Influence of Protective Face Coverings on the Speech Recognition of Cochlear Implant Patients

The beneficial effect of transparent surgical masks on the communication of adults with hearing loss within clinical settings

Purpose: The study examined the benefits of transparent versus non-transparent surgical masks on the speech intelligibility in quiet of adult cochlear implant (CI) users, in conjunction with patient preferences and the acoustic effects of the different masks on the speech signal.

Methods: Speech tracking test (STT) scores and acoustical characteristics were measured in quiet for live speech in three different conditions, without mask, with a non-transparent surgical mask and with a transparent surgical mask. Patients were asked about their experience with the face masks. The study sample consists of 30 patients using a cochlear implant.

Results: We found a significant difference in speech perception among all conditions, with the speech tracking scores revealing a significant advantage when switching from the non-transparent surgical mask to the transparent one. The transparent surgical mask, although it does not transmit high frequencies effectively, seems to have minimal effect on speech comprehension in practice when lip movements are visible. This substantial benefit is further emphasized in the questionnaire, where 82% of the patients express a preference for the transparent surgical mask.

Conclusion: The study highlights significant benefits for patients in speech intelligibility in quiet with the use of medically safe transparent facemasks. Transitioning from standard surgical masks to transparent masks demonstrates highly significant effectiveness and patient satisfaction for patients with hearing loss. This research strongly advocates for the implementation of transparent masks in broader hospital and perioperative settings.

The impact of face coverings on audio-visual contributions to communication with conversational speech

The use of face coverings can make communication more difficult by removing access to visual cues as well as affecting the physical transmission of speech sounds. This study aimed to assess the independent and combined contributions of visual and auditory cues to impaired communication when using face coverings. In an online task, 150 participants rated videos of natural conversation along three dimensions: (1) how much they could follow, (2) how much effort was required, and (3) the clarity of the speech. Visual and audio variables were independently manipulated in each video, so that the same video could be presented with or without a superimposed surgical-style mask, accompanied by one of four audio conditions (either unfiltered audio, or audio-filtered to simulate the attenuation associated with a surgical mask, an FFP3 mask, or a visor). Hypotheses and analyses were pre-registered. Both the audio and visual variables had a statistically significant negative impact across all three dimensions. Whether or not talkers' faces were visible made the largest contribution to participants' ratings. The study identifies a degree of attenuation whose negative effects can be overcome by the restoration of visual cues. The significant effects observed in this nominally low-demand task (speech in quiet) highlight the importance of the visual and audio cues in everyday life and that their consideration should be included in future face mask designs.

Socioeconomic status and pediatric cochlear implant usage during COVID-19

OBJECTIVE

COVID-19 (COVID) delayed access to speech and hearing services. The objective of this study was to identify interactions between socioeconomic status (SES) and cochlear implant (CI) usage during COVID.

METHODS

Consecutive pediatric patients (age 0-17) with CI and audiology visits between 2019 and 2022 at a tertiary care children's hospital were reviewed. Age, sex, race, insurance type, and proxy measures for SES using zip code were recorded. Hours spent with CI on and in different listening environments were compared between pre-COVID (1/1/2019-12/31/2019), COVID (4/1/2020-3/31/2021), and most recent (6/1/2021-5/31/2022) time periods.

RESULTS

Most patients were male (32/59, 54 % ears of 48 patients) and White, non-Hispanic (45/59, 76 %). Median age at implant was 2.0 years (range:0.6-12.2). There were no significant differences in hours spent with CI on during COVID compared with pre-COVID. However, children spent more time listening to louder noises (70-79 dB and ≥80 dB) recently compared with during COVID (p = 0.01 and 0.006, respectively). During COVID, children living in areas with greater educational attainment showed smaller reductions in total hours with CI on (β = 0.1, p = 0.02) and hours listening to speech in noise (β = 0.03, p = 0.005) compared with pre-COVID. In the most recent time period, children of minority race (β = -3.94 p = 0.008) and those who were older at implant (β = -0.630, p = 0.02) were more likely to experience reductions in total hours with CI on compared with during COVID.

CONCLUSION

Interventions which mitigate barriers of implant use and promote rich listening home-environments for at risk populations should be implemented during challenging future social and environmental conditions.

Being a deaf student in a face mask world: Survey data from Italian university students

In response to the COVID-19 pandemic, universities made face masks mandatory during face-to-face classes and/or switched to virtual classes. Such situations pose a challenge for students with hearing loss as they generate listening conditions that make speech comprehension difficult. This study aimed to explore the listening difficulties perceived by Italian university students with hearing loss (HL) and typical hearing (TH) as well as their adoption of self-advocacy strategies . We measured listening difficulties as a function of teaching modality (face-to-face and virtual classes) and the type of face mask (opaque and transparent) worn by the lecturer. In face-to-face classes, the most challenging situations for HL students involved speech comprehension when groups of students were working simultaneously and lecturers talked and moved at the same time during their lessons. The use of transparent masks, compared to opaque one, by the lecturer did not reduce the perceived listening difficulties . In virtual classes, the greatest listening difficulties for HL students occurred when the lecturer's face was not visible or she/he did not use a microphone, while subtitles and sign language interpreters were speech comprehension facilitators. The TH group perceived the same situations as most challenging both in face-to-face and virtual classes, albeit to a lesser extent than the HL respondents. Despite most students demonstrated proactive self-advocacy strategies to improve speech comprehension, in some listening contexts inactive behaviors still persisted. To reduce the listening difficulties posed by pandemic measures, training to improve students' self-advocacy strategies and educators' hearing loss awareness behaviors, as well as the development of interventions aimed at reducing noise in classes, are essential to improve speech perception among HL students.

Speaking with mask in the COVID-19 era: Multiclass machine learning classification of acoustic and perceptual parameters

The intensive use of personal protective equipment often requires increasing voice intensity, with possible development of voice disorders. This paper exploits machine learning approaches to investigate the impact of different types of masks on sustained vowels /a/, /i/, and /u/ and the sequence /a'jw/ inside a standardized sentence. Both objective acoustical parameters and subjective ratings were used for statistical analysis, multiple comparisons, and in multivariate machine learning classification experiments. Significant differences were found between mask+shield configuration and no-mask and between mask and mask+shield conditions. Power spectral density decreases with statistical significance above 1.5 kHz when wearing masks. Subjective ratings confirmed increasing discomfort from no-mask condition to protective masks and shield. Machine learning techniques proved that masks alter voice production: in a multiclass experiment, random forest (RF) models were able to distinguish amongst seven masks conditions with up to 94% validation accuracy, separating masked from unmasked conditions with up to 100% validation accuracy and detecting the shield presence with up to 86% validation accuracy. Moreover, an RF classifier allowed distinguishing male from female subject in masked conditions with 100% validation accuracy. Combining acoustic and perceptual analysis represents a robust approach to characterize masks configurations and quantify the corresponding level of discomfort.

Evaluating the accuracy of speech to text applications for cochlear implant candidates during COVID-19

OBJECTIVES

Universal mask wearing due to COVID-19 has introduced barriers to clear communication. In hearing impaired individuals this can impact informed surgical consent. For cochlear implant candidates, who do not rely on sign language, real-time transcription with a stenographer (CART) is the gold-standard in assistive technologies. If CART is not available, speech to text (STT) applications have been advertised as solutions, but their transcription accuracy with or without an N95 mask is not well-established. Herein, we sought to investigate the transcription accuracy of three STT solutions for iPhone and compare their performance to the CART service at our institution.

METHODS

Three native English speakers and three non-native English speakers read two passages (a cochlear implant consent and the non-medical 'Rainbow passage') with and without an N95 mask. Error rates from the comparison of the transcript (from either the STT app or CART) with the original passage were calculated.

RESULTS

The CART service had the lowest error rate of all testing conditions (4.79-7.14%). Ava 24/7 (15.0 ± 9.49%) and the iPhone dictation (15.6 ± 6.65%) had significantly lower average error rates than the Live Transcribe (37.7 ± 20.3%) (P < 0.0001) application. Neither the presence of an N95 nor the type of passage had a statistically significant impact on the error rate.

CONCLUSION

CART should be used to augment communication with patients who are hard of hearing. If CART is not available, a STT application such as Ava 24/7 or the native iPhone dictation application may be considered, even in the context of medical terminology.

Challenging Times for Cochlear Implant Users - Effect of Face Masks on Audiovisual Speech Understanding during the COVID-19 Pandemic

Unhindered auditory and visual signals are essential for a sufficient speech understanding of cochlear implant (CI) users. Face masks are an important hygiene measurement against the COVID-19 virus but disrupt these signals. This study determinates the extent and the mechanisms of speech intelligibility alteration in CI users caused by different face masks. The audiovisual German matrix sentence test was used to determine speech reception thresholds (SRT) in noise in different conditions (audiovisual, audio-only, speechreading and masked audiovisual using two different face masks). Thirty-seven CI users and ten normal-hearing listeners (NH) were included. CI users showed a reduction in speech reception threshold of 5.0 dB due to surgical mask and 6.5 dB due to FFP2 mask compared to the audiovisual condition without mask. The greater proportion of reduction in SRT by mask could be accounted for by the loss of the visual signal (up to 4.5 dB). The effect of each mask was significantly larger in CI users who exclusively hear with their CI (surgical: 7.8 dB, p = 0.005 and FFP2: 8.7 dB, p = 0.01) compared to NH (surgical: 3.8 dB and FFP2: 5.1 dB). This study confirms that CI users who exclusively rely on their CI for hearing are particularly susceptible. Therefore, visual signals should be made accessible for communication whenever possible, especially when communicating with CI users.

Listening Effort and Speech Perception Performance Using Different Facemasks

PURPOSE

The aim of this study was to assess the effect of eight different facemasks on speech perception and listening effort in listeners with normal hearing (NH) and hearing loss by manipulating both mask type and background noise levels.

METHOD

Forty adults listened to Quick Speech-in-Noise Test sentences recorded by a female talker through eight different facemasks including a baseline condition with no mask. Listeners were tested in the sound field positioned 6 ft from the loudspeaker. Signal-to-noise ratio (SNR) loss and listening effort were measured.

RESULTS

Listeners with NH exhibited a mild SNR loss, whereas those with hearing loss experienced a moderate SNR loss. Scores for the mild hearing loss group were significantly poorer (higher) than those with slight hearing loss. Speech perception performance was best in the no mask, KN95, and surgical mask conditions and poorest in the cloth mask and cloth mask plus face shield conditions for all groups. As listening effort decreased, speech perception increased for all groups.

CONCLUSIONS

The impact of different types of facemasks on speech perception in noise was demonstrated in this study indicating that as the SNR was reduced, listening effort increased and speech perception performance decreased for listeners with NH and slight/mild hearing loss. No mask, KN95, and surgical masks had the least impact on performance, whereas cloth masks posed a significant detriment to communication. If communication is to occur in a background of noise while wearing masks, a KN95 mask and an SNR of at least +15 dB is recommended regardless of hearing status.

Classroom language during COVID-19: Associations between mask-wearing and objectively measured teacher and preschooler vocalizations

During the COVID-19 pandemic, mask-wearing in classrooms has become commonplace. However, there are little data on the effect of face-masks on children’s language input and production in educational contexts, like preschool classrooms which over half of United States children attend. Leveraging repeated objective measurements, we longitudinally examined child and teacher speech-related vocalizations in two cohorts of 3.5–4.5-year-old children enrolled in the same oral language classroom that included children with and without hearing loss. Cohort 1 was observed before COVID-19 (no face-masks, N = 20) and Cohort 2 was observed during COVID-19 (with face-masks; N = 15). Vocalization data were collected using child-worn audio recorders over 12 observations spanning two successive school years, yielding 9.09 mean hours of audio recording per child. During COVID-19 teachers produced a higher number of words per minute than teachers observed prior to COVID-19. However, teacher vocalizations during COVID-19 contained fewer unique phonemes than teacher vocalizations prior to COVID-19. Children observed during COVID-19 did not exhibit deficits in the duration, rate, or phonemic diversity of their vocalizations compared to children observed prior to COVID-19. Children observed during COVID-19 produced vocalizations that were longer in duration than vocalizations of children observed prior to COVID-19. During COVID-19 (but not before), children who were exposed to a higher number of words per minute from teachers produced more speech-related vocalizations per minute themselves. Overall, children with hearing loss were exposed to teacher vocalizations that were longer in duration, more teacher words per minute, and more phonemically diverse teacher speech than children with typical hearing. In terms of production, children with hearing loss produced vocalizations that were longer in duration than the vocalizations of children with typical hearing. Among children observed during COVID-19, children with hearing loss exhibited a higher vocalization rate than children with typical hearing. These results suggest that children’s language production is largely unaffected by mask use in the classroom and that children can benefit from the language they are exposed to despite teacher mask-wearing.

The Impact of the COVID-19 Lockdown on Quality of Life in Adult Cochlear Implant Users: A Survey Study

Background: The COVID-19 pandemic rapidly spread through Europe in the first months of 2020. On the 9th of March 2020, the Italian government ordered a national lock-down. The study’s objectives were: to investigate the effect of lockdown on CI users; and to detect the difference in the perception of discomfort existing between unilateral cochlear implant (UCI) users and bilateral cochlear implant (BCI) users, due to the lockdown experience. Methods: A 17-item, web-based, anonymous online survey was administered to 57 CI users, exploring hearing performance, emotions, practical issues, behavior, and tinnitus. Participation in the study was voluntary. Results: all CI users obtained an abnormal score in all questionnaire themes. For the emotion theme and the practical issue theme, the age range 61–90 showed a significant difference between UCI and BCI users in favor of BCI users (emotion theme: UCI mean = 3.9, BCI mean = 2.3, p = 0.0138; practical issues: UCI mean = 4, BCI mean = 3, p = 0.0031). Conclusions: CI users experienced the lockdown negatively as regards behavior, emotions, hearing performance, and in practical issues. CI subjects with UCI in old age suffered more from the experience of lockdown than subjects with BCI in the same age, with regards to emotions and practical issues.

Effect of Protective Face Coverings on Sentence Recognition in Noise for Cochlear Implant Patients

PURPOSE

The purpose of this study was to assess the influence of talker protective face coverings on sentence recognition in noise for cochlear implant users.

METHOD

The AzBio sentences were recorded in three conditions: (a) without any face covering (uncovered), (b) with an N95 mask, or (c) with an N95 mask plus face shield. Target sentences were presented at 60 dB SPL, and the 10-talker masker was presented at 50 dB SPL (10 dB signal-to-noise ratio. Speech recognition for these auditory stimuli was compared across conditions for 21 adult subjects with at least 6 months of cochlear implant (CI) use.

RESULTS

Significant deterioration in sentence recognition was observed for the N95 plus face shield (Mdn = 27% [IQR: 14%-35%]) compared with the N95 (Mdn = 72% [IQR: 55%-78%]) condition and for the N95 compared to uncovered (Mdn = 86% [IQR: 68%-91%]) condition.

CONCLUSIONS

Talker protective face coverings have a significant influence on speech recognition in noise for CI users. More research is needed to understand the influence of visual cues with protective face coverings that include a plastic component allowing visualization of the talker's face.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.19326395.

Face Masks Impact Auditory and Audiovisual Consonant Recognition in Children With and Without Hearing Loss

Teachers and students are wearing face masks in many classrooms to limit the spread of the coronavirus. Face masks disrupt speech understanding by concealing lip-reading cues and reducing transmission of high-frequency acoustic speech content. Transparent masks provide greater access to visual speech cues than opaque masks but tend to cause greater acoustic attenuation. This study examined the effects of four types of face masks on auditory-only and audiovisual speech recognition in 18 children with bilateral hearing loss, 16 children with normal hearing, and 38 adults with normal hearing tested in their homes, as well as 15 adults with normal hearing tested in the laboratory. Stimuli simulated the acoustic attenuation and visual obstruction caused by four different face masks: hospital, fabric, and two transparent masks. Participants tested in their homes completed auditory-only and audiovisual consonant recognition tests with speech-spectrum noise at 0 dB SNR. Adults tested in the lab completed the same tests at 0 and/or -10 dB SNR. A subset of participants from each group completed a visual-only consonant recognition test with no mask. Consonant recognition accuracy and transmission of three phonetic features (place of articulation, manner of articulation, and voicing) were analyzed using linear mixed-effects models. Children with hearing loss identified consonants less accurately than children with normal hearing and adults with normal hearing tested at 0 dB SNR. However, all the groups were similarly impacted by face masks. Under auditory-only conditions, results were consistent with the pattern of high-frequency acoustic attenuation; hospital masks had the least impact on performance. Under audiovisual conditions, transparent masks had less impact on performance than opaque masks. High-frequency attenuation and visual obstruction had the greatest impact on place perception. The latter finding was consistent with the visual-only feature transmission data. These results suggest that the combination of noise and face masks negatively impacts speech understanding in children. The best mask for promoting speech understanding in noisy environments depend on whether visual cues will be accessible: hospital masks are best under auditory-only conditions, but well-fit transparent masks are best when listeners have a clear, consistent view of the talker's face.

Impact of SARS-CoV-2 Virus (COVID-19) Preventative Measures on Communication: A Scoping Review

Introduction

Face coverings and distancing as preventative measures against the spread of the Coronavirus disease 2019 may impact communication in several ways that may disproportionately affect people with hearing loss. A scoping review was conducted to examine existing literature on the impact of preventative measures on communication and to characterize the clinical implications.

Method

A systematic search of three electronic databases (Scopus, PubMed, CINAHL) was conducted yielding 2,158 articles. After removing duplicates and screening to determine inclusion eligibility, key data were extracted from the 50 included articles. Findings are reported following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Extension for Scoping Reviews, including the PRISMA-ScR checklist.

Results

Studies fell into three categories: Studies addressing the impacts of personal protective equipment (PPE) and/or distancing on communication in healthcare contexts (n = 20); studies examining the impact of preventative measures on communication in everyday life (n = 13), and studies measuring the impact of face coverings on speech using acoustic and/or behavioral measures (n = 29). The review revealed that masks disrupt verbal and non-verbal communication, as well as emotional and social wellbeing and they impact people with hearing loss more than those without. These findings are presumably because opaque masks attenuate sound at frequencies above 1 kHz, and conceal the mouth and lips making lipreading impossible, and limit visibility of facial expressions. While surgical masks cause relatively little sound attenuation, transparent masks and face shields are highly attenuating. However, they are preferred by people with hearing loss because they give access to visual cues.

Conclusion

Face coverings and social distancing has detrimental effects that extend well beyond verbal and non-verbal communication, by affecting wellbeing and quality of life. As these measures will likely be part of everyday life for the foreseeable future, we propose that it is necessary to support effective communication, especially in healthcare settings and for people with hearing loss.

The impact of face masks on the communication of adults with hearing loss during COVID-19 in a clinical setting

OBJECTIVE

The aim of the study was to investigate the effect of surgical masks and face shields on speech intelligibility of adults with moderate to severe hearing loss.

DESIGN

This study measured speech tracking scores in quiet for life speech in three different conditions: without a mask, with a surgical mask and with a face shield. Acoustic effects of the masks and face shields on the speech signal were also investigated. Study sample: The study sample consists of 42 patients with moderate to severe hearing loss, 23 cochlear implant users and 19 hearing aid users.

RESULTS

A significant average difference in speech perception scores was found for the use of a surgical mask compared to the listening situation "without mask". The worse the speech understanding in quiet, the larger the impact of the surgical mask. For the worse performers even the face shield had a negative impact on speech perception. The sound distortion for the face shield compared to the surgical mask was greater.

CONCLUSION

This study shows that even for speech perception in quiet, surgical face masks, and face shields to a lesser extent, have a negative effect for patients with moderate to severe hearing loss.