How to Hear Better in the Car


Hearing in the car is a challenging listening environment for people with hearing loss. The signal to noise ratios are less than optimal for maximum speech understanding. Moreover, conventional directional microphones are typically oriented for face to face communication which is not ideal when communicative partners are seated side by side or behind. Binaural directional microphones which can add an additional 3-4 dB of SNR improvement definitely require a face to face orientation in order to work properly. Finally, one cannot take advantage of lip-reading cues, especially if one is the driver. At night, the lack of adequate lighting negates the use of lip-reading cues for the passenger as well.

The noise levels generated inside an automobile can vary greatly by type of vehicle and the speed the vehicle is traveling. There are several websites available that list the interior noise levels of various automobiles. The data in the chart below, taken from http://www.auto-decibel-db.com/, is a sampling of several vehicles operating at various speeds.Noise Levels in Car

As you can see the noise levels can vary as much as 12 dB. Typically high end gas powered luxury sedans tend to have the lowest interior noise levels, while entry level automobiles and diesel cars tend to have higher noise levels. If we assume that speech is typically 65 dB in intensity, what then are the signal to noise ratios? In the table below, I have simply subtracted the measured noise levels from the 65 dB speech levels to obtain the SNR.

Noise levels in car 2 SNR

The next thing we need to consider is what SNR’s do people with various degrees of hearing loss need in order to communicate effectively. Below is the classic Killion data showing SNR’s as a function of hearing loss. Note that this is data for a typical adult. Children need higher SNR’s as do many geriatric clients. It is therefore ideal to actually assess a client’s speech in noise capabilities through a test such as the Listening in Spatial Noise Test – Sentences with the Prescribed Gain Amplifier, otherwise known as the LiSN-S PGA.

Noise levels in car 3 SNR Needed

Let’s look at a couple of examples of how to apply this information. The first example is a 40 year adult with a moderate sensorineural hearing loss. This gentleman owns a Honda Civic and frequently drives on highway of speeds 100-120 KM/hr. He is usually is driver rather than passenger Our chart indicates that the SNR at 100 km/h would be -1 dB and the SNR at 120 km/h would be -3 dB. The Killion data suggests that he will requires a SNR of at least 6 dB in order to understand speech. Which technology will work for him?

First there are conventional directional microphones that can only pick up speech from in front of the listener. This will of course not work in a car since a driver must face the road whilst driving and not the talker beside. Some hearing aids have the capacity to shift the directionality of the microphones to the side and in some cases stream the signal to the other side of the head that does not have an optimal microphone placement. The signal to noise ratio improvement that can be obtained from this arrangement is still the same as conventional directional microphone and is about 4-5 dB. This will be satisfactory for speeds up to 80 km/h, but not higher speeds.

What about a binaural directional microphone? Hearing aids with these features combine all of the microphones on each hearing aid to achieve an SNR of 8-9 dB. While this certainly fits the SNR criteria numerically, it will not work in this case as he is frequently the driver and must keep his head facing the road. Binaural directional microphones work in front only.

The final options are remote microphone technologies such as Bluetooth or FM (non-adaptive) or adaptive digital remote microphone such as the Roger microphones from Phonak. Since Bluetooth remote mics provide about a 10 dB improvement this will certainly meet the criteria.

But what happens if one needs a higher SNR or there is a need to hear multiple talkers? This is certainly the case with the next example. This is a 38 year old mother with two children. She frequently needs to drive her 2 children or her elderly parents to various appointments in her Ford Focus. She presents with a moderate-severe sensorineural hearing loss and the LiSN-S PGA results were in the red zone indicating that she needs SNR boosts of at least 15 dB. In this client’s case she could use a non-adaptive remote Bluetooth remote microphone for local 50 km/h city roads as this will improve the SNR from about 7 to 17 dB.   However, she will still experience difficulties hearing multiple talkers and at highway driving speeds. The only technology that can cover all of her driving listening needs would be an adaptive digital remote microphone.

Below is a picture of a set-up that I have commonly used for these situations. In it you see both communication partners using adaptive digital remote microphones that switch automatically between the talkers.  In this picture, we are using two Phonak Roger Pen transmitters.  These transmit both the talkers voices to receivers connected to hearing aids or cochlear implants.

Noise levels in car 4 Two Mics Pic

In summary, I would recommend that you and your hearing care professional look at the following critical pieces of information:

  1. What car do you drive ?
  2. Are you typically the driver or the passenger?
  3. Do you do a lot of highway driving?
  4. Do you need to hear multiple talkers?
  5. How do you perform on a Speech in Noise test.

Only when you have all the relevant information can you determine the best solution for listening in a car.

 

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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.

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?”

World’s Best Travelled Hearing Ear Dog


Amie loved her long walks.

 

Last weeks blog posting was a bit heavy. Its time for a lighter blog post…and a fan favorite in the blogosphere.  Amie the Hearing Ear Wunderdog.

I guess I am getting sentimental again because Amie is having a tough time these days.    Due to the Transitional Cell Carcinoma in her bladder, she is having suffering from urinary incontinence.  We need to keep her diapered at all times or in the crate with an incontinence liner.  Its stressful for all of us…

Hence the need to reflect upon better days when Amie and I travelled the world together.  We came up with a list of all the places Amie and I have been together.  I must say, it’s pretty impressive for a dog.  Here’s what we came up with:

  • San Diego, California
  • Salt Lake City Utah
  • Chicago, Illinois
  • Atlanta, Georgia
  • Vancouver, Victoria, Whistler, and Kelowna in BC
  • Calgary and Edmonton in Alberta.
  • Hiking in the Alberta Rockies
  • Saskatoon and Regina Saskatchewan
  • Winnipeg and other parts of Manitoba
  • Pretty much every city in Ontario
  • Quebec City and Montreal, Quebec
  • Halifax, NS
  • Charlottetown, PEI
  • Moncton, NB
  • Whitehorse, Yukon
  • Zurich, Stafa, Bern, Kandersteg, Murton, and other places in Switzerland.
  • Plus more, but cannot recall

It is during these trips that I have had some of my funniest stories with Amie.  One time we were doing a training session at the Westin in Ottawa.  Normally Amie just sits in the room while I present, or maybe greets some guests.  But this time she we suddenly realized she was gone.  Turns out she sniffed out that some bankers in the next seminar room had a way better buffet of cheeses and meats (we had veggies and dip…boring!).  Little monkey.

Amie sitting nicely, hoping for treats.

Another time I was in a Montana’s Steak House.  We were seated in a booth and I took Amie’s leash off while she sat beneath the table.  She couldn’t go anywhere…we were in a booth.  Right?  Wrong!  Turns out the walls to the booth did not extend all the way to the floor.  She snuck out and was seated in front on a table of a nice old couple who were sharing their Prime Rib with her.

Another favorite is during a trip to Kandersteg, a village high up in the Swiss Alps.  The Inn owner was terrified of dogs her entire life…until she met Amie.  Amie’s sweet and kind disposition essentially cured this woman’s lifelong fear of dogs.  By the end of our trip, the Inn owner was taking Amie by the leash and introducing her to all the other guests in the Pub.

For years I have done what I like to call “Kids Days” at Phonak. Here we bring kids to the Phonak office and give them a factory tour, followed by a pizza lunch and an Amie Hearing Ear Dog Demonstration.  But for the longest time, I kept getting the same kids returning year after year.  The teacher’s explained that the kids could go wherever they wanted for their trip, but they all wanted to come to Phonak.  Well, it really turns out that they all wanted to come see Amie again. “Forget the Zoo, forget Rock Climbing, we want Amie”.  And here I thought they wanted to come see me.  Nope.

Going to Bass Pro Shops looking for matching outfits.

As we get closer to the difficult day, I want to make sure we always remember Amie in her glory years…as one of the most well travelled and loved Hearing Ear Dogs in the whole world.

Everybody loves Amie, especially her mom.

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.

Putting an End to the Chubby Deaf Guy


Greetings readers from South Beach, Miami Florida.

I have not been the healthiest guy. I eat too much and don’t exercise enough. Very bad.

I am on blood pressure medication as well as cholesterol reducing drugs.

Frankly I have had enough of this crappy lifestyle. I am 47 years old and if I don’t get my shit together, I am going to be faced with a future of even more disabling conditions. And that is not Living Life to the Max with Hearing Loss.

In the past 21 days, I have made some major changes.

First, I have stopped chewing Nicorette. Yes, I quit smoking quite a while ago, but I have been using Nicorette for about 10 years. It has now been 21 days since I have had a piece of Nicorette. So as far as I am concerned, nicotine addiction is over. Check one.

Second, I have stopped eating crap. I have drastically reduced my portion size and I have reduced my consumption of fatty foods. Funny thing is that I now get a feeling of being full and satisfied with much smaller portion sizes. Its great!

Third, I do cardio-vascular exercises at least 5 out of 7 days a week. I slap on the heart monitor and keep my heart rate at about 140 bpm for 30 minutes.

Fourth change is I do weight training at least 3 times per week. I have learned that muscles burn more calories, even at rest. That’s why really fit people can eat more food and stay slim. Their resting basal metabolic rate is higher.

So far, after 21 days I have noticed the following changes.

1. I have lost about 10 lbs.

2. I sleep like a bear at night.

3. My mouth is feeling better now that I don’t chew Nicorette.

4. I already look a bit better.

5. My self esteem has improved.

Starting to get slimmer...10 lbs down, 40 to go.

We have a $400 bet going on at work. The winner will be the person who loses the most percentage weight. I fully intend to win.

This is a gift I am giving to myself, and one that you can give to yourself too. I am convinced that to do this successfully, it must come from a combination of reduced portion size, improved quality of food, cardio exercise, and weight training.

Not only that, but there are some studies have shown that there is a correlation between hypertension and hearing loss. So getting fit might preserve residual hearing.

Wish me luck!!

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.

More Gig Pics…


Performing live music in a band is like a dream come true for me.  I still can’t believe that I am able to do this with my hearing loss.  On one hand, I am a bit pissed that I have a hearing loss at all, but the fact of the matter is that shit happens to all of us in one form or another. Hearing loss is the hand that has been dealt to me, but I am going to play this hand the best I can.  If it was not for cochlear implants, hearing aids and FM systems, I would have been really screwed.  But I am not.  This pictures are proof of that to me.  I am one lucky dude.

Again, I must thank my friend and professional photographer Arsenio Santos for taking photos of the event.  There were so many good ones to choose, but here are some of my personal favorites.

Thanks also to me awesome bandmates Deb, Luigi and Warren.  I love you guys!  Thanks also to my buddy Dave for doing the acoustic set.  And one more shout out to one of my best friends in the world, Ryan Switzer from Massive Tank Studios, not just for doing the sound, but for helping me become a musician.

Deb is such a passionate singer.

Looking cool in a B&W photo

Warren is a fantastic drummer.

Luigi singing and playing guitar. You are awesome Luigi!

I am having a good time, can you tell?

But I do need a haircut.