Training transcripts
Transcript for Immittance Training Part 2
– [Nancy] Hi, and welcome to part six. My name is Nancy Pajak.
In this section, I will be going over some examples of immittance with you. We hope you find it helpful and possibly even enjoyable. You need to have a worksheet that looks like the one on your screen so that you’re able to follow along. This will also allow you to review the results after you’re finished with the tutorial. You’ll see there are 31 examples for you. I won’t be going through all of them, but I’ll talk you through a selection of them. Something that is important for you to remember before we begin going over the examples is that we’re to look today only at results of immittance screening. We know that in real life, the recommendations based on screening results will include not only immittance results, but also results from OAE screening or pure-tone screening, whichever has been used, depending upon the child’s age, and that of an otoscopic cursory evaluation. But for our purposes today, we’re just looking at the immitance results from the screening as to whether or not we’ll be rescreening or passing the children’s whose results we’re looking at. Another important point to remember while we’re going over these examples is that we’re using these results as the child’s first screening results. We’re not showing you the results of the rescreen, which happens four to six weeks later. Now, if we were to go through the very same results again saying these are the second screening results, then our referrals, our recommendations would be different. We would probably refer much more. Many of these kids were saying, okay, we’re gonna see them four to six weeks later. Then, based on what we find four to six weeks later, we’re gonna either refer to audiology or we’re gonna refer to primary care physician. But for our purposes today, please look at these results as coming from the child’s first screening episode. So let’s get started. Please go to number two on your worksheet. In example number two, we note that the child’s age is 14 years of age. Let’s go look at this child’s right ear to begin with. We look at the ear canal volume and see it’s 0.79. From the information presented in the other parts of the tutorial, we understand that 0.79 would probably be all right for a child who is 14 years of age. But let’s go to the left ear, and compare with that ear canal volume. As we have learned, just as your feet are similar sizes, your ear canal volumes will also probably be similar sizes. We look over at the left ear, and it’s 0.66, 0.79 and 0.66 are fine. They’re approximately in the same ballpark with each other. Now I’m going back to the right ear again. I see my ear canal volume is 0.79. I’ve decided that that is okay for a child who is age 14. The middle ear pressure is minus 15. I know that my middle ear pressures are fine. If they’re between minus 250 and plus 100. I know my middle ear pressure is fine. Then I look at my static compliance, my tympanic membrane compliance. Whatever you choose to, however you choose to refer to it, it’s 0.14. I know from my training, I would like to see it at least 0.2 or above. However, I have one more piece of information to add into my equation. That is the presence of an acoustic reflex. If my static compliance is less than 0.2, but if I have an acoustic reflex present, that results in a pass. So looking at my ear canal volume, my middle ear pressure, my static compliance with the presence of an acoustic reflex, I determine that right ear results are a pass. Now, let’s go over to the left ear. My ear canal volume is 0.66. For a 14-year-old, that’s fine. My middle ear pressure is minus 10. My static compliance is 0.29. My acoustic reflex is absent. It does not matter if my acoustic reflex is absent at that point because my static compliance is over 0.2. The left ear is also a pass. For this child who is age 14, both ears have passed today. The recommendation for that child at this point would be to have their hearing screened annually, unless concerns arise or a change in hearing is noted, at which point in time the child’s hearing should be evaluated sooner. This child at age 14 should also be cautioned against the use or the exposure to loud levels of noise, and the use of hearing protection. Okay, let’s move on to example number five. We note that the child’s age is age six. We go to the results from the right ear. We see the ear canal volume is 0.58. I’m gonna quickly go over, and compare it to the ear canal volume in the left ear. I see that they’re pretty similar. I know that that’s approximately a right size volume for a child who is six years of age. Back to the results in the right ear, ear canal volume is fine. Middle ear pressure. Hmm, my equipment has given me an N/A. They cannot find the value, the static compliance N/A. The equipment cannot find the value, and the acoustic reflex has been stimulated, and has not been found. I know from what I have learned in the tutorial that these results would result in a fail for this child’s right ear. Now, I go over to the left ear. Again, my ear canal volume is 0.6, I like that. Middle ear pressure minus 60. Well within the range of what is acceptable. Static compliance 0.40. Well within the range of what is acceptable, meaning I’d like to see it over 0.2, an acoustic reflex is present. So now we have a child who has failed one ear, and passed one ear. What do you do with this child? Well, I hope that you have answered by saying that we will rescreen this child in four to six weeks. This is a good time to go back, and review some information about rescreenings. Remember that when the child who was age six, who we said was gonna be rescreened in four to six, when that child is rescreened in four to six weeks, please remember to do both ears all of the components. What I mean by that is this, that the right ear is screened using immittance, using either pure tone or OAE and using otoscopy. The left ear, even though it passed the first time around, is also re-screened, using, again, the entire protocol, the otoscopy, the OAE or pure tone depending upon the age of the child. This child is age six. They have been probably screened pure tone, so unless there is a developmental delay, and also, of course, to do the immittance. Now, please, if you will look at example number six. The child is eight years of age. We look at the results from this child’s right ear. The ear canal volume is 0.75. I quickly look at the ear canal volume from the left ear. Yes, they’re very similar, I like that. Back to the right ear. The middle ear pressure is minus 30. I know that my range is minus 250 to plus 100. That middle ear pressure is fine. My static compliance is 0.77. That tells me that that static compliance is acceptable for our screening purposes. At this point, I do not need to take into account that acoustic reflex, even though it’s present. Remember, we only use the acoustic reflex in determining or understanding when the child has passed or failed if the static compliance is less than 0.2. So I’m happy to say that this 8-year-old child’s right ear would be a pass for the immittance part of the screening that was done today or at the time this child was seen. Now, let’s look at the left ear. Ear canal volume 0.77. I like it. Middle ear pressure minus 195, a little bit more, but still within my range of what is acceptable, static compliance 0.76. And even though the acoustic reflex is absent, this child continues to pass the immittance portion of the hearing screening. Now, we must remember to take into account the OAE results or the pure tone results before we determine whether or not ultimately this child is a pass or fail. Since we don’t have that, we’re just basing these referrals today on immittance results only. We’re assuming that because the child is eight years of age, that pure tones screening was done, but we don’t know. So we’re gonna say that this child is a pass. We’re going to suggest that this child’s hearing be rescreened in one year, that they use hearing protection if they’re exposed to high levels of noise. But that hearing should be rescreened at any time if concerns arise or a change in hearing is noted. Okay, on we go to example number 10. We have an 11-year-old child. Results from the right ear of the immittance screening show us that this child’s right ear has an air canal volume of 0.38. Hmm, that raises a flag in my head. That seems small for a child who is 11 years of age. Let me compare it with the left ear. 1.02, I was right. There is a difference between those ear canal volumes beyond what I would find acceptable. Just as my feet are both size six and 1/2. I want my ear canal volumes to be pretty similar in size. Let me go on with looking at the results obtained in the right ear. The middle ear pressure is recorded as N/A. That means the equipment was not able to find a value that it could reflect static compliance N/A, same thing. Equipment could not find a value. It was going to put something in that space. So it says not applicable. Acoustic reflex was stimulated and found to be not present. I have a small ear canal volume. I have no recordable middle ear pressure, and static membrane compliance, and an absent acoustic reflex. Think about what might be going on in that ear. I know that before you have done immittance, you have also otoscopy. I wonder when you looked in with your otoscope, if you were able to clearly visualize the tympanic membrane. My guess is that you were not able to. However, we know that doesn’t matter if we can see the tympanic membrane or not due to cerumen present presence. What we do know is that we stop the screening. If there is a foreign object that is viewed, or if there is active drainage from the ear. With the ear canal volume being 0.38, my guess is that there is impacted cerumen within that ear canal. However, let’s go over to look at the left ear. We see an ear canal volume of 1.02, I know from my history of screening that that’s probably pretty typical of a child who is 11 years of age. The middle ear pressure is minus 10. Well within what I’d like to see it to be static compliance, 0.55, that looks great, and an acoustic reflex present. The left ear would be a pass. The right ear would be a fail. Because both of these ears are attached to the same child, the entire child will be referred for a rescreen in four to six weeks. We know at that time that both ears on that child will be rescreened using all of the screening tools, otoscopy, immittance, and then either, otoacoustic emissions or pure tones. Again, this child’s 11 years of age, most likely pure tones, unless there is a developmental delay of some sort. At this point in this screening, I may ask the child, do you hear better out of one ear than the other? Most likely this child is going to indicate that he hears best outta his left ear. If this child when rescreened in four to six weeks fails again on the right ear, this child will be referred to the primary care physician for intervention. We are now looking at example 12. We note that the child is five years of age. The results from the immittance screening for the right ear for this child shows an ear canal volume of 0.76. I like it. That sounds good. Let me quickly compare to the left ear, 0.81, very similar. Back to the right ear, middle ear pressure minus 210. Well, that’s more than what I have seen before, but we still know that it has to be minus 250 before for our purposes, this child fails to screening. So I have a good ear canal volume, a middle ear pressure that is within the range of typical, and a static compliance of 0.25. I don’t need to look at the acoustic reflex because I know that this child has already failed, or I’m sorry, already passed this immittance portion of the screening. But it’s there, I look at it, it confirms what I believe, which is at the right ear is a pass. Alright, over to the other side. Left ear, ear canal volume 0.81, I like it. Middle ear pressure, hmm, N/A. The equipment was not able to record a value within the range where it is able to screen. Static compliance, same thing, N/A, cannot give me a value, and an acoustic reflex is absent. I know when I see the N/A that I’m probably gonna rescreen that child right away again. I’m gonna remove the probe. I’m gonna put the probe back in, and I’m going to get a second screening result. If the second screening result yields the same type of results, which is N/A, N/A. Now I’ve just confirmed that I trust much better the results that have been obtained, and I know that the left ear is a fail, but I wonder why. Let’s see. I’ve looked into the ears with the otoscope. I could see the ear canals. It’s not a problem with cerumen. There’s no foreign object. The equipment cannot give me a middle air pressure or a static compliance. So I know that I’m gonna rescreen the child in four to six weeks. It’s my guess, and it’s only a guess. It’s not for us to diagnose, but I’m guessing that there’s something back behind the eardrum, possibly fluid that is keeping this eardrum from moving as well as we would like it to move, and hence forth, the equipment is saying, nope, I cannot find a value for you. So I’m going to rescreen this child in four to six weeks, and hope that this problem has mediated itself in the left ear, knowing that if it has not, this child will be referred to the primary care physician for care. Now, please skip over example 13, 14, 15, 16, and look at number 17. We have a child who is age three, and we have noted that during the otoscopy, tubes were visible in both ears. Alright, let’s go look at results. Right ear. We have an ear canal volume of 0.64. Well, that would probably be pretty acceptable for a little kid who’s three. Let me compare it to the left ear. Oh, here we have 3.90. What does that suggest? To me it suggests that the tube in the left ear, I can suspect is open or patent. The tube in the right ear that was visualized, I’m going to guess, is either extruded or is clogged with debris. Let me stay with the right ear just for a minute. The ear canal volume, even though a tube is there would suggest that it’s been extruded or is clogged with debris. The equipment cannot yield a middle ear pressure. It cannot yield a static compliance, and an acoustic reflex is absent. That tells me that this is a fail, and that that child will need to be rescreened. Let’s go over to look at the left ear. We see an ear canal volume of 3.90 with the tube that was visible. That suggests to me that that tube is open and doing its job. Although the equipment again yields a middle ear pressure of N/A and a static compliance of N/A, and acoustic reflex for N/A, this immittance result for this ear today with the tube present would suggest that that child is a pass. And that is the difference between having an open tube and a tube that is not open. Now, let’s talk about this kid just for a little a bit. Because they have tube, it suggests that this child is at risk for having hearing loss. There’s obviously been a history of middle ear problems because the ear, nose and throat physician, and the parents have gone ahead, and have had the child receive tubes. So my self as a screener, I’m going, hmm, one tube is closed, one tube is open. There’s a history of concern. I’m not going to wait and rescreen this child in four to six weeks because of the child’s history. I’m going to refer this child today. I’m going to skip over the rescreen, tell the parents that one of the tubes appears to be needing physician’s attention, and refer the child to the physician based on what are the initial screening results for this child. I hope that makes sense as to why we’re doing that. Let me stay on example number 17 to make one more point. Let’s suppose that the ear canal volume in the right ear, instead of being 0.64 had been similar to the ear canal volume obtained on the left ear. Let’s say it was 3.7. So now we’ve looked in the child’s ears, we’ve seen tubes in both ears, and we get large ear canal volumes in both ears. We know that a 3-year-old wouldn’t typically have an ear canal volume of 3.7 or 3.9. So this leads us to suspect that both tubes are open, and doing their job. The equipment’s reading not only the ear canal volume of the ear canal, but going through and reading the space of the middle ear cavity, and possibly even an open eustachian tube. So now we have a little kid who I’m going to say passes immittance in both ears with large volume readings indicating or suggesting that the tubes are working well. This is a little person that we want to follow more carefully because they’re at risk for hearing loss based on a history of chronic monilia problems for which the ear, nose, and throat physician and parents have opted to insert tubes. I’m going see this little person again, not in a year, but in three months. Run them through the screening again to see if the tubes are still in place and working properly. Think of the difference of if we said, oh yeah, we’ll see this little kid back in a year. They’re doing fine. Let’s say that we’re doing our screening in September, and that everything is fine. Let’s say that we’re not going to screen this little person again until September. Many children are followed very well by their primary care physicians or their ear, nose, and throat physicians. However, some children are not followed well, meaning they may have moved to a new community. They don’t have a primary care physician arranged, and they may go a year without having to have a doctor’s attention for any reason. Hence for their ears are not looked in, and the are not visualized. If we were to wait a year, lets say that these tubes came out in December, and let’s say that the middle ear problems reoccurred, and let’s say that along with the presence of the middle ear fluid hearing loss occurred. We could be missing this little person sitting in the developmental preschool, classroom, the child development center, playgroup, et cetera, et cetera, for December, January, February, March, April, May, June, July, August, September for many, many months. Now, not saying that that’s going to happen, but our job as screeners is to follow the little people with tubes just a bit more often. See them every three months, see how they’re doing. Let the parents know the results. Let the physician know the results. It’s added value to what information can come from the hearing screening that will allow these little people to continue to hear well, even though they’re under physician’s care. Onto example number 20. Oh, we have so many interesting ears to look at. Here’s a child who’s five, and during the cursory otoscopic examination, a tube was visible in the child’s left ear. Let’s see what we got for results. Right ear, ear canal volume 3.19. I know that that is a large ear canal volume for a five-year-old. That’s a large ear canal volume for an adult. Let’s see what else the equipment tells me. Middle ear pressure, not applicable. Static compliance, not applicable. Acoustic reflex, absent. Hmm, what’s going on? Well, could it be that there was a tube in the right ear that was not visible? Yes, it could be that there was a tube in the right ear that was not visible by the person who was looking into the child’s ears. It could be that that tube is there and open. Hmm, what else could it be? Could it be that there’s a perforation of the tympanic membrane? You bet. 3.19 tells me that there’s something going on with the tympanic membrane. Most probably either a perforation or a patent tube. But I know one thing that is not a pass for me at this point because I could not view a tube. Let’s see what the left ear has going. The left ear, I saw a tube in there. Ear canal volume 0.77. Okay, I know that that is too small of a volume to have that tube be open in a 5-year-old, especially with an ear canal volume of 3.19 in the other ear. I’m guessing that that tube is either out of the tympanic membrane or the tube is clogged with debris. But my middle ear pressure is plus 15. Because it doesn’t have a negative in front it, everything is plus. So it’s positive 15. I know that’s okay, minus 250 to plus 100. Oh, and look at this, static compliance is 0.92. That eardrum is moving beautifully, and just to verify everything, there’s an acoustic reflex present. So even though there’s a tube in the left ear that’s either extruded or filled with debris, that left ear is holding its own, that eustachian tube is aerating the middle ear cavity, the eardrum is moving well. Okay, what to do here? What I’m going to do is I know that this child, first and foremost, is a rescreen and four to six weeks. I may ask the child, do you have tubes in your ears? The child may or may not know. They may say, I have no tubes. They may say, I have tubes. They may look at you like, what are you talking about? But I know that I’m going to, at this point in time, rescreen the child in four to six weeks, and this is why. I either have a perforation or a patent tube in the right ear. If it’s a perforation, that perforation may have just happened, and it may heal itself and the ear may maintain it’s good work just as the left ear has done with the tube that’s either out or plugged. So at this point, I’m gonna say about this child, I’m gonna rescreen in four to six weeks. I need more information. I’ll know after four to six weeks, I’ll either refer or something will have changed, and the child will be a pass in both ears at this point in time. Let’s do something a bit different with example number 27. First of all, let’s all go to example number 27. You see we have a child who is four years of age, but we’re going to give you not only the results from the first screening in example A, but we’re going to look at the results of the second screening in example B. Okay, let’s go back to 27 A. 4-year-old child first screening, right ear, ear canal, volume 1.46. Hmm, kind of a big ear canal volume. Let’s look at what happened in the left ear. 0.61 for an ear canal volume that is much more reasonable for a little kid who’s four. So what’s going on in the right ear? Well, let’s take a look. No middle ear pressure or static compliance could be displayed by the equipment, and an acoustic reflex was stimulated and not present. Okay, one of two things. I didn’t see a tube when I looked in while I was doing my cursory otoscopic inspection. So it could be that the child has a perforation or there could be a tube that’s hidden someplace in there behind a little bit of wax or just out of where I looked in its placement in the eardrum. Left ear, let’s see. Ear canal volume 0.61, I like that, middle ear pressure minus five, that’s very much within the range of acceptable. Static compliance, 0.19. Hmm, that’s a little bit low, but look it, there is an acoustic reflex present. So I know that the left ear passes, the right ear fails. So my recommendation is going to be, let’s see this child again in four to six weeks. Now please go to 27 B. Four to six weeks later, same child, still four years of age, no birthday has happened. Ear canal volume in the right ear is 0.50, oh, boy. Middle ear pressure still can’t be displayed. Static compliance can’t be displayed, and acoustic reflex is absent. Let’s go just look at the left ear again. Ear canal volume is 0.57 as compared with 0.41. You know that’s about the same. That’s still pretty good. I’m looking at the first screening results versus the second screening results for the left ear. So ear canal volume was 0.61, second screening 0.57. That hasn’t changed. That’s pretty typical. Middle ear pressure was minus five. Now it cannot be displayed. Static compliance cannot be displayed. Acoustic reflex is absent. Okay, what’s happened here? I’m going to speculate and it’s just speculation. What really happens here is that this child is referred for medical care. Now, that’s all that our job as screeners is, just to say, this child did not pass the screening. This child goes on to the primary care physician, the ear, nose, and throat doctor, or audiology. In this instance, when immittance screening results are a fail, they’re going first to the primary care or ear, nose and throat physician, whoever’s providing the medical intervention. So I know that by looking at the child’s second screening results, that both ears are a fail. Now, I’m going to guess what’s going on here. I bet, or I believe, or it’s possible that during the first screening results, the 1.46 ear canal volume was reflective of possibly a perforation in the ear canal that resulted after a tube was extruded. That tympanic membrane healed, the perforation was healed, which it typically will do within, oh, one to two weeks after having been perforated. It is healed itself, but in this little person, the eustachian tubes have not been able to stand up, do their job and aerate the middle ear cavities. Henceforth, something is behind the ear drums. Again, I’m gonna guess that it’s fluid, not my job to diagnose, but I’m going to guess for my own sake that there’s possibly fluid back behind the ear drums, and that this little person’s eardrums cannot move well, and I need to refer physician, which is what I’m going to do at this point. So that’s one of the benefits of being able to look at the child’s first screening results versus the child’s second screening results. At this point in time, this little person is gonna be referred to their primary care physician, and put on my list to rescreen in four to six weeks. Why? Why do I need to see them again? To make certain that the child has been able to see their physician, and to see that there is a plan in place so that this little person’s hearing is not compromised due to middle situations. Please move now to example 29. We’re almost to the end of the examples that we’re going to visit about today. In example, 29, we have noted that the child is three years of age, and there is a tube visible in the right ear. Now, please look at how these results are displayed. Each manufacturer will display their results in a slightly different way, but nonetheless, the information we need is available to us. Look on the right side, which is where the right results are for this piece of equipment. So we have the right ear on the right side. Let’s start with the ear canal volume. This is a 3-year-old who has a 2.0 ear canal volume reading, and there was a tube present. Let me just jump over and see what the left ear is doing. 0.7, and I didn’t see a tube in there. From my experience, my knowledge, I think that 0.7 is pretty typical for a little kid, or very acceptable, let’s say for a little kid who’s three years of age. So the ear canal volume with the tube visible in the right ear suggests to me that today this tube is in place and open. I see a peak, which means my static compliance, and the equipment can’t give it to me. It says NP. It says I can’t find a peak. Then I look at my middle ear pressure, it says NP. It says, I can’t find a middle ear pressure, and I look at my acoustic reflex, which has been stimulated at 1000 hertz, and I see NR, there’s no response. So this tells me I have a large ear canal volume, which would make sense for an open tube, which also makes sense that if the tube is open, oftentimes NP, NA, NR are going to be displayed to you by the equipment because the equipment is screening equipment. It has been told, put something, put a value in that box, in that slot, in that place on the equipment. When it cannot register an ear canal volume or a static compliance within its range of measurement, it puts that in for you, NP. So I’m looking at the right ear, and saying, okay, 2.0, ear canal volume tube visible, 3-year-old, I think that tube’s open, okay? I’m gonna look at that ear and say, well, that ear needs to be rescreened in probably three months ’cause I have a functioning tube available. But this child has another ear. Let’s look at it. Ear canal, volume 0.7. That’s pretty typical for a 3-year-old. All right, it says the middle pressure is minus 35. That tells me that that little person’s eustachian tube is working well. It’s aerating that middle ear cavity, and the middle ear pressures minus 35. The tympanic membrane compliance, the static compliance, the peak compliance is 0.6. I want it to be at least a 0.2. I’m good to go with that ear. And I see that when an acoustic reflex was stimulated at 1000 hertz one was present at 95 dB HL. Okay, I have a normally functioning left middle ear system today, and I have a patent tube in the right ear today. I’m going to say, let’s see this child again in how many months, three, unless something comes to you to tell you to do it earlier. Let’s go to example number 30. Last, but certainly not least, let’s look at the results for this little 2-year-old. I always start in the right ear. I like to get into a pattern of looking at information. My ear canal volume for this little 2-year-old is 0.4. Let me see what’s going on in the left ear. 0.4, they’re equal. That makes me feel pretty good about the ear canal volumes. Now, middle ear pressure for the right ear minus 105. Sure, that works, that’s good. Peak compliance 0.2. Hey, that’s also good. Now, oh oh, my acoustic reflex is no response when it was stimulated at 1000 hertz, but I don’t need to have that acoustic reflex present because my ear canal volume, my middle ear pressure, and my peak compliance all fall within the ranges that would be considered typical for a screening for a 2-year-old. So even though the acoustic reflex appears to be absent today, this ear is still a pass. Let’s go over to the left ear. Ear canal volume we’ve looked at, it was 0.4. I like that. Middle ear pressure minus 190. I know that’s within the range of normal. Tympanic membrane compliance or static compliance, peak compliance 0.2, I like that as well. Then I look, oh, my acoustic reflex is present for the left ear. When it was stimulated at 1000 hertz, there was one noted present at 105 dB HL. Okay, my left ear is a pass as well. I have a right ear pass, I have a left ear pass. This little kid should be seen again annually for a hearing evaluation, unless of course concerns arise or a change in hearing is noted, and two years of age is not too young to start to caution parents to protect their children’s hearing from excessive noise. Those are all the examples that we’re going to cover in this discussion today. Please feel free to go back, and go through it again if you feel it would be helpful to you. Couple reminders about what we have just done. Please remember that we looked at the results as though they were the results of the child’s first hearing screen. Hence forth, many of our recommendations were to rescreen that child in four to six weeks. I hope that you realize that if we had looked at these results as the child’s results from their second screening, that the recommendations would’ve been either to refer or they would’ve been a pass. After you screen the child two times a referral of some sort is made if the results are not a pass. If the results are a pass at the time of the second screening, which many of your kids will pass the second time. But if the results are a fail, then the child is either going to be referred to the primary care physician or to an audiologist. The purpose of screening is to find the children who have typical hearing, and to find the children whose hearing is outside the range of typical, and to refer them on to the next step, which is a diagnostic, either medical or audiological. For the sake of training, it was fine to go over just immittance results, but we know in real life that we would always take into account the results from all of the screening components, the cursory, otoscopic inspection, the immittance screening, and either the OAE, and the pure tone in determining where that child, and if that child is referred. We also need to remind you one last time that when a child is rescreened, so they’ve had their first screening, and you’re gonna see them again in four to six weeks that as we said before, each ear is redone even if they passed the first time, and each ear receives all of the screening components. Otoscopy, OAE pure tones and immittance. Thank you so much for listening.