Oticon Clinical Update

« JUNE 2006, NO. 1 »
Pediatric Update:
to pediatric amplification.
Eriksholm News:
A summary of results and implications
based on 50 people wearing experimental
fittings for 50 weeks.
Technology:
Helping blind people to see using technology founded upon cochlear implant
innovation.
Oticon Clinical Update
Interview:
Dr. Mark Ross reflects on his personal
experience with hearing aid, T-coil and FM
amplification and discusses issues relating
OTICON CLINICAL UPDATE
Oticon Clinical Update
Oticon Clinical Update
Oticon Clinical Update
for children.
Oticon Clinical Update
Datalogging to better understand the
benefits of advanced, automatic systems
« 2006 No. 1 »
What’s Inside
Interview with Mark Ross Ph.D. Dr. Mark Ross addresses his own
daily use of FM and T-coils, as well as offering his thoughts on pediatrics and the use of directional and noise reduction systems.
»4«
$1.8 Million Grant to Walter Reed Army Medical Center. The
Oticon Foundation awarded 1.8 million (US) dollars to Walter Reed
Army Medical Center to fund research relating to distortion secondary to sensorineural hearing loss.
»6«
50 “man years” of Listening. Eriksholm Research Center recently
reported the culmination of one of the largest hearing aid studies ever
completed.
»7«
Oticon Delta: Success with new users. Improved speech perception in noise, as well as qualitative and other subjective improvements have been experienced by new hearing aid users wearing Oticon’s Delta.
»8«
Datalogging: A tool to better understand the benefits of automatic
systems for children. Multiple benefits of datalogging are reported
based on the analysis of data from 25 children.
» 10 «
Noise Management: Differences between “noise management” and
“noise reduction” are explored. The rationale for counseling patients
using the preferred term are offered.
» 12 «
Components of the Process. The importance and benefits of recognizing and discussing the patient’s unique needs are reviewed.
» 13 «
Hearing Aid Fitting Case Study: Hearing aid fitting options for a 42
year old female with an asymmetric SNHL are explored.
» 14 «
« 2 update »
Emerging Science and Technology: Helping Blind People to See.
Many of the same technologies pioneered in cochlear implants have
been successfully applied to visual implants for blind patients.
» 16 «
Genie Tips and Tricks. Genie 7.0 helps the professional maximize
the hearing aid fitting process. Directionality and loudness concerns
are explored and additional insight is offered.
» 18 «
« 2006 No. 1 »
Dear Colleague
It is an honour to introduce the Oticon Clinical Update
The Oticon Clinical Update (OCU) is a quick read with
useful, pragmatic, timely and entertaining features.
The primary features of the OCU will rotate with
each edition to address the multitude of topics which
impact the hearing healthcare professional.
Mark will address new users and their initial experiences with Delta, the usefulness of Envirograms
with pediatric hearing aid fittings and the functionality and application of the newly updated Genie Fitting
Software.
The editors of the OCU are Douglas L. Beck Au.D.,
Mark C. Flynn Ph.D. and Donald J. Schum Ph.D.
Doug will present an interview with Mark Ross Ph.D.
and a discussion regarding the emerging science of
retinal prosthetics.
The OCU will regulary feature
special guest authors and interviewees who offer their insight on
related clinical, research and sientific topics.
In this inaugural issue, Don will
address speaking with patients
regarding noise reduction and
he’ll offer his thoughts on fitting
patients with asymmetric sensorineural hearing loss.
The OCU will regulary
feature
special
guest authors and in-
We are excited to present this first edition
of the Oticon Clincal Update to you, and
we hope you’ll find it enjoyable and useful. The second edition is scheduled for
autumn 2006.
terviewees who offer
Please feel free to contact us with your
suggestions and feedback.
their insight on related
Sincerely yours,
clinical, research and
Douglas L. Beck Au.D.
Mark C. Flynn Ph.D.
Donald J. Schum Ph.D.
scientific topics.
« update 3 »
Oticon’s development house in Denmark includes three fully equipped, modern and professional sound
studios offering great flexibility and effectiveness.
« 2006 No. 1 »
Mark Ross, Ph.D.
Interview
With Mark Ross, Ph.D.
Good Morning, Mark. Thanks for being the
first “interviewee” in the new Oticon Clinical Update.
...an individualized
I am honoured, Doug. It’s nice to work with
you, again, too.
rehabilitation program
Mark, regarding amplification, what key
concepts would you like professionals to
keep in mind?
or group-based aural
is always
Not to be critical, but there are a few. For example, hearing aids alone cannot resolve problems caused by hearing loss. However, hearing aids are the foundation upon
which the rest of the program is built. Hearing loss is best
addressed by the professional and the patient working
together. The individual needs of patients at work, home
and recreation need to be identified and managed through
appropriate amplification using hearing aids, assistive
listening systems and other helpful technologies. And, of
course, this means that an individualized or group-based
aural rehabilitation program is always a good idea.
« 4 update »
As professionals we haven’t always gotten the word out
that there’s more to the process than hearing aids. Some
clients/patients think once they get their hearing aids
“OK, I’m finished.” However, your point is well taken; although hearings aids are the foundation, they are not the
whole program.
Exactly. For example, I use my hearing aid T-Coils and
my FM all the time to make difficult listening situations better. As you know, I call my personal FM system
my “third ear.” I have a binaural profound hearing loss
and I use a neck loop with both T-Coils while using the
telephone and I do pretty well.
Mark, I wonder if you would comment on using advanced technologies when fitting children?
I think we all agree that we
need to identify and treat
a good idea...
children with hearing loss
as quickly as possible. Children treated earlier have the
best outcomes with respect to speech, language and
other measures, too, and children have different
auditory needs than adults. Because children are
learning speech and language, every sound is important. In fact, thanks to newborn hearing screenings,
children are sometimes fit with amplification at 2 and
3 months of age - and that’s fantastic. Of course we’re
all looking forward to paediatric outcome-based studies using advanced technology, but in the meantime, if
the technology is good and beneficial in adults, it may
be appropriate to offer it to children, too. The audiologist and the parents have to make the best possible
decisions for the child, based on the child’s specific
needs. For example, adaptive directionality may be appropriate for children because speech and noise are
dynamic and originate from multiple locations and
sources, often at the same time. I think it’s fair to say
that if adaptive directionality is beneficial for adults,
it’s likely good for children, too. But, of course, insofar
as children are concerned (unlike adults) the theoretical advantages have to be confi rmed through consistent and sensitive clinical observations.
What about noise reduction in paediatric fittings?
In general, noise reduction systems are probably a
good thing. We know they make it more comfortable
« 2006 No. 1 »
We can assure phone communication using
many systems; FM, T-Coils, Hearing Aids,
Neck Loops, Instant Messages, amplified
phones, TTY’s, the CapTel system, etc…
for adults wearing hearing aids to listen in noise, even
though there is no direct evidence confirming superior
speech perception scores. When noise reduction circuits fi rst became available, there was concern that
noise reduction potentially reduced speech sounds
while reducing noise, and that’s a reasonable concern,
as children need to hear all speech sounds.
Yes, that’s been an ongoing concern. Noise reduction
circuits for children must protect speech sounds. Fortunately, the latest generation of hearing aids with dedicated speech detectors protect critical speech components while attenuating background noise. Mark, can
you comment on your experience with dynamic feedback cancellation (DFC) and your thoughts regarding
DFC and paediatric fittings?
DFC allows me to successfully wear hearing aids. In
fact, last year (2005) I was considering a cochlear implant because I couldn’t get sufficient audibility out of
my power aids without acoustic feedback. Imagine if
a child experienced acoustic feedback every time he/
she moved their head in a certain way, or hugged their
mom or dad, or moved their jaw. Very quickly they
would learn to dislike the hearing aid, and so I am a
proponent of DFC.
I know you were an early proponent of FM systems, too.
Can you tell me your current view on FM systems?
Any other key concepts you’d like to mention?
There are a few other things for the professional to
keep in mind. Everyone needs to communicate using
the phone. We can assure phone communication using many systems; FM, T-Coils, Hearing Aids, Neck
Loops, Instant Messages, amplified phones, TTY’s, the
CapTel system, etc…whatever works for the individual
must be done. People also need access to their televisions via closed caption as well as via sound transmitted through FM, infrared and and induction loops. I
also encourage all hard-of-hearing people to attend a
short-term group aural rehabilitation (AR) program -after they acquire appropriate amplification -- to learn
about care and maintenance of their hearing aids and
other useful devices and communication strategies.
AR works in creating more satisfied patients, obtaining more referrals, decreasing returned hearing aids
and creates loyalty. Lastly, Smoke and Fire Alarm
detection systems must be available for hard of hearing and deaf people. All of the tools I mentioned are
available commercially, they make an enormous difference, and they impact the quality of lives of the
clients/patients.
Thanks for many contributions to our profession, and
to the clients/patients we serve.
Thanks Doug. It’s my pleasure.
« update 5 »
I was an early adapter regarding FM systems and I use
them quite a lot myself. We published a couple of studies in 1971 and 1973 on the classroom use of an FM
system and we showed that by using FM to improve
the signal-to-noise ratio, speech perception went up
dramatically. I believe it is very important to have FM
systems for children in schools, and very important
for adults as well, particularly when their hearing loss
progresses into the severe and profound range.
« 2006 No. 1 »
$1.8 Million Grant to Walter Reed
Army Medical Center
The Oticon Foundation has awarded a US $1.8 million,
three year grant to Walter Reed Army Medical Center (WRAMC) near Washington DC. The grant funds
a project designed to better understand distortions
caused by sensorineural hearing loss with the longterm goal of facilitating hearing aid signal processing
to counteract these distortions. The research will be
carried out by experienced auditory scientists from
Project aims to create basis for signal processing
to counteract distortions caused by sensorineural
hearing loss
several Walter Reed laboratories and the Veterans Administration research division in Portland, Oregon.
Brian Walden, Ph.D. is the administrative director for
the grant and serves as co-principal investigator along
with researchers Ken Grant, Ph.D., Van Summers, Ph.D.
and Marjorie Leek, Ph.D., and the Research Section of
the Army Audiology and Speech Center at WRAMC.
« 6 update »
Research has shown that the more normal a listener’s
suprathreshold auditory function is, the greater is the
likelihood of their success with hearing instruments.
To date, the only direct attempt to compensate for suprathreshold distortions which is in widespread use is
amplitude compression. Other common signal processing approaches, like directional microphones, attack
the communication problem by preventing some of the
input signal from arriving at the eardrum.
It is also known that individual variations in suprathreshold auditory function are very large. Therefore
the WRAMC research team will focus on characterizing suprathreshold auditory function on a person-byperson basis, as they are convinced that future signalprocessing solutions will have to be customized to
each listener’s particular idiosyncrasies of auditory
processing. Dr. Walden believes this work provides a
real opportunity to understand the distortions that are
introduced by hearing impairment in a way that will
allow something completely new to be done about it.
The research group will receive input from an advisory
board of scientists working on related problems, as well
as individual consultations with other laboratories.
About Walter Reed Army Medical Center
The Walter Reed Health Care System provides comprehensive health care for more
than 150,000 soldiers, other service members,
family members and retirees in the National
Capital Area. Its hub is Walter Reed Army
Medical Center, the clinical center of gravity
of American military medicine. The Walter
Reed Health Care System is also the Army’s
leading center of clinical research and innovation, attracting annual research support for such efforts as prostate disease research, coronary artery disease reversal, comprehensive breast care, therapy of
traumatic brain injury, amputee care and limb salvage,
advanced diabetes management, technical advances
in robotic surgery, nursing care delivery, evaluation of
balance disorders, telemedicine, treatment of chronic
viral hepatitis, and many other programs.
About The Oticon Foundation
As one of the world’s oldest foundations, the Oticon
Foundation sponsors social and educational programs,
publications, conferences, cultural activities and campaigns for researchers, hearing care professionals and
the general public. The Foundation’s statutes mandate
that proceeds be used to support the needs of hearingimpaired individuals as well as organizations that
serve people with hearing loss. The Oticon Foundation is the largest shareholder in William Demant
Holding (which owns the Oticon Company), with a
shareholding just below 60 percent. Income is derived
through this share ownership.
« 2006 No. 1 »
Fifty “man-years” of listening
News from Eriksholm
Graham Naylor Ph.D.
Research Director, Oticon A/S
Eriksholm Research Center, Denmark
auditory dynamic range and smaller differences in dynamic range between low and high frequencies, and
with more restricted auditory lifestyles.
In March 2006, two articles* appeared in the International Journal of Audiology. Both authored by Professor
Stuart Gatehouse (UK Medical Research Council’s
Institute of Hearing Research), Graham Naylor (Head
of Oticon Research at Eriksholm) and Claus Elberling
(Senior Scientist, Oticon A/S). These two articles represent the culmination of one of the largest hearing aid
studies ever carried out.
One key purpose of this study was to evaluate compression release-time. Previous research seemed to
provide confl icting evidence about whether fast or
slow-acting compression is best. We found that on average, slow-acting compression was a little better for
comfort, whereas fast-acting compression was a little
better for intelligibility. However, by looking beyond
averages to individual differences, and then coupling
Fifty hearing-aid users from Scotland
participated in the study. Each participant wore experimental hearing-aid fittings for 50 weeks. Every ten weeks they
completed questionnaires and objective
speech-in-noise measurements before
having their hearing aids re-programmed
with the next experimental prescription.
This research protocol kept two audiologists busy for 18 months!
Cognitive function may be just as important as
hearing thresholds in determining performance in
complex listening situations
The result was an enormous set of data allowing
comparison of the relative benefits of five different
prescription approaches. The emphasis was on contrasts between linear and non-linear amplification
and between different release-time configurations in
non-linear amplification. Just as important as the outcome measures were the fact that all subjects had been
through a series of measurements of ‘predictor variables,’ which we hoped might correlate with outcome
measures. Predictor variables included; standard
audiometric variables, psychoacoustic factors (such
as temporal and spectral resolution), cognitive function and ‘auditory lifestyle’ (listening conditions experienced in daily life).
These results are preliminary, but they clearly indicate
that to accomplish truly optimal fittings of advanced
hearing aids, we must look beyond average preferences
and audiograms.
Many of the results noted above have since been reconfi rmed at Eriksholm. In particular, we have found
that a person’s level of cognitive function may be just
as important as their hearing threshold in determining
their performance in complex listening situations.
*References:
Gatehouse S, Naylor G and Elberling C “Linear and non-linear hearing
aid fittings – 1. Patterns of benefit”, Int. J. Audiol., 45, pp 130-152, 2006.
Gatehouse S, Naylor G and Elberling C “Linear and non-linear hearing
aid fi ttings – 2. Patterns of candidature”, Int. J. Audiol., 45, pp 153-171,
2006.
« update 7 »
Some of the collected data support generally held
beliefs, while others do not. On average, non-linear
amplification provided better performance than linear, but a substantial minority of subjects (about 20%)
performed best with linear amplification (not due to
the volume control). Better performance with linear
fittings was associated with flatter audiograms, wider
them to the predictor variables, an interesting trend
was seen. People tended to do better with fast-acting
compression (relative to slow-acting) if they possessed
higher cognitive function and/or auditory lifestyles
with rapid variations in sound levels.
« 2006 No. 1 »
Oticon Delta:
Success with new users
Mark C. Flynn, PhD
Director of Product Definition
Oticon A/S, Denmark
Oticon Delta was designed specifically to meet the
needs of adults with mild-to-moderate high frequency
hearing loss. To facilitate this desire, Delta took the
novel approach to hearing instrument development
and design by ensuring that it met three predetermined
success criteria. These being;
1. Maximising speech understanding in noise, rather
than overall loudness compensation.
2. Excellent sound quality with no audible distortions
3. Great design and physical transparency.
The Study
Nine adults with acquired sensorineural hearing loss
(Figure 1) agreed to participate in the study. No participants had used hearing instruments previously. All
participants were fitted with Delta 8000 bilaterally in
prescribed settings. The Automatic Adaptation Manager was activated and by the completion of the study
all participants were in Adaptation Step 3.
-10
dB HL
-10
0
0
10
10
20
Speech
Spectrum
30
20
30
40
40
50
50
60
60
70
70
80
80
90
90
100
100
110
110
120
120
125
« 8 update »
dB HL
250
500
1000
2000
4000
8000 Hz
125
250
500
1000
2000
4000
8000 Hz
Figure 1. Audiograms from nine participants. Note the diversity of hearing loss as it relates to the fitting range of Delta.
« 2006 No. 1 »
first time users with a
hearing solution that
they can actually
appreciate...
Following a three-month
period of wearing Delta
binaurally, performance
was evaluated using both
subjective and objective
measures of benefit. Objective performance was
evaluated in a sound proof
laboratory using the Dantale-2 speech perception
test in background noise.
Figure 2 indicates the improved speech understanding achieved with Delta. It was pleasing to note that
the directional microphone technology developed for
Delta resulted in an impressive 3 dB of speech understanding benefit; a 3 dB improvement in S/N translates to an approximate 30% improvement in speech
understanding. It is also important to note that this 3
dB improvement was achieved with a fully open dome
fitting, as is standard for Delta for the hearing losses fit
in this study.
Summary
The current study summarises the
performance of a group of first time
users with Oticon Delta. All participants demonstrated improvements in
speech understanding in noise and
all subjects demonstrated qualitative
benefit in addition to their continued
use of amplification.
-10.00
-8.00
-6.00
-4.00
-2.00
0.00
Delta Surround
Delta Adaptive Directionality
Figure 2. Directional benefit obtained by first time users
of Oticon Delta.
Other digital (reference data)
Oticon Delta 8000
6
4
2
0
Clarity of Speech
Listening Comfort
Overall
Figure 3. Subjective ratings of performance benefit in terms of clarity of
speech, listening comfort and overall perceived benefit.
« update 9 »
Oticon Delta provides first time users
with a hearing solution that they can
actually appreciate and offers the po-
Score (x/10)
Examination of individual data revealed that all
participants obtained a significant benefit in speech
understanding. Subjective test scores are interesting
for first time users, as they typically view amplification
negatively as it may not deliver what was promised or
perceived. Figure 3 illustrates that very good scores
were recorded for speech understanding, listening comfort and
overall performance. Importantly,
when compared with reference data
10
for first time users of other digital
hearing instruments, the reported
benefit was significantly higher with
8
Delta than with other premium digital
instruments (p<.01).
tential that after a number of years of false starts we
may begin to provide suitable solutions for this population. Unlike previous attempts, Delta succeeds by
recognising that the needs of this population are categorically different from those with a more significant
hearing loss and therefore the fresh approach provided
by Delta is required.
SNR[dB]
Oticon Delta provides
« 2006 No. 1 »
Datalogging:
A tool to better understanding of the benefits of automatic systems for children
Overall Envirogram
Mark C. Flynn, PhD
Director of Product Definition
Oticon A/S, Denmark
The rapid development of digital hearing aids featuring advanced automatic systems (e.g. automatic directionality and/or noise reduction) there is some concern
about the benefits for children. For example, can the
audiologist be certain about the accuracy of the system
to cancel the unwanted noise signal while leaving the
speech signal intact?
Datalogging provides a solution to this issue, as the
performance of the hearing aid is recorded over time
and displayed later to the audiologist1. Information is provided regarding the use of the hearing aid
in terms of total hours and access to telecoil or FM
systems. Data regarding the use of automatic systems is available and the audiologist can be certain
that automatic systems were applied sparingly and
appropriately.
To better understand the operation of automatic systems for children, we evaluated the use of Oticon
Syncro with 25 children in middle school (ages: 9 –
15 years). For each child, an Envirogram was collected
and group data was averaged. An Envirogram is a level
histogram collected over time that allows graphical
representation of the action of the noise reduction and
directionality systems2.
40%
Noise Only
30%
Speech in Noise
20%
The overall Envirogram (Figure 1) illustrates the wide
range of sound levels that children are exposed to
during their day. This variability demonstrates the
necessity of multiple channel non-linear compression
systems for children. Compression ensures the softest sounds are amplified sufficiently to be within the
child’s dynamic range while controlling the amplification of loud sounds to avoid discomfort. Matching
a compression approach with amplification strategies
such as DSL v5.03 results in the best possible access to
the speech signal.
The Envirogram provides information about the action of the TriState Noise Reduction and Directionality systems. The TriState system is unique in that
it combines both speech (VoiceFinder4) and noise
detection systems. The benefit of this approach is
that the dedicated speech detector ensures that when
speech is present the noise reduction is shaped by the
Articulation Index so that little reduction is applied in
the important speech frequencies, thus ensuring that
speech understanding is never degraded. It should be
noted that noise reduction does not make noise inaudible, but rather reduces the impact of noise so that the
child’s daily listening effort is reduced.
The Envirogram demonstrates how salient speech
information is to the child, with 76% of the child’s
listening day spent listening to speech. Importantly,
for most of the day, the speech signal was provided in
clear listening situations, with speech in noise representing 10.5% of listening time and noise only occurring
20% of time. All of these occurrences were when the
listening situation was complex and allowed the signal
to be remapped at more appropriate levels for the child
ensuring greater listening ease in difficult listening
situations.
Speech
10%
Quiet
0%
« 10 update »
<40
40-50
50-60
60-70
70-80
>80
Figure 1. Envirogram data for 25 children showing the action
of the TriState Noise Reduction system across sound levels.
Similarly, the action of the multiband adaptive directionality system is instructive as to the use and benefits that directionality provides (Figure 2). In Oticon
hearing instruments, the directional decision making
is controlled by Artificial Intelligence technology5.
Artificial Intelligence (AI) makes real-time calculations of the Speech to Noise ratio (SpNR). Only when
« 2006 No. 1 »
...the use of datalogging
and the Envirogram
the SpNR can be
improved will
directionality be
implemented.
increase the certainty of
paediatric fittings.
For the children (Figure 2), directionality was implemented on average 22% of the time which is consistent with other independent evaluations of directional benefit in the real-world6. Importantly, for any
given sound level, the hearing instrument is capable
of being in either directional or surround mode. Directional benefit is therefore based on more than input level or the sound scene (e.g. speech in noise) but
within each and every complex listening situation
various microphone modes may provide benefit at any
given time. Through the analysis provided by AI, the
hearing instrument makes a decision based on actual
benefit rather than environmental sound scene. The
audiologist can then be certain that directionality
is implemented sparingly and only when it provides
quantifiable benefit.
40%
Full-Dir
30%
Split-Dir
20%
Surround
10%
0%
<40
40-50
50-60
60-70
70-80
>80
Figure 2. Envirogram data for 25 children showing the
action of the directionality system across sound levels.
Summary
Datalogging in hearing instruments provides many
benefits to the audiologist such as information about
amount of hearing aid and FM use per day. In addition
to this usage data the audiologist can make use of the
Envirogram to examine the performance and benefit
of the various automatic systems in the child’s hearing
instrument.
While there has been some concern about the implementation of advanced automatic systems for children,
the use of datalogging and the Envirogram increases
the certainty of paediatric fittings. Using these tools,
the audiologist can quickly evaluate whether automatic systems are enacted appropriately, the degree of
operation and the types of environments in which they
operate. The audiologist can verify advanced systems
are operating only when they provide a benefit and
only in the most difficult listening situations.
References
1. Flynn MC. Datalogging: A new paradigm in the hearing instrument
fitting process. The Hearing Review 2005;12(3):52-57.
2. Flynn MC. Envirograms: Bringing greater utility to datalogging. The
Hearing Review 2005;12(11):32-38.
3. Scollie S, Seewald R, Cornelisse L, Moodie S, Bagatto M, Laurnagaray D, et al. The Desired Sensation Level Multistage Input/Output
Algorithm. Trends in Amplification 2005;9(4):1-39.
4. Elberling C. About the VoiceFinder. News From Oticon: Audiological Research Documentation 2002;3:1-11.
5. Flynn MC. Maximizing the Voice-to-Noise ratio (VNR) via Voice Priority Processing. The Hearing Review 2004;11(4):54-59.
6. Walden BE, Surr RK, Cord MT, Dyrlund O. Predicting hearing aid
microphone preference in everyday listening. J Am Acad Audiol
2004;15(5):365-96.
« update 11 »
Unique to the Oticon Syncro and Safran hearing
instruments is the implementation of three microphone modes. Those being Surround, Split-directional and Full directional. Surround provides the full
omnidirectional response where signals from all
sides are equally audible. Surround is excellent for
quiet listening situations or when signals from behind the child are important (e.g. another child in
class asking a question). Split-directionality provides
directionality above 1000 Hz, leaving the signal below
1000 Hz in surround. Therefore, the child receives
the benefit of directionality for the higher frequency
speech sounds while the omni-directional signal
ensures environmental awareness. Full-directional,
which is only available at louder levels, provides directionality across the full bandwidth of the hearing
instrument. Datalogging demonstrates that for most
situations, in which directionality is preferred, Splitdirectional is more likely to be implemented. Thereby,
reducing any concerns regarding removing access to
important environmental sounds (e.g. warning sirens
or traffic).
« 2006 No. 1 »
Noise Management
Noise Management means noise is less overwhelming,
less loud, and noise management allows you to better
focus on the speech signal
Donald J. Schum Ph.D.
Vice President Audiology & Professional Relations
Oticon Inc.
Patients with sensorineural hearing loss have extreme
difficulties in noise. Therefore, many of these same patients are intrigued by the concept of noise reduction.
The most common misunderstanding held by patients
regarding noise reduction is that these systems remove
the noise while keeping the speech signal intact. Unfortunately, noise reduction systems do not work that
way, although they do provide important benefits.
The purpose of noise management is to make it easier
and more comfortable to be in noisy situations. Directional microphone systems also facilitate better understanding in noise.
Therefore, the professional can counsel that while using
noise management systems..... Noise won’t be as loud, it
will be less tiring and less overwhelming when listening to speech in noise, and noise management allows
you to better focus on what is being said.
In Oticon products we use the term “Noise Management” rather than “Noise Reduction” to help the patient
and their family have a more realistic understanding
and expectation from this advanced circuitry.
Noise Management
Makes listening more
comfortable
Reduces the level of
background noise
Reduces annoyance
and fattigue
Comfort in noise
We all know the feeling. The drone of a certain
noise can be incredibly irritating. And the longer it
lasts, the greater your mental fattigue.
Sure, sound can be enjoyable, even fun. But once
sound becomes noise pollution, it becomes tiring
and very uncomfortable.
« 12 update »
Safran effectively reduces and helps combat the
fattigue of unwanted noises. As a result, it extends
the amount of time you can enjoy sounds you want
to hear - and makes what youy want to hear sound
better.
Figure 1:
Description of the purpose of Noise Management from eCaps.
Figure 2: Description of the purpose of Noise Management
from the Safran consumer brochure
« 2006 No. 1 »
Components of the process:
Focusing on patient’s needs
Donald J. Schum Ph.D.
Vice President Audiology & Professional Relations
Oticon Inc.
and adjustments and follow-up, the true value of the
COSI emerges. The value of the COSI is not merely as a
bookkeeping tool. Rather, the value lies in the patient
seeing tangible evidence that the professional is treating the hearing aid fitting on a personal, individualized basis. The COSI strategy is designed to help create
a bond between the patient and professional, while
improving the patient’s personal “investment” in the
hearing aid fitting process.
In 1995, Oticon entered into an agreement with the
National Acoustics Laboratory (NAL) of Australia to
distribute printed and electronic versions of the Client
Oriented Scale of Improvement (COSI). At that time,
we recognized how the COSI helped the professional
focus the hearing aid fitting process on the expressed
needs of the patient. Although the COSI was not the
first tool to structure the hearing aid fitting process
around specific needs, it provided a simple, yet elegant
tool, for the professional, patient and family members
to agree on the agenda. Effective professionals have
always recognized the importance of discussing and
recognizing the patient’s specific listening needs.
In the example given in Figure 1, the needs are expressed in very specific terms. That is an important
part of the COSI strategy: focusing in on key, specific
situations in order to solve general problems that the
patient is experiencing. The patient is better able to
recognize and acknowledge the benefits of amplification when performance is evaluated in these same key,
specific situations.
When the patient and professional commit to the
agenda as recorded by the COSI, and when the COSI
becomes the centerpiece of their discussions about
product and feature selection, as well as programming
The COSI form is available in the Genie fitting software, with the goals also viewable in eCaps.
COSI - Client Orientated Scale of Improvement
1
Being able to understand my grandaughter’s voice on the phone
2
Being able to keep the TV at a volume that my husband is happy with
2
Being able to understand what store clerks are saying
r
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« update 13 »
Figure 1: The specific goals from a typical patient.
ffe
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Understanding my best friend at our favorite pizza place
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Final Ability
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Specific Needs
« 2006 No. 1 »
Case Study
Patient: G.J. 42 yr. old female
Many of the most important functions of the auditory
system are based on binaural processing. Our field has
a long history of emphasizing bilateral hearing aid fittings in order to capitalize on these natural abilities.
However, when the patient’s auditory disorder has different effects on the two ears, there may be times when
an alternative fitting approach makes sense.
Background & Presentation:
G.J. was diagnosed and has been medically treated for
Meniere’s disease for the past 18 months. She initially
presented with severe vertigo with hearing loss and
tinnitus in the left ear. Approximately 1 year ago, her
hearing thresholds declined in the right ear. Her vestibular symptoms have been under control for the past
-10
Her goal at this time
is to hear and understand, especially in the
work environment, as
« 14 update »
well as is possible.
Figure 1:
The audiogram for G.J.
6 months. Her hearing thresholds and word recognition scores have been stable for the past two months.
The patient delayed amplification until she was sure
the vestibular symptoms were under control. Now that
balance is no longer her primary concern, she is ready
for hearing aid amplification.
The patient owns a boutique-clothing store. Since the
onset of her Meniere’s disease she minimized her
personal contact with customers. Now that her balance
issues have abated, she desires a return to the more
satisfying part of the job, direct contact with customers. Hearing aid cost is not an issue for G.J. Her goal at
this time is to hear and understand, especially in the
work environment, as well as is possible.
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« 2006 No. 1 »
Question:
Based on the asymmetric thresholds and speech understanding, How should this fitting be approached?
100
dB
Pure tone
80
Answer:
Some clinicians may avoid the poorer ear entirely,
opting for a monaural or perhaps a Bi-CROS fitting.
Although one can make those arguments, we prefer
an alternative strategy (Note - There is no conclusive
test which determines if an ear can make use of acoustic amplification. Often, the best protocol is to fit the
ear and see if the patient achieves benefit). Although
the word recognition score in the poorer ear is significantly reduced, hearing remains and some amount of
suprathreshold processing ability is apparent.
Althoug it is typical to fit bilateral hearing loss with
binaural amplification, there are times when the hearing aid fitting process may be better served by fitting
one ear at a time. Therefore, one strategy is to treat this
case as two monaural fittings.
Given the asymmetry, one can assume if the hearing
remains stable, the patient will primarily rely on her
right ear. Assuming that’s true, the right ear fitting
must be as effective as possible. Once a maximal right
ear fitting has been attained, the left ear can be fitted
to see if it adds to the overall auditory performance of
the patient.
Fitting the left ear may prove useful, but it is unlikely to
be the dominant ear for the patient. Obtaining loudness
balance or similar sound quality goals will probably
not be relevant in a case like this. Rather, the goal may
be to achieve a solution in which the right ear is fit
optimally while the left ear provides additional assistance without competing with or distracting from the
right. Further, the prescribed gain values for the left
ear may not be relevant as full restoration (based on
the threshold hearing loss in the left ear) may compete
with or reduce the word recognition of the right ear.
Target_50
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50
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125
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1000
2000
4000
8000 Hz
Figure 2: The prescribed (dotted line) and use
(solid line) insertion gain for the Syncro Power
BTE on the left ear of G.J.
threshold hearing loss, however, it was assumed the
full power of Sumo DM would not be needed given
the etiology, and the philosophical approach that the
left was the “secondary” ear. The patient went through
three follow-up sessions to fi ne-tune the left hearing
aid.
The hearing aid on the right ear has been worn on settings approximating the Voice Aligned Compression
prescription. As indicated in figure one, the patient has
been using the Syncro Power at settings with between
5 and 10 dB less than the prescribed gain on the left.
G.J. reports a clear but unspecific advantage for using
both hearing aids, as compared to just using the right.
She uses both devices while at work, although at home
she will occasionally use just the right device. The hearing aid fitting has been stable for the past four months.
Conclusion:
Significant asymmetrical SNHL may be seen as two
different fittings, with a dominant ear and a secondary
ear. Achieving the best possible fitting on the dominant ear should occur first, with intentional and cautious addition of the secondary ear, in a step-wise and
evaluative manner.
« update 15 »
In this case, the professional started with a Syncro
Power BTE in the right ear. The Power device was
not required based on current thresholds (see audiogram), however, extra gain and output may be needed
if the hearing thresholds drop. After two months of
adjustments and adaptation, the hearing care professional added another Syncro Power BTE on the left.
The Sumo DM was considered based on the left ear’s
60
« 2006 No. 1 »
Emerging science & technology
Helping blind people to see
...the digital visual image is
processed and sent to the
electrode array, which has
been surgically placed on
the retina…
While using the device, blind
patients were able to see
shapes and images.
Douglas L. Beck Au.D.
Director of Professional Relations
Oticon Inc.
The illustration above shows the camera within the eyeglass lens,
wireless transmitter on eyeglass frame, implanted receiver, and the
implant on the retina. Illustration courtesy of Doheny Eye Institute/
USC, Los Angeles, California.
Audiologists are familiar with how cochlear implants
help people with severe and profound sensorineural
hearing loss (SNHL) regain the perception of speech.
However, many audiologists are surprised to learn
similar technologies have been applied to help blind
people see.
« 16 update »
When blindness is caused by retinal degenerative processes such as retinitis pigmentosa (RP) and macular
degeneration, as is the case for more than three million people in the western world , some of these people
may benefit from advanced retinal prosthetics.
Second Sight® Medical Products, Inc. (founded 1998,
located in Sylmar, California, USA) pioneered the
development and application of many of these technologies through their sister company, Advanced Bionics,
a cochlear implant manufacturer and part of Boston
Scientific Group. Significant pioneering work on this
project was initiated by Dr. Mark Humayun at the
University of Southern California (USC). These groups
and individuals are working with government and
university partners to further this work.
The visual input is gathered through sophisticated external hardware, including a miniature digital movie
camera mounted within a pair of glasses. The image is
processed and sent to the electrode array. The retinal
prosthetic electrode array is surgically placed on the
retina where neural fibers are physically contacted,
stimulated, and their bioelectric signal is transmitted
along the optic nerve. Future retinal electrode arrays
« 2006 No. 1 »
will be hermetically sealed and protected using an
ultrananocrystalline diamond (UNCD) film, which is
safe, long lasting, electrically insulating and extraordinarily tough. The diamond grains within the film
are five millionths of a millimeter across.
Even with the early 16-electrode array, blind subjects
were able to see different shapes and images and were
able to tell the difference between a cup, a plate and a
spoon, and they could identify large letters.
The visual implant is still in FDA trials with six
patients implanted to date. The oldest implant was
implanted more than four years ago and is still being
used daily by the patient. A second-generation device
is planned to be tested in patients soon. These technologies provide exciting opportunities for scientific
and clinical advances, and like cochlear implants, the
opportunity to enhance the quality of life for many
people is indeed exciting.
The photograph above shows the relative size of the
early 16-electrode array as compared to the human
eye. Photograph courtesy of Second Sight Medical
Products.
The illustration above shows the location of an electrode
array on the retina. Illustration courtesy of
Doheny Eye Institute/USC, Los Angeles, California.
For additional information, please contact:
Robert Greenberg M.D., Ph.D.,
President and CEO of Second Sight®.
Second Sight Medical Products Inc.,
« update 17 »
Although the device pictured above is an early array
with 16 electrodes, electrode arrays under development contain more then ten times that number. The
exact “ideal number” of electrodes is not yet known,
but as is true with cochlear implants, successful
transmission of sensory information (auditory and/or
visual) is far more complex than might be reflected
by a single number quantifying the number of electrodes. Each unique patient, their particular situation
and their ability contributes to their candidacy for the
visual implant, and eventual outcome.
« 2006 No. 1 »
Genie
Tips and Tricks
Mark C. Flynn, PhD
Director of Product Definition
Oticon A/S, Denmark
The fitting of adults and children with a severe or
profound hearing impairment provides a number of
challenges to the audiologist. Two of these challenges
revolve around how best to match the loudness expectations of the client and also the appropriateness
of directional technology for this population. We
will address these two issues through the use of the
Overall Loudness Trimmer in SumoDM and the directionality options available in the Oticon Syncro and
Safran hearing instruments. All of these solutions are
available in Genie 7.0.
Overall Loudness Trimmer in SumoDM
Loudness is a concern for people with severe and
profound hearing loss. Some people note their hearing
aids are too loud, others may say too soft. Often, the
fi rst fine-tuning action is to increase or decrease gain.
Unfortunately, in Super Power instruments, the ability to increase or decrease gain is often constrained by
compression limits, feedback limits, and dead regions.
« 18 update »
To address these issues, we incorporated an Overall
Loudness Trimmer (OLT) in Sumo DM. The OLT adjusts loudness across all programs by changing the gain
and MPO while preserving unique loudness strategy of
each Identity. When the OLT is adjusted, gain and MPO
change while maintaining compression and audibility
desires for each Identity.
The Overall Loudness Trimmer acts differently than
the ‘All’ button on the trimmer panel. The ‘All’ trimmer
adjusts gain for the specific program (unless multiple
programs are linked on the tool bar). Conversely, for
the OLT, gain and MPO are adjusted while compression
ratios are maintained across rationales or identities.
Importantly, changes are applied automatically across
all programs as loudness is considered to be a global
issue for this population. Importantly, OLT is fully reversible. If the adjustment is too much, you can easily
reverse the decision and return to the previous setting.
Genie 7.0 fitting screen highlighting the Overall
Loudness Trimmer (OLT) for Sumo DM.
Allowing more directional benefit for people with a
severe hearing loss.
Directional microphones provide the only proven
method for better speech understanding in noise.
For people with a severe hearing loss, two additional
issues should be considered
1. Directional roll-off.
One of the problems with directionality is the natural
microphone roll-off. For people with a mild to moderate low frequency hearing loss, the easy solution is
to automatically compensate for this roll-off with increased gain. Unfortunately, for people with a severe
hearing loss, there may be insufficient reserve gain
in the hearing instrument to replace this lost gain. In
this situation, a loss of audibility occurs in the low frequencies, which is exactly where we wish to preserve
audibility for someone with a severe hearing loss.
Therefore, the patient may complain that when the
hearing aid switches to directional mode it suddenly
becomes soft or their speech understanding decreases.
« 2006 No. 1 »
2. Activeness of the automatic system.
When a hearing aid switches between omni and directional microphones modes an audible ‘shift’ may be
heard, this ‘shift’ is more salient across the low frequencies. For someone with a severe hearing loss they
may perceive this as increased distortion and not appreciate the effect on sound quality.
The Split-directionality mode in Oticon Safran and
Syncro allows a solution to this problem. When fitting a
severe hearing loss, Genie will configure the automatic
directionality in Program 1 to be Dual mode rather
than Tri-mode. Dual mode refers to the fact that the
full-directional mode is not available. Directionality
will therefore switch between the Surround and Split
Directional modes only.
Directional microphones provide significant
benefit to hearing impaired people in terms
of providing a proven mechanism for better
speech understanding in noise.
As Split-directional processes sound up to 1000 Hz in
omnidirectional mode, directional roll-off is not an issue. Similarly, the restriction of directionality to above
1000 Hz results in a dramatic reduction in the perceived
artefacts of when a directional system shifts from omni
into full-directional mode.
Changing te directionality mode for each program
is conducted using the directionality controls in the
Expanded Panel.
2. Offer a fixed directional program. Leave Program 1
in dual-mode, but set-up Program 2 as Full directional.
When the patient switches from P1 to P2 the hearing
aid will be in Full directional providing the greatest
directional benefit and the multiband adaptive directionality will simultaneously track and cancel up to
four separate noise sources.
When used with suitable patients, both of these solutions will allow the patient to experience greater
directional benefit and better speech understanding
in noise.
Although the above solution works for most patients,
some prefer greater directional benefit in more difficult
listening situations. In these situations there are two
additional alternatives.
« update 19 »
1. Rather than changing Identity, change directional mode
from dual-mode to tri-mode, allowing the Full directional mode thereby providing potentially more speech intelligibility in the most challenging listening situations.
Oticon A/S
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# 03-19/20
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