Nov 2018 Dezeen
These 3D-printed hearing aids could help people who are partially deaf to tune out unwanted background noise, but they also function as regular earphones. Manchester Metropolitan University student Elen Parry designed the hexagonal-shaped earbuds, called Hex, to resemble normal earphones. Aiming to "reduce the stigma" of wearing an aid, her aim is to create a product that can be used by everyone, so that those with hearing loss don't have to feel self-conscious. "People with disabilities often feel excluded and conspicuous because of their medical devices," said Parry, who studied on the Industrial Digitalisation MSc programme. "I want to transform hearing aids into a wearable technology product that gives people better hearing, style and confidence – something that anyone might want to wear," she explained.
The earbuds use a processing chip that differentiates between background noise and active noise, such as music or a voice on a phone call. The earpiece enables users to increase or decrease the volume of background noise themselves, allowing those with hearing difficulties to more easily tune out surrounding noise. As well as immediately improving the quality of hearing, Parry's aids also prevent the user's hearing from deteriorating further. Regular silicone earbuds can be attached to the hearing aids to transform them into headphones. The device can then be connected to Bluetooth to listen to music or receive phone calls.
"I looked into designing something that could create an improved situation for everyone, rather than a niche for people who are seen as less abled," said Parry. She came up with the idea for the product after noticing her cousin feeling self-conscious wearing a standard, over-the-ear hearing aid. "It has been an interest of mine for a while to try to remove stigma through desirable design," she said. "Medical devices tend to stay the same over time – they are designed by engineers, who don't necessarily think about user experience.” A rechargeable graphene battery is inserted into the product. She mocked up the design on computer-aided design (CAD) software and 3D-printed the pieces using medical grade titanium. A rechargeable graphene battery is inserted into the product, with dual connectivity strips for faster charging. "The idea behind creating Hex earbuds was to create a hearing device for everyone, whether you live with hearing loss or perfect hearing," she explained.
Feb 2021 The Hearing Journal
As 2021 begins in full force with optimism for a COVID-19 endgame, economic upturn, and global healing, emerging developments in hearing technology promise a significant impact, particularly on helping audiologists and patients cope with the new normal. From improved artificial intelligence to new mask mode features, to smart earbuds, these developments are transforming hearing care provision—as well as patient expectations—as additional factors, including over-the-counter (OTC) access and diverse device price points, are entered into a complex equation.
To shed light on this interesting convergence of hearing care provision, technology, and pending regulatory changes, The Hearing Journal (HJ) hosted an online roundtable discussion with leaders from the American Academy of Audiology (AAA), Academy of Doctors of Audiology (ADA), and American Speech-Language-Hearing Association (ASHA). In this month's cover story, we continue our discussion with ADA President Victor Bray, PhD, ASHA's Vice-President for Audiology Practice, Sharon A. Sandridge, PhD, and AAA President Angela Shoup, PhD, along with HJ’s Editorial Board Chair Fan-Gang Zeng, PhD, as the discussion moderator, on optimising advances in hearing technology, including OTCs and personal sound amplification products (PSAPs), to support hearing care professionals and audiology practices this new year.
Dr. Zeng: What recent advances in hearing technology are you most excited about, and how would you incorporate these—including OTCs, PSAPs, and hearables—into your practice? Do you think these advancements are threats or opportunities?
Dr. Bray: My first answer is about audiology in general and separate from consumer electronics. The single and most important update in audiology is the seating of the new congress and resubmission of the Medicare Audiology Access and Services Act, which is jointly supported by ADA, AAA, ASHA, and HLAA. Practitioner status, direct access, and recognition of both diagnostic and rehabilitative roles of audiology are critical to the maturing of the profession and logically necessary to the proper outcome of the AuD degree transition.
More specifically to the question of consumer electronics, there have always been efforts underway to alter or even disrupt the traditional provision of amplification to audiology patients. Personally, as a participant in three different start-ups working in that space, it has always been about disrupting the current models to see if we could bring something better to market—and at times we are able to do that. Certainly, many innovative products today and those on the horizon can potentially change the way patients and consumers access the tools to enable better hearing.
Here's what I am teaching our AuD students to prepare them for the world in which they will practice upon graduation in 2023. Dr. Dillon, a decade ago, described this as “connectivity and convergence.” For example, at present, a person with impaired hearing may be fit with RIC aids, a smartphone with Bluetooth, and a remote microphone. The technology already exists today to use a pair of earbuds as the ear-level device, a Bluetooth smartphone, and an app to reshape the sound for someone with mild to moderate hearing loss, with the smartphone utilised as the remote microphone. ADA has a long history of supporting entrepreneurial activities, and we do not necessarily view the new consumer electronic offerings as a threat. Any change is a potential opportunity to find and incorporate better solutions for hearing care, and we must keep an open mind. An important development is having major companies like Apple and Google contribute to the message that hearing loss is a major health concern. This can help raise awareness that hearing loss must be addressed and not ignored by individuals, families, and our health care system. Any time audiology prioritises the needs of our patients, audiology will win out.
Dr. Sandridge: We have this motto, “Challenges are opportunities to grow.” These challenges to our profession are incredible, great opportunities to embrace. I look forward to incorporating all kinds of OTCs. [At Cleveland Clinic], we are even talking about working with our innovations team in designing our own PSAP so we can have a Cleveland Clinic-branded, very inexpensive amplifier that we can market here at the clinic. There are tremendous opportunities to get on board with all of these developments. As Victor said, anytime you can raise awareness about hearing loss and its impact on health-related quality of life—it's a win-win situation.
The other day, I had a patient come in who had two sets of PSAPs that she bought from Amazon for $37 and $70. And she got what she paid for—they were crap. We ended up getting her into very low-end hearing aids. But why not offer these as an early solution?
Years ago, we put together a questionnaire, which we recently redesigned with questions for patients, including, “Do you want to be a part-time user?” and “Do you want to just use this occasionally?” With this questionnaire, you can create a perfect avenue to offer patients with inexpensive units that they can use occasionally to just get them started [with amplification]. And when they want to use amplification full-time, you can offer them other routes. If we don't embrace them, then we are not going to be providing our patients with the whole continuum of care.
It is also an exciting time because there are so many options. The biggest challenge I see is trying to find which device to embrace and bring in. There is no reason why we can't bring in Apple AirPods and Bose products, for example, and sell them to make it convenient for the person to purchase it right there and then from us. The options are limitless, and the opportunities are there. We just have to put it in our business plan and go for it.
Dr. Shoup: Advances in technology that can offer additional benefits to patients are always an opportunity to positively impact their quality of life. However, I do think these do not replace the critical role of the audiologist. In many cases, there is an increased need for the person to have access to knowledgeable skilled providers who can review the many options and identify those best suited to meet the individuals’ hearing care needs.
It is one thing to take AirPods, for example, and put them on somebody who has perfectly normal hearing or even somebody who has a mild pure-tone hearing loss. But when we start looking at people with more complex hearing needs, they just become frustrated. Fitting the right solution into the complex communication and lifestyle needs of individuals with unique auditory systems and brain experiences really requires knowledge and experience—and that is what we bring. Furthermore, we have to ensure that multiple technologies can be appropriately integrated and that the end-user is capable of implementing the recommended strategy to effectively utilise the recommended system. These often require both provider expertise and individualised training and counselling, which could take a bit of time depending on the digital literacy gap that we may be encountering.
Regarding the type of technology I'm most excited about right now, I tend to stay very focused on patients who have significant hearing difficulties and significantly impacted auditory systems. I am most excited about the potential of new connectivity options using Bluetooth that will allow similar ease of access as we have with telecoils and loop systems. For example, having open-source options, such as the low-energy audio being developed by the European Hearing Industry Manufacturing Associations in collaboration with the Bluetooth Special Interest Group, will allow hearing aid and cochlear implant users to access sound in large venues without requiring complicated pairings or additional technology. It will be very freeing to patients! It will enhance their access to information and entertainment and their enjoyment of media. They can become more engaged with their communities. The concept of finding something that is freely accessible in entertainment venues and large group opportunities is something that I'd be most excited about.
Dr. Zeng: Based on what Angela, Sharon, and Victor just said, we are entering a very exciting time. This naturally leads to the next question: What is your personal and organisational position on the regulatory side? And perhaps, more importantly, as audiologists and as a profession, where and how can you make money as a business?
Dr. Bray: Times of change are times of opportunity. But for some people, these can be times of threat. It is an opportunity for audiology to embrace the challenge even though our initial response might be fear and threat, e.g., “This can't be good for me because it is going to change what I have been doing.” But if we look at the positive side, change can be good. It takes the right mindset to take advantage of an opportunity. Regarding OTC, ADA continues to support the bipartisan and bicameral Over-the-Counter Hearing Aid Act of 2017. We also continue to support the recommendations from the consensus report that came from ADA, AAA, ASHA, and IHS. These are established product requirements: define concise out-of-the-box labeling, define comprehensive inside-the-box labelling, define the new OTC category that is easily comprehensible by consumers, and provide adequate provisions for consumer protection. We continue to support all of those things. Many ADA members may choose to incorporate OTC devices into their practices just as many of them now incorporate PSAP amplifier options. We can also expect to see a continuation of many business practices that incorporate variations of bundling and unbundling of services from the product as determined to be the best for that audiology practice. Decisions about bundling and unbundling are not necessarily dependent upon whether we are talking about hearing devices, hearing accessories, PSAPs, or OTCs because OTCs can be successfully incorporated into a practice with either model.
Dr. Sandridge: Challenges are opportunities. OTCs were initially seen as a huge threat and a huge challenge, but we can take it as an opportunity to incorporate them. As Angela said, it is our responsibility to make sure that we educate the consumers. Noting the findings of the MarkeTrak 10 survey, the people who had gone to health care providers were very determined to go back to and get devices from health care providers because they had the knowledge and expertise. There are many opportunities for us to promote our expertise, knowledge, and abilities as professionals to consumers such that when they have a hearing problem, they may easily want to go get an inexpensive OTC or PSAP, but they know that they can come to us to help them set up their device. We'll be the professionals to help them along the way. For those who will experience distortions, and won't do well with OTCs, for example, we'll be there to help them when they realise these are not their best option.
Dr. Shoup: We at AAA are still in support of the consensus recommendations for the new OTC hearing aid classification. We very much support the idea that the individual member will have to make choices for their unique practices. The Academy does provide multiple resources to assist with planning for the unbundling of services from products.
Most important is to recognise that audiologists are integral to the accurate identification and appropriate management of hearing loss. With their knowledge base, audiologists work to develop a comprehensive treatment recommendation, which may include device selection and optimisation, as well as supportive counselling, training, and guidance through a customised hearing rehabilitation plan on what to expect and how to be successful. OTCs can be part of this process. Some patients may have already accessed OTCs before they see an audiologist. The audiologist can then work with the patient to verify whether the device meets the individual's needs. If it does not, is it possible to optimise that specific device to meet the needs as best as possible? Audiologists must also educate the patient on the appropriate use and care of the device and how to integrate the device functionality into the overall hearing rehabilitation plan.
Also in the discussion of OTC devices, we need to recognise the importance of informed choice. If patients come in with an OTC device that we think may not be best for them, we have the ability to assess it—and I've seen this work beautifully. We need to educate patients about speech sounds—which speech sounds they are getting, which ones they are not, and where the device is falling short in giving them access to those speech sounds. They can make the decision then while also considering other options and price points. We must not push these people away and keep them from getting the appropriate education so that they will address their communication needs more effectively.
Dr. Zeng: I enjoyed listening to your insightful comments. It is indeed an exciting time. Thank you for sharing your time and expertise with us in this virtual roundtabl
Aug 2020 The Hearing Journal
Neurofibromatosis type 2 (NF2) is a hereditary tumour disorder that predisposes patients to develop multiple cranial and spinal tumours. This rare condition affects approximately one in 25,000 individuals. In particular, NF2 patients develop bilateral vestibular schwannomas (VS), which are benign intracranial neoplasms that affect the cochleovestibular nerve. Hearing loss (HL) in this patient population can occur from the tumour itself or a result of treatment (i.e., microsurgical resection or radiosurgery). When the cochlear nerves are severely damaged, hearing aids and cochlear implants (CI) may not provide patients with useful hearing. The auditory brainstem implant (ABI) is a surgically implantable device that delivers electrical stimulation to the cochlear nucleus of the brainstem, bypassing the inner ear and cochlear nerves. When the ABI electrodes stimulate the cochlear nucleus, information is transmitted to the auditory cortex that will allow NF2 patients to hear. The ABI is FDA-approved to improve the hearing of NF2 patients 12 years of age and older.
Figure 1: The patient's pre-operative audiogram. The right ear had sensorineural hearing loss with moderate impairment that progressed to a very poor degree of impairment. The left ear had profound hearing loss. Neurofibromatosis, audiology, surgery.
Figure 2: MRI images showing the stability of the left vestibular schwannoma (VS) over several years following surgical resection and radiosurgery. The right VS grew despite treatment with CyberKnife (CK) radiosurgery. Neurofibromatosis, audiology, surgery.
Figure 3: Intraoperative details. A translabyrinthine approach was used to place the auditory brainstem implant paddle (A), which had 21 electrode contacts (B). Neuromonitoring is critical to identifying off-target effects during stimulation (C). Neurofibromatosis, audiology, surgery.
Figure 4: Speech discrimination test scores.
Testing was performed in quiet using monitored live voice in Spanish. Test scores using lipreading and auditory brainstem implant (ABI) were higher than those with ABI or lipreading alone. Neurofibromatosis, audiology, surgery.
Because of a growing need to provide NF2 patients with better hearing options, the University of Miami (UM) developed a comprehensive ABI program in 2019. The multidisciplinary team consists of: (1) neuro-otologists and skull base neurosurgeons who remove the VS and place the ABI, (2) an electrophysiologist who verifies placement of the ABI by reading electrically evoked auditory brainstem responses (eABR), and (3) audiologists who evaluate and counsel patients pre-operatively, help confirm ABI placement, program the ABI, and evaluate hearing outcomes. Other specialists include anesthesiologists, neuro-monitoring specialists, implant company representatives, neurointensivists, audio-verbal therapists, psychologists, and social workers. Thus far, we have implanted three NF2 patients with an ABI. In this article, we describe our institution's ABI process and the experience and hearing outcomes of the first implanted patient.
A 64-year-old woman with a history of NF2 was referred to our clinics for VS surgery and ABI placement. In 1996, she underwent a subtotal resection and Gamma Knife radiosurgery for a left VS at an outside institution. Although her tumour had remained stable in size, she developed profound HL on the left side after radiation. Surveillance imaging in 2010 showed a new right VS, which was followed over time. In 2015, she received CyberKnife radiosurgery for right-sided tumour growth and developed progressive HL. She also reported having bilateral tinnitus, chronic dizziness, and right-sided facial paresthesia.
Because the ABI is placed on the brainstem, a thorough head and neck examination is important to evaluate the cranial nerves, which includes a fiberoptic laryngoscopy to evaluate vocal cord mobility. A visual acuity test is vital because NF2 patients can develop cataracts and tumours of the optic nerves that may interfere with obtaining visual cues important for lip-reading and ABI use. A neuropsychological assessment will determine a patient's learning, cognitive, and psychological variables that can interfere with ABI success. In this patient, these exams were unremarkable, except for reduced sensation on the right side of the face.
Although no audiologic criteria exist for ABI candidacy, comprehensive audiogram and unaided speech discrimination testing should be performed to assess whether NF2 patients would benefit from hearing aids or a CI. Distortion product otoacoustic emissions (DPOAE) and auditory brainstem response (ABR) tests may help determine whether CIs may be a better option in certain situations. In our patient, audiological testing revealed left anacusis and right mild-to-profound sensorineural HL. The unaided word discrimination was 64 percent at 85 dB (Fig. 1). DPOAE and ABR testing revealed absent responses, suggesting that hearing preservation surgery and a CI may not be the best option. Videonystagmography demonstrated absent bithermal and ice caloric responses, suggesting total bilateral vestibular loss.
Magnetic resonance imaging (MRI) is also important in helping surgeons evaluate tumour characteristics and the best treatment modality (e.g., observation, radiation, and/or off-label chemotherapy), as well as in determining the feasibility of an ABI for hearing. Of note, additional radiation for the patient's right VS was not possible. Because the patient had serviceable hearing in the right ear, surgery was not the best option and chemotherapy with bevacizumab was recommended. The patient, however, did not pursue chemotherapy because of the potential side effects. Thus, the patient's tumour was observed for another seven months, during which time her hearing became non-serviceable (20% at 85 dB; 32% at 100 dB; Fig. 2). Noting the decline in the patient's hearing and the continuous growth of the tumour, the surgical team performed a right translabyrinthine approach for VS resection and an ABI placement in March 2019.
Intraoperatively, neuromonitoring was performed to monitor cranial nerves and brainstem function throughout the surgery. Vital signs and cardiac telemetry were monitored by anesthesia. During the surgery, the neurotologist and neurosurgeon resected the right VS, inserted the ABI, and placed the ABI paddle on the cochlear nucleus (Fig. 3A). Two audiologists and one electrophysiologist were present to stimulate the ABI and measure eABRs from pairs of electrode contacts. The ABI team communicated frequently to ensure that the ABI paddle was placed in a location that elicited eABRs from the most electrodes while minimising off-target effects. In this patient, we were able to achieve eABRs with 18 of the 21 electrode contacts (Fig. 3B); electrode contact 2, 5, and 8 caused tachyarrhythmias. The ABI did not trigger any other off-target response related to the cranial nerve and brainstem (Fig. 3AC).
The surgical site was then closed and the patient was transferred to the intensive care unit (ICU) for post-operative recovery. Six weeks later, ABI activation was performed in the ICU while the patient was on cardiac telemetry, and her vital signs were monitored. The electrode contacts were stimulated one by one, and the patient was asked to judge the loudness of the sound and the severity of off-target effects if present. The patient reported varying levels of chest discomfort after the activation of seven electrodes. On subsequent programming sessions, two additional electrodes were deactivated, leaving her with 12 active electrodes (Fig. 3B).
With the ABI, the patient was able to detect sounds and voices as well as repeat several words and phrases, especially with visual cues. ABI activation was a very emotional session for the patient and the multidisciplinary team because the patient was depressed from being completely deaf for six weeks. She was unable to detect sound without the ABI; however, frequency-specific testing with the ABI at three months after the initial stimulation revealed good sound detection across all tested frequencies (20-30 dB HL from 250 through 8 kHz). With the ABI, she scored 50 percent on the Sound Effects Recognition Test and 100 percent on pattern perception testing of the Early Speech Perception Test. With bisyllabic word tests in Spanish, she scored 16 percent with the ABI only, 92 percent with lip-reading only, and 100 percent when lip-reading was combined with the ABI (Fig. 4).
In the closed-set test with simple phrases, which is a more complex task, she scored 25 percent in the ABI-only condition, 75 percent with lip-reading only, and 100 percent in the ABI and lip-reading condition. When tested with open-set common phrases, which are even more challenging than closed-set tests, the patient scored zero percent in the ABI-only condition, 36 percent in the lip-reading condition, and 91 percent in the ABI plus lip-reading condition(Fig. 4). The test results were consistent with the patient's subjective experiences; she was able to follow conversations in her daily activities when using the ABI with visual cues. She also reported a decrease in tinnitus while using the device.
A common misconception is that ABIs cannot provide useful sound input than can they aid in speech understanding in deaf patients with NF2. Based on this case report and our other experiences at our institution, ABIs can deliver meaningful sound perception that can enhance speech understanding with the use of visual cues. It is worth noting that ABIs can provide sound awareness that is important for safety (e.g., hearing a smoke detector or car horn). Auditory input from an ABI can also help mitigate depression and cognitive deterioration associated with sound deprivation and social isolation common in deaf individuals. Moreover, ABIs can allow NF2 patients to communicate better with family and friends.
Having a dedicated and experienced multidisciplinary team capable of implanting, activating, and programming the ABI is essential to ABI success. Other variables are also critical to maximising ABI outcomes, such as access to pre-operative counselling, which is important in setting realistic expectations for hearing with an ABI, strong emotional and psychological support systems, good transportation to attend frequent clinic visits, and stable health insurance coverage. Visual and cognitive impairments can also affect hearing outcomes; thus, efforts toward improving these medical conditions, when possible, can help patients better understand speech while using an ABI and lip-reading.
Successful ABI outcomes can drastically improve the quality of life of patients with NF2, which is a debilitating and devastating tumour disorder associated with bilateral VS and deafness, among other neurological problems. Providing NF2 patients with the ability to hear via an ABI is truly a rewarding process.
Dec 2019 CBS Pittsburgh
When their son Gus wasn’t speaking at nearly two years old, Eve Kollar and her husband were concerned. “He was reacting to movement and changes in light, but not so much to sounds,” said Eve Kollar. An evaluation at Children’s hospital revealed Gus had profound hearing loss, in both ears. “We were devastated when we learned that he was deaf, because it brings up a lot of feelings inside that we’d missed something,” Eve Kollar added.
Dr. David Chi, Chief of Pediatric Otolaryngology at UPMC Children’s Hospital says there’s no way the couple could’ve known what Gus was experiencing. “He had a genetic cause of his hearing loss,” Dr. Chi explained. “There are no other conditions with a genetic hearing loss except for the hearing loss itself.” At Children’s, the family met Dr. Chi. The first step for Gus was trying hearing aids. Eve Kollar explained that didn’t work: “We tried out our Shop-Vac, right behind him, and he didn’t even turn to hear that sound. He wasn’t startled by it.”
The family then decided Gus would have cochlear implant surgery. “Dr. Chi told us that we would have him implanted around Thanksgiving,” Eve Kollar said, “which he was implanted November 27th and we’d have something to be thankful for, and he would be activated before Christmas, so we’d have one of the best Christmases ever, and we really did that year.”
After years of work — learning to recognize sounds and speak — Gus is now thriving in middle school. He shared, “I play violin, I play guitar, I play soccer.” He and his mother are grateful for Children’s. “It’s a very emotional moment when you know that your child does not have one of the five senses and then to be able to provide that,” Eve Kollar said. The priceless gift of hearing, that’s opened a new world for Gus.
June 2020 The Hearing Journal
Editor's note: This is the second instalment of a four-part series. In part one of this article series, we uncovered the walking wounded—patients with underwhelming hearing aid outcomes despite having aidable hearing loss and appropriately fitted hearing aids (HAs)—and discussed how these patients often return for an inordinate number of fine-tuning visits without achieving HA satisfaction. Some of these patients may complain little, if at all, and return every few years looking for something better. In many cases, the walking wounded are those who have given up and mostly wear their HAs in the drawer.
While hearing care professionals can guess from these behaviours which patients may be among the walking wounded, research updates on the speech perception (SP) gap can help us address the problem sooner and not wait until a patient is exasperated or clinical time has been wasted.
Figure 1.: PB max and aided single word scores as a function of four-frequency PTA
An SP gap is a discrepancy between a patient's maximum cochlear potential for word recognition (PB max) and actual aided word recognition (WRaided), which can be expressed as SP gap = PB max WRaided. To review, because PB max is the best possible word recognition (WR) score a patient can achieve given the extent of cochlear damage, it also serves as the upper limit of possible WRaided, making it a useful treatment validation metric. Instead of patients simply doing better with their HAs than without, we want them to achieve their full cochlear potential for WR as a result of treatment.
Why is this important? Recent studies have revealed that 25 to 30 percent of well-fitted HA patients have a significant SP gap (defined as ≥ 18% based on the Thornton-Raffin criterion), indicating that despite having been appropriately fit with a hearing device, these patients are unable to reach their full cochlear potential. One study reported that the average SP gap among all patients was 20 percent, with some being as large as 70 percent.
Figure 1 shows an example of a patient with an SP gap. Notice that despite having a PB max or cochlear potential of 68 percent in the right ear and 80 percent in the left, her corresponding WRaided scores were only 44 percent and 48 percent, giving her an SP gap of 24 percent in her right ear and 32 percent in her left ear. It's easy to see why this patient returned to her provider multiple times, complaining that she should be hearing better than she actually was. And she's right: 24 to 32 percent of her cochlear potential remains untapped despite wearing appropriately fitted hearing aids.
WHY SP GAPS OCCUR
Before we discuss the particulars of measuring a patient's SP gap, it's helpful to understand the prevailing thought about why it occurs in patients with properly fitted HAs. It has nothing to do with the hearing aid. Patients who have an SP gap have it no matter what type of HA they are wearing and despite the device being well matched to gain and output targets. The issue is thought to lie in an inefficiency in the middle ear transfer function. This is not to be conflated with middle ear disorder. Just as one can have an inefficient metabolism without having a metabolic disorder, so too can one have an inefficient middle ear transfer function without having a middle ear disorder.
A transfer function refers to how energy makes it from point A to point B, in this case, from the tympanic membrane to the oval window. We know that acoustic energy transfer through the middle ear is least efficient for frequencies between 2 and 4 kHz. The HA is delivering appropriate acoustic energy (gain) to the eardrum, as evidenced by a good match to real ear targets, but too much of the sound is absorbed in the middle ear and therefore never makes it to the cochlea. Consequently, some patients can be ideally fitted using real ear measurement (REM) and still find treatment ineffective. And why shouldn't this be true? It's rare for a treatment to work equally well for everyone who tries it. Hearing aids are no exception.
IDENTIFYING AT-RISK PATIENTS
We know why SP gaps occur and that they do so in roughly a quarter of patients with sensorineural hearing loss (SNHL). The question now is this: Since most hearing loss cases are sensorineural, can we narrow the field so we can identify which patients with SNHL are at the greatest risk of presenting with an SP gap? Hoppe's 2016 study on speech perception in HA users shows that although SP gaps exist at all hearing levels, the most significant ones seem to affect those with moderate to severe high-frequency loss or a four-frequency (0.5, 1, 2, and 4 kHz) PTA of 50 to 85 dB HL, as shown in Figure 1. It's worth remembering that 38 percent of all patients with hearing loss have moderately severe to severe loss. The same patients wear 70 percent of all hearing aids.
The assumption that good real ear measures equate to good outcomes persists despite recent evidence to the contrary. Recall the 2016 McRackan and Dubno study referenced in part one of the article series that found that appropriately fitted, audiometrically similar patients with statistically equivalent PB max scores had WRaided that differed from one another by a range of 50 to 60 points. This major finding showed that the current fitting paradigm of assuming that similar patients have similar outcomes is inherently flawed.
Patients respond differently to treatment and vast outcome variability prevents the accurate prediction of treatment effectiveness even when word recognition and REMs are good. This begs the question: Is it necessary to test aided word recognition on every patient? Recent research shows that we should be testing those with moderate to severe hearing loss at the very least.
It's clear that aided speech testing can be a reliable means of validating treatment effectiveness. In part three of this article series, we'll discuss the particulars of how to use aided speech testing to identify SP gaps. In part four, we'll talk about what patients can do to reach their full cochlear potential when it can't be done with hearing aids. Hint: Because their HA isn't the problem, it also won't be the solution.
Jan 2021 Geauga Maple Leaf
Rosalind “Roz” Kvet was not surprised when she started losing her hearing in her mid-40s
Many of her relatives have the same condition where the hair cells in the inner ear degrade, gradually causing deafness, she said. Hearing aids allowed Kvet, 79, of Chardon, to continue to teach elementary school students in Kirtland until her retirement, but the children’s’ high-pitched voices were a challenge, even with a microphone system the school district installed for her.
When Kvet learned Cochlear had developed a highly successful cochlear implant that bypasses the damaged cells and sends electric signals to the brain which interprets them as sound, she thought the program was only for people who had been born deaf. “I never, ever dreamed I would get an implant,” she said.
So, she continued using hearing aids as her hearing continued to deteriorate. Then, during a visit to her audiologist, the subject of an alternative came up. “She surprised me by saying, ‘I think you’d qualify for a cochlear implant,” recalled Kvet. So she went for the test – and failed. The process tests how much hearing a person has in his or her “good” ear and she still had a high enough percentage that she didn’t qualify for an implant, Kvet explained. Not to be deterred, she returned a year later and she had lost enough of her hearing to qualify for a cochlear implant.
In 2012, Kvet met with Dr. Cliff Megarian, otolaryngology surgeon with University Hospitals, and her operation was arranged.
The process took about 90 minutes.
“I came out looking like a Civil War soldier,” she said, adding her head all bandaged up. The surgeon had drilled a hole in her skull for the internal implant just under the skin behind her ear. The second part of the system is an audio processor, worn externally, that detects sounds and sends them to the implant. After a while, the bandages were removed, but Kvet knew the equipment wouldn’t be turned on remotely for a month, so she waited to fully heal and went on with her life.
When the miracle occurred, she remembers she was washing something in the bathroom sink. Kvet thought she heard popcorn cooking until she realised it was the soap bubbles popping in the sink. The excitement she felt is reflected in part in her poem “Bubbles, Birdies, My Buddy —and Popcorn,” which reads: “Amazing!!! Awesome!!! Adoring!!! “I hear forgotten sounds — be still my heart! “NO! Sing with joy!”
But “hearing” the more complicated sounds, like someone talking, took a little more time.
“For three days, it felt like Donald Duck talking — an acoustic guitar in one ear and an electric guitar in the other,” Kvet said, adding her brain started to sort it out after a while. Being able to carry on a conversation with friends and relatives made a big difference. Better still, she was able to hear sounds made by her infant grandson for the first time.
Kvet has a deep appreciation for everyday noises most take for granted. When a wren outside her window serenades her or her only grandchild, Quinn Krapf, 8, sings to her, joy is the best word to describe her emotion. It is a main component of the freeform poem she wrote and the quilted collage she created recently, both of which she submitted to the Inspire Us contest held by Cochlear. Kvet’s poem and the collage, featuring pictures of Quinn, were selected to decorate the Cochlear Americas headquarters southeast of Denver, Co.
There are interesting details of her experience with the cochlear implant Kvet is happy to discuss.
Every six months, she visits with a cochlear implant audiologist and is hooked up to a computer to check the device’s operation and make some minute alterations to volume and other aspects of the connection. “They have to make changes. Otherwise, your brain goes to sleep,” Kvet said. “She can see how many hours you use your implant.”
Technology has advanced incredibly and Kvet has learned to use a “clicker” or remote control to adjust for speaking on the phone, listening to music or even to others when there is a lot of background noise. “Usually, I can hear better in a restaurant than other people,” Kvet said. “My hearing is like 96%.” She is also an A-plus student in her speech and hearing therapy. Her homework consists of listening to various programs to keep her hearing sharp.
A little icing on the cake: Medicare paid for the cochlear implants, Kvet said. Because of her family history, she is also active in encouraging people with hearing loss to be aware the progression eventually could affect their minds. “My mother was stone deaf. I couldn’t have conversations with her,” Kvet recalls, adding if a person loses the ability to hear, he or she may also forget the meaning of words. “It may have caused Mom’s dementia,” she said.
Her daughter and Quinn’s mother, Stacy Kvet, is a psychologist at DePaul University in Chicago and Kvet insisted she visit an audiologist to determine a hearing baseline. The testing showed Stacy, 50, has started to lose her hearing. “Make sure you get hearing aids. If you wait too long, it could be too late,” Kvet said.
Jan 2020 Techno EA
Mitch Albaugh, who works in a law firm during the day and takes centre stage at the theatre at night, used to be an extrovert. After an operation that unexpectedly left Mitchell deeply deaf in his left ear and his right ear suffered from Meniere’s disease, he began to use hearing aids.
After years in hearing aids, Mitch reached a point where hearing aids just weren’t enough. He did not understand his colleagues at work, he did not hear the signals from other actors on stage and he did not feel connected to his loved ones. Mitch felt isolated and went through life on the margins.
Mitch moved to Winter Park in 2005 and started seeing a new audiologist who told him he had to examine the cochlear implants if he wanted better clarity of sound. Hearing aids amplify sounds and can benefit a person with mild to moderate hearing loss. However, when hearing loss progresses from moderate to profound and the hearing aids start to sound like a loud, poorly tuned radio, this is when a cochlear implant can help.
Mitch had a misconception that cochlear implants were like carrying a satellite dish to the side of the head. Instead, his audiologist told him about an available external sound processor the size of a small medallion, and he wouldn’t have to carry a bunch of equipment. After learning about the cochlear implants covered by Medicare, Mitch went to a hearing implant specialist to test and see if he was a candidate for cochlear implants. After being approved, he continued cochlear implant surgery and received the Cochlear Kanso system in his right ear in June 2017. Ten months after his initial surgery, Mitch obtained his second implant in his left ear .
With his cochlear implants, Mitch has returned to the life he loves. Before his implants, Mitch had to withdraw from the action and became a master of ceremonies at the theatre. Now he plays in a play he wrote. Her life has changed for the better in many other ways as well. He can hear his colleagues around the conference table of his law firm, and he can have conversations with his wife, Leslie – even when they are not in the same room! “What I didn’t know was the quality of the sound from the implants – it’s so close to normal.”
Aug 2020 ScienceDirect.com
Assessment of two techniques for electrode insertion during cochlear implantation which are the round window and the traditional cochleostomy insertions. Children (n=200) between 2 to 8 years old who had bilateral severe to profound SNHL and received a unilateral cochlear implant, 100 children had a round window insertion and were labeled the RW group while the other 100 children had a cochleostomy insertion and were labeled the C group which was taken as a control group.
All the participants in this study were followed up and tested twice for their cochlear implant outcomes, the first time when the duration of using their implants was no less than 24 months and no more than 30 months. The second time between 31 to 36 months post implantation. For speech perception, the Consonant-Nucleus-Consonant test (CNC) and the Bamford-Kowal-Bench sentence lists (BKB). For language acquisition, the Preschool Language Scale-fourth edition (PLS-4) and the Peabody Picture Vocabulary Test, Fourth edition (PPVT-4). For speech production, the Diagnostic Evaluation of Articulation and Phonology (DEAP).
Conclusion: Round window insertion is associated with superior cochlear implantation outcomes regarding speech perception, language acquisition and speech production rather than the standard cochleostomy insertion