5 VRA challenges solved with the Equinox Evo

When you're doing audiometry with children, it's a little bit more complicated than when you test an adult who can press a button.

The launch of the Equinox Evo device addresses some of the challenges that you may face as a pediatric clinician when working with children and trying to test their hearing, with several solutions to make it easier for you to get reliable results.

In this article, we’ll focus on how the Equinox Evo helps to solve some of the challenges you may face when performing visual reinforcement audiometry (VRA).

Challenge 1: Communication in a two-tester setup

One of the main challenges in VRA is the best practice of a two-tester setup. So, you have one audiologist controlling the audiometer and the VRA controls, and another audiologist playing with the child (Figure 1).

The reason for having two testers is that if somebody isn't playing with the child, then the child is likely to get bored and start looking around. We need to engage the child in some kind of activity to be certain that a sharp head turn looking toward the visual reinforcer is associated with the stimulus presentation.

So, it's important that there's a clinician focused on, and engaging with, the child.

If you have a two-room setup like in Figure 1, it would be very difficult for the clinicians to talk to each other without a two-way communication system, which allows each audiologist to speak to the other without everybody else in the room being able to hear them as well.

Furthermore, we want the second tester (sat with the child) to be able to hear the stimulus presentations. That's very easy when we're testing in the sound field (as in Figure 1), because everybody in the room can hear it. But if the child wore headphones, insert earphones, or a bone conductor, the second tester wouldn’t hear anything without a two-way communication system.

Solution: Two-way communication

So, having a two-way communication system that works through the audiometer can allow both clinicians to hear not only each other, but also the stimulus presentations. And this is what Equinox Evo provides.

There's a two-way integrated communication system with wired headsets that work through the actual audiometer device. You can control the levels so that if somebody has a hearing loss, you can make it a little bit louder.

If the stimuli are so loud that any parents or carers in the room can hear them, you can turn the level down. And you can also make use of the monitor functionality of the audiometer so that the second tester can hear the onset and offset of stimulus presentations and thereby help to judge whether a response is a true response or not.

Challenge 2: Providing engaging visual reinforcement

Another challenge in the world of VRA is that the old-fashioned toy boxes can be quite limited in how much they captivate the child's interest. They can work very well for the very youngest children, but once they’ve seen the toys a few times, the child may begin to find them a bit boring.

Solution: Screen setups

So, it's a good option to have some kind of screen setup as well where you can customize the reinforcers. You can integrate VRA Pure from Interacoustics into the Equinox Evo, giving you many visual-reinforcer options.

There are default videos, which are very engaging, but you can also add other images and videos to customize the reinforcers to the patient’s specific interests.

Challenge 3: Multitasking

In VRA, the audiologist:

• Controls the audiometer controls
• Controls the visual reward controls
• Enters the information on a ticksheet (best practice)
• Coordinates with the second tester if it’s a two-tester setup
• Keeps an eye on the child while also assessing their responses
• Makes clinical decisions on presentation levels and choice of stimuli

All at the same time.

For a new tester, it can feel overwhelming and like you need about eight arms to control everything that you need to do. This is why a lot of clinicians don't end up doing everything. So, they might choose not to do VRA at all because it seems too complicated. They might not use the ticksheet because it's another thing that overwhelms them.

Solution: Integrated VRA controls

Equinox Evo has integrated VRA controls (using VRA Pure) within the Equinox Suite and/or within the Touch Keyboard. So, you no longer have two different systems to control. You have all your controls in one place, making the test more straightforward for you and allowing you to concentrate on the child and your clinical decision making.

Challenge 4: Boring stimuli

One of the challenges that a lot of parents report is that the child is not going to turn to the stimuli because they're quite boring. Most audiometers have traditional stimuli such as pure tones and warble tones. You might also get narrowband noise. But these are quite limited in how well they will capture sufficient attention span.

Solution: Mix between a range of stimuli

With the Equinox Evo, we have a range of different stimuli as standard within the suite:

• PED noise
• Pure tones
• Warble tones
• Narrowband noise

You also have the option to add new stimuli, such as the Ling-6 sounds and the ManU-IRU stimuli. As speech-like sounds, they are ideal for conditioning, potentially being more familiar to the child.

They are also ideal for aided testing, allowing you to check whether the sounds that we want to get through the patient’s hearing aids are getting through and are reaching the child's brain in such a way that they then provide a response.

Challenge 5: Ticksheets

The best practice is to use a VRA ticksheet when you perform this type of test. The reason for this is that it's very important to keep a record of how the child responded to each sound and to keep a record of how the clinician performed the test. It's also a very useful record to have access to as VRA can be a bit chaotic and a very busy assessment to perform.

However, many of the existing manual and electronic VRA ticksheets aren’t sufficient, providing an unclear record of how the VRA test proceeded.

Read more: Recording responses using VRA ticksheets

Solution: Integrated and automatic ticksheet

The Equinox Evo includes an integrated and automated ticksheet within the pediatric test screen. This ticksheet is populated using crosses and ticks depending on whether you presented the visual reinforcer or not. A positive head turn response from the child should involve you presenting the visual reinforcer, whereas you shouldn’t reinforce a non-response (no head turn).

The Equinox Evo ticksheet follows this method:

• Descending presentations are recorded in the same column.
• Ascending presentations are recorded in the adjacent column.
• Repeat presentations are recorded in the adjacent column.

As this ticksheet is completed automatically, you do not need to manually enter the responses, allowing you to focus on the patient and the testing process.

If you select the conditioning button within the Equinox Suite or on the Touch Keyboard, a C will be placed in the ticksheet. The ticksheet algorithm will place a tick if you present a reinforcer within four seconds of the onset of the stimulus, a cross if you don’t present the reinforcer, or a cross if you present the reinforcer later than four seconds after the stimulus onset.

Traditional VRA vs Equinox Evo VRA

In summary, the Equinox Evo addresses many of the main challenges associated with VRA testing, which should make your life easier in – what can be – difficult assessments (Table 1).

Table 1: Traditional VRA vs Equinox Evo VRA.

To learn more about how you can enhance your pediatric testing, discover the Equinox Evo.