I Didn’t Think That Had Anything To Do With Hearing…


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The other day I was talking to a friend who heard another person claim that I was a snob.  Conversation went something like this:

“Hey Pete, how’s it going”

Good, thanks, and you?

“Fine.  Hey, I bumped into someone the other day that knows you.  Funny thing she said that you were stuck up.”

Really, me? Stuck up??  A snob??  Why did she say that?

“Well, you walked by her the other day.  She said “Hi!”, but you just kept on walking on by.  Didn’t say a word to her.  She was really insulted”

Ahhh.  Could it be I just didn’t hear her?

This got me thinking about some of the funny or unusual things people with hearing loss sometimes do.  Most people would not connect that these behaviors are in fact related to our hearing loss.  Below is a list of some of the weird things people with hearing loss do, why we do it, and how we can make it better.

  1. Ignore People.  This is the example above.  Likely what happened to me is that the environment was noisy and I didn’t hear my name in all the racket.  Alternatively, the person could have been on my left side, which is my non-implanted ear.  I don’t hear much on that side even in quiet.  Or my batteries might have been dead.  Or maybe I just wanted to enjoy some peace and quiet and turned everything off.
    1. What to do about it:  First off, anyone that knows me, knows I am a very social person who never snub anyone.  Don’t take offense.  Try to get my attention visually or by tapping me on the shoulder.
  2. Close Proximity:  I do not do this too often, but I have seen others with hearing loss do this.  Since we can’t hear well, especially in background noise, we sometimes invade one’s social space try to get closer to the sound source, in this case the talker.
    1. What to do about it.  First off, this behavior is most likely exhibited by people who do not get amplification to assist with the hearing loss.  Get proper hearing aids and assistive listening technology for noise and you won’t have to do this anymore.
  3. Forgetting Names.  Actually, I am not sure I am forgetting people’s names, but rather I never heard it correctly in the first place.  The reason we have such a hard time with names is that there is no linguistic context to assist us.  For example, if some said “Please pass the salt and _______”, we know that the most likely final word is pepper.  But if someone says, “Hello my name is ______”, it could be anything.  Other times, I may have misheard the name and called someone the wrong name.  Eg, Norma instead of Nadia.  Hearing, learning, and remembering names is brutal for people with hearing loss.  
    1. What to do about it.  Well use a wireless system that gets rid of noise.  So in a noisy social situation, you have a better chance of hearing the name correctly.  I also use a buddy system with my wife who has normal hearing.  She fills me in with the names after the introductions.  I also have a cue for my wife when introducing her to someone whose name I ought to know.  For example, if I do not now the name of a person I really ought to know, I turn to my wife and say “Have you two met yet”.  She then promptly extends her hand and says “Hello my name is Kim”.  Other person reciprocates.  Problem solved.
  4. Knock Over Drinks at Dinner Table.  How on earth could this be related to hearing loss you ask?  Simple. I am busy listening to someone across the table.  It is a noisy restaurant.  So now I have to rely more on lipreading cues for communication.  I am staring at the person’s lips, reach for my beverage without properly looking, and then knock it over.
    1. What to do about it.  Don’t reach for the beverage while trying to listen.  Use a wireless system to get rid of noise.
  5. Bump Into Things/Scratch Up My Watch.  This is very similar to the above scenario.  If I am walking down the street with someone I am looking at their face face to lipread.  Since I am not paying attention to what’s in front of me, I bash my watch into walls and posts.  Sometimes I crash into people.
    1. What to do about it.  Buy cheap watches.  Apologize profusely to people I bump into.  And again, use a wireless system to get rid of the noise.
  6. Speaking Too Loud.  This one is more obvious.  Folks with hearing loss routinely have trouble monitoring their vocal intensity.  And it gets worse when in noisier environments where it is harder to hear oneself or others.
    1. What to do about it.  This behavior is also more typical in people who do not have personal hearing aids yet.  Get some!
  7. Speaking Too Soft.  This is more common for me.  I do this for a number of reasons.  First, I am scared that I am speaking too loud and so I overcompensate.  Secondly, I do have a tendency to overestimate the hearing capabilities of normal hearing people.  I think you can hear a whisper from across a room.
    1. What to do about it.  I carefully watch the faces of people I am speaking with.  If it looks like they are straining to hear me, I speak up.  If their eyes widen and they push back from the table, I am likely speaking too loud.  Lastly, I inform close friends and family to let me know if I am too loud or too soft.
  8. Inconsistent Hearing Behaviors.  Sometimes I hear you, sometimes I don’t. What’s up with that?  Guy must be faking it.  Actually, no.  The inconsistencies are likely due to varying noise levels.  Sure in a face to face situation in a quiet room I hear pretty well. BUT THE WORLD IS  REALLY NOISY PLACE.  I would say that I find myself in a ideal listening environment at best about 10% of the time.  The other 90% of the time, the noise levels severely impact my ability to communicate.
    1. What to do about it: This is why I have been using my wireless FM system so diligently.  I cannot imagine how I could function without this technology.

So there you have it.  Some weird behaviors that are in fact related to hearing.  I am sure there are other examples.  So please share your stories, I would love to hear about them.

How Do You Know You Need a Wireless Microphone?


In my last blog posting, I spoke about the technologies available to help you hear better in noise.  These included:

  1. Directional Microphones
  2. Fixed Gain Wireless Systems.
  3. Dynamic Wireless Systems. ZoomLink+ Transmitter

But how do you know what technology you need?  This is a very important question that needs to be answered right away before you decide what kind of hearing devices you wish to purchase.  Let’s say you need Dynamic Wireless system in addition to hearing aids.  If you have sufficient financial resources at your disposal, you may wish to purchase a premium hearing and a wireless system.  This is the best of all worlds.  But if you have limited resources, you may wish to spend less money on your hearing aids in order to have enough money left over for a wireless system.

It is also important to know this in order to have realistic expectations about your hearing instruments.  If your hearing loss requires that you use a wireless microphone system in order to hear in a noisy environment, you can do countless hours of hearing aid fine tuning with your Hearing Care Professional and you are still not going to hear better in noise.  Its simple physics: a Dynamic Wireless microphone placed in close proximity to a speaker’s mouth will always outperform a microphone at the ear level.

Ideally you will have answered this question early in your hearing device selection process.  Here’s how this question can be answered:

  1. Experience with Existing Hearing Devices.  If you already have hearing aids or a CI equipped with directional microphones and you are still struggling to hear better in a noisy environment, you will have answered your question about the need for a wireless system.
  2. Experience with a Bluetooth Wireless Microphone.  As I mentioned in my previous blog posting, a Bluetooth Wireless Microphone will provide better performance than a directional microphone on your hearing devices.  But if you are still struggling with the Bluetooth mic, there are still significant improvements that can be obtained with a Dynamic Wireless System.  The microphones cut noise better, and the dynamic nature of the system will reduce the amount of noise your hearing aid or CI microphones will pick up.
  3. Experience with a Fixed Gain Wireless System.  Similar to the above, if you already have tried a fixed gain system (Eg Phonak Campus, SmartLink SX, ZoomLink or EasyLink; Oticon Amigo, Comfort Audio Digisystem) and are still having trouble, then a Dynamic System will provide additional benefits particularly at noise levels at around 70 dB or greater.  This is about the level of a restaurant.
  4. Audiogram Approach.  Most people with moderate-severe hearing loss or greater will require more than a directional microphone on the hearing instruments.
  5. Direct Assessment of Hearing in Noise Abilities.  There are several tests that your Hearing Care Professional can perform to help determine right away what kind of technology you need.  The one I am most familiar with is the LiSN-S PGA test and as such I will highlight this test in the remainder of this blog posting.

LiSN-S PGA stands for Listening in Spatialized Noise.  Performed under headphones, a virtual 3D space is created with target sentences coming from the front and distracting sentences are coming from the left and the right.  The PGA stands Prescribed Gain Amplifier.  The stimuli are amplified according your hearing test results.  So it simulates the way you would hear in a noisy environment if you had hearing aids and an omni-directional microphone.

LISN-S PGA

LiSN-S PGA accurately measures your ability to understand speech in noise as if you were wearing hearing instruments (amplification), and by your performance on LiSN-S PGA with normative data stored in the software, LiSN-S PGA predicts accurately the your performance in noisy situations compared to normal hearing listeners of the same age, and if the predicted performance is not good, LiSN-S PGA gives you clear, individual, technology recommendations how to improve speech understanding in noise. So based on your responses to the sentences, you get an evidence based recommendation.

The test takes about 5 minutes to perform.  You will hear noise first coming into both ears.  It will seem like the noise is coming from the sides.  Then you will hear a sentence that sounds like it is coming from in front of you.  Your task is simply to repeat back the sentence.  Your Hearing Care Professional simply needs to click on how many words you repeated correctly.  The computer will then automatically make the next sentence softer or louder depending on how well you did.  The test stops when the software has sufficient results to make a recommendation for you.

Condition 1

Here is what the recommendations screen looks like:

recommendation

Personally I find it interesting that difficulty hearing in noise is one of the most common complaints that a person reports when getting a hearing test, yet most hearing care professionals never assess this.  Far too often we wait for a patient to fail with the hearing devices before we explore additional noise reduction technologies.  This is unacceptable.  Why frustrate people with hearing loss unnecessarily?

I know many Hearing Care Professionals are thinking, “Yes Peter, but many patients won’t use additional microphones, so I don’t bother introducing this technology”.  This thinking is also unacceptable.  You are making a pre-determination and denying people hearing loss technology that is critical to helping them function in our noisy world.   Our duty, as Hearing care Professionals is to help people with hearing loss make an informed decision.  Yes, some may reject such technologies initially, but it is still their right to be informed.

For more information about the LiSN-S PGA, click here.

For more information about the development of the LiSN-S PGA test click this link here.

Elephant Shoes or I Love You…The Good and Bad of Lipreading.


Lipreading, or speechreading is the process in which we try to understand speech by observing the movements of the face, lips, and tongue of a talker.   Note that I say we “try” to understand speech.  It is not possible to fully understand speech from visual cues alone.  Here’s why:

All speech sounds can by classified by three parameters (see chart below):  Place, manner, and voicing.  Place of articulation refers to where the sound is made.  For example, the sounds /p/, /b/, and /m/ are all referred to as bilabials since they are produced using both lips.  The sounds /f/ and /v/ are referred to as labiodentals since the lower lip is placed between the teeth.  There are a whole bunch of sounds that are produced at the alveolar ridge, which is the little shelf jest behind your two front teeth.  With these sounds, the tongue is placed on this ridge.   The remaining sounds are produced further back in the mouth and are pretty much invisible to the eye.  These include sounds such as /sh/, /ch/, /g/,  /k/, and /h/.

Bilabial Labiodental Interdental Alveolar Palatal Velar Glottal
Stops Voiced /b/ bet /d/ dent /g/ goat
Voicedless /p/ pet /t/ tent /k/ coat
Fricatives Voiced /v/ vet /th/ these /z/ zed /zh/ garage
Voicedless /f/ fed /th/ think /s/ sent /sh/ sheep /h/ hot
Affricates Voiced /j/ jeep
Voicedless /ch/ cheap
Nasals Voiced /m/ met /n/ net /ng/ bang
Liquids Voiced /l/ let /r/ reap
Glides Voiced /w/ wet /y/ yell

The other two parameters are manner and voicing.  Manner refers to the type of sound produced.  For example, fricatives sound like air rushing or hissing.  Stops or plosives sound like a burst of sound.  It is very hard to see the manner of a consonant.

Voicing refers to the use of our vocal folds when we make a sound.  Try this little experiment.  Place your hand on your throat and make the /f/ sound and then the /v/ sound.  Don’t say these letters, make the sound.  You will feel your vocal folds vibrating for the /v/ sound, but not the /f/ sound.  This is of course invisible to the eye; we cannot see vocal folds vibrating.

Now lets look again at the sounds /p/, /b/, and /m/.  All three of these sounds will look pretty much the same via lipreading.  However they certainly sound different and more importantly, they change the meaning of the word.  If I say “pat”, “bat”, and “mat”, one cannot see the difference between these words.

So the reason that communicating exclusively via lipreading is difficult is due to two main reasons.  First, many sounds are produced at the back of the mouth and are completely invisible.  Examples include /h/, /g/, /k/, /ng/.  Second, many sounds look exactly the same because they are produced at the same place in the mouth.  The  consonants /p/, /b/, /m/ are a good example of that.

But lipreading can still be useful as a supplement to hearing.  Numerous research studies over the years have confirmed this.  Most studies show that while the scores of most people on lipreading tasks is typically quite low, it makes a great supplement to the auditory channel such that auditory-visual speech perception (lipreading + hearing) is much greater that auditory only.  In fact, I recall reading a study examining auditory only, visual only, and auditory visual speech perception in older adults.  Even though these adults scored 0% on visual only speech perception, their auditory-visual speech perception score was still greater than auditory only.

While I consider myself a pretty good lipreader, I have made some amusing errors over the years.  Here are some examples of embarrassing mistakes I have made. First sentence is what was actually said, and the second is what I thought was said.  It may also reveal the workings of my twisted mind.

What Was Actually Said:  My teacher is so cool, she plays the guitar.

What I Thought:  My teacher is so cool, she pees in a jar.

 

What Was Actually Said:  I am going to design you a tattoo.

What I Thought:  I am dying to touch you.

 

What Was Actually Said:  There is some nice grass over there for your dog.

What I Thought:  There is some nice ass over there…

So here is my advice when it comes to lipreading:

  1. Use it as a supplement to your hearing.
  2. Hearing is still the most important sense we have for communication via speech.
  3. If your are finding that you need to lipread a lot in quiet, you should consider getting assessed for a cochlear implant.  Lipreading all day long is highly inaccurate and very tiring.
  4. If you find yourself lipreading a lot when in noise, consider getting a wireless microphone system such as an FM system to help improve the signal to noise ratio.  Or get out of the noise.
  5. Training to improve lipreading skills is debatable.  Instead, focus on creating favorable conditions for llipreading.  Tune in next time to a discussion on how to enhance the conditions for successful lipreading.

Things to be Thankful for…


In Canada, this is our Thanksgiving Weekend.  While the originally designed to give thanks for the harvest, we generally use this holiday to share a meal with friends and family and reflect on all things for which we are grateful.  For me, the following represents things for which I am most thankful. There is no particular rank order here…

 

  1. Cochlear Implant Technology.  This technology has dramatically changed my life in enormous ways.  Simply put, without it I could not function.  Communication would be almost impossible.  I probably would have embraced sign language to a greater degree, but I would be limited to communicating to a much smaller and limited set of people.  I would have completely lost my ability to enjoy music.  Do I wish for improvements from this technology?  Sure.  Music perception and hearing in noise and are still challenges, but I have developed some additional compensatory techniques.  Still, a day does not pass in which I remind myself how my different my life would be without the CI.
  2. Wireless Microphone Technology.  While the the cochlear implant implant is amazing, it is the synergy of the FM system in conjunction with the CI that provides me even greater capabilities.  Adding FM technology allows me to use my mobile phone via Bluetooth, hear in noisy cars, restaurants, and bars, enjoy social events more fully, and enhances my ability to hear and perform music.  I wish more CI users would realize how much more they could get out of life if only they added FM or other wireless microphones.
  3. Music.  Music brings light to my soul.  It always has the ability to brighten my darkest days.  I am so grateful that I can still not only enjoy listening to music, but to perform it as well.  It has not been easy to keep music a part of my life.  I needed to experiment with vibrating platforms, compressors, equalizers, FM systems, and soundboards to make it happen.  Lots of money and time has been spent on this.  But it can be done.
  4. Family.  I have a wonderful, intelligent and beautiful wife that puts up with my shenanigans.  And I have a handsome, brilliant, and kind hearted son who is so full of passion.  I love you both.
  5. Health.  A weird thing happened the other day.  My son’s friend was looking at some pictures of both my son and I from his early childhood.  The friend remarked that I look younger today the I did 10 years ago.  That was such a compliment!  Losing 40 pounds of excess weight and getting into better shape has had the effect of turning back the sands of time.  Next week I will be completing a half marathon, something I never dreamed I would be capable of doing.  I am so grateful that I am finally on the road to better life.  It feels great.

 

Happy Thanksgiving!

Top Ten Reasons Why I Need a Hearing Ear Dog


As many of you are aware, my sweet dear Hearing Ear Dog Amie passed away on June 13 of this year.  Initially, I did not even want to think about getting another dog.  As a family, we all needed time to grieve the loss of such a special friend.

Are we over the loss of Amie yet?  Absolutely not.  But I think I can now start to think about  getting another Hearing Ear Dog.  This is of course not about replacing Amie.  That is impossible.  But our hearts are certainly big enough to make room for a new dog to become part of our family.

One interesting thing that has happened to me over the few months is other people have also enquired as to whether I will get another hearing ear dog.  Interestingly, the question is not always posed the same.  In fact, they can be classified into three categories.

First, are the “Genuinely Curious”.  These people are truly just asking out of interest.  They do not hold any biases or preconceptions.  They are not fully aware of the impact of hearing loss in general, nor do they fully understand my particular details.  To these people, I do not mind explaining both my situation, the nature of deafness, and the role of hearing ear dogs.

The second group I call the  “Erroneously Positive”.  These people may make comments like “I really do not see you as deafened” or “You seem to be doing just fine”.  Generally, I do not sense any animosity or ill will.  Instead, I believe these people are actually complimenting me.  They judge my degree of disability (or rather lack of disability) on my functional abilities in a one on one conversation, rather than the results of my audiogram.  Interestingly, this flies in the face of the so-called ‘hearing aid effect” in which people with larger hearing aids are judged less positively than those with smaller devices.   These studies were done with photos.  I believe that showing static photos bears no relationship to the real world of communication.  Here I am with a cochlear implant, bigger than the biggest BTE hearing aid from 25 years ago, a hearing aid in the other ear and an FM system in my hand and yet folks don’t think I have that much of a hearing loss at all.  Its quite remarkable really.

The third and last group are what I call the “Ignorantly Hostile”.  Sadly there are quite a few of these people.  They make judgmental comments laced with suspicion and almost hostility.  They make comments like “Yeah, but you don’t really need a hearing ear dog…you just want a pet”.  Some comments are just ignorant, not so much hostile but annoying nonetheless.  Example “Now that you have your cochlear implant, you don’t need Amie anymore, right?”  I am not alone…I have read similar stories from other CI users.  For example, a CI user named Denise wrote “So? If you have a cochlear implant now, why do you need a dog? Didn’t that (as she gestured towards my CI and bling) fix you?”

One thing that many CI users would like others to know is that the cochlear implant is not a cure for deafness.  We have artificial battery operated ears that does not sound like normal hearing (See What Does a Cochlear Implant Sound Like).  It has an electronic microphone that does not have the same sensitivity as the normal ear.  Hearing aid and cochlear implant microphones work best in a 3-5 foot range.  Moreover, the CI or hearing aid does not have the same capacity to filter out noise like the normal cochlea.  Lastly, we cannot wear these devices 24-7.  When we sleep at night we are even more deaf than we were before we got our implants!

To illustrate the limitations of microphones, try this experiment.  Stand about 20 feet (6 meters) from another person.  Have a recording device in your hand.  Most mobile phones have a voice recorder.  Now have the other person speak to you and record their voice.  Did you hear and understand ok?  I am sure you did fine.  Now play it back the recorded version.  Listen to how thin it sounds and how much background noise there is.  Now do it again, but add some additional background noise from say a stereo or TV.  Listen again to how much harder it is to understand the recorded version.

Welcome to the world of people with hearing aids or CI’s.  This little experiment only shows the limitations of electronic microphones.  It does not even address the lack of noise filtering of our impaired auditory systems.

In short, here is tonight’s Top Ten List entitled “Reasons Why I Still Need a Hearing Ear Dog”

1. When I sleep at night, I take my CI off and I hear absolutely nothing.  I need to wake up to get to work in the morning and a regular alarm clock will not work.  Vibrating alarms are not bad…but read on.

2. Similarly, most fires occur at night when people are asleep.  Studies show that visual fire alarms do not work effectively in waking people up (see this article on Waking effectiveness of visual alerting systems ).  A hearing ear dog will physically wake me up.

3. I travel extensively for my work and I cannot take a suitcase full of technical devices with me everywhere I go.  I am not sure how I can hook up these devices to the main fire alarm of a hotel anyway.

4. I have had hotel staff march into my room while I was in my birthday suit.  I did not hear them knock.

5. Hearing aid and CI microphones are not as sensitive as natural hearing.  So I am hit and miss with sounds.  The hearing ear dog will ensure consistency.

6. Many times the sounds I need to hear (doorbell, phone, microwave etc) are not at an adequate signal to noise ratio for a person with hearing loss.  It is buried under noise making it impossible for our damaged cochlea to detect.

7. If I know someone is coming to my house and I am alone, I must sit and wait on the main floor in order to hear them knock or ring the doorbell.  I can’t reliably hear these sounds from another floor of the house.

8. I sleep better at night knowing someone is there listening for me.

9. Traveling is actually easier with a working dog, at least to the countries I go to.  It reminds airline staff I cannot hear the announcements to board so they come get me ahead of time for pre-boarding.

10.  Hearing ear dogs help to filter out the assholes of the world.  If you don’t like dogs, I won’t like you.  So I get to find out a serious flaw in someone’s personality a lot faster.

For more information on Hearing Ear Dogs see the links below:

Lions Foundation of Canada

Pacific Assistance Dogs Society

The Cochlear Implant Experience of Another Deafened Audiologist


I have a friend and colleague, Dr. Nashlea Brogan, with is also an audiologist with a profound hearing loss.  She received a Cochlear Implant on July 23rd of this year and was activated recently on August 23th.  We have been emailing back and forth a bit about how things were progressing for her.  I asked her if I could post these exchanges in my blog.  I think you will enjoy reading about her experience.  

A few background notes:

1. Nashlea received the Med-El Cochlear Implant. 

2. Nashlea was born with normal hearing.  She believes her hearing started to decrease in her teens.  She was tested at age 14 and by 18 years received her first set of hearing aids.  Since that time her hearing continued to progressively deteriorate such that she lost most of her hearing in her twenties and early thirties.  

2. Med-El, Cochlear, and Advanced Bionics all use different numbers of electrodes in their CI’s. So when Nashlea talks about the 13 electrodes, thats the number that Med-El uses.  My CI is from Cochlear Corporation and has 24 electrodes.  Note also that the length of the electrode arrays differ between the manufacturers.  There is on-going debate as to what the optimal length and optimal number of electrodes should be which I am not going to discuss here, but I just wanted you the reader to be aware of this.

June 17, 2012

Hello Peter,

Well, I have my big day for cochlear implant surgery on July 23 and activation on August 23rd in London. I was expecting the surgery to be in the 2013 winter but they called last week with an opening for this summer, eek!!!!

If you have any advice or recommendations I would truly appreciate it.  I have to continue managing my Hearing Centre’s during this time and do not know what to expect or how to even possibly plan. How long is recovery? Did you work between surgery and activation? After you were activated when did you return to work? Many people reported that they were exhausted in the first few months from sound? Did you travel during the initial months? What was work like when you returned? Sorry for all the questions, I am trying to leave the month after surgery and 2-3 months after activation as open as possible, but I am a planner. Is there anything you would have done differently?

Hi Nashlea.

I am very excited for you!

1. Recovery: varies greatly from person to person. I had my surgery on a Thursday. Went home next day Friday. Was back at work Monday. Others get really dizzy and need a week or two off.

2. Yes I worked between surgery and activation. I only took one day off.

3. I was not exhausted from sound. But I was impatient. You need to really chill out and wait. It takes months to get full benefit.

4. Read my blog!!!!

Aug. 10, 2012

Hello Peter,

Thanks for the reply and I really enjoyed your Blog both from the cochlear implant perspective and as an Audiologist.

I had my surgery and all went well, they made a full insertion through the entire cochlea with all 13 electrodes of the Med-El. I wasn’t really myself until 10 days after surgery, I had a lot of ear pain 5-6 days post surgery.   I am also living with my FM system, I never truly grasped how difficult having monaural hearing was.  My FM system, has made car trips, dining, work and any public situation manageable. I don’t know what I would have done without it. So, next the step is activation on August 23! Now I need to learn patience.

Thanks again

August 29, 2012

Hello Peter,

Activation a dream come true.

I had my cochlear implant activated last Thursday.  Now, I had prepared myself for a difficult time, I was scared from talking to other people and not being able to wear my hearing aid for three months in my other ear. I had advised my receptionist that I wouldn’t be able to see patients until I could understand some speech, I was terrified.

Today, I feel like I won the lottery of life!!!!! The audiologist first tested all 13 electrodes from 250Hz to 6000Hz and I could hear all of them. Once I was activated both the Audiologist and my husband sounded like daffy duck or mermaids!!! That sound lasted only a few hours, we went to a restaurant after my appointment and I could hear the waitress, the music, the other people talking. It has since gotten better hour by hour.

My biggest and most rewarding moment of all this was my children. For the first time, I heard all my 3 year old girls little words!!! She hasn’t stopped talking to me since. I can hear my nieces and friends children talking. When they say mommy to me from behind or another room I hear them. Not hearing children was the hardest part of having a hearing loss for me. I was happy going to work, I did public talks all over Sarnia, I travelled, went out, the hearing loss was more of an inconvenience for these things. But with children I felt isolated and dependent on other people to help me understand what my 3 year old niece was asking me, even my own daughter! I was nervous going to my sons mothers day’s tea in SK because of me not hearing him singing, or if his friend might ask me something with the other mothers looking on.

No sounds have been too loud, all the environmental sounds are exactly as a I remember them. A little history on me, I was born with normal hearing, they think it started to decrease in my teens, at age 14 I was tested but not enough loss for amplification and by 18 years I received my first hearing aids (I had normal hearing to 1500Hz at that time), I have lost most of my hearing in my twenties and early thirties.

I just never imagined this…..its so wonderful and to think its getting better!!! The one thing that i have never heard or read about CI’s is how separate every sound is. I always felt with hearing aids that all the sounds were meshed together, for example I could hear lots of noises in a car, it was loud and made speech hard to understand but the sounds were all blended in one big ball of background noise. Now, I can hear all the indicators, the sounds the buttons make when you press them, the tires hitting the road or cracks, and the acceleration of the motor every time the gas is pressed, and speech is separate not competing with the car sounds.

I haven’t felt any background noise since the moment of activation, in restaurants, cars, and the mall. I hear all the sounds of people walking, talking, machines, music but I wouldn’t describe them as background noise like a hearing aid!

I could type forever. I feel so happy, so full of energy, I don’t even want to take the implant off at night. What an amazing and incredible device!!! What sounds should I go listen to today, ha ha!!

Well Nashlea, thanks so much for allowing me to share your experiences.  I want the readers to know that everyone’s CI experience is unique.  I had no post-surgical ear pain or dizziness, yet Nashlea did.  On the other hand, I needed months to achieve the benefits from my CI that Nashlea received in only a few hours.  Patience is the key.

Details about Nashlea’s Audiology practice:

Bluewater Hearing Centre
316 George St.
Sarnia, ON
N7T 4P4 Canada
Phone: 519.344.8887
Fax: 519.344.4873email:info@bluewaterhearing.ca

What Do You Do When You Can’t Hear Anymore?


Here’s a simple question that seems to confound many hearing health care professionals.  What do you do with a patient who can’t hear anymore?

I guess we should back up a bit a define what we mean by “can’t hear anymore”.  What I am referring to is patients with hearing losses typically in the profound hearing loss range with auditory-only monosyllabic word identification scores typically around 25% or less.  Note that we need to look at both the hearing loss and the word identification score as the variability of communication performance in this hearing loss range is massive.  Additional, we should look at auditory-visual word identification to see how well the patient can utilize the addition of lip-reading information.

Lets look at a case that I recently encountered.  The woman had a left corner audiogram.  Word identification score was 0%.  Auditory visual speech perception was not much better, but was not assessed by the clinical audiologist with an AuD so we don’t really know.

I was contacted and asked if I could help with the FM fitting at this office.  I agreed, but as is always the case, I was not given all the details.  I got there, asked to see the file and my jaw dropped.  The conversation with hearing health care professional (HHCP) went something like this:

Me: So what are we doing with this patient?

HHCP: We are fitting an FM system?

Me: Why?

HHCP: What do you mean why?

Me:  I mean “why?”, thats what I mean.  What will the FM system do?

HHCP: It will help the client hear better.  She and the family are pretty frustrated.

Me:  Well of course they are.  But how will the FM help the client hear better?  Will it improve her word identification score?

HHCP: Sure.

Me:  How?

HHCP:  By improving the signal-to-noise ratio.

Me:  When you did the word identification test, did you do it in background noise, or in quiet?

HHCP:  In quiet.

Me:  So we are already looking at the best possible score and thats 0%.

HHCP:  I guess…

Note that this is not the first time I have had a conversation like this with an audiologist or a hearing instrument practitioner.  It seems to me that most clinicians have no clue what to do with patients who have little or no hearing.  I am not 100% sure of the reason for this, but I suspect that it goes back to our problems with our training. And that is as follows:  We are only trained on how to assess hearing and how to fit a hearing aid.

The audiologist in this example is, like most of my colleagues, a good and decent human being who truly wants to help the patient, but doesn’t know how.  He is simply the end product of his training.

As an audiologist who also had 0% word identification and little hearing, I would like to offer my hearing health care professional colleagues a few suggestions on what to do with these kinds of patients.  This is just a starter list…books could probably be written on this topic.

1. Counsel the patient.  Specifically, let them know that they cannot hear anymore and we need to change tactics.  In the case example above, and with the managing audiologist’s permission, I sat down the patient and her family and told them just that.  The woman’s son practically had tears in his eyes…tears of frustration.  He said “You are finally the first person to finally tell us what we have been saying for years, “my mother can’t hear”.

2. Let them know what a hearing aid can realistically do.  In this woman’s case, it might provide a few basic awareness cues of loud sounds in the environment.  Thats it.  It will do little for speech perception.

3. The patient has two basic choices now.  1. Cochlear Implants or 2. Switch entirely to a visual approach.

4. Cochlear Implants:  Make the referral to the closest implant program.  Give a basic description of what it does, but stress that you are NOT a cochlear implant audiologist and they should get the correct information from the proper professional.  Resist the temptation to give too much information here, unless you are very informed about CI’s.  And don’t worry about candidacy.  Let the CI centre work that one out.  Most audiologists wait way too long to refer to an implant centre. When in doubt, refer to the CI centre.

5. The second option is to switch to visual approach.  This can include learning sign language, using written notes, using text messaging via a mobile phone, things of that nature.

6. Lip-reading as an exclusive method if communication is not an option in my opinion.  An explanation why is another entire blog posting, but basically far too many words look the same on the lips and it is extremely exhausting to lip-read all day long.  It is best used as a supplement to hearing.  Works great for folks who still have some usable hearing.  See a fellow blogger’s posting on this topic.

7. Discuss alerting devices that use visual or tactile stimulation.  This folks need to know when there is someone at the door, if the phone rings, if there is a fire etc.  Hearing Ear Dogs could be discussed here as well.

8. Give options for phone communication.  In the past that would have meant getting a TTY (sometimes called TDD’s).  Nowadays, we have even more options including text messaging, instant messaging, email via computers, email via smart-phones etc.

9. Make sure the patient knows about captioning.  This includes TV, but also real-time captioning (CART).

I provided all this information to this lady and her family.  I also took back the FM and told them that it would be a waste of money at this time, but if they got a cochlear implant, an FM system can be added then.

This woman, who’s hearing loss was progressive over the years, should have started using an FM system when her hearing loss was moderate-severe.  Her time for the FM came and went.  FM systems need to be added much earlier, not when the client is a CI candidate.  That’s too late.

What Does a Person with Hearing Loss Know About Hearing Loss?


Recently I was sent an email from an audiologist (really nice recent grad) asking how to help a patient with hearing loss hear better in the noisy workplace.

When the issue of using an FM system came up, apparently the person with hearing loss stated “No, that would not work in my situation because it is too noisy”.  So I was asked to come up with some other suggestions.

Ummm, ok,  I have a whole bunch of problems with this.

First, I think we need to clarify when we need to listen to our patients and follow the patients lead.  At other times we, as audiologists, SLP’s, hearing instrument practitioners or hearing resource teachers need to provide leadership and guidance to our clients with hearing loss. As an Audiologist with hearing loss, I have walked in both sets of shoes, so I would like to offer some suggestions.

First, here is a list of things where the person with hearing loss knows best:

  1. Ask and find our all the different situations in which the person with hearing loss is having difficulty.  List them all and seriously look at how we are going to help overcome those challenges.
  2. The patient knows and can tell you how it feels to be in a given situation.  Don’t be afraid to ask about this.  When a patient says ‘I could not hear at my daughter’s wedding” find out how they felt about that.  It is good to just let the patient explore their feelings and frustrations.
  3. Discuss past experiences both good and bad to see what you are up against.  For example, find out if the client ever tried an FM system or ever used directional microphones in the past.  Likely if something was a failure in the past, find out how much coaching the patient had in how to use the equipment.

In short the patient knows, better than you the clinician, the situations they are having the most difficulty in, and what it feels like to have a hearing loss.  But here is what the patient does not necessarily know and where the expertise of the professional is required.

List of Things a Patient with Hearing Loss Does NOT Know;

  1. Whether or not a hearing aid is even needed.
  2. What electroacoustic characteristics are needed in the hearing instrument
  3. What style of hearing instrument is most appropriate.  A patient can wish all they want for a tiny hearing aid, but if the loss is too severe, it can’t be done.  Period.  Yes, many patients have lots of choices of the form factor, but some do not.  We need to lead here, not follow.
  4. What technology for managing noise is needed?  For example, if a client has a moderate severe loss and a speech in noise test such as the LiSN-S PGA indicates that an FM system is needed, the hearing health professional NEEDS to communicate this to the client.  The client does not know what technology is required.  They just know the situations they find challenging.
  5. How to effectively use the equipment.  You cannot simply toss the equipment at the client and hope they figure out how to use it in the difficult listening situations that were identified.  Patients need our counseling and coaching here.

Now back to the patient who can’t hear at work.  The specific situations at work need to be fully explored.  Ideally, you can do this formally with the COSI.  Again, the patient understands this so much better and he needs to tell us as much as he can about his challenges if we are going to have any chance of finding solutions.  Next we need to explore why he feels that an FM system would not work.  He likely does not know how the technology works or how to use it effectively.  There are excellent FM counseling tools available for this purpose.

But we have to stop letting patients dictate the wrong things.  I have seen in my 20+ years of professional experience numerous patients who are wearing “dirty little secret” tiny aids and are not getting the correct amplification.  We need to provide leadership here and work the client towards more appropriate amplification.

Similarly, we must always consider not just the amplification needs but also the hearing in noise needs as they relate to the client’s own personal situation.  Will the client need directional microphone technology?  Should it be fixed or adaptive directional microphones? Will directional microphone technology be enough or will FM technology be needed?  Most patients with moderate severe loss and greater will likely find themselves in situations in which a hearing aid or cochlear implant is not enough.

I agree that we cannot force anyone to take our professional advice.  But patients do have a right to make an informed decision.  In my opinion, we are obligated as Hearing Health Care Professionals to give the patient all the facts.  Too often, when I give talks about directional microphones, FM systems, and other assistive devices,  a patient will ask me “How come this is the first time I am hearing about this stuff?”

Seeing the Forest for the Trees…What’s Wrong with Audiology


I love my Audiology colleagues.  But I do not always love my Audiology profession.  For the most part, Audiologists are very skilled and knowledgable professionals.  We do an excellent job of assessing hearing levels, and identifying the site of lesion of the hearing loss.  We have incredible diagnostic tools at our disposal ranging from basic pure tone audiometry (we still mask better than anyone else), to ABR, to Otoacoustic emissions.  We understand how hearing aids work, how to fit them, and how to verify performance using real ear measurement techniques.  In short, we are very well trained at performing assessments.

So whats my beef?  Let me illustrate from a few examples.

  1. When I started working as an educational audiologist in the 90’s, I was asked to report on the progress of child with hearing loss.  I did the usual…hearing assessment, hearing aid selection and verification.  I was an early adopter of the RECD, and I proudly showed how well the hearing aids were meeting DSL targets.  But the parents kept asking me why their kid couldn’t hear well, and I just kept thinking “Beats me, but I did a great job of hitting targets, so there”.  This started to make me realize I needed to look at things differently.
  2. I have had numerous times where I have been asked to assist with an FM fitting on an adults who essentially who have no hearing left.  As recently as just a few months ago, an Audiologist, who was a recent graduate from a Doctor of Audiology (AuD) Program, asked me to help with a client who only have hearing at 250 Hz and 500 Hz.  In other words- deafened.  I thought, “Now you want to try an FM system on this client?  You should have introduced this 10 years ago when the client had a moderate-severe loss.”
  3. The percentage of people with moderate severe losses or greater who use FM systems is disappointingly low.  Yes, I can hear my colleagues protesting saying “Adults won’t use FM”.  Well, if you polled the patients with hearing loss and asked them why they don’t use an FM, their likely answer will be “What’s an FM system?”, or “I was never told about these devices”.
  4. People with hearing loss routinely complain of hearing in noise yet we rarely assess this.  We cannot just do a pure tone audiogram in quiet.  We need to assess the problem that is vexing our patients the most and then find equipment and strategies to deal with that.
  5. How often are the limited number of rehabilitative lectures at Audiology conferences pushed back to Saturday morning.
  6. How many patients know about other assistive devices such as vibrating alarm clocks and fire alarms that are also needed for daily living with a hearing loss?
  7. I frequently am asked situational based rehabilitative questions.  For example, “Peter, how do you help a client hear in meetings” or “How can I help my client who works in a call centre?” etc.  Audiology seems poorly equipped at finding solutions to these situational problems.

What we need is to change Audiology practice from one that is almost exclusively diagnostically-driven to one that is also rehabilitative in nature. We have daily opportunities to do both in parallel:  to complete exemplary testing and then guide the rehabilitation of the patient based on test results.

Frankly the AuD has not helped expand the scope of our interventions, in fact, it has made us even more diagnostically focused.  This bias reduces our practice habits to those of technicians rather than professionals who practice to the full scope of our expertise.

In 2002, the World Health Organization introduced a classification of functioning, disability and health (ICF) to measure health and disability at both individual and population levels. The ICF “takes into account the social aspects of disability and does not see disability only as a medical or biological dysfunction. By including contextual factors, in which environmental factors are listed, ICF records the impact of the environment on the person’s functioning.” (www.who.com). The ICF can help identify: What is the patients level of functioning? What treatments or interventions can maximize functioning? What are the needs of persons with various levels of disability- impairments, activity limitations and participation restrictions?

How do we apply this framework to Audiology?  We view hearing loss as medical/biological dysfunction and our practice culture encourages us to focus on this.  We cannot stop at this – we must go further to examine patient’s functional capacities.

Without question, every patient should have their hearing levels fully and accurately assessed. In addition, we need to accurately determine, to the best of of ability with our non-invasive procedures, the site of lesion. The hearing loss is the genesis of the problem and we cannot proceed we fully understand what we are dealing with.  This is where Audiology shines.

Next we need to look at function.  At a minimum, we should perform a Hearing in Noise Test such as the LiSN-S PGA an all of our clients.  The world is a noisy place and we need to know in what situations our patients will have difficulty.

Functional capacities can also be assessed by asking our patients directly how they function in the context of their own daily lives using a tool such as the COSI.

Once we identify functional concerns, we need to then determne how to maximize function.  Here we need to consider all of the equipment needed.  For example, consider a client with a moderate severe hearing loss that performed poorly on the LiSN-S PGA and has identified several hearing in noise problems on the COSI.  Such a client will likely need a hearing aid with directional microphones, an FM system, and perhaps some alerting devices.  Then this client will need to be counselled how to use these devices properly.  This is a wholistic treatment plan.  But too often, a hearing aid is selected solely based on cosmetic concerns.  Nothing else is recommended, equipment such as FM systems are not discussed.  This is unacceptable.  We owe it to our clients to counsel them properly on the pros and cons of different equipment choices and on how to best navigate the world at-large with a hearing loss . In the absence of this collective practice change, our clients will succeed or fail only through trial and error. I believe that we are capable of delivering more.

These fundamental changes need to occur at the University level.  Audiologists are intelligent and compassionate people; they are fully capable of practicing in this model.  They are simply not taught to think in this way.

Once we shift our focus to maximizing client function, we will be able to see not only the trees but the forest as well.

Research on Music Perception with a Cochlear Implant.


As you all know, I love music.  I wish I loved visual art or sports more, but I don’t.  I love music and with my verkakte ears, its not an easy task.  I decided to review the literature and see what the research tells us about music perception in cochlear implants (CI’s).

If you look at some of the earlier research prior to 2000, you barely see much reference to music perception in CI’s.  I think the researchers, and engineers were busy working on getting good speech perception.  Makes sense.  And as the speech perception abilities of CI users began to improve, interest began to shift to other important listening  abilities such as musical perception.

One researcher who has done a lot of work in this area is Dr. Kate Gfeller.  In a 2000 article (J Am Acad Audiol. 2000 Jul-Aug;11(7):390-406), Gfeller et al found that 83% of adult CI users reported diminished music enjoyment post-implantation.  In fact one third of the CI users even avoided music altogether as they found it to be an aversive sound.  These are not encouraging results.  But do remember that these folks received their implants in the 1990’s.  This technology is now 20 years old.

Looi et al, 2007 (Ear & Hearing: April 2007 – Volume 28 – Issue 2 – pp 59S-61S) did a study comparing the music perception of CI users compared to hearing aid (HA) users.  Note that the HA users were all potential CI candidates, so they all had significant hearing loss.  This study showed that while neither device (HA or CI) provided satisfactory music perception results, the CI users gave slightly better ratings than the HA users.  So now we are actually seeing some data showing music perception getting better with a CI, but still not great.

Another study by Looi et al in 2008 (Ear & Hearing: June 2008 – Volume 29 – Issue 3 – pp 421-434) looked again at CI users and HA users who were potential CI candidates. So again these HA users also had significant hearing loss.  On a rhythm recognition task, both groups did about the same.  On the pitch perception task, the HA users outperformed the CI users (oh oh, not good).  In fact many of the CI users needed two pitches to be at more than a quarter of an octave apart before the notes sounded any different.  Not good.  In western music you need to be able to hear a one semitone difference.

After reading this article, I checked what my skills were like using a CI only.  I had my brother play a bunch of two note pairs on a piano keyboard.  My task was to say if the two notes were the same or different and then secondly which note was higher in pitch.  For the notes above middle C, I was able to reliably report if the two notes were same or different even if they were only one semi-tone apart.  I was about 80-90% accurate at identifying which note was higher or lower.  For notes below middle C, I needed notes to be at least one full tone apart to get the same level of accuracy, but performance deteriorated as the pitches got lower.

So here’s the thing now.  Looks like I am not getting good low frequency pitch perception with the CI which is so critical for music.  Low pitches may not be that important for speech as the consonants are mainly high pitched and consonants give you speech intelligibility.

I therefore personally decided to use a hearing aid in my non-implanted ear.  I hear music much better whilst using a combination of a HA and a CI.  But is it just me?  No.  A study be El Fata et al (Audiol Neurootol. 2009;14 Suppl 1:14-21. Epub 2009 Apr 22) looked at 14 adults who continued to use a hearing aid in their non-implanted ear after getting a CI.  Subjects were asked to identify excerpts from 15 popular songs, which were familiar to them.  The presentations were done bimodally, with the CI alone and then HA alone. Musical excerpts were presented in each condition with and then without lyrics. Those subjects who had more low frequency residual hearing (> 85 dB HL in the lows) did much better on all the tasks with both a CI and an HA than either the CI only condition or HA alone.

Another study by Gfeller et al in 2007 (Ear & Hearing: June 2007 – Volume 28 – Issue 3 – pp 412-423)  also confirms the need for better low frequency hearing for music perception.  In this study, CI users which electrical only stimulation (the regular type of CI) were compared to subjects with a hybrid implant.  The hybrid implant uses a shorter electrode array for giving you the high pitches whilst still using a hearing aid type of air conduction for the low pitches.  Usesing low frequecny acoustic hearing significantly improved pitch perception compared with elctric only CI’s.  But before you go rushing off asking for a hybrid implant, you need to know that not everyone can get one of those.  You need to still have sufficient low frequency hearing.

So here’s what I can conclude from these articles:

1. The newer studies seem to show better music perception in CI users than older studies.  This is most likely due to improvements in technology in which the newer implants give a richer sound than the older devices.

2. Music perception with a CI via electrical stimulation could still be improved.  It seems to be related to the poor perception of the low frequencies.

3. If you still have some usable residual hearing in your non-implanted ear, use a hearing aid in that ear.

4. Help your ears by making music easier to hear.  Use some of the techniques I use by adding FM technology to your CI and hearing aid for either live music or with an iPod.