Case Study Treatment Plan Project

Patient: Selena Perez

Student Clinicians: Kailan Butler, Bernadette Fitzpatrick, & Sophie Pierre-Louis
Date: 10/13/2015

Background History Information

Selena was born in Texas in 1948. She was the daughter of a well-known Mexican
American singer. She began singing when she was seven years old, she was the lead singer of
her familys band.
After years of performing, Selena took a break from her career to spend time with her
family. She is married and has two children. Now, twenty years later, Selena has decided to do a
final worldwide tour. She has been having issues hearing which is also affecting her
performance. Selena's family says that it seems like she is "screaming at them" when they
communicate with her. She frequently has to ask others to repeat themselves. She sometimes
turns her right ear towards the speaker so that she can hear better. Two weeks ago during a
rehearsal for her Revival Tour, Selena noticed that her hearing has worsened and she wasnt able
to hear anything from her earpiece.

CASE HISTORY SUMMARY

Selena Perez is a 67 year old female who is a well-known singer and entertainer.
Although her first language is Spanish, she understands and speaks English also. She reports that
she has had hearing loss for years, but it has been worsening recently. She attributes her hearing
loss to her many years of touring and being near loud speakers. She describes her hearing loss
with better hearing in the right ear. Selenas primary concern is that she is having difficulty

listening and understanding conversation. In order to compensate for her hearing loss, she asks
the speaker to repeat their statement or write down what they would like to communicate to her.
She has positive family hx for hearing loss secondary to her father having an acquired hearing
loss also. Selena states that when she had her hearing tested last month, the results yielded a
sensorineural hearing loss. She is scheduled to meet with her physician this month to address
treatment for her hearing loss. She has a dx of Autoimmune Inner Ear Disease. Selena presents
with the following in her current hx: vision problems, dizziness, falls, allergies, noise exposure
and tinnitus. Her current medications are: Diovan (for high blood pressure), Centrum Silver
(multivitamin), Calcium pills, Vitamin D pills, and New Phase Complete (for menopause).
Selena reports that she has difficulty hearing/understanding in a variety of settings during her
everyday activities such as, watching TV, using the telephone, going to restaurants with
family/friends, and during meetings where multiple people are present. Selena uses her right ear
when using the telephone and is right- hand dominant. Selena reports that she has worn a hearing
aid before, but does not use one currently. Selena has not received any prior speech services. She
would like to have speech services to allow for increased socialization and more participation in
business meetings.

Diagnosis: ICD-10 Codes

Selenas Primary diagnoses are:
H83.3X3 Noise effects on inner ear, bilateral
Noise induced hearing loss
H90.3 Sensorineural hearing loss, bilateral

Sensorineural hearing is noise induced

H83.8X2 Other specified diseases of the left inner ear
Autoimmune inner ear disease
Secondary diagnoses:
F80.4 Speech articulation impairment due to hearing loss
-

Speech articulation impairment due to sensorineural hearing loss

Description of Impairment
There is a profound sensory hearing loss along with autoimmune inner ear disease in the
left ear, which is presented by a downward sloping audiogram. There is a mild-moderate
sensorineural hearing loss in the right ear, which is presented by an audiogram with a flat
configuration. A sensorineural hearing loss is a combined loss of sensitivity and clarity.
Speech Audiometry results- The SRT is the softest level at which speech can be detected
and recognized. For the LEFT EAR, the SRT is 100 dB. For the RIGHT EAR, the SRT is 40
dB. The SDT was not tested because the SRT was used. The WDT is an assessment of clarity
and how well a person can understand speech. For Selenas LEFT EAR, it could not be tested
because the presentation level is untestable. For the RIGHT EAR, the WDT results were 6068%; presentation level 75dB.
These results of speech audiometry further define that Selena has a sensorineural hearing
loss. The WDT results demonstrate the Selena presents with loss of clarity of speech, which is
present with a sensorineural hearing loss. Results of the SRT illustrate the softest intensity
spondee words that Selena is able to repeat at least 50% of the time. The SRT of the right and

left ear coincide with the degree of hearing loss presented in each ear, mild-moderate and
profound respectively.
Both of Selenas ears present with type A tympanograms. There are no conductive
pathologies present. Both ears failed Otoacoustic Emission
Speech-Language Impairment
Selena presents with a speech articulation impairment secondary to her bilateral
sensorineural hearing loss. This speech impairment is due to the loss of clarity of speech that
occurs when a sensorineural hearing loss is present. Understanding speech has also been
impaired. Patients chief complaint is that she has trouble understanding people in conversation.

Impact of hearing loss on communication ability.

Selena completed the Hearing Handicap Inventory for the Elderly-Screener (HHIE-S)
and her husband completed the Hearing Handicap Inventory for the Elderly- Spouse or
Significant Other (HHIE-SP). Selenas husband, Chris, also filled out a Speech questionnaire
regarding Selenas speech.
Selena scored a 34 on the HHIE-S. According to Selenas answers on the HHIE-S, she
presents with difficulties in meeting new people in her profession she becomes embarrassed. She
also becomes frustrated when talking to members of her family and feels handicapped by her
hearing problem. She responded yes to having difficulty hearing when someone is whispering,
listening to the T.V. or radio, and hearing relatives or friends in a restaurant. Selena responded
sometimes to having difficulties with hearing when visiting friends and family, attending
religious services less often due to hearing problems and her hearing problems causing
arguments with friends and family.

Selenas husband scored a 32 on the HHIE-SP. Chris responses were very similar to
Selenas responses, the only difference is that he does not believe that Selenas hearing
impairment is causing arguments between Selena and family members. On the speech
questionnaire Chris commented that Selena will have rarely understand a fast paced conversation
with more than one person. She will sometimes understand spoken directions without gestures,
understand a general conversation about everyday topics, and complicated ideas and explanation.
Selena will only sometimes initiate conversation with her husband and her speech at times is
slow and halted with mispronunciations. Chris also commented that her speech now is different
from her speech prior to her hearing loss.
Speech articulation impairment is not being able to accurately have proper production of
consonants and vowels. Speech articulation impairment will not only have an effect on
consonants and vowels in isolation, it will also affect them in syllables, words, and sentences.
However, there is coarticulation, where one speech sound may affect the production of another
speech, this is different from an improper production of speech sounds. Contrastingly, Selenas
speech articulation impairment is due to her sensorineural hearing loss. Selena has lost sensitivity
and clarity of speech sounds due to her sensorineural hearing loss. This loss of clarity and
sensitivity has led to Selenas speech articulation impairment because she is unable to hear the
precision in others speech and monitor her own speech, through hearing. As Selenas hearing
loss worsens her articulation will worsen.
A person with just speech articulation impairment can receive speech therapy for
articulation. They may begin to produce the target speech sound correctly within a few sessions
and after multiple repetitions. Whereas, Selena may not benefit from just speech therapy for

articulation only because of her hearing loss. Her sensorineural hearing loss has impaired her
speech discrimination.

Audiological treatments/remediation/interventions
Since Selena has two etiologies causing her hearing loss, we will need to implement
multiple treatments. First, we will refer to a primary care physician to treat the autoimmune inner
ear disease (AIED) which can be treated medically through steroids. Common steroids that are
prescribed for AIED include prednisone, and dexamethasone (Hain, 2012). According to Harris
(2013), AIED resolves after steroid treatment in 40-60% of patients. We would expect her
hearing to improve after this treatment. The steroids are given orally and as injections in the ear.
Harris (2013) also found that patients with AIED, had their hearing improve after four weeks of
prednisone. In their study, 9 patients were treated with steroids and seven and out of the nine
patients had stable hearing or some fluctuation in hearing. One patient had a relapse of AIED and
another needed a cochlear implant. Overall the results were positive for steroid treatment of
AIED. Plasmapheresis and cell gene therapy are other types of interventions that have been used
with patients who are diagnosed with AIED (Hain, 2012).
With regards to Selenas noise induced hearing loss (NIHL), we will highly recommend
for her to avoid loud noise. The number one prevention of NIHL is to avoid loud noises. Due to
Selenas career, it is very challenging for her to avoid loud noise. This may require her to
continue to put her tour on hold and to refrain from attending other concerts or participating in
playing loud music. However, we are now in a time period where hearing protectors can be worn
to reduce the exposure to noise. When Selena first started her career as child and teenager,

hearing protectors were not worn by musicians. If Selena chooses to continue to tour and
perform in concerts, we will recommend using hearing protectors.
Hearing aids are typically used for mild-moderate hearing loss. Hearing aids will be
tested out with Selena after her hearing improves with AEID medical treatment and once she has
clearance from her doctor. Although the steroids, will not cure Selenas hearing loss, it will bring
her loss down to bilateral mild-moderate sensorineural hearing loss instead of a profound. Our
suggestion would be an in the ear device by Oticon. One of Oticons in the ear devices is the
Alta2 Pro. We will be stay in contact with the physician and audiologist to monitor Selenas
hearing changes. The audiologist who we will refer Selena to is Cornelia Vandervliet, MA,
CCC-A, FAAA. She works at University Hospital in Newark, NJ. 973-972-4300

Considerations for other physical aspects

There are no physical aspects affecting Selenas condition however, she does wear
glasses. She needs them for reading. We will make sure she has them during therapy.
Selena has reported feeling down the past few months because she has not been able to
hear as well as she used to and is frustrated that others around her have been questioning her
speech. Also, she is devastated that she had to put her tour on hold. Its not just a career, its her
life that is being put on hold. Unfortunately, her manager is not very patient and is frustrated
with putting the tour on hold because it has caused a lot of complications. Selena did not want to
let her fans and family down but she realized this change in her hearing has impacted all aspects
of her life. She is constantly worrying about what will happen in the future and if her condition
will improve so that she can continue to perform around the world. With everything that is going
on currently, it may be beneficial to encourage Selena to speak to a psychologist. We can provide

resources (pamphlet, website, or phone number) to Selena and her family about psychologists
located in her area. We will also provide Selena with information about the Hearing Loss
Association of America (HLAA). There are support groups that she can meet with to help her
adjust.

Modification for Speech Language Interventions

Selena has a sensorineural hearing loss which is impacting her ability to hear others and
speak with precise articulation. Speaking loudly does not necessarily mean that this will improve
the patients clarity. During the first session, we will need to have visuals present because she
does not yet have hearing aids. If she does not hear all of the verbal directions, then we will have
visual directions to help her complete the tasks. We need to rule out cognitive or language
disorders to make sure that Selena understands what is being asked of her. If a cognitive or
language impairment is present then we will need to modify the treatment activities to an
appropriate level based on Selenas cognitive and receptive language abilities. During the first
session, the SLP will have a conversation with Selena about her daily activities and how she can
still maintain some independence without hearing aids. Selena can also benefit from practicing
lip reading during the first session.
The goal of therapy will be to work on articulation (/s/ /t/ /f/ /v/ are typically impacted)
and clarity. If Selena gets hearing aids, therapy will also include using the phone with her
hearing aids so that she can carry this skill over to everyday life and maintain independence. We
will assess Selenas speech through the use an articulation screener. We also will complete a
comprehensive language assessment.

Collaboration is essential in the field of speech language pathology. We will need to

collaborate with the audiologist, primary care physician, psychologist, hearing aid dispensers and
insurance representatives when providing care for Selena. The audiologist will continue to assess
Selenas hearing and will decide if hearing aids or other audiological devices are required. The
primary care physician will provide medical treatment for the autoimmune inner ear disease. We
will refer Selena to a psychologist since she has reported feeling down. Oticon will be the
hearing aid dispenser and will deal with all repairs of any future hearing aids that are needed.

Demographics
Selena is a 67 year old female. She is a professional singer and musician with a high
socioeconomic status. She was raised as a Jehovahs Witness but converted to Catholicism
before her marriage to her husband. Selena is Mexican American and speaks English as a second
language. However, there is no language barrier. She learned English at the age of 4 and is fluent
in both languages. There is no lack of compliance on Selenas part, however, she does have
slight transportation issues. Selena is afraid to drive at the moment since her hearing has
worsened. She relies on her husband to get to appointments. Her husband currently works so we
will need to base her appointments around his schedule. He is flexible and willing to work with
us so this will be definitely make scheduling easier.

Laws and Regulations

Americans with Disabilities Act

Prohibits discrimination and ensures equal opportunity for persons with disabilities in
employment, State and local government services, public accommodations, commercial

facilities, and transportation. (United States Department of Justice- Civil Rights

Division, 2010).
o This law is important to consider when assisting Selena with finding jobs and free
services. For example, if she needs telephone relay services to help her use the
telephone, there are resources that can help her with this.
HAC (1988) - Hearing Aid Compatibility Act

States that any form of telecommunications within the United States must be compatible
to use with hearing aids. This is important for Selenas functional communication every
day and ability to maintain independence.

Air Carrier Access Act (ACAA)

Since Selena has to travel on the plane frequently going to interviews and shows, she
should be aware of accommodations that can be made. For example, closed captions on
any televisions and audio-visual displays are beneficial for Selena to understand any
important information that may be given.

After self-identification of hearing loss, the specific airport will ensure that any
information from announcements (delays, gate changes, flight cancellation) is properly
relayed to the passenger.

In addition, the ACAA ensures that passengers on the plane are receiving information
through effective communication to ensure that the passenger is aware of any new
information.

HIPAA

As a professional, we are required to maintain patient confidentiality. We will not discuss

Selenas information with anyone who is not part of the team treating her. Since Selena,
is a well-known musician, there may be reporters or fans who will want to know about
Selenas situation. We will not let others invade her privacy at the site.

Works Cited
Hain, T.C. (2012). Autoimmune inner ear disease. American Hearing Research
Foundation.http://american-hearing.org/disorders/autoimmune-inner-ear-disease-aied/#treated
Harris, D. Mikulec, A., & Carls, S. (2013). Autoimmune inner ear disease preliminary case
report: Audiometric findings following steroid treatment. American Journal of Audiology: 22,
120-124.
Hearing Loss Association of America. (2015). Hearing Aid Compatibility (HAC). Retrieved
from http://www.hearingloss.org/advocacy/know-your-rights/hearing-aid-compatibility-act.
Lincoln, N.B. (1982). The Speech Questionnaire: An Assessment of Functional Language
Ability. International Rehabilitation Medicine. 4: 114-117
United States Department of Justice-Civil Rights Division. (2015). The Americans with
Disabilities Act of 1990 and Revised ADA Regulations Implementing Title II and Title III.
Retrieved from http://www.ada.gov/2010_regs.htm.
U.S. Department of Transportation. (2015). About the Air Carrier Access Act. Passengers with
Disabilities. Retrieved from https://www.transportation.gov/airconsumer/passengers-disabilities.
U.S. Department of Health and Human Services. (2015). Health Information Privacy. Retrieved
from http://www.hhs.gov/ocr/privacy/.