FM for Cochlear Implants Chapter 13. Effects of Accessory-Mixing Ratio on Performance with Personal FM and Cochlear Implants

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1 FM for Cochlear Implants Chapter 13 Effects of Accessory-Mixing Ratio on Performance with Personal FM and Cochlear Implants Jace Wolfe & Erin C. Schafer Jace Wolfe, Ph.D., is the Director of Audiology at the Hearts for Hearing Foundation. He also is an adjunct Assistant Professor in the Audiology Department at the University of Oklahoma Health Sciences Center. Dr. Wolfe is the co-author of Programming Cochlear Implants, a textbook scheduled to be published in March of He serves as the editor for the American Speech Language Hearing Association s Division 9 journal and is a member of the Better Hearing Institute s Pediatric Advisory Board as well as the Audiology Advisory Boards for Cochlear Americas and the Phonak Hearing Aid Company. He is also serves on the editorial board of The Hearing Journal, and he is a reviewer for several peer-reviewed journals. His areas of interests are pediatric amplification and cochlear implantation, personal FM systems, and signal processing for children. He provides clinical services for children and adults with hearing loss and is also actively engaged in research in several areas pertaining to hearing aids, cochlear implants, and personal FM systems.

2 146 Effects of Accessory-Mixing Ratio on Performance with Personal FM and Cochlear Implants Effects of Accessory-Mixing Ratio on Performance with Personal FM and Cochlear Implants Jace Wolfe & Erin C. Schafer Introduction It is widely recognized that cochlear implants are the most successful sensory prosthetic device in medicine. The numerous benefits of cochlear implantation are well-established with many recipients achieving excellent open-set speech recognition. Adults who are post-lingually deafened typically can converse over the telephone with use of their cochlear implant (Adams et al, 2004), and several research studies have shown that children who are born with pro - found hearing loss can develop age-appropriate speech, language, and auditory skills when they receive a cochlear implant at an early age (Moog & Geers, 2003; Nicholas & Geers, 2006; Robbins et al, 2004). In fact, performance outcomes with cochlear implants are so impressive that children who are implanted at an early age and adults who are post-lingually deafened often achieve a perfect or near perfect score on open-set speech recognition tests in quiet (Zeng, 2004). Figure 1. Speech recognition in quiet of 18 adults using Advanced Bionics HiResolution Cochlear Implant Systems Unfortunately, it is also well established that persons with cochlear implants still have difficulty understanding speech in adverse listening situations. Particularly, users of cochlear implants frequently experience difficulty understanding soft speech and signals from a distance (Firszt et al, 2004; Wolfe & Schafer, in press). Firszt and colleagues (2004) showed that speech recogni tion of adults with cochlear implants decreased from a mean score of approximately 40 % correct at 60 db SPL (conversational speech) to 20 % correct at 50 db SPL (soft speech). Figure 1 depicts similar results for 18 adults using Advanced Bionics High Resolution cochlear implant systems (Wolfe, 2006). A statistically significant (p <.001) deterioration in speech recognition was found when the presentation level was decreased from conversational speech to soft speech. Furthermore, many cochlear-implant users continue to experience considerable difficulty with speech understanding in the presence of background noise (Firszt et al, 2004; Nelson et al, 2003; Schafer & Thibodeau, 2003, 2004; Stickney et al, 2004; Wolfe & Schafer, in press). Schafer and Thibodeau (2003, 2004) reported that speech recognition may decline by approximately 50 % correct in noise versus quiet. Figure 2 shows mean speech-recognition performance for the aforementioned group (Wolfe, 2006) of successful adult cochlear-implant users. This group has excellent open-set speech recognition for the Hearing In Noise Test (HINT) sentences in quiet; however, at a 5 db signal-to-noise ratio, which may be commonly encountered in the real world, performance is significantly poorer (p <.001). This finding explains why people with excellent performance in quiet report substantial difficulty in the real world and in noise. For this reason, audiologists often assess speech recognition at multiple presentation levels in quiet (conversational and soft levels) and speech recognition in noise (Firszt et al 2004; Madell, 2007). Address correspondence to: Jace Wolfe, Hearts for Hearing Foundation, 3525 NW 56th Street, Suite A-150, Oklahoma City, OK 73112, Telephone: , Address: jace.wolfe@heartsforhearing.org

3 Jace Wolfe & Erin C. Schafer 147 Figure 2. Speech recognition in quiet and noise on the Hearing in Noise Test Despite strong evidence supporting the use of electrically-coupled personal FM systems, many clinicians have expressed reticence in recommending these systems for their patients. This reluctance may be related to the number of parameters necessary to optimize the interface between the FM system and the cochlear implant. These adjustable parameters may include FM-receiver gain, input dynamic range of the speech processor, sensitivity of the speechprocessor microphone, and audio-mixing ratio. Until recently, no recommendations were given on how these parameters should be set to maximize patient performance. Our current research centers on the effects of these parameters on performance of people using cochlear implants and electrically-coupled personal FM systems. The potential impact of the FM-receiver gain and input dynamic range are discussed in the preceding article (Schafer & Wolfe). The remainder of this manuscript will focus on the effects of audiomixing ratio on patient performance. Given the challenges of noisy environments, it is likely that manufacturers will focus on improving cochlear implant hardware and signal processing strategies for listening in noise. Despite these expected improvements, maximum performance may continue to be achieved with the use of a frequency-modulated (FM) system. A variety of FM options exist for cochlear-implant users, including soundfield systems, personal soundfield systems, and electricallycoupled personal FM systems (see Schafer & Wolfe for a description of these systems). Although soundfield systems are commonly recommended for children with cochlear implants, research indicates that these systems do not always significantly improve speech recognition in noise compared to the cochlear implant alone (Crandell et al 1998; Schafer & Thibodeau, 2004). However, use of electricallycoupled personal FM systems does offer significant improvements in speech recognition in noise (Schafer & Thibodeau, 2003, 2004; Wolfe & Schafer, in press). In addition, performance with an this system is significantly better than with a personal soundfield system (Schafer & Kleineck, in submission). Audio-Mixing Ratio With most cochlear implant systems, the audiologist has the option of adjusting the audio-mixing ratio. The audio-mixing ratio controls the emphasis between input from the microphone of the speech processor and input from the FM system. In most situations, users prefer to keep the FM and speech-processor micro phones active. This enables the users to hear the signal from the FM system while maintaining audibility of sound in their lis - tening environment, including their own voices. The ideal relationship between these two signals will vary according to the listening environment. For instance, in a very noisy environment, it may be beneficial to place more emphasis on the signal from the FM system. However, while in a quiet classroom, it may be more important to maintain full sensitivity for the speech processor, which will be equal to the signal from the FM system. This will allow the student to hear sounds throughout the classroom and also monitor his or her own voice while asking or answering questions. The mixing-ratio options vary across cochlear implant manufacturers; therefore, it is necessary to examine mixing ratio parameters

4 148 Effects of Accessory-Mixing Ratio on Performance with Personal FM and Cochlear Implants in a company-specific manner. When programming cochlear implants manufactured by the Advanced Bionics Corporation, clinicians have several mixing-ratio options. For the 50/50 ratio, the signal from the processor microphone and the signal from the FM system receive equal emphasis. This is the default option in the Soundwave programming software system. In the 30/70 mixing ratio, the signal from the speech-processor microphone is atte nuated by 10 db, resulting in a relatively greater emphasis placed on the FM signal. This is an option that is commonly recommended for use with FM systems to allow for better access to the FM signal. The Auxiliary Input Only (Aux Only) option deactivates the speechprocessor microphone. With this setting, the FM signal is the only input the recipient receives (this is similar the FM only mode available with many hearing aids). For the Microphone Only (Mic Only) setting, the speech-processor microphone is enabled, but the FM input is deactivated. For cochlear implants manufactured by the Cochlear Corporation, the audiomixing ratio parameter is referred to as the accessory-mixing ratio. Clinicians have several accessory-mixing-ratio options from which to select. The 1:1 ratio provides no attenuation to the signal from the speech-processor microphone. Therefore, equal emphasis is placed on the FM signal and the signal from the speech-processor microphone. With the 2:1 ratio, the signal from the speech-processor microphone is attenuated by 6 db, resulting in relatively greater emphasis being placed on the input from the FM system. In the 3:1 ratio, the signal from the speechprocessor microphone is attenuated by 9 db. The 3:1 accessory mixing ratio is the default option in the CustomSound programming software system. The 10:1 ratio attenuates the speech-processor microphone by 20 db, resulting in significantly greater emphasis being placed on the signal from the FM system. The effects of the audio-mixing ratio on patient performance were evaluated in two studies. The first study included subjects using the Advanced Bionics Corporation High Resolution cochlear implant system and the iconnect FM auxiliary earhook. In the second study, participants used the Cochlear Corporation Nucleus Freedom cochlear implant system with the Phonak Freedom MicroLink FM receiver. Case studies will be provided to illustrate the results of this research. Advanced Bionics iconnect Study We are in the process of completing a study on speech recognition of adults using the Advanced Bionics Auria and Harmony speech processors coupled to iconnect earhooks and Phonak MLxS FM receivers (see Figure 3). Portions of this study have been described previously (Wolfe & Schafer, in press). Speech recognition in quiet, speech recognition in noise, and subjective questionnaires were given when participants were using the 30/70 and 50/50 audio-mixing ratios. These are the most commonly selected mixing ratios for FM system use. Currently, 15 adult subjects have participated in the study. Speechrecognition testing was conducted both with and without use of the FM system. We evaluated speech recognition in quiet using full consonant-nucleus-consonsant (CNC) word lists at 50 and 65 dba SPL with speech presented at 0 degrees azimuth. Speech recognition in noise was evaluated with HINT sentences at 65 dba SPL and four-talker babble noise at 60 dba SPL. The speech signal was presented from 0 degrees and noise was presented at 180 degrees azimuth. Figure 3. Advanced Bionics Corporation Auria Sound Processor with iconnect earhook and Phonak MicroLink MLxS receiver For all measures, the transmitter was

5 Jace Wolfe & Erin C. Schafer 149 positioned with the micro phone located 6 inches from the loudspeaker at 0 degrees azimuth. For the No FM conditions, the FM microphone was muted or deactivated. We used the Phonak Campus S transmitter to evaluate performance in the booth. The mute function on the microphone allowed us to simulate a condition where mixing ratio is enabled, but the signal of interest is not received by the FM microphone. Subjects used the Phonak SmartLink transmitter during real-world trials. During the trial, the gain of the MLxS receiver was set at the manufacturer default setting of +10 db. Subjects used the FM system for four weeks, two weeks at each mixing ratio. The order of the mixing ratios was counter-balanced, and they were blinded to the mixing ratio used during each two-week trial. The following case study is illustrative of the results obtained for the group of subjects. tial to significantly improve his speech recognition in background noise and for softly-spoken speech. Furthermore, it is clear that he experiences greater difficulty with speech understanding at low-presentation levels with the 30/70 mixing ratio relative to the 50/50 mixing ratio, a finding that was consistent across subjects. As such, use of a mixing ratio that attenuates the signal from the speech processor is expected to reduce audibility and speech understanding for speech spoken from a distance and soft speech that is not directed to the FM microphone. Table. 1 Percent-Correct Performance in Quiet of Subject AB Audio-Mixing Ratio FM Off FM On 30/70 8 % 52 % 50/50 38 % 46 % Case Study: Subject AB, Advanced Bionics Case Study Subject AB was a 71-year old man who has used an Advanced Bionics High Resolution cochlear implant with an Auria speech processor for two years. Although he reported that his cochlear implant provided substantial benefit, he also noted substantial difficulty understanding speech in noise. In fact, prior to the study, he was very emotional when describing the difficulty he continued to experience communicating in adverse listening situations. He stated that he was just about ready to give up meeting with his friends and family in social situations. He had an acceptable noise level of 20 db. This result compares unfavorably to the typical acceptable noise levels from our subjects (8 of 10) with cochlear implants. In short, he experiences considerable difficulty with listening in noise. His experiences with the personal FM system in the real world are consistent with the improvement observed in the audiometric test booth. Subject AB provided several comments on his experiences with the personal FM system: He reported that his hearing is much better in noisy situations. He reported that he places the transmitter near the television in his living room and is able to understand the television without closed caption. He feels much more comfortable communicating in social settings. Subject AB elected to purchase the personal FM system at the completion of the study. His Auria speech processor was loaded with three programs, each with a different mixing ratio: Speech recognition in noise on the HINT (+5 db) was 0 % without the FM system and improved to 85 % with the FM system. Table 1 provides a summary of speech-recognition results for this subject in quiet. It is apparent that the personal FM system has the poten- Program 1: 50/50. He reports that he uses the 50/50 mixing ratio in his Sunday School classroom. The teacher wears Smart Link, and he is able to hear her very effectively. He prefers the 50/50 mixing ratio in this quiet type of setting with multiple

6 150 Effects of Accessory-Mixing Ratio on Performance with Personal FM and Cochlear Implants signals of interest because he can also hear other people in the class as they comment on the discussion. He also uses this program in quiet boardroom -type meetings. He places the SmartLink transmitter in omni-directional mode at the end of the table and is able to hear colleagues across the table, while also hearing people close to him with the speech-processor microphone at full sensitivity. Program 2: 30/70. He uses this program when he is in environments with soft to moderate noise. Program 3: Auxiliary Input Only (FM Only). He uses this program in situations with intense background noise. He was unable to understand speech adequately in these situations prior to use of the personal FM system. When he eats with his wife in noisy restaurants, she wears the transmitter on Zoom mode (directional mode). He reports that he is able to hear her very well. This program is also used in the car when riding with his wife. One thing to note in this case is the benefit he received from use of the SmartLink transmitter with the telephone. Subject AB also uses a hearing aid for the ear oppo - site his cochlear implant. He feels that his hearing is optimized when he is able to listen with both ears. Of course, this was a challenge for telephone use. After completion of the study, a personal FM system was dispensed for his hearing aid as well. He was then able to use his Bluetooth enabled cellular telephone to simultaneously direct the telephone signal to his cochlear implant and his hearing aid via the SmartLink. This solution has dramatically improved his ability to converse over the telephone. Cochlear Corporation Freedom MicroLink Study We are also in the process of completing a study on speech recognition of adults using the Cochlear Corporation Nucleus Freedom speech processor coupled to the Phonak Freedom MicroLink FM receiver (see Figure 4). For this study, speech recog nition in quiet, speech recognition in noise, and subjective benefits in the real world were evaluated at the two accessory- mixing ratios. These two ratios are commonly recommended for personal FM systems in clinical settings and include the 1:1 and the 3:1 mixing ratio. At this time, nine sub jects have participated in this study. Speech-recognition testing was conduc ted both with and without use of the FM system. We evaluated speech recognition in quiet at 50 dba SPL using full CNC word lists presented from 0 degrees in the hori zontal azimuth. Speech-recognition performance in noise was evaluated with the Bamford-Kowal-Bench Speechin-Noise (BKB-SIN) test, yielding a 50 % correct speech-in-noise threshold. The speech signal is presented from 0 degrees and the noise signal presented from 180 degrees in the horizontal azimuth. For all measures, the transmitter was positioned with the microphone located 6 inches from the loud speaker. For No FM conditions, the FM microphone was muted or deactivated. The Campus S transmitter was used for the booth testing portion of the study. Figure 4. Cochlear Corporation Freedom Processor with Phonak MicroLink Freedom FM receiver For the real-world component of the study, subjects used the Phonak Easylink transmitter. This portion of the study is designed similarly to the directional microphone research by Brian Walden and his colleagues at Walter Reed Army Medical Center (Surr et al, 2002). In the present study, subjects were counseled regarding the potential benefits of personal FM systems and how the system should be used in daily life. Participants were provided with two programs in their speech processor, one with a 1:1 mixing ratio and one with a 3:1 mixing ratio. The

7 Jace Wolfe & Erin C. Schafer 151 order of the programs was counterbalanced, and subjects were blinded to the difference between the programs. When using the FM system, they were asked to switch back and forth between the two programs and determine whether they had a preference for one program over the other. They were also asked to keep a journal of their experiences and record at least one entry per day. Examples of characteristics they were asked to describe include quiet or noisy situations, positioning of the FM system relative to the source, and signals of interest and their location. For each of the aforementioned situations, the subjects were asked to record their program preferences. The following case study is illustrative of the results obtained for the group of subjects. Table % Correct Speech-in-Noise Thresholds (db) of Subject CC. FM Off FM On at 1:1 FM On at 3: Table. 3 Percent-Correct Performance in Quiet of Subject CC. Audio-Mixing Ratio FM Off FM On 3:1 70 % 10 % 1:1 72 % 74 % Case Study: Subject CC, Cochlear Corporation Case Study Subject CC is a 58 year-old man who is retired, but volunteers four days a week in clinic settings. He has progressive macular degeneration and is very dependent upon his hearing. He is a satisfied and successful cochlear-implant user, but he does report continued difficulty in noisy situations. Speech-recognition results for subject CC are provided in Tables 2 and 3. Speech-recognition performance in quiet and in noise substantially improved with the personal FM system. It appears that the 3:1 mixing ratio provides better speech recognition in noise than the 1:1 mixing ratio. In contrast, he experiences greater difficulty with speech understanding at low presentation levels with the 3:1 mixing ratio relative to the 1:1 mixing ratio. This finding was consistent across subjects. Therefore, use of a mixing ratio that attenuates the signal from the speech processor may be expected to reduce audibility and speech understanding for signals at a distance and not directed to the FM microphone. This patient s experiences with the personal FM system in the real world were consistent with the improvement observed in the audiometric test booth. In his journal he described several situations where he heard better in noise when using the 3:1 mixing ratio. However, he preferred the 1:1 mixing ratio in quiet situations, especially when multiple signals of interest were present. The following are excerpts from his journal: In a noisy steakhouse with my wife She wore the SmartLink on Zoom setting. Noise was loud and located all around the restaurant. Program 1 (3:1 mixing ratio) was much better than program 2 (1:1). Understood 90 % with program #1 and maybe 70 % at best with program #2. Background noise was too loud in program #2. Program 2 (1:1 mixing ratio) is much better than program #1 in my living room. Program 1 is too soft. Hear 10 % less with program 1. Discussion Overall, use of personal FM systems improves speech recognition in noise and speech understanding at low-presentation levels for persons with cochlear implants. This statement is supported by

8 152 Effects of Accessory-Mixing Ratio on Performance with Personal FM and Cochlear Implants speech-recognition assessment in an audiometric test booth and field trials, with both showing significant improvement with FM use. Furthermore, the iconnect and the Freedom MicroLink both provide an easy and effective solution for wireless coupling of a personal FM receiver to a cochlear implant speech processor for both the audiologist and the patient. The results of these studies support the use of personal FM systems for children in educational and social settings and also for adults in a variety of listening situations. Speech recognition in noise was significantly better with use of the personal FM system at every mixing ratio evaluated in these studies (i.e., 30/70, 50/50, 3:1, and 1:1) relative to the no-fm condition. However, mixing ratios, that attenuate the signal from the speech-processor microphone, such as 30/70, 3:1, or FM only, possess the best potential to optimize performance in noise. In contrast, mixing ratios that attenuate speech-processor microphone (i.e., 30/70 or 3:1) resulted in considerable reductions in speech recognition for soft sounds not directed to the FM transmitter microphone. As such, these mixing ratios may result in deterioration of low-level sounds and environmental sounds originating from a distance. Because of potential reduction in access to incidental sounds, it is the authors opinion that these mixing ratios should be used with caution with children. Ideally, the mixing ratio should be adjusted dependent upon the acoustical characteristics of the environment. For example, in quiet situations, a mixing ratio that places equal emphasis on signals from the speechprocessor microphone and the FM system will allow the user optimal access to all signals in the environment. Conversely, in noisy situations, the user would benefit from attenuation of the speech-processor microphone and emphasis on the FM input. This is especially relevant when the signal of interest is primarily directed to the FM transmitter. Optimally, the magnitude of attenuation provided for signals from the speech-processor microphone should become greater as the noise level increases. This arrangement would provide consistent audibility of the FM signal. Cochlear-implant recipients may be fitted with multiple programs in their speech processor with each program possessing different mixing ratios for users in particular situations. Unfortunately, this solu - tion may not be feasible for children or adults with physical or cognitive disabilities. Therefore, cochlear implant manufacturers should consider developing a program that would adaptively vary the mixing ratio depending upon the acoustical characteristics of the environment. In noisy situations, with speech-like signals arriving from the FM system, attenuation could be automatically provided for the signal from the speech-processor microphone. In quiet situations, equal or greater emphasis could be provided to the signal from the speech-processor microphone. Clinical Recommendations The clinical implications of these studies can be summarized in the following bullet points: For children, the 50/50 or 1:1 mixing ratio is most appropriate because neither will sacrifice audibility for incidental sounds (especially soft speech and environmental sounds). 30/70 and 3:1 mixing ratios may prevent children from hearing important sounds that are not directed to the FM microphone. If background noise is the main culprit, then mixing ratios that result in a greater emphasis on the FM signal will optimize performance, especially when there is one signal of interest that is directed to the FM microphone. Adults and older children, who can switch between different programs, may benefit from having multiple programs with different mixing ratios for various situations. Implant manufacturers may want to consider automatic, adaptive-mixing ratios to provide the optimal signal for various listening situations.

9 Jace Wolfe & Erin C. Schafer 153 References Adams, J., Hasenstab, M., Pippin, G., & Sismanis, A. (2004). Telephone use and understanding in patients with cochlear implants. Ear, Nose, & Throat Journal, 83(2), Crandell, C., Holmes, A., Flexer, C., & Payne, M. (1998). Effects of soundfield FM amplification of the speech recognition of listeners with cochlear implants. Journal of Educational Audiology, 6, Firszt, J. B., Holden, L. K., Skinner, M. W., Tobey, E. A., Peterson, A., Gaggl, W., et al. (2004). Recognition of speech presented at soft to loud levels by adult cochlear implant recipients of three cochlear implant systems. Ear & Hearing, 25(4), Madell, J. (April, 2007). Developing a speech perception test protocol for children. Presentation at the 11 th International Conference on Cochlear Implants in Children, Charlotte, NC. Moog, J. S. & Geers A. E. (2003). Language skills of children with early cochlear implantation. Ear & Hearing, 41(1), Supplement, 46S 58S. Nelson P. B., Jin S. H., Carney A. E., & Nelson D. A. (2003). Understanding speech in modulated interference: Cochlear implant users and normal-hearing listeners. Journal of the Acoustical Society of America, 113(2), Nicholas, J. G. & Geers, A. E. (2006). Effects of early auditory experience on the spoken language of deaf children at 3 years of age. Ear & Hearing, 27(3), Robbins, A. M., Koch, D., Osberger, M. J., Zimmerman-Phillips, S., & Kishon-Rabin, L. (2004). Effect of age at cochlear implantation on auditory skill development in infants and toddlers. Archives of Otolaryngology, Head, and Neck Surgery, 130, Schafer, E. C. & Kleineck, M. P. (2008). Improvements in speech recognition using cochlear implants and three types of FM systems: A meta-analytic approach. Manuscript submitted for publication. Schafer, E. C. & Thibodeau, L. M. (2003). Speech recognition of children using cochlear implants and FM systems. Journal of Educational Audiology, 6, Schafer, E. C. & Thibodeau, L. M. (2004). Speech recognition abilities of adults using cochlear implants and FM systems. Journal of the American Academy Audiology, 15, Stickney, G. S., Zeng, F. G., Litovsky, R., & Assmann, P. F. (2004). Cochlear implant speech recognition with speech maskers. Journal of the Acoustical Society America, 116(2), Surr, R., Walden, B., Cord, M., & Olson, L. (2002). Influence of environmental factors on hearing aid microphone performance. Journal of the American Academy of Audiology, 13, Wolfe, J. (April, 2006). Clinical experiences with FM fitting and the iconnect TM. Presented at the Advanced Bionics Corporation Advanced Programming Workshop, Minneapolis, MN. Wolfe, J. & Schafer, E. C. (in press). Optimizing the benefit of Auria sound processors coupled to personal FM systems with iconnect TM adaptors. Journal of the American Academy of Audiology. Zeng, F. (2004). Trends in cochlear implants. Trends in Amplification, 8(1), 1 34.

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