CLINICA ORL AUDIOLOGIA - audioprotesisti.org · 2017-04-26 · Malattia di Menière sinistra....
Transcript of CLINICA ORL AUDIOLOGIA - audioprotesisti.org · 2017-04-26 · Malattia di Menière sinistra....
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Prof.ssa Claudia Aimoni
CLINICA ORL – AUDIOLOGIA
UNIVERSITA’ degli STUDI di FERRRARA
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L'orecchio esterno è composto dal padiglione auricolare o pinna, e dal condotto uditivo esterno.
La struttura cartilaginea della pinna con il suo complesso di rilievi e solchi è in relazione a funzioni di localizzazione delle sorgenti sonore sul piano frontale-verticale.
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-20
-15
-10
-5
0
5
10
15
20
0,25 0,5 1 2 4 8 16
kHz
dB
RISPOSTA IN FREQUENZA DEL C.U.E.
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ORECCHIO MEDIO
STRUTTURE ANATOMICHE
membranatimpanica
tegmentympani
tubauditiva
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-2000
-1500
-1000
-500
0
500
1000
0,1 1 10
kHz
oh
m a
cu
stic
i
reattanza
resistenza
IMPEDENZA ORECCHIO MEDIO
-10
0
10
20
30
40
50
60
70
0,1 1 10
kHz
dB
SP
L
SOGLIA UDIBILITA’
ORECCHIO MEDIO
PROPRIETA’ FISICHE E SENSIBILITA’ UDITIVA
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ORECCHIO INTERNO
LABIRINTO MEMBRANOSO
10. finestra ovale11. finestra rotonda12. scala vestibolare13. scala timpanica5. coclea membranosa4. sacculo14. utricolonervo
coclea
osso temporale
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COCLEA
STRUTTURE ANATOMICHE
scalatimpanica
dottococleare
membranaReissner
endo-ostio(leg.spirale)
organo Corti
scalavestibolare
membrana tectoria
membrana Reissner
lamina spirale ossea
canale spirale
Rosenthal
endo-ostio
osso
tunnelCorti
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COCLEA
MICROSTRUTTURA
nervococleare
membrana Reissner
membrana tectoria
CCI CCE
cellulesupporto
striavascolare
membrana basilare
pilastriesterni
pilastriinterni
cell.Deiters
cell.Hensen
fibren. cocleare
membranabasilare
membranareticolare
membranatectoria
CCICCE
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CELLULE CIGLIATE ESTERNE-INTERNE
MICROSTRUTTURA
CCE
CCI
CCE
CCI
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CCE=12500
CCI=3500
AFFERENZA95%
EFFERENZA5%
NERVO COCLEARE100%
CELLULE CIGLIATE
INNERVAZIONE
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STRIA VASCOLARE
MICROSTRUTTURA
C
leg.spir.
organoCorti
cellmarginali
cellintermedie
cellbasali
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COCLEA
COMPARTIMENTAZIONE ELETTROCHIMICA
0 mV-60mV
+80mV
perilinfa
NERVO
perilinfa = K+ 4meq/l, Na+ 139 meq/l
endolinfa = K+144 meq/l, Na+ 1.3 meq/l
striavascolare
endolinfa
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35 30 25 20 mm
f stim. 50 100 200 300 Hz
MB
spostam
ento
apice
ONDA VIAGGIANTE, (von Bekesy )
base
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ONDE VIAGGIANTI
SMORZAMENTO
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rarefazione compressione
iperpolarizzazionedepolarizzazione
n. spike/ sec
SCALA MEDIASCALA MEDIA
CCE
CCICCI
CCE
CELLULE CIGLIATE
MOVIMENTI A CESOIA
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1. deflessione cigliare2. > p di apertura canali3. entra K+4.cambia il V di membrana5.entra Ca++6.esce mediatore sinaptico7.esce K+
deflessione
1
2
K+
K+
Ca++
Ca++
DV
K+
1
23
4
5
6
7
CELLULE CIGLIATE
TRASDUZIONE
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DRconduttanza
D
corrente recettore
+_
DForzaproc.attivo
+_
DXtrasmettitori
DPsspikes
stimolo
PROCESSI MOTORI
PR
OC
ES
SI S
EN
SO
RIA
LI
CELLULE CIGLIATE TRASDUZIONE (Patuzzi, 1996)
DVpotenziali membrana
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100
90
80
70
60
50
40
30
20
10
dB spl
2 5 10 20 kHz
tuning re. MB velocità 0.04 mm/s
tuning neurale fc 18 kHz
SINTONIA NEURALE E MECCANICA (Sellick, 1982)
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VIE UDITIVE CENTRALI
CN
SOC
LL
IC
SC
MG
AC I
CN
SOC
LL
IC
SC
MG
AC I
TB
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input
nervo
output
60
40
20
0
f=500 Hz, 80 dB SPL, 1 sec
0 2 4 6 8 10 msintervalli inter-spike
stimolo
spikes
t
CONVERGENZA
FIBRE NEURALI
RISPOSTA PERIODICA
c
ba
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100
90
80
70
60
50
40
30
20
10
dB spl
0.1 1 10 50 kHz
RISPOSTE DI SINTONIA NEURALE
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60
50
40
30
20
dB spl
2 3 4 5 6 7 kHz
INIBIZIONE LATERALE
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ecceccinib inib
N.OL.S.
N.COC.
N.SPIR.
UDITO BINAURALE: AFFERENZE
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AREE CORTICALI UDITIVE
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corteccia udit. I , gatto, (Evans)
0102030405060708090
vis
ivo
no r
esp
st a
cu
st
st. com
pl
ton
i
eccit
az
inib
iz on
off
on
-off
FM
% u
nit
à
RISPOSTE DEI NEURONI
DELLA CORTECCIA UDITIVA
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CLASSIFICAZIONE DEI SUONI
vibrazioni
suoni semplici
suoni complessi
armonicinon armonici
rumori
segnali
stazionari,
deterministici
periodici quasi
periodici
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COMBINAZIONI TONI PURI
f+2f
f+3f
f+f
f+f(180°)
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TONI PURI E SPETTRI
f1
f2
f1+f2
f2 f (Hz)
f1 f (Hz)
f1 f2 f (Hz)
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SUONI COMPLESSI E SPETTRI
100 msI
W N
f
dB
t
amp
0
10
20
30
40
50
60
70
62.5 250 1000 4000 Hz
dB
125 500 2000 8000
400 ms
ampamp
PARLATO
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AUDIOGRAMMA
0 -
10 -
20 -
30 -
40 -
50 -
60 -
70 -
80 -
90 -
100-
110-
120-
.125 .25 .5 1 2 4 8 KhZ
dB
H
L
dx sx
v.a.
v.o. > <v.a. mask.
v.o.mask
X
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METODO ADATTIVO
dB
stimolo n. 1 2 3 4 5 6 7 ................................
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0 -
10 -
20 -
30 -
40 -
50 -
60 -
70 -
80 -
90 -
100-
110-
120-
.125 .25 .5 1 2 4 8 KhZ
dB HL
va
vo
va mask
vo mask
>
x< dx sx
x x x x
xx
x
< < < <
<
otosclerosi
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otosclerosi
0 -
10 -
20 -
30 -
40 -
50 -
60 -
70 -
80 -
90 -
100-
110-
120-
.125 .25 .5 1 2 4 8 KhZ
dB HL
va
vo
va mask
vo mask
>
x
< dx sx
xx
x
xx
x>
>
>
>>
<
< <
<
<
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0 -
10 -
20 -
30 -
40 -
50 -
60 -
70 -
80 -
90 -
100-
110-
120-
.125 .25 .5 1 2 4 8 KhZ
dB HL
va
vo
va mask
vo mask
>
x
<
dx sx
xx
>
>
>
> >
Malattia di Menière sinistra
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Malattia di Menière sinistra
0 -
10 -
20 -
30 -
40 -
50 -
60 -
70 -
80 -
90 -
100-
110-
120-
.125 .25 .5 1 2 4 8 KhZ
dB HL
va
vo
va mask
vo mask
>
x
<
dx sx
x
>
>>
> >
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0 -
10 -
20 -
30 -
40 -
50 -
60 -
70 -
80 -
90 -
100-
110-
120-
.125 .25 .5 1 2 4 8 KhZ
dB HL
va
vo
va mask
vo mask
>
x
<
dx sx
x
x
>>
>>
>
Otite acuta emorragica
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Barotrauma (da immersione)
0 -
10 -
20 -
30 -
40 -
50 -
60 -
70 -
80 -
90 -
100-
110-
120-
.125 .25 .5 1 2 4 8 KhZ
dB HL
dx sx
va
vo
va mask
vo mask
x
<>
xxxx
xxx
<< <
< <
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Barotrauma (da immersione)
0 -
10 -
20 -
30 -
40 -
50 -
60 -
70 -
80 -
90 -
100-
110-
120-
.125 .25 .5 1 2 4 8 KhZ
dB HL
dx sx
va
vo
va mask
vo mask
x
>
x xx x
x
< < <
<
x x< <
![Page 43: CLINICA ORL AUDIOLOGIA - audioprotesisti.org · 2017-04-26 · Malattia di Menière sinistra. Malattia di Menière sinistra 0 - 10 - 20 - 30 - 40 - 50 - 60 - 70 - 80 - 90 - 100-110-120-.125](https://reader034.fdocument.pub/reader034/viewer/2022043010/5f9f29fd0e10d119911cd853/html5/thumbnails/43.jpg)
MASCHERARE
LA VIA OSSEA
0102030405060708090
100110120
0,25 0,5 1 2 4 8
kHz
dB
0102030405060708090
100110120
0,25 0,5 1 2 4 8
kHz
dB
MASCHERARE
LA VIA AEREA
![Page 44: CLINICA ORL AUDIOLOGIA - audioprotesisti.org · 2017-04-26 · Malattia di Menière sinistra. Malattia di Menière sinistra 0 - 10 - 20 - 30 - 40 - 50 - 60 - 70 - 80 - 90 - 100-110-120-.125](https://reader034.fdocument.pub/reader034/viewer/2022043010/5f9f29fd0e10d119911cd853/html5/thumbnails/44.jpg)
AUDIOMETRIA AUTOMATICA
dB
H
L
0
20
40
60
80
100
120
.125 .25 .5 1 2 4 8 KhZ
dB
H
L
0
20
40
60
80
100
120
.125 .25 .5 1 2 4 8 KhZ
dB
H
L
0
20
40
60
80
100
120
.125 .25 .5 1 2 4 8 KhZ
dB
H
L
0
20
40
60
80
100
120
.125 .25 .5 1 2 4 8 KhZ
I II
III IV
int
cont
int
cont
int
cont
![Page 45: CLINICA ORL AUDIOLOGIA - audioprotesisti.org · 2017-04-26 · Malattia di Menière sinistra. Malattia di Menière sinistra 0 - 10 - 20 - 30 - 40 - 50 - 60 - 70 - 80 - 90 - 100-110-120-.125](https://reader034.fdocument.pub/reader034/viewer/2022043010/5f9f29fd0e10d119911cd853/html5/thumbnails/45.jpg)
AUDIOSCAN
dB
H
L0
10
20
30
40
50
.125 .25 .5 1 2 3 4 6 8 KhZ
dB
H
L
0
10
20
30
40
50
.125 .25 .5 1 2 3 4 6 8 KhZ
a
b
![Page 46: CLINICA ORL AUDIOLOGIA - audioprotesisti.org · 2017-04-26 · Malattia di Menière sinistra. Malattia di Menière sinistra 0 - 10 - 20 - 30 - 40 - 50 - 60 - 70 - 80 - 90 - 100-110-120-.125](https://reader034.fdocument.pub/reader034/viewer/2022043010/5f9f29fd0e10d119911cd853/html5/thumbnails/46.jpg)
INTELLIGIBILITA’ ADULTI E BAMBINI
0102030405060708090
100
0 5 10 15 20 25 30 35 40 50
dB
% r
isp
oste
co
rrett
eadulti 4-8 aa
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ARIA
ACQUA
ORECCHIO MEDIO
TRASFORMATORE DI IMPEDENZA
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220 -800 Hz
genric
mic
Z-meter
pompa
+200, -400 mm H2O
IMPEDENZOMETRO-schema
C.U.E.
M.T.
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-400 -200 0 200mm H2O
c.c.
1.5
1.2
0.9
0.5
0.3
0-400 -200 0 200
mm H2O
c.c.
1.5
1.2
0.9
0.5
0.3
0
-400 -200 0 200mm H2O
c.c.
1.5
1.2
0.9
0.5
0.3
0-400 -200 0 200
mm H2O
c.c.
1.5
1.2
0.9
0.5
0.3
0
TIPO A TIPO C
TIPO D TIPO B
CLASSIFICAZIONE TIMPANOGRAMMI
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5
4
3
2
1
0
+200 0 -200
mm
mh
os
15
12
9
6
3
0
+200 0 -200
mm
mh
os
5
4
3
2
1
0
+200 0 -200
mm
mh
os
+200 0 -200
mm
mh
os
15
12
9
6
3
0
220 Hz
678 Hz
220 Hz
678 Hz
“mass controlled” “stiffness controlled”
VARIARE IL TONO SONDA
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Hz
200
400
800
1000
Hz
1100
1200
1300
Hz
1400
1600
1800
IMPEDENZOMETRIA MULTIFREQUENZIALE
-200 +200 mm H2O
![Page 52: CLINICA ORL AUDIOLOGIA - audioprotesisti.org · 2017-04-26 · Malattia di Menière sinistra. Malattia di Menière sinistra 0 - 10 - 20 - 30 - 40 - 50 - 60 - 70 - 80 - 90 - 100-110-120-.125](https://reader034.fdocument.pub/reader034/viewer/2022043010/5f9f29fd0e10d119911cd853/html5/thumbnails/52.jpg)
0
213 4
-200 +200
TIMPANOMETRIA: FUNZIONALITÀ TUBARICA
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+400 __
-200 __
mmH2O
apertura
spontanea
deglutizioni
TIMPANOMETRIA-FUNZIONALITÀ TUBARICA
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stapedial m.
CN
TRAPEZOID
BODY
auditory n.
stapedial m.
facial n.facial n.
MSO
mot.7n.mot.7n.
MSO
CN
MSO: media superior olivary complex. CN: cochlear nucleus
ARCO RIFLESSO STAPEDIALE - schematico
![Page 55: CLINICA ORL AUDIOLOGIA - audioprotesisti.org · 2017-04-26 · Malattia di Menière sinistra. Malattia di Menière sinistra 0 - 10 - 20 - 30 - 40 - 50 - 60 - 70 - 80 - 90 - 100-110-120-.125](https://reader034.fdocument.pub/reader034/viewer/2022043010/5f9f29fd0e10d119911cd853/html5/thumbnails/55.jpg)
0 -
10 -
20 -
30 -
40 -
50 -
60 -
70 -
80 -
90 -
100-
110-
120-
.125 .25 .5 1 2 4 8 KhZ
dB HL
Au stimolatorosso destro, blu sinistro
( riflesso controlaterale* riflesso ipsilaterale
OO X O O OX X X X
(* ) ( ( ( () ) ) )* ** ** * * * *
RIFLESSI STAPEDIALI - rappresentazione
![Page 56: CLINICA ORL AUDIOLOGIA - audioprotesisti.org · 2017-04-26 · Malattia di Menière sinistra. Malattia di Menière sinistra 0 - 10 - 20 - 30 - 40 - 50 - 60 - 70 - 80 - 90 - 100-110-120-.125](https://reader034.fdocument.pub/reader034/viewer/2022043010/5f9f29fd0e10d119911cd853/html5/thumbnails/56.jpg)
O0 -
10 -
20 -
30 -
40 -
50 -
60 -
70 -
80 -
90 -
100-
110-
120-
.125 .25 .5 1 2 4 8 KhZ
dB HL
O
X
OO
OX X X X
(*
)
( (
( () ) ) )
* *
*** * * * *
O
-400 -200 0 200mm H2O
DEPRESSIONE AEREA ENDOTIMPANICA A DESTRA
![Page 57: CLINICA ORL AUDIOLOGIA - audioprotesisti.org · 2017-04-26 · Malattia di Menière sinistra. Malattia di Menière sinistra 0 - 10 - 20 - 30 - 40 - 50 - 60 - 70 - 80 - 90 - 100-110-120-.125](https://reader034.fdocument.pub/reader034/viewer/2022043010/5f9f29fd0e10d119911cd853/html5/thumbnails/57.jpg)
0 -
10 -
20 -
30 -
40 -
50 -
60 -
70 -
80 -
90 -
100-
110-
120-
.125 .25 .5 1 2 4 8 KhZ
dB HL
OO
O
X
* * * * *
O
-400 -200 0 200mm H2O
O
X X X
(
(
VERSAMENTO ENDOTIMPANICO A DESTRA
X
![Page 58: CLINICA ORL AUDIOLOGIA - audioprotesisti.org · 2017-04-26 · Malattia di Menière sinistra. Malattia di Menière sinistra 0 - 10 - 20 - 30 - 40 - 50 - 60 - 70 - 80 - 90 - 100-110-120-.125](https://reader034.fdocument.pub/reader034/viewer/2022043010/5f9f29fd0e10d119911cd853/html5/thumbnails/58.jpg)
0 -
10 -
20 -
30 -
40 -
50 -
60 -
70 -
80 -
90 -
100-
110-
120-
.125 .25 .5 1 2 4 8 KhZ
dB HL
OO
O
X
* * * * *
O
-400 -200 0 200mm H2O
O
X X X
FISSITA’ OSSICULARE A DESTRA (otosclerosi)
((
X
![Page 59: CLINICA ORL AUDIOLOGIA - audioprotesisti.org · 2017-04-26 · Malattia di Menière sinistra. Malattia di Menière sinistra 0 - 10 - 20 - 30 - 40 - 50 - 60 - 70 - 80 - 90 - 100-110-120-.125](https://reader034.fdocument.pub/reader034/viewer/2022043010/5f9f29fd0e10d119911cd853/html5/thumbnails/59.jpg)
0 -
10 -
20 -
30 -
40 -
50 -
60 -
70 -
80 -
90 -
100-
110-
120-
.125 .25 .5 1 2 4 8 KhZ
dB HL
O
X
O O
X
* * * * *
O
-400 -200 0 200mm H2O
O
X X X
INTERRUZIONE CATENA OSSICULARE A DESTRA
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0 -
10 -
20 -
30 -
40 -
50 -
60 -
70 -
80 -
90 -
100-
110-
120-
.125 .25 .5 1 2 4 8 KhZ
dB HL
O
X
O O
X
O
-400 -200 0 200mm H2O
O
X X X
CO=CA
(* ) ( ( ( () ) ) )* * * ** * * * *
COCLEOPATIA A DESTRA (“Metz” positivo)
![Page 61: CLINICA ORL AUDIOLOGIA - audioprotesisti.org · 2017-04-26 · Malattia di Menière sinistra. Malattia di Menière sinistra 0 - 10 - 20 - 30 - 40 - 50 - 60 - 70 - 80 - 90 - 100-110-120-.125](https://reader034.fdocument.pub/reader034/viewer/2022043010/5f9f29fd0e10d119911cd853/html5/thumbnails/61.jpg)
O0 -
10 -
20 -
30 -
40 -
50 -
60 -
70 -
80 -
90 -
100-
110-
120-
.125 .25 .5 1 2 4 8 KhZ
dB HL
O
X
OO
X
O
-400 -200 0 200mm H2O
O
X X X
CO=CA
) ) ) )* * * *) *
LESIONE RETROCOCLEARE A DESTRA
![Page 62: CLINICA ORL AUDIOLOGIA - audioprotesisti.org · 2017-04-26 · Malattia di Menière sinistra. Malattia di Menière sinistra 0 - 10 - 20 - 30 - 40 - 50 - 60 - 70 - 80 - 90 - 100-110-120-.125](https://reader034.fdocument.pub/reader034/viewer/2022043010/5f9f29fd0e10d119911cd853/html5/thumbnails/62.jpg)
O0 -
10 -
20 -
30 -
40 -
50 -
60 -
70 -
80 -
90 -
100-
110-
120-
.125 .25 .5 1 2 4 8 KhZ
dB HL
O X O O OX X X X
** * * *** *
-400 -200 0 200mm H2O
LESIONE TRONCOENCEFALICA
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O0 -
10 -
20 -
30 -
40 -
50 -
60 -
70 -
80 -
90 -
100-
110-
120-
.125 .25 .5 1 2 4 8 KhZ
dB HL
O X O O OX X X X
( ( ( ( (* * * * *
O
-400 -200 0 200mm H2O
PARALISI NERVO FACCIALE A DESTRA
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CONDOTTO UDITIVO ESTERNO:
RADIAZIONE
ORECCHIO MEDIO:
INERZIA
stimstim
Condilo
ear canal
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ALTERNATE BINAURAL
LOUDNESS BALANCE (ABLB)
0 ________
10________
20________
30________
40________
50________
60________
70________
80________
90________
100________
O
O
O
X
X
X
X
XO
O
0 ________
10________
20________
30________
40________
50________
60________
70________
80________
90________
100________
O
O
O
X
X
X
X
O
0 ________
10________
20________
30________
40________
50________
60________
70________
80________
90________
100________
O
O
O
X
X
X
X
O
RECRUITMENT NON RECRUIT.
RECRUIT. PARZIALE
dBHL
10
30
50
70
90
xx
xx
x
x
1 2 4 kHz
1 kHz 2 kHz 4 kHz
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TEST DI LUESCHER
+ 40 dB SL
+1dB
+0,25 dB
dBHL
10
30
50
70
90
xxxx x x
1 2 4 kHz
STAZIONARIO
MODULATO
MODULATO
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SHORT INCREMENT SENSITIVITY INDEX (S.I.S.I.)
+ 20 dB SL
+ 20 dB SL
+ 5 dB
+ 1 dB
dBHL
10
30
50
70
90
xx
xx
x x
1 2 4 kHz
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TEST DI ROSENBERG
+ 10 dB SL
+ 30 dB
min. 1
adattamento liminare
dBHL
10
30
50
70
90
xxxx
x x
1 2 4 kHz
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TEOAEs
Stimolo
Risposta
TEOAE
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DPOAEs
Risposta DP
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Tipi di OAE
Transienti (TEOAE): si stimola la coclea con un
segnale transitorio (click).
Prodotti di Distorsione (DPOAE): si
stimola la coclea con due toni puri di frequenza differente
Spontanee (SOAEs) Recorded at the absence
of any stimulus.
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TEOAE acquisition*
* patent of David Kemp
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I I I I I I I I I I I
0 1 2 3 4 5 6 7 8 9 10 ms
I IIIII
IVV
VIVII
MG
IC
LL
SO
CN
AA
ABR - GENERAZIONE
VIII