Download Hearing Assistive Technologies for Deaf and Hard of Hearing children

Hearing Aid Technologies
Perry C. Hanavan, Au.D.
HA Developments
• Nanotechnology providing water resistant hearing
aids
HA Directional Microphones
• Most HA have directional microphones
• Proven beneficial technology
• Data support use of directional hearing aids in some
noisy school environments
• Suggest use of directional mode should be limited to
situations in which all talkers of interest are located
in front of the student.
(Ricketts & Galster 2007)
Digital Feedback Reduction (DFR)
• Technology has dramatically
improved the reduction of
acoustic feedback
• Helps increase HA gain
without “whistle”
Digital Noise Reduction (DNR)
• Significant increase in “ease of listening” with DNR
(Bentler, Wu, Kettel & Hurtig 2008)
• Spectral changes from noise suppression ALWAYS
improve speech.
– Therefore, we tentatively recommend DNR systems be
routinely enabled for children of all ages…just like adults.
(Dillon, Ching & Golding 2008)
• DNR does NOT have negative effect on perception of
nonsense syllables, words or sentences
– Stelmachowicz et al 2010)
Extended HF Frequency Bandwidth
Stelmochowitz found bandwidth beyond 5 kHz
(Stelmachowicz et al 2004)
(Stelmachowicz 2010)
Pittman found that children with HL require 3X the exposure to
learn each new word and concepts due to reduced acoustic
bandwidth caused by HL
(Pittman 2008)
• Most modern HA have bandwidth from 6 to 10 plus kHz
• However telecoil use may only amplify to 4 kHz
• Thus FM technology for speech and language develop may be
better than telecoil-induction loop technology
• However telecoil option remains critically import for:
– Phone
– More public facilities (churches, theaters, sports arenas, etc.) are
getting looped (Get in the Loop initiative) AAA, HLAA, Sertoma
10,000 kHz Bandwidth
Bandwidth & Phoneme ID in Students
CAM2
• CAM2 software prescribes the amount of amplification of
high-frequency sounds above 6000 Hz-required to
restore audibility
• Most HA software only prescribes amount of
amplification to 6000 Hz
• Higher frequencies help distinguish sounds such as “sh”,
“ch” and “f”
• Listening situations, such as in a room where several
people are speaking at once—higher frequencies make it
much easier to understand the person you want to
listen/hear.
• Higher frequencies can improve sound localization
Get in the Hearing Loop
• American Academy of
Audiology
• Hearing Loss Association of
America
• Sertoma Foundation grants
available for looping
• 2nd Annual Loop Conference
held in Washington, DC, June
19-20, 2011
Loops &Telecoils-What Is It?
Telecoil--Advantages
• Universal
• Convenient--no additional apparatus, special
equipment , streamers, remotes, etc.
• No battery drain
• No pairing – universal signal worldwide/standardized
• Most HA have T/TM/M options for classroom use
• Inexpensive (little or no cost to parents)
• No time delay from microphone to HA
• Can accommodate hundreds of listeners in the loop
• Most HA and all CI have telecoil
• Used with all landline phones, many cell phones with
T3/T4 ratings
HA with Telecoils
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•
•
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7 of 28 CIC
8 of 10 ITC
20 of 42 RIC/RITE
24 of 35 “Slim- & Thin-Tube” HA
38 of 38 ITE
29 of 30 BTE
(Oct 2010)
(May/Jun 2009)
(Jan 2010)
(Feb 2010)
(Sep 2010)
(Jan 2009)
Telecoil Mode Options
• Paper investigated the preference of classroom assistive listening devices (ALDs) based
on induction loop systems. Comparing the assessments of T-mode (telecoil mode) and
M-mode (microphone mode)
• M-mode and T-mode give two advantages to choose from: better audibility or
better awareness. Less effort is required to hear using T-mode. M-mode gives a better
recognition of the environment around students and the possibility of hearing other
students not using an ALD
• Students with severe hearing loss benefit more using T-mode compared to the better
hearing students
• Loss of bilateral advantage using an ALD results in a decrease in localization and
segregation of sounds
• Students use different choices between M-mode and T-mode are made depending on
the listening situation
• Students noted they solve the choice between audibility and awareness by using one
hearing aid in M-mode and the other in T-mode, or by using one or both HA in a M+Tmode
• Pedagogical paradigm changes the auditory scenario and consequently also the quality
specifications of ALDs. Evaluation of these systems in terms both
audibility and awareness requires an approach where several attributes to hearing and
disability are assessed. A questionnaire in the dimensions of speech hearing, spatial
hearing, and other qualities is a promising tool for this evaluation. Open-ended
questions as well as additional notes add to the understanding of the result.
(Odelius & Johansson 2010)
Telecoil Available for CI
Telecoil—Frequency Response
• Currently, frequency response characteristics limited
in low and high frequencies (decreased bandwidth)
Telecoil—Orientation
• Telecoil situated
perpendicular to installed
loop wire or telephone
• Incorrect orientation of
telecoil results in attenuated
signal
• Head orientation and tilting
head may result in poor
signal reception
• Placement not ideal for
landline phone
Orientation & Frequency Response
CI Telecoil Orientation
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•
•
•
MED-EL Opus 2:
Advanced Bionics Harmony:
Cochlear Nucleus 5:
Cochlear Nucleus Freedom:
Vertical
45 deg angle
Horizontal
Vertical
Calibrated to International Standard?
• Field Strength Meter
assesses
electromagnetic
interference and is
used to calibrate loop
installations
• Loop induction
installations need to
be electromagnetic
free and calibrated for
uniform signal strength
Looping Options Beyond the Classroom
• School
– Auditorium
– School secretary office
– Librarian desk
• Community
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Church
Grocery store checkout
Library checkout
Transportation
Ticket booths
Drive-up windows
Frequency Lowering HAs
• Studies show that frequency lowering aids improve
speech recognition with severe to profound high
frequency SNHL
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–
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–
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Simpson et al, 2005
Glista et al, 2009
Nyffeler 2008
Wolfe et al, 2010
Wolfe et al 2011
• “Non-linear frequency compression algorithm is the most
important development in pediatric amplification in over
a decade.”
(Richard Seewald)
Non-Linear Frequency Lowering
High Frequency Loss
• Phonak (Naida) and Widex (Inteo) hearing aids
• Frequency lowering (frequency transposition)
hearing aids for persons with un-aidable high
frequency hearing loss.
• Creates new acoustic cues for hearing /s/ sound
important in plurals (e.g., books, it’s)
• Speech recognition cues improve over time from
initial fit
• Students function better in classroom and in various
communication situations
(Glista et al 2009)
High Frequency Lowering Compression
• NLFC improves speech recognition and speech
production for children with moderate to profound
hearing loss
• NLFC should be considered for all children moderate
to profound high-frequency hearing loss
• Verification is essential for success of these children
• Kids with essentially no hearing above 1500 Hz
should be referred for CI evaluation
(Wolfe et al 2010)
Hearing Tests for High Frequency
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University of Western Ontario Plurals Test
Phonak Logatome Test
BKB-SIN
Recorded /sh/ and /s/, University Western Ontario
UWO Plural Test
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Recorded test
Open set test
Female speaker
15 words familiar to school-aged children in both
singular and plural form (/s/ or /z/ in final position)
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Skunk/skunks
Book/books
Fly/flies
Crayon/crayons
• Presented at 50 dB SPL from loudspeaker 1 meter
directly in front of child
UWO /s/--/sh/ Video Game
Phonak Logatom Test
• Adaptive, computer controlled test
• Developed by Phonak
• Female speaker: “My name is…”
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ASA
ASA (filter to 6 kHz)
ADA
AKA
AFA
ASHA
ATA
• Software track level in dB SPL that corresponds to 50%
correct performance
BKB-SIN
BKB-SIN
• 10 sentences presented
twice
• Increasing noise with each
sentence
• Indicates ability to
understand speech in noise
• Helps audiologist select
appropriate hearing aid and
hearing assistance
technologies
RITA, RIC & MARIC
• RITA
Receiver in the aid
• RIC
Receiver in canal
• MARIC
Mike and receiver in canal
HA Streamers
• Bluetooth streamers/Remote controls
• System that allows HA to connect with virtually any
audio device – cell phones, IPods, PDAs, TV, etc.
• Short distance wireless communication
• Can be worn around neck or held in hand
• Battery drain increase
• No standardization between various HA
manufacturers
Personal FM
• FM/Radio Frequency Devices
• The benefits of FM systems are well documented and
include:
– Eliminating negative effects of noise and reverberation on
speech perception, and
– maintaining constant speech input regardless of distance
between the speaker and listener
• (Boothroyd, 2004; Chisholm et al, 2007).
– FM use specifically with cochlear implants, the overwhelming
majority of these studies pertain to children in educational
setting (Davies et al, 2001; Schafer & Thibodeau, 2006).
– Research with children has shown significant improvement in
speech understanding in noise when an FM system is used in
conjunction with a cochlear implant (Davies et al, 2001; Schafer
& Thibodeau, 2006).
Personal Adaptive (Dynamic) FM
• On the objective measures, Phonak
adaptive FM processing resulted
in significantly better speech
recognition in noise compared to
fixed FM processing for 68- and 73dBA noise levels.
• On the subjective measures, all
individuals preferred adaptive over
fixed processing for half of the
activities.
• Adaptive processing was also
preferred by most (8–9) individuals
for the remaining 4 activities.
(Thibodeau 2010)
Phonak FM Recievers
IDEA 2004 & CI
• (2) Nothing in paragraph (b)(1) of this section-- (i) Limits the
right of a child with a surgically implanted device (e.g.,
cochlear implant) to receive related services (as listed in
paragraph (a) of this section) that are determined by the IEP
Team to be necessary for the child to receive FAPE.
• (ii) Limits the responsibility of a public agency to appropriately
monitor and maintain medical devices that are needed to
maintain the health and safety of the child, including
breathing, nutrition, or operation of other bodily functions,
while the child is transported to and from school or is at
school; or
• (iii) Prevents the routine checking of an external component
of a surgically-implanted device to make sure it is functioning
properly, as required in Sec. 300.113(b).
Binaural CI Advantages
Infrared Light Pulses Could Make
Better Bionics for Deafness
• Optical signals could be used
instead of electrical signals to
stimulate cells in the body
CIs and FM Systems
• Remote Microphone
• Bilateral Wireless Systems
• Includes HA for non-CI ear if aidable with remote
microphone
• Meta-analysis:
– Classroom amplification systems (3% improvement — not
significant improvement)
– Desktop amplification systems (17% improvement—
significant improvement)
– Personal FM systems—38% improvement—significant
improvement over the other two)
(Schafer & Wolfe 2010)
Note FM component on CI
MLxi Universal Receiver
• Phonak’s universal Dynamic FM receiver.
• When attached to the user’s hearing
instrument, MLxi provides all the benefits of
Phonak’s Dynamic FM technology.
• Dynamic Speech Extractor - an algorithm that
improves signal-to-noise ratios by up to 15 dB
and speech scores in noise by dozens of
percentage points.
• Fully automated product; the user just needs
to switch it on; child-proof and backwards
compatible
• Compatible with virtually all BTEs and cochlear
implants
• Compatible with all Phonak transmitters
CI Performance in Noise w/o FM
CI plus Personal FM
• Personal FM system have been used to assist HA users for
improving hearing in difficult listening environments
• Personal FM systems are the most effective means to
assist CI users to hear better in noise (Wolfe & Schafer,
2008; Wolfe et al, 2009)
• Audiologists have been reluctant to consider personal FM
because:
– Multiple parameters that must be adjusted with some FM
systems including:
• Ratio of the FM input to the processor mic input (i.e.,
Mixing Ratio)
• Gain of the FM receiver
• Input Dynamic Range (IDR)
CIs and FM Systems
• Meta-analysis
– HA or CI on 2nd ear (bilateral)—1.1 dB improvement on
average
– CI with FM on one side—13.3 dB improvement
– 2nd CI or HA on second side—
– Binaural FM—best signal option (Dynamic FM will
improve listening in noise, social situations, restaurants,
etc.)
• Recommendation:
– If family/school can afford, best option is binaural Dynamic
FM with binaural CI or CI and HA
– Next best option is Dynamic FM on 1st cochlear implant
side
(Wolfe 2010)
Dynamic FM
• Advanced Bionics Cochlear implants improve
dramatically with Phonak’s Dynamic FM and ASC
activated in noise
• Cochlear with ASC activated improves in noise
• No difference between Advanced Bionics and Cochlear
when ASC activated
• Even with the FM off, ASC provided the best performance
in noise!
• ADRO plus ASC program activation provides best option
for listening in noise
• No data on MEDEL
(Wolfe 2010)
Dynamic FM (Phonak)
Dynamic SoundField
Take Home Message
• Consider Phonak’s Dynamic FM for all children
• Know the parameters for optimizing performance of
the CI and personal FM
– Work with audiologist
– Refer audiologists to Jace Wolfe, audiologist at Hearts for
Hearing in Oklahoma, JAAA 2008, 2009, 2010, 2011,
Audiology Online #18191
• Consider simultaneous use of Phonak Dynamic FM
Soundfield classroom amplification with personal FM
+ CI
Neckloop Receivers
• Not recommended by AAA for HA or CI for
children
• Head movement, head orientation, and
telecoil orientation in HA affect signal
quality
• However, Oticon Arc neckloop shows
improvement and is helpful
• Nucleus 5
– Use manual t-coil, not audio t-coil to see
benefit
Auditory Neuropathy/Dyssynchrony
Classroom Soundfield Amplification
• Benefits
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Children with temporary HL
Improve S/N ratio
Reduce teacher vocal fatigue
Children with APD and ADHD (hearing in noise)
Improves academic achievement and behavior
Increased word and sentence recognition
Improves literacy growth
• Disadvantages
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Do not use in place of Dynamic FM for HA and CI users
Will not compensate for poor classroom acoustics
Poor installation/systems may not be helpful
Poor microphone management by teacher not helpful
Unclear speech by teacher not helpful
Classroom Amplification Systems
Self install systems:
• LightSpeed
REDCAT
• Phonak
Dynamic SoundField
Phonak Dynamic Soundfield
• Inspiro Dynamic microphone
• Compatible with Dynamic FM
receivers, BAHA, other HA
• Software updatable
• Remote computer access
• Monitors classroom environment
and adjusts volume and
frequency
• Provides optima S/N ratio
• Connects to Smartboard
Dynamic SoundField
BAHA (unisensory conductive loss)
Bone Anchored Hearing Aid:
• Surgically embedded titanium "post" into skull
with a small abutment
• A sound processor sits on abutment
• The implant vibrates the skull and stimulates
the cochlea via bone conduction bypassing
outer & middle ear
• Can utilize FM receiver
• Treatment for:
– Conductive loss
– Mixed hearing losses
– Unilateral sensorineural hearing loss
– Chronic ear infections
– Congenital external auditory canal atresia
Alpha 1 (M) Bone Conduction Hearing
System
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•
•
•
•
Sophono, Inc.
Surgical procedure video
Abutment free
Up to a 45 dB HL conductive loss
Available with telecoil & FM interface
Envoy Implant
• Middle Ear Implant
• Envoy Medical
Envoy ESTEEM Implant Criteria
• At least 18 years of age
• Stable, moderate-to-severe, bilateral sensorineural hearing loss
(Range = 40 dB to 70 dB, defined as the average of pure tone
thresholds at .5, 1, 2 KHz)
• Speech recognition test score (WRS) greater than, or equal to,
40% in the worst hearing ear
• Normal tympanic membrane & middle ear anatomy
• Normally functioning Eustachian tubes
• Worn properly fit hearing aids for at least one month
• No history of immune compromise or chronic staphylococcal
skin infections
• Room in their mastoid cavity to accept the ESTEEM components
• Able to undergo a 3-4 hours general anesthetic
VIBRANT SOUNDBRIDGE Middle Ear
Implant System (Medel)
Placement Options:
Ossicular
Round Window
Smartphones ($1.99) App
• Variety of apps that may be
beneficial to students
• Music ID, lyrics
• Phone IP Relay, etc.
• Google Voice … can listen or
read text
• Many have M4 and T4 ratings
to interface with HA or CI
telecoil
Assessment Tools
• A variety of assessment tools that identify and
support the need for assistive technologies include:
– Observation of student functioning in classroom and other
environments
– Questionnaires and checklists for teachers, parents,
students and peers (where age appropriate)
– Functional listening evaluation which attempts to replicate
how the student functions with listening in the classroom
– Diagnostic evaluations to assess clinically how students
hear in noise
Questionnaire/Inventory/Survey
• Adolescent SAC / SOAC
Questionnaire
• SSQ
• Listening Inventories For
Educators (L.I.F.E.)
• Children’s Auditory
Performance Scale (CHAPS)
• SIFTER
• CHILD
• ELF
Go to www.hear2learn.com for
additional surveys
PARC
• Placement And Readiness Checklists
• PARC is a set of placement and readiness checklists
designed to assist IEP teams, including students,
teachers, specialists, parents and school
administrators, when making decisions about
programming and placement for individuals who are
deaf and hard of hearing (DHH).
• http://www.handsandvoices.org/pdf/PARC_2011.pdf
Ling 6 Sound Check
• Evaluate student at
variety of distances
to determine
maximum distance
Ling sounds heard
• Ling 6 Sound Check
Chart
• Ling 6 Behavioral
Daily Checklist
• Ling 6 Recording
Chart
Functional Listening Evaluation
• Determine how listening abilities are affected by noise,
distance, and visual input in an individual’s natural listening
environment
• Designed to simulate listening ability in situations that
represent actual listening conditions in student’s classroom–
not sound booth
• Administration of the evaluation, the student’s teachers,
parents, and others gain understanding affects of adverse
listening conditions encountered by the student.
• The evaluation results are also useful in justifying
accommodations, such as assistive listening devices, sign
language or oral interpreters, notetakers, captioning, special
seating, and room acoustic modifications.
• Functional Listening Evaluation
(Ying , 1990), (Ross, Bracken & Maxon, 1992)
FLE (cont.)
• Test administration takes approximately 30 minutes,
including set up, with sentences and 20 minutes with
words.
1. Auditory-Visual
Close
Quiet
2. Auditory
Close
Quiet
3. Auditory-Visual
Close
Noise
4. Auditory
Close
Noise
5. Auditory-Visual
Distant
Noise
6. Auditory
Distant
Noise
7. Auditory
Distant
Quiet
8. Auditory-Visual
Distant
Quiet
FLE (cont.)
FLE (Example)
BKB SIN Test
• 10 sentences presented twice
• Increasing noise with each sentence
• SNR loss is the increased S/N ratio required by a
listener to understand speech in noise
• BKB-SIN Test scores are reported in SNR
• Age normative data
• Allows audiologist to recommend appropriate
assistive technology (e.g., omni-directional
microphones, directional microphones, array
microphones, FM systems, etc.) for students with HL
to function in noisy situations
• Rich in semantic context, thus individuals with HL
may be using top-down processing to improve their
performance—does not tax bottom-up processing
(Niquette et al 2003)
Words in Noise (WIN) Test
• Uses monosyllabic words in seven signal-to-noise ratios
of multitalker babble to evaluate the ability of
individuals to understand speech in background noise
• Developed with the Northwestern University Auditory
Test No. 6 (NU-6) monosyllabic words
• Female speaker
• Age normative data
• Test scores are reported in SNR
• Can test down to age 6
• WIN is sensitive to bottom-up processing
(Wilson et al 2010)
Practical Hearing Aid Skill Tasks
(PHAST)
• Can student and parents pass the PHAST?
• Perhaps modify this for use with assistive devices?
(Desjardins & Doherty 2009)
HA Functioning in Preschool Setting
• Over half of the HA tested were determined to have
at least one or more problems
• Problems detected using listening and visual checks
• Failure rates based on basic listening and visual
checks among the HA examined in this study
demonstrate no improvement over those reported in
the 1970''s
• The results re-emphasize the need for a national
dialogue on this topic
(Burkhalter et al 2011)
ReSound (iOS, Android) free
Bibliography
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speech perception of children listening in a typical classroom with hearing aids or a cochlear
implant. J Educ Audiol, 12, 14–28.
Anderson K & Smaldino J. (1999). Listening Inventories for Education: A classroom measurement
tool. Hear Journal, 52(10), 74–76.
Bentler R, Wu, Kettel & Hurtig. (2008). Digital noise reduction: outcomes from laboratory and
field studies. International Journal of Audiology Vol 47):
(Boothroyd, 2004;
Burkhalter, C. L., Blalock, L., Herring, H., & Skaar, D. (2011). Hearing aid functioning in the
preschool setting: Stepping back in time?. International Journal of Pediatric
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real-life functional performance of children with severe or profound hearing loss. Int J Audiol,
47(8), 461–475.
Bibliography
Ching TYC, Hill M, Dillon H, van Wanrooy E. (2004). Fitting and evaluating a hearing aid for
recipients of unilateral cochlear implants: the NAL approach. Part 1. Hearing Review,
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