伦·史密斯说，他的左耳已经听不见了。他在建筑工地工作，他说，昨天他的工地上有一个变压器超载，导致了一场巨大的爆炸，他认为这导致了他的听力损失。史密斯先生报告说，爆炸前他的听力正常。他否认有任何耳胀、耳鸣或头晕。他的病史并不引人注目，他否认还有其他爆炸造成的伤害。听力学检查结果见表8.11-8.13和图8.4。
You call the audiologist right away and review your concerns with her. Both the air-conduction and bone- conduction thresholds for the left ear need to be masked. Cross-hearing should have occurred before those thresholds were obtained. Furthermore, you would not expect to obtain no response for bone-conduction testing with the bone oscillator on the left side when the hearing in the right ear is evidently normal. You also note that the PTA and the SRT are not in agreement for the left ear. ARTs are better than you would expect them to be (given the puretone thresholds for the left ear). A patient with hearing thresholds at 90 dB HL would be expected to have ARTs in the range of 95 to 125 dB HL at 500 Hz and 100 to 125 dB HL at 1,000 and 2,000 Hz (Gelfand et al., 1990). Lastly, the WRS was only obtained at 20 dB SL in the left ear, yet Mr. Smith’s WRS is 76%, which is better than expected. According to Dubno et al. (1995), a patient with a PTA of 90 dB HL would have an expected WRS of less than 24%. You suggest to the other audiologist that obtaining TEOAEs would further assist in this diagnosis. The audiologist performs TEOAEs (see Table 8.14) to confirm the suspected diagnosis and faxes the results to you.
你马上打电话给听力学家，和她讨论你的担忧。左耳的空气传导阈值和骨传导阈值都需要掩蔽。交叉听证应该发生在这些阈值之前。此外，在右耳听力明显正常的情况下，用左侧的骨振子进行骨传导测试时，你不会期望没有反应的。您还注意到，左耳的PTA和SRT不一致。ARTs比你想象的要好（考虑到左耳的纯音阈值）。听力阈值为90 dB HL的患者，在500 Hz时的ARTs值为95至125 dB HL，在1000和2000 Hz时的ARTs值为100至125 dB HL （Gelfand et al.，1990）。最后，左耳的WRS仅为20 dB SL，Smith先生的WRS为76%，好于预期。根据Dubno等人（1995）的研究，PTA为90 dB HL的患者预期WRS小于24%。您向其他听力师建议，做TEOAEs检查将进一步有助于诊断。听力师执行TEOAEs（见表8.14）来确认疑似诊断并将结果传真给您。
Based on the pattern of test results, your suspected diagnosis is nonorganic hearing loss. Let us review the facts. First, the patient’s left ear thresholds are elevated above where cross-hearing should have occurred. Second, the objective test results (tympanometry, ARTs, and OAEs) reveal no conductive component and suggest that outer hair cells are functioning normally. However, the puretone and speech audiometry results suggest a severeto-profound unilateral hearing loss in the left ear, which is inconsistent with the objective results. Several crosschecks identified inconsistencies (e.g., ARTs and puretones; PTA–SRT agreement; puretone thresholds and OAEs). At this point, you could suggest that the audiologist reinstruct the patient and then retest the left ear, masking appropriately. If the thresholds for the left ear are still elevated, a Stenger test could be performed to confirm the accuracy of the left puretone thresholds. If the Stenger test result is positive (i.e., the patient does not respond to the stimulus), this would be additional evidence that the apparent hearing loss is nonorganic. This case highlights the importance of a high-quality diagnostic battery (including masking where appropriate) and use of cross-checks to confirm our test results. 根据测试结果，您的疑似诊断是非器质性听力损失。让我们回顾一下事实。首先，患者的左耳阈值高于应该发生交叉听力的地方。第二，客观的测试结果（鼓室测量、ARTs和OAEs）显示没有传导性损失因素，表明外毛细胞功能正常。然而，纯音和言语测听结果显示左耳有严重的单侧听力损失，与客观结果不符。几个交叉检查发现了不一致性（例如，ARTS和纯音；PTA–SRT协议；纯音阈值和OAEs）。此时，你可以建议听力师重新指导病人，然后重新测试左耳，适当掩蔽。如果左耳的阈值仍在升高，则可以进行一次斯登格氏试验【斯登格氏试验（检伪装的单侧耳聋）】，以确认左耳纯音阈值的准确性。如果斯登格氏试验结果为阳性（即患者对刺激没有反应），这将是严重的听力损失是非器质性的。本例强调了高质量诊断组块（包括适当的掩蔽）和使用交叉检查确认测试结果的重要性。
Case 4
案例4
CASE HISTORY
病史
Ms. Ashley Jackson, age 27, has had hearing problems all of her life. She has been told by her audiologist that she has only a mild sensory/neural hearing loss. Her doctor always tells her that her hearing is really very good. She tried hearing aids a few years ago but she says that they did not help at all. Unfortunately, Ms. Jackson cannot hold a job because of her hearing difficulties. Her bosses always cite miscommunication problems as the reason for her dismissal. Ms. Jackson is here today to see if her hearing has changed. Tables 8.15 and 8.16 show otoscopy and tympanometry results. Figure 8.5 shows puretone and speech audiometry results.
27岁的阿什利·杰克逊生活中存在听力问题。她的听力师告诉她，她只有轻微的感音/神经性听力损失。她的医生总是说她的听力很好。几年前，她尝试过助听器，但她说它们一点用也没有。不幸的是，由于听力障碍，杰克逊女士无法保住工作。她的老板总是以沟通不畅为理由解雇她。杰克逊女士今天来看看她的听力是否有变化。表8.15和8.16显示了耳镜检查和鼓室测量结果。图8.5显示了纯音和言语测听结果。
Ms. Jackson’s puretone results appear to be consistent with the previous hearing tests in her medical record. There are some red flags that warrant additional testing, though. First, her reports of listening difficulties and communication problems in her case history suggest that she may have more than a mild sensory/neural hearing loss. Additionally, her word recognition scores are poorer than expected given her puretone thresholds. You would expect a patient with PTAs in this range to have WRS of 68% or better (Dubno et al., 1995). The next tests that should be performed are ARTs and OAEs. Tables 8.17 and 8.18 show the results of those tests.
杰克逊的纯音测试结果似乎与她之前的病历记录一致。不过，也有一些需要进行额外测试的危险信号。首先，她的病例记录中的听力障碍和沟通问题表明她可能不仅仅是轻微的感音/神经性听力损失。此外，考虑到她的纯音阈值，她的单词识别分数低于预期。您会期望此范围内的PTA患者的WRs为68%或更高（Dubno等人，1995年）。接下来应该进行的测试是ARTs和OAE。表8.17和8.18显示了这些试验的结果。
Now that you have completed your testing, you cross check your test results. First, the patient’s ARTs are not consistent with her puretone thresholds. With a mild sensory/ neural hearing loss you would expect acoustic reflexes to be present (Gelfand et al., 1990). The patient’s TEOAEs are present and robust which would not be expected based on Ms. Jackson’s puretone thresholds. These findings in conjunction with the poor WRS indicate a need for additional testing such as an ABR. You suspect that the patient has ANSD. Results of the ABR and a medical evaluation may help to confirm or rule out your suspected diagnosis. Without the addition of both ARTs and OAEs to the test battery, Ms. Jackson’s disorder might have been missed again. The recommendations for patients with ANSD or other retrocochlear pathologies are often very different from the recommendations for those who have a peripheral hearing loss. Misidentification of the site of lesion for a hearing loss like Ms. Jackson’s might result in delayed or inappropriate rehabilitation recommendations. Unfortunately, ANSD can be missed easily in clinical practice if the audiologist does not perform a thorough test battery (Smart and Kelly, 2008).
既然您已经完成了测试，那么就要交叉检查测试结果。首先，患者的ARTs与纯音阈值不一致。如果有轻微的感音/神经性听力损失，你会期望出现听觉反应（Gelfand等人，1990年）。根据杰克逊女士的纯音阈值，患者的TOAEs是存在的，并且是强大的，这是不可预期的。这些结果与较差的WR一起表明需要进行额外的测试，如ABR。你怀疑病人患有ANSD。ABR和医学评估的结果可能有助于确认或排除您的疑似诊断。如果不做ARTS和OAE，杰克逊的疾病可能会再次漏诊。对患有ANSD或其他耳蜗后病变的患者的建议通常与对外周听力损失患者的建议非常不同。对于像杰克逊女士这样的听力损失，误认损伤部位可能导致延迟或不当的康复建议。不幸的是，如果听力学家不进行全面的测试，那么ANSD在临床实践中很容易被忽略。（Smart和Kelly，2008年）。
Case 5
案例5
CASE HISTORY
病史
Mr. Don Warner, age 58, is being seen today with his primary complaint being a constant ringing in his right ear. He notes that the ringing has been present off and on for over 3 years but it has become more bothersome recently. When asked about his hearing he admits that he has difficulty understanding what others are saying in noisy places. He denies aural fullness and dizziness. He plays tennis regularly and generally is in great health. Results from your testing are shown in Tables 8.19–8.22 and Figure 8.6.
现年58岁的唐华纳今日来就诊，他的主诉是右耳一直在嗡嗡作响。他注意到响声已经断断续续地响了3年多，但最近变得更严重了。当被问到他的听力情况时，他承认他很难理解别人在嘈杂的地方说什么。他否认耳胀和头晕。他经常打网球，身体健康。测试结果如表8.19-8.22和图8.6所示。
The order of test administration is important. Because you performed immittance testing and TEOAEs first, you knew that the patient’s tympanic membrane is mobile, that the ART pattern is abnormal in the right ear, and that the outer hair cells of the right ear do not appear to be functioning normally. You were able to obtain this information before the patient provided any information through subjective testing. The patient’s asymmetry in high-frequency audiometric thresholds and poor WRS in the right ear combined with the objective results suggest a retrocochlear pathology and warrant an ENT referral for additional testing. The patient’s report of unilateral tinnitus, the abnormal ART pattern, the asymmetry in puretone thresholds, and the apparent rollover in the patient’s right-ear word recognition are all suggestive of retrocochlear dysfunction. Taken in isolation, each might be sufficient for you to make a referral for a medical evaluation. However, having consistent results from several tests allows you to be more confident in your recommendation and provide the ENT with as much information as possible.
测试执行的顺序很重要。因为你首先进行了导抗测试和TEOAEs，你知道病人的鼓膜是活动的，右耳的ART模式是不正常的，右耳的外毛细胞似乎不能正常工作。在获得患者主观测试所提供的信息之前，您可以获得这些信息。患者高频听力阈值不对称，右耳WRS差，结合客观结果，提示耳蜗后病变，并保证耳鼻喉科转诊进行额外检测。患者的单侧耳鸣报告、异常ART模式、纯音阈值不对称以及患者右耳单词识别的明显翻转均提示耳蜗后功能障碍。在孤立的情况下，每一个都可能有助于你转诊进行医疗评估。但是，几项测试获得一致的结果，您可以更加确信自己的转诊建议，并向ENT提供尽可能多的信息。
Case 6
案例6
CASE HISTORY
病史
Mr. José Gonzalez, age 24, was seen today for an audiologic evaluation. He was just hired as a clerk for a federal judge and therefore has to undergo a rigorous physical examination, including a hearing test. Mr. Gonzalez denies any hearing difficulties, tinnitus, dizziness, or aural fullness. He reports that he is in great health and is currently training for a marathon.
现年24岁的何塞·冈萨雷斯先生今天进行了听力检查。他刚刚被联邦法官聘为书记员，因此必须接受严格的身体检查，包括听力测试。冈萨雷斯先生否认任何听力障碍、耳鸣，头晕或耳胀。他说，他的身体很好，目前正在为马拉松训练。
Based on the testing you have completed thus far you would expect this patient has normal hearing. His case history and all objective tests suggest hearing within normal limits. You proceed with your puretone and speech testing.
根据目前已完成的测试，您预计该患者听力正常。他的病史和所有客观测试表明听力在正常范围内。你继续进行纯音和语音测试。
Results from your testing are shown in Tables 8.23–8.26 and Figure 8.7.
测试结果如表8.23-8.26和图8.7所示。
The puretone and speech audiometry results are surprising because they conflict with the results from the objective tests. Specifically, ARTs and TEOAEs within normal limits are not consistent with a measured profound hearing loss in the left ear. Your first thought is nonorganic hearing loss. You decide to reinstruct Mr. Gonzalez and retest the left ear air-conduction thresholds. This time you tell Mr. Gonzalez that you are going to play some more beeps in his left ear and all he has to do is press the button when he hears the tone. He nods and appears to understand the instructions. You begin retesting at 1,000 Hz and Mr. Gonzalez does not respond at the maximum limits of the audiometer. As you enter the booth to reinstruct again, Mr. Gonzalez informs you that he never heard a beep and has been waiting for you to present the tone. In fact, he notes that he has not heard anything from the left earphone. You check the headphone jack connections and find that the left headphone jack is unplugged. After you plug in the jack and retest Mr. Gonzalez’s left ear, you obtain thresholds within normal limits. It is important to note that the patient history and the objective test results were not consistent with the subjective test results. Although having a well-constructed test battery is important, you also want to be flexible with your test order and be vigilant to notice inconsistencies between test results as you go. This flexibility would allow you to notice the unplugged headphone jack sooner and save time and frustration for you and Mr. Gonzalez.
纯音和语音测听结果令人惊讶，因为它们与客观测试的结果相冲突。具体来说，在正常范围内的ARTs和TEOAEs与左耳的重度听力损失是不一致的。你首先想到的是非器质性听力损失。你决定重新指导冈萨雷斯先生，重新测试左耳的空气传导阈值。这一次，你告诉冈萨雷斯先生，你要在他的左耳里再放一些哔哔声，他只要听到哔哔声就按下按钮。他点点头，似乎听懂了指令。你在1000赫兹开始重新测试，冈萨雷斯先生在听力计的最大分贝没有反应。当你再次进入测听室进行指导时，冈萨雷斯先生告诉你，他从来没有听到过哔的一声，他一直在等着你说出那个声音。事实上，他注意到他没有听到任何从左耳机发出的声音。检查耳机插孔连接，发现左侧耳机插孔未插拔。在插入插孔并重新测试冈萨雷斯的左耳后，就可以获得正常范围内的阈值。需要注意的是，患者的病史和客观测试结果与主观测试结果不一致。尽管拥有一个构造良好的测试组块很重要，但是您也希望灵活地执行您的测试顺序，并且在您进行测试时要注意到测试结果之间的不一致性。这种灵活性可以让你更快地注意到耳机插孔没有插电，为你和冈萨雷斯节省时间和挫败感。
LIMITATIONS OF THE AUDIOLOGIC TEST BATTERY
听力测试组块的局限性
The combination of well-validated test measures, precise patient instruction, careful scoring, and application of the cross-check principle should result in accurate diagnostic and rehabilitative decisions for most patients. It is important to remember, however, that real-world patients usually do not present as textbook cases. The case studies contained in this chapter and the diagnostic criteria published in the audiologic test literature should be treated as guidelines rather than absolute rules. High-quality diagnosis depends on both the construction of a high-quality test battery and skill in interpreting ambiguous or seemingly contradictory test results. A good rule for daily practice is this: When test results seem in disagreement, first check the tester (rule out the clinician’s own mistakes); then, check the equipment (rule out malfunction or equipment performing out of calibration); and finally, check the patient (rule out patient error or pseudohypacusis).
经过充分验证的测试措施、精确的患者指导、仔细的评分和交叉检查原则的应用相结合，应能为大多数患者做出准确的诊断和康复决策。然而，重要的是要记住，现实世界的患者通常不会以教科书的形式出现。本章中包含的案例研究和听力测试文献中公布的诊断标准应该被视为指南而不是绝对规则。高质量的诊断既取决于高质量测试组块的构建，也取决于对含糊或看似矛盾的测试结果的解释能力。日常实践的一个很好的规则是：当测试结果似乎不一致时，首先检查测试仪（排除临床医生自己的错误）；然后，检查设备（排除故障或设备执行未校准）；最后检查患者（排除患者错误或假性催眠）。
MAKING REFERRALS
转诊
No audiologist is an island. A team approach to the treatment of hearing and balance disorders, particularly in pediatric patients, is often indicated. Appropriate treatment of a patient seen for audiologic evaluation may require consultation with specialists including (but not limited to) allergists, endocrinologists, neurologists, occupational therapists, ophthalmologists, psychiatrists, rheumatologists, and speech-language pathologists. Referral of pediatric patients with hearing loss to an ophthalmologist is particularly important; approximately 50% of children born with severe-to-profound hearing loss also have abnormalities of vision (American Academy of Pediatrics, 2007).
没有听力学家是孤岛。一种治疗听力和平衡障碍的团队方法，特别是在儿童患者中。对听力学评估的患者进行适当的治疗可能需要咨询专家，包括（但不限于）过敏科医生、内分泌科医生、神经科医生、职业治疗师、眼科医生、精神病学家、风湿病学家和言语病理学家。将听力受损的儿童患者转诊给眼科医生尤为重要；大约50%的先天性重度极重度听力丧失的儿童也有视力异常（美国儿科学会，2007）。
Referral for Medical Otolaryngologic Evaluation
转诊进行耳鼻喉科医学评估
The most common referral made by audiologists is to a medical doctor. Sending a patient to an otolaryngologist, primary care physician, or pediatrician is indicated if the audiologic evaluation reveals evidence of an underlying medical condition. Symptoms may include ear pain, bleeding or drainage from the ear (otorrhea), tympanometric abnormality without known etiology, or physical abnormality observed during otoscopy. Patients who report frequent ear infections, fluctuating or sudden hearing loss, or balance disturbance should also be seen by a medical professional (see Table 8.27). Newly identified hearing loss is also reason for referral. Although some audiologists undertake cerumen management in their own practice, many others prefer to refer to an otolaryngologist or the patient’s primary care physician for removal of impacted wax. Children who exhibit a previously undiagnosed hearing loss or who exhibit delays in speech or language development should be seen by a pediatric otolaryngologist or developmental pediatrician prior to any audiologic management.
听力学家最常见的转诊是看医生。如果听力学评估显示有潜在疾病的证据，则应将患者送往耳鼻喉科医生、初级保健医生或儿科医生。症状可能包括耳痛、耳朵出血或引流（耳漏）、鼓室检查异常（病因不明）或耳镜检查时观察到的身体异常。报告反复耳部感染、心律不齐或突然失聪或平衡紊乱的患者也应由医疗专业人员进行检查（见表8.27）。新发现的听力损失也是转诊的原因。尽管一些听力学家在他们自己的实践中进行了耵聍处理，但许多其他人更愿意咨询耳鼻喉科医生或患者的初级护理医师，以去除受影响的耵聍。在进行听力学治疗前，儿童耳鼻喉科医生或发育儿科医生应先对先前未确诊的听力损失或言语或语言发育迟缓的儿童进行检查。
With respect to the audiologic test battery, disagreement among objective and subjective test measures which cannot be resolved as tester, equipment, or patient error is indicative of need for medical referral. Abnormally poor speech scores relative to the audiogram, asymmetric hearing loss, and reports of aural fullness and/or tinnitus are other signs of possible serious ear disease which should be evaluated by a physician.
关于听力测试组块，客观和主观测试措施之间的分歧不能作为测试者、设备或病人错误来解决，这表明需要进行医疗转诊。与听力图相关的异常差的语言评分、不对称听力损失、耳胀和/或耳鸣报告是其他可能的严重耳疾的迹象，应由医生进行评估。
Referral for Auditory Processing Evaluation
听力处理评估转诊
Disagreement between objective and subjective hearing tests may be reason to refer a patient for an evaluation of auditory processing. Patients with apparently normal peripheral auditory function may still have difficulty processing complex signals such as speech. These individuals often report that they can hear well, but have difficulty understanding what others are saying, particularly in the presence of noise. Tests of speech perception in noise such as the Bamford– Kowal–Bench Speech-in-Noise Test (BKB-SIN; Etymo -tic Research, 2005), Quick Speech-in-Noise Test (QuickSIN; Etymo -tic Research, 2001), and Hearing in Noise Test (HINT; Nilsson et al., 1994) may help to confirm this difficulty. If performance on speech-in-noise tests is poor, particularly if the audiogram is normal or suggests good hearing sensitivity, auditory testing should be performed. Parental concerns about a child’s ability to process speech in noisy or reverberant places may also indicate need for APD evaluation. Auditory processing evaluation and rehabilitation are described in Chapters 27 to 30 of this textbook.
客观和主观听力测试的不一致可能是推荐患者进行听力处理评估的原因。外周听觉功能明显正常的患者可能仍然难以处理复杂的信号，如语音。这些人经常说他们能很好地听到，但是对别人说的话，尤其是在有噪音的情况下，理解能力很差。噪声中的言语知觉测试，如班福德-科瓦尔-斯台噪声中的言语知觉测试(BKB-SIN;词源学研究，2005)，快速语音噪声测试(QuickSIN;词源学研究，2001)，噪声测试中的听力(提示;尼尔森等人，1994)可能有助于证实这一差异。如果在噪音测试中表现不佳，特别是在听力记录正常或显示听力敏感性良好时，应进行听力测试。父母对孩子在嘈杂或混乱环境中处理语言能力的担忧也可能表明需要进行APD评估。听觉处理评估和康复在这本教科书的第27至30章描述。
Referral for Vestibular Evaluation
前庭评估转诊
Formal vestibular evaluation may be indicated by patient history or results of a doctor’s physical evaluation. The symptoms of vestibular dysfunction are often obvious to the patient, but he or she may not realize that they are a relevant part of the audiologic case history. Therefore, it is important for any audiologist’s case history form to include questions specifically asking about vertigo or balance problems to elicit this information. Reports of dizziness (particularly recent dizziness), vertigo, or feelings of spinning suggest need for evaluation by a vestibular specialist and/or otolaryngologist. Reports of imbalance (as opposed to vertigo) are also reason for medical evaluation, but may require treatment by a physical therapist rather than an audiologist. Other specific indicators for vestibular testing include history of exposure to ototoxins (particularly vestibulotoxins, such as aminoglycoside antibiotics), bacterial meningitis, or perilymph fistula. Patients with genetic conditions such as Pendred syndrome, Usher syndrome, and CHARGE syndrome are also candidates for vestibular referral. Pediatric patients presenting with inner ear dysplasia of unknown origin or delays in motor or balance skills should also be referred. Vestibular evaluation (Chapter 21) and rehabilitation (Chapter 22) are discussed in detail later in this textbook.
正式的前庭评估可以通过患者病史或医生的体格检查结果来表示。前庭功能障碍的症状对患者来说往往是显而易见的，但他或她可能没有意识到它们是听力学病史的一个相关部分。因此，对于任何听力学家的病例记录表来说，重要的是包含这些问题，尤其是专门询问有关眩晕或平衡问题的问题来引出这些信息是很重要的。头晕（特别是最近的头晕）、眩晕或旋转感觉的报告提示需要前庭专家和/或耳鼻喉科医生进行评估。不平衡的报告（与眩晕相反）也是医学评估的原因，但可能需要由物理治疗师而不是听力学家治疗。前庭检查的其他特殊指标包括耳毒素（特别是前庭毒素，如氨基糖苷类抗生素）、细菌性脑膜炎或外淋巴管炎的接触史。遗传性疾病患者如Pendred综合征、Usher综合征和Charge综合征的患者也可作为前庭转诊的候选者。儿童原因不明的内耳发育不良或运动或平衡技能延迟也应转诊。前庭评估（第21章）和康复（第22章）将在本教材后面详细讨论。
Referral for Genetic Evaluation
遗传评估转诊
Roughly 0.1% to 0.3% of children are born with some hearing loss, and about half of these cases appear to be related to some genetic cause. Of these genetic cases, about 30% are syndromic, meaning that they can be related to sets of clinically recognizable features or symptoms known to cooccur. The remaining 70% of genetic hearing loss cases are characterized by hearing loss in isolation and are referred to as nonsyndromic. Approximately 50% of cases of autosomal recessive nonsyndromic hearing loss are due to mutation in gap junction beta-2 (GJB2), the gene that encodes the gap junction protein connexin 26 (CX26) (Kelsell et al., 1997). Hearing loss resulting from connexin 26 mutation is typically present from birth and can range in severity from moderate to profound. More than 90 mutations of GJB2 have been identified.
大约0.1%到0.3%的儿童天生有听力损失，其中大约一半的病例似乎与某些遗传原因有关。在这些遗传病例中，大约30%是综合征，这意味着它们可能与一系列临床上可识别的特征或已知的症状有关。其余70%的遗传性听力损失病例以孤立性听力损失为特征，称为非综合征性听力损失。大约50%的常染色体隐性非综合性听力损失是由于缝隙连接β-2（gjb2）突变造成的，缝隙连接β-2是编码缝隙连接蛋白26（cx26）的基因（Kelsell等人，1997年）。由连接蛋白26突变引起的听力损失通常在出生就存在，其严重程度从中度到重度不等。已鉴定出90多个GJB2突变。
Testing for GJB2 mutation is an emergent field in early hearing loss identification. Quick and low-cost screening methods have been developed and are available through many medical centers and genetic testing service providers. It should be noted that many patients and parents may be hesitant to undergo formal genetic testing because of fears that their health insurance costs may increase if a genetic predisposition to disease is found. For these patients, a consultation with a genetic counselor may be preferable to a referral to a medical geneticist.
检测gjb2突变是早期听力损失鉴定的一个新兴领域。快速和低成本的筛选方法已经开发出来，并可通过许多医疗中心和基因检测服务提供商获得。应该注意的是，许多患者和家长可能会犹豫是否接受正式的基因测试，因为他们担心如果发现遗传易感性，他们的医疗保险费用可能会增加。对于这些患者，咨询遗传顾问可能比转诊给医学遗传学家更好。
SUMMARY
总结
A well-constructed and consistently administered test battery provides the foundation for high-quality audiologic diagnosis and care. The case studies contained within this chapter are intended to underscore the importance of the diagnostic battery in terms of test selection, test order, and use of cross-checks. When test discrepancies cannot be resolved or a patient presents with complaints or symptoms outside of the audiologist’s scope of practice, a referral to an appropriate specialist is indicated. Consultation with other specialists can also help the audiologist form a more complete picture of a patient’s hearing health, increasing the likelihood of success in audiologic or vestibular rehabilitation.
一个构造良好且持续使用的测试组块为高质量的听力诊断和护理提供了基础。本章包含的案例研究旨在强调诊断组块在测试选择、测试顺序和交叉检查使用方面的重要性。如果测试差异无法解决，或者患者出现了超出听力师实践范围的主诉或症状，则需要转诊到合适的专科医生。咨询其他专家也可以帮助听力专家对患者的听力健康进行更全面的了解，增加听力或前庭康复成功的可能性。
FOOD FOR THOUGHT
引人深思的事
For each of the cases presented in this chapter, what are some ways that the test order may have affected your thought process regarding the potential diagnoses?
对于本章中提出的每个案例，测试顺序可能通过哪些方式影响您对潜在诊断的思考过程？
How might you modify the order that you administer tests in your test battery, or change particular tests, based on individual patient factors such as age or cognitive ability?
您如何根据患者的个人因素，如年龄或认知能力，修改您在测试单元中执行测试的顺序，或更改特定的测试?
Imagine that you notice a colleague in your clinic administering tests in an order that you think is unhelpful or omitting tests that would help to differentiate between possible diagnoses. What might you say or do to suggest a different test battery or test sequence? What evidence might you use to support your suggestion?
Chapter8 Diagnostic audiology
第八章 诊断听力学
INTRODUCTION
简介
Diagnostic audiology is the use of audiologic tests to determine the location of a problem in the auditory system and, in many cases, further insights about the disorder. Diagnostic audiology can be likened to crime shows you may watch on television. Each test serves as a clue that points toward a diagnosis of the patient’s hearing disorder. However, if individual tests (or clues) are examined without taking other evidence into consideration, a wrong conclusion might be made. For audiologists to make correct diagnoses, an audiologic test battery is used. A test battery is a series or combination of tests used to assess the auditory system. For most of the examples in this chapter, we will limit discussion of diagnostic audiology to tests that are commonly performed in an audiologic clinic, including puretone air-conduction and bone-conduction testing, speech testing, tympanometry, acoustic reflex thresholds (ARTs, also called middle-ear muscle reflexes [MEMRs]), and otoacoustic emissions (OAEs). These tests are discussed more fully in other chapters in this textbook and we refer you to these chapters for specific test procedures and norms (see Table 8.1); however, it is important to understand how to utilize these tests synergistically to arrive at an accurate diagnosis for each patient. Audiometric tests are used in conjunction with one another to help reinforce or, alternatively, rule out the diagnosis of a particular type of hearing loss or the site of lesion. The test battery is useful for determining some, but not all, auditory disorders.
诊断听力学是使用听力学测试来确定听觉系统中问题所在的位置，在许多情况下，进一步了解疾病。诊断听力学可以比作你可能在电视上看到的犯罪节目。每一项测试都是一条线索，指向对患者听力障碍的诊断。然而，如果在不考虑其他证据的情况下对个别测试（或线索）进行检查，可能会得出错误的结论。为使听力学家作出正确的诊断，使用了听力学测试组块。测试组块是一系列或组合的测试，用于评估听觉系统。对于这一章里大多数的例子，我们将把诊断听力学的讨论局限于听力学临床中常见的测试，包括纯音空气传导和骨传导测试、言语测试、鼓室测量、听觉反射阈值（ARTS，也称为中间值），耳肌反射（MEMS）和耳声发射（OAES）。这些测试在本教材的其他章节中进行了更全面的讨论，我们将向您介绍这些章节，以了解具体的测试程序和规范（见表8.1）；然而，重要的是要了解如何协同利用这些测试，以达到对每个病人的准确诊断。听力测试与其他测试一起使用，以帮助加强或排除对特定类型听力损失或病变部位的诊断。测试组块有助于对于确定部分但不是全部的听觉障碍。
Following a brief introduction to the cross-check principles employed by audiologists, this chapter will utilize a case study format. Finally, we will address the limitations of the test battery and discuss situations when referrals for other testing are indicated.
在简要介绍听力学家采用的交叉检验原则之后，本章将使用案例研究格式。最后，我们将讨论测试组块的局限性，并讨论被推荐的其他测试情况。
CROSS-CHECKING TEST RESULTS
交叉检验测试结果
The major reason that an audiologist uses a diagnostic battery is to be able to check the results of individual tests with each other. The idea that “the results of a single test are cross-checked by an independent test measure” is referred to as the cross-check principle (Jerger and Hayes, 1976, p. 614). Since the cross-check principle was first proposed, many manuscripts have revisited the concept as new diagnostic tests have been developed and different test batteries have been proposed to diagnose specific disorders. The goal of comparing the results of two or more tests is to increase the rate of correct identification of disorders (hit rate) and to decrease the rate of diagnosing a disorder when no disorder exists (false alarm rate) (Turner, 2003).
听力学家使用诊断组块的主要原因是能够相互检查单个测试的结果。“单次测试的结果通过独立的测试措施进行交叉检验”的观点被称为交叉检验原则（Jerger和Hayes，1976年，第614页）。自从交叉检验原则被首次提出以来，随着新的诊断测试的开发和不同的测试组块被提出来诊断特定的疾病，许多手稿重新审视了这一概念。比较两个或两个以上测试结果的目的是提高疾病的正确识别率（命中率），并在不存在疾病的情况下降低疾病的诊断率（误报率）（Turner，2003年）。
Cross-checks for Puretone Air Conduction
纯音空气传导的交叉检查
If you only obtained puretone air-conduction thresholds then you would not be able to accurately diagnose the type of hearing loss. Air-conduction audiometry is normally cross checked with bone-conduction audiometry or tympanometry to rule out a conductive component of the hearing loss. If a difference greater than 10 dB exists between the airconduction and bone-conduction thresholds at the same frequency, a conductive component is indicated. Similarly, air-conduction thresholds for an ear may be within normal limits; however, if a tympanogram for that ear falls outside of the norms for middle-ear pressure and compliance (e.g., Jerger Type B or Type C), a conductive component may be present. ARTs can reveal more information about the type of loss based on the pattern of responses obtained, thus serving as an additional cross-check for puretone air conduction.
如果您只获得纯音空气传导阈值，那么您将无法准确诊断听力损失的类型。空气传导测听术通常与骨传导测听术或鼓室测听术交叉检查，以排除听力损失的传导成分。如果在相同频率下，空气传导阈值和骨传导阈值之间存在大于10分贝的差异，则表明存在传导性因素。同样，耳朵的空气传导阈值可能在正常范围内；但是，如果该耳朵的鼓室图不符合中耳压力和顺应性规范（例如，Jerger B型或C型），则可能存在传导性因素。ARTS可以根据所获得的响应模式显示更多关于损失类型的信息，从而作为纯音空气传导的额外交叉检查。
Cross-checks for Puretone Audiometry
纯音测听交叉检查
When puretone audiometry (air- and bone-conduction testing) suggests a significant air–bone gap, tympanometry and ARTs can be used to reinforce the diagnosis of the conductive element and to contribute to a specific diagnosis. OAEs also can be used as a cross-check of puretone audiometry. OAEs are used to assess the health of the outer hair cells of the cochlea, but their measurement may be affected by disorders in the conductive pathway. An audiologist might use OAEs as a cross-check to aid in potentially ruling out a nonorganic hearing loss, to verify outer hair cell function and the degree of cochlear hearing loss, and to further assist with the diagnosis of conductive components, auditory neuropathy spectrum disorder (ANSD), and other retrocochlear disorders. In addition, ARTs have been used to cross check puretone audiometry (Jerger et al., 1974), although other objective tests, such as tone-burst–stimulated auditory brainstem response (ABR), are considered to be better procedures for estimating hearing thresholds. Acoustic reflexes can be used to help identify the presence of hearing loss in young children as well as in adults with language and/or cognitive issues that may reduce the validity and reliability of behavioral measures (Hall, 2010). Acoustic reflexes can also be used to determine site of lesion within the auditory pathway, specifically in differentiating between cochlear and retrocochlear pathologies.
当纯音听力测试（空气和骨传导测试）显示有明显的气骨间隙时，鼓室测量和ARTS可用于加强对传导元件的诊断，并有助于特定诊断。OAE也可以用作纯音测听的交叉检查。OAE用于评估耳蜗外毛细胞的健康状况，但其测量可能会受到传导通路紊乱的影响。听力学家可以使用OAE作为交叉检查，以帮助排除潜在的非器质性听力损失，验证外毛细胞功能和耳蜗听力损失程度，并进一步帮助诊断传导成分、听神经病频谱障碍（ANSD），以及其他耳蜗后疾病。此外，ARTS还被用于交叉检查纯音听力测试（Jerger等人，1974年），尽管其他客观测试，如短纯音刺激听觉脑干反应（ABR）被认为是评估听力阈值的更好方法。声音反射可用于帮助识别幼儿和成人中存在的听力损失，语言和/或认知问题可能会降低行为测量的有效性和可靠性（Hall，2010年）。听觉反射也可以用来确定听觉通路中的损伤部位，特别是在区分耳蜗和耳蜗后病理学方面。
Cross-check for Puretone Average
纯音平均值的交叉检查
A puretone average (PTA) is usually calculated as the average of the air-conduction thresholds at 500, 1,000, and 2,000 Hz for each ear. Normally, the PTA should agree with the speech recognition threshold (SRT), meaning that the PTA and SRT should be within 10 dB of one another in the same ear. One instance in which the audiometric thresholds may cause the PTA to be greater than the SRT by 10 dB is when the audiogram configuration is sharply sloping or sharply rising. In such instances, it is preferable to use a two-frequency PTA by averaging the two lowest (e.g., best) thresholds at 500, 1,000, and 2,000 Hz. The two-frequency PTA should then be in agreement with the SRT. Another instance in which the PTA and SRT may disagree is if a person is malingering or intentionally exaggerating a hearing loss. Outside of these special circumstances, we would expect SRTs and PTAs to be highly correlated (except when language or foreign language is a major factor). This allows us to use the SRT to validate the PTA (American Speech-Language-Hearing Association, 1988).
纯音平均值（PTA）通常计算为每只耳朵500、1000和2000赫兹的空气传导阈值的平均值。正常情况下，PTA应与语音识别阈值（SRT）一致，这意味着PTA和SRT应在同一耳朵中彼此之间的10分贝范围内。当听力图表现急剧倾斜或急剧上升时，听力阈值可能导致PTA大于SRT 10 dB。在这种情况下，最好通过在500、1000和2000 Hz下平均两个最低（例如，最佳）阈值来使用双频PTA。两个频率的PTA应与SRT一致。另一个PTA和SRT可能不同意的情况是，如果一个人在恶意或故意夸大听力损失。除这些特殊情况外，我们希望SRT和PTA高度相关（除非语言或外语是主要因素）。这允许我们使用SRT来验证PTA（美国语言听力协会，1988年）。
Considerations for Assessing Speech Understanding
评估言语理解的注意事项
One additional step that audiologists may take to address a patient’s complaint of not being able to understand speech in noisy environments is to administer a speech-in-noise test in addition to the word recognition testing in quiet. Although this is technically not a cross-check, the addition of a speech-in-noise test, especially with sentence stimuli, will provide a more realistic test environment to evaluate a common patient complaint. The puretone audiogram does not necessarily correlate with the amount of difficulty a listener will have in noise (Killion and Niquette, 2000). In addition, when word recognition testing is performed in quiet at a single speech presentation level, no guarantee exists that the test is measuring the patient’s maximum speech understanding (Wiley et al., 1995).
听力师在处理病人在嘈杂环境下听不懂说话的主诉时，可能采取的另一个步骤是，除了在安静的环境下进行单词识别测试外，还要进行语音噪声测试。虽然这在技术上不是一个交叉检查，但是添加一个语音噪声测试，特别是有句子刺激的，将提供一个更现实的测试环境来评估一个常见的病人诉求。纯音听力图并不一定与听者在噪音中的困难程度相关（Killion and Niquette, 2000）。此外，当单词识别测试在单一的语音表达水平上安静地进行时，并不能保证该测试能够测量患者最大的语音理解能力(Wiley et al.，1995)。
Cross-check Considerations for Pediatric Testing
儿科测试的交叉检查考虑因素
For children, it is imperative that the audiologist utilize the cross-check principle. The behavioral responses obtained via behavioral observation audiometry (BOA) or visual reinforcement audiometry (VRA) are considered to be accurate reflections of a child’s true thresholds when these tests are conducted carefully (Madell and Flexer, 2008). However, because children often do not respond as consistently or as quickly as adults, it is possible that a child’s behavioral responses may still be elevated compared to actual thresholds. As a result, the audiologist may judge the child’s responses as unreliable (Baldwin et al., 2010). Regardless of the judged reliability of such measures, audiologists should use objective tests such as OAEs and tympanometry as cross-checks for pediatric behavioral responses (Baldwin et al., 2010; Littman et al., 1998; Madell and Flexer, 2008). In addition, OAEs and acoustic reflexes have been shown to be good cross-checks for ABR in young children (Berlin et al., 2010; Stach et al., 1993). The Joint Committee on Infant Hearing Position Statement (JCIH; American Academy of Pediatrics, 2007) also recommends that electrophysiological measures be employed as a cross-check for behavioral response audiometry for children younger than 6 months chronological age. The statement further stresses the importance of obtaining behavioral thresholds as soon as possible using the most age-appropriate method “to cross check and augment physiologic findings” (American Academy of Pediatrics, 2007, p. 910).
对于儿童来说，听力学家必须利用交叉检查原则。通过行为观察测听（BOA）或视觉强化测听法（VRA）获得的行为反应被认为是这些测试仔细进行时儿童真实阈值的准确反映（Madell和Flexer, 2008）。然而，由于儿童的反应往往不像成年人那样一致或快速，因此，与实际阈值相比，儿童的行为反应仍有可能升高。因此，听力学家可能会判断孩子的反应是不可靠的（Baldwin et al.， 2010）。不管这些测量方法的判断可靠性如何，听力学家都应该使用客观测试，如OAEs和鼓室测压法，作为儿童行为反应的交叉检查（Baldwin et al.， 2010;Littman等，1998;Madell和Flexer, 2008）。此外，OAEs和声学反射已被证明是幼儿ABR的良好的交叉检查（柏林等，2010;Stach等，1993）。婴儿听力联合委员会立场声明（JCIH;美国儿科学会，2007年）也建议使用电生理测量作为6个月以下儿童行为反应测听的交叉检查。声明还强调了使用最适合年龄的方法“交叉检查和增强生理机能”尽快获得行为阈值的重要性（美国儿科学会，2007年，第910页）。
Electrophysiological Tests as Cross-checks
作为交叉检查的电生理测试
Although beyond the scope of this chapter, it should be noted that certain electrophysiological tests can be used to cross check behavioral measures, as well as to cross check each other and to help confirm diagnoses of certain disorders (Bachmann and Hall, 1998; Berlin et al., 2010; Gravel, 2002; Hall and Bondurant, 2009; Stapells, 2011). For example, Berlin et al. (2010) discussed the use of cross-checking test results to diagnose ANSD: “ . . . the presence of a [cochlear microphonic] or reversing waves at the beginning of the trace does NOT make a diagnosis of ANSD . . . without the cross-check of middle-ear muscle reflexes (MEMR), OAEs, and an ABR latency-intensity function” (p. 32). For further information about these tests, the reader is referred to the chapters that discuss electrophysiological tests in the text. Table 8.2 summarizes many of the cross-check tests that are used in audiology.
尽管超出了本章的范围，但应注意的是，某些电生理测试可用于交叉检查行为测量，相互交叉检查，并有助于确定某些疾病的诊断（Bachmann和Hall，1998年；Berlin等人，2010年；Gravel，2002年；Hall和Bondurant，2009年；Stapells，2011年）。例如，Berlin等人（2010）讨论了交叉检查测试结果在诊断ANSD中的应用：“…在跟踪开始处有[耳蜗微音]或反向波不能诊断为ANSD。…没有中耳肌肉反射（MEMR）、OAES和ABR潜伏期强度功能的交叉检查（第32页）。关于这些测试的更多信息，读者可以参考本文中讨论电生理测试的章节。表8.2总结了听力学中使用的许多交叉检查测试。
Order of Tests Administered
测试执行顺序
Although we acknowledge that there is considerable variability in test protocols across clinics, we recommend that testing begin with the objective tests unless contraindicated. At least two major advantages can be found for testing objective measures first. The first advantage is that the audiologist will have a good idea of the type and degree of hearing loss before beginning the subjective tests. The second advantage is the reduced risk for misdiagnosis of disorders such as ANSD and vestibular schwannoma, as well as failure to detect a patient who is malingering. One caveat needs to be discussed with conducting objective tests first. With rising costs of health care we need to be cautious that we are doing tests that are necessary. It is possible that, if the patient’s hearing is completely normal (with no listening complaints) or the patient is profoundly deaf (with previous documentation to support the initial diagnosis), tests such as OAEs and acoustic reflexes will be unlikely to add further information about the patient (but we would
recommend that everyone have tympanometry for the reasons previously discussed). We think that a nonorganic component is more likely to be present during subjective testing and may not be discovered until cross-checked with objective tests. For these reasons, we recommend objective testing first. A suggested testing order is shown in Figure 8.1. Nevertheless, it should be noted that some audiologists advocate giving puretone and speech tests first when the patient may be more alert and can actively respond to these tests and then relax during the objective tests.
尽管我们承认，不同诊所的测试方案存在相当大的差异，但我们建议测试从客观测试开始，除非有禁忌。首先测试目标度量至少有两个主要优点。第一个优点是，在开始主观测试之前，听力学家会对听力损失的类型和程度有很好的了解。第二个优点是减少了误诊ANSD和前庭神经鞘瘤等疾病的风险，以及未能发现病人装病。需要与进行客观测试讨论一个注意事项。随着医疗保健费用的不断上涨，我们需要谨慎地进行必要的测试。如果患者听力完全正常（无听力方面的主诉，或者患者严重失聪（以前的文档支持初步诊断），诸如OAES和声学反射等测试将不可能增加关于患者的进一步信息。（但我们会的基于前面讨论过的原因，建议每个人都做鼓室检查）。我们认为，非有机成分在主观测试中更可能存在，只有与客观测试交叉检查才能发现。出于这些原因，我们首先建议进行客观测试。建议的测试顺序如图8.1所示。然而，应该注意的是，一些听力学家提倡在患者可能更加警觉的时候，首先进行纯音和语音测试，并且能够积极应对这些测试，然后在客观测试中放松。
Beyond the Test Battery
测试组块以外
Although the use of a test battery is important, it is also vital for the audiologist to remember the case history and the patient complaints. In some ways, one may consider this patient-reported information to be a cross-check of the test battery itself. The case studies presented below demonstrate examples of diagnostic audiology in action.
尽管使用测试组块很重要，但对于听力师来说，记住病史和患者投诉也是至关重要的。在某些方面，人们可能认为这个患者报告的信息是对测试组块本身的交叉检查。下面的案例研究证明了诊断听力学的应用实例。
CASE STUDIES
案例研究
The importance of objective testing in conjunction with subjective tests can be seen through the use of case examples. The following cases are a range of examples that highlight the use and benefit of incorporating the cross-check principle into your clinical practice. The cases will be presented with a brief history and test results. A discussion of potential difficulties and challenges in interpreting the audiologic data is incorporated within each case. Although there is an ideal order to the test sequence as noted above, the order of tests often varies because of tester preference, patient complaint, age of patient, and so on. Therefore, the test order in the cases below varies to better represent what may be actually done in a clinical setting or what a student clinician may see from his/her supervisors. For the sake of simplicity, all of the cases represent testing with standard audiologic procedures on adults. As you read through each case, we encourage you to make a decision tree based on the order of tests presented in the case and then think about how you might decide to change the test order. It is important to review your clinical decision making periodically to ensure that your practice is evidence based.
客观测试和主观测试的重要性可以通过使用实例来看出。以下案例是一系列例子，突出了交叉检查原则在临床实践中的应用和益处。这些案例将提供简要的病史和测试结果。在每个案例中都包含了对解释听力数据的潜在差异和挑战的讨论。尽管如上所述，测试顺序是理想的，但由于测试人员的偏好、患者投诉、患者年龄等原因，测试顺序通常会有所不同。因此，以下案例中的测试顺序会有所不同，以更好地表示在临床环境中实际执行的操作，或学生临床医师从其导师那里看到的操作。为了简单起见，所有的病例都是用标准的听力学程序对成人进行测试。在您阅读每个案例时，我们鼓励您根据案例中提供的测试顺序制作决策树，然后考虑如何决定更改测试顺序。定期回顾你的临床决策很重要，以确保你的实践是基于证据的。
Case 1
案例1
CASE HISTORY
病史
Mr. Ang Kim, age 36, is being seen today after he failed the hearing screening at his company’s health fair. His medical history is generally unremarkable, though he reports that he is just getting over a sinus infection and recently underwent surgery for a slipped disc in his back. You have backto-back patients today and because there is nothing remarkable in his history you decide to do a quick audiogram and send him on his way. Results from otoscopy, puretone, and speech audiometry are shown in Table 8.3 and Figure 8.2.
现年36岁的金先生因未能通过公司体检中的听力筛查。他的病史一般都不起眼，尽管他说自己刚从鼻窦感染中恢复过来，最近因腰椎间盘突出而做了手术。你今天一个接一个的病人，因为他的病史没有什么特别的，你决定做一个快速的听力检查，然后送他回去。耳镜检查、纯音和言语测听结果如表8.3和图8.2所示。
With subjective information alone this audiogram could indicate many things. For example, you may inaccurately diagnose Mr. Kim with a collapsed ear canal, an impacted cerumen plug, or a perforated tympanic membrane without additional tests to cross check your findings. Despite your busy schedule, you decide you need more information to make an accurate diagnosis, so you perform objective testing to cross check your subjective results. The results from immittance testing and OAE testing are shown in Tables 8.4–8.6.
仅凭主观信息，这张听力图就能说明许多问题。例如，如果没有额外的测试来交叉检查你的发现，你可能会用耳道塌陷、耵聍堵塞或鼓膜穿孔来错误地诊断金正恩。尽管你的日程很忙，你还是决定需要更多的信息来做出准确的诊断，所以你会进行客观的测试来交叉检查你的主观结果。导容抗测试和OAE测试结果如表8.4-8.6所示。
With this information, you have several different tests to confirm your finding of a conductive hearing loss. The Type B tympanogram in the right ear reveals normal ear canal volume but no mobility. The normal ear canal volume suggests that the TM is not perforated and there is no cerumen plug. The pattern of the ARTs is consistent with a right conductive pathology. TEOAEs in the right ear are absent which is expected with a conductive pathology.
有了这些信息，你就有了几个不同的测试来验证你的传导性听力损失的发现。右耳B型鼓室图显示耳道容量正常，但无活动能力。正常耳道容积提示鼓膜未穿孔，也没有耵聍。ARTs的模式与正确的传导病理学是一致的。右耳未见TEOAEs，这是一种传导性病变。
The combination of the subjective and objective test results correctly leads you to suspect otitis media with effusion and would require a referral for Mr. Kim to a physician. In this case, you are able to make an appropriate referral based on the information you obtained from a test battery incorporating both objective and subjective measures.
主观和客观测试结果的结合正确地导致您怀疑分泌性中耳炎，需要将金先生转诊给医生。在这种情况下，您可以根据从包含客观和主观测量的测试组块中获得的信息进行适当的转诊。
Case 2
案例2
CASE HISTORY
病史
Mrs. Edith Jones, age 77, is being seen today for a hearing test. She does not perceive a listening difficulty but her husband was recently fit with hearing aids and insisted she have her hearing checked too. Her medical history is remarkable for high blood pressure and type 2 diabetes which are both controlled by medication.
现年77岁的伊迪丝·琼斯夫人今天正在接受听力测试。她没有感觉到听力障碍，但她的丈夫最近配戴了助听器，并坚持让她也检查一下听力。她的病史因高血压和2型糖尿病而引人注目，这两种疾病都是由药物控制的。
You conduct a basic audiometric evaluation on Mrs. Jones. Results for otoscopy are displayed in Table 8.7 and puretone and speech audiometry results are shown in Figure 8.3.
你对琼斯夫人做一个基本的听力评估。耳镜检查结果见表8.7，纯音和言语测听结果见图8.3。
If you decide not to proceed with further tests to cross check your results, you might diagnose this patient with normal hearing in the right ear and a mild conductive hearing loss in the left ear. You might then refer Mrs. Jones to an Ear Nose and Throat physician who would order more tests.
如果你决定不进行进一步的测试来交叉检查你的结果，你可能会诊断这个病人右耳听力正常，左耳轻度传导性听力丧失。然后你可以把琼斯太太介绍给耳鼻喉科的医生，他会安排更多的检查。
Instead, you decide to proceed and include additional tests in your battery that would provide a cross-check. We will review those results next (see Tables 8.8–8.10).
相反，您决定继续进行，并在您的组块中包含额外的测试，以提供交叉检查。接下来我们将回顾这些结果（见表8.8-8.10）。
These results suggest that Mrs. Jones has normal hearing that contradicts your puretone findings. Normal results on tympanometry, ARTs, and TEOAEs are not consistent with a mild conductive hearing loss. With this information you review the patient’s case history and puretone findings again and realize that the apparent conductive hearing loss in the right ear is likely the result of a collapsing ear canal. It is not uncommon for the pressure of the supra-aural headphones to cause the canal to collapse, particularly in older patients for whom the cartilage supporting the ear canal is soft. To confirm this finding you decide to retest Mrs. Jones with insert earphones. When you repeat your audiogram using the insert earphones, you measure Mrs. Jones’s rightear air-conduction thresholds at 5 or 10 dB HL for all frequencies tested. You are able to report to Mrs. Jones that her hearing appears to be normal!
这些结果表明琼斯夫人的听力正常，这与你的纯音听阈发现相矛盾。鼓室压力测量，ARTs和TEOAEs的正常结果和轻度传导性听力损失不一致。利用这些信息，您可以回顾患者的病史和纯音情况，并再次认识到，明显的传导性听力损失，在右耳可能是由于耳道坍塌。压耳式耳机的压力导致耳道塌陷的情况并不少见，尤其是对那些支持耳道的软骨较软的老年患者。为了证实这一发现，你决定用插入式耳机重新测试琼斯夫人的听力。当你用插入式耳机重复你的听力记录时，你测量琼斯夫人在所有频率，空气传导阈值均在5或10dBHL。你可以向琼斯太太报告她的听力似乎很正常！
Both cases 1 and 2 highlight the importance of using objective test results in conjunction with subjective test results to avoid misdiagnosis. Both audiograms revealed similar test results but very different actual diagnoses, which were only confirmed with the use of objective testing.
案例1和案例2都强调了将客观测试结果与主观测试结果结合使用以避免误诊的重要性。两种声像图的检测结果相似，但实际诊断有很大差异，只能通过客观检测加以证实。
Case 3
案例3
You receive the following case, accompanied by a patient-signed medical information release, via fax. A recently graduated audiologist at a practice across town just finished testing Mr. Smith and would like a second opinion.
您将通过传真收到以下病例，并附上患者签署的相关就诊信息。一个刚刚毕业的听力师在镇上的一个诊所里刚刚完成了对史密斯先生的测试，他想听听你的的意见。
CASE HISTORY
病史
Mr. Aaron Smith, 49, reports that he can no longer hear out of his left ear. He works in construction and reports that a transformer overloaded at his work site yesterday, resulting in a loud explosion which he believes caused his hearing loss. Mr. Smith reported that his hearing was normal prior to the explosion. He denies any aural fullness, tinnitus, or dizziness. His medical history is unremarkable and he denies any other injuries as a result of the explosion. Results of the audiologic testing are shown in Tables 8.11–8.13 and Figure 8.4.
49岁的亚伦·史密斯说，他的左耳已经听不见了。他在建筑工地工作，他说，昨天他的工地上有一个变压器超载，导致了一场巨大的爆炸，他认为这导致了他的听力损失。史密斯先生报告说，爆炸前他的听力正常。他否认有任何耳胀、耳鸣或头晕。他的病史并不引人注目，他否认还有其他爆炸造成的伤害。听力学检查结果见表8.11-8.13和图8.4。
You call the audiologist right away and review your concerns with her. Both the air-conduction and bone- conduction thresholds for the left ear need to be masked. Cross-hearing should have occurred before those thresholds were obtained. Furthermore, you would not expect to obtain no response for bone-conduction testing with the bone oscillator on the left side when the hearing in the right ear is evidently normal. You also note that the PTA and the SRT are not in agreement for the left ear. ARTs are better than you would expect them to be (given the puretone thresholds for the left ear). A patient with hearing thresholds at 90 dB HL would be expected to have ARTs in the range of 95 to 125 dB HL at 500 Hz and 100 to 125 dB HL at 1,000 and 2,000 Hz (Gelfand et al., 1990). Lastly, the WRS was only obtained at 20 dB SL in the left ear, yet Mr. Smith’s WRS is 76%, which is better than expected. According to Dubno et al. (1995), a patient with a PTA of 90 dB HL would have an expected WRS of less than 24%. You suggest to the other audiologist that obtaining TEOAEs would further assist in this diagnosis. The audiologist performs TEOAEs (see Table 8.14) to confirm the suspected diagnosis and faxes the results to you.
你马上打电话给听力学家，和她讨论你的担忧。左耳的空气传导阈值和骨传导阈值都需要掩蔽。交叉听证应该发生在这些阈值之前。此外，在右耳听力明显正常的情况下，用左侧的骨振子进行骨传导测试时，你不会期望没有反应的。您还注意到，左耳的PTA和SRT不一致。ARTs比你想象的要好（考虑到左耳的纯音阈值）。听力阈值为90 dB HL的患者，在500 Hz时的ARTs值为95至125 dB HL，在1000和2000 Hz时的ARTs值为100至125 dB HL （Gelfand et al.，1990）。最后，左耳的WRS仅为20 dB SL，Smith先生的WRS为76%，好于预期。根据Dubno等人（1995）的研究，PTA为90 dB HL的患者预期WRS小于24%。您向其他听力师建议，做TEOAEs检查将进一步有助于诊断。听力师执行TEOAEs（见表8.14）来确认疑似诊断并将结果传真给您。
Based on the pattern of test results, your suspected diagnosis is nonorganic hearing loss. Let us review the facts. First, the patient’s left ear thresholds are elevated above where cross-hearing should have occurred. Second, the objective test results (tympanometry, ARTs, and OAEs) reveal no conductive component and suggest that outer hair cells are functioning normally. However, the puretone and speech audiometry results suggest a severeto-profound unilateral hearing loss in the left ear, which is inconsistent with the objective results. Several crosschecks identified inconsistencies (e.g., ARTs and puretones; PTA–SRT agreement; puretone thresholds and OAEs). At this point, you could suggest that the audiologist reinstruct the patient and then retest the left ear, masking appropriately. If the thresholds for the left ear are still elevated, a Stenger test could be performed to confirm the accuracy of the left puretone thresholds. If the Stenger test result is positive (i.e., the patient does not respond to the stimulus), this would be additional evidence that the apparent hearing loss is nonorganic. This case highlights the importance of a high-quality diagnostic battery (including masking where appropriate) and use of cross-checks to confirm our test results. 根据测试结果，您的疑似诊断是非器质性听力损失。让我们回顾一下事实。首先，患者的左耳阈值高于应该发生交叉听力的地方。第二，客观的测试结果（鼓室测量、ARTs和OAEs）显示没有传导性损失因素，表明外毛细胞功能正常。然而，纯音和言语测听结果显示左耳有严重的单侧听力损失，与客观结果不符。几个交叉检查发现了不一致性（例如，ARTS和纯音；PTA–SRT协议；纯音阈值和OAEs）。此时，你可以建议听力师重新指导病人，然后重新测试左耳，适当掩蔽。如果左耳的阈值仍在升高，则可以进行一次斯登格氏试验【斯登格氏试验（检伪装的单侧耳聋）】，以确认左耳纯音阈值的准确性。如果斯登格氏试验结果为阳性（即患者对刺激没有反应），这将是严重的听力损失是非器质性的。本例强调了高质量诊断组块（包括适当的掩蔽）和使用交叉检查确认测试结果的重要性。
Case 4
案例4
CASE HISTORY
病史
Ms. Ashley Jackson, age 27, has had hearing problems all of her life. She has been told by her audiologist that she has only a mild sensory/neural hearing loss. Her doctor always tells her that her hearing is really very good. She tried hearing aids a few years ago but she says that they did not help at all. Unfortunately, Ms. Jackson cannot hold a job because of her hearing difficulties. Her bosses always cite miscommunication problems as the reason for her dismissal. Ms. Jackson is here today to see if her hearing has changed. Tables 8.15 and 8.16 show otoscopy and tympanometry results. Figure 8.5 shows puretone and speech audiometry results.
27岁的阿什利·杰克逊生活中存在听力问题。她的听力师告诉她，她只有轻微的感音/神经性听力损失。她的医生总是说她的听力很好。几年前，她尝试过助听器，但她说它们一点用也没有。不幸的是，由于听力障碍，杰克逊女士无法保住工作。她的老板总是以沟通不畅为理由解雇她。杰克逊女士今天来看看她的听力是否有变化。表8.15和8.16显示了耳镜检查和鼓室测量结果。图8.5显示了纯音和言语测听结果。
Ms. Jackson’s puretone results appear to be consistent with the previous hearing tests in her medical record. There are some red flags that warrant additional testing, though. First, her reports of listening difficulties and communication problems in her case history suggest that she may have more than a mild sensory/neural hearing loss. Additionally, her word recognition scores are poorer than expected given her puretone thresholds. You would expect a patient with PTAs in this range to have WRS of 68% or better (Dubno et al., 1995). The next tests that should be performed are ARTs and OAEs. Tables 8.17 and 8.18 show the results of those tests.
杰克逊的纯音测试结果似乎与她之前的病历记录一致。不过，也有一些需要进行额外测试的危险信号。首先，她的病例记录中的听力障碍和沟通问题表明她可能不仅仅是轻微的感音/神经性听力损失。此外，考虑到她的纯音阈值，她的单词识别分数低于预期。您会期望此范围内的PTA患者的WRs为68%或更高（Dubno等人，1995年）。接下来应该进行的测试是ARTs和OAE。表8.17和8.18显示了这些试验的结果。
Now that you have completed your testing, you cross check your test results. First, the patient’s ARTs are not consistent with her puretone thresholds. With a mild sensory/ neural hearing loss you would expect acoustic reflexes to be present (Gelfand et al., 1990). The patient’s TEOAEs are present and robust which would not be expected based on Ms. Jackson’s puretone thresholds. These findings in conjunction with the poor WRS indicate a need for additional testing such as an ABR. You suspect that the patient has ANSD. Results of the ABR and a medical evaluation may help to confirm or rule out your suspected diagnosis. Without the addition of both ARTs and OAEs to the test battery, Ms. Jackson’s disorder might have been missed again. The recommendations for patients with ANSD or other retrocochlear pathologies are often very different from the recommendations for those who have a peripheral hearing loss. Misidentification of the site of lesion for a hearing loss like Ms. Jackson’s might result in delayed or inappropriate rehabilitation recommendations. Unfortunately, ANSD can be missed easily in clinical practice if the audiologist does not perform a thorough test battery (Smart and Kelly, 2008).
既然您已经完成了测试，那么就要交叉检查测试结果。首先，患者的ARTs与纯音阈值不一致。如果有轻微的感音/神经性听力损失，你会期望出现听觉反应（Gelfand等人，1990年）。根据杰克逊女士的纯音阈值，患者的TOAEs是存在的，并且是强大的，这是不可预期的。这些结果与较差的WR一起表明需要进行额外的测试，如ABR。你怀疑病人患有ANSD。ABR和医学评估的结果可能有助于确认或排除您的疑似诊断。如果不做ARTS和OAE，杰克逊的疾病可能会再次漏诊。对患有ANSD或其他耳蜗后病变的患者的建议通常与对外周听力损失患者的建议非常不同。对于像杰克逊女士这样的听力损失，误认损伤部位可能导致延迟或不当的康复建议。不幸的是，如果听力学家不进行全面的测试，那么ANSD在临床实践中很容易被忽略。（Smart和Kelly，2008年）。
Case 5
案例5
CASE HISTORY
病史
Mr. Don Warner, age 58, is being seen today with his primary complaint being a constant ringing in his right ear. He notes that the ringing has been present off and on for over 3 years but it has become more bothersome recently. When asked about his hearing he admits that he has difficulty understanding what others are saying in noisy places. He denies aural fullness and dizziness. He plays tennis regularly and generally is in great health. Results from your testing are shown in Tables 8.19–8.22 and Figure 8.6.
现年58岁的唐华纳今日来就诊，他的主诉是右耳一直在嗡嗡作响。他注意到响声已经断断续续地响了3年多，但最近变得更严重了。当被问到他的听力情况时，他承认他很难理解别人在嘈杂的地方说什么。他否认耳胀和头晕。他经常打网球，身体健康。测试结果如表8.19-8.22和图8.6所示。
The order of test administration is important. Because you performed immittance testing and TEOAEs first, you knew that the patient’s tympanic membrane is mobile, that the ART pattern is abnormal in the right ear, and that the outer hair cells of the right ear do not appear to be functioning normally. You were able to obtain this information before the patient provided any information through subjective testing. The patient’s asymmetry in high-frequency audiometric thresholds and poor WRS in the right ear combined with the objective results suggest a retrocochlear pathology and warrant an ENT referral for additional testing. The patient’s report of unilateral tinnitus, the abnormal ART pattern, the asymmetry in puretone thresholds, and the apparent rollover in the patient’s right-ear word recognition are all suggestive of retrocochlear dysfunction. Taken in isolation, each might be sufficient for you to make a referral for a medical evaluation. However, having consistent results from several tests allows you to be more confident in your recommendation and provide the ENT with as much information as possible.
测试执行的顺序很重要。因为你首先进行了导抗测试和TEOAEs，你知道病人的鼓膜是活动的，右耳的ART模式是不正常的，右耳的外毛细胞似乎不能正常工作。在获得患者主观测试所提供的信息之前，您可以获得这些信息。患者高频听力阈值不对称，右耳WRS差，结合客观结果，提示耳蜗后病变，并保证耳鼻喉科转诊进行额外检测。患者的单侧耳鸣报告、异常ART模式、纯音阈值不对称以及患者右耳单词识别的明显翻转均提示耳蜗后功能障碍。在孤立的情况下，每一个都可能有助于你转诊进行医疗评估。但是，几项测试获得一致的结果，您可以更加确信自己的转诊建议，并向ENT提供尽可能多的信息。
Case 6
案例6
CASE HISTORY
病史
Mr. José Gonzalez, age 24, was seen today for an audiologic evaluation. He was just hired as a clerk for a federal judge and therefore has to undergo a rigorous physical examination, including a hearing test. Mr. Gonzalez denies any hearing difficulties, tinnitus, dizziness, or aural fullness. He reports that he is in great health and is currently training for a marathon.
现年24岁的何塞·冈萨雷斯先生今天进行了听力检查。他刚刚被联邦法官聘为书记员，因此必须接受严格的身体检查，包括听力测试。冈萨雷斯先生否认任何听力障碍、耳鸣，头晕或耳胀。他说，他的身体很好，目前正在为马拉松训练。
Based on the testing you have completed thus far you would expect this patient has normal hearing. His case history and all objective tests suggest hearing within normal limits. You proceed with your puretone and speech testing.
根据目前已完成的测试，您预计该患者听力正常。他的病史和所有客观测试表明听力在正常范围内。你继续进行纯音和语音测试。
Results from your testing are shown in Tables 8.23–8.26 and Figure 8.7.
测试结果如表8.23-8.26和图8.7所示。
The puretone and speech audiometry results are surprising because they conflict with the results from the objective tests. Specifically, ARTs and TEOAEs within normal limits are not consistent with a measured profound hearing loss in the left ear. Your first thought is nonorganic hearing loss. You decide to reinstruct Mr. Gonzalez and retest the left ear air-conduction thresholds. This time you tell Mr. Gonzalez that you are going to play some more beeps in his left ear and all he has to do is press the button when he hears the tone. He nods and appears to understand the instructions. You begin retesting at 1,000 Hz and Mr. Gonzalez does not respond at the maximum limits of the audiometer. As you enter the booth to reinstruct again, Mr. Gonzalez informs you that he never heard a beep and has been waiting for you to present the tone. In fact, he notes that he has not heard anything from the left earphone. You check the headphone jack connections and find that the left headphone jack is unplugged. After you plug in the jack and retest Mr. Gonzalez’s left ear, you obtain thresholds within normal limits. It is important to note that the patient history and the objective test results were not consistent with the subjective test results. Although having a well-constructed test battery is important, you also want to be flexible with your test order and be vigilant to notice inconsistencies between test results as you go. This flexibility would allow you to notice the unplugged headphone jack sooner and save time and frustration for you and Mr. Gonzalez.
纯音和语音测听结果令人惊讶，因为它们与客观测试的结果相冲突。具体来说，在正常范围内的ARTs和TEOAEs与左耳的重度听力损失是不一致的。你首先想到的是非器质性听力损失。你决定重新指导冈萨雷斯先生，重新测试左耳的空气传导阈值。这一次，你告诉冈萨雷斯先生，你要在他的左耳里再放一些哔哔声，他只要听到哔哔声就按下按钮。他点点头，似乎听懂了指令。你在1000赫兹开始重新测试，冈萨雷斯先生在听力计的最大分贝没有反应。当你再次进入测听室进行指导时，冈萨雷斯先生告诉你，他从来没有听到过哔的一声，他一直在等着你说出那个声音。事实上，他注意到他没有听到任何从左耳机发出的声音。检查耳机插孔连接，发现左侧耳机插孔未插拔。在插入插孔并重新测试冈萨雷斯的左耳后，就可以获得正常范围内的阈值。需要注意的是，患者的病史和客观测试结果与主观测试结果不一致。尽管拥有一个构造良好的测试组块很重要，但是您也希望灵活地执行您的测试顺序，并且在您进行测试时要注意到测试结果之间的不一致性。这种灵活性可以让你更快地注意到耳机插孔没有插电，为你和冈萨雷斯节省时间和挫败感。
LIMITATIONS OF THE AUDIOLOGIC TEST BATTERY
听力测试组块的局限性
The combination of well-validated test measures, precise patient instruction, careful scoring, and application of the cross-check principle should result in accurate diagnostic and rehabilitative decisions for most patients. It is important to remember, however, that real-world patients usually do not present as textbook cases. The case studies contained in this chapter and the diagnostic criteria published in the audiologic test literature should be treated as guidelines rather than absolute rules. High-quality diagnosis depends on both the construction of a high-quality test battery and skill in interpreting ambiguous or seemingly contradictory test results. A good rule for daily practice is this: When test results seem in disagreement, first check the tester (rule out the clinician’s own mistakes); then, check the equipment (rule out malfunction or equipment performing out of calibration); and finally, check the patient (rule out patient error or pseudohypacusis).
经过充分验证的测试措施、精确的患者指导、仔细的评分和交叉检查原则的应用相结合，应能为大多数患者做出准确的诊断和康复决策。然而，重要的是要记住，现实世界的患者通常不会以教科书的形式出现。本章中包含的案例研究和听力测试文献中公布的诊断标准应该被视为指南而不是绝对规则。高质量的诊断既取决于高质量测试组块的构建，也取决于对含糊或看似矛盾的测试结果的解释能力。日常实践的一个很好的规则是：当测试结果似乎不一致时，首先检查测试仪（排除临床医生自己的错误）；然后，检查设备（排除故障或设备执行未校准）；最后检查患者（排除患者错误或假性催眠）。
MAKING REFERRALS
转诊
No audiologist is an island. A team approach to the treatment of hearing and balance disorders, particularly in pediatric patients, is often indicated. Appropriate treatment of a patient seen for audiologic evaluation may require consultation with specialists including (but not limited to) allergists, endocrinologists, neurologists, occupational therapists, ophthalmologists, psychiatrists, rheumatologists, and speech-language pathologists. Referral of pediatric patients with hearing loss to an ophthalmologist is particularly important; approximately 50% of children born with severe-to-profound hearing loss also have abnormalities of vision (American Academy of Pediatrics, 2007).
没有听力学家是孤岛。一种治疗听力和平衡障碍的团队方法，特别是在儿童患者中。对听力学评估的患者进行适当的治疗可能需要咨询专家，包括（但不限于）过敏科医生、内分泌科医生、神经科医生、职业治疗师、眼科医生、精神病学家、风湿病学家和言语病理学家。将听力受损的儿童患者转诊给眼科医生尤为重要；大约50%的先天性重度极重度听力丧失的儿童也有视力异常（美国儿科学会，2007）。
Referral for Medical Otolaryngologic Evaluation
转诊进行耳鼻喉科医学评估
The most common referral made by audiologists is to a medical doctor. Sending a patient to an otolaryngologist, primary care physician, or pediatrician is indicated if the audiologic evaluation reveals evidence of an underlying medical condition. Symptoms may include ear pain, bleeding or drainage from the ear (otorrhea), tympanometric abnormality without known etiology, or physical abnormality observed during otoscopy. Patients who report frequent ear infections, fluctuating or sudden hearing loss, or balance disturbance should also be seen by a medical professional (see Table 8.27). Newly identified hearing loss is also reason for referral. Although some audiologists undertake cerumen management in their own practice, many others prefer to refer to an otolaryngologist or the patient’s primary care physician for removal of impacted wax. Children who exhibit a previously undiagnosed hearing loss or who exhibit delays in speech or language development should be seen by a pediatric otolaryngologist or developmental pediatrician prior to any audiologic management.
听力学家最常见的转诊是看医生。如果听力学评估显示有潜在疾病的证据，则应将患者送往耳鼻喉科医生、初级保健医生或儿科医生。症状可能包括耳痛、耳朵出血或引流（耳漏）、鼓室检查异常（病因不明）或耳镜检查时观察到的身体异常。报告反复耳部感染、心律不齐或突然失聪或平衡紊乱的患者也应由医疗专业人员进行检查（见表8.27）。新发现的听力损失也是转诊的原因。尽管一些听力学家在他们自己的实践中进行了耵聍处理，但许多其他人更愿意咨询耳鼻喉科医生或患者的初级护理医师，以去除受影响的耵聍。在进行听力学治疗前，儿童耳鼻喉科医生或发育儿科医生应先对先前未确诊的听力损失或言语或语言发育迟缓的儿童进行检查。
With respect to the audiologic test battery, disagreement among objective and subjective test measures which cannot be resolved as tester, equipment, or patient error is indicative of need for medical referral. Abnormally poor speech scores relative to the audiogram, asymmetric hearing loss, and reports of aural fullness and/or tinnitus are other signs of possible serious ear disease which should be evaluated by a physician.
关于听力测试组块，客观和主观测试措施之间的分歧不能作为测试者、设备或病人错误来解决，这表明需要进行医疗转诊。与听力图相关的异常差的语言评分、不对称听力损失、耳胀和/或耳鸣报告是其他可能的严重耳疾的迹象，应由医生进行评估。
Referral for Auditory Processing Evaluation
听力处理评估转诊
Disagreement between objective and subjective hearing tests may be reason to refer a patient for an evaluation of auditory processing. Patients with apparently normal peripheral auditory function may still have difficulty processing complex signals such as speech. These individuals often report that they can hear well, but have difficulty understanding what others are saying, particularly in the presence of noise. Tests of speech perception in noise such as the Bamford– Kowal–Bench Speech-in-Noise Test (BKB-SIN; Etymo -tic Research, 2005), Quick Speech-in-Noise Test (QuickSIN; Etymo -tic Research, 2001), and Hearing in Noise Test (HINT; Nilsson et al., 1994) may help to confirm this difficulty. If performance on speech-in-noise tests is poor, particularly if the audiogram is normal or suggests good hearing sensitivity, auditory testing should be performed. Parental concerns about a child’s ability to process speech in noisy or reverberant places may also indicate need for APD evaluation. Auditory processing evaluation and rehabilitation are described in Chapters 27 to 30 of this textbook.
客观和主观听力测试的不一致可能是推荐患者进行听力处理评估的原因。外周听觉功能明显正常的患者可能仍然难以处理复杂的信号，如语音。这些人经常说他们能很好地听到，但是对别人说的话，尤其是在有噪音的情况下，理解能力很差。噪声中的言语知觉测试，如班福德-科瓦尔-斯台噪声中的言语知觉测试(BKB-SIN;词源学研究，2005)，快速语音噪声测试(QuickSIN;词源学研究，2001)，噪声测试中的听力(提示;尼尔森等人，1994)可能有助于证实这一差异。如果在噪音测试中表现不佳，特别是在听力记录正常或显示听力敏感性良好时，应进行听力测试。父母对孩子在嘈杂或混乱环境中处理语言能力的担忧也可能表明需要进行APD评估。听觉处理评估和康复在这本教科书的第27至30章描述。
Referral for Vestibular Evaluation
前庭评估转诊
Formal vestibular evaluation may be indicated by patient history or results of a doctor’s physical evaluation. The symptoms of vestibular dysfunction are often obvious to the patient, but he or she may not realize that they are a relevant part of the audiologic case history. Therefore, it is important for any audiologist’s case history form to include questions specifically asking about vertigo or balance problems to elicit this information. Reports of dizziness (particularly recent dizziness), vertigo, or feelings of spinning suggest need for evaluation by a vestibular specialist and/or otolaryngologist. Reports of imbalance (as opposed to vertigo) are also reason for medical evaluation, but may require treatment by a physical therapist rather than an audiologist. Other specific indicators for vestibular testing include history of exposure to ototoxins (particularly vestibulotoxins, such as aminoglycoside antibiotics), bacterial meningitis, or perilymph fistula. Patients with genetic conditions such as Pendred syndrome, Usher syndrome, and CHARGE syndrome are also candidates for vestibular referral. Pediatric patients presenting with inner ear dysplasia of unknown origin or delays in motor or balance skills should also be referred. Vestibular evaluation (Chapter 21) and rehabilitation (Chapter 22) are discussed in detail later in this textbook.
正式的前庭评估可以通过患者病史或医生的体格检查结果来表示。前庭功能障碍的症状对患者来说往往是显而易见的，但他或她可能没有意识到它们是听力学病史的一个相关部分。因此，对于任何听力学家的病例记录表来说，重要的是包含这些问题，尤其是专门询问有关眩晕或平衡问题的问题来引出这些信息是很重要的。头晕（特别是最近的头晕）、眩晕或旋转感觉的报告提示需要前庭专家和/或耳鼻喉科医生进行评估。不平衡的报告（与眩晕相反）也是医学评估的原因，但可能需要由物理治疗师而不是听力学家治疗。前庭检查的其他特殊指标包括耳毒素（特别是前庭毒素，如氨基糖苷类抗生素）、细菌性脑膜炎或外淋巴管炎的接触史。遗传性疾病患者如Pendred综合征、Usher综合征和Charge综合征的患者也可作为前庭转诊的候选者。儿童原因不明的内耳发育不良或运动或平衡技能延迟也应转诊。前庭评估（第21章）和康复（第22章）将在本教材后面详细讨论。
Referral for Genetic Evaluation
遗传评估转诊
Roughly 0.1% to 0.3% of children are born with some hearing loss, and about half of these cases appear to be related to some genetic cause. Of these genetic cases, about 30% are syndromic, meaning that they can be related to sets of clinically recognizable features or symptoms known to cooccur. The remaining 70% of genetic hearing loss cases are characterized by hearing loss in isolation and are referred to as nonsyndromic. Approximately 50% of cases of autosomal recessive nonsyndromic hearing loss are due to mutation in gap junction beta-2 (GJB2), the gene that encodes the gap junction protein connexin 26 (CX26) (Kelsell et al., 1997). Hearing loss resulting from connexin 26 mutation is typically present from birth and can range in severity from moderate to profound. More than 90 mutations of GJB2 have been identified.
大约0.1%到0.3%的儿童天生有听力损失，其中大约一半的病例似乎与某些遗传原因有关。在这些遗传病例中，大约30%是综合征，这意味着它们可能与一系列临床上可识别的特征或已知的症状有关。其余70%的遗传性听力损失病例以孤立性听力损失为特征，称为非综合征性听力损失。大约50%的常染色体隐性非综合性听力损失是由于缝隙连接β-2（gjb2）突变造成的，缝隙连接β-2是编码缝隙连接蛋白26（cx26）的基因（Kelsell等人，1997年）。由连接蛋白26突变引起的听力损失通常在出生就存在，其严重程度从中度到重度不等。已鉴定出90多个GJB2突变。
Testing for GJB2 mutation is an emergent field in early hearing loss identification. Quick and low-cost screening methods have been developed and are available through many medical centers and genetic testing service providers. It should be noted that many patients and parents may be hesitant to undergo formal genetic testing because of fears that their health insurance costs may increase if a genetic predisposition to disease is found. For these patients, a consultation with a genetic counselor may be preferable to a referral to a medical geneticist.
检测gjb2突变是早期听力损失鉴定的一个新兴领域。快速和低成本的筛选方法已经开发出来，并可通过许多医疗中心和基因检测服务提供商获得。应该注意的是，许多患者和家长可能会犹豫是否接受正式的基因测试，因为他们担心如果发现遗传易感性，他们的医疗保险费用可能会增加。对于这些患者，咨询遗传顾问可能比转诊给医学遗传学家更好。
SUMMARY
总结
A well-constructed and consistently administered test battery provides the foundation for high-quality audiologic diagnosis and care. The case studies contained within this chapter are intended to underscore the importance of the diagnostic battery in terms of test selection, test order, and use of cross-checks. When test discrepancies cannot be resolved or a patient presents with complaints or symptoms outside of the audiologist’s scope of practice, a referral to an appropriate specialist is indicated. Consultation with other specialists can also help the audiologist form a more complete picture of a patient’s hearing health, increasing the likelihood of success in audiologic or vestibular rehabilitation.
一个构造良好且持续使用的测试组块为高质量的听力诊断和护理提供了基础。本章包含的案例研究旨在强调诊断组块在测试选择、测试顺序和交叉检查使用方面的重要性。如果测试差异无法解决，或者患者出现了超出听力师实践范围的主诉或症状，则需要转诊到合适的专科医生。咨询其他专家也可以帮助听力专家对患者的听力健康进行更全面的了解，增加听力或前庭康复成功的可能性。
FOOD FOR THOUGHT
引人深思的事
For each of the cases presented in this chapter, what are some ways that the test order may have affected your thought process regarding the potential diagnoses?
对于本章中提出的每个案例，测试顺序可能通过哪些方式影响您对潜在诊断的思考过程？
How might you modify the order that you administer tests in your test battery, or change particular tests, based on individual patient factors such as age or cognitive ability?
您如何根据患者的个人因素，如年龄或认知能力，修改您在测试单元中执行测试的顺序，或更改特定的测试?
Imagine that you notice a colleague in your clinic administering tests in an order that you think is unhelpful or omitting tests that would help to differentiate between possible diagnoses. What might you say or do to suggest a different test battery or test sequence? What evidence might you use to support your suggestion?
想象一下，你注意到一位同事在你的诊所里按照你认为没有帮助的顺序进行测试，或者省略了有助于区分可能诊断的测试。你会说什么或做什么来建议一个不同的测试组块或测试序列？你会用什么证据来支持你的建议？
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