Speech in Noise: Using Measurements in Fitting. Presenter: Lori Bunkholt Exclusive Networks Education and Training Starkey Hearing Technologies

Transcription

1 Speech in Noise: Using Measurements in Fitting Presenter: Lori Bunkholt Exclusive Networks Education and Training Starkey Hearing Technologies

2 From the desk of our Attorney The views expressed in presentations made at International Hearing Society (IHS) educational events are those of the speaker and not necessarily of IHS. Presentations at IHS events, or the presence of a speaker at an IHS event, does not constitute an endorsement of the speaker's views. Download the slides at

3 Agenda Why should we do Speech in Noise Testing QuickSIN ANL Q&A These presentations slides will be available to download at ihsinfo.org/convention

4 I don t have time! Why should I do more than Air/Bone/Speech? It s what we ve always done I have a VERY busy practice Let s look at it a few different ways Best Practices Patient Satisfaction More successful practice

5 Best Practices Definition Commercial or professional procedures that are accepted or prescribed as being correct or most effective A method or technique that has consistently shown results superior to those achieved with other means, and that is used as a benchmark In addition, a "best" practice can evolve to become better as improvements are discovered Oxford Dictionary; Business Dictionary

6 Best Practices Several organizations publish Best Practices for hearing health care practitioners AAA ASHA ISA Several organizations publish what consumers should expect BHI HLAA Consumer Reports

7 Best Practices They are all a little different There are common themes Hearing Evaluation More than just the audiogram More than just quiet speech Verification The hearing aid is doing what it should It is functioning appropriately Validation The hearing aid is doing what the patient needs There is perceived benefit by the patient

8 Patient Satisfaction Patient satisfaction is linked to The perception of expertise and caring of the practitioner The perceived benefit provided by the devices The number of situations in which the devices provide benefit

9 Patient Satisfaction Practitioner How much time do they spend with the patient? How well do they explain? How inclusive is the protocol? Kochkin, et al, Hearing Review 2010

10 How Inclusive Is The Protocol? Kochkin, et al, Hearing Review 2010

11 How Inclusive Is The Protocol? Kochkin, et al, Hearing Review 2010

12 Perceived Benefit Customer satisfaction with hearing aids in various listening situations hearing aids are <= 4 years old Kochkin, 2010, Hrg Journal 55%

13 Perceived Benefit Customer satisfaction with hearing aids in various listening situations hearing aids are <= 4 years old Kochkin, 2010, Hrg Journal 43%???

14 Satisfaction with HA benefit Number of Situations Satisfaction with benefit is highly dependent on the number of listening situations hearing aids work Kochkin, 2010, Hrg Journal Very Dissatisfied Dissatisfied Somewhat dissatisfied Neutral 23 Somewhat satisfied 31 Satisfied 64 Very satisfied % listening situations satisfied or very satisfied

15 Wait, wait, wait I AM A VERY BUSY PERSON!!

16 Added protocal Remember when we talked about Verification Validation Doing some form of either one?

17 More Successful Practices Kochkin, Hearing Review 2011 If you do neither You have 10 new patients each month 34 patient visits for the fitting If you did both, it would drop to 24 visits Leaving 10 additional hours per month

18 Still not sure about this? Let s think about it

19 Let s think about it What if we did an additional test the first time we saw our patient We might do a better job of addressing their needs Less follow-ups Which means

20 Eureka moment Those extra 10 hours a month? More sales Community outreach Time to complete chart notes One more round of golf

21 So what can we do? Today, let s look at just a couple of tests that can have a significant impact QuickSIN ANL

22 Back to Patient Satisfaction If we want to improve satisfaction with hearing aids, we need to improve the user s ability to hear in noise Your patient can hear you, just fine, in your office But they cannot hear at the restaurant Then the problem is greater than audibility How can we predict their performance in the real world?

23 QuickSIN

24 Signal-to-Noise Ratio (SNR) Loss Similar to Hearing Loss, we define SNR Loss as the increase in signal-to-noise ratio required by a listener to obtain 50% correct, compared to normal performance

25 Why measure SNR Loss? It s the #1 complaint of hearing-impaired patients It can t be reliably predicted from the pure tone audiogram or other standard audiometric tests

26 An example PTA = 53/55 WRS = 80%/84% PTA = 52/53 WRS = 76%/80% SNR Loss = 3 db, 1 db SNR Loss = 9 db, 9 db

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28 QuickSIN Equipment you need QuickSIN CD Headphones/ear inserts Set up CD in the audiometer Patient in Sound Booth

29 QuickSIN Test v1.3 IEEE sentences, female talker, in 4-talker babble 1 sentence at each of 6 SNRs (25, 20, 15, 10, 5, 0) 12 equivalent lists; each takes 1 minute 3 additional list pairs for research, where more lists are needed

30 QuickSIN Presentation Using the calibration tone on Track 1, adjust both channels of the audiometer to read 0 VU Present the test with earphones or in a sound field, with the attenuator dial set to 70 db HL For subjects with PTA hearing losses greater than 45 db HL, set the attenuator dial to a level that is loud but OK Instruct the patient to repeat the sentences spoken by the target (female) talker. Score the five key words underlined in each sentence, giving one point for each word repeated correctly

31 Instructions Imagine you are at a party. There will be a woman talking and several other talkers in the background. The woman s voice is easy to hear at first, because her voice is louder than the others. Repeat each sentence the woman says. The background talkers will gradually become louder, making it difficult to understand the woman s voice, but please guess and repeat as much of each sentence as possible.

32 QuickSIN Process Use one practice list Found on tracks Not equivalent to the test lists Prefered Present 3 lists Average the score

33 QuickSIN Demo SNR Correct 1. To have is better than to wait and hope The screen before the fire kept in the sparks Thick glasses helped him read the print The chair looked strong but had no bottom They told wild tales to frighten him A force equal to that would move the earth. 0 0 Total Correct = 18 SNR Loss = = 7.5

34 QuickSIN Statistics: Reliability QuickSIN Manual, Table 3 No. of Lists % C.I % C.I

35 QuickSIN Results SNR Loss Degree of SNR Impairment Recommendation 0 3 db Normal/near normal Should do fine in noise 4 7 db Mild SNR loss Omni/Directional Microphones 8 15 db Moderate SNR Loss Directional Microphones >15 db Severe SNR Loss FM system

36 QuickSIN Patient wants an IIC Their SNR Loss is 3 How will they do in noise? Patient wants a wireless CIC Their SNR Loss is 10 How will they do in noise? How do we get them to understand? DEMO

37 QuickSIN Can be used to verify effectiveness of directional microphones in SF Speech and babble separated Tracks Calibrate both channels Target talker = Channel 1 = Front speaker 4-talker babble = Channel 2 = Back Speaker Examiner sets presentation levels

38 Split-track QuickSIN Use whatever setup you have (45/135 or 0/180) Results reflect location of SF loudspeakers and the directional mic s polar pattern Consider mounting the noise speaker on the ceiling Must have two speakers Be aware of the limitations of any tests done in a sound booth Compare omni to directional Use as a demonstration tool

39 Separated Lists Channel 1 (Target) Channel 2 (Babble) Dial (db HL) Dial (db HL) SNR (db) Sentence Sentence Sentence Sentence Sentence Sentence Scoring: 25.5 Total Correct = SNR Loss

40 QuickSIN Statistics: Comparing Two Conditions QuickSIN Manual, Table 4 Lists / cond % C.I % C.I

41 QuickSIN Remember the patient with SNR loss of 10 and wants a CIC? What if you used the QuickSIN as a Demo We did 3 lists in each condition with minibte Omni Mic SNR Loss of 9 db in SF Directional SNR Loss of 5 db in SF SLM Remote Mic SNR Loss of 2 db in SF

42 QuickSIN Patient came from a doctor referral Main complaint is following conversations in mid to large groups Failed hearing screening at office At end of trial, send report back to doctor Summary of test results at evaluation Air/Bone/Speech, QuickSIN Recommendations based upon testing

43 QuickSIN Summary of patient validation results IOI-HA HHIE Summary of post fitting verification Functional WRS QuickSIN Soundfiled

44 Advanced Testing: Acceptable Noise Level

45 What is Acceptable Noise Level (ANL)? A measure of a person s tolerance to noise The highest level of background noise someone is willing to put up with while listening to speech

46 Why is ANL important? It is the only predictor that a patient will be a successful hearing aid user

47 Level Acceptable Noise Levels Listener adjusts speech to a comfortable level

48 Level Acceptable Noise Levels ANL = Speech Level - Noise Level ANL Add low level noise Listener adjusts the level of the noise to the maximum amount they are willing to tolerate

49 ANL Predicts Successful HA Use Nabelek et al, 2006

50 Distribution of ANLs Likely to be successful? Likely to be unsuccessful Nabelek et al., 2006

51 Research Goals Identify the perceptual basis for ANL Determine if hearing aid technology can turn a poor ANL patient into a good ANL patient Unsuccessful HA wearer Successful HA wearer

52 General Method Participants were tested in a sound booth Speech and noise were presented at 0⁰ Speech = Arizona Travelogue Noise = 8-talker babble

53 Experiment 1 Level Dependency Research Question: Can we predict how ANL varies with level? Hypothesis: Subjects will adjust the noise to a constant perceptual criterion E.g. loudness, intelligibility

54 Method 10 hearing impaired subjects Measure ANL at different stimulus levels Predict ANL based on: Equal loudness criterion Equal intelligibility criterion

55 ANL db (db) SNR Loudness Model and ANL Recker et al., 2009

56 ANL (db) Intelligibility and ANL 4 subjects based on Intelligibility criterion

57 Loudness Model and ANL db SNR ANL (db)

58 Loudness Model and ANL db SNR ANL (db)

59 Experiment 2 Focus on Intelligibility? Focus on Loudness of Noise

60 Experiment 2 Research Question: Can we predict how ANL varies with different noise spectra? Hypothesis: Data from subjects with good ANL can be predicted by a constant intelligibility criterion

61 Distribution of ANLs Focus on Intelligibility? Focus on Loudness of Noise Nabelek et al., 2006

62 Amplitude (db SPL) Spectra of the background noise stimuli Broadband Lowpass Highpass LF Bandpass HF Bandpass Babble Frequency (Hz)

63 ANL (db) Average ANL Scores Broadband Lowpass Highpass LF BP HF BP Babble Series Stimulus

64 SII and Intelligibility HI listeners on average set the background noise to achieve ~ 80% intelligibility Hargus and Gordon-Salant, 1995

65 Distribution of ANLs Set intelligibility to 80% Nabelek et al., 2006

66 Experiment 3 Confirm Bad ANL = Noise Loudness Focus + Confirm Hearing Aids Can Help

67 SIGNAL VALUE SIGNAL VALUE Experiment 3 Research Question: Does Noise Reduction affect ANL? TIME, s TIME, s

68 Experiment 3 Hypothesis: Noise Reduction will not affect ANL for those with good (low) unaided ANL They are focused on intelligibility Noise Reduction will improve ANL for those with bad (high) unaided ANL They are focused on noise loudness

69 Method Measure aided ANL with and without Noise Reduction

70 Low, Mid, and High Subject Groups Focus on Intelligibility? Focus on Loudness of Noise

71 Low, Mid, and High Subject Groups

72 Low, Mid, and High Subject Groups

73 Low, Mid, and High Subject Groups

74 Low, Mid, and High Subject Groups Likely to be successful? Likely to be unsuccessful

75 Conclusion There appear to be 2 types of patients Group A: Those focused on intelligibility Group B: Those focused on noise comfort Group B is more at risk of being unsuccessful hearing aid wearers

76 Conclusion If you identify a Group B patient Increase strength of noise reduction Less gain for high-level sounds Strongly counsel to avoid noisy locations Provide an aggressive noise comfort memory

77 Our Patient Let s look at our case study utilizing ANL

78 Jan Right ear MCL: 70dB UCL: 110 Discrim: 80% Left ear MCL: 70dB UCL: 110 Discrim: 86%

79 Jan Thinking about her hearing loss Anything jump out at you? Anything look weird?? Yes, that s what we thought as well

80 Jan Hearing loss from birth Discovered at age of 18 Tried h/a 2x-unsuccessful She is a writer of Help books in technology Attends many board room meetings Has many conference phone calls

81 Jan Stopped living life for many years We fit her at age 49 It is now 4 years later

82 Jan Even with top technology and noise management maxed Struggled in busier environments Thought some sounds were still too harsh Overwhelmed in a cooking class

83 Jan We did ANL on her She came in at 12.2 Her actual db levels came in at 62.4 Bottom line-she doesn t like noise She has NOT been a problem patient at all Had investigated what it means to wear h/a Has always accepted we live in a very busy world It was all ok, but

84 Jan ANL gave us that extra piece of information Provided extra boost of noise management Uses our wireless accessory w/remote mic for business meetings and conference calls

85 Jan She is the happiest she has ever been with amplification But do you know what is also important? We took that extra step to identify and meet her personal needs

86 Yes, we need to do this!

87 Questions Please complete an Evaluation Form for this seminar These presentations slides will be available to download at ihsinfo.org/convention

88 Thank you for attending! To be eligible for CE credit, be sure to get your IHS Attendance Record page in your directory hole-punched as you exit! Contact Lori Bunkholt at