International Journal of Health Sciences and Research www.ijhsr.org ISSN: 2249-9571 Case Report Usefulness of Extended Audiological Test Battery for Identifying Unsafe Type of CSOM in A Non Hospital Audiology Set Ups- Single Case Study on Secondary Acquired Cholesteatoma Prajna Bhat. J1, Shivali Appaiah. K2, Suresh Thontadarya3 1Visiting Faculty, Samvaad Institute of Speech and Hearing, Bangalore; 2PhD Candidate, Mcquire University, Australia 3Associate Professor and Research Coordinator, Dr S. R. Chandrashekhar Institute of Speech and Hearing, Bangalore University, Bangalore, India; Corresponding Author: Prajna Bhat. J ABSTRACT Background: The present paper highlights a single case study where inclusion of additional Immittance procedures such as Multifrequency tympanometry (MFT), Multicomponent (MCT) tympanometry along with single frequency tympanometry, reflexometry and other tests in a test battery approach helped in identifying a cholesteatoma / CSOM during our regular outpatient audiological procedures of a teaching college of speech and hearing. Method: Pure tone audiometry, Single probe tone frequency tympanometry, MFT, MCT, Reflexometry and Bone Conduction Auditory brainstem response (BC-ABR) were carried out. Result and conclusion: The results of Pure-tone audiometry test indicated Normal hearing sensitivity in left ear and a Profound mixed hearing loss in right ear. The single probe tone tympanometry revealed an „As‟ type and an „A‟ type tympanogram in the right and left ear respectively. MFT revealed a mass dominated pathology in the right ear and a normal resonance in the left ear which in turn correlated with the results of MCT. The threshold of right BC- ABR was obtained at 40dBnHL, which indicated cochlear hearing to be affected to a smaller degree as to be expected in advanced CSOM conditions. Compilation of results of test battery assists the Audiologist to draw the attention of the treating ENT specialist towards appropriate diagnosis, designing a suitable intervention plan, effective counselling and appropriate referrals. Key Words: Cholesteatoma, MFT, MCT, BC-ABR BACKGROUND Therefore it may be common to see a client Middle ear assessment is a regular who approach for a routine hearing check component of audiological investigation up or suggestion on amplification but would even in non hospital based audiology require proper medical/ surgical treatment centers. In India, people may approach for their middle ear condition. An audiology services directly and therefore Audiologist need to be aware of techniques may not always have had all necessary which helps him to identify non threatening investigations for their hearing problems or type of conductive hearing losses from that may not have attended regular follow ups of conditions which need immediate recommended by earlier physicians. medical attention. This would help him to International Journal of Health Sciences & Research (www.ijhsr.org) 406 Vol.9; Issue: 6; June 2019 Prajna Bhat. J et.al. Usefulness of Extended Audiological Test Battery for Identifying Unsafe Type of CSOM in A Non Hospital Audiology Set Ups- Single Case Study on Secondary Acquired Cholesteatoma counsel the client on need of consulting the to identify the disease. Observation of ENT surgeon expert in that particular area. marginal perforation or attic perforation and Cholesteatoma is one such condition and / or keratosis is often enough to rise prevalence of it in population which do not suspicion for an ENT specialist. They rely seek medical services on a regular basis is on audiological evaluation to know the high. Cholesteatoma is a progressive and degree of damage to middle ear the disease destructive disease that occurs in the middle has caused and whether inner ear is affected ear cleft and has the capacity to destroy the by disease process. Here we are discussing a soft and hard tissue surrounding it. Acquired case wherein no such prior information on cholesteatoma are commoner to be seen in disease process was available to the an audiology practice of semi urban or audiologist and the patient was also not tertiary care hospitals. Both Primary and aware of the medical condition underlying Secondary Acquired Cholesteatoma may be his hearing impairment. The patient had asymptomatic for a longer period of times failed to follow up with ENT for many years i.e without discharge or discomfort and probably due to absence of ear discharge therefore the client may have discontinued and approached audiology facility for medical treatment or have neglected to go concern on hearing loss. Therefore alertness for a follow up. Hearing impairment may be on audiologist's part in deciding to the only troubling problem for him/her. investigate the conductive hearing loss in a Cost effective methods of detail manner is essential, in the background investigations are required for developing of this patient‟s presentation of clinical countries. CSOM is considered as a public details or lack of it. health emergency in some countries by In a general clinical set up, routine WHO (WHO, 2004). [1] Berman (1995) [2] audiological evaluation includes pure-tone and Bluestein (1983) [3] reported that CSOM and speech audiometry, single component is prevalent in developing countries. The tympanometry and reflexometry. The incidence is more in lower socioeconomic information obtained through these routine conditions (Ologe & Nwawalo, 2003). [4] procedures may not be sensitive enough to WHO (2004) [1] also documents that many provide a complete clinical picture of the prevalent socio economic conditions like client‟s condition and the extent to which poverty, malnutrition etc contributes to this the disease has progressed. We incorporated prevalence. Though India does not come three additional tests i.e. Multifrequency under WHO listed countries of CSOM as a tympanometry (MFT), Multicomponent public health emergency, the prevalence tympanometry (MCT) and Bone conduction figures are still high. The figures vary auditory brainstem response (BC-ABR) regionally, 6% in South India (Rupa, Jacob CSOM. The patient had not consulted ENT & Joseph, 1999), [5] to 15.3% in Haryana in past many years as there was no (Verma, et. al., 1995). [6] CSOM is also a recurrence of ear discharge or any other major part of work of an audiology symptoms in ear. Unlike 226 Hz probe tone department in INDIA. Ramesh (2016) [7] immittance, MCT can be more informative reported that CSOM constituted 12.9% of on the status of middle ear status (mass or total cases seen in Audiology department of space occupying lesion in middle ear). MFT AIISH, Mysore for a period of August 2014 also provides information regarding the to May 2015. resonant frequency of the middle ear and Diagnosis of cholesteatoma is often any change in the resonance frequency not a requirement of audiologist‟s routine caused by the pathology. While BC work. Cytology, Radiological Investigations thresholds on pure tone are seen as evidence (CT Scans) microscopic examination of ear of whether or not cochlea is affected, often and observation of clinical signs are the CSOM itself can affect BC thresholds. BC- methods an ENT Specialist often relies on ABR therefore can help to concur with the International Journal of Health Sciences & Research (www.ijhsr.org) 407 Vol.9; Issue: 6; June 2019 Prajna Bhat. J et.al. Usefulness of Extended Audiological Test Battery for Identifying Unsafe Type of CSOM in A Non Hospital Audiology Set Ups- Single Case Study on Secondary Acquired Cholesteatoma results of pure tone audiometry regarding Tests revealed Normal hearing the cochlear reserve gain. It enables us to sensitivity in left ear and Profound mixed know whether the disease has progressed to hearing loss in right ear (Fig 1). Speech the cochlear region and the extent of reception thresholds and speech recognition progression. scores in the left ear was 5dBHL and 90% The aim of the current study is an respectively. Severity of hearing loss was a attempt to emphasize the role of an deterrent to carry out these tests in right ear. experienced Audiologist in assessment of Therefore, only speech awareness level was CSOM by use of an extended Audiological attempted with contralateral masking. The test battery. Our recommendation is to speech awareness threshold was 95 dBHL. utilize MCT / MFT routinely in all cases Speech recognition scores were obtained for who present with history of ear discharge BC presentation of speech stimulus with BC and / or conductive hearing loss on PTA, vibrator placed on right mastoid and even though he/ she may not have ear contralateral masking noise applied to left discharge currently or just have „As‟ type ear via insert transducer. The results showed tympanogram on routine immittance testing. scores to be 82% at 60 dB HL with masking noise being at 40 dB HL. CASE PRESENTATION A 23 year old female visited our B. Immittance Audiometry results; institute with the complaint of reduced Single probe tone tympanometry hearing sensitivity in the right ear. She revealed an „As‟ type in right ear and an „A‟ reported of normal hearing sensitivity in the type tympanogram in the left ear left ear. The patient reported that the hearing respectively. Ipsilateral reflexes were absent loss was noticed since one year and it was in the right side and present in left ear. gradually progressing. She gave a history of Contralateral reflexes were absent for both discharge in right ear 8 years ago and she is ears. symptom free for last two years. The client consulted an ENT Specialist recently for a C. MFT and MCT results: On MFT, routine check up during which a posterior Resonant frequency was 600Hz in the right superior retraction pocket and keratosis ear and 1000 Hz in the left ear. The results flakes were observed in the right ear. The of MCT are presented in table 1, 2 and 3. ENT evaluation recommended routine The tympanic curve changed from reduced audiological investigation for CSOM. He single peak at 226 Hz probe tone to had guarded his decision on CT scan until multipeaked at higher probe tone later.