Sound field audiometry: recommended stimuli and procedures

Validation of a Self-Fitting Over-the-Counter Hearing Aid Intervention Compared with a Clinician-Fitted Hearing Aid Intervention: A Within-Subjects Crossover Design Using the Same Device

In October of 2022, the US Food and Drug Administration finalized regulations establishing the category of self-fitting over-the-counter (OTC) hearing aids, intended to reduce barriers to hearing aid adoption for individuals with self-perceived mild to moderate hearing loss. Since then a number of self-fitting OTC hearing aids have entered the market, and a small number of published studies have demonstrated the effectiveness of a self-fitted OTC intervention against a traditional clinician-fitted intervention. Given the variety of self-fitting approaches available, and the small number of studies demonstrating effectiveness, the goal of the present study was to evaluate the effectiveness of a commercially available self-fitting OTC hearing aid intervention against a clinician-fitted intervention. Consistent with previous studies, we found that the self-fitted intervention was not inferior to the clinician-fitted intervention for self-reported benefit and objective speech-in-noise outcomes. We found statistically significant improvements in self-fitted outcomes compared to clinician-fitted outcomes, though deviations from best audiological practices in our clinician-fitted intervention may have influenced our results. In addition to presenting our results, we discuss the state of evaluating the noninferiority of self-fitted interventions and offer some new perspectives.

Effects of Stimulus Type on 16-kHz Detection Thresholds

OBJECTIVES

Audiometric testing typically does not include frequencies above 8 kHz. However, recent research suggests that extended high-frequency (EHF) sensitivity could affect hearing in natural communication environments. Clinical assessment of hearing often employs pure tones and frequency-modulated (FM) tones interchangeably regardless of frequency. The present study was designed to evaluate how the stimulus chosen to measure EHF thresholds affects estimates of hearing sensitivity.

DESIGN

The first experiment used standard audiometric procedures to measure 8- and 16-kHz thresholds for 5- to 28-year olds with normal hearing in the standard audiometric range (250 to 8000 Hz). Stimuli were steady tones, pulsed tones, and FM tones. The second experiment tested 18- to 28-year olds with normal hearing in the standard audiometric range using psychophysical procedures to evaluate how changes in sensitivity as a function of frequency affect detection of stimuli that differ with respect to bandwidth, including bands of noise. Thresholds were measured using steady tones, pulsed tones, FM tones, narrow bands of noise, and one-third-octave bands of noise at a range of center frequencies in one ear.

RESULTS

In experiment 1, thresholds improved with increasing age at 8 kHz and worsened with increasing age at 16 kHz. Thresholds for individual participants were relatively similar for steady, pulsed, and FM tones at 8 kHz. At 16 kHz, mean thresholds were approximately 5 dB lower for FM tones than for steady or pulsed tones. This stimulus effect did not differ as a function of age. Experiment 2 replicated this greater stimulus effect at 16 kHz than at 8 kHz and showed that the slope of the audibility curve accounted for these effects.

CONCLUSIONS

Contrary to prior expectations, there was no evidence that the choice of stimulus type affected school-age children more than adults. For individual participants, audiometric thresholds at 16 kHz were as much as 20 dB lower for FM tones than for steady tones. Threshold differences across stimuli at 16 kHz were predicted by differences in audibility across frequency, which can vary markedly between listeners. These results highlight the importance of considering spectral width of the stimulus used to evaluate EHF thresholds.

Description of the Baseline Audiologic Characteristics of the Participants Enrolled in the Aging and Cognitive Health Evaluation in Elders Study

PURPOSE

The Aging and Cognitive Health Evaluation in Elders (ACHIEVE) study is a randomized clinical trial designed to determine the effects of a best-practice hearing intervention versus a successful aging health education control intervention on cognitive decline among community-dwelling older adults with untreated mild-to-moderate hearing loss. We describe the baseline audiologic characteristics of the ACHIEVE participants.

METHOD

Participants aged 70-84 years (N = 977; Mage = 76.8) were enrolled at four U.S. sites through two recruitment routes: (a) an ongoing longitudinal study and (b) de novo through the community. Participants underwent diagnostic evaluation including otoscopy, tympanometry, pure-tone and speech audiometry, speech-in-noise testing, and provided self-reported hearing abilities. Baseline characteristics are reported as frequencies (percentages) for categorical variables or medians (interquartiles, Q1-Q3) for continuous variables. Between-groups comparisons were conducted using chi-square tests for categorical variables or Kruskal-Wallis test for continuous variables. Spearman correlations assessed relationships between measured hearing function and self-reported hearing handicap.

RESULTS

The median four-frequency pure-tone average of the better ear was 39 dB HL, and the median speech-in-noise performance was a 6-dB SNR loss, indicating mild speech-in-noise difficulty. No clinically meaningful differences were found across sites. Significant differences in subjective measures were found for recruitment route. Expected correlations between hearing measurements and self-reported handicap were found.

CONCLUSIONS

The extensive baseline audiologic characteristics reported here will inform future analyses examining associations between hearing loss and cognitive decline. The final ACHIEVE data set will be publicly available for use among the scientific community.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24756948.

The significance of masking for the poor hearing ear in pure tone audiometry

BACKGROUND

In pure tone audiometry, when the difference of the Average Air Conduction Threshold of pure tone (AACT) between bilateral ears is more than 40 dB HL masking must be performed on the poor side, However, we found that masking also make significance difference when the binaural AACT difference (AACT-d)was less than 40 dB HL in some patients.

AIMS/OBJECTIVE

Assessing the significance of masking for the poor ear in pure tone audiometry in patients with different types of deafness to obtain preoperative accurate hearing.

MATERIAL AND METHODS

A comparative analysis of 163 cases (163 ears) with hearing difference between two ears was conducted, who were divided into three groups: G1 Congenital Malformation of the Middle and Outer Ear (CMMOE)as conductive deafness, 63 ears, G2 sudden deafness as sensorineural deafness, 65 ears, and G3 media otitis as conductive or mixed deafness,35 ears. AACT-d before and after the poor ear masking was analyzed under the following three conditions: (1) 0.125-8 KHz each frequency, (2) 0.5-4 KHz on average, (3) the frequencies of AACT-d ≥ 40 dB HL and <40 dB HL between the two ears before masking. If the sample data did not follow a normal distribution, the Wilcoxon rank sum test was used for comparasion of AACT, and p < 0.05 was considered statistically significant. It is clinically effective for AACT-d ≥ 15 dB HL at 1 frequency or 10 dB HL ≤ AACT-d at 2 frequencies <15 dB HL before and after masking.

RESULTS

Among the three groups, (1) the comparasion of AACT-d before and after the poor ear masking for each frequency of 0.125-8 KHz and 0.5-4 KHz on average with all p < 0.05, and the AACT-d of the G1 group was the largest, with an average 0.5-4KHz of 7.5 dB HL, and the first two were 14.5 dB HL and 13.8 dB HL at 0.125 KHz and 0.25 KHz, respectively. (2) AACT-d ≥ 40 dB HL and <40 dB HL between the two ears before masking were distributed at the full frequency of 0.125-8KHz, the clinically effective rates of ≥40 dB HL groups were G1 (89.3%), G2 (45.5%) and G3 (5.3%), while those of < 40 dB HL groups were G1 (69.7%), G2 (34.4%) and G3 (31.3%), respectively.

CONCLUSION AND SIGNIFICANCE

For all three groups, there was statistically significant in AACT-d before and after the poor ear masking across each frequency of 0.125-8 KHz and on average 0.5-4 KHz. The distribution of AACT-d ≥ 40 dB HL and <40 dB HL between the two ears before masking was observed throughout the full frequency range of 0.125-8 KHz. AACT-d before and after the poor ear masking showed clinical effectiveness in all three groups, with the highest effective rate observed in the G1 group and the highest AACT-d at 0.125 KHz and 0.25 KHz. Therefore, regardless of whether the AACT-d between the two ears before masking is ≥40 dB HL or <40 dB HL, the full frequency masking should be employed in three groups, especially for the G1 group of CMMOE, particularly at 0.125 KHz and 0.25 KHz.

Auditory stream segregation of amplitude-modulated narrowband noise in cochlear implant users and individuals with normal hearing

Voluntary stream segregation was investigated in cochlear implant (CI) users and normal-hearing (NH) listeners using a segregation-promoting objective approach which evaluated the role of spectral and amplitude-modulation (AM) rate separations on stream segregation and its build-up. Sequences of 9 or 3 pairs of A and B narrowband noise (NBN) bursts were presented which differed in either center frequency of the noise band, the AM-rate, or both. In some sequences (delayed sequences), the last B burst was delayed by 35 ms from their otherwise-steady temporal position. In the other sequences (no-delay sequences), the last B bursts were temporally advanced from 0 to 10 ms. A single interval yes/no procedure was utilized to measure participants’ sensitivity (d′) in identifying delayed vs. no-delay sequences. A higher d′ value showed the higher ability to segregate the A and B subsequences. For NH listeners, performance improved with each spectral separation. However, for CI users, performance was only significantly better for the condition with the largest spectral separation. Additionally, performance was significantly poorer for the largest AM-rate separation than for the condition with no AM-rate separation for both groups. The significant effect of sequence duration in both groups indicated that listeners made more improvement with lengthening the duration of stimulus sequences, supporting the build-up effect. The results of this study suggest that CI users are less able than NH listeners to segregate NBN bursts into different auditory streams when they are moderately separated in the spectral domain. Contrary to our hypothesis, our results indicate that AM-rate separation may interfere with the segregation of streams of NBN. Additionally, our results add evidence to the literature that CI users build up stream segregation at a rate comparable to NH listeners, when the inter-stream spectral separations are adequately large.

Development of Sound Field Audiometry System for Small Audiometric Booths and Comparison of Its Equivalence With Traditional System

OBJECTIVES

Sound field (SF) audiometry tests are usually conducted in audiometric booths measuring greater than 2×2 m in size. However, most private ENT clinics carry about 1×1-m-sized audiometric booths, making SF audiometry testing difficult to perform. The aims of this study were to develop an SF audiometry system for use in smaller audiometric booths and compare its performance with traditional system.

METHODS

The newly developed SF audiometry system can yield an SF signal at a distance of about 30 cm from the subject's ears. Its height can be adjusted according to the subject's head height. We compared SF hearing results between the new SF system and the traditional SF audiometry system in 20 adults with normal hearing (40 ears) and 24 adults with impaired hearing levels (38 ears) who wore hearing aids. Comparative parameters included warble tone audiometry threshold, a speech reception threshold (SRT), and a speech discrimination score (SDS). For statistical analysis, paired t-test was used. The equivalence of both SF systems was tested using two one-sided test (TOST) with a margin of 5 dB (normal hearing participants) and 10 dB (hearing aids wearing participants).

RESULTS

Among participants with normal hearing, warble tone hearing thresholds of 0.5, 1, 2, and 4 kHz, average values of these four frequencies, and SRT were similar between the two systems (all P>0.05). Participants with hearing aids showed similar warble tone threshold and SRT (P>0.05) in both systems except for threshold of 4 kHz (P=0.033). SDS was significantly higher in the newly developed system (P<0.05). TOST results showed equivalent SF audiometry results using either system.

CONCLUSION

Audiometric results of the newly developed SF audiometry system were equivalent to those of a traditional system. Therefore, the small SF audiometry system can be used at small audiometric booths present in most private ENT clinics.

Comparison of Acceptable Noise Level Generated Using Different Transducers and Response Modes

The acceptable noise level (ANL) was defined by subtracting the background noise level (BNL) from the most comfortable listening level (MCL) (ANL = MCL − BNL). This study compared the ANL obtained through different methods in 20 Chinese subjects with normal hearing. ANL was tested with Mandarin speech materials using a loudspeaker or earphones, with each subject tested by himself or by the audiologist. The presentation and response modes were as follows: (1) loudspeaker with self-adjusted noise levels using audiometer controls (LS method); (2) loudspeaker with the subject signaling the audiologist to adjust speech and noise levels (LA method); (3) earphones with self-adjusted noise levels using audiometer controls (ES method); and (4) earphones with the subject signaling the audiologist to adjust speech and noise levels (EA method). ANL was calculated from three measurements with each method. There was no significant difference in the ANL obtained through different presentation modes or response modes sound. The correlations between ANL, MCL, and BNL obtained from each two methods were significant. In conclusion, the ANL in normal-hearing Mandarin listeners may not be affected by presentation modes such as a loudspeaker or earphones nor is it affected by self-adjusted or audiologist-adjusted response modes. Earphone audiometry is as reliable as sound field audiometry and provides an easy and convenient way to measure ANL.

Audiometric Thresholds: Stimulus Considerations in Sound Field and Under Earphones

PURPOSE

This study evaluates a new stimulus, FREquency Specific Hearing assessment (FRESH) noise, to obtain hearing thresholds and reviews the potential pitfalls of using narrow band noise.

METHOD

Twelve adults with simulated gradually sloping hearing loss and 12 adults with steeply sloping hearing loss participated. Hearing thresholds were measured in sound field and under a supraaural earphone for FRESH noise, warbled tones, and narrowband noise. Pure-tone thresholds were also measured under the supraaural earphone.

RESULTS

FRESH noise thresholds were similar to pure-tone and warbled-tone thresholds regardless of audiometric configuration. For the group with gradually sloping hearing loss, thresholds obtained with narrowband noise were approximately 4 dB better than those obtained with the other test stimuli. For the group with steeply sloping hearing loss, narrowband noise significantly underestimated hearing thresholds-the steeper the hearing loss, the greater the underestimation.

CONCLUSIONS

When hearing loss is suspected, FRESH noise is appropriate for accurately determining audiometric thresholds in sound field and under earphones. A wider band, attention-getting stimulus such as narrowband noise can result in thresholds that are inaccurate. Clinical decision making regarding choice of test stimulus is discussed.

Calibration of Clinical Audio Recording and Analysis Systems for Sound Intensity Measurement

PURPOSE

Sound intensity is an important acoustic feature of voice/speech signals. Yet recordings are performed with different microphone, amplifier, and computer configurations, and it is therefore crucial to calibrate sound intensity measures of clinical audio recording and analysis systems on the basis of output of a sound-level meter. This study was designed to evaluate feasibility, validity, and accuracy of calibration methods, including audiometric speech noise signals and human voice signals under typical speech conditions.

METHOD

Calibration consisted of 3 comparisons between data from 29 measurement microphone-and-computer systems and data from the sound-level meter: signal-specific comparison with audiometric speech noise at 5 levels, signal-specific comparison with natural voice at 3 levels, and cross-signal comparison with natural voice at 3 levels. Intensity measures from recording systems were then linearly converted into calibrated data on the basis of these comparisons, and validity and accuracy of calibrated sound intensity were investigated.

RESULTS

Very strong correlations and quasisimilarity were found between calibrated data and sound-level meter data across calibration methods and recording systems.

CONCLUSIONS

Calibration of clinical sound intensity measures according to this method is feasible, valid, accurate, and representative for a heterogeneous set of microphones and data acquisition systems in real-life circumstances with distinct noise contexts.

Spatial separation benefit for unaided and aided listening

OBJECTIVES

The benefit attributable to spatial separation of speech and noise was measured as a function of low-pass cutoff frequency with and without bilateral hearing aids.

DESIGN

Fourteen younger and 10 older adults with normal hearing and 12 older adults with mild-to-moderate sloping high frequency hearing loss were included to assess the effects of age and hearing loss. Subjects with hearing loss were provided commercially available bilateral hearing aids. Consonant recognition was measured at 70 dB SPL in a background of speech-shaped noise at 66 dB SPL. Speech and noise were low-pass filtered at 1.7, 3.4, and 7.1 kHz. Nonsense syllables were always at 0° and noise was at either 0° or 90°. Speech and noise spectra for all conditions were digitally recorded using a probe microphone placed in each ear canal of each subject. Spectra and levels of speech, and quiet thresholds for narrowband noises, were used to calculate the Articulation Index and provide predictions of unaided and aided (hearing-impaired only) consonant recognition, spatial benefit, and hearing aid benefit for each condition. Subjective ratings of workload (NASA Task Load Index) were obtained for all unaided and aided measures of speech recognition.

RESULTS

Consonant recognition in noise improved for all groups with speech and noise spatially separated and with the addition of high-frequency speech information. Scores were poorer overall for the older adults with hearing loss than for the other groups. For normal-hearing subjects, observed scores and spatial benefit were better than predicted. For hearing-impaired subjects, scores did not significantly improve with hearing aids, even with higher frequencies and spatial separation, and were poorer than predicted especially for aided listening. Similar to subjects with normal hearing, spatial benefit for hearing-impaired subjects was larger than predicted.

CONCLUSIONS

Younger and older adults with normal hearing benefited from spatial separation of speech and noise sources to a greater extent than predicted based on simple audibility. Thus, no age-related deficits in the use of interaural difference cues were observed. Although hearing aid benefit was negligible, perceived listening effort was lower aided than unaided, especially with spatial separation. Articulation Index predictions revealed that speech audibility was generally restored with hearing aids across a wide bandwidth of speech, especially in the far ear. Thus, reduced audibility was not a primary factor in limited hearing aid benefit, suggesting that peripheral, central-auditory and/or cognitive changes may have played a role. In contrast, unaided and aided spatial benefit was better than predicted, and spatial benefit was slightly larger with hearing aids than without. Thus, these older adults with hearing loss using bilateral hearing aids were able to take advantage of binaural cues to improve consonant recognition in noise.

Effect of stimuli, transducers and gender on acoustic change complex

The objective of this study was to investigate the effect of stimuli, transducers and gender on the latency and amplitude of acoustic change complex (ACC). ACC is a multiple overlapping P1-N1-P2 complex reflecting acoustic changes across the entire stimulus. Fifteen males and 15 females, in the age range of 18 to 25 (mean=21.67) years, having normal hearing participated in the study. The ACC was recorded using the vertical montage. The naturally produced stimuli /sa/ and /si/ were presented through the insert earphone/loud speaker to record the ACC. The ACC obtained from different stimuli presented through different transducers from male/female participants were analyzed using mixed analysis of variance. Dependent t-test and independent t-test were performed when indicated. There was a significant difference in latency of 2N1 at the transition, with latency for /sa/ being earlier; but not at the onset portions of ACC. There was no significant difference in amplitude of ACC between the stimuli. Among the transducers, there was no significant difference in latency and amplitude of ACC, for both /sa/ and /si/ stimuli. Female participants showed earlier latency for 2N1 and larger amplitude of N1 and 2P2 than male participants, which was significant. ACC provides important insight in detecting the subtle spectral changes in each stimulus. Among the transducers, no difference in ACC was noted as the spectra of stimuli delivered were within the frequency response of the transducers. The earlier 2N1 latency and larger N1 and 2P2 amplitudes noticed in female participants could be due to smaller head circumference. The findings of this study will be useful in determining the capacity of the auditory pathway in detecting subtle spectral changes in the stimulus at the level of the auditory cortex.

Evaluation of different signal processing options in unilateral and bilateral cochlear freedom implant recipients using R-Space background noise

BACKGROUND

Difficulty understanding in background noise is a common complaint of cochlear implant (CI) recipients. Programming options are available to improve speech recognition in noise for CI users including automatic dynamic range optimization (ADRO), autosensitivity control (ASC), and a two-stage adaptive beamforming algorithm (BEAM). However, the processing option that results in the best speech recognition in noise is unknown. In addition, laboratory measures of these processing options often show greater degrees of improvement than reported by participants in everyday listening situations. To address this issue, Compton-Conley and colleagues developed a test system to replicate a restaurant environment. The R-SPACE™ consists of eight loudspeakers positioned in a 360 degree arc and utilizes a recording made at a restaurant of background noise.

PURPOSE

The present study measured speech recognition in the R-SPACE with four processing options: standard dual-port directional (STD), ADRO, ASC, and BEAM.

RESEARCH DESIGN

A repeated-measures, within-subject design was used to evaluate the four different processing options at two noise levels.

STUDY SAMPLE

Twenty-seven unilateral and three bilateral adult Nucleus Freedom CI recipients.

INTERVENTION

The participants' everyday program (with no additional processing) was used as the STD program. ADRO, ASC, and BEAM were added individually to the STD program to create a total of four programs.

DATA COLLECTION AND ANALYSIS

Participants repeated Hearing in Noise Test sentences presented at 0 degrees azimuth with R-SPACE restaurant noise at two noise levels, 60 and 70 dB SPL. The reception threshold for sentences (RTS) was obtained for each processing condition and noise level.

RESULTS

In 60 dB SPL noise, BEAM processing resulted in the best RTS, with a significant improvement over STD and ADRO processing. In 70 dB SPL noise, ASC and BEAM processing had significantly better mean RTSs compared to STD and ADRO processing. Comparison of noise levels showed that STD and BEAM processing resulted in significantly poorer RTSs in 70 dB SPL noise compared to the performance with these processing conditions in 60 dB SPL noise. Bilateral participants demonstrated a bilateral improvement compared to the better monaural condition for both noise levels and all processing conditions, except ASC in 60 dB SPL noise.

CONCLUSIONS

The results of this study suggest that the use of processing options that utilize noise reduction, like those available in ASC and BEAM, improve a CI recipient's ability to understand speech in noise in listening situations similar to those experienced in the real world. The choice of the best processing option is dependent on the noise level, with BEAM best at moderate noise levels and ASC best at loud noise levels for unilateral CI recipients. Therefore, multiple noise programs or a combination of processing options may be necessary to provide CI users with the best performance in a variety of listening situations.

Optimizing the perception of soft speech and speech in noise with the Advanced Bionics cochlear implant system

OBJECTIVE

This study aimed to provide guidelines to optimize perception of soft speech and speech in noise for Advanced Bionics cochlear implant (CI) users.

DESIGN

Three programs differing in T-levels were created for ten subjects. Using the T-level setting that provided the lowest FM-tone, sound-field threshold levels for each subject, three additional programs were created with input dynamic range (IDR) settings of 50, 65 and 80 dB.

STUDY SAMPLE

Subjects were postlinguistically deaf adults implanted with either the Clarion CII or 90K CI devices.

RESULTS

Sound-field threshold levels were lowest with T-levels set higher than 10% of M-levels and with the two widest IDRs. Group data revealed significantly higher scores for CNC words presented at a soft level with an IDR of 80 dB and 65 dB compared to 50 dB. Although no significant group differences were seen between the three IDRs for sentences in noise, significant individual differences were present.

CONCLUSIONS

Setting Ts higher than the manufacturer's recommendation of 10% of M-levels and providing IDR options can improve overall speech perception; however, for some users, higher Ts and wider IDRs may not be appropriate. Based on the results of the study, clinical programming recommendations are provided.

The effect of initial stimulus type for visual reinforcement audiometry

Visual reinforcement audiometry (VRA) is routinely used with infants to assess hearing level. It is an operant procedure based on the association of auditory and visual stimuli. There are several recommended test procedures for VRA. One clinical VRA procedure involves presenting the initial auditory stimulus without activation of the visual reward. If the infant generates a head orientation response, the visual reward is then activated. The aim of this study was to investigate the unconditioned response rates (head orientation towards loudspeaker) to two different sound-field-presented stimuli, 1000-Hz narrowband noise (NBN) and 1000-Hz frequency-modulated tones (FMTs), using this VRA procedure. For each stimulus type, 100 infants presenting for VRA were assessed (age range 6-30 months, mean age 13 months). Of the infants presented with NBN, 69% responded, compared to 25% of infants presented with FMTs. Chi-squared analysis revealed a highly significant statistical difference in favour of NBN. In conclusion, this study demonstrated the effectiveness of using a 1000-Hz NBN stimulus over a 1000-Hz FMT stimulus in securing an unconditioned head orientation response in infants presenting for VRA.

Binaural advantage for younger and older adults with normal hearing

PURPOSE

Three experiments measured benefit of spatial separation, benefit of binaural listening, and masking-level differences (MLDs) to assess age-related differences in binaural advantage.

METHOD

Participants were younger and older adults with normal hearing through 4.0 kHz. Experiment 1 compared spatial benefit with and without head shadow. Sentences were at 0 degrees, and speech-shaped noise was at 0 degrees, 90 degrees, or +/-90 degrees. Experiment 2 measured binaural benefit with the near ear unplugged compared with plugged for sentences at 0 degrees and masker at 90 degrees. Experiment 3 measured MLDs under earphones for 0.5-kHz pure tones in Gaussian and low-noise noise, and spondees in speech-shaped noise.

RESULTS

Spatial-separation benefit for speech did not differ significantly for younger and older adults but was smaller than predicted by an audibility-based model for older adults and larger than predicted for younger adults. Binaural listening benefit was observed for younger participants only. Tonal MLDs suggested that listeners benefit from interaural difference cues during noise dips for signals out of phase. Neither tonal nor speech MLDs differed significantly between younger and older participants.

CONCLUSION

Binaural processing of sentences revealed some age-related deficits in the use of interaural difference cues, whereas no deficits were observed for more simple detection or recognition tasks.

Initial Clinical Experience With a Totally Implantable Cochlear Implant Research Device

OBJECTIVE

To evaluate the effectiveness and issues associated with a research totally implantable cochlear implant (TIKI).

STUDY DESIGN

Limited patient trial.

SETTING

Tertiary referral center.

PATIENTS

Three adult human subjects with severe-to-profound sensorineural hearing loss.

INTERVENTIONS

Subjects were implanted with a research TIKI developed by Cochlear Limited and the Co-operative Research Centre for Cochlear Implant and Hearing Aid Innovation. The TIKI has a lithium ion rechargeable battery, a package-mounted internal microphone, and sound-processing electronics that enable the use of "invisible hearing" without the use of an external device. The TIKI also functions with an external ESPrit 3G sound processor as a conventional cochlear implant. The standard surgical technique was modified to accommodate the larger device package. Postoperatively, subjects used TIKI in both invisible hearing and the conventional ESPrit 3G modes.

MAIN OUTCOME MEASURES

Device use was recorded in both invisible hearing and ESPrit 3G listening modes. Performance of the internal battery and microphone was assessed over time. Psychophysical MAP data were collected, and speech perception was measured at 1, 3, 6, and 12 months postoperatively in both listening modes.

RESULTS

There were no surgical or postoperative complications. All subjects use both invisible hearing and conventional ESPrit 3G modes. Speech perception outcomes for all patients showed improvement from preoperative scores. As a consequence of the reduced sensitivity of the implanted microphone, speech perception results using the invisible hearing mode were significantly lower than the ESPrit 3G mode. Subjects reported some body noise interference that limited use of the invisible hearing mode; however, all continue to use the invisible hearing mode on a limited daily basis. The rechargeable battery functioned well, with a cycle time indicating the low-power implant design is effective and will deliver long battery life.

CONCLUSION

This study demonstrates that the challenges in developing a safe and effective TIKI can be overcome. Three subjects implanted with the research TIKI all reported benefit from routine use. For each subject, hearing outcomes using invisible hearing mode were not as good as when using the external ESPrit 3G sound processor in the conventional mode.

Clinical evaluation of higher stimulation rates in the nucleus research platform 8 system

OBJECTIVE

The effect on speech perception of using higher stimulation rates than the 14.4 kHz available in the Nucleus 24 cochlear implant system was investigated. The study used the Nucleus Research Platform 8 (RP8) system, comprising the CI24RE receiver-stimulator with the Contour electrode array, the L34SP body-worn research speech processor, and the Nucleus Programming Environment (NPE) fitting and Neural Response Telemetry (NRT) software. This system enabled clinical investigation of higher stimulation rates before an implementation in the Freedom cochlear implant system commercially released by Cochlear Limited.

DESIGN

Use of higher stimulation rates in the ACE coding strategy was assessed in 15 adult subjects. An ABAB experimental design was used to control for order effects. Program A used a total stimulation rate of between 12 kHz and 14.4 kHz. This program was used for at least the first 3 mo after initial device activation. After evaluation with this program, each subject was provided with two different higher stimulation rate programs: one with a total stimulation rate of 24 kHz and the other with a total stimulation rate of 32 kHz. After a 6-week period of familiarization, each subject identified his/her preferred higher rate program (program B), and this was used for the evaluation. Subjects then repeated their use of program A for 3 wk, then program B for 3 wk, before the second evaluation with each. Speech perception was evaluated by using CNC open-set monosyllabic words presented in quiet and CUNY open-set sentences presented in noise. Preference for stimulation rate program was assessed via a subjective questionnaire. Threshold (T)- and Comfortable (C)-levels, as well as subjective reports of tinnitus, were monitored for each subject throughout the study to determine whether there were any changes that might be associated with the use of higher stimulation rates.

RESULTS

No significant mean differences in speech perception results were found for the group between the two programs for tests in either quiet or noise. Analysis of individual subject data showed that five subjects had significant benefit from use of program B for tests administered in quiet and for tests administered in noise. However, only two of these subjects showed benefit in both test conditions. One subject showed significant benefit from use of program A when tested in quiet, whereas another showed benefit with this program in noise. Each subject's preferred program varied. Five subjects reported a preference for program A, eight subjects reported a preference for program B and two reported no overall preference. Preference between the different stimulation rates provided within program B also varied, with 10 subjects preferring 24 kHz and five preferring 32 kHz total stimulation rates. A significant increase in T-levels from baseline measures was observed after three weeks of initial experience with program B, however there was no difference between the baseline levels and those obtained after five weeks of use. No significant change in C-levels was found over the monitoring period. No long-term changes in tinnitus that could be associated with the use of the higher stimulation rates were reported by any of the subjects.

CONCLUSIONS

The use of higher stimulation rates may provide benefit to some but not all cochlear implant recipients. It is important to optimize the stimulation rate for an individual to ensure maximal benefit. The absence of any changes in T- and C-levels or in tinnitus suggests that higher stimulation rates are safe for clinical use.

Speech recognition with the advanced combination encoder and transient emphasis spectral maxima strategies in nucleus 24 recipients

One of the difficulties faced by cochlear implant (CI) recipients is perception of low-intensity speech cues. A. E. Vandali (2001) has developed the transient emphasis spectral maxima (TESM) strategy to amplify short-duration, low-level sounds. The aim of the present study was to determine whether speech scores would be significantly higher with TESM than with the advanced combination encoder (ACE) strategy fitted using procedures that optimize perception of soft speech and other sounds. Eight adult recipients of the Nucleus 24 CI system participated in this study. No significant differences in scores were seen between ACE and TESM for consonant-vowel nucleus-consonant (CNC) words presented at 55 and 65 dB SPL, for sentences in noise presented at 65 dB SPL at 2 different signal-to-noise ratios, or for closed-set vowels and consonants presented at 60 dB SPL. However, perception of stop consonants within CNC words presented at the lower level (55 dB SPL) was significantly higher with TESM than ACE. In addition, percentage of information transmitted for words at 55 dB SPL was significantly higher with TESM than with ACE for manner and voicing features for consonants in the initial word position. Analysis of closed-set consonants presented at 60 dB SPL revealed percentage of information transmitted for manner was significantly higher with TESM than with ACE. These improvements with TESM were small compared with those reported by Vandali for recipients of the Nucleus 22 CI system. It appears that mapping techniques used to program speech processors and improved processing capabilities of the Nucleus 24 system contributed to soft sounds being understood almost as well with ACE as with TESM. However, half of the participants preferred TESM to ACE for use in everyday life, and all but 1 used TESM in specific listening situations. Clinically, TESM may be useful to ensure the audibility of low-intensity, short-duration acoustic cues that are important for understanding speech, for recipients who are difficult to map, or if insufficient time precludes the use of mapping techniques to increase audibility of soft sound.

An investigation of input level range for the nucleus 24 cochlear implant system: speech perception performance, program preference, and loudness comfort ratings

OBJECTIVE

Cochlear implant recipients often have limited access to lower level speech sounds. In this study we evaluated the effects of varying the input range characteristics of the Nucleus 24 cochlear implant system on recognition of vowels, consonants, and sentences in noise and on listening in everyday life.

DESIGN

Twelve subjects participated in the study that was divided into two parts. In Part 1 subjects used speech processor (Nucleus 24 SPrint trade mark ) programs adjusted for three input sensitivity settings: a standard or default microphone sensitivity setting (MS 8), a setting that increased the input sensitivity by 10.5 dB (MS 15), and the same setting that increased input sensitivity but also incorporated the automatic sensitivity control (ASC; i.e., MS 15A) that is designed to reduce the loudness of noise. The default instantaneous input dynamic range (IIDR) of 30 dB was used in these programs (i.e., base level of 4; BL 4). Subjects were tested using each sensitivity program with vowels and consonants presented at very low to casual conversational levels of 40 dB SPL and 55 dB SPL, respectively. They were also tested with sentences presented at a raised level of 65 dB SPL in multi-talker babble at individually determined signal to noise ratios. In addition, subjects were given experience outside of the laboratory for several weeks. They were asked to complete a questionnaire where they compared the programs in different listening situations as well as the loudness of environmental sounds, and state the setting they preferred overall. In Part 2 of the study, subjects used two programs. The first program was their preferred sensitivity program from Part 1 that had an IIDR of 30 dB (BL 4). Seven subjects used MS 8 and four used MS 15, and one used the noise reduction program MS 15A. The second program used the same microphone sensitivity but had the IIDR extended by an additional 8 to 10 dB (BL 1/0). These two programs were evaluated similarly in the speech laboratory and with take-home experience as in Part 1. RESULTS PART 1: Increasing the microphone input sensitivity by 10.5 dB (from MS 8 to MS 15) significantly improved the perception of vowels and consonants at 40 and 55 dB SPL. The group mean improvement in vowel scores was 25 percentage points at 40 dB SPL and 4 percentage points at 55 dB SPL. The group mean improvement for consonants was 23 percentage points at 40 dB SPL and 11 percentage points at 55 dB SPL. Increased input sensitivity did not significantly reduce the perception of sentences presented at 65 dB SPL in babble despite the fact that speech peaks were then within the compressed range above the SPrint processor's automatic gain control (AGC) knee-point. Although there was a demonstrable advantage for perception of low-level speech with the higher input sensitivity (MS 15 and 15A), seven of the 12 subjects preferred MS 8, four preferred MS 15 or 15A, and one had no preference overall. Approximately half the subjects preferred MS 8 across the 18 listening situations, whereas an average of two subjects preferred MS 15 or 15A. The increased microphone sensitivity of MS 15 substantially increased the loudness of environmental sounds. However, use of the ASC noise reduction setting with MS 15 reduced the loudness of environmental sounds to equal or below that for MS 8. RESULTS PART 2: The increased instantaneous input range gave some improvement (8 to 9 percentage points for the 40 dB SPL presentation level) in the perception of consonants. There was no statistically significant increase in vowel scores. Mean scores for sentences presented at 65 dB SPL in babble were significantly lower (5 percentage points) for the increased IIDR setting. Subjects had no preference for the increased IIDR over the default. The IIDR setting had no effect on the loudness of environmental sounds.

CONCLUSIONS

Given the fact that individuals differ in threshold (T) and comfort (C) levels for electrical stimulation, and preferred microphone sensitivity, volume control, and noise-reduction settings, it is essential for the clinicid recipient to determine what combination is best for the individual over several sessions. The results of this study clearly show the advantage of using higher microphone sensitivity settings than the default MS 8 to provide better speech recognition for low-level stimuli. However, it was also necessary to adjust other parameters such as map C levels, automatic sensitivity control and base level, to optimize loudness comfort in the diversity of listening situations an individual encounters in everyday life.

Spectral contributions to the benefit from spatial separation of speech and noise

Speech recognition in noise improves when speech and noise sources are separated in space. This benefit has two components whose effects are strongest in different frequency regions: (1) interaural level differences (e.g., head shadow), which are largest at higher frequencies, and (2) interaural time differences, which have their greatest contribution at lower frequencies. Binaural interactions enhance the separation of signals from noise through the use of these interaural differences. Here, the benefit attributable to spatial separation was measured as a function of the low- and high-pass cutoff frequency of speech and noise. Listeners were younger adults with normal hearing, older adults with normal hearing, and older adults with hearing loss. Binaural thresholds for narrowband noises were measured in quiet and in a speech-shaped masker as a function of masker low-pass cutoff frequency. Speech levels corresponding to 50% correct recognition of sentences from the Hearing in Noise Test (HINT) were measured in a 65-dB SPL speech-shaped noise. Thresholds for narrowband noises and for speech were measured with two loudspeaker configurations: (1) signals and speech-shaped noise at 0 degrees azimuth (in front of the listener) and (2) signals at 0 degrees azimuth and speech-shaped noise at 90 degrees azimuth (at the listener's side). The criterion measure was spatial separation benefit, or the difference in thresholds for the two conditions. Benefit of spatial separation for unfiltered speech averaged 6.1 dB for younger listeners with normal hearing, 4.9 dB for older listeners with normal hearing, and 2.7 dB for older listeners with hearing loss. Benefit was differentially affected by low-pass and high-pass filtering, suggesting a trade-off of the contributions of higher frequency interaural level differences and lower frequency interaural timing cues. As expected, older listeners with hearing loss benefited little from the improved signal-to-noise ratios in the higher frequencies resulting from head shadow, but showed some benefit from lower frequency cues. Spatial benefit for older listeners with normal hearing was reduced relative to benefit for younger listeners. This result may be related to older listeners' elevated thresholds at frequencies above 6.0 kHz.

Effects of stimulation rate with the Nucleus 24 ACE speech coding strategy

OBJECTIVE

The primary objective of the study was to determine whether individual cochlear implant recipients recognize speech better with an electrical stimulation rate of 720 or 1800 pulses per second per channel (pps/ch) using the Nucleus 24 Advanced Combination Encoder (ACE) speech coding strategy. The secondary objective was to determine, for each active electrode, the relation between psychophysical measures and MAP minimum and maximum stimulation levels for each rate, as well as the stability of MAP minimum and maximum levels during the study.

DESIGN

Eight postlinguistically deaf adults implanted with the Nucleus 24 device participated in this study comparing the effect of a moderate (720 pps/ch) and a fast (1800 pps/ch) rate of electrical stimulation on speech recognition of words in quiet and sentences in noise presented at 50, 60, and 70 dB SPL in the laboratory and on listening to sound in everyday life over a 14-wk time period. At the beginning of the study, psychophysical measures (i.e., counted threshold and maximum acceptable loudness [MAL] levels) were obtained for each active electrode with each of the two rates to initially set MAP minimum and maximum stimulation levels. These levels were then adjusted to make speech and environmental sound clear and comfortable in everyday life. Threshold and MAL levels were obtained again half way through the study to monitor possible hearing changes. A four-phase test design for evaluation of speech recognition was followed; an equal number of subjects started with each of the two rates and alternated rates for each phase. In the last 2 wk of each phase, word and sentence scores were obtained, and subjects responded to a questionnaire. For the group, factorial analyses of variance were conducted for subject, stimulation rate, and time period (first two phases versus second two phases) for words, phonemes within words, and sentences at each level. Additional analyses were obtained for individual subjects.

RESULTS

Group mean scores across time periods were significantly higher for 1800 pps/ch than 720 pps/ch for phonemes and sentences in noise at 50 dB SPL. There was no significant difference in scores for phonemes and sentences at 60 and 70 dB SPL or for words at any of the three levels. Group mean scores across stimulation rate were significantly higher during the second half than the first half of the study for words, phonemes, and sentences at 50 dB SPL. This result is consistent with subjects learning to recognize speech cues near threshold. A subject by rate interaction was seen for sentences at 70 dB SPL and for all three speech measures at 50 dB SPL. These interactions reflect the fact that two subjects performed significantly better with 720 pps/ch, whereas two other subjects performed significantly better with 1800 pps/ch. Responses to the questionnaire indicated that two subjects preferred 720 pps/ch, three preferred 1800 pps/ch, and three had no preference. The minimum and/or maximum levels in most subjects' final MAPs differed from the psychophysical measures for both rates. Changes in Current Level at threshold and MAL were minimal from the first to the second half of the study for each rate.

CONCLUSIONS

More than half the subjects preferred one of the two rates for use in everyday life, and four subjects performed significantly better with one of the two rates on at least one test measure. These findings underscore the clinical importance of creating MAPs for each implant recipient that include at least a moderate and a fast rate within ACE during the first months of device use. Given the significant learning effects for soft speech that occurred over several weeks use of each rate in this study, it is suggested that each rate be used alone for a week or two before comparing them and deciding which provides more benefit. In addition, adjustments in an individual's MAP minimum and maximum levels are needed at each rate so soft and normal conversational speech as well as loud sound are clear and comfortable in everyday life.

Evidence on the efficacy of insert earphone and sound field VRA with young infants

Visual reinforcement audiometry (VRA) with insert-earphone stimulus delivery provides a means of obtaining early ear-specific information on the auditory status of infants. The aim of this study was to investigate the efficacy of VRA in young infants, and to compare the use of sound field and insert-earphone stimulus presentation. VRA was performed on 41 normally developing infants aged between 20 and 42 weeks. Infants were tested in the sound field (n=22) and with insert earphones (n=19). Results showed significantly more minimum response levels (MRLs) obtained with sound field testing, and with older children. Nevertheless, in the insert-earphone group, 36% of those aged 32 weeks or more gave two or more MRLs, and 25% of the infants aged 25 weeks or less gave one or more MRLs. This study provides data from developmentally normal infants which confirms the efficacy of insert-earphones as well as sound field VRA with 32-42-week-olds, with reasonable expectation of success. The data in this study also suggest that VRA could be usefully employed for younger infants aged approximately 20-26 weeks where information, although less easily obtained, may be of particular value to early diagnosis and habilitation.

Comparison of two methods for selecting minimum stimulation levels used in programming the Nucleus 22 cochlear implant

Minimum stimulation levels for active electrodes in a Nucleus 22 cochlear implant were set at threshold (clinical default value) and raised levels (M = +2.04 dB) to determine if raised levels would improve recipients' understanding of soft speech sounds with the SPEAK speech coding strategy. Eight postlinguistically deaf adults participated in a 4-phase A1B1A2B2 test design. Speech recognition was evaluated with consonant-vowel nucleus-consonant (CNC) words in quiet and sentences in noise, both presented at 50, 60, and 70 dB SPL during 2 weekly sessions at the end of each phase. Group mean scores were significantly higher with the raised level program for words and phonemes at 50 and 60 dB SPL and for sentences at 50 and 70 dB SPL. All participants chose to use the raised level program in everyday life at the end of the study. The results suggest that clinical use of a raised level program for Nucleus 22 recipients has the potential to make soft sounds louder and, therefore, more salient in everyday life. Further research is needed to determine if this approach is appropriate for other cochlear implant devices.

Visual reinforcement audiometry. Comparison of loudspeaker arrangements

Two different loudspeaker arrangements are currently used when performing Visual Reinforcement Audiometry (VRA). In the one arrangement, the loudspeakers are mounted on separate movable arms and positioned 15 cm from each ear. In the other, the loudspeakers are rigidly mounted close to their respective picture monitor at a distance of 50-70 cm from the child. In the present study, these two arrangements were compared by measuring real-ear sound pressure levels and actual sound field conditions. It was shown that a predominantly monaural stimulation was best achieved by using the 15-cm position, but also that the measurements were significantly more affected by small head movements when using this close position. When assessing the acoustics as well as practical aspects, it was concluded that loudspeakers mounted beside the picture monitors at a distance of 50-70 cm from the child makes a generally appropriate arrangement for VRA.

Measurement of variability in sound field audiometry due to subject movement

Sound field audiometry is used primarily for hearing assessment in young children and for functional hearing aid evaluation. It is important that measurements are accurate and reliable as they affect the management of patients. Most clinics use a substitution method for calibration and, as a result, if the subject moves from the calibrated test point, the sound pressure level (SPL) at the ears will vary as the sound field is very rarely uniform. This variation can result in inaccurate threshold estimation and increased test-retest variability. A commonly used method for evaluating the potential errors due to subject movement involves measuring the variation in SPL, with respect to the test point, at six points around the test point. This method makes assumptions about the sound field which may not be valid and could lead to an underestimation of the variation present. The aim of this investigation was to assess the accuracy of this method. Measurements of variation were taken with a microphone and repeated with a head and torso simulator (HATS) which was used to represent a test subject. The total degree of variation indicated by these two methods was compared. The microphone measurements indicated less variation than the HATS measurements. The differences were statistically significant but small in clinical terms. Assuming that the HATS is properly representative of the normal population, then this result indicates that simple microphone measurements are acceptable for normal clinical practice but that higher quality measurements are desirable for critical work.

Individual follow-up of hearing aid fitting

Fifty new hearing aid users were summoned to individual follow-up about one year after they had completed their hearing aid fitting. About 30% of the hearing impaired seldom used their hearing aid (< 1 h/day). The hearing aid was mainly used in conversation between two, conversation in groups, listening to TV/radio, etc. The hearing impaired who had a steep hearing loss used the aid to a lesser extent. There is a strong need of follow-up visits. Reliability of the subject's own judgement was good.

A discussion of current sound field calibration procedures

Calibration of sound fields is an area which has caused much confusion and about which there is some uncertainty. Appropriate calibration is essential if hearing results are to accurately represent the hearing status of a patient, and such results significantly affect the management of many patients. This paper outlines the basis of calibration procedures with respect to sound fields, reviews the recent work in this area, and puts forward the options open to audiologists. The issue of using the dB(A) scale rather than attempting to calibrate in dB HL is discussed and recommendations are made.

When is a decibel not a decibel?: The application of decibel scales and calibration in clinical audiology

Decibel scales are a very important but potentially confusing subject for the clinician. Misunderstanding can, at worst, lead to inappropriate management which is detrimental to the patient. This paper sets out, from the viewpoint of an acoustician, the calibration and meaning of the various decibel scales in common use, shows how they are applied to the clinical setting, and explains their limitations.

Reliability in warble-tone sound field audiometry

Test-retest reliability of sound field audiometry has been evaluated by means of repeated determinations of hearing threshold levels for frequency-modulated tones on normal-hearing and hearing-impaired subjects. Two modulation frequencies, 5 and 20 Hz, and two frequency deviations, 4 and 25%, were used, with centre frequencies in the range from 250 to 8,000 Hz. No significant influence on the standard deviations for test-retest differences was found for any of the three parameters studied: modulation frequency, frequency deviation, and normal versus impaired hearing in the listeners. The standard deviation values obtained were smaller than those previously obtained for regular pure-tone threshold audiometry using headphones. They indicate a test-retest reliability allowing functional gain measurements of hearing aids on the real ear to be performed at least as accurately as insertion gain measurements at frequencies above 2 kHz. In the hearing-impaired listeners, some influence was found from modulation frequency and frequency deviation on the sound field hearing threshold levels obtained.