Slide 1 - Country Selector Phonak - life is on

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					Keeping up with the Jones’

    The changing criteria for hearing aid
Doesn’t it make you feel all
warm and SNUGGIE?
•   We know that 95% of those with SNHL
    can be helped with digital hearing aids *

•   90% of hearing aids in use are digital *

•   Directional mics can improve
    understanding in noise *

•   9 out of 10 hearing aid users report
    improved quality of life *

•   We also can confidently select the
    appropriate amplification for our patients
    based on audiometrics, lifestyle and needs

*Better Hearing Institute
Mild to Moderately-
Severe SNHL

  What would you
  select for this loss?
Mild to Moderately-
Severe SNHL

Now what would you do?
•47 yom
•Wants wireless
•Hands free
•Smallest available
•High tech
Moderate to severe
to profound SNHL
Moderate to severe
to profound SNHL

•68 yof
•Needs to hear better
At dining room table
Normal to mild high
frequency HL
What if you knew
• This same patient cannot focus to understand
  conversations in a crowded bar restaurant?

• Misses a lot of her manager’s instructions at big
  group meetings when he is at the front of the

• Can hear but not understand when her daughter
  whispers to her?
Even with a mild
hearing loss…
• May cause you to miss 25-40% of the speech
• Reduced clarity since the brain is receiving some
  sounds but not all of the information
• Problems understanding someone farther away
  than a normal distance for conversation
   – Or even up close if the background
     environment is noisy
• Weak voices are also difficult to understand for
  people with mild hearing losses.
Oh, the possibilities!

• And so it seems, the criteria for candidacy based on
  audiogram has changed drastically!

• Why is this so exciting to our field? We can now address
  needs that could previously not be met:
   – Mild high-frequency loss, with subjective complaints
   – Mild high-frequency loss presenting with tinnitus
   – Normal to mild SNHL presenting with Auditory
      • isense, open fit
   – Assymetry with normal ear
      • Alternatives to CROS
Evidence Based
• Evidence does not yet exist to support all the management
  decisions that an audiologist must make upon identifying
  minimal or mild bilateral hearing loss or unilateral hearing

• McKay S, Gravel JS, Tharpe AM. Amplification
  considerations for children with minimal or mild bilateral
  hearing loss and unilateral hearing loss. Trends Amplif.
  2008 Mar;12(1):43-54. Review.
Fitting a mild high
frequency hearing loss
As a profession, we tended to ―shy-away‖ from fitting this
  degree of hearing loss; WHY?

   – Concerned about over amplifying
   – Nothing available—ITE would provide the least amount
     of gain, however add 20dB+-- primarily related to the
     shell, not whats inside
      • If you open up for comfort…there is risk for feedback!
   – Don’t need a hearing aid for their loss and associated
   – Will they hear the circuitry?
Concerns about

• Now that WDRC is possible, there is less worry
  for over amplifying with a mild loss, as soft
  sounds will be made audible and loud will be
  made tolerable. However, there is something to
  be said for giving more gain than needed that
  can add to the annoyance factor of wearing
  hearing aids—especially in the lows where there
  is already a tendency to feel ―plugged up‖ for
  those with even moderate levels of SNHL.
The Good Ol’ OE

• Enhanced SPL of signal is trapped in the residual cavity of
  the ear canal, which makes its way to the inner ear via
  bone conduction

• von Bekesy indirectly talked about the hearing aid OE in
  his 1960 book, Experiments in Hearing, where he states,
  ―For maximally useful hearing, it is important to reduce not
  only the sounds of vocalization but also noises produced by
  chewing, swallowing, and the like. Even walking produces
  vibrations of the body that can be heard if the auditory
  meatus is closed...‖
Lybarger (1980) – effects of SAV
vents on low-frequency response
Occluded Response

Varies based on vent size:

  – Average OE is 12-16dB in range of 200-1000

  – Range from 5-8dB, up to 25-30dB
Open fits have changed our
field more than we realize.
• Not only are they able to address hearing losses and
  needs we previously had no options for such as the case
  with a mild hi-Hz loss….

They have also:
• Forced the industry to improve hearing aid technology in
  order to meet the demanding needs of an open fitting

• Allow for easy access with same day fits
   – Benefits and drawbacks of demo-ing

• Impacted our numbers by changing purchasing trends
   – Average age of first-time user is 8 years younger*
   – BTE sales are on the rise, while custom product sales
     have decreased
What features have digital
hearing aids allowed?

• Directional microphones

• Noise canceling

• Improved feedback management

• Automatic switching
Do your patients report lack of
satisfaction with hearing aid use in
one of the following listening
• Small Groups

• Large Groups

• Places of Worship

• Watching TV

• In a Restaurant

• Riding in a Car

• In noisy situations
Directional hearing
• Improve the signal-to-noise-ratio (SNR) of
  speech occurring in a noisy background.

• Directional microphones are the only "hearing aid
  option" proven to improve speech understanding
  in noise.

• Other technologies (FM systems, direct audio
  input, assistive listening devices, etc.) can
  improve the SNR further.
Performance in noise with slim
tubes–omni versus digital
             Speech recognition in noise
                                                 •Phonak in-house study

                                                 •Average SRT in noise for
 SNR in dB

                                                 20 subjects with sloping
                                                 High-frequency SNHL

             -5   Decreasedperformance in
                  Improved performance in
             -6   dSZ
                  Unaided   omni    microSavia
Valente, M. and Mispagel, K. Unaided and Aided
performance with a directional open fit hearing aid.
International Journal of Audiology. Volume 47, Number 6,
June 2008 , pp. 329-336(8)

   • 26 new-users
   • Fitted bilaterally
   • After 4 weeks collected objective & subjective measurements
   • Procedure:
      – Differences in performance between unaided and aided, and
         omni and directional were assessed
      – Measured RTS using HINT
      – HINT presented at 0º azimuth, with restaurant noise
         constant at 65dBA presented via 8 loudspeakers 45 degrees
      – Measured subjective report via APHAB
   • Results:
      – Significant differences in RTS b/w directional and omni, and
         directional and unaided—suggests a patient would require
         directional mics in order to perform significantly better than
Digital Noise

• Benefit: comfort, ease of listening for low level
  ambient noises

• Work well in steady-state noise (car, fan,..)

• Minimal improvement in speech intelligibility
Digital Noise Reduction

Mueller, G., Weber, J., Hornsby, B. The Effects of Digital Noise
  Reduction on the Acceptance of Background Noise. Trends
  in Amplification, Vol 10, No.2, 83-93 (2006).
• 22 adults fit with 16-ch WDRC instruments with DNR
• Collected data on speech intelligibility (HINT) and
  acceptable noise level (ANL) with DNR on and DNR off
• Significant improvement for the ANL with DNR on, no
  significant improvement in HINT performance
• Suggests improved ease of listening for speech-in-noise

• Improved feedback cancellation systems

• Allow for high-frequency gain to be preserved or
  increased when vent size is increased in an effort
  to minimize occlusion

• Practical limitation in the range of 30dB max
  stable high-Hz gain for unoccluded earmolds used
  with open fit devices
Automatic operation
within hearing devices
• In quiet situations a directional mic has the disadvantage
  that sounds from behind are not heard as easily as sounds
  from the front.
• For hearing aid users to gain the most benefit from a
  conventional directional mics they must be able to correctly
  identify appropriate listening situations.
• The responsibility for manually switching between omni an
  directional in a hearing aid to suit listening environments
  requires not just physical skills from cognitive ones as well.
• Automatic operation of directional mics eliminate the need
  for manual switching
Open fit programming for
• Ensure kneepoints are high in low-frequencies for comfort;
  while keeping them low in the high-frequencies for clarity
• Increase mid-level gain overall
• Engage digital noise reduction in quiet setting for annoying
  ambient noises such as AC vent or computer running
• Present background noise behind patient, demonstrate
  differences between omni and directional settings by
  switching between the 2 in the software, this achieves 2
   – They hear the difference and improvement with SIN
   – They learn the hearing aid will perform this switch
                   Sergei Kochkin, Ph.D.

Thin Tube Mini-BTE Survey
                   September 11, 2006
 Likelihood of purchasing
 hearing aid in absence of thin
 tube Mini-BTE

• 22% would not have purchased anything

• Would have been fit instead with:
  –   BTE (12%)
  –   Mini-BTE (14%)
  –   ITE (7%)
  –   ITC/CIC (46%)
Does the thin tube BTE product result in
more people seeking a hearing solution?

 • The evidence in favor of more people seeking a
   hearing solution due to the availability of the
   thin-tube BTE;
   – Lower age of new users by 9 years
   – Increased new user rate by 29% points
   – 1 in 5 consumers are reported to have rejected all other
     hearing aid styles in the absence of the thin-tube BTE.

• The appeal of the product is primarily due to
  improvements in occlusion, sound quality, fit
  and comfort and perceptions of benefit.

• In MarkeTrak VIII we will use a nationally
  representative sample of hearing aid
  consumers to confirm that:
  – more people seek a hearing solution if a thin-tube BTE is
  – that satisfaction increases with the use of this product
Mild Hearing loss
presenting with Tinnitus
• Clinical evidence shows that the use of hearing aids in
  tinnitus patients provides two benefits:
    – It makes the patient less aware of the tinnitus
    – It improves communication by reducing the annoying
      sensation that sounds and voices are masked by the
• Out-dated alternatives:
    – Sound machines-would need to carry around, so could
      become extremely cumbersome and only offer constant
      reminder of reason for need
M I Trotter and I Donaldson (2008). Hearing aids and tinnitus
  therapy: a 25-year experience. The Journal of Laryngology
  & Otology, 122 , pp 1052-1056
Del Bol, L & Ambrosetti, U. 2007. Hearing Aids for the
  Treatment of Tinnitus. Prog Brain Research. 166:341-5.
Normal to mild SNHL with
Auditory Processing Disorders

• The use of mild-gain, open-ear fitting hearing
  aids with a directional microphone and noise
  reduction algorithm may be attempted on some
  children with APD on a trial basis.
Case Studies
Mild high-frequency
hearing loss
• 60 yof
• Social worker
• Known mild high-frequency hearing loss, was tested 5
  years ago
• c/o difficulty communicating with girlfriends at get-
  togethers, at work in the courtroom, and when out at
• Husband is insistent she do something!
• She chose micro Exelia Art, and is doing well with reports of
  natural sound quality and improved understanding at wine
Asymmetry with
normal ear
• 38 yof
• Left ear: profound SNHL; Right ear: normal HL
• c/o difficulty focusing in a group at work, understanding
  partner at a bar/restaurant
• Did not like the look of the CROSLink, although she did
  appreciate the sound quality
• Alternative options:
   – Micro fitting on good ear
   – Isense with Smartlink transmitter for work and socializing
   – Naida on corner audio ear

• She chose the versata micro for her right ear, and reports
  tremendous improvement at work and when socializing.

• Now we can address the needs of the patient with mild hi-
  Hz SNHL suffering from difficulty hearing in noise by fitting
  with an open-fit device. This approach achieves many tasks
  at once!
• Specifically:
  1. Applying gain only where needed

  2. Applying features to improve understanding in noise and
     reduce feedback

  3. Reduces occlusion effect

  4. Instant fit!

• Fabry, D. May 2006. Facts vs. Myths: The skinny on slim-
  tube open fittings. The Hearing Review. 20-26.
• Mueller, G., Weber, J., Hornsby, B. 2006. The Effects of
  Digital Noise Reduction on the Acceptance of Background
  Noise. Trends in Amplification, Vol 10, No.2, 83-93 .
• Mueller, G. & Ricketts, T. November 2006. Open-canal
  fittings: Ten take home tips. The Hearing Journal. 24-39.
• Sandin, R. Textbook of hearing aid amplification,
• Valente, M. and Mispagel, K. June 2008. Unaided and Aided
  performance with a directional open fit hearing aid.
  International Journal of Audiology. Volume 47, Number 6,