Aural Rehab Midterm

Based on the study guide provided on Canvas.

Goals of aural rehab

1. Alleviate the difficulties related to hearing loss (i.e. hearing aid will provide audibility of speech sounds to help with word recognition

2. Lessen the consequences (if we can’t remove the problem, we can try and lessen)

Services included in AR plans

1. diagnosis and quantification of hearing loss

2. provision of appropriate hearing devices

3. training in the use of hearing devices

4. communication strategies training

5. vocational counseling

6. noise protection

7. counseling and instruction for family members

Who provides AR?

• SLPs

• Audiologists

• Otolaryngologist (restore hearing for some)

• Teacher of Deaf/Heard-of-Hearing

Basic configuration of hearing loss

refers to the extent of the hearing loss at each frequency and gives an overall description of the hearing loss

How is HL categorized?

Degree, onset, causation, and time course

Sensorineural hearing loss

a type of hearing loss that has cochlear or retrocochlear origin; stems from a disturbance in the inner ear, CN VIII, brainstem, midbrain, or auditory cortex

Conductive hearing loss

results from an obstruction within the outer or middle ear

Mixed hearing loss

a hearing loss that has both conductive and a sensorineural component

Degree of hearing loss

• normal: PTA 25 db HL or better, for children: 15 dB HL

• mild: PTA: 26-40 db HL or better, for children: 16 dB HL

• moderate: PTA 41-55 db HL

• moderately severe: PTA 56-70 dB HL

• severe: PTA 71-90 db HL

• profound: PTA is poorer than 90 db HL

Difference between symmetrical and asymmetrical hearing loss

symmetrical hearing loss means the degree and configuration of hearing loss are the same in each, asymmetrical means the two ears differ

Tinnitus

the perception of sound in the head without an external cause, 35-50% of people with hearing loss also report tinnitus

causes: cerumen, Meniere’s disease, ototoxic drugs (cisplatin, aspirin), noise, acoustic neuroma

currently no FDA approved therapeutics for tinnitus

Older adults and special considerations

• be sensitive to health factors that may interfere with communication:

  • including loss of vision

  • stroke, memory loss

  • Arthritis or muscle weakness may impact listener’s ability to manipulate hearing aid battery

• Dementia + Alzheimer’s disease may impact ability to manipulate hearing aids

  • some studies show for Alzheimer’s patients that the ability to hear what goes on around them helps them stay in tune with their surroundings for a longer period of time

• should patients in assistive care facilities and/or nursing homes be fitted with HA?

  • some may choose ALDs for phones, TV, doorbells

  • some fear techonology - it’s best to keep it simple for them

• include family members or caregivers

Age of onset of hearing loss

• 20s: may impact job choices or college major

• 40s: may change outlook in regards to making a career change

• 60s: may lessen interest in traveling, going to classes

Psychological adjustment

patients may need to process coming to terms with their hearing loss - may experience shock, disbelief, depression, anger, guilt, acceptance

Prelingual

hearing loss occurs before language has developed, usually before 2 yrs old

Perilingual

hearing loss occurs before language has “solidified,” usually after 2 yrs and before 5 yrs old

Postlingual

hearing loss occurs after 5 yrs of age, after language foundation has fully developed; can be broken down into:

• prevocational (5-17)

• early working age (18-44)

• later working age (45-64)

• retirement age (65+)

Congenital

implies the hearing loss was present at birth

Acquired

implies the hearing loss was incurred after birth

Assessing communication handicap

• interview

• questionnaire

• daily log

• group discussion

• structured communication interaction

Interview

• open-ended, similar to case history, but with more generous listening, semi-structured conversational format

• advantage: rapport established with patient, lots of flexibility in follow-up questions

• disadvantage: can’t qualify with outcome assessments

  • settings discussed: home, social settings, school workplace

Questionnaire

• pre-selected set of questions, can be open-set (qualitative data) or closed set (quantitative data)

• advantage: most are easily quantified for outcomes assessment

• disadvantage: some questions do not apply to patients (ex: how well do you hear at church? But the patient doesn’t attend)

• need to choose an appropriate questionnaire, not universal

  • some are also designed for communication partners, ex: HHIA-SP

• ex: COSI, HHIA

Daily log

patient self-monitors behaviors of interest related to hearing difficulties

advantage: patient may be getting instinct through this process

disadvantage: must make it highly specific or patients may come back with nothing or notebooks full of irrelevant details

provide them something that includes detailed instructions, short number of items, be specific

Group discussion

a class or group of people (and significant others) that contributes to a list of problems common to many DHH individuals, ex: group AR classes for adults

advantage: DHH and partner realize that they are not alone

disadvantage: DHH individuals may not take advantage of group classes

Communication strategy

course of action taken to enhance communication

Facilitative strategies

actions taken to prevent a communication breakdown, ex: arranging seats in a circle to assist speech-reading, good lighting, closed doors, etc.

Repair strategies

corrective actions once a breakdown has occurred, ex: asking for clarification, when in doubt - write it out, move to quiet spot

specific repair strategies

they request the listener to:

• repeat the part or all of the message

• confirm the message

• choose between two candidates

• simplify the message

these are preferred to continue good conversational fluency

Nonspecific repair strategies

• huh?

• what?

• pardon?

these responses should be avoided because they are not specific enough on what parts of the initial message was not received

Talker

the person speaking and using good strategies for clear communication, ex: please speak slowly and clearly

Message

what type of message is being communicated, ex: boring text vs. intriguing story, ex: DHH person uses strategies to limit possible response from communication partner —> do you like watching comedies or drams?

Environment

difficult/adverse listening environments: poor lighting, noise, echo, distance; DHH person can:

• move to quiet places

• move closer to the speaker

• find good lighting, away from glare

• avoid highly reverberant rooms ex: gyms

Listener (heard-of-hearing person)

good or bad speech reader (may be culturally related such as not looking at the face, degree of hearing loss/residual hearing, acceptance of loss)

factors that influence with the reception of message:

• relaxation

• strategies that counteract maladaptive behaviors

• appropriate expectations

• self-advocacy

• anticipating potential vocabulary

• degree of hearing loss, consistent use of hearing devices

Who is a candidate for hearing aids?

anyone with hearing loss or hearing difficulty who is motivated

Basic components of hearing aids

• microphones (transmitter) - picks up sound and converts sound to electrical signal

• amplifier - increases the strength of the electrical signal, done with a computer chip to digitize and multiply the signal to place sound into audible range

• receiver - small loudspeaker that converts the electrical signal back to an acoustic signal

• battery - provided the energy to power the system

Specialized features of HA

• volume control

• tele-coil

• directional microphones

• multiple programs, remote control

• noise reduction algorithms

• feedback cancellation algorithms

• frequency compression.transposition

• tinnitus reduction/masker

Completely in canal

Cons: CIC are small, options often are not available such as: on/off switch, volume control, and telecoil

Pros:

• easy to insert and remove

• better sound quality some people report

• reduction of feedback, improved sound localization

• virtually invisible if cosmetics is important to the DHH person

In-the-ear or in-the-canal

hearing aids that fit into the concha of the ear

Pros:

• usually has room for volume control and directional microphones

• custom fitted to the user’s ear

• closeness of the receiver to the tympanic membrane means less gain is required to provide adequate amplification for certain levels of hearing loss

Cons:

• can magnify an occlusion effect for those with good hearing in the lower frequencies

• subjected to ear wax build up

• user’s voice can sound distorted or too loud

Behind the ear BTE

hearing aids that are worn over the pinna and coupled to the ear by means of an ear mold, most appropriate for infants, toddlers, children

Pros:

• provides the most gain without feedback

• best when high levels of gain needed

• allows for directional microphones

• can be hardwired to an assistive listening device

Cons: cosmetically may be an issue for people who do not want their HA to be visible

Bone conduction or BAHA

style used in cases of conductive hearing loss such as aural atresia, chronic drainage, challenging fit etc. —> can be worn on a headband for children or those who don’t want surgery

Pros:

• can help by pass problems of feedback, occlusion effects, cerumen buildup

Cons:

• high cost

• surgery

Tele-coil

a small coil inside HA - works as a small receiver which picks up signals from a loop system that acts as an electromagnetic field. HA with an activated telecoil can convert this electromagnetic field into a sound signal

• listens to magnetic signal instead of the sound

• magnetic signal can be from a telephone, CD, TV, personal ALD, headphone, loop

• advantage is improved signal-to-noise

• usually on BTEs

• may have to ask or demand for tele-coil

Directional microphone

• allows for better signal-to-noise ratio for sound source in front of listener

• manual or auto selection

  • has selectable modes such as:

    • quiet situations: pick up everything

    • noisy situations: block background noise from sides and back of head

Tinnitus masker

An electronic hearing aid that generates and outputs noise at low levels for the purpose of masking an individual’s tinnitus

Feedback reduction

Algorithms that stop the output from a hearing aid receiver from re-entering the microphone, which can send the system into oscillation and create a squealing noise if it goes through

Wireless connection to devices (phones/TV)

When sound is transmitted from the sound source to the individual by means of radio waves or infrared signals, the wireless system picks up the audio signal through a microphone or by direct electrical plug-in. Sound is then converted into an electrical signal by a transmitter and delivered through the air to a receiver worn by the user

Remote microphone hearing assistance tech RMHAT

When a microphone is placed close to the talker’s mouth, where the decibel level of the acoustic speech signal is well above that of interfering noise and reverberation. The resulting high quality signal is delivered to the listener via a personal FM receiver or sound field loudspeaker

Monaural vs binaural

• Binaural is recommended in most situations for reasons, especially if the hearing loss is moderate or severe. Even though two hearing aids are more expressive than one and may require more effort to maintain, binaural amplification fitting offers many advantages over monaural fitting, such as:

  • improvement in background noise, HA can detect non-speech and silence it

  • localization is easier

  • avoid possible deterioration of unaided ear

  • keep ear stimulated (for possible cochlear implant)

Head shadow

With one hearing aid, sound coming from the unaided side of the head may be attenuated by as much as 12 to 16 dB, especially high-frequency sounds. Use of two hearing aids allows sound to be received on both sides of the head

Loudness summation

When sound is received by both ears, a summing of the two signals results. Thresholds for sound may improve by 3 dB or more compared with monaural thresholds in either ear

Binaural squelch

Listening performance will be better in noise when the user wears two hearing aids instead of one. The improvement in signal-to-noise ratio may be 2 or 3 dB

Localization

People with normal hearing are sensitive to interaural differences in a sound’s intensity and phase and this allows them, in part, to perceive the direction and the location of a sound source and to segregate one sound source from another. A monaural hearing aid fitting disrupts these cues, whereas binaural hearing aids serve to preserve this localization ability

What is involved with HA verification, and why is it necessary?

It is the means to determine that the hearing aid meets a set of standards, including standards of basic electroacoustics, real-ear electroacoustic performance, and comfortable fit. Other steps involve:

• verify sound quality is good (ask questions and listen to hearing aids)

• verify patient doesn’t have feedback (can run a feedback test and activate feedback cancellation)

• verify for comfortable fit

• teach patient or parent how to use, insert batteries, change volume or program, clean hearing aid and ear mold

• review warranty (loss and damage + repair)

• how to adjust to new sounds, physical fit of device

• how often to ear (in case of infants/children, ASAP and for all waking hours)

• use of probe microphone

What is involved with HA validation, and why is it necessary?

Determines the extent to which hearing-related disability has been reduced by an intervention, such as receipt of a hearing aid. Other steps involved include:

• “aided” audiogram (limited benefit measured by audibility of pure tones), not always the most reliable strategy

• Speech in noise testing (most important “aided” testing)

• Outcome measure: questionnaires, COSI, HHIA

Subjective benefit/Validating fit of devices

Seven categories of self-report outcome data. Choice of a particular self-assessment scale might be based on which of these seven categories you are interested in assessing

Benefit

The change in hearing-related disability that has resulted from the use of amplification

Satisfaction

An overview of the physical, psychological, and financial changes that have resulted from the use of amplification

Use time

Often related to the severity of the hearing loss and contextual factors, but is an incident of how helpful and beneficial the hearing aid is for the patient

Residual activity limitations

The hearing-related difficulties that the patient continues to experience despite the use of amplification (where/when are you still having difficulties?)

Residual participation restrictions

Limitations that prevent an individual from fulfilling a role in life (ex: volunteering at a soup kitchen, business meeting, etc.)

Impact on others

Usually determined by a frequent communication partner (not many instruments are available for this purpose), family members, etc.

Quality of life

Including improvements in social life and mental health

Hearing assistive technology systems

They are listening, alerting, and/or signaling devices that facilitate patients’ communication with the environment or enhance their personal safety through the use of auditory, visual, or tactile modalities; encompass assistive listening devices and other assistive devices. Basic components include:

• microphones

• amplifier

• receiver

• battery

Loop systems

Works by running a wire around the circumference of a room or table that conducts electrical energy from an amplifier and thus creates a magnetic field, which induces the telecoil in a hearing aid to provide amplified sound to the user

TV ears

Amplified telephones and devices for the television set

Impact of speech perception in a room

1. power of sound source

   1. how loud is the voice

2. distance from the sound source

   1. how far away is the listener from the speaker

3. reverberation (echo)

   1. how many smooth or hard surfaces

4. background noise

   1. signal-to-noise ration or S/N

Signal-to-noise ratio (S/N)

The level of a signal relative to a background of noise

ex: when I am 1 m away, my voice (the signal) is 78 dB SPL. IF the background noise is 60 dB SPL, then the S/N is 78/60 or +18 S/N

Ratio needed for DHH individuals

DHH students need on average +20 S/N to function at the same level as students with typical hearing can function at 0 S/N; adults with mature auditory systems, larger vocab/ability for auditory closure, don’t need as much

Impact of residual hearing on speech reading

Even a small amount of hearing can significantly improve the ability to lip read, individuals with hearing loss must rely even more heavily on visual cues to supplement what they miss with their ears

Benefit of visual + auditory input

• Even people with typical hearing use visual information for cues as to the meaning of an utterance

• Some words can mean something entirely different if said with a smile, or even with different emphasis

Analytic vs synthetic training

• analytics (bottom up) - students learn to recognize individual speech sound movements; identify whether the word contained a specific speech sound in its initial, medial, or final position (without having to identify the word itself), etc. TRAIN THE EYES

• Synthetic (top down) - students try to use the “whole” to get the gist of the message. They use whatever information is available - auditory, visual, contextual cues, etc.. The instructor may give a category, such as, “National Holidays,” so that context narrows down the possibilities. The point is for the speech reader to recognize the general meaning, even if he or she does not know each individual word that was said.

Visual perception

The speech reader must be able to perceive the invidious speech sound movements

Visual memory

The speech reader must retain the string of speech movements in memory so it can be processed

Visual closure

The average spoken message includes more phonemes per second than the eye can follow. The speech reader must be able to “fill in the blanks” when information is missing

Visual figure-ground

The speech reader must be able to ignore extraneous visual information and focus on the face

Visual attention

The speech reader must be able to pay attention to the available visual cues. This requires concentration

Group AR general factors

• length of program

• Class format

• Individual or group therapy sessions (ACE has both)

Ground rules

Examples can include:

1. Only one person speaks at a time

2. Let us know when you are finished speaking by nodding your head

3. Everything said in this room is confidential

4. Be specific and use examples

Topics

Stay on topic and focus on the question or issue under discussion, jumping from topic to topic can lead to communication breakdowns

Who should attend?

DHH person and partner together

Speech reading

Involves integrating what is seen with what is heard

Incidence of HL is the US + Incidence of congenital HL

The Hearing Loss Association of America is the nation’s leading organization representing the 48 million Americans with hearing loss. About 2-3 out of every 1000 children in the US are born with a detectable level of hearing loss in one or both ears.

Incidence of HL in the US

Incidence of congenital HL