Moving From Words in Quiet

Speech In Noise

Presenter:

Wendy Switalski, MBA AuD

Sr. Market Development Manager – Fitting

Audiology Systems/Otometrics

www.AudiologySystems.com

Introduction - Why do we need to assess SIN ability?

Measuring SNR Loss using the QuickSIN

Measuring tolerance for noise using the ANL

Bringing it home – and how to get started

Q&A

Agenda

These presentations slides will be available

to download at ihsconvention.org

1. List commonly available SIN test options, and why to use

them

2. Explain how to apply SIN results to hearing instrument

selection

3. Describe how to use SIN testing as a validation

procedure

Learning Objectives

These presentations slides will be available

to download at ihsconvention.org

Introduction to SIN Testing

It all begins with our patients Why do they come to see us – what are they experiencing?

The obvious answer – because they are having difficulty and have had a defining moment that led to a realization that they are failing to fully experience the world around them

The cause is likely hearing loss, usually sensorineural in origin

How do we assess them? Using an audiometric test battery that assess pure tone thresholds, speech thresholds, and word recognition in quiet. Additional measures such as comfort (and comfort limits) may also be provided

What are the results, and what is the outcome? Background noise challenges are frequently cited as an HI complaint and reason for non-use (Kochkin, 2000)

Satisfaction is linked to successful use across multiple listening environments, many of which include background noise of varying degrees (Kochkin, 2007)

Sensorineural hearing loss has two main components:

Audibility Effects – the loss of access to sound energy that contains access to speech and environmental cues from outer hair cell damage

Distortion Effects – the loss of cochlear compression, impaired spectral and temporal resolution, and the loss of ability to sort out multiple simultaneous signals while trying to focus

What is our ‘usual’ assessment battery focusing on?

It’s almost exclusively focused on AUDIBILITY, which leaves a significant stone unturned.

How does this correlate to what our patients report about their challenges and experiences of dealing with untreated (and even treated) HL?

The gap between the patient’s reality and our assessment protocol

PTA has shown to be a poor indicator of hearing in noise

ability (Grant & Walden, 2013).

What about word recognition testing in quiet?

Studies using Words In Noise (WIN) testing showed that across

3,430 subjects, 70% had good-excellent WR scores in quiet.

However, only 6.9% of these same patients had normal scores on

WIN. (Wilson, 2011).

Conversely, 98.5% of the patients with normal WIN scores had

normal WR in quiet scores

Wilson’s recommendation? Think of WIN as a ‘stress test’ for

auditory performance.

Can’t we draw conclusions from the protocol we currently use?

The inevitable conclusion:

we can only get crucial SIN performance prediction from

SIN assessment.

Measuring Speech Understanding Performance

in Real World Noise

Why the QuickSIN? Offers a fast and easy-to-implement

approach to determining signal-to-noise ratio deficit (SNR

loss)

QS is made up of lists of 6 sentences that are pre-mixed

with competing speech, similar to a lively cocktail party.

Patients are instructed to repeat the entire sentence as they

hear it, and 5 key words are scored.

Each sentence provides a more challenging condition,

beginning with +25dB SNR and ending with +0dB SNR

Guesses on administration time?

Enter the QuickSIN

Presentation Level: remove audibility effects by devivering at a

‘Loud but OK’ level (MCL+). For PTA < 45 dBHL, present at

70 dBHL.

Presentation Method: after providing a binaural practice list,

present 2 lists to each ear monaurally and then consider

presenting 1-2 lists binaurally as well.

Scoring: calculate an SNR score by adding the correct key

words together and subtracting from 25.5. When multiple lists

are used, average the list scores together for a ‘final score’

A point for discussion – where does it belong in the order of

testing?

Administering the QuickSIN in the assessment stage

Sentence 1: +25dB SNR

Sentence 2: + 20dB SNR

Sentence 3: +15dB SNR

Sentence 4: +10dB SNR

Sentence 5: +5dB SNR

Sentence 6: +0dB SNR (still hanging in there?)

Let’s try it..

Let’s try it..

Results

SNR Loss (and %) Category of SNR Loss Expected Performance with Directionality * (Consistent with technology at time of test development)

0-3 dB (88 – 100%)

Normal/Near Normal Performance equal to NH in noise

3-7 dB (73 – 87%)

Mild Performance almost as good as NH in noise

7-15 dB (41 – 72%)

Moderate Some benefit provided but will likely need additional features

> 15 dB (0 – 40%)

Severe Requires maximum improvement – remote mic, FM system, etc

*Balance with other factors that are important in the selection process – lifestyle, environments, etc.

Alerts you to any clinical ‘surprises’

Poorer (or better!) SNR score than you would anticipate based on

audiometric results …. although based on what we have learned,

this shouldn’t be a surprise

Uncovers asymmetry that could create challenges in

monaural or even binaural fittings

Can reinforce or enlighten the satisfaction history for

previous hearing instrument users.

Gives you insight for counseling, family support,

accessories, and even the follow-up times needed

So…how can this help your selections?

Sometimes a patient will report that they cannot remember the sentence long enough to repeat it back. This makes it impossibly to truly score their SNR, because it is a measure of intelligibility rather than recall and cognitive processing.

While this is not an intent of the test, it is useful to know and can help you provide additional information for the patient and significant others about strategies to maximize communication effectiveness.

Another option is to use the BKB-SIN, which uses easier test materials and is primarily used for pediatrics.

What about patients who cannot perform the test?

Process remains the same but the presentation changes:

Present unaided and aided in the freefield at soft and/or normal

conversational levels, and measure the difference

Could be incorporated into the technology demonstration

May not be always be sensitive enough to compare different

hearing instruments or features, but it can be worth trying to

provide an objective data point for this purpose (QuickSIN

manual provides critical difference guidance).

Can also use it to monitor changes in unaided and aided

performance over time

Using QuickSIN for Validation

A study by McArdle and Wilson (2006) showed

variability for individuals with HL (but not for those with

NH)

Specifically, these lists were 4, 5, 13, and 16

Consider reserving these lists for practice lists

A factor to consider:

The QuickSIN also includes HFE (high-frequency

emphasis) lists and HFE-LP (low-pass filtered) lists

Designed for Ski-slope losses

For best accuracy, present 4 lists in each condition.

Condition A – HFE – provides an approximation of the patient’s

amplification experience, applying 30dB of high frequency gain

Condition B – HFE-LP – provides the same, but sharply drops the

response above 2500 Hz.

Additional QuickSIN applications

This may help determine if the patient’s performance is helped (or at

least maintained), or if it is hindered by this additional high frequency

input

This can then be applied to the amplification strategy:

If the patient’s performance is poorer for the HFE-LP condition, then you can

work towards providing high frequency gain with confidence

However, if the patient’s performance improves without the additional high-

frequency information, then it may be cochlear dead regions are at work –

and then use caution in providing high frequency gain above 2500 Hz.

NOTE: list equivalency was also studied and it is recommended to use

lists 1, 4, 5, and 10 for the HFE selection. Also, a strong practice effect

was noted even after 2 practice lists were provided. (Johnson, 2009).

Ski-Slope QuickSIN - application

The QuickSIN also offers list options

that separate the speech and noise for

presentation through separate channels

to provide a measure of directionality

benefit.

Performed in the freefield using a 2-

speaker set-up, with both omni and

directional conditions

Can be used for both objective

(traditional scoring) and subjective

validation

QuickSIN for Directionality

QuickSIN is incorporated into most PC-based

audiometers, although it might require a license purchase.

The advantages for presentation, scoring, and reporting

are worth it!

For CD test, you can order from www.etymotic.com

What do you need to get started?

Measuring Individual Tolerance for Real World Noise

The ANL measures the level of background noise that a listener would tolerate before becoming ‘annoyed,’ an entirely different parameter than speech understanding in noise

The components of the ANL test are:

Most comfortable level (MCL) for recorded running speech

Background noise level (BNL) for competing noise relative to the speech at MCL level

Acceptable noise level (ANL) which is calculated by subtracting the BNL from the MCL.

*The intelligibility of the running speech is not evaluated or even discussed during the administration

Introducing the Acceptable Noise Level (ANL) Test

Consistency is key

ANL is measured by first obtaining an MCL measure for

recorded speech. Testing can be done binaurally.

Next, competing ‘background noise ’ is added and the level is

increased in 2 dB increments until the patient indicates that

their annoyance level has been reached. (Start at 30dB and

increase in 5 dB increments for first pass)

Plyler (2015) recommends using ‘Too hot, too cold, just right’

description to aid patients in identifying their true ANL.

Result is verified by confirming this response level

Guesses on administration time?

(ANL) Test Administration

Results can be used to categorize patients as follows:

Low ANL (≤ 7 dB). These patients are not very annoyed by listening in background noise even at poor SNR’s. They also are found to have high probability of hearing aid success for various technologies and counseling approaches.

Mid-Range (8-12 dB). These patients have a wide range of hearing aid performance success. Studies have shown that using NR and Directionality can increase the ANL level, especially for those with a ‘worse’ baseline scores, so these features may provide benefit for this group in leading to successful HA use.

High (≥ 13 dB). This group is found to have significant challenges even with advanced HA technology and may not be as successful with HA’s as the other groups of users. Counseling is key.

ANL scoring and interpretation

Original studies of the ANL suggested a high correlation between the categories and daily use of hearing aids. Follow-up studies have not shown the same level of correlation, but have still shown trends that can provide clinical value.

As an example, Wu (2016) found that there was a correlation to self-reported outcomes during the first 3 months of use, but less so after 12 months of use. This may be helpful for reminding patients to consider the long-term benefits of amplification.

ANL scoring and interpretation

The ANL test and CD are available from Frye Electronics.

Others have used their own readily available recorded

speech and competing noise tracks to measure ANL. Be

cautious that outcomes may be impacted somewhat and

may not be directly consistent with other reported

findings.

What do you need to get started?

Taylor and Bernstein (2011) studied 47 patients,

consisting of current and prospective HA users.

Conventional audiologic test battery was supplemented

with both QuickSIN and ANL testing.

Bringing them together

5

4

5

6

Device selection and configuration can be optimized, with volume control and/or manual program control provided for patients who require optimization of clarity and/or enhanced comfort in noisy settings. Remote mic/FM could also be helful.

Information can assist with patient counseling to outline patient’s goals, lifestyle, and expectations and align them. This information does not mean that amplification should not be attempted or that patients cannot be successful.

Consider using with current patients both to practice test administration but also to detect patterns in your patient group. Correlating to a subjective questionnaire (such as the IOI-HA, available at http://www.harlmemphis.org//index.php?cID=133) may also be valuable.

Using this Red Flag Matrix Approach:

Another interesting angle is measured by the Performance Perceptual Test.

This test starts with measurement of SNR performance (typically using the Hearing In Noise Test/HINT) for an absolute performance score

The test is then administered and scored based on the patient’s perception of their performance

The difference between these is the Performance-Perceptual Discrepancy. Patients can be divided into underestimators, accurate estimators, or overestimators of their ability to hear in noise.

Overestimation and Underestimation may impact not only decisions about the need for amplification, but also satisfaction.

Additional SIN Considerations

Even when advanced assessment of temporal and spectral resolution is evaluated and considered for further definition of SNR impairment, there is still a currently unexplained 25-30% of SNR loss. This is not related to audibility, age, spectral and temporal resolution – so may be related to cognitive function or temporal fine structure beyond what is assessed (Grant and Walden, 2013).

Even with all of these correlations, there is no conclusion about the ultimate benefit and satisfaction our patients can receive from amplification. Still, the benefits of SIN testing far outweigh the ease and time of test administration.

Additional SIN Considerations

Consider these tests as suggestions for getting started, or for adding to your existing SIN protocol.

Gain comfort and confidence with them by allowing yourself the time to practice, including a few extra minutes into your evaluation and/or validation appointment times.

We are in need of useful and relevant ways to COMPARE function between various devices – including HA’s, PSAP’s, and OTC devices. SIN tests could be a powerful method to do that.

Where to go from here?

Bibliography and Additional Resurces

Grant, K., & Walden, T. (2013). Understanding Excessive SNR Loss in Hearing-Impaired Listeners. JAAA, 24, 258-273. Johnson, J. (2009) QuickSIN HFE and LP Lists: Learning Effect, Equivalence, and Sensitivity. Poster Presentation – AAS 2009. Retrieved from http://www.harlmemphis.org/files/7013/4625/3285/AAS-jani.pdf Mueller, H.G. (2010, April). Three pre-tests: What they do and why experts say you should use them more. Hearing Journal, 63(4), 17-24. Mueller, H.G. (2016, September). Signia Expert Series: Speech-in-noise testing for selection and fitting of hearing aids: Worth the effort? Audiology Online, Article 18336. Retrieved from http://www.audiologyonline.com Plyler, P. (2015, June). 20Q: Acceptable Noise Level Test - The basics and beyond. Audiology Online, Article 14403. Retrieved from http://www.audiologyonline.com.

QuickSIN User Manual. Retrieved from https://www.etymotic.com/downloads/dl/file/id/259/product/159/quicksin_user_manual.pdf

Bibliography and Additional Resurces

Taylor, B. (2011, April). Using Speech-in-Noise Tests to Make Better hearing Aid Selection Decisions. Audiology Online, Article 832. Retrieved from http://www.audiologyonline.com Taylor, B. and Bernstein, J. The Red Flag Matrix Hearing Aid Counseling Tool. Audiology Online, Article 816. Retrieved from http://www.audiologyonline.com Wilson, R.H. (2011). Clinical experience with the words-in-noise test on 3430 veterans: comparisons with pure-tone thresholds and word recognition in quiet. JAAA, 22(7), 405-423. Wu, Y. H., Stangl, E., Pang, C., & Zhang, X, Y. (2014). The effect of audiovisual and binaural listening on acceptable noise level (ANL): Establishing an ANL conceptual model. JAAA, 25, 141-153 Wu, Y.H., Ho, H.C., Hsiao, S.H., Brummet, R.B. & Chipara, O. Predicting three-month and 12-month post-fitting real-world hearing-aid outcomes using pre-fitting acceptable noise level (ANL). 2016. IJA, 55(5), 285-294.

Questions?

Contact Wendy Switalski at

wendy@audiologysystems.com

Visit www.audiologysystems.com

Or see us in the Expo Hall!

These presentations slides will be available

to download at ihsconvention.org