1. 臨床上，一些聽力學檢查現象，可以有助於耳蝸性及耳蝸後聽障之鑑別，下列那些具此特性?
ABR之第四波，波間潛時延長
OAE的消失
蹬骨肌反射(Acoustic reflex)之異常消失
語言測試的rollover現象
(A) 1, 3, 4 (B) 2, 3 (C) 3, 4 (D) 1, 4
ans: C
**Common ABR waveform patterns .(書上只強調一，三，五波) A well-formed and clear wave I at a delayed latency value for the maximum stimulus intensity level is characteristic of a conductive or mixed hearing loss. When wave I is small and poorly formed, but interwave latency values are within normal limits (the wave I–V latency value is less than 4.60 milliseconds), a high-frequency sensory (cochlear) hearing loss is suspected. Delayed interwave latency values are the signature of retrocochlear auditory dysfunction. Abnormal delays between the early wave components (e.g., I–III) are consistent with posterior fossa lesions involving the eighth nerve and/or lower brainstem, whereas a prolonged III–V latency suggests intraaxial auditory brainstem dysfunction. (p1664)
…wave IV 較無臨床上的價值
** . Clinical applications reported for otoacoustic emissions (p1668)
--Diagnostic audiologic assessment in difficult-to-test, neurologically impaired, developmentally delayed, or multiply-involved children.
--Newborn and infant hearing screening
--Monitoring hearing status during medical therapy with potentially ototoxic drugs
--Verification of normal cochlear function in patients undergoing central auditory processing assessment
--Neurodiagnosis of auditory dysfunction in adults (e.g., differentiation of sensory versus neural dysfunction)
--Verification of hearing status in patients suspected of malingering (pseudohypacusis or nonorganic hearing loss)
--Early detection and confirmation of noise/music induced cochlear hearing loss.
….由此看來 OAE也可助於cochlear vs retrocochlear的判別 ，不過題旨似乎在於retrocochlear lesion 的診斷，故未入選.
**Acoustic reflex If a reflex is present, reflex decay can be measured by presenting the signal 10 dB above the reflex threshold for 10 seconds. If the contraction of the stapedial muscle cannot be maintained for at least half strength for the 10 seconds, the result of the test is a positive retrocochlear finding. Significantly increased or absent thresholds (in comparison with cochlear norms) or decay (or both) has a sensitivity of about 85% for detecting retrocochlear problems (p1902)
**rollover A decrease in speech recognition performance (in percent correct) at high signal intensity levels versus lower levels. Rollover is an audiometric sign of retrocochlear auditory dysfunction. (p1671;1902)
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2. 一位四十幾歲女性，主訴單耳聽電話不清楚，先予以純音聽力及聽阻聽力檢查，試問下列那些狀況，仍需予以施行ABR以排除聽神經瘤。
高頻率聽損(high tone loss)
純音聽力檢查正常(Normal PTA threshold)
蹬骨肌反射閥值異常升高(ART threshold elevation)
(A) 1, 2, 3 (B) 1, 2 (C) 2, 3 (D) 1, 3
ans: A
**On pure-tone air and bone conduction testing, the patient who has a vestibular schwannoma typically has a sensorineural hearing loss unless there is also a middle-ear problem, in which case a mixed loss is present. Although any hearing loss configuration may be observed, a high-frequency sensorineural hearing loss is the most common pattern (65%), and it may be either a gradual slope or an abrupt configuration37. It is important to know that 5% of patients have normal hearing (p1902)
**Significantly increased or absent thresholds (in comparison with cochlear norms) or decay (or both) has a sensitivity of about 85% for detecting retrocochlear problems (p1902)
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3. 一位母親帶一位四歲幼兒至門診，主訴其四歲兒童聽力有問題，請問下列處置何者正確?
(A) 告之5-6歲時再來，因為屆時配合度高，做聽力檢查較準
(B) 予以做耳聲傳射檢查，若為正常，便予以告之聽力正常
(C) 予以安排純音聽力檢查
(D) 予以藥物令幼兒睡著，再施予精密ABR檢查(Click刺激音)，若為正常，即囑咐家長安心
ans:c
The ABR can provide a threshold estimate of hearing in the 1,000–4,000 Hz range in young or difficult to test children. With the use of a 500 Hz tone burst stimulus, low-frequency hearing sensitivity can also be estimated. (p1099)
…..click sti. :只能大約反映 1-4kHz 的聽力
OAE:Results are interpreted in terms of the presence of cochlear function in a defined frequency region as opposed to estimating actual sensitivity thresholds.(p1099)
By a developmental age of 5 years, standard adult testing techniques can be used in audiometric assessment; however, the audiologist remains flexible in implementing and reverting to any of the behavioral pediatric test techniques. .(p1099)
....臨床上四歲也可試著作PTA
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4. 雙耳聽障患者，如能兩耳配戴助聽器，較之單耳配戴的優點好處，下列何者錯誤，
(A) 抵消頭遮蔽效用(Head shadow effect)，使高頻率聲音更高易聽清楚
(B) 聲音方向感較佳(Sound localization)
(C) 聲音響度不會有加成效果，但使得低音較清晰
(D) 增加在噪音環境下之語言辨識 (S/N )
ans:c
improved hearing with two hearing aids in noise conditions relates to the phase differences of the signal and noise occurring between the two ears. Another advantage to a second hearing aid is improved sound localization because the microphone is placed close to each ear. Binaural amplification also eliminates the head shadow effects, which reduce the high-frequency cues necessary for hearing many consonants. Furthermore, the use of a second hearing aid results in an increase in the loudness of the sound due to binaural summation31. (p1968)
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5. 耳聲傳射(OAEs)，在幼童之聽力學應用，下列何者錯誤?
(A) 新生兒聽力篩檢
(B) 無法客觀地評估聽力閥值
(C) 難以鑑別功能性聽障(functional hearing loss)
(D) 耳毒性藥物之監測
ans:C
** TABLE 132-2. Clinical applications reported for otoacoustic emissions (p1668)
--Diagnostic audiologic assessment in difficult-to-test, neurologically impaired, developmentally delayed, or multiply-involved children.
--Newborn and infant hearing screening
--Monitoring hearing status during medical therapy with potentially ototoxic drugs
--Verification of normal cochlear function in patients undergoing central auditory processing assessment
--Neurodiagnosis of auditory dysfunction in adults (e.g., differentiation of sensory versus neural dysfunction)
--Verification of hearing status in patients suspected of malingering (pseudohypacusis or nonorganic hearing loss)
--Early detection and confirmation of noise/music induced cochlear hearing loss.
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6. 有關於膽脂瘤之併發症—內耳瘻管(labyrinth fistula)，下列何者錯誤?
(A) 其發生比率約為10%
(B) 噪音可能使病患感到眩暈
(C) 施行外耳加壓之fistula test，病人一定會感眩暈，且有眼振
(D) 水平半規管之瘻管最為常見
ans:c
A labyrinthine fistula may be found in up to 10% of patients with long-standing cholesteatoma or in revision cases. Suspect a fistula in patients with chronic ear disease who have sensorineural hearing loss and/or vertigo induced by noise or pressure changes in the middle ear. Suppurative labyrinthitis with complete hearing loss and vestibular function may occur secondary to a fistula from a cholesteatoma. High-resolution, thin-section CT of the temporal bone may reveal a fistula of the semicircular canals or the basal turn of the cochlea. Fistulae of the horizontal semicircular canal are most common13. A positive fistula test with manipulation of the external canal may be present, although its absence does not preclude a fistula. (p1795)
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7. 有關耳聲傳射(OAEs)，下列何者正確?
(A) DPOAE之刺激音為Click
(B)TEOAE之刺激音為兩個純音F1, F2
(C)DPOAE之產生地點是介於F1, F2之間，且靠近F2處
(D)TEOAE具有頻率專一性，DPOAE則否
ANS:C
--Distortion-product otoacoustic emissions (DPOAEs) are produced when two pure-tone stimuli at frequencies f1 and f2 are presented to the ear simultaneously The most robust DPOAE occurs at the frequency determined by the equation 2f1-f2, whereas the actual cochlear frequency region that is assessed with DPOAE is between these two frequencies and probably close to the f2 stimulus for recommended test protocols2,17..
--Transiently evoked otoacoustic emissions (TEOAEs) are elicited by brief acoustic stimuli such as clicks or tone bursts. (P1668)
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8. 以下均是unilateral loss of peripheral vestibular function的sign，何者正確?
1. 自發性眼震，slow phase向lesion side
2. head motion時有visual disturbance (blurred vision或 disequilibrium)
3. vestibulospinal activity (past-pointing, Romberg sign) 之改變
4. Sensation of falling向lesion side
(A) 1, 2 (B) 1, 3, 4 (C) 2, 4
(D) 1, 2, 3
ANS:B
Sudden-onset Unilateral Disorders
A lesion involving one labyrinth reduces the action potentials going to the central nervous system from the affected labyrinth, resulting in a reduction of activity in the ipsilateral vestibular nucleus and a reduction in the tonic activity of oculomotor nerves that produce contralateral eye movements. If the right labyrinth is affected, slow eye movements to the right (fast-phase nystagmus to the left) and a sensation of falling to the right (P1973)
With severe loss of bilateral vestibular function, the vestibulo-ocular reflex stops working and patients experience severe visual disturbances with head movements. This condition, called oscillopsia, refers to an oscillating environment during head movements. Due to lack of vestibulo-ocular reflexes, head movements cause the visual field to slip across the retina, resulting in an inability to track visually during rapid head movements, particularly when head velocities exceed the limits of the smooth pursuit and optokinetic systems (30 to 50 degrees per second). (P1974)
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9. 對於sinus tympani中的膽脂瘤，以下那些手術法比較可以完全清除乾淨?
a. Facial recess approach
b. Intact canal wall procedure
c. Canal-wall down procedure
d. Bondy procedure
e. Oto-endoscopy
(A) a, c, d (B) a, c, e (C) c, e
(D) c, d, e
ANS:B
**Sinus tympani retraction cholesteatoma is perhaps technically the most difficult case for surgery because it involves working in an area that is usually not visualized. It is a fallacy that these cases must undergo a radical mastoidectomy for removal of disease.
With diligent dissection and use of Crabtree elevators (Storz Instrument Company, St. Louis) and the facial recess approach, disease can be removed
**there are several disadvantages of the intact canal wall approach. This approach results in an increased risk of residual and recurrent disease. Widely varying results using a canal-wall-up mastoidectomy have been reported in the literature; most larger series reveal residual cholesteatoma in 20% to 35% of cases and recurrent disease in 5% to 20%11–19. These results can be contrasted to those reported for open procedures with or without obliteration in which there is a 2% to 17% rate of residual disease and a 0% to 10% rate of recurrent disease11–13,18–21. The most common site for residual disease is the mesotympanum17. Another potential problem with the intact canal wall procedure is delayed breakdown of the posterior canal wall due to compromise of its blood supply. Other disadvantages of the intact canal wall approach are that residual disease behind the intact posterior canal may not be visible in the postoperative follow-up period, and there may be increased likelihood of leaving cholesteatoma in the lateral portion of the facial recess
The Bondy procedure34, is a variation of the modified radical mastoidectomy; this procedure is used in cases of large attic cholesteatomas. The posterior ear canal wall is removed down to the annulus superiorly and the facial ridge inferiorly. As in the modified radical mastoidectomy, the floor of the ear canal is level with the floor of the mastoid cavity. The scutum is removed, exposing the epitympanum. The cholesteatoma is marsupialized and the keratin content debrided. The medial wall of the cholesteatoma matrix is left in place over the body of the incus and malleus and seals the middle ear space. If the cholesteatoma is seen extending around the ossicles, the surgeon must be prepared to perform a standard modified radical mastoidectomy. In the Bondy procedure, the middle ear is not entered. This operation is reserved for those ears in which a large, primary acquired cholesteatoma is present but hearing is preserved and the ossicular chain and middle ear are free of disease.
**oto-endoscopy: 下面是我在網上找到的資料
DIA
可經由耳膜破洞伸進中耳腔探察以發現殘留的病灶，嚴格來說並不是一種手術，不過重點在於要能看的見才能處理吧
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10. 下列何種藥物所引起的ototoxicity，不是導因於內耳毛細胞的破壞？
(A) Neomycin
(B) Cisplatin
(C) Furosemide
(D) Aspirin
ANS:C
A) Neomycinàdamage to outer hair cells and vestibular receptors.
(B) Cisplatinà toouter hair cell damage，cell loss，degeneration of the stria vascularis and the spiral ganglion cells.
(C) Furosemideà injury to stria vascularis (potassium transport)
(D) Aspirin à maybe related to decreaed cochlear blood flow or alteration of outer hair cell function. (p1894-1896)
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11. 治療moderate stage的耳廓軟骨膜炎 (auricular perichondritis) 使用下列何種的抗生素組合最合理?
(A) Augmentin 口服加steroid耳滴劑
(B) Cleocin 口服加tarivid耳滴劑
(C) Minocin 口服加sulfadrug耳滴劑
(D) Ciproxin 口服加gentamicin耳滴劑
ANS:D
Recall the usual infecting gram-positive and gram-negative flora mentioned previously, and cover for them. In addition to anti-Pseudomonas ear drops, common choices of oral antibiotics are antistaphylococcal penicillins, first-generation cephalosporins, or one of the antipseudomonal fluoroquinolones such as ciprofloxacin. The last is an oral antibiotic effective against Pseudomonas species (p1717)
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12. 小耳症(microtia)是外耳(有時包括中耳)的發育異常。發育中止的時間，決定了最後外耳及中耳的形態。以下的外耳及中耳構造中，那一部份最晚發育成熟?
(A) auricle
(B) ear canal, lateral part
(C) ear canal, medial part
(D) middle ear
ANS:B
The deep portion of the EAC is apparent from the eighth week as a strand of epithelial cells running down to the disc-shaped precursor of the tympanic membrane3. At around 28 weeks, this epithelial core has canalized from medial to lateral to allow communication to the tympanic membrane. The epithelial core is the precursor of the bony EAC. (p1611)
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13. 下列特徵那些屬於central lesion之Nystagmus, 選出最適當的項目?
Vertical, horizontal 或torsional nystagmus
associated with nausea
directional clanging nystagmus
minimal suppression with visual fixation
(A) 1, 2 (B) 1, 3 (C) 1, 2, 4
(D) 1, 3, 4
ANS:D
(p1982; table 157.2)
nystagmus of central causes:
directionàvertical ，horizontal or tortional
direction changingàyes
associated nauseaàminimal
suppression with visual fixationàminimal
latencyànonefatigueà none
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14. 一位單側聽障患者，右耳PTA為90dB，左耳為20dB，請問其右耳之monoaural impairment (MI) 及 overall hearing handicap(HH) 各為何?
(A) 85%, 10%
(B) 92%, 50%
(C) 96.5%, 16%
(D) 100%, 75%
ANS:C
1. Hearing loss does not begin to be handicapping until the pure-tone average HTL at 0.5, 1, 2, and 3 kHz exceeds 25 dB.
2. Handicap grows at the rate of 1.5% per decibel of hearing loss beyond 25 dB HL.
3. Because unilateral deafness is only a mild handicap, the two ears should not be equally weighted. Specifically, a 5 to 1 weighting favoring the better ear is used.
The monaural impairment for each ear is first calculated from the four-frequency pure-tone average (PTA):
MI = 1.5 (PTA - 25)
The overall hearing handicap (HH), ranging from 0% to 100%, is then calculated as a weighted average favoring the better ear:
HH = [5 (MIb) + (MIw)]/6
(p1889)
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15. 急性或慢性中耳炎有時會引起顳骨內，甚至顱內的併發症，發生併發症的早期徵象(early sign)要特別小心，以下對併發症早期徵象，那一項是錯誤的?
(A) 急性發炎症狀持續2週以上
(B) 兩至三週內症狀又復發
(C) 慢性發炎中症狀急遽惡化，且伴有惡臭之耳漏
(D) 培養出厭氧菌
Impending complication
Persistence of acute infection for 2 weeks
Recurrence of symptoms within 2 weeks
Acute exacerbation of chronic infection, especially
if fetid
Fetid discharge during treatment
Haemophilus influenzae, type B, or anaerobes
ANS:D---應該也對才是?
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16. 當代數位式助聽器採用下列何種訊號處理方式可以有效增加配戴者在嘈雜環境下的訊雜比 (Signal/Noise ratio) ?
(A) 多頻道壓縮(multiple channel compression)
(B) 反饋音消除機制(feed back cancellation)
(C) 方向性麥克風(directional microphone)
(D) 移頻 (frequency transposition)
ANS:C directional microphone improves SNR based on the spatial location of the signal of interest (front hemisphere) (p1693)
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