UCSF CME · Table of Contents . Educational Objectives...
Transcript of UCSF CME · Table of Contents . Educational Objectives...
Division of Audiology, Department of Otolaryngology University of California, San Francisco School of Medicine
presents
UCSF Audiology Amplification Update XI
November 1– 2, 2013 Holiday Inn, Fisherman’s Wharf
San Francisco, California
Course Chair Robert W. Sweetow, PhD
University of California, San Francisco
University of California, San Francisco School of Medicine
Acknowledgement of Commercial Support
This CME activity was supported in part by educational grants from the following:
Oticon, Inc
Starkey Hearing Technologies
Exhibitors
Audiology Systems Inc. – an Otometrics partner
CaptionCall
Cochlear Americas
Elite Hearing Network
Health Care Instruments (HCI)/Audiometrics
Fuel Medical
Lyric by Phonak
MED EL
Neurotone
Oticon Medical
Oticon USA
Phonak
ReSound
Siemens Hearing Instruments
Starkey Hearing Technologies
Unitron
Widex
Table of Contents Educational Objectives ....................................................................................................... 5 Accreditation ....................................................................................................................... 5 General Information ............................................................................................................ 6 Linguistic Competency Information .................................................................................. 7 Course Faculty .................................................................................................................... 9 Disclosures ........................................................................................................................ 10 Course Program ................................................................................................................ 11
Friday, November 1, 2013 Evidence base for hearing aid features, the 'What, How .......................................... 12-30 and Why' of Technology Selection, Fitting, and Assessment J. Andrew "Drew" Dundas, PhD Evaluating New Technology ........................................................................................ 31-57 Ruth Bentler, PhD Cochlear Implants: Where we’ve been; where we are ............................................... 58-70 Colleen Polite, AuD Basal Ganglia Neuromodulation for Tinnitus Suppression ...................................... 71-78 Steven W. Cheung, MD
Saturday, November 2, 2013 Assessment and Interventions for Hearing Loss-related Fatigue ............................ 79-83 Benjamin W.Y. Hornsby, PhD Techniques and Challenges Related to Participation and ..................................... 84-103 Compliance with Aural Rehabilitation Robert W. Sweetow, PhD Pediatric Bone Anchored Implants: Protocols and Strategies ............................. 104-123 Lisa Christensen, AuD Registrant List .......................................................................................................... 124-126
University of California, San Francisco School of Medicine Presents
UCSF Audiology Amplification Update XI
This course is designed as a state-of-the-art course is designed as a state-of-the-art update of contemporary audiological practice, including evidence-based fitting and verification of hearing aids, pediatric use of bone anchored implants, listener effort and fatigue from amplification, as well as techniques and challenges associated with aural rehabilitation, tinnitus, and cochlear implants. Although it is intended as a course for practicing audiologists, professionals engaged in hearing aid dispensing, audiology graduate students, physicians, and others involved in the management of adults and children with hearing disorders will also benefit. The program consists of four primary components: lectures presented by renowned faculty from around the country, moderated question and answer periods at the conclusion of each morning and afternoon session, moderated panel discussions, and updates on new technology presented by manufacturer representatives. Educational Objectives
An attendee completing this course will be able to: • Compare evidence-based research for current hearing aid fitting and verification; • Assess information regarding listener fatigue and how to minimize it; • Distinguish best practice guidelines for pediatric bone anchored implants; • Illustrate new strategies for cochlear implant patients; • Analyze recent research findings on the generation of tinnitus; • Practice new approaches to aural rehabilitation; • Solve challenges to participation and compliance in auditory rehabilitation. Accreditation
University of California, San Francisco is a Speech-Language Pathology and Audiology and Hearing Aid Dispensers Board (SLPAHADB) approved provider for continuing professional development courses. This live activity meets the qualifications for 12 hours of continuing professional development credit for audiologists as required by SLPAHADB for hearing-aid related and non-hearing aid related. Provider #PDP313. This educational activity is approved for up to 1.2 CEUs and up to 1.2 Tier 1 CEUs from the American Academy of Audiology: Program number 13UCA-100.
General Information Attendance / Sign-In Sheet / Certificates Please return your Attendance Verification Record (AVR) form by the end of the course along with your evaluation. Certificates will be mailed to you, at the address you registered with, in approximately 3-4 weeks post course. Each participant is required to sign-in and claim the number of credits in order to receive a certificate. The sign-in sheet will be located at the UCSF Registration Desk. Evaluation Your opinion is important to us. Please complete and return the course evaluation as it is important to future course planning. The evaluation is the colored sheet you received with your course syllabus. Please turn in the evaluation with your AVR form. Security We urge caution with regard to your personal belongings. Please do not leave any personal belongings unattended in the meeting room during lunch or breaks or overnight. Exhibits Industry exhibits will be available outside the ballroom on the Mezzanine level during breakfasts and breaks, and lunches. Course Reception: Friday, November 1 A course reception will be held directly after the lecture on Friday, November 1 from 5:30 pm -7:00 pm on the Mezzanine level. This is open to all attendees. Final Presentations PowerPoint presentations will be available on our website, www.cme.ucsf.edu, approximately 3 – 4 weeks post course. Only presentations that have been authorized for inclusion by the presenter will be included
Federal and State Law Regarding Linguistic Access and Services for Limited English Proficient Persons
I. Purpose.
This document is intended to satisfy the requirements set forth in California Business and Professions code 2190.1. California law requires physicians to obtain training in cultural and linguistic competency as part of their continuing medical education programs. This document and the attachments are intended to provide physicians with an overview of federal and state laws regarding linguistic access and services for limited English proficient (“LEP”) persons. Other federal and state laws not reviewed below also may govern the manner in which physicians and healthcare providers render services for disabled, hearing impaired or other protected categories
II. Federal Law – Federal Civil Rights Act of 1964, Executive Order 13166, August 11,
2000, and Department of Health and Human Services (“HHS”) Regulations and LEP Guidance.
The Federal Civil Rights Act of 1964, as amended, and HHS regulations require recipients of federal financial assistance (“Recipients”) to take reasonable steps to ensure that LEP persons have meaningful access to federally funded programs and services. Failure to provide LEP individuals with access to federally funded programs and services may constitute national origin discrimination, which may be remedied by federal agency enforcement action. Recipients may include physicians, hospitals, universities and academic medical centers who receive grants, training, equipment, surplus property and other assistance from the federal government. HHS recently issued revised guidance documents for Recipients to ensure that they understand their obligations to provide language assistance services to LEP persons. A copy of HHS’s summary document entitled “Guidance for Federal Financial Assistance Recipients Regarding Title VI and the Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons – Summary” is available at HHS’s website at: http://www.hhs.gov/ocr/lep/ . As noted above, Recipients generally must provide meaningful access to their programs and services for LEP persons. The rule, however, is a flexible one and HHS recognizes that “reasonable steps” may differ depending on the Recipient’s size and scope of services. HHS advised that Recipients, in designing an LEP program, should conduct an individualized assessment balancing four factors, including: (i) the number or proportion of LEP persons eligible to be served or likely to be encountered by the Recipient; (ii) the frequency with which LEP individuals come into contact with the Recipient’s program; (iii) the nature and importance of the program, activity or service provided by the Recipient to its beneficiaries; and (iv) the resources available to the Recipient and the costs of interpreting and translation services. Based on the Recipient’s analysis, the Recipient should then design an LEP plan based on five recommended steps, including: (i) identifying LEP individuals who may need assistance; (ii) identifying language assistance measures; (iii) training staff; (iv) providing notice to LEP persons; and (v) monitoring and updating the LEP plan. A Recipient’s LEP plan likely will include translating vital documents and providing either on-site interpreters or telephone interpreter services, or using shared interpreting services with other Recipients. Recipients may take other reasonable steps depending on the emergent or non-emergent needs of the LEP individual, such as hiring bilingual staff who are competent in the skills required for medical translation, hiring staff interpreters, or contracting with outside public or private agencies that provide interpreter services. HHS’s guidance provides detailed examples of the mix of services that a Recipient should consider and implement. HHS’s guidance also establishes a “safe harbor” that Recipients may elect to follow when determining whether vital documents must be translated into other languages. Compliance with the safe harbor will be strong evidence that the Recipient has satisfied its written translation obligations. In addition to reviewing HHS guidance documents, Recipients may contact HHS’s Office for Civil Rights for technical assistance in establishing a reasonable LEP plan.
III. California Law – Dymally-Alatorre Bilingual Services Act.
The California legislature enacted the California’s Dymally-Alatorre Bilingual Services Act (Govt. Code 7290 et seq.) in order to ensure that California residents would appropriately receive services from public agencies regardless of the person’s English language skills. California Government Code section 7291 recites this legislative intent as follows:
“The Legislature hereby finds and declares that the effective maintenance and development of a free and democratic society depends on the right and ability of its citizens and residents to communicate with their government and the right and ability of the government to communicate with them. The Legislature further finds and declares that substantial numbers of persons who live, work and pay taxes in this state are unable, either because they do not speak or write English at all, or because their primary language is other than English, effectively to communicate with their government. The Legislature further finds and declares that state and local agency employees frequently are unable to communicate with persons requiring their services because of this language barrier. As a consequence, substantial numbers of persons presently are being denied rights and benefits to which they would otherwise be entitled. It is the intention of the Legislature in enacting this chapter to provide for effective communication between all levels of government in this state and the people of this state who are precluded from utilizing public services because of language barriers.”
The Act generally requires state and local public agencies to provide interpreter and written document translation services in a manner that will ensure that LEP individuals have access to important government services. Agencies may employ bilingual staff, and translate documents into additional languages representing the clientele served by the agency. Public agencies also must conduct a needs assessment survey every two years documenting the items listed in Government Code section 7299.4, and develop an implementation plan every year that documents compliance with the Act. You may access a copy of this law at the following url: http://www.spb.ca.gov/bilingual/dymallyact.htm
Faculty List
Course Chair Robert W. Sweetow, PhD Professor of Otolaryngology
Guest Faculty
Ruth A. Bentler, PhD Professor Department of Speech Pathology & Audiology University of Iowa Iowa City, IA Lisa Christensen, AuD Pediatric Audiologist Outreach Support Services Program Arkansas School for the Deaf Little Rock, AK Benjamin W.Y. Hornsby, PhD Assistant Professor Department of Hearing and Speech Sciences Vanderbilt University
Course Faculty (University of California, San Francisco)
Steven W. Cheung, MD, FACS Professor, Department of Otolaryngology-Head and Neck Surgery J. Andrew “Drew” Dundas, PhD Director, Audiology Assistant Professor, Department of Otolaryngology-Head and Neck Surgery Colleen Polite, AuD Assistant Director, Cochlear Implant Center Department of Otolaryngology-Head and Neck Surgery
;
Disclosures
The following faculty speakers, moderators, and planning committee members have disclosed they have no financial interest/arrangement or affiliation with any commercial companies who have provided products or services relating to their presentation(s) or commercial support for this continuing medical education activity: Ruth A. Bentler, PhD Steven W. Cheung, MD, FACS J. Andrew “Drew” Dundas, PhD
Benjamin W.Y. Hornsby, PhD Colleen Polite, AuD
The following faculty speakers have disclosed a financial interest/arrangement or affiliation with a commercial company who has provided products or services relating to their presentation(s) or commercial support for this continuing medical education activity. All conflicts of interest have been resolved in accordance with the ACCME Standards for Commercial Support: Robert Sweetow Consultant and stock shareholder Neurotone, Inc. Lisa Christensen Consultant Cochlear Americas This UCSF CME educational activity was planned and developed to: uphold academic standards to ensure balance, independence, objectivity, and scientific rigor; adhere to requirements to protect health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA); and, include a mechanism to inform learners when unapproved or unlabeled uses of therapeutic products or agents are discussed or referenced. This activity has been reviewed and approved by members of the UCSF CME Governing Board in accordance with UCSF CME accreditation policies. Office of CME staff, planners, reviewers, and all others in control of content have disclosed no relevant financial relationships.
UCSF Audiology Amplification Update XI COURSE AGENDA
Holiday Inn Fisherman’s Wharf, San Francisco, CA
(Maximum 12 SLPAHADB Audiology Hours; 12 SLPAHADB Dispenser Hours; 1.2 AAA Credits; 1.2 ABA Tier 1 Credits)
FRIDAY, NOVEMBER 1, 2013
7:30 am Registration/Continental Breakfast
8:00 Welcome Robert W. Sweetow, PhD
8:05 Updates on New Technology Manufacturer Representatives
9:05 *Evidence base for hearing aid features - J. Andrew "Drew" Dundas, PhD, the 'What, How and Why' of Technology Selection, Fitting, and Assessment
10:35 Break, Exhibits Open
11:00 *Evaluating New Technology Ruth Bentler, PhD 12:30 pm *Question and Answer Panel
1:00 Lunch on your own - Exhibits Open 2:30 *Cochlear Implants: Where we’ve been; where we are Colleen Polite, AuD
3:30 Break, Exhibits Open
4:00 *Basal Ganglia Neuromodulation for Steven W. Cheung, MD Tinnitus Suppression
5:00 *Question and Answer Panel
5:30 pm Adjourn
5:30-7;00 pm Reception and Exhibits SATURDAY, NOVEMBER 2, 2013
7:30 am Registration and Continental Breakfast
8:00 Welcome Robert W. Sweetow, PhD
8:05 Updates on New Technology Manufacturer Representatives
9:05 *Assessment and Interventions for Benjamin W.Y. Hornsby, PhD Hearing Loss-related Fatigue
10:35 Break, Exhibits Open
11:00 *Auditory Training and Challenges Associated Robert W. Sweetow, PhD with Participation and Compliance 12:30 pm *Question and Answer Panel
1:00 Lunch on your own - Exhibits Open
2:30 *Pediatric Bone Anchored Implants: Lisa Christensen, AuD Protocols and Strategies
4:00 Break and Exhibits
4:30 *Panel on Current Hearing Aid Dispensing Issues Conference Speakers 5:30 pm Adjourn
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{
Evidence base for hearing aid features:
the ʹwhat, how and whyʹ of technology selection, fitting and assessment.
Drew Dundas, PhDDirector of Audiology, Clinical Assistant Professor of OtolaryngologyUCSF Medical Center
HI Industry research background – Starkey Hearing Technologies, 2010‐2012
Realities of hearing aid features don’t always fit with marketing spin, conventional wisdom or published research
Disclosure
Today’s Topics
Frequency Lowering
DNR
D‐Mics
Directional microphones
Digital Noise Reduction
Frequency Lowering
What, How, Why…
What the technology is intended to accomplish
How it actually works
Why you might want to recommend it
Assessing benefit:
Objective
Subjective
The take home message
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Foundations…
Critical terms and concepts
Recruitment
“an abnormally rapid growth of loudness for sounds presented at levels greater than the threshold of detection”
Abnormally rapid?
Growth of loudness?
Loudness
Perceptual correlate of intensity
Sound must be audible to have loudness
Change in loudness is affected by:
Magnitude of intensity change
Duration of intensity change
Loudness
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The compressor of a hearing aid can be thought of as a loudness control
system. Why do we care?
Objective Subjective
Gain vs. Response
Gain = (Output – Input)
Device gain ≠ change in audibility
Response = Intensity
REIG vs. REAR
Real Ear Insertion Gain
REIG ≠ Audibility
Real Ear Aided Response
REAR > Threshold = Audibility
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Why do we care?
We need both gain and audibility to produce benefit that is:
Objective
and
Subjective
Channels vs. Bands
Channel = A subset of the bandwidth for signal analysis and processing
Band = A subset of the bandwidth where you can control gain
Loudness and Gain
The compressor of a hearing aid can be thought of as a loudness control system.
Signal processing features are gain control systems.
The main course
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Today’s Topics
Frequency Lowering
DNR
D‐Mics
Directional microphones
Digital Noise Reduction
Frequency Lowering
Directional Microphone Technology
How?
Why?
What?
Noise is an unwanted competitor.
It can also drive the compressor level estimate.
This can result in decreased signal audibility, as well as poor SNR.
The theory
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How do they work? Polar Response Pattern
Displays relative sensitivity of the mic at different angles.
Convention: Up is the ‘look’ direction.
Convention: Where the line gets close to the center, the mic is less sensitive.
A little like this…
Fixed directional
Automatic directional
Adaptive directional
Automatic adaptive directional
The implementations
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Switches between omnidirectional and fixed directional
When to switch is governed by sound environment analysis
Automatic directional Dual Omni‐directional
Change time delay, change response
Vary the time delay, vary the polar response pattern
Adjust response pattern to maximize overall SNR
Adaptive Directional
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Adaptive Null‐Steering
Automatic Adaptive Directional
Adds the low noise benefit of an omnidirectional response pattern
When conditions are appropriate – e.g., high SNR, low level listening.
DI on the head Directional Benefit
Typically 20% ‐35% when: The sound source of interest is in front and nearby
Competing noise is mainly behind or surrounds the listener
Reverberation is moderate or less The instrument has a high average directivity index (DI) (3.5 – 5.5 dB)
(Ricketts, 2008)
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Caveat: Microphone Drift
Degraded Pattern due to 0.6‐dB Sensitivity Mismatch
Normal Hypercardioid Pattern
DI = 6.0 dB DI = 4.0 dB
Nulls are lost.DI drops by 2 dB.
The take home message
Directional Mics are good for almost everyone, but… They are not magic
If you don’t have audibility, they can’t help.
if there is a vent, they cannot provide benefit if you are not at least 0dB insertion gain
Digital Noise Reduction
How?
Why?
What?
The theory
Identify which parts of sound are speech, and which parts are noise.
Don’t amplify the noise.
Simple, right?
…um, no.
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Fast vs. Slow acting
Noise reduction vs. Speech preservation
The implementationWhat it does
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Calculate Noise spectrum
For a given Time & Frequency: Turn gain up when Speech
Turn gain down when Noise
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TC = 0.02; Slope = 0.45; Offset = 10
Apply Gain Rules
In Running Speech
Noise Reduction
Speech Preservation
“Strict” Detection
“Lenient” Detection
A Balancing Act
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Comfort and Annoyance(Palmer, Bentler, Mueller, 2006)
*
Acceptance of Background Noise
(Mueller, Weber, Hornsby, 2006)
*
DNR makes noise more acceptableCognitive Benefits
(Sarampalis et al., 2009)
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The take home message
Effects of DNR:
Enhanced comfort
Some listeners may experience enhanced speech understanding in noise
May make HAs more acceptable
May free up cognitive resources for other tasks
Frequency Lowering
How?
Why?
What?
The theory
Some listeners may not benefit from HF audibility
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Theory
Off‐frequency listening
‘Sensory overload’
Distortion
Adverse effects on speech understanding
Frequency Lowering
/S/
The implementations
Three Current Implementations
Frequency Compression
Transposition
Feature Synthesis
1 2 3 4 5 64 5 6
Non‐Linear Frequency Compression
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Frequency (Hz)
Frequency Compression
Increased audibilityDecreased bandwidth at all timesReduced sound quality
Technique
Frequency Transposition
1 2 3 4 5 6 Frequency Transposition
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Frequency Transposition
• Increased audibility• Speech cue confusion• Reduced sound quality
Preserve bandwidth
Identify HF consonant sounds
Generate a spectral analogue at a lower frequency
Provide appropriate audibility of the analogue re: concurrent speech sounds
Feature Synthesis
Feature Synthesis
• Consonant sounds replicated in real time
• Bandwidth preserved
• Quality usually preserved
The evidence
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Frequency Lowering: Adults(Frequency Compression)
(Glista et al., 2009)
*
Frequency Lowering: Adults
(Glista, Scollie, Bagatto, Seewald, Johson, 2009)
Frequency Lowering: Adults(Frequency Transposition)
(Kuk, Peeters, Keenan, & Lau, 2007)
Consonant Recognition
(Galster, Valentine, Dundas & Fitz, 2011)
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Assessing benefit
Probe mic measures can be useful with bandwidth limited techniques
Demonstrates change in audibility
Problem: how much audibility is appropriate?
What targets do you aim for?
The take home message
Provides measurable real‐world benefit
Tuning for listener preference is necessary
Like fitting targets, one size does not fit all
Recent research suggests that preserving bandwidth is preferred even in patients with suspected dead regions
Sound quality matters
Summary
Frequency Lowering
DNR
D‐Mics
Directional microphones
Digital Noise Reduction
Frequency Lowering
Positive effects
Directionality
DNR
Frequency lowering
All can provide measurable benefit for appropriately selected and fit patients
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Negative Effects?
Can occur
Choose settings carefully, using verification and patient perceptions as guides
1. Have to be applying gain with D‐Mics and DNR to change the output signal
2. Must be audible to be perceptible
3. Magnitude of perception is dependent on the loudness growth curve
Gain, Audibility & Magnitude of Perceptual effects
The 3 concepts are linked
Direct vs. Amplified Path
Comparing sealed coupler measurements to real‐world is not always realistic
Direct sound arriving through the vent may reduce signal processing effects
In challenging cases, and more severe hearing losses, consider less open fittings to maximize effect
Questions?
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Evaluating New Technologies
RUTH BENTLER
UNIVERSITY OF IOWA
1
Levels of Evidence* APFs (Catherine Palmer, 2009)
◦ What does the algorithm do?
◦ What are the parameters that impact the doing?
Efficacy of the design
◦ In a well-controlled (contrived?) environment, do we get an effect?
◦ Or, what is the effect of the feature in the lab?
Effectiveness of the design ◦ In the real-world use of this design, do we get an effect?
◦ Or, what is the effect of the feature in the real world?
*Ala Bentler
http://www.uiowa.edu/~neuroerg/siren.html
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Levels of Evidence* APFs (Catherine Palmer, 2009)
◦ What does the algorithm do? ◦ What are the parameters that impact the doing?
Efficacy of the design ◦ In a well-controlled (contrived?) environment, do we get an
effect? ◦ Or, what is the effect of the feature in the lab?
Effectiveness of the design ◦ In the real-world use of this design, do we get an effect?
Or, what is the effect of the feature in the real world?
Efficiency (not studied in my lab)
*Ala Bentler
Directional Microphones
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APFs THE FIRST STEP IS TO UNDERSTANDING THE
BLACK BOX….
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Cardioid
Hypercardioid
Supercardioid
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Cardioid
Hypercardioid
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And so… oWe are able to measure the acoustic and physical
facts (APFs) for all possible scenarios of test;
oSuch APF testing is necessary to develop our hypotheses;
oNewer technique for quantifying polar response patterns and directivity indices (DI) helps us understand static function in a dynamic world of noise Wu & Bentler, 2009, 2010, 2012)!
Polargram
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Data? Plenty of efficacy data for all designs depending upon
◦ Baseline used
◦ Speaker arrangement
◦ Noise type
◦ Etc
Effectiveness data a bit harder to come by…
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Understanding in
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DIR
CST Test Condition
Test Booth Field Ratings 10 Very Good
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p < .0001
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Walden, Surr, & Cord, 2003
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Research Question of Study #1
• How do visual cues affect DIR benefit?
Laboratory
Real world
Speech recognition test
Speech Recognition Performance
SNR (dB)
1062-2-6-10
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ecognitio
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%)
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Auditory-Only
Wu & Bentler, 2010, Ear Hear
OMNI
DIR
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Speech Recognition Performance
SNR (dB)
1062-2-6-10
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Auditory-Only
Wu & Bentler, 2010, Ear Hear
Summary of Study 1
• The advantage (benefit) of visual cues can overshadow
the measured benefit of directional mic schemes in real
world environments.
Research Question of Study #2
• How does age impact DIR benefit?
• Laboratory
• Real world
Age
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Wu, 2010, JAAA
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Wu, 2010, JAAA
Summary of Study #2
• Listeners of different ages obtain comparable benefits
from DIR in the laboratory.
• Older users tend to perceive less DIR benefit than do
younger users in the real world.
• Due to lifestyle differences, primarily
• The focus of future efforts in the lab
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Example of unexpected function…
Front
Back
Backward DIR Backward DIR
Forward DIR Forward DIR
Condition
Conversation Listening
Dir
ectio
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l B
en
efit
(dB
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p < 0.05
Wu, Stangl & Bentler, 2013
Our Data Manufacturer’s Data
http://www.despicableme.com/
Front
Back
Big dogs can be dangerous.
Backward DIR Backward DIR
Front
Back
Big dogs can be dangerous.
Backward DIR Backward DIR
Forward DIR Forward DIR
Front
Back
The boy fell from the window.
Forward DIR Forward DIR
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Condition
Conversation Listening
Directio
nal B
enefit
(dB
)
0
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p = 0.17
p < 0.05
Wu, Stangl & Bentler, 2013
Our Data Manufacturer’s Data
Briefly, for DIR ◦APFs are clear as to expected impact ◦Efficacy has been demonstrated repeatedly; newer algorithms take special consideration
◦Effectiveness depends on many factors
◦ Environment, age, etc
◦ …crud
Digital Noise Reduction
75
Analog NR (1980-90s) Early spectral approaches
◦ Switch
◦ ASP (means low frequency compression)
◦ Adaptive filtering
◦ Frequency dependant input compression
◦ Adaptive compressionTM
◦ Zeta Noise BlockerTM
Today’s versions oMost are modulation-based with some algorithm for
where and how much gain reduction should occur; oAt least one other (Oticon) first introduced a strategy
called “synchronous morphology” treating harminic inputs like speech; oMany are now implementing Wiener filters as well; oMany are now implementing impulse noise
reduction; oMany also use some mic noise reduction, expansion,
wind noise reduction, and even directional mics as part of the strategy they promote.
APFs THE FIRST STEP IS TO UNDERSTANDING THE
BLACK BOX….
78
11/1/2013
14
Siemens (TRIANO 3)
Frequency (Hz)
250 500 1000 2000 4000 8000
Diffe
ren
ce
(dB
, 1
/3 O
cta
ve)
-12
-10
-8
-6
-4
-2
0
2
SIREN
TRAFFIC
DINING
Frequency (Hz)
125 250 500 1000 2000 4000 8000
Diffe
ren
ce
(d
B,1
/3o
cta
ve
)
-25
-20
-15
-10
-5
0
5
GN ReSound (CANTA 770-D)
a
Frequency (Hz)
125 250 500 1000 2000 4000 8000
Diffe
rence (
dB
,1/3
octa
ve)
-25
-20
-15
-10
-5
0
5
ICRA
Speech
Random Noise
Babble
Starkey (AXENT II AV MM)
b
Frequency (Hz)
125 250 500 1000 2000 4000 8000
ON
ve
rsu
s O
FF
(ou
tpu
t ch
an
ge
)
-16
-14
-12
-10
-8
-6
-4
-2
0
2
SNR00
SNR05
SNR10
SNR15
70dB
Frequency (Hz)
125 250 500 1000 2000 4000 8000
ON
vers
us O
FF
(outp
ut change)
-16
-14
-12
-10
-8
-6
-4
-2
0
2
SNR00
SNR05
SNR10
SNR15
85dB
Starkey J13 Axent AV75 dB
--SPEECH,RANDOM, MUSIC--
Frequency(Hz)
125 250 500 1000 2000 4000 8000
DIF
FE
RE
NC
E (
dB
,1/3
octa
ve)
-25
-20
-15
-10
-5
0
5
Guitar
Piano
Saxophone with background music
Random Noise
Plain Speech
11/1/2013
15
What happens in the time domain?
Siemens (Triano)
Starkey (Axent)
APFs…10 years later
88
Any reason to expect SNR-50 would change?
Ou
tpu
t S
NR
(re
: L
inea
r)
Miller et al. 2012
11/1/2013
16
Data?
• Still, plenty of efficacy and effectiveness data for all
designs if you are asking the right question: • Walden et al (2000)
• Boymans and Dreschler (2000)
• Alcantara et al (2003)
• Ricketts & Hornsby (2005)
• Marcoux et al (2006)
• Mueller et al (2008)
• Bentler et al (2009)
• Sarampalis et al (2009)
• Bentler et al (2010)
• Stelmachowicz et al (2010)
• Pittman et al (2011):
• And those are good outcomes
Briefly, for DNR ◦APFs are clear as to expected impact
◦Efficacy and Effectiveness have been demonstrated…if you are asking the right question
Frequency Lowering
93
Not really a new concept
Four (sort of) choices on the market:
◦ Frequency compression
◦ Frequency transposition
◦ Frequency “cueing”
◦ Combination of above
Concept makes sense
◦ Providing the widest input bandwidth possible
◦ Data suggest this may be most important for children re: speech and language development
APFs THE FIRST STEP IS TO UNDERSTANDING THE
BLACK BOX….
95
What is happening here?
Frequency compression hearing aid
Default settings
Steeply sloping loss
Freq compression: OFF
Assessed on 11/23/09
SN:0906H109W
Input: 1s pure tones 100 Hz spaced with 500ms intervals (~75dB SPL)
Upper graph: output of Hearing aid
96
11/1/2013
17
1st peak: 3468 Hz, 2nd peak: 4091 Hz, 3rd peak: 4700 Hz Input: 4091 Hz
97
1st peak: 3661 Hz, 2nd peak: 4306 Hz, 3rd peak: 4927 Hz Input: 4306 Hz
98
1st peak: 3765 Hz, 2nd peak: 4392 Hz Input 4392 Hz
99
1st peak: 4070 Hz, 2nd peak: 4694 Hz, 3rd peak: 5336 Hz Input 4694 Hz
100
1st peak: 5490 Hz Input 5490 Hz
101
1st peak: 5598 Hz Input 5598 Hz
102
11/1/2013
18
1st peak: 5457 Hz, 2nd peak: 6093 Hz Input: 6093 Hz
103
1st peak: 5553 Hz, 2nd peak: 6201 Hz Input: 6201 Hz
104
1st peak: 5665 Hz, 2nd peak: 5603 Hz Input 6309 Hz
105
1st peak: 1937 Hz, 2nd peak: 2562 Hz Input 6395 Hz
106
What is happening here?
Frequency compression hearing aid
Default settings
Steeply sloping loss
Freq compression: ON
Assessed on 11/23/09
SN:0906H109W
Input: 1s pure tones 100 Hz spaced with 500ms intervals (~75dB SPL)
Upper graph: output of Hearing aid
107
1st peak: 1071 Hz, 2nd peak: 1701 Hz, 3rd peak: 2346 Hz Input: 4091 Hz
108
11/1/2013
19
1st peak: 1894 Hz, 2nd peak: 1538 Hz Input: 4306 Hz
109
1st peak: 1207 Hz, 2nd peak: 1359 Hz, 3rd peak: 2851 Hz, 4th peak: 2001 Hz, 5th peak: 2482 Hz – Input 4392 Hz
110
1st peak: 1343 Hz, 2nd peak: 1656 Hz, 3rd peak: 1981 Hz, 4th peak: 2626 Hz – Input 4694 Hz
111
1st peak: 1351 Hz, 2nd peak: 1672 Hz, 3rd peak: 1981 Hz, 4th peak: 2626 Hz – Input 5490 Hz
112
1st peak: 1287 Hz, 2nd peak: 1916 Hz, 3rd peak: 2410 Hz, 4th peak: 2562 – Input 5598 Hz
113
1st peak: 1624 Hz, 2nd peak: 2260 Hz, 3rd peak: 2907 Hz Input: 6093 Hz
114
11/1/2013
20
1st peak: 1720 Hz, 2nd peak: 2368 Hz Input: 6201 Hz
115
1st peak: 1830 Hz, 2nd peak: 2466 Hz Input 6309 Hz
116
1st peak: 1937 Hz, 2nd peak: 2562 Hz Input 6395 Hz
117
500
1500
2500
3500
4500
5500
6500
7500
500 1500 2500 3500 4500 5500 6500 7500
Input (frequency in Hz)
Ou
tpu
t (f
req
ue
ncy in
Hz)
CF2.6; CR1.7
CF1.7; CR1.6
Uncompressed
CF6.0; CR1.5
CF5.9; CR2.1
CF4.7; CR2.0
CF3.8; CR1.9
CF3.2; CR1.8
CF2.2; CR1.7CF1.9; CR1.5
CF1.5; CR1.5
CF1.5; CR2.0
CF1.5; CR2.5
CF1.5; CR3.2
CF1.5; CR4.1
Graph from A Perreau dissertation, 2011 118
Output of frequency-lowering hearing aids
as a function of input frequency
990.53
1528.861507.32
1356.59
1550.39
1550.39
1744.19
1765.72
1787.26
500
750
1000
1250
1500
1750
2000
2250
2500
500 1000 1500 2000 2500 3000 3500 4000 4500 5000
Input (frequency in Hz)
Outp
ut
(fre
quency in H
z)
*N=7/11: Lowered Output <1500Hz
*
Graph from A Perreau dissertation, 2011 119
Microphone
Low-pass filter
High-pass filter
FFT Bin 1 Bin 2 Bin 3
.
.
. Bin 24
Σ Oscillators Bin 1 Bin 2 Bin 3
.
.
. Bin 24
Processing of data blocks
delay = 9 ms
Σ
Receiver
Cutoff Frequency
Microphone
Graph from A Perreau dissertation, 2011 120
11/1/2013
21
Sound quality
Guitar Original Guitar Max Comp
Singer Original Singer Compressed
Piano Original Piano Compressed
Evidence (efficacy here):
• Better speech-sound perception • Simpson et al (2005) 8/17 improvement phoneme recognition
• Simpson et al (2006) 1/7 (words) 1/5 (sentences) improved speech perception; 1/6 better APHAB
• Kuk et al (2007; 2009) improved consonant recognition (group)
• Gifford et al (2007): 2/6 improved sentence recognition in Q and N; more (group) benefit on EC, BN and RV subscales of APHAB
• Robinson et al (2007) 4/7 improved affricates; 5/7 improved /s and /z/
• Nyffeler (2008) improved (group) satisfaction (11 adults)
• Robinson et al (2009) 1/5 improved affricates; 1/5 improved /s and /z/
• Glista et al (2009) 5/11 children, 5/13 adults benefit for /s/ and /z/ detection
• O’Brien et al (2010) initial improvement in speech perception (23 adults)
• Wolfe at al (2010) group improvement for tokens /asa/ and /ada/ in quiet (15 children)
• Wolfe et al (2011) group improvement for tokens /asa/, /ata/ and /ada/ in quiet; after 6 mo. of use improvement on nonsense syllable SRT in quiet, 13/15 improved on plural test
Evidence:
• Better speech perception/satisfaction • Simpson et al (2005) 8/17 improvement phoneme recognition
• Simpson et al (2006) 1/7 (words) 1/5 (sentences) improved speech perception; 1/6 better APHAB
• Kuk et al (2007; 2009) improved consonant recognition (group)
• Gifford et al (2007): 2/6 improved sentence recognition in Q and N; more (group) benefit on EC, BN and RV subscales of APHAB
• Robinson et al (2007) 4/7 improved affricates; 5/7 improved /s and /z/
• Nyffeler (2008) improved (group) satisfaction (11 adults)
• Robinson et al (2009) 1/5 improved affricates; 1/5 improved /s and /z/
• Glista et al (2009) 5/11 children, 5/13 adults benefit for /s/ and /z/ detection
• O’Brien et al (2010) initial improvement in speech perception (23 adults)
• Wolfe at al (2010) group improvement for tokens /asa/ and /ada/ in quiet (15 children)
• Wolfe et al (2011) group improvement for tokens /asa/, /ata/ and /ada/ in quiet; after 6 mo. of use improvement on nonsense syllable SRT in quiet, 13/15 improved on plural test
Evidence:
• Better speech perception/satisfaction • Simpson et al (2005) 8/17 improvement phoneme recognition
• Simpson et al (2006) 1/7 (words) 1/5 (sentences) improved speech perception; 1/6 better APHAB
• Kuk et al (2007; 2009) improved consonant recognition (group)
• Gifford et al (2007): 2/6 improved sentence recognition in Q and N; more (group) benefit on EC, BN and RV subscales of APHAB
• Robinson et al (2007) 4/7 improved affricates; 5/7 improved /s and /z/
• Nyffeler (2008) improved (group) satisfaction (11 adults)
• Robinson et al (2009) 1/5 improved affricates; 1/5 improved /s and /z/
• Glista et al (2009) 5/11 children, 5/13 adults benefit for /s/ and /z/ detection
• O’Brien et al (2010) initial improvement in speech perception (23 adults)
• Wolfe at al (2010) group improvement for tokens /asa/ and /ada/ in quiet (15 children)
• Wolfe et al (2011) group improvement for tokens /asa/, /ata/ and /ada/ in quiet; after 6 mo. of use improvement on nonsense syllable SRT in quiet, 13/15 improved on plural test
Evidence:
• Better speech perception/satisfaction • Simpson et al (2005) 8/17 improvement phoneme recognition
• Simpson et al (2006) 1/7 (words) 1/5 (sentences) improved speech perception; 1/6 better APHAB
• Kuk et al (2007; 2009) improved consonant recognition (group)
• Gifford et al (2007): 2/6 improved sentence recognition in Q and N; more (group) benefit on EC, BN and RV subscales of APHAB
• Robinson et al (2007) 4/7 improved affricates; 5/7 improved /s and /z/
• Nyffeler (2008) improved (group) satisfaction (11 adults)
• Robinson et al (2009) 1/5 improved affricates; 1/5 improved /s and /z/
• Glista et al (2009) 5/11 children, 5/13 adults benefit for /s/ and /z/ detection
• O’Brien et al (2010) initial improvement in speech perception (23 adults)
• Wolfe at al (2010) group improvement for tokens /asa/ and /ada/ in quiet (15 children)
• Wolfe et al (2011) group improvement for tokens /asa/, /ata/ and /ada/ in quiet; after 6 mo. of use improvement on nonsense syllable SRT in quiet, 13/15 improved on plural test
Evidence:
• Better speech perception/satisfaction • Simpson et al (2005) 8/17 improvement phoneme recognition
• Simpson et al (2006) 1/7 (words) 1/5 (sentences) improved speech perception; 1/6 better APHAB
• Kuk et al (2007; 2009) improved consonant recognition (group)
• Gifford et al (2007): 2/6 improved sentence recognition in Q and N; more (group) benefit on EC, BN and RV subscales of APHAB
• Robinson et al (2007) 4/7 improved affricates; 5/7 improved /s and /z/
• Nyffeler (2008) improved (group) satisfaction (11 adults)
• Robinson et al (2009) 1/5 improved affricates; 1/5 improved /s and /z/
• Glista et al (2009) 5/11 children, 5/13 adults benefit for /s/ and /z/ detection
• O’Brien et al (2010) initial improvement in speech perception (23 adults)
• Wolfe at al (2010) group improvement for tokens /asa/ and /ada/ in quiet (15 children)
• Wolfe et al (2011) group improvement for tokens /asa/, /ata/ and /ada/ in quiet; after 6 mo. of use improvement on nonsense syllable SRT in quiet, 13/15 improved on plural test
11/1/2013
22
Evidence:
• Better speech perception/satisfaction • Simpson et al (2005) 8/17 improvement phoneme recognition
• Simpson et al (2006) 1/7 (words) 1/5 (sentences) improved speech perception; 1/6 better APHAB
• Kuk et al (2007; 2009) improved consonant recognition (group)
• Gifford et al (2007): 2/6 improved sentence recognition in Q and N; more (group) benefit on EC, BN and RV subscales of APHAB
• Robinson et al (2007) 4/7 improved affricates; 5/7 improved /s and /z/
• Nyffeler (2008) improved (group) satisfaction (11 adults)
• Robinson et al (2009) 1/5 improved affricates; 1/5 improved /s and /z/
• Glista et al (2009) 5/11 children, 5/13 adults benefit for /s/ and /z/ detection
• O’Brien et al (2010) initial improvement in speech perception (23 adults)
• Wolfe at al (2010) group improvement for tokens /asa/ and /ada/ in quiet (15 children)
• Wolfe et al (2011) group improvement for tokens /asa/, /ata/ and /ada/ in quiet; after 6 mo. of use improvement on nonsense syllable SRT in quiet, 13/15 improved on plural test
Evidence:
• Better speech perception/satisfaction • Simpson et al (2005) 8/17 improvement phoneme recognition
• Simpson et al (2006) 1/7 (words) 1/5 (sentences) improved speech perception; 1/6 better APHAB
• Kuk et al (2007; 2009) improved consonant recognition (group)
• Gifford et al (2007): 2/6 improved sentence recognition in Q and N; more (group) benefit on EC, BN and RV subscales of APHAB
• Robinson et al (2007) 4/7 improved affricates; 5/7 improved /s and /z/
• Nyffeler (2008) improved (group) satisfaction (11 adults)
• Robinson et al (2009) 1/5 improved affricates; 1/5 improved /s and /z/
• Glista et al (2009) 5/11 children, 5/13 adults benefit for /s/ and /z/ detection
• O’Brien et al (2010) initial improvement in speech perception (23 adults)
• Wolfe at al (2010) group improvement for tokens /asa/ and /ada/ in quiet (15 children)
• Wolfe et al (2011) group improvement for tokens /asa/, /ata/ and /ada/ in quiet; after 6 mo. of use improvement on nonsense syllable SRT in quiet, 13/15 improved on plural test
And now for the conflicting evidence:
• Worse performance or no change
• Simpson et al (2005) 8/17 no improvement phoneme recognition; 1/17 poorer
• Simpson et al (2006) 4/7 (words) 4/5 (sentences) no improvement speech perception; 2/7 (words)
poorer; 4/6 APHAB preference for conventional amplification, 1/6 APHAB no preference
• Kuk et al (2007; 2009): no change in vowel recognition (group data; n=13, 8)
• Gifford et al (2007): 4/6 no diff in sentence recognition in Q and N; more (group) aversiveness on
APHAB
• Robinson et al (2007) 3/7 no effect affricates; 2/7 no improvement /s and /z/
• Nyffeler (2008) no improvement (group) in sentence recognition in noise
• Robinson et al (2009) 2/5 decreases performance affricates; 4/5 no improvement /s/ and /z/; 4/5
preferred control (no compression) condition 1/5 had no clear preference
• Glista et al (2009) 5/11 children, 6/13 adults no benefit for /s/ and /z/ detection; 1/11, 1/13 showed
poorer performance
• O’Brien et al (2010) initial improvement in speech perception (23 adults) disappeared after 8
weeks. No difference/improvement on SSQ.
• Wolfe at al (2010) no improvement (group) for sentence recognition in noise or for tokens /afa/,
/aka/, /asha/ or /ata/ in quiet
• Wolfe et al (2011) no improvement (group) for sentence recognition in noise or for tokens /afa/,
/aka/, or /asha/, no effect for 2/15 who performed at ceiling on plural test
More recent data (still efficacy)
• Mussoi pre-dissertation project:
• Less is more
• Musical training makes the distortion more negative
NH-NTNH-T
HL-NTHL-T
Moderate compression
NH-NTNH-T
HL-NTHL-T
Max. compression
Slight preference
Moderate preference
Strong preference
NH-NTNH-T
HL-NTHL-T
No compression
% P
refe
ren
ce
0
10
20
30
40
50
60
Group
More recent data (still efficacy)
• Perreau dissertation
• Adults tend to opt for conventional technology as the bimodal
option to CI
• No objective evidence of better localization
Perreau, Bentler & Tyler, 2013
More recent data (still efficacy)
• Perreau dissertation
• Adults tend to opt for conventional technology as the bimodal
option to CI
• No objective evidence of improved speech perception
Perreau, Bentler & Tyler, 2013
11/1/2013
23
Effectiveness data
• Perreau dissertation
• Adults tend to opt for conventional technology as the bimodal
option to CI…..
Perreau, Bentler & Tyler, 2013
“OCHL” Study (real effectiveness data)
• Outcomes of Children with Hearing Loss
• Co-PIs Mary Pat Moeller, J Bruce Tomblin
• Multi-site (UIowa, UNC, Boys Town)
• Using accelerated longitudinal design
• Recruited children 6 mos-7 years of age
• Follow same children for 3+ years
• Lengthy burden tables resulting in many data points!
NIH/NIDCD R01 DC009560
Recruitment • Sampling Regions
• Iowa, Nebraska, Eastern Kansas/Northern Missouri, Illinois, Southern Virginia, North Carolina, Minnesota
• Sampling Method
• Referral from Newborn Hearing Screening
• Children identified in EHDI via follow up clinics
• Children identified via audiology or medical service providers
• Children identified through school screening
135
Sample
• 321 children with hearing loss
• 182 children with normal hearing
• Ages 6 months to 7 years, 3 months
• Speaks English in the home
• No major secondary disabilities
• Permanent Bilateral Mild to Severe Hearing Loss
– PTA of 25-75 dB HL (500, 1k, 2k, 4 kHz)
136
Domains of Study
137
Child and Family
Outcomes
Background characteristics of child/family
Hearing & Speech
Perception
Speech Production
Language Skills
Academic Abilities
Psychosocial and
Behavioral
Interventions (clinical,
educational, audiological)
Opportunity to observe:
• What hearing aids children wear;
• How they are fit;
• How long they wear them (i.e., use time);
• What kind of audibility is provided;
• If any of the above impact outcomes in speech and
language.
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24
This Data Set
• Three age levels (3-, 4- and 5-yr olds)
• All children had 1+ yrs. experience with aids and ~equal
number in each group:
• Nonlinear Frequency Compression (NLFC)
• Conventional signal processing
• Data from one site only since that site fit majority of
subjects using NLFC, using “best-practice” verification
protocol.
Questions
• Are children using nonlinear frequency compression
(NLFC) in their hearing aids getting better access to the
speech signal than children using conventional
processing schemes?
Questions
• Are children using nonlinear frequency compression
(NLFC) in their hearing aids getting better access to the
speech signal than children using conventional
processing schemes?
• We hypothesized that children whose hearing aids
provided wider input bandwidth would have more access
to the speech signal, as measured by an adaptation of the
Speech Intelligibility Index (SII, ANSI S3.5-1997, R2007)
Questions
• Are speech and language skills different for children who
have been fit with the two different technologies; if so, in
what areas?
Questions
• Are speech and language skills different for children who
have been fit with the two different technologies; if so, in
what areas?
• We hypothesized that if the children were getting
increased access to the speech signal as a result of their
NLFC hearing aids (Question 1), we would see improved
performance in areas of speech production,
morphosyntax, and speech perception compared to the
group with conventional processing.
Demographics
• No significant differences between groups (NLFC and
conventional processing) at any age (3, 4, 5):
• Age loss confirmed
• Age began intervention
• Months using hearing aids
• Reported daily use time
• Datalogged use time
• Mother’s education
• Family income
• All children wore current hearing aids > 1 year
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25
Outcome Measures, Age 3
• Goldman-Fristoe Test of Articulation-2 (GFTA-2,
Goldman & Fristoe, 2000) is a standardized measure of
speech production;
• Vineland Adaptive Behavior Scales-II (VABS-II;
Sparrow, Cicchetti, & Balla, 2005), parent-report
questionnaire of personal/social behavior;
• Comprehensive Assessment of Spoken Language
(CASL 3-4; Carrow-Woolfolk, 1999), standardized
measure of global language development.
Outcome Measures, Age 4
• VABS-II also administered in the 4-year old protocol;
• Test of Preschool Early Literacy (TOPEL; Lonigan et
al., 2007), standardized measure of early literacy,
specifically phonological processing and print knowledge;
• CASL 3-4 also administered in the 4-year old protocol;
• Wechsler Preschool and Primary Scales of
Intelligence-III (WPPSI-III; Wechsler, 2002), standardized
measure of verbal and nonverbal intelligence
Outcome Measures, Age 5 • Goldman-Fristoe Test of Articulation-2 also administered in the 5-
year old protocol;
• Peabody Picture Vocabulary Test-4 (PPVT-4; Dunn & Dunn, 2007),
standardized measure of receptive vocabulary;
• TOPEL also administered in the 5-year old protocol;
• CELF-4 Word Structure. Subtest of the Clinical Evaluation of
Language Fundamentals-4 (CELF-4; Semel, Wiig, & Secord, 2003),
assesses morphological development using picture stimuli;
• Comprehensive Test of Phonological Processing (CTOPP;
Wagner, Torgesen, & Rashotte, 1999), standardized measure of
phonological processing;
• Preschool Language Assessment Instrument (PLAI-2; Blank et al,
2003), standardized measure of expressive and receptive discourse;
• PBKs for speech perception Frequency (Hz)
250 500 1000 2000 4000 8000
He
ari
ng
Le
ve
l (d
B)
-10
0
10
20
30
40
50
60
70
80
90
100
110
Non-Compressed
Compressed
Three-year olds
3 year olds NLFC Conventional P value
GFTA 88.9 99.6 .07
Vineland 94.8 97.1 .66
CASL 82.1 95.5 .02
Better ear PTA 56.5 50.8 .23
Better ear aided SII (50) .52 .59 .37
Better ear aided SII (65) .70 .78 .16
Better ear unaided SII .21 .20 .44 Frequency (Hz)
250 500 1000 2000 4000 8000
He
ari
ng
Le
ve
l (d
B)
-10
0
10
20
30
40
50
60
70
80
90
100
110
Non-Compressed
Compressed
Four-year olds
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26
NLFC Conventional P value
Vineland 90.29 95.39 .31
CASL 99.77 102.16 .74
TOPEL Phono 85.55 91.67 .40
WPPSI Block 10.67 9.81 .55
WPPSI Reasoning 11.89 10.53 .40
WPPSI Vocab 7.44 8.13 .60
Better Ear PTA 53.0 47.9 .29
4-year olds
Frequency (Hz)
250 500 1000 2000 4000 8000
Heari
ng L
evel (d
B)
-10
0
10
20
30
40
50
60
70
80
90
100
110
Non-Compressed
Compressed
Five-year olds
5-year olds NLFC Conventional P value
GFTA 93.7 95.0 .84
PPVT 100.8 100.3 .94
TOPEL 104.2 105.7 .74
CELF 9.1 8.2 .57
PLAI 110.9 106.4 .54
PBK 79.0 78.6 .93
Better Ear PTA 52.4 51.6 .85
Limitations
• Not a true comparison of impact of NLFC on bandwidth
(i.e., audibility) in that this was a between-groups
analysis;
• Reflects best-case fitting methods, which may not be
representative of other clinics;
• The audiometric data of the subjects did not support
assumption that NLFC would be more readily fit to
children with more sloping configuration of loss.
Summary of OCHL findings
• In this study, audiograms and unaided audibility (ala SII)
same for both groups at each age;
• Aided audibility was not different for the two groups
(NLFC and Conventional) for soft or average inputs;
• As an expected consequence, speech and language
outcomes were not different for the two groups.
• Emerging data suggest that detection may be enhanced
for some children, but there is still little evidence of
broader advantage for children of this audiometric profile.
• More longitudinal data of this sort necessary.
OCHL Team Members
156
University of Iowa
J. Bruce Tomblin, Ph.D. (Co-PI)
Marlea O’Brien, Program Coordinator
Rick Arenas (IT)
Ruth Bentler, Ph.D.
Lenore Holte, Ph.D.
Elizabeth Walker, Ph.D., CCC-A/SLP
Connie Ferguson, M.S., CCC-SLP
Marcia St. Clair, SLP Examiner
Wendy Fick
Jacob Oleson, Ph.D. (biostatistics)
BTNRH
Mary Pat Moeller, Ph.D. (Co-PI)
Patricia Stelmachowicz, Ph.D.
Meredith Spratford, Au.D.
Lauren Berry, M.S., CCC-SLP
Emilie Sweet, M.S., CCC-SLP
Sophie Ambrose, Ph.D. (LENA)
University of North Carolina-Chapel Hill
Melody Harrison, Ph.D.
Patricia A. Roush, Au.D.
Shana Jacobs, Au.D.
M. Thomas Page, M.S., CCC-SLP
11/1/2013
27
Briefly, for frequency lowering
◦APFs are manageable, but different for different algorithms;
◦Efficacy has been demonstrated repeatedly in terms of sibilant detection & discrimination for adults and children;
◦Little effectiveness data not very encouraging.
What can we do?
i .e., we as in cl inicians, not me as in researcher
What can we do? Know the black box (APFs)
◦ DIR/DNR: test it!
◦ Frequency Lowering: Verify it!
Look at efficacy measures: ◦ Have high ecological validity
◦ Represent individual’s listening environments
◦ Include a variety of test situations
Look at effectiveness ◦ COSI, e.g.
◦ Self-report measures
..and the “evidence” will have the strength (both in level and grade) to impact decision-making in the clinics.
Buzz words… Evidence-based design
Evidence-based practice
Evidence
Evidence
Evidence
So, how does this all go? Three prongs
◦ Empirical evidence
◦ Clinician experience/evidence
◦ Patient needs and characteristics
Acknowledgements
National Institute on Disability and Rehabilitation Research (NIDRR)
National Institute on Health (NIH/NIDCD)
ASHFoundation
AAA Foundation
Starkey laboratories, Inc.
Siemens Hearing Instruments, Inc.
Research participants
10/31/2013
1
Cochlear Implants:Where we’ve been,Where we are
Colleen Polite, AuDAssistant DirectorCochlear Implant CenterOtolaryngology Head and Neck SurgeryUniversity of California,San Francisco
November 1, 2013
• No disclosures
2
3
Objectives
• Candidacy Criteria
• Cases Warranting Referral
• Emerging Indications
Poll: I work with CIs in my practice
10/31/2013
2
Poll: How many CI candidates have you seen in ... Poll: How many patients have you referred for ...
AudiologyNOW 2008 Survey
7
0
10
20
30
40
50
60
Saw None Saw 1‐4 Ref'd None Ref'd 1‐4
Population Statistics
• 1,000,000 potential CI candidates in US
• 7.5% of people who could benefit from CI have one
• 3% of audiograms met FDA criteria for CI
8
Huart, 2009
10/31/2013
3
Consumer Survey
• Average time from onset of severe-profound hearing loss to CI = 12 years
• Average time from learning about CI and discovering eligibility to surgery <1 year
• Almost 80% of CI recipients said they would have gotten a CI earlier if they had known about it
9
Market
10
ENT-VSL-3.2 Increase the proportion of persons who are deaf or very hard of hearing and who have cochlear implants
11
Baseline: 76.8 per 10,000 personsTarget: 84.7 per 10,000 persons
10 percent improvement
www.healthypeople.gov/2020
12
10/31/2013
4
13
Where we’ve been
Bilger Report, 1977
14
• Benefits lipreading
• Environmental sound awareness
• Better modulation of voice
• Possibilities of improvement
Where we’ve beenCandidacy: Adult
15
1985Age: 18 yrs+Hearing loss: bilateral profound post-lingualSpeech recognition: 0% words or sentences with HAsHearing aid use: 6 months
• First outcomes reported pre-op vs. post-op• Comparisons of HA users and CI users • Results on CI outcomes in patients with more
hearing pre-op
16
Where we’ve beenCandidacy: Adult
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5
Candidacy: Adult
17
Figure 2. Advances in technology and signal processing in cochlear implants have resulted in improved performance outcomes. Shown are group mean scores for CUNY and HINT sentences in quiet and CNC monosyllabic words from multiple sources: Skinner et al. (1994), Skinner et al. (1991);Pijl et al. (2009).
Huart, 2009
Where we areCandidacy: Adult
18
TodayAge: 18 yrs+
Hearing loss: bilateral MODERATE – PROFOUND, post-, peri- or pre-lingual
Speech recognition: ≤50% on sentences in ear to be
implanted and ≤60% best aided/contralateral ear
19
• Speech scores can approximate normal hearers
• Near ceiling performance at 3 - 6 months experience
• Updated speech battery (MSTB 2011)
20
Where we areCandidacy: Adult
Gifford, 2008
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6
Candidacy: Pediatric
1990Minimum age: 2 yrsHearing loss: profoundCommunication: 0% words or sentences with HAsHearing aid use: 6 months
21
Candidacy: Pediatric
22
TodayMinimum age: 12 – 23 mos
Hearing loss: <24 mos prof HL; ≥24 mos sev-prof
Communication: 30-40% word or sentence scores
Hearing aid use: 3-6 months
Candidacy: Pediatric
• Lower minimum age
– Higher communication performance– Higher scores on all language measures
23
Word Learning
24
Houston, et al. 2012
10/31/2013
7
Will Older Children Catch Up?
25
Nicholas & Geers, 2007
Candidacy: Pediatric
• More hearing
– Children with poorer hearing pre-CI had lower language skills at 3.5 yrs
– Accounted for almost 60% of variance in language performance
26
Nicholas and Geers, 2006
Candidacy: Pediatric
• Reduced HA trial period• Children diagnosed and using hearing aids at the earliest ages
experienced longer periods of hearing aid use before implantation. • Children with greater aided residual hearing also experienced longer
hearing aid trials before implantation. • These data suggest long periods of hearing aid use prior to cochlear
implantation may not always be the most beneficial course of action for young children who may be CI candidates.
27
Where we areReferral Warranted
• Fluctuating hearing loss
28
10/31/2013
8
29
Enlarged Vestibular Aqueduct
• Most common imaging finding
• Excellent candidates for CI
– Early referral for patients with progressive/fluctuating loss• Variable outcomes when associated with other
cochlear malformations
• Surgical risk of CSF gusher– Managed intra-operatively– Has no significant effect on speech outcomes (Adunka, et
al., 2012)
Audiogram (Pre-Eval)
Word Recognition RE: 4%LE: 84%PTARE: 72 dB HLLE: 105 dB HL
Drop in RE hrg 1 mo ago following head injury
Increased tinnitus since drop in hrg
Audiogram (CI Eval)
Aided Speech CNC AzBio-Q/+10
RE: 0% LE: 60% B: 50% 58% / 42%
Audiogram (CI)
Speech Perception 1 moCNC AzBio-Q/+10
CI: 56% 75% / 32%Speech Perception 3 mos
CNC AzBio-Q/+10/+5CI: 74% 71%/57%/17%CI+HA: 96% 100%/88%/73%
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Méniere’s Disease
• Significant improvement
– Even with previous chemical or surgery treatment
• Results similar to other post-lingually deaf adults
• Improvement in tinnitus
• Most achieve stable hearing
33
Lustig, et al., 2003
Where we areReferral Warranted
• Fluctuating hearing loss
– EVAS– Meniere’s
• Asymmetrical hearing loss
– Implant poorer ear– Bimodal listeners
34
Where we areReferral Warranted
• Fluctuating hearing loss
– EVAS– Meniere’s
• Asymmetrical hearing loss
– Implant poorer ear– Bimodal listeners
• Auditory Neuropathy Spectrum Disorder
35 36
Auditory Neuropathy
• No progress with auditory or language skills
– refer for CI evaluation– CI may offer neural synchronization
• Outcomes are variable
– Comparable to SNHL in those without other medical/cognitive issues
– ? Contraindicated in hypoplasia/aplasia of cochlear nerve– Counseling is key
10/31/2013
10
Where we areReferral Warranted
• Fluctuating hearing loss
– EVAS– Meniere’s
• Asymmetrical hearing loss
– Implant poorer ear– Bimodal listeners
• Auditory Neuropathy Spectrum Disorder
• WRS ≤ 50%
37
Where we areReferral Warranted
• Fluctuating hearing loss
– EVAS– Meniere’s
• Asymmetrical hearing loss
– Implant poorer ear– Bimodal listeners
• Auditory Neuropathy Spectrum Disorder
• WRS ≤ 50%
• Ski-slope hearing loss
– Hybrid/EAS– Improved hearing in noise, music quality
38
Ski-slope Hearing Loss
39
Cochlear Malformations: CI Candidacy
• Candidate– Common cavity– Cochlear hypoplasia– Incomplete partition– SCC dysplasia– Enlarged Vestibular
Aqueduct
40
• Not candidate– Complete labyrinthine
aplasia– Cochlear aplasia– Absent auditory nerve
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11
Where we are goingEmerging Indications
• <12 months• SSD/Unilateral
41
Where we are goingEmerging Indications
• <12 months– What happens when there is no access to auditory
information in the first year of life?– Cognitive mechanisms/language processes– Sensitive periods
42
Emerging indications/Expanding Criteria
• <12 months– Improved phonological skills – Superior speech understanding– Language skills growth rate similar to normal-hearing
peers– Support non-verbal cognitive development (Coletti,
2011)
• Risks
– Minimalized by experienced pediatric surgeons and anesthesiologists
43
Where we are goingEmerging Indications
• <12 months
• SSD/Unilateral
44
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Where we are goingEmerging Indications
• <12 months• SSD/Unilateral
– Less difficulty hearing in noise– Some benefit for localization– Reduced tinnitus– ? Hearing quality– ? Binaural benefits
45
Success
46
47
Summary
• Patients may have complex issues that need to be fully evaluated in the CI work-up
• Early referral of children for CI is best
• Moderate to profound HL indicates referral
• Less than fair WRS warrants referral
• Refer any patient with PTA and WRS discrepancy
Thank you!
10/31/2013
13
References
• available upon request
49
9/4/2013
1
Basal Ganglia Neuromodulation for Tinnitus Suppression
Audiology Amplification Update XI
Steven W. CheungUniversity of California, San Francisco
1 November 2013
Disclosure
• No personal financial or institutional interest in any of the drugs, materials, or devices discussed in this presentation.
Agenda
Background
New Onset Tinnitus Clinical Course
Basal Ganglia Overview
Target Selection for Deep Brain Stimulation (DBS)
DBS of the Striatum: Two Experiments
Tinnitus Conceptual Model
Phase I Clinical Trial
Tinnitus – Auditory PhantomsAuditory Percept Without an External Source
Pathophysiology
Aberrant Activity Originating from the Auditory System
Hyperactivity; Synchronized Oscillations; Reorganized Cortical Maps
Brain Networks Acting in Concert
Tinnitus‐Related Distress
Auditory Phantom Qualia Uncorrelated with Tinnitus Severity
Loudness Level; Sound Character
Modulators
Limbic System: Reinforcement, Mood, Behavior
Others: Eye, Facial, Cervical Movements; Sounds
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2
Tinnitus Functional Index (0 – 100 score)≤ 10 (not a problem), 10-20 (small problem), 30-40 (moderate problem), 40-60 (big problem), and 60-90 (very big problem)
Therapeutic Modalities
Reduce ContrastMask Phantom PerceptSuppress Hyperactivity
Exampleso Hearing Aidso Maskerso Cochlear Implantso Cortical Stimulationo Vagal N Stimulation
Reclassify Phantom PerceptReduce SaliencyMitigate Emotional Distress
Exampleso Tinnitus Retrainingo Cognitive-behavioral therapyo Neuromonicso Fractal toneso Antidepressants
Disrupt Information ConveyanceExampleso Transcranial Magnetic Stimulationo Direct Electrical Stimulationo Basal Ganglia Neuromodulation
Auditory-Striatal-Limbic Connectivity
‘Natural History’ of New Auditory Phantoms
Initial Complaints (≤ 3 months)▫ Unfamiliar▫ Relatively loud▫ Commands attention▫ Intrusive and annoying
Typical Course (6 – 12 months; 80%)▫ Familiar▫ Much softer▫ Easy to ignore▫ Not particularly noticeable
Atypical Course (≥ 1 year; 20%)▫ Familiar▫ Remains relatively loud▫ Still commands attention▫ Drives associated emotional and behavioral reactions
Investigational Therapies
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3
General Role of the Basal Ganglia
A multisensory integration system that:
• Detects interpretations of sensory patterns
• Releases responses
Medial Surface of the Basal Ganglia
1. Head of Caudate Nucleus
2. Body of Caudate Nucleus
3. Caudatolenticular Gray Bridge
4. Putamen
5. Tail of Caudate Nucleus
6. External segment of Globus Pallidus
7. Internal segment of Globus Pallidus
8. Amygdaloid Body
9. Nucleus Accumbens
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4
Functional Loops of the Basal GangliaSensorimotor ▫ Sensorimotor (Auditory) and Premotor Cortices
▫ Tectum (Colliculi)
Associative▫ Dorsolateral Prefrontal Cortex
▫ Lateral Orbitofrontal Cortex
▫ Higher Order Auditory Cortex
Limbic▫ Limbic and Paralimbic Cortices
▫ Hippocampus
▫ Amygdala
Limbic to Sensorimotor Connections
DLS – Dorsolateral Striatum
IL - Infralimbic
Corticobasal Loops and Interconnectivity
Basal Ganglia Target Selection
63 year old otolaryngologist with 40 year history of mostly constant, high‐pitched tinnitus. Tinnitus was mostly louder in the left ear, with episodic increases in loudness. Audiogram showed right moderate and left moderate‐to‐severe sensorineural hearing losses.
Left hemispheric stroke involving ‘the more dorsal part of the corona radiata. In addition there is involvement of the neostriatum, including the body of the caudate and the caudodorsal aspect of the putamen. As such it most likely involves thalamocortical radiations and corticothalamic projection in addition to corticocortical fibers running in the superior longitudinal fasciculus.’
o Tinnitus Suppressed Completelyo Hearing Remained Unchanged
Lowry et al (2004) Otol Neurotol
Diffuse Basal Ganglia Lesion
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56 year old woman underwent deep brain stimulation (DBS) for implantation of the left subthalamic nucleus for medically refractory Parkinson’s disease. Baseline ‘hissing’ tinnitus was reported to be reduced on the first postoperative day. Long‐term data showed enduring outcomes.
Larson and Cheung (2012) J Neurosurgery
o Tinnitus Suppressed Substantiallyo Hearing Remained Unchanged
Focal Basal Ganglia Lesion
Probe Delivers stimulation to deep brain nuclei
Anchor SecuresProbe to the skull
Connector Establisheslink to the Controller
Programmer Communicates with the Controller to customize therapy
Controller Determines parameters for brain stimulation and houses the power source
Deep Brain Stimulation System
Caudate Nucleus (Area LC) – DBS Target
• The caudate is routinely traversed during deep brain stimulation surgery for movement disorders.
▫ Opportunity to perform acute caudate stimulation experiments without altering the surgical procedure.
▫ Study population with known nigrostriatal dysfunction.
• IRB approval obtained.
TWO ELECTRICAL STIMULATION EXPERIMENTS IN THE CAUDATE NUCLEUS
Neuromodulation of Auditory Phantoms▫ Loudness Level
▫ Sound Quality
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6
Caudate Nucleus Confirmed by Stealth Trajectory and Microelectrode Recordings
Loudness Level Modulation
Sound Quality Modulation
Subject (age/gender) & side of stimulation
Stimulation parameters in frequency & pulse width
Stimulation threshold to effect in volts
(range)
Tinnitus baseline quality
Tinnitus baseline loudness
(0‐10 scale)
Tinnitus loudness at stimulation threshold
Area LC Neuromodulation effect
A (63/m)Right/Left
Microlesion effect
Tonal5 Left1 Right
0 Left1 Right
Suppressexisting phantom
B (51/m)Right
185 Hz90 µsec
5V(0 ‐ 8)
Noise‐like5 Left5 Right
0 Left0 Right
Suppressexisting phantom
C (57/m)Right
180 Hz90 µsec
10V(0 ‐ 10)
Cricket‐like5 Left5 Right
1 Left1 Right
Suppressexisting phantom
D(67/m)Right
150 Hz60 µsec
4V(0 ‐ 8)
Musical4 Left4 Right
2 Left2 Right
Suppressexisting phantom
E (66/m)Right
185 Hz90 µsec
3V(0 ‐ 8)
Tonal3 Left7 Right
2 Left2 Right
Suppressexisting phantom
F (61/m)Right
180 Hz60 µsec
4V(0 ‐ 10)
None0 Left0 Right
2 Left0 Right
Triggerclick sequences
G (50/f)Right
10 Hz60 µsec
2V(0 ‐ 10)
None0 Left0 Right
6 Left0 Right
Triggerjet takeoff sounds
H (67/f)Left
10 Hz60 µsec
4V(0 ‐ 10)
None0 Left0 Right
1 Left1 Right
Triggercreaking sounds
Cheung and Larson (2010) NeuroscienceLarson and Cheung (2012) Neurosurgery
Summary of Deep Brain Stimulation in Area LCTinnitus Loudness & Sound Qualia Modulation
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7
Striatal Neuromodulation Effects on Tinnitus
• Baseline loudness of auditory phantoms was modulated, to higher and lower perceptual levels.▫ Mostly Bilateral
• New auditory phantoms may be triggered in a controllable manner.▫ Mostly Contralateral
• No changes to hearing with acute stimulation.
• No seizures up to 10V stimulation.
Key Features
Instruction on details of phantom percepts are represented in the central auditory system.
Permission to gate candidate phantom percepts for conscious awareness is controlled by the dorsal striatum.
Action to attend, reject or accept phantom percepts, and form perceptual habits is decided by the ventral striatum.
Determination of tinnitus distress severity is mediated through the limbic and paralimbic system‐nucleus accumbens‐ventral striatum loop.
Tinnitus Conceptual Framework
Phase I Clinical Trial
o NIH/NIDCD Funded (8 – 10 Subjects)
o Key Inclusion Criterion: TFI > 50
o Enrollment Starts Winter 2013
o Specific Aims To estimate the treatment effect size of DBS in area
LC on tinnitus severity (TFI score).
To assess preliminary safety and tolerability of DBS in area LC (neuropsychological assays).
o Enrollment Starts Winter 2013
Study Flowchart
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Basal Ganglia Neuromodulation for Tinnitus Suppression
10/21/2013
1
Hearing Loss and Fatigue: Assessment and Intervention
Benjamin W.Y. Hornsby, Ph.D.
Acknowledgements and Disclosures• Research collaborators
– Dan Ashmead, PhD
– Fred Bess, PhD
• Lab members
– Zoe Doss
– Alissa Harbin
– Amanda Headly
– Julie Fix
– Katie Makowiec
– Bridget Stone
Funding for the works described here was provided by NIH R21 DC012865-01A1 IES #R324A110266 the ASHFoundation
– Erin Picou, PhD
– Aaron Kipp, PhD
Phonak, Inc., Starkey Inc., and the Dan Maddox Foundation
What is Fatigue?
• Fatigue is a complex construct that can occur in both the physical and mental domains.
– Our focus is on mental fatigue
• Subjectively, defined as a mood or feeling of tiredness, exhaustion or lack of “energy”
• Often associated with a lack of, or decline in,
– Focus, concentration, alertness and/or mental energy and efficiency
• Kennedy, 1988; O’Conner, 2006; Lieberman, 2007; Boksem and Tops, 2008
Consequences of Fatigue• Decreased attention, concentration, mental processing, and decision‐making
– van der Linden et al. 2003; DeLuca, 2005
• Less productive and more prone to accidents
– Ricci et al. 2007
• Less active, more isolated, less able to monitor own self‐care, and more prone to depression
– Amato, et al. 2001; Eddy and Cruz, 2007
10/21/2013
2
Who has Fatigue?
• Everybody!
– Complaints of transient fatigue are common even in healthy populations
• Recurrent fatigue is common in many chronic health conditions
– Cancer, HIV AIDs, Parkinson’s, Multiple Sclerosis
– Very little work specifically looking at hearing loss and fatigue
Hearing Loss and Fatigue• Fatigue is a common accompaniment of hearing loss with severe consequences on quality of life
– Listening IS exhausting!!!• Post on hearingaidforums.com
– “…since I lost most of my hearing…, I've had periodic bouts of tiredness that are deeper and of a different quality than I ever experienced before.”
• Copithorne, 2006
– “I go to bed most nights with nothing left. It takes so much energy to participate in conversations all day, that I’m often asleep within minutes.”
• Blog post http://hearingelmo.wordpress.com/2008/06/17/fatigue‐fear‐and‐coping/
• Fatigue can be measured many ways
– Subjectively using surveys, rating scales and questionnaires that ask about mood or feelings
• Many options, none specific to hearing loss
• Fatigue scales may be
– Uni‐dimensional: Assess “general” fatigue
• a composite fatigue measure
– Multidimensional: Assess various fatigue constructs
• E.g., General, physical, mental, emotional, sleep, etc…
– Can also assess frequency and severity
Quantifying Fatigue Subjectively Subjective Measures of Fatigue
• Profile of Mood States (POMS)
– 65 items used to derive six mood scores including fatigue and vigor (uni‐dimensional)
• Sensitive to effects of multiple variables on fatigue
Below is a list of words that describe feelings that people have. Please read each word carefully. Then circle the number that best describes how you have been feeling during the PAST WEEK, including today.
McNair et al, 1971
Not at all A little Moderately Quite a bit Extremely
Item # Item 0 1 2 3 4 Construct4 Worn Out Fatigue
7 Lively Vigor
11 Listless Fatigue
15 Active Vigor
29 Fatigued Fatigue
51 Alert Vigor
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3
Subjective Measures of Fatigue
• Multidimensional Fatigue Symptom Inventory (MFSI‐short form; Stein et al., 2004)
– 30 items; four fatigue scores (General, Physical, Emotional, Mental), a vigor and total score
Below is a list of statements that describe how people sometimes feel. Please read each item carefully, then circle the one number next to each item which best describes how true each statement has been for you in the past 7 days.
Not at all A little Moderately Quite a bit Extremely
Item # Item 0 1 2 3 4 Construct
2My muscles ache Physical3 I feel upset Emotional
7 I feel lively Vigor
12 I am worn out General
15I have trouble paying attention Mental
Subjective fatigue in adults seeking hearing help
• Participants: Subset of individuals scheduled for a hearing test or hearing aid evaluation.
– ≥ 55 years old (mean: 72.3 years; s.d. 10.2 years)
• range 55‐94 years.
– N=116 adults (63% males).
• Participants were mailed two self‐report measures of fatigue and a measure of hearing handicap
– POMS (fatigue and vigor subscales)
– Multidimensional fatigue scale (MFSI)
– Hearing handicap inventory (HHIE/HHIA)
• Adults seeking hearing help reported more fatigue and significantly less vigor than age‐matched adults recruited from church and community groups (Nyenhuis et al., 1999) *p<0.01
* *
• Our group was much more likely to report severe fatigue and vigor deficits
Severe fatigue and vigor deficits
• 1.5 st. dev above normative mean is a common “cutpoint” for identifying cases needing additional attention
– Expect ~7% of cases based on normative data
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4
Degree of loss and subjective fatigue
• Suggests factors other than “increased effort” affect fatigue in adults with HL
Better Ear PTA0 10 20 30 40 50 60 70 80
POM
S Fa
tigue
Sco
re
0
5
10
15
20
25
3095% Confidence IntervalRegression PredictionRaw Data
• Surprisingly, no relationship between degree of hearing loss and subjective fatigue or vigor
Age: 67Gender: Male
Hearing handicap and fatigue
• Strong relationship between hearing handicap and subjective fatigue (POMS and MFSI)
MFSI Total Score-20 -10 0 10 20 30 40 50 60 70 80 90
HH
IE/A
Tot
al S
core
0
20
40
60
80
100
95% Confidence IntervalRegression Prediction
MFSI Total Score-20 -10 0 10 20 30 40 50 60 70 80 90
HH
IE/A
Tot
al S
core
0
20
40
60
80
100
PTA = 25 dB HL
PTA = 75 dB HL
• As fatigue increases, hearing handicap increases
• Suggests consequences of hearing loss and fatigue are associated
PTA: 35Age: 67Gender: Male
Subjective fatigue in children with HL
• CHL report significantly more fatigue. Pervasive across domains
General Sleep/Rest Cognitive Overall
Peds
QL
Scor
e
0102030405060708090
100CHL CNH
Mor
e Fa
tigue
* * *
* p< 0.05
Hornsby, Werfel, Camarata, and Bess (2013). Subjective Fatigue in Children with Hearing Loss, AJA. Summary
• Fatigue is a complex multidimensional construct that can be defined subjectively as a mood or feeling and quantified using various subjective measures
– E.g., POMS, MFSI, PedsQL‐MFS
• Results using validated, generic, measures confirm
– fatigue is increased in adults and children with HL,
– risk for more severe fatigue is increased in these groups,
– Psychosocial consequences of hearing loss and fatigue are related
10/21/2013
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• Fatigue has also been defined behaviorally
– A decline in cognitive performance due to sustained mental demands
• Kennedy 1988; DeLuca 2005
• Measures of attention, concentration, processing speed, and decision‐making have been used as objective markers of fatigue
– van der Linden et al. 2003; DeLuca, 2005
• Very limited work in this area in HI persons
Objective Measures of Fatigue
Trial BlockST 1 2 3 4 5 6 Mean
Rea
ctio
n Ti
me
(in m
s)
250
300
350
400
450
500Unaided Aided Basic
Error bars = 1 st. error
Objective fatigue measures• Unaided RTs slow over time consistent with onset of fatigue
• Aided RTs are more stable suggesting some resistance to fatigue
Visual Reaction times
• Reaction times (RT) during a demanding dual‐task requiring sustained (~50 minutes)speech processing
Hornsby, B. (2013). The Effects of Hearing Aid Use on Listening Effort and Mental Fatigue Associated With Sustained Speech Processing Demands. Ear and Hearing
Subjective Ratings
• Demanding listening IS fatiguing especially unaided!
• I.e., Aids help consistently across participants
Pre-Test Post-Test
Fatig
ue S
ubsc
ale
Sco
re
0
2
4
6
8
10Unaided Aided
More Fatigued
Less Fatigued
Change in POMS Fatigue Scores after sustained listening during a demanding speech task
Change in Unaided Fatigue Rating0 5 10 15 20 25 30
Cha
nge
in A
ided
Fat
igue
Rat
ing
0
5
10
15
20
25
30
Mean
More Fatiguing when Aided
More Fatiguing when Unaided
References
• DeLuca, J. (2005). Fatigue, Cognition, and Mental Effort. In J. DeLuca (Ed.), Fatigue as a window to the brain (pp. 37‐58). Cambridge, Mass.: MIT Press.
• Hetu, R., Riverin, L., Lalande, N., Getty, L. and St‐Cyr, C. (1988). "Qualitative analysis of the handicap associated with occupational hearing loss." British Journal of Audiology 22(4): 251‐64.
• Hornsby, B. W. Y. (2013). The Effects of Hearing Aid Use on Listening Effort and Mental Fatigue Associated With Sustained Speech Processing Demands. Ear and Hearing. doi: 10.1097/AUD.0b013e31828003d8
• Hornsby, B. W., Werfel, K., Camarata, S., & Bess, F. H. (2013). Subjective Fatigue in Children with Hearing Loss: Some Preliminary Findings. Am J Audiol. doi: 10.1044/1059‐0889(2013/13‐0017)
• Lieberman, H. R. (2007). Cognitive methods for assessing mental energy. NutrNeurosci, 10(5‐6), 229‐242.
• van der Linden, D., Frese, M., & Meijman, T. F. (2003). Mental fatigue and the control of cognitive processes: effects on perseveration and planning. Acta Psychol(Amst), 113(1), 45‐65. doi: S0001691802001506 [pii]
10/14/2013
1
Auditory Training and Challenges Associated with Participation and
Compliance
Robert Sweetow, Ph.D.
University of California, San Francisco
1
Everything we do as audiologists is aural or audiologicrehabilitation (AR) : counseling, hearing aids, ALDs, communication strategies, auditory training)…
BUT……...
• less than 20% of new users (and less than 10% of experienced users) receive any form of audiologicrehabilitation (beyond hearing aids)
• only 2 ‐ 5% are provided with formal retraining opportunities
– Kochkin, MarkeTrak VIII, 2009
2
Why do patients seek our help?
3
Elements of Communication (Kiessling, et al, 2003; Sweetow and Henderson-Sabes, 2004)
4
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Potential impediments to achieving mastery of these elements
• Hearing loss
• Neural plasticity and progressive neurodegeneration
• Global cognitive decline
• Maladaptive compensatory behaviors
• Loss of confidence
5
The biggest mistake we currently make may be…….
• Making hearing aids the focus of our attention, when the focus should be….
• Enhancing communication
6
Are we really testing communication?
7
Current speech perception tests….
• Don’t take the contextual nature of conversation into account
• Don’t take the interactive nature of conversation into account
• Don’t allow access to conversational repair strategies that occur in real life
Flynn, 20038
10/14/2013
3
Relevant domains for assessment
• Communication expectations and needs• Sentence recognition in noise• Tolerance of noise• Ability to handle rapid speech• Binaural integration (interference)• Cognitive skills (working memory, speed of processing,
executive function)• Auditory scene analysis• Perceived handicap• Confidence / self‐efficacy• Dexterity• Vision
9
Measures beyond the audiogram that can be used to define residual auditory function.
Objective procedures• QuickSIN
– BKB‐SIN
• Hearing in Noise Test (HINT)• Listening in Spatialized Noise Sentences (LiSN‐S) • Acceptable Noise Levels (ANL)• Binaural interference • Dichotic testing• Listening span (Letter Number Sequencing)• TEN• Rapid (compressed) speech test• Speechreading• Dual‐tasking
• Need for screening measures
Communication Needs Assessment
10
Measures beyond the audiogram that can be used to define residual auditory function.
Subjective measures• Hearing Handicap Inventory for the Elderly – Screening HHIE‐S• Communication Scale for Older Adults (CSOA)• Communication Confidence Profile (CCP) or Listening Self
Efficacy Questionnaire• Self Assessment and Communication partner subjective scales
(SAC and SOAC)
Combined (objective and subjective) methods• Performance Perceptual Test (PPT)
Communication Needs Assessment
11
Communication Confidence Profile
Please circle the number that corresponds most closely with your response for each answer.
If you wear hearing aids, please answer the way that you hear WITH your hearing aids.
Sweetow, R and Sabes J. Hearing Journal: (2010); 63:12 ;17‐18,20,22,24.
12
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1. Are you confident you can understand conversations when you are
talking with one or two people in your own home?
2. Are you confident in your ability to understand when you are
conversing with friends in a noisy environment, like a restaurant?
3. In order to hear better, how likely are you to do things like moving
closer to the person speaking to you, changing positions, moving to a
quieter area, finding better lighting, etc?
4. If you are having trouble understanding, how likely are you to ask a
person you are speaking with to alter his or her speech by slowing
down, repeating, or rephrasing?
5. How sure are you that you are able to tell where sounds are coming
from (for example, if more than one person is talking, can you identify
the location of the person speaking?)
6. Are you confident that you are able to follow quickly‐paced
conversational material?13
7. Are you confident that you can focus on a conversation when other
distractions are present?
8. Are you confident that you can understand a person speaking in large
rooms like an auditorium or house of worship?
9. In a quiet room, are you secure in your ability to understand people
with whom you are not familiar?
10. In a noisy environment, are you confident in your ability to
understand people speaking with whom you are not familiar?
11. Are you confident that you can switch your attention back and forth
between different talkers or sounds?
12. If you are having difficulty understanding a person talking, how likely
are you to continue to stay engaged in the conversation? 14
CCP interpretation
• 50+ = Confident• 40‐50 = Cautiously certain• 30‐39 = Tentative• Below 29 = Insecure
15
Some facts related to aging
• 2/3 of people age 70 and older have hearing loss• Older adults with hearing loss have a 24% higher risk of cognitive impairment
• A 25 dB hearing loss equals the reduction in cognitive performance associated with a 6.8 year age difference
• Could be related to common cause hypothesis (shared neural pathways) , extra resource expenditure; isolation from hearing loss
Lin (2011, 2013)
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• Imaging studies of word identification in unfavorable signal‐to‐noise ratios have revealed greater activation of memory and attention brain regions in older adults compared with younger adults (Neuropsychologia2009;47[3]:693‐703). To compensate for reduced audibility or deficits in temporal processing (J Neurosci2012;32[41]:14156‐14164; J Acoust Soc Am 2006;119[4]:2455‐2466), older adults appear to draw more on cognitive resources than younger adults do (Ear Hear 2010;31[4]:471‐479).
• Despite this greater need to rely on cognitive resources, older adults often have a diminished cognitive reserve when trying to communicate in a complex listening environment (Trends Amplif2006;10[1]:29‐59).
17
• Older adults with hearing loss and poor working memory are more susceptible to hearing aid distortions from signal‐processing algorithms, suggesting that cognitive skills should be taken into account in the hearing aid fitting.
– Arehart, et al; Ear Hear 2013;34[3]:251‐260)
18
Montreal Cognitive Assessment
• designed to assist in the detection of mild cognitive impairment (J Am Ger Soc 2005;53[4]:695‐699).
• http://www.mocatest.org
19
So what’s the point?
• Like other diagnostic testing, any single measure (including speech in noise testing) may not provide enough additional information to justify the time or cost.
• However consideration of a combination of objective and subjective measures beyond the audiogram can supply important rehabilitation data.
20
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Is this practical?????
21
Pilot study – what can busy clinical audiologists fit in?
• UCSF Request
– Minimum of 2 objective and 2 subjective measures
– Keep track of time
– Keep track of how additional data impacted therapy plan
• Results
– 80% received CCP and HHIE/A‐S
– 70% performed Quick SIN
– 10% performed ANL, PPT‐DIS, etc.
22
However………
70% provided usable information above and beyond the “comp audio”
23
Why?????
• a) not enough time
• b) inconvenient
• c) don’t believe additional data will help
• d) all of the above
• e) don’t feel it is important to follow the instructions of the boss
24
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Expectations vs. Goals
• Expectations have a product orientation–Patient assumes passive role
–Whatever goes wrong is the professional’s fault
• Goals have a rehabilitation orientation–Patient assumes active role
–Patient shares in the process
25
Assessing Motivation and Readiness for AR
• Source : internal vs. external• Level:
handicap perception• desire to rehabilitate
• Don’t fit an unmotivated patient
26
Ida Institute tools
• Circle of change
• Line
• Decisional Balance Box
27
……. and don’t forget assessment!!!!!!!!!!!!
28
(Prochaska and DiClemente, 1984)
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Outcome assessment should relate explicitly to the needs and goals
determined.
Gatehouse 2003; Cox et al 2000
29
Benefit does NOT equal satisfaction!
• Cox (1997) estimated that satisfaction is comprised of:
• 40% benefit (both psychosocial and acoustic);
• 25% personal image;
• 19% service and cost;
• and 16% negative features.
30
How will your patient (and you) assess outcome?
• Hearing soft sounds• Louder perception• Understanding speech in noise• Listening effort (elevators don’t make travel from floor 1 to floor 20 more effective, but they do make it easier) !!!!! (Irv Hafter)
• End of day fatigue• Use of new strategies• Quality of life• Benefit or satisfaction• RFC
31
Client Oriented Scale of ImprovementCOSI
• Self‐report questionnaire requiring patient to list 5 listening situations in which help with hearing is required. Post‐rehab, the reduction in disability and the resulting ability to communicate in these situations is quantified.
• Takes less than 5 minutes of patient time, 2 minutes professional time for interpretation
32
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Characteristics of Amplification Tool COAT
• 9‐item measure of non‐audiologic information to determine if technology is required.
• Takes 3 minutes of patient time, 2 minutes professional time for interpretation
33
Characteristics of Amplification Tool(COAT)
Newman and Sandridge
• Assesses
– Motivation
– Expectations
– Preferences
– Cosmetics
– Cost considerations
http://www.audiologyonline.com/management/uploads/articles/sandridge_COAT.doc
34
Mini BTE
Look at the pictures of the hearing aids. Please place an X on the picture or pictures of the style you would NOT be willing to use. Your audiologist will discuss with you if your choices are appropriate for you ‐ – given your hearing loss and physical shape of
your ear.
35
"It doesn't sound normal"
• Normal to the hearing impaired patient may not be normal to the normal listener
• What do post‐surgery patients report?
• Status quo is what the patient brings to the evaluation
• “If it sounds right, it’s probably wrong”
36
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What do we do for a patient receiving an artificial limb?
What do we do for a cochlear implant patient?
What do we do for a patient with a balance disorder?
What do we do for a hearing impaired patient?
How can a person be trained to form whole perceptual units from
auditory fragments?
38
39
Definition of an auditory processing disorder Jerger and Musiek, 2000
• An auditory processing disorder is a deficit in the processing of information in the auditory modality. It may be related to difficulty in listening, speech understanding, language development, and learning. These problems can be exacerbated in unfavorable acoustic environments.
• What does a peripheral disorder do?????
40
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Does peripheral hearing loss lead to central auditory dysfunction
If so, can anything be done to compensate?
41
Why should AT be expected to produce benefit?
• Acuity and sensitivity are lower level functions
• Higher level functions (i.e. speech in noise) require more complex (hierarchical) processing (such as temporal analysis) that may utilize multiple channels of perceptual processing not governed by critical bands
42
Training‐related physiological changes have been attributed to……
• 1) a greater number of neurons responding in the sensory field
• 2) improved neural synchrony (or temporal coherence)
• 3) may be a neural “decorrelative” processes in which training decorrelates activity between neurons, making each neuron as different as possible in its functional specificity relative to the other members of the population. – This process assumes that information common to two stimuli is disregarded, while responses to unique features of each stimulus are enhanced.
Tremblay, 2006
43
Physiologic changes post training
• MRI shows increases in grey matter (Boyke, et al 2008)
• Cortical thickening in older adults (Engvig, et al, 2010)
• Changes in mismatched negativity response for adults trained on synthetic phoneme discrimination tasks (Kraus (1995); Recanzone (1995)
• Changes using auditory evoked magnetic fields ‐magnetoencephalography (Vasama and Makela (1995)
• Enhanced NI‐P2 on novel speech sounds and demonstrated training effects (Tremblay, et al (1998, 2001)
• Physiological changes occur quite rapidly, and precede changes in perception. (Tremblay, 1998)
44
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Evidence based review of auditory rehabilitation and training in adults
(Sweetow and Palmer, 2005)
• Group– Beynon, Thornton and Poole, 1997
– Chisolm, Abrams, and McArdle, 2005
• Individual– Kricos and Holmes, 1996
– Montgomery, Walden, Schwartz, and Prosek, 1984
– Walden, Erdman, Montgomery, Schwartz, and Prosek, 1981
– Rubenstein and Boothroyd , 1987
– Kricos, Holmes and Doyle, 1992
– Wright, B., Buonomano, Mahncke, and Merzenich, 1997
– Bode and Oyer, 1970
45
AT Studies since 2000 meeting Evidenced Based criteria(Sweetow and Palmer, 2005)
Henshaw and Ferguson , PLOS 2013; CBAT*
• – Fu and Galvin, 2007• – Oba, Fu and Galvin, 2011• – Miller, Watson, Kistler, Wightman and
Preminger, 2008• – Sweetow and Sabes, 2004• – Sweetow and Sabes, 2006• – Barcroft, Sommers, Tye‐Murray et al., 2011• – Ingvalson, Lee, Fiebig and Wong, 2013• – Zhang, Dorman, Fu and Spahr, 2012• – Levitt, Oden, Simon et al., 2011.
46
CONCLUSIONS
• 1) less than 5% of studies published on auditory training meet rigorous evidenced based criteria
• 2) auditory training resulted in improved performance for trained tasks in nearly all the articles that met evidenced‐based criteria
• 3) although significant generalization of learning was shown to untrained measures of speech intelligibility, cognition, and/or self‐reported hearing abilities, the improvements were variable, relatively small and not robust, though retention of learning was shown at post‐training
47
Benefits of AR Programs
• Reduced return rate (13 vs 3%) of hearing aids (Martin, 2007); 9% ‐ 3% (Northern and Beyert, 1999)
• Increased sale of assistive listening devices• Fewer trouble‐shooting visits • Referrals from friends, co‐workers, and family members
• Free advertising provided by satisfied hearing aid users
• Good community relations
48
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Examples of good group rehab formats
• ACE (Active communication education program) (Hickson, 2007)
• Learning to Hear Again (Wayner and Abrahamson, 1996).
• Mayo Clinic (Hawkins, 2004)
• Kricos
• Beynon, et al
• Northern and Meadows
• Abrams, Chisholm, et al
49
What happened to Aural Rehabilitation?
• declined because outcome measures concentrated on auditory training and speechreading and didn’t consider emotional and psychological by‐products
• boring?• too speech pathology like?• too time consuming?
• lack of reimbursement
50
Training is not a new concept….
But now we have the means to do it effectively……via computer aided auditory rehabilitation….so that…..
• It can be performed in a private, non‐threatening environment
• It can proceed at the individual’s optimal pace
• Progress assessment can be done automatically
51
What we can learn from learning theory?
1. Distribution of practice should be suitable for the task to be learned.
2. Active participation by the learner is superior to passive receptivity.
3. Practice material should be varied so that the learner can adapt to realistic variation and so that his motivation during drill is improved.
4. Accurate performance records need to be maintained in order to evaluate progress and effects of training.
5. The most useful single contribution of learning theory is the provision for immediate knowledge given to learners regarding their performance.
Wolfle (1951)
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What we can learn from neuroscience…?
• Appropriate feedback (Holroyd et al. 2004, Birdsong studies)
• Motivation (Kilgard and Merzenich, 1998)
• Reward (Benenger and Miller, 1998)
• Training near threshold (Blake et al., 2002)
• Incremental training: Go slow and steady (Linkenhoker and Knudsen, 2002)
• Speed and spacing of the training (Hairston and Knight, 2004, Marquet, 2001)
Many available Computer‐based Auditory Training Programs
• Baldi• Computer‐Assisted Speech Perception Testing and Training (CASPER)• CogMed• Computer Assisted Speech Training (CAST/TigerSpeech)– Sound and WAY Beyond– Seeing and Hearing Speech– Sound Express• eARena• FastForWord• I Hear What You Mean• IMPACT• LACE (Listening And Communication Enhancement)• Read My QUIPs• SoundScape• Speech Perception Assessment and Training System (SPATS)• The Listening Room
54
Music Training
• Kraus’ lab (Northwestern) has shown:
• Better understanding of speech in noise across age groups
• Shorter brainstem timing delays• Neurobio Aging 2012:33(7):1483
55
OPERA
• Overlap: in the anatomy and physiology for speech and music
• Precision: more precision is required for music processing than speech
• Emotions “ strong emotions evoked by music may induce plasticity via brain’s reward centers
• Repetition: extensive practice tunes the auditory system• Attention: focused attention to details of sound is required
when playing an instrument
Aniruddh D. Patel (Nat Rev Neurosci 2010;11(8):599
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LACE(Listening and Communication Enhancement)
• Cognitive– Auditory Working Memory– Speed of Processing
• Degraded and competing speech– Background noise– Compressed speech– Competing speaker
• Context / Linguistics• Interactive communication
All of the above are designed to enhance listening and communication skills and improve confidence levels
Sweetow and Henderson‐Sabes, 2006
57
Note: Henderson‐Sabes (2012) separated the 3410 20‐lesson finishers into groups according to their initial QuickSIN SNR loss tested at MCL
58
Note: Even a 1 dB reduction in SNR has been equated with a 6‐8% improvement in sentence recognition (Crandell, 1991; Wilson et al, 2007)
• On average, normal hearing people require a +2 dB signal to noise ratio for 50% recognition of words in sentences while people with hearing loss require a 8 dB signal to noise ratio (Killion, 2002).
• Even a 1 dB reduction in SNR has been estimated to be commensurate with a 6‐8% improvement in percent correct scores for sentence recognition (Crandell, 1991; Wilson et al, 2007)
• 5 dB SNR loss = 20% quality estimation (Killion (2011)
59
Good news• Higher benefit from training is significantly correlated with reduced listening effort (Olsen and Preminger, 2012)
• New hearing aid users in the training group experience the largest improvement (Preminger, 2011)
• Patients with more severe handicap show greater benefit (Henderson‐Sabes and Sweetow, 2007; Kuk et al, 2009; Hickson et al, 2011)
• Patients with more severe handicap are more likely to comply with therapeutic recommendations (Sweetow and Sabes, 2007)
• Reduced return rate (13 vs. 3%) of hearing aids (Martin, 2007); 9% ‐ 3% (Northern and Beyer, 1999)
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Difference in Average S/B Score1st to 4th Quarter
0 10 20 30 40 50 60 70-15
-10
-5
0
5
Subject
(dB
SN
R)
Difference in Average CS Score1st to 4th Quarter
0 10 20 30 40 50 60 70-25
-20
-15
-10
-5
0
5
10
Subject
(dB
SN
R)
Difference in Average TC Score1st to 4th Quarter
0 10 20 30 40 50 60 70-30-25-20-15-10-505
10
Subject
(dB
SN
R)
Difference in Average TW Score1st to 4th Quarter
0 10 20 30 40 50 60 70-2
-1
0
1
2
3
Subject
(dB
SN
R)
Difference in Average TW Score1st to 4th Quarter
0 10 20 30 40 50 60 70
-4
-3
-2
-1
0
1
Subject
(dB
SN
R)
MWDifference in Average MW Score – 1st to 4th quarter
The biggest unresolved questions
• Will audiologists recommend it?
– Impact on return for credit rate?
• Will patients do it?
– Cost of effort
– They do for physical therapy
• Why? – MD recommendation
– Immediate modeling of therapy after surgery
62
Why audiologists don’t recommend AR
• Belief that hearing aids alone are adequate
• Lack of belief in outcome measures
• Belief that additional resources (time, money) are required
• Lack of confidence regarding who needs AT
• Lack of reimbursement
• Reluctance to ask patients to spend more time or money
• Inertia
• Laziness
63
Something to consider
• Results from a counseling‐based group AR program indicated that hearing aid users that participated in the program performed better on the Communication Profile of the Hearing Impaired than hearing aid users with no group AR experience at the conclusion of the program.
• However, there were no significant differences between the groups after one year.
Chisolm TH, Abrams HB, McArdle, R. (2004) Short‐ and long‐term outcomes of adult audiological rehabilitation. Ear Hear 25:464‐477.
• So what does this imply?64
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Compliance• Clinical data from over 3,000 individuals reported that
adherence (defined as completion of at least half of the recommended number of training sessions) was less than 30%. (Sweetow and Sabes, 2010)
• Similarly, in a study of home‐based computerized AT for cochlear implant users, Stacey and Summerfield (2005) reported that about 1/3 of their users completed less than 1/3 of the recommended training.
• Non‐compliance with prescribed medication regimens for hypotensive treatment ranges from 5% to 80% among glaucoma patients (Olthoff et al, 2005).
• Vincent (1971) reported that 43% of glaucoma patients refused to take the physician‐ordered measures necessary to prevent blindness, even when that refusal had already led to impairment in one eye.
65
AT Studies from 2000 – 2012 meeting Evidenced Based criteria
(Sweetow and Palmer, 2005)Henshaw and Ferguson , PLOS 2013; CBAT*
• – Fu and Galvin, 2007• – Oba, Fu and Galvin, 2011• – Miller, Watson, Kistler, Wightman and
Preminger, 2008• – Sweetow and Sabes, 2004• – Sweetow and Sabes, 2006• – Barcroft, Sommers, Tye‐Murray et al., 2011• – Ingvalson, Lee, Fiebig and Wong, 2013• – Zhang, Dorman, Fu and Spahr, 2012• – Levitt, Oden, Simon et al., 2011.
66
CONCLUSIONS
• 1) less than 5% of studies published on auditory training meet rigorous evidenced based criteria
• 2) auditory training resulted in improved performance for trained tasks in nearly all the articles that met evidenced‐based criteria
• 3) although generalization of learning was shown to untrained measures of speech intelligibility, cognition, and/or self‐reported hearing abilities, the improvements were variable, relatively small and not robust, though retention of learning was shown at post‐training
67
Reasons
• Denial of the problem
• Cost (money, time, risk of failure) of the treatment
• Difficulty of the regimen
• Unpleasant outcomes or side‐effects of the treatment
• Lack of trust
• Apathy
• Previous negative experience• Failure to persuade that compliance is in their best interest
• Lack of “rewards” or recognition for effort68
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Six predictors of positive compliance
• Higher socioeconomic status• Greater initial self reported hearing disability• Lower pre‐contemplation stage (denial)• Greater action stage of change• Lower chance locus of control• Greater hearing disability perceived by others and self
– Laplante‐Levesque, Hickson, and Worrall (Ear & Hearing, 2012)
69
Suggestions
• Compliance generally increases if patients are given clear and understandable information about their condition and progress in a sincere and responsive way
• Do the first session face to face
• Simplify instructions and treatment regimen as much as possible.
• Have systems in place to generate treatment and appointment reminders
70
LACE CE and Compliance
In Clinic At Home0
10
20
30
40
50
* Patients training at home maychoose not to upload data
Where Patient Completed Session 1
Perc
ent o
f pat
ient
s up
load
ing
at le
ast 1
0 se
ssio
ns(%
)
71
How should success be measured?
• On‐task improvement
• Generalized speech recognition performance
• Quality of life
• Subjective communication confidence
• Individual vs group mean data
72
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Attitude of the Professional
• Audiologists sell a process, not a product
• Patients will not regard listening programs to be important unless the clinician appears to believe it is important
• Radical changes in technology have immediate impact
• Changes in practice or procedures must overcome the hurdle of inertia
73
Summary
• Identify and manage patient’s emotional status• Help the patient feel safe and free to express his/her feelings
• Manage emotional barriers• Select appropriate amplification in accordance with the patient’s personality and needs
• Teach and orient the patient regarding adaptation and the use of the hearing aids
• Help the patient manage telephone use• Help the patient attain realistic expectations• Make the patient understand that hearing aid use is only one component of the hearing rehabilitation process
• Document your work• Provide a rehabilitation plan
74
Challenges
• Convince MDs / audiologists / patients of importance• Large scale studies on AR/AT• Better diagnostic/prognostic assessments• Establish optimal training parameters• Raise acceptance to level of acceptance of “Brain games” (e.g. Lumosity, Brain HQ, Posit Science)
• More enjoyable AT (e.g. enhanced LACE with videos) • More mobile apps (e.g. Hear Coach) • More “fun” games (e.g. Read My Quips) • Non‐speech, i.e. music training (e.g. Kraus and Anderson)• Incentives• Determine appropriate outcome measures
75
Aural (auditory, audiologic) rehab……
Should NOT be considered an add‐on!
Incorporate it at the very beginning
Above all……….. Do something!!!!!
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Lisa Christensen, Au.D. Arkansas School for the Deaf
PEDIATRIC BONE ANCHORED IMPLANTS:
PROTOCOLS AND STRATEGIES
Consultant for Cochlear Americas BAS
DISCLOSURE
¡ Osseointegrated devices have treating conductive and mixed hearing loss since 1977.
¡ Works through direct bone conduction.
¡ Sound is conducted through the skull bone bypassing the outer and middle ear and stimulating the cochlea.
¡ Contains three parts: § titanium implant § external abutment § detachable sound processor § BAHA – Entific Medical Systems § Baha ™ Cochlear Americas § Ponto – Oticon Medical § Osseointegrated implants § Bone Anchored Implants – BAI
§ Aided testing - B
BONE ANCHORED IMPLANTS
¡ Softbands • No age restrictions • Bilateral CHL • Bilateral MHL • SSD or unilateral losses • Unilateral or bilateral softbands available
¡ Implants • FDA - age 5 years old or older • FDA: Bilateral implants (can be simultaneously implanted) must be
symmetric bone conduction thresholds less than 10 dB difference on average (500, 1000, 2000, and 3000 Hz) or less than 15 dB at individual frequencies
CANDIDACY
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¡ Conductive Hearing Loss • TCS • Atresia/microtia
¡ MHL implants
• Bilateral with BC PTA or 35 dB or less for children (Christensen) • Power devices • 5 years of age as other implantation guidelines
¡ Single sided deafness (SSD)
• Unilateral hearing loss profound SNHL, MHL, or CHL • Normal (15 dB or less) in the “good ear” • Softband
CANDIDACY
• Placement of Baha Softband § Infants - not always on mastoid § Toddlers § Preschoolers
• Fitting the Softband § Helping parents find the perfect fit
• Functional gain/aided audiogram
SOFTBAND FITTING
¡ Bilateral CHL/MHL will be fit ASAP • Just like traditional hearing aid fittings • Some will be implanted when they are 5 years old • Some will receive other surgical intervention
¡ Unilateral losses (SNHL/MHL/CHL)
• fit at 9 to 12 months of age when we can get a Softband near the affected ear on a full time basis
SOFTBANDS: WHEN TO FIT
¡ For bilateral CHL/MHL most common verification is Functional Gain • under 6 months of age – BOA
§ Testing Babies: You Can Do It! Behavioral Observation Audiometry (BOA) by Jane R. Madell
Perspectives on Hearing and Hearing Disorders in Childhood December 2011 21:59-65.
• over 6 months – VRA, CPA, etc
¡ Outcome measures ¡ SLPs/AV Therapists
SOFTBAND VERIFICATION
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SOFTBAND VALIDATION
Any va l idat ion measure you cur rent l y use fo r other t rad i t iona l BTE f i t t ings wi th ch i ld ren wi l l work we l l w i th sof tband va l idat ion fo r b i la tera l CHL/MHL. Karen Ander son - Success fo r K ids w i th Hear ing Loss
§ https://successforkidswithhearingloss.com/tests ¡ ELF - Ear l y L is ten ing Funct ion ¡ CHILD - Ch i ld ren ’s Home Inventor y o f L is ten ing D i f f i cu l t ies ¡ Preschoo l S IFTER – Preschoo l Screen ing Ins t rument For Target ing Educat iona l R isk ¡ SIFTER – Screen ing Ins t rument For Target ing Educat iona l R isk o f E lementar y School Ch i ld ren ¡ Secondar y S IFTER - Secondar y Screen ing Ins t rument For Target ing Educat iona l R isk ¡ LIFE -R – Rev ised L is ten ing Inventor y For Educat ion ¡ LIFE – Learn ing Inventor y For Educat ion ¡ LIFE Student Appra isa l ¡ LIFE Student Appra isa l P ic tures ¡ LIFE Teacher Appra isa l ¡ CHAPS- Ch i ld ren ’s Audi tor y Per formance Sca le ¡ SAC- A -Se l f Assessment o f Communicat ion - Ado lescent ¡ SOAC- A– S ign i f i cant Other Assessment o f Communicat ion – Adolescent ¡ FLE – Funct iona l L is ten ing Eva luat ion ¡ Chi ldrens Peer Re lat ionsh ip Sca le ¡ Minnesota Soc ia l Sk i l l s Check l i s t fo r Students who are Deaf - Hard o f Hear ing ¡ PARC– P lacement Readiness Check l is ts fo r Ch i ld ren who are Deaf o r Hard o f Hear ing
(Co lorado)
¡ When in doubt…follow the rules
§ State licensure laws for verification and validation of hearing aids and implantable devices
§ Clinical practice guidelines (AAA, ASHA, etc)
RULES
ARKANSAS LICENSURE LAW
Evaluation of hearing aids must be performed with the hearing aids on the patient. This shall be accomplished EITHER in sound field OR with instruments which objectively measure hearing aid performance with appropriate prescriptive techniques to account for the dif ferent means of programming the hearing aid (linear versus nonlinear, digital versus analog). The preferred verification method of fitting is to use probe microphone measures in conjunction with the patient’s ear, ear mold, and personal amplification system. A real ear to coupler dif ference (RECD) can be obtained and probe tube measurement performed in a coupler if a patient is unwilling to tolerate probe microphone measurement in the ear. A prescriptive measure addressing gain should be in place to address the possibility of over- or underestimating gain until the patient is five (5) years of age.
3. AUDIOLOGIC CANDIDACY CRITERIA (page 12) Recommendations for Determining Candidacy Children with permanent conductive hearing loss should be fit with air conduction hearing aids when anatomically possible (sufficient external ear and canal anatomy to support the coupling of an earmold and retention of the device), or bone conduction hearing aids if anatomy is insufficient for coupling (atresia, chronically draining ears, or other significant anatomical malformations).
AAA CLINICAL PRACTICE GUIDELINES PEDIATRIC AMPLIFICATION JUNE 2013
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6.2.3 Aided Thresholds in the Sound Field (pp 39-40) 2. In cases of bone conduction hearing aids, real-ear probe microphone measures cannot be conducted (when there is no acoustic signal in an ear canal), and the aided audiogram may be the most readily available verification option. In spite of its limitations, the aided audiogram can provide information, and in the case of bone conduction and frequency transposition/compression hearing aids, may be the most valid way to quantify the aided response with currently available technologies.
AAA CLINICAL PRACTICE GUIDELINES PEDIATRIC AMPLIFICATION JUNE 2013 SOFTBAND VERIFICATION
SOFTBAND CASES ¡ DOB 3/30/2010 ¡ Female ¡ 36 weeks gestational age ¡ 3 lbs.15 oz. ¡ Failed NBHS in rural part of Arkansas ¡ No family history of hearing loss
SOFTBAND CASE 1
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¡ Seen at 4 months of age for follow up NBHS
¡ Tech notes ear pit right ear
¡ Type B high frequency tymps AU
¡ Failed OAEs AU
SOFTBAND CASE 1
¡ ENT examination – Stenosis and No TM identified in the clinic
¡ ABR at 7 months - During possible PET placement was consistent with a Moderate CHL AU
SOFTBAND CASE 1
¡ Loaner device fit at 8 months old ¡ Personal Softband fit at
9 months 22 days
SOFTBAND CASE 1
¡ Cleft palate ¡ Chromosome deletion 18p ¡ Failed NBHS and follow up screenings
§ NO atresia § NO stenosis
¡ Behavioral testing at 6 months consistent with moderate/severe CHL
SOFTBAND CASE 2
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¡ Fit with loaner device 6 months
¡ Personal Baha fitting at 8 months
¡ Numerous repairs …
SOFTBAND CASE 2
¡ Fit with BP100 at 2 years of age
§ Titanium § Lockable battery door § Moisture resistant
• Importance of pediatric features • Softbands • loaners
SOFTBAND CASE 2
SOFTBAND CASE 3
¡ Down Syndrome
¡ 8 years old at the time of initial fitting
¡ Raised by great grandparents at the time and due to dexterity issues a Softband was the best option for the family
¡ Also allowed for less adjustments by the audiologist
SOFTBAND CASE 3
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Reimbursement for Softbands?
1. Key phrases § Cannot benefit from traditional BTEs § Malformation § Congenital
2. Provide data
SOFTBAND FUNDING
¡ Hol et al 2005 • Two subjects
§ 3 y/o and 29 months • Compared Baha Compact, Baha Classic, and Oticon E 300 P • The electro-acoustic measurements showed minor
differences in gain between the three devices • Both children showed speech and language
development that was in accordance with their cognitive development.
¡ Conclusions: The BAHA Softband was a valid intervention in children with congenital bilateral aural atresia who were too young for percutaneous BAHA application
SOFTBAND DATA
¡ Arkansas Children’s Hospital § A retrospective study of Baha charts of 20 infants
and children 2002 to 2006 § 20 infants and children § 8 months to 16 years (mean age = 5.04 years) § Inclusion criteria was:
(a) bilateral symmetrical conductive hearing loss (b) fit with Baha at ACH (c) consistent full-time Baha use on a Softband (d) followed at ACH for 6 months or longer
SOFTBAND DATA
Nicholson, N. Christensen, L, Dornhof fer, J . Mart in, P, Smith-Ol inde, L. (2011).Verif ication of speech spectrum audibi l i ty for pediatr ic baha sof tband users with craionfacial anomalies. Clef t Palate-Craniofacial Journal , (48)1: 56-65.
SOFTBAND DATA
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IMPLANTATION ¡ Surgical procedures
§ FDA recommendations - 5 years and older § 1 stage vs. 2 stage surgeries § Osseointegration § Wait times § New surgical techniques § New technology
IMPLANTATION
PRE-SURGICAL CONSIDERATIONS
¡ History § Progressive HL? § Sudden HL?
¡ CT § EVAS? § Other middle or inner ear anomalies?
¡ Family and child must be motivated ¡ Hygiene/ability to care for abutment by family
and/or child § Complications happen and should be discussed
¡ 7 years old ¡ Wore BTEs for bilateral moderate CHL ¡ Normal pinnas AU ¡ Chronic otitis externa
¡ Implanted bilaterally with a two stage surgery 6 months osseointegration period between two stages
IMPLANT CASE 1
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IMPLANT CASE 1
Unaided
BTE Aided
Bilateral Baha Implants
¡ Family choice
¡ Aided thresholds were similar
¡ Never wore a Softband
¡ Chronic otitis externa was their priority
¡ Still uses FM as she did with the BTEs
IMPLANT CASE 1
¡ Why choose bone anchored implants over traditional bone conduction aids?
¡ Is it worth the money?
¡ How does a traditional bone conduction aid compare to the Softband? To a implanted Baha?
TRADITIONAL BC AIDS VS. BAHA SYSTEM
¡ Verstraeten et al (2008) ¡ 3 conditions:
§ Baha implanted unilaterally § Baha coupled to a headband § Baha coupled to the test band
¡ Results § Headband vs. test band were similar § Implantation was superior to both headband and test
band
HEADBAND VS. IMPLANTATION
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Retrospective study of 10 subjects (a) 6 months to 18 years of age (b) congenital bilateral conductive hearing loss (c) initially fit with a traditional bone conduction hearing aid (d) fit unilaterally with a Baha Compact or Divino via the Softband (e) implanted unilaterally with the Baha system (f) unaided and aided soundfield thresholds available for four frequencies from 500 Hz to 4000 Hz (g) consistent full-time use of amplification
¡ Ear and frequency specific thresholds obtained via supra aural headphones at 500, 1000, 2000, and 4000 Hz were recorded on datasheets and transferred to an Excel®
¡ Audiometric data for frequency specific unaided and aided sound field thresholds obtained with the speaker positioned at a 90° azimuth to the target ear were also transferred to an Excel sheet
BAHA VS. TRADITIONAL BC AID FUNCTIONAL GAIN RESULTS
• Bone conduct ion t ransducer prov ides the most gain of any dev ice tested
• The implanted Baha system prov ided second h ighest amount of funct ional gain
• Sof tband resul ts prov ided the th i rd amount of h ighest funct ional gain .
• Tradi t ional bone conduct ion hear ing a ids prov ided the least amount of funct ional gain .
• There is some over lap among dev ices at 1000 Hz , but at no other f requency . ¡ Implanted Baha has stat is t ica l ly as much gain as a bone conduct ion t ransducer at
a l l f requencies tested;
¡ Implanted Baha prov ides stat is t ica l ly more gain at 500 Hz than the Baha at tached to a Sof tband
¡ Tradi t ional bone conduct ion hear ing a id prov ides s igni f icant ly less gain than a l l the other dev ices at a l l f requencies wi th the except ion of the Baha with Sof tband at 2000 Hz .
Christensen L, Smith-Olinde L, Kimberlain J, Richter G, Dornhoffer J (2010). Comparison of traditional bone-conduction hearing aids with the Baha system. 20:3.
RESULTS
BILATERAL
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¡ Bosman, A.J. et al (2001) ¡ ‘Audiometric Evaluation of Bilaterally Fitted Bone-
anchored Hearing Aids’ • 25 adults • Aged 12 to 69 years of age • Required at least 3 months experience with bilateral
Baha implants • All had symmetrical bone conduction thresholds across
0.5, 1, 2, and 4 kHz • Baha Classic (no longer manufactured)
PREVIOUS RESEARCH
¡ Results: § Better localization skills § Better speech in noise § Better Binaural Masking Level Difference (BMLD)
§ The masked threshold of a signal can sometimes be lower when listening with two ears rather than one
§ The detection of a signal in noise is improved when either the phase or level differences of the signal at the two ears are not the same as the masker.
¡ Conculsions: § Results for localization, speech in noise and BMLD
measurements indicate that bilateral Baha “do indeed result in binaural hearing” to an extent.
BOSMAN ET AL RESULTS
¡ 18 year old female
¡ TCS
¡ First implanted unilaterally in another state
¡ Received second implant approximately 2 years after the first implant
BILATERAL CASE 1
BILATERAL CASE 1
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¡ Hearing In Noise Test (HINT) § 10 sentences that are scored based on the number of words
repeated correctly.
§ Left Baha § + 10 dB S/N ratio = 80%
§ Right Baha § + 10 dB S/N ratio = 82%
§ Bilateral Baha § + 10 dB S/N ratio = 91%
BILATERAL CASE 1
¡ Di George Syndrome ¡ Mixed Hearing Loss ¡ Malformed outer, middle, and inner ear ¡ Wore BTEs since shortly after birth ¡ Terrible balance/vestibular problems…Tons of repairs!!! ¡ Used Bilateral Softband prior to implantation ¡ Bilateral Implants
BILATERAL CASE 2
BILATERAL CASE 2
Unaided
BTE Aided
Baha Aided
SINGLE SIDED DEAFNESS (SSD)
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¡ 35% failed at least one grade
¡ 13.3% were in need of some special resource assistance
¡ 20% were described by teachers as having behavioral problems
¡ 50% showed some difficulty in educational progress
(Bess & Tharpe,1986)
SINCE 1986…UNILATERAL HEARING LOSS…
¡ Judith Lieu, MD § Washington University
¡ 70% of children with unilateral loss have IEP
¡ Unilateral loss IS associated with worse speech and language scores in children
Lieu, J . , (2004). Speech- language and educat ional consequences of uni lateral hearing loss in chi ldren. Arch Otolar yngol Head Neck Surg. 130 (5) :524-530. L ieu, J . , Tye-Murray, N, Karzon, R. , Piccir i l lo , J . (2010) . Uni lateral hear ing loss is associated with worse speech- language scores in chi ldren. Pediatr ics . 125(6) ; 1348-1355.
UNILATERAL LOSSES
1. FM systems § Personal or soundfield § Works well for elementary grades
2. Preferential classroom seating 3. Counsel it away 4. Hearing aids
§ 50% parents report “never” wearing it (Davis et al 2004) 5. CROS 6. BAI
UHL TREATMENTS
AUDIOLOGIC CANDIDACY CRITERIA (p 12) Recommendations for Determining Candidacy 1. Children with aidable unilateral hearing loss should be considered candidates for amplification in the impaired ear due to evidence for potential developmental and academic delays. Children with unilateral hearing loss are at greater risk than children with normal hearing for speech and language delays and academic dif ficulties. For children with severe or profound unilateral hearing losses and normal hearing in the other ear, Contralateral Routing of Signal (CROS) or bone conduction devices may be considered depending on the child’s age and ability to control their environment. Currently there is a paucity of data available to inform these decisions.
AAA CLINICAL PRACTICE GUIDELINES PEDIATRIC AMPLIFICATION JUNE 2013
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PRINCIPLES UNDERLYING EFFECTIVE AMPLIFICATION (pp14-16) Uni lateral Hearing Loss Contralateral routing of the signal (CROS) and Bilateral routing of the signal (BICROS) fittings are specially designed for patients having either unilateral hearing loss or bilateral asymmetrical hearing loss where one ear is unaidable, respectively. Currently, wired and wireless configurations are available. For the child with unilateral deafness, an FM system with the wireless remote microphone receiver portion coupled to the open, good ear may be preferable in classroom situations to the CROS arrangement to give the benefit of increased signal to noise ratio, a benefit in a noisy classroom. The transcranial CROS is an option for individuals who have no auditory response in one ear. In this configuration, a powerful hearing aid is fit to the non-responsive ear so interaural attenuation is overcome and sound is perceived by the functioning cochlea. This is not a common fitting for children and again, an appropriately fit assistive l istening device may be a better communication solution in the classroom. The osseointegrated hearing device described earlier also can be used as an implanted transcranial CROS; evidence supporting benefit of this arrangement in children is l imited.
AAA CLINICAL PRACTICE GUIDELINES PEDIATRIC AMPLIFICATION JUNE 2013
• Shapiro 1997 Archives of Otolaryngology • 10 children (7 to 17 years) fit with CROS • Results based on teacher report and parent report (how much use?
Was child forced to use it?) • 7 of 10 children were considered successful with CROS
• Kenworthy 1990 Ear & Hearing § Speech recognition abilities of children with unilateral SNHL – goal § Compared unaided; CROS and personal FM § FM system was the only audiological recommendation that did not
produce a marked reduction in speech recognition in at least one listening environment
• Updike 1994 JAAA • 6 children amplification and CROS did not improve speech
understanding in noise and had detrimental results in noisy situations.
CROS
¡ Is anyone really doing this? ¡ Why are we doing it? ¡ Does it really work? ¡ How do you know if it really works? ¡ Do these kids really wear that? ¡ Is this a one hit wonder?
BAHA & SSD
• CHL or SNHL – unaidable by traditional amplification options
• Normal ear must be NORMAL and without known risk or progression
• Testing using “power” device coupled to a metal headband
• Ability by family and/or child to care for abutment properly
• Counseling pre-implant to verify the family and child knows the benefits and limitations of the Baha This is NOT a cure for their hearing loss.
SSD GUIDELINES
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¡ Speech in noise testing § Testing with and without noise § Hearing in Noise Test (HINT) (Nilsson, Soli, and Sullivan, 1994);
Words in Noise (WIN) (Wilson, 2003; Wilson and Burks, 2005); QuickSIN (Etymotic Research, 2001; Killion et al., 2004), Bamford-Kowal-Bench SIN (BKB-SIN) (Etymotic Research, 2005; Bench, Kowal, and Bamford, 1979; Niquette et al., 2003).
¡ Outcome Measures
§ Use testing that looks at “listening skills” also not just “hearing” § CHILD (5 to 12 year olds) § SSQ (13 years and older) § LIFE
SSD EVALUATION WAIT…WHAT IF IT’S AN INFANT OR TODDLER?
¡ Speech in noise § Body parts § WIPI § SRT/SAT § Spondee Picture Cards
¡ Outcome Measures § Must be parent measures § SLP evaluations
¡ 17 Y 6M female § Normal hearing left ear; Profound (no response) right ear § Seen yearly to monitor loss § In office trial and testing § Single stage surgery
SSD CASE 1
Pre-implant Testing
¡ HINT § +10 SNR = 100% § +5 SNR = 100% § 0 SNR = 68% § - 5 SNR = 23%
¡ SSQ
§ Speech = 4.29 § Spatial = 1.47 § Quality = 5.61
Post Implant Testing
¡ HINT § +10 SNR = 100% § +5 SNR = 100% § 0 SNR = 100% § - 5 SNR = 36%
¡ SSQ § Speech = 9.07 § Spatial = 9.06 § Quality = 8.89
SSD CASE 1
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¡ 13 year old female
§ Normal hearing right ear § Profound left ear – absent VIIIth nerve § Yearly monitor of hearing loss
SSD CASE 2
Pre-implant Testing
¡ HINT § +10 SNR = 79% § +5 SNR = 60% § 0 SNR = 23%
¡ SSQ
§ Speech = 6.86 § Spatial = 5.06 § Quality = 7.76
3 Months Post Implant
¡ HINT § +10 SNR = 100% § +5 SNR = 100% § 0 SNR = 96% § - 5 SNR = 96%
¡ SSQ
§ Speech = 9.79 § Spatial = 9.59 § Quality = 9.00
SSD CASE 2
1. Catch Phrases § Congenital § Cannot benefit from traditional amplification
2. Show HINT and CHILD/SSQ scores § Everyone gets percentages
3. Provide the data
SSD REIMBURSEMENT
¡ Average scores for all 26 subjects
¡ Pre-Implant
0 SNR = 41% +5 SNR = 76% +10 SNR = 95%
¡ Post-Implant 0 SNR = 82% +5 SNR = 97% +10 SNR = 99%
HINT RESULTS
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Scores 1 to 10 on 15 situations Average scores for all 25 subjects Parent Version Pre-Implant = 4.58 Child Version Pre-Implant = 4.50
Parent Version Post-Implant = 7.19 Child Version Post-Implant = 7.24
CHILD RESULTS
¡ Christensen, Richter, Dornhoffer (2010). Update on bone-anchored hearing aids in pediatric patients with profound unilateral sensorineural hearing loss, Archives of Otolaryngology , 136(2): 175-177.
¡ Christensen L, Dornhoffer JL, Bone-Anchored Hearing Aids for Unilateral Hearing Loss in Teenagers, Otology Neurotology, 2008;29:1120-1122.
SSD DATA
¡ SSQ Pre-Implant (N=9)
Speech = 4.20 Spatial = 2.41 Quality = 5.40
¡ SSQ Post-Implant 3 months (N=9) Speech = 7.87 Spatial = 6.60 Quality = 7.70
UNPUBLISHED SSQ RESULTS
UNILATERAL CHL
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¡ 16 year old male
§ Atresia right ear; Normal hearing left ear
UNILATERAL CHL CASE
Pre-implant Testing
¡ HINT § +10 SNR = 100% § +5 SNR = 92% § 0 SNR = 73% § - 5 SNR = 12%
¡ SSQ
§ Speech = 5.60 § Spatial = 7.18 § Quality = 7.76
3 months
¡ HINT § +10 SNR = 100% § +5 SNR = 98% § 0 SNR = 91% § - 5 SNR = 11%
¡ SSQ
§ Speech = 8.14 § Spatial = 8.69 § Quality = 8.58
UNILATERAL CHL CASE
THE FUTURE: SSD AND BAI
¡ Prosper Meniere Society Meeting, Austr ia § Japan § Adults only
¡ Audiology Today, Jennifer Torres & Daniel Zeit ier, September/October 2013
§ 10 year old with UHL “By al l accounts, the patient was noted to be a bright student and was not having any noticeable trouble hearing in the classroom, in af ter school or social activ it ies, or in the home. In fact, the patient repor ts that many of her fr iends didn’t real ize she had hearing loss unti l she decided to tel l them “so they would not think I was ignoring them.” However, her family admits they made some signif icant l i festyle modifications to adapt to the patient’s UHL as well as to preserve the hearing she had lef t ( i .e. , infrequent restaurant dining, no l ive spor t ing events, no firework shows).”
§ Tried CROS but did not like wearing a device in her hearing ear § Used BAI with softband, which she liked (and had slightly better test results) but
insurance denied § CI (which insurance approved)
¡ At 3 months post-op testing SNR loss with the CI was increased to 3 dB SNR (from 7.5 dB SNR) indicating that the patient did not per form any better with the CI than she did with the CROS or the BAI during preoperative test ing condit ions.
¡ However subjectively the patient greatly preferred the CI
WHAT ABOUT COCHLEAR IMPLANTS?
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¡ Cochlear malformations ¡ Absent VIII nerves
WILL WE STILL NEED BAI FOR SSD?
COMPLICATIONS
¡ Retrospective study on extrusion rate ¡ 57 children ¡ 20 adults ¡ 3mm and 4mm implants used ¡ Mean age
§ 12 years 3 months for the children § 52 years for the adults
COMPLICATIONS
¡ Complication rates in Arkansas
§ 21% for children
COMPLICATIONS
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§ Young age § Syndromic status § Possible failure to penetrate the inner cranium § Soft tissue infections § Local trauma
§ All of these factors are assumed to be the cause of the complication rate in children.
Lee C, Christensen L, Richter G, Dornhoffer J. (2011). Arkansas
BAHA Experience: Transcalvarial fixture placement using osseointegration surgical hardware. Otology Neurotology. 32:444-447.
COMPLICATIONS
¡ SSD and CI ¡ Softbands will remain… ¡ Complications ¡ New Technology
FUTURE
MMH14004: Audiology Amplification
11/2/2013University of California San Francisco
City, StateName
Registrant ListUCSF OCME Page 1 of 3
1 Santa Rosa, CAAldred Joyce E.
2 HAD Palo Alto, CAAma Lais
3 Napa, CAAmornpongchai Aunyaporn
4 AuD Ukiah, CAAndrus Gary Wyatt
5 MA Porterville, CAApilado Benjamin
6 PhD Fresno, CAArnst Dennis
7 MS Palo Alto, CAAshley Debra
8 MA Vallejo, CAAthey Joseph T.
9 AuD Davis, CABarga Patrick
10 PhD Danville, CABarrett Jillian G.
11 Sacramento, CABarry Michelle
12 AuD Redding, CABass Roberta
13 AuD Menlo Park, CABaxter Jane H.
14 PhD Hollister, CABelt Donald
15 MS, CCC-A Salinas, CABenko Kay Lynn
16 PhD Iowa City, IABentler Ruth
17 Gold River, CABigler Stephanie
18 San Francisco, CABillheimer Kenneth
19 AuD San Bruno, CABlazek Barbara L.
20 MA Petaluma, CABurt Phyllis J.
21 AuD Chico, CAChalmers Crystal L.
22 MD, FACS San Francisco, CACheung Steven W.
23 AuD Little Rock, ARChristensen Lisa V.
24 AuD Los Altos, CAClark Debbie
25 MS Oakland, CACohen Beth R.
26 MA Santa Rosa, CAConley Judith
27 AuD Alameda, CACrookston Ray G.
28 AuD San Jose, CADias Maria M.
29 MD Bainbridge Island, WADonohue Sally Jo
30 AuD Napa, CADuguay Brian
31 PhD San Francisco, CADundas Drew
32 AuD Greenbrae, CADundas Lisa
33 MD Emeryville, CAEpter David D.
34 Huntington Beach, CAEverson Megan Greenya
35 E. Palo Alto, CAEwing Kelly
36 Santa Rosa, CAFellores Jayme
37 MA Walnut Creek, CAFitzgibbons Gregory
38 Walnut Creek, CAFitzgibbons Valerie
City, StateName
Registrant ListUCSF OCME Page 2 of 3
39 MD Peoria, AZFitzke Jeanette
40 San Diego, CAFitzsimmons Nelson
41 San Diego, CAFlowers Jeremy
42 Palo Alto, CAGholami Honey
43 Oceano, CAGibson Keiko
44 San Jose, CAGriffin Cari
45 San Francisco, CAGriffin Michelle
46 Sacramento, CAHanson Judy
47 Los Altos, CAHarrigan Erin
48 San Diego, CAHarris Caton A
49 MED, CCC/A Saratoga, CAHavard Joan
50 Walnut Creek, CAHavard Jovina
51 Elk Grove, CAHightower Nichole M.
52 Montcenis, FranceHoche Antoine
53 PhD Nashville, TNHornsby Benjamin
54 PhD Penngrove, CAJarvis John
55 Sacramento, CAJohnston Laura
56 AuD Novato, CAJoseph Michal
57 Eureka, CAKelly Julie
58 MA Santa Clara, CAKhetrapal Tara F.
59 San Jose, CAKinder Molly
60 Sacramento, CAKnudsen Kimberly
61 San Francisco, CALampert Jeffrey
62 MA Stanford, CALarky Jannine
63 San Francisco, CALee Shui-lan
64 AuD Menlo Park, CALim Shu-En
65 MA Yuba City, CALind Richard C.
66 AuD Menlo Park, CALisi Margaret
67 San Francisco, CALittle Heather
68 AuD Oakley, CALooper Louis (Tony)
69 Oakland, CAMakeig Heidi
70 AuD San Mateo, CAMarculescu Rebecca
71 AuD Davis, CAMcNamara Betty L.
72 MD Los Osos, CAMolin Lisa
73 San Jose, CAMontgomery Pat
74 Salinas, CAMoore Dawn
75 San Jose, CAMusko Sally
76 AuD San Jose, CANelson Amy
77 AuD Palo Alto, CANovick Marni
78 AuD Fremont, CAOza Kalindi
79 AuD Shingle Springs, CAPayne Lonnie Mark
80 MA Rancho Murieta, CAPepin Nancy T.
City, StateName
Registrant ListUCSF OCME Page 3 of 3
81 Travis AFB, CAPerro Jamie
82 MA Napa, CAPfau Elly
83 AuD, MS, CCC-A San Francisco, CAPolite Colleen
84 Palo Alto, CAPrice Melissa
85 MD San Mateo, CAPumford John
86 AuD Los Altos, CARaguskus Brook
87 AuD Santa Clara, CARammaha Haifa A.
88 Salinas, CARamsey Robin
89 AuD Carmichael, CAReed Analisa
90 AuD Larkspur, CAReilly Kathy
91 Chico, CARoot Allison Townsend
92 AuD Santa Clara, CASanchez Keleigh
93 MS Napa, CASchreuder Wendy
94 Napa, CASchwaderer Nonie
95 MA San Francisco, CAShalles Jennifer L.
96 MA Algodones, NMSimpson Roberta J.
97 MS Alameda, CASliheet Jane T.
98 Hercules, CASostarich Mary E
99 MA Amador City, CASpencer Raymond E.
100 San Francisco, CAStong Mont
101 BSC Harbor City, CASturm Arthur G.
102 PhD San Francisco, CASweetow Robert W.
103 MS San Francisco, CATannenbaum Melissa
104 Fresno, CAToney Ronald Eugene
105 AuD San Carlos, CATu Clara
106 San Rafael, CAWeissman Lee
107 AuD Mill Valley, CAWill Toni
108 Sacramento, CAWilliams Kelle P
109 MA Benicia, CAWright Lorna
110 AuD San Francisco, CAYee Jenny
111 MS Davis, CAZiarati Roya
111Total Number of Attendees for MMH14004: