Who is in the audience today? Topics for Discussion. PA Great Start Conference 08/06/2013

Transcription

1 Who is in the audience today? Thinking Beyond Hearing Aids and Cochlear Implants: Assistive Technology and Connectivity Options Reva Batheja, Au.D., CCC-A Manager, Hearing Aid Program Carmen D. Hayman, Au.D., CCC-A, CISC Coordinator, Cochlear Implant Program Parents? Hearing aids Cochlear implants Audiologists? Speech-Language Pathologists? Teachers of the Deaf and Hard of Hearing? Others?, 8/7/2013 Topics for Discussion Appropriate technology based on degree and type of hearing loss Setting hearing aids, which features are appropriate for children Basics of programming a cochlear implant Types of FM Systems Connectivity options for hearing aids & cochlear implant users (hands-on session) Manufacturer updates Consideration in Amplification Recommendations Type/Degree of Hearing Loss RECOMMENDATIONS Medical Family Academics Lifestyle/ Extra- Curricular Fitting Children with Hearing Aids Children vs. Adults Pediatric Audiologist or extensive experience in fitting hearing aids to children No one hearing aid is appropriate for everyone One versus two hearing aids Fitting Children with Hearing Aids Factors audiologist consider: Degree, shape and type of hearing loss Durability and service of hearing aid manufacturers/models Compatibility with special amplification systems used in school Batheja & Hayman 1

2 How Natural Hearing Works Hearing Aids How we hear Goal of amplification Considerations of hearing aid fitting Verifying the hearing aid fit How a Hearing Aid Works Goal The general goal of any hearing aid fitting is to provide a signal that makes soft, moderate, and loud sounds audible but not uncomfortable and provides excellent sound quality in a variety of listening environments. (Pediatric Amplification Protocol, 2003) Hearing Aid Fitting Hearing Aid Fitting Ear Canal Acoustics Infant vs adult ear canal Measured in Sound Pressure Level (SPL) Probe microphone measurement Assess how the hearing aid processes speech Determines the levels at which output is limited Efficient, reliable and valid Capable of being used with infants Probe Microphone Measurements Tiny microphone is placed in the ear canal next to the earmold Measures the performance of the hearing aid in the ear Effect of the size of the ear canal At birth the ear canal is less than 14mm in length Adult size about age 7 years Completed with BTE, ITE and CIC hearing aids Batheja & Hayman 2

3 Loudness (db HL) Hearing Aid Fitting Hearing Aid Fitting Prescriptive Fitting Strategies Uses audiometric threshold information available ABR - for very young Behavioral results - >6 months of age Establish targets for hearing aid gain Evaluate hearing aid settings End Result: Auditory Skill Development Digital Technology Hearing Aid Features Many manufacturers have stopped making analog hearing aids Most state Medicaid programs are now covering low-end digital hearing aids Digital technology is a clearer/cleaner signal and more flexible (to program) than analog technology What is Bandwidth? Extended Bandwidth Frequency (Hz) Traditionally amplification had a bandwidth out to about 4000 Hz Extended bandwidth Today, typical range is out to 7 10k Hz Manufacturers answered the call of researchers who demonstrated the need for hearing instruments to have a broader frequency response Batheja & Hayman 3

4 Extended Bandwidth Frequency Lowering Stelmachowicz PG, Pittman AL, Hoover M, Lewis DE. Effect of stimulus bandwidth on the perception of /s/ in normal- and hearing-impaired children and adults, Journal of the Acoustical Society of America 2001; 110: Stelmachowicz PG, Lewis DE, Choi S, Hoover B. Effect of stimulus bandwidth on auditory skills in normal-hearing and hearing-impaired children. Ear and Hearing 2007; 28(4): Pittman AL.Short-term learning rate in children with normal hearing and children with hearing loss in limited and extended high-frequency bandwidths. Journal of Speech, Language and Hearing Research 2008; 51: Is extended bandwidth enough? High frequencies are shifted to lower frequencies where there is more usable hearing Candidates? Initially intended for sloping high frequency hearing loss and severe to profound hearing loss. Now used for flat hearing loss and mild to moderate hearing loss as well Frequency Lowering Frequency Lowering Phonak Sound Recover en/library/features/soundrecover.html Widex Audibility Extender ion/audibilityextender/ Picture courtesy of Phonak Datalogging The ability of a hearing instrument to log use. Logs duration of wear, program usage, volume control (if applicable) May track the sound environment the wearer is in as well Helpful in counseling and determining best configuration of options for patient Accessed in programming software during hearing aid check appointments. Directional Microphones (DM)* DM allow the user to hear the person speaking directly in front of them better than the noise/speakers around them The hearing aid decreases gain from the sides and back on the user This is not recommended for young children as they are not always looking at the speaker (are often running away from them!) Also the user wearing DM should be on the same plane as the speaker Often we don t use this features because we want young children to learn from overhearing and have incidental learning *= every manufacturer is different; this explanation is worst case scenario Batheja & Hayman 4

5 Noise Cancellation (NC) Feedback Canceller (FC) NC is supposed to cut out background noise to help the user understand in a noisy environment Some hearing aid strategies are too aggressive and cut out too much information Some hearing aids cut out speech information- the function of this feature needs to be verified by the audiologist Evidence shows that for adults NC does not help them understand better but instead allows them ease of listening and comfort (still important) If the audiologist is comfortable with a manufacturer/model s strategy for NC they may turn on this feature for children There are often different levels for NC (weak, strong) Feedback occurs when sound comes out of the ear and travels back into the hearing aid microphone This can occur when there is a lot of gain (severe to profound hearing loss) or an earmold/hearing aid is not fitting well This can also occur occasionally when something comes close to the HA mic (i.e. hat, hug) Some hearing aids have FC that reduces gain to stop feedback (can change the user s understanding of speech) Some hearing aids have FC that just come on for the occasional feedback and do not reduce gain ( phase canceller ) FC should not be used to stop constant feedback- another solution should be considered (i.e. new earmold, frequency lowering technique) This feature, when it does not turn down gain, is often activated for children Multiple Programs Hearing aids with advanced technology give the ability to use these features in different programs There can be a program for quiet environments which has no features activated and then a program for noisy environments which has the DM and NC activated There is often a button on the hearing aid to switch programs Buttons are generally deactivated for children to avoid being in the wrong program There is evidence that many adults do not change programs appropriately Automatic Programs Hearing aids with multiple programs may have the option of allowing the hearing aid itself to change programs based on input i.e. change from program for quiet environment to program for noisy environment (activate DM and NC) when noise is detected Many adults and children utilize this feature But there is limited proof that the hearing aids change programs appropriately and consistently This feature shouldn t be considered for anyone not using the features involved (i.e. DM and NC) It is usually not activated for children under 5 years FM Programs Some hearing aids/styles are not FM compatible (specifically the very smallest size) and should not be fit on children Some hearing aids/styles are not compatible with direct ear-level FM coupling These may be compatible with FM through streaming devices and can be an option for older children Some hearing aids need a special FM program within the hearing aid which then can require using multiple programs to access advanced features FM Programs Some hearing aids have automatic FM programs- use of this is highly discouraged as there isn t enough evidence showing this feature works consistently All children should be fit with hearing aids that have FM access (they may realize they need FM even as late as in college) Batheja & Hayman 5

6 Volume Control Types of Hearing Aids Hearing aids have the ability to control how much gain to give based on the volume of the input Most children (and some adults) have volume controls deactivated to prevents them from adjusting inappropriately and unnecessarily The most difficult situation is for children with fluctuating hearing loss as their overall volume may need to be adjusted as hearing changes (these parents may be able to get remote controls to make adjustments) In the ear Receiver in the canal or slim tube Behind the ear with earmold Slim tube fitting Bone Conduction Hearing Devices Benefits Cosmetics! High frequency amplification Decreased feedback with more open fit Limitations FM capability limited Durability Wax Auditory device that transmits sound via bone conduction Can be implanted or worn on a soft band FM compatible Bone Conduction Hearing Devices - Candidacy When not able to wear air conduction hearing instruments Atresia/microtia Chronic middle ear disease (draining ears) Other potential candidates Single-sided deafness Unilateral hearing loss and not a candidate for air conduction hearing aids Case-by-case following an extensive trial period Sound transmission transcranial Cochlear Implants Batheja & Hayman 6

7 How a Cochlear Implant Works Cochlear Implant Basics Two components of a cochlear implant : Cochlear Implant Basics Two components of a cochlear implant: Cochlear Implant Basics Two components of a cochlear implant: 1 An internal implant placed just under the skin, behind the ear 1 An internal implant placed just under the skin, behind the ear 2 And an external sound processor General Candidacy Criteria Candidacy Considerations Pediatric vs Adult CHOP Process No medical or radiological contraindications to surgery Motivated family Educational placement able and willing to provide a concentrated auditory skill development program Appropriate expectations Batheja & Hayman 7

8 Pediatric Candidacy Guidelines Severe to profound sensorineural hearing loss in both ears > 12 months of age Lack of progress in development of auditory skill with hearing aid or other amplification For younger children As demonstrated on the IT-MAIS or MAIS Therapist and or teacher reports Receive little or no benefit from hearing aids For older children Score < 30% correct on word recognition test Adult Candidacy Guidelines Moderate to Profound SNHL, bilaterally 50% or less - sentence recognition in the ear to be implanted 60% or less - sentence recognition in the opposite ear or binaurally Pre-linguistic or post-linguistic onset of moderate-to profound SNHL No medical contraindications A desire to be a part of the hearing world Candidacy of School Age Children Child must: Be an active participant in the evaluation process 8+ years part of CI information meeting Want the cochlear implant Understand that there is a surgery involved Understand that there may be time post-implant that they do not wear the hearing aid Considerations: Timing of surgery During the school year vs. over a school break Candidacy w/ Malformed Cochlea Enlarged Vestibular Aqueduct (EVA) No concern Mondini Malformation Some concern Questionable auditory nerve Great concern Cochlear implant surgery Cochlear Implant Programming Device placed in a 2-3 hour procedure Performed under general anesthesia Implantation of electrode array likely sacrifices remaining hair cells in the cochlea.* Child can continue to wear hearing aid in opposite ear following surgery Batheja & Hayman 8

9 In the OR Electrically Evoked Compound Action Potential (ECAP) Surgery In the operating room Test device (impedance measures) Obtain some measurements (NRI/NRT/ART) X-ray Stimulate through the implant causing neurons in the cochlea to fire. Generates a neural response (action potential) that is recorded. Confirms device function and neural interface Info can be used in programming Available by all 3 manufacturer s Programming/Tuning/Mapping A map/program is created by selecting parameters/processing strategy and making psychophysical measurements. The speech processing or coding strategy used determines how the implant will translate pitch, loudness and timing of sound into electrical signals. Programs are downloaded and stored in the child s processor. Processors hold multiple programs. What happens at a tuning? Implant impedance test (every visit) How well electricity flows at each electrode site in the electrode array. Quick and requires no behavioral input from the child Used to detect conditions when an electrode should not be used: Open circuit no flow of electricity Short circuit too much flow of electricity High impedance too little flow of electricity If a problem is found the electrode is deactivated Prevents distortion of sounds Impedance Test Cochlear Americas Channels 4 and 12 should be deactivated Impedance Test Advanced Bionic All electrodes functioning Batheja & Hayman 9

10 Electrical Stimulation Level Psychophysics T and C/M Levels Programming the speech processor Find the Threshold Level (T-level) The least amount of electrical stimulation your child responds to all of the time. Find the Most Comfortable Level (M-level or C- level) The amount of electrical stimulation that your child can listen to comfortably all the time. Difference between the T-level and the M or C- level is the dynamic range Electrode C/M Levels T Levels Setting T or C/M-levels Setting T or C/M-levels Under 1 year to age 2.5 years ECAPs visual reinforcement behavioral observation Age 2.5 to 5 years of age Transition to conditioned play tasks (throwing blocks, peg board, stickers, magnets, marbles, etc) Attempt two choice loudness scaling Work on this in therapy! (use non speech sounds) Loudness Scaling (C/M-Levels) Setting T or C/M-levels Age 6+ years Move toward hand raising More discrete loudness scaling Age 9+ years Hand raising for T- levels Patient & Audiologist set C/M-levels Batheja & Hayman 10

11 Programming Screen Advanced Bionics T-levels do not need to be measured. Programming Screen Cochlear Americas Measure T and C-levels. Can interpolate electrodes not measured. The Cochlear Implant Learning Process Monitoring Performance When we first activate, child s tolerance for current may be very low. First 3 months, the amount of current child needs to hear will fluctuate, even day to day. Performance will fluctuate as well. Child needs time with device, maps should stabilize more over time. Following initial acclimation, map can be monitored, but less global changes will likely be made. Audiologist may provide one to four programs based on child s needs. If child is not making appropriate progress, other stimulation strategies, parameters may be attempted. Parent/therapist report of auditory behavior Audiogram Speech perception testing Adjustments needed? Adjustment Indicators c c c c c Following Initial Acclimation Period Changes in speech production/perception Child can no longer hear/produce a sound that was previously heard Child making substitutions with speech sounds Speech slurred mushy Drops final consonants, plurals Changes in vocal quality Increased requests for repetitions Professionals need to weigh known expectations of speech language development with factors of child acclimating to new electrical stimulation and possible language or learning issues. Batheja & Hayman 11

12 When is it the equipment? Child not hearing at all Wires kinked, broken Device not working typically Child only hearing very loud sounds Raising voice to get child s attention AB families Please check the T-mic Cochlear families Please replace the mic protectors Child alerts you something is different FM Systems What is it? Who needs one and when? Who pays for it? Note: Some content in this portion of presentation was provided by Advanced Bionics and Cochlear Americas. Student Variables of Listening Interest, motivation and attention Hearing status Academic skill level Age and/or maturation Cognitive level Effects of Noise on Performance Adults with normal hearing need a S/N of +6 db for optimal performance Children (< 15 years old) with normal hearing need a S/N of +10 db for optimal performance Children and adults with hearing loss need a S/N of +20 db for optimal performance Distance from Sound Source Every time you double the distance between you and the listener, the signal decreases by 6 db As intensity of speech signal decreases, perception of speech decreases Batheja & Hayman 12

13 Noise and Distance Effects Purpose of an FM System Average teacher s voice level = 65 db SPL at 3 Average classroom ambient noise = 60dB S/N at 3 = +5dB Voice level will be 59 db SPL at 6, 53 db SPL at 12 feet and so on Children in back of room will have poorer S/N Make it easier to identify and understand speech in noisy situations or over distance Reduce the effects of: Background Noise Reverberation (Echo) Distance of the speaker Transmitter (microphone) picks up speech and sends the signal via radio wave to an FM receiver Purpose of FM Fitting Things to Know About FM Systems Ensure speaker s voice is presented at a consistent db level Tune out competing conversations Improve listening in rooms with poor acoustics Reduce listening effort and maximize learning FM systems are expensive They work on a channel (216 MHz frequency) They can interfere with one another (who else in school is using one?) Some can be programmed (both the transmitters and receivers) FM systems have a range Transmitter and receiver should be within feet FM systems should be fit by an audiologist Ideal setting is different for each hearing aid and cochlear implant FM System Transmitter FM System Receivers Hearing Aids Traditional Lapel or Boom mic Hand-held Lavaliere Universal Integrated Neck Loop Batheja & Hayman 13

14 FM Receivers Cochlear Americas FM Receivers - Advanced Bionics Euro Adaptor with MLxi Receiver ML14i Receiver color to match processor FM Receivers - Med-El Opus 2 Soundfield or Desktop FM Benefits: Soundfield all people in the area may benefit No additional equipment needed to troubleshoot Challenges: Desktop child may find obtrusive/dislike the attention it gets Relies on proper speaker positioning Speakers may be at too great of a distance to benefit those with Cis Soundfield has the least SNR benefit, followed by desktop, as compared to personal FM (either coupled by telecoil or electrically) Neckloop Receivers Telecoil coupling: Neckloop with sound processor on telecoil (or combined telecoil and microphone setting): This works by the speaker wearing an FM transmitter FM Receiver with neckloop attached is worn by recipient Recipient uses sound processor or hearing aid on telecoil setting (or mixed telecoil/microphone setting) Neckloop Receiver FM Benefits: Can get input to both ears with a single receiver Can wear under clothing without effect on sound quality Has its own battery, does not impact sound processor battery life Not specific to device type or manufacturer Easy to perform listening check using monitor earphones Fewer parts to troubleshoot Challenges: Potential for magnetic interference from computers, power sources, etc. (reduce sensitivity to manage) May be cumbersome for small children or sports activities Batheja & Hayman 14

15 Ear-Level Receivers Ear-Level Receiver Direct connect with sound processor or Integrated with the hearing aid FM transmitter worn by speaker FM receiver connected directly to the sound processor using an adaptor or a cable FM receiver picks up signal from transmitter and sends it to the processor or hearing aid Benefits: Cosmetically appealing Good signal-to-noise ratio achievable, as compared to desktop or soundfield systems Challenges: Sound processor transmitting coil s proximity may create fitting challenges for some users More parts to troubleshoot May be device/manufacturer specific Which one is best? Style it depends; personal preferences Manufacturer it depends; personal biases Research Some articles to look to for guidance on best practices Dynamic FM vs. Traditional FM Phonak products Currently available for AB, Med-EL, Cochlear N5 (only) Freedom MicroLink is Traditional FM - however when using an autosensitivity program in the processor improved performance in noise was noted (work around for all Freedom users) NEW! Roger DM Use FM Instructing entire class Repeating what other students say Adult-directed small group discussions Giving oral instructions /exams Watching a video Student giving oral presentation Don t Use FM Independent seatwork Addressing another student individually Whenever speech is not directed toward the student. teachers lounge, another teacher, restroom, etc. FM Use Beyond the Classroom Verifying FM Systems Informal Checking Behavioral Testing Verification with hearing aids Batheja & Hayman 15

16 Informal Checking Troubleshooting Tools Perform a listening check: Have recipient repeat Ling Sounds Count numbers Count number of syllables in word Indicate long or short sounds Follow simple instructions: e.g. clap your hands Daily Listening Checks The equipment With the child Ling Sounds Ask questions Who Pays? Practical Considerations School Medical Insurance Family Other FM must be set by audiologist familiar with FM s and cochlear implants Equipment is only as good as how comfortable the personnel are with it Communication among teachers, therapists, educational audiologist, and cochlear implant audiologist is essential Have copies of user manuals/videos for speech processor and FM system on site Identify an individual to perform daily listening check and troubleshooting Don t use FMs where they are not needed Don t forget about FMs when you have a superstar Batheja & Hayman 16

17 FM For CI CHOP Map should be stable Recommendations vary depending on where the child lives - how it is handled PA varying preferences Many requesting: Last year of preschool to get use to it More considering neckloop (bilateral patients) Collaboration between hearing aid/ci audiologist and educational audiologist is essential An Introduction to Connectivity Connectivity Options TV & Entertainment Systems Wireless Interface Built in antenna Paired to devices that are Sends signal to both hearing aids compatible Pushing a button provides user hands-free access to a variety of devices Wireless without FM system Dedicated adaptor is needed and is connected to the television or entertainment system User wears interface to receive signal into hearing aids Wireless with FM system Audio cable is connected from FM system to TV or entertainment system Audio only accessible to hearing aid user Not meant for group activities Mobil Phone Wireless Requires use of wireless interface OR Bluetooth compatible FM transmitter Cell Phone needs to be Bluetooth compatible and paired with the device Allows hearing aid wearer to have hands-free conversation Hear phone conversation through both hearing aids Mobil Phone Hard-wired Direct Audio Input cords get plugged into mobile phone and connect via Neck loop OR T-Link Silhouette style ear hook Works with telecoil in hearing aids Built in microphone Single and dual headset available Batheja & Hayman 17

18 Music and Computers Music and Computers Wireless without FM Requires use of wireless interface paired with Bluetooth compatible MP3 player or computer If device is not Bluetooth compatible or a Bluetooth adaptor is not available, connect device to wireless interface using audio cable Wireless with FM Connect MP3 player or computer to FM transmitter using audio cable Make sure that hearing aids are in FM + M program Music and Computers Hard-wired Connect MP3 player or computer or handheld game direct audio input cable May be manufacturer specific May need alternate mixing ratio for best enjoyment Music-Link Silhouttes Hands-On Session Contacting the CHOP CI Team CI: Technology Update Carmen Hayman, AuD, CCC-A Coordinator, CI Program (215) hayman@ .chop.edu (best way to reach me!) citeam@ .chop.edu Any question you, a student or parent has we ll be directed to the correct person Appointments: , option #2 CI Packets; scheduling post-implant appointments Batheja & Hayman 18

19 THANK YOU FOR JOINING US TODAY! Thank You For Listening Today! Batheja & Hayman 19