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.

 

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.

Best Ways to Hear Better in Noise


Noisy-restaurants

Hearing loss results in two main problems; loss of audibility and loss of clarity in noise.

Loss of Audibility. This means that sounds are too soft to hear.  We have a couple of strategies to make sounds more audible.

    1. Amplification. Today’s modern hearing aids selectively make softer sounds louder than louder sounds.
    2. Frequency Compression.  In some hearing aids such as the ones provided by my company, Phonak, the hearing aid can shift high pitched sounds down to lower pitches.  The logic is that you may have too much damage in the high pitches to amplify the sounds sufficiently, so we will shift these sounds to regions where you have better hearing.
    3. Cochlear Implants.  If high powered hearing aids equipped with frequency compression no longer helps you hear, we now turn to a Cochlear Implant to make sound audible.  See these links for more information of Cochlear Implants.  Also here.

Loss of Clarity in Noise.  I wish that hearing loss was merely a problem of loss of audibility.  It would be so much easier just to amplify the sounds and be done with it.  Just like wearing a pair of corrective lenses for vision, right?  Wrong.

After we do our best to make sound audible, we also have to do something about getting rid of the background noise.  As one’s hearing loss gets worse, not only do we need stronger and stronger hearing aids, but we also need to get rid of more and more noise.  For example, a person with normal hearing can handle a signal-to-noise (SNR) ratio of 0 and still understand most of what is being said.  An SNR of 0 means that the person talking to you is the same loudness as the person you don’t want to listen to.  This happens all the time.  Imagine a restaurant.  There are people all around you talking at the same loudness as your significant other across from you.  You normal hearing folks can handle this, people with hearing loss cannot.

Strategies to Hear Better in Noise.

  • Ear Level Directional Microphone Technology
  • Remote Bluetooth Microphones
  • Fixed Gain FM/Infra-Red/Digital Technology
  • Dynamic FM

These 4 strategies are not all the same.  They vary significantly in the amount of noise reduction provided.

Directional Microphones:

A directional microphone works by picking up the sound from one direction (typically the front) but not from anywhere else.  So now you won’t hear the annoying kid in the restaurant behind you as much.  Independent research has shown that a directional microphone on the hearing aid does help you hear better in noise compared to a regular omni directional microphone. The range of improvement found in these studies is anywhere from 3 to 8 dB.  So it gets rid of about 5 dB of noise.  This is not huge, but for people with milder losses of hearing, this may be all they need.  It certainly is convenient.  You don’t need to carry extra equipment.  In fact, in today’s modern hearing aids such as Phonak Bolero Q or Virto Q, these microphones get switched on automatically when it gets noisy.  Pretty awesome technology in there.

Remote Bluetooth Microphones.

Many companies, including the one I work for, now have affordable Bluetooth microphones that can be used with your hearing aids.  You clip this microphone onto the person you want to hear and it transmits wireless via Bluetooth radio waves to a device around your neck which in turn sends it to your hearing aids.  By moving a microphone from the ear level to a much closer proximity to the talker’s mouth, we can achieve much higher signal-to-noise ratios than a directional microphone located on your head.  Here is the example from Phonak which involves the use of the Remote Microphone in conjunction with either a ComPilot or an iCom.

Phonak Remote Mic

The advantage of Bluetooth microphones are that you get rid of more noise compared to ear level directional microphones.  They are convenient, and easy to use with simple and intuitive controls (just an on/off switch and volume).  Finally they have the advantage of low cost.  It is a very affordable solution, much less than FM.

Traditional and Fixed Gain Wireless Systems

To achieve an improvement in SNR up from a Bluetooth Microphone system would be to use a fixed gain wireless system. Examples of include:

  • Phonak’s 2nd Generation systems such as Campus, SmartLink SX, ZoomLink, EasyLink (silver casing)
  • Oticon Amigo
  • Comfort Audio Digisystem

These are all examples of fixed gain systems and achieve similar results.  The reason these perform a bit better than the Bluetooth microphones is that most incorporate directional microphones on the transmitters and therefore can get rid of more noise.  Additional benefits include greater operating ranges and longer battery life.  However, cost is significantly higher for what is really just a modest improvement over a lower cost Bluetooth microphone system.

Adaptive Wireless Systems

Some wireless systems are adaptive.  For example, the Dynamic FM technology that Phonak uses is different than fixed gain systems in that it adjusts the FM gain depending on the environmental noise level.  Therefore additional gain is added if the background noise level increases.  The technology works by measuring the ambient noise levels in the room during speech pauses.  If the ambient noise level rises to over 57 dB SPL, a command is sent from the transmitter to the Dynamic FM receivers to increase the FM gain.  When the FM gain increases, you get a higher signal to noise ratio.  It is still comfortable to listen to because today’s modern hearing aids all have compression which keeps this at a comfortable level.  Examples of Adaptive Wireless Systems include Phonak inspiro, SmartLink+, ZoomLink+, EasyLink+ and any 3rd generation Phonak receiver (eg MLxi, ML9i to ML16i)

ZoomLink+ with Dynamic FM

How Do These Technologies Compare?

1. Directional Microphones vs Fixed Gain FM.  This classic study by Valente et al in 2002 compares an omni mic to a directional mic on a hearing aid which in turn compares this to an FM system.  The data is backwards, so the lower the number, the better the result.  It is very powerful data showing how well an FM system can help over just an ear level directional microphone.

Valente et al 2002

2. Fixed Gain vs Adaptive Gain Wireless Systems.

The most extensive study comparing fixed gain vs adaptive gain wireless systems was conducted by  Dr. Linda Thibodeau, PhD, University of Texas at Dallas, USA, and the Callier Centre for Communication Disorders, Dallas.  AFMA refers to the Adaptive Gain FM while Fixed of course refers to fixed gain wireless less.  Remember that fixed gain wireless systems include Bluetooth microphones, Phonak’s second generation FM (Campus), Oticon Amigo, and Comfort Audio DigiSystem to name a few.  As you can see, when the room noise gets louder, the word recognition score for the adaptive gain wireless system is much higher.  In this example, the transmitter used was the Phonak inspiro with Dynamic FM.

Results of Dynamic FM over traditional

3. Adaptive FM vs Digital Wireless.

This study, conducted at the University of Orebro in Sweden, compared a digital wireless system with fixed gain (Comfort Audio Digisystem) to a adaptive gain FM system (Phonak Dynamic FM).  The question is what leads to better performance in noise.  The result s clearly showed that the adaptive gain system (Phonak Dynamic FM) leads to better performance.

Dynamic vs Digital

So which do you need?

I will make my next blog post on how to select the correct technology for your needs.  But here are the summary points.

  1. You need technology that helps you not only hear soft sounds, but also helps get rid of background noise.
  2. Directional microphones on the hearing aid itself can get rid of about 5 dB of noise.
  3. Bluetooth microphones provide additional improvement in noise.
  4. Fixed gain wireless systems such Phonak’s second generation FM, Oticon Amigo and Comfort Audio Digisystem provide additional improvements over a Bluetooth microphone, but these may be modest improvements.
  5. Adaptive gain wireless systems such as Phonak Dynamic FM still provides the largest amount of noise reduction.

On Being Normal…


As a person with hearing loss, I often ponder the question of what it means to be normal.  Does my cochlear implant give me normal hearing again?  Am I a normal person?  If not, am I less of a person because not everything about me is normal?

For any hearing aid or cochlear implant user, I think no one will ever have normal hearing again.   There is some form of damage in the auditory system that cannot be corrected.  For example, in cases of sensorineural hearing loss, the hair cells remain damaged even after we add the hearing devices.  Until hair cell regeneration therapies become clinically available, the ear is still not normal.

Some people have compared using hearing aids to using eyeglasses to restore vision.  While it is tempting to draw such an analogy, I do not think this comparison works.  For most people with glasses, there is nothing damaged or unhealthy about the eyes.  Typically, the lenses of the eye are simply not the correct shape but the eye is still healthy.  Moreover, eyeglasses do not convert the light energy from one form, digitize it, manipulate it and then attempt to reconvert it back into light energy again.  What hearing aids do is far more complex than eyeglasses.

What we can do when it comes to hearing loss is try to restore normal function. By this I mean we can use equipment and communication strategies to allow us to function better in the various communication situations we face.

In cases of milder hearing loss, we try to restore the normal function of the outer hair cells via sophisticated hearing aids that amplify softer sounds more than louder. We try to restore normal ability to hear in noise via directional microphone technology or additional wireless microphones. We try to restore normal audibility of high frequency speech sounds via techniques such as non-linear frequency compression.  When hearing aids no longer help, we try to restore normal audibility via a cochlear implant.

But at no point are we ever making hearing normal.  The ear is still not the same as someone with a fully intact auditory system.  The extent to which we can normalize function is contingent upon many factors such as the degree of hearing loss, the technology employed, the behaviors we use and sadly financial resources.

Clearly, the more severe a hearing loss is, the more challenging it will be to communicate even with the best equipment currently available.  Also, if one has a more severe loss and chooses not to utilize the proper type of amplification for the hearing loss including wireless microphones, then such a person will also not function as well in all situations.  This also relates to behaviors.  Learn to how to use the equipment in various situations.  Learn how to communicate effectively.  Teach others how to best communicate with you.

Ok, so my hearing is not normal.  Does that make me an abnormal person?  Maybe, but frankly who on this planet is completely normal.  If you are not the ideal weight, not the ideal height, take medications for some medical condition, you too would not be perfectly normal either.  But so what?

I do not worry or care about being perceived as normal because frankly very few people on this planet are normal.  But just because I am not “normal”, this does not make me less of a human being.  I still want all the things anyone else wants in life.  I do not want to be discriminated against nor denied things simply because of my hearing loss.

So lets not even worry or talk about being normal…it is an impossible quest.  Lets learn to embrace  and accept all of the things that make us different and make us who we are.

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.

What Does a Cochlear Implant Sound Like?


It has been almost 7 years since I received my Cochlear Implant.  However, it seems just like yesterday.  I can still remember every detail from the time of surgery, to my first activation, and all the steps along the way to the restoration of my hearing.

I was not always deaf.  I was born with normal hearing.  I did not have meningitis, nor do I have any family history of hearing loss.  The only thing notable thing in my clinical history was that I had a series of painful ear infections.  It is likely one of those infections that caused the damage to my inner ear.

I began using hearing aids at the age of 5.  Over time, my hearing continued to worsen.  By the time I was in high school, my hearing loss was moderate-severe.  In University, my loss was in the severe range.  Interestingly, I did not begin using an FM system until my third year of University.  I simply did not know such devices even existed. I wish I was made aware of FM systems earlier, as I suffered academically from not hearing well.  In high school with smaller class sizes, I was an Honour Role student.  But in first year University, my average dropped to 60% and my initial hopes for studying Medicine were dashed.

I vowed to ensure that all people with hearing loss become fully informed of all the hearing devices or other forms of help that are available.  I did not want to see others struggle needlessly from hearing loss.  Thus, I decided to pursue studying Audiology and make this my personal mission.

But back to my original story about my CI.  Even though my loss was now in the severe range, hearing aids and FM systems provided me with considerable assistance.  My word identification scores were still in the 70% range.  However, as I crossed the line into a profound loss of hearing, my ability to understand speech started to diminish considerably.  By the time I became a candidate for a Cochlear Implant, my word identification scores were 0% for my right ear and 10% for my left ear.  Phone use was virtually impossible.  I struggled to lipread every word.  It was exhausting to try to carry on a  conversation.

I received my Cochlear Implant from the excellent surgery and audiology team at Sunnybrook Hospital in Toronto.  The surgery process went without a hitch.  I was out of the hospital the next day, and took a only a few days off from work.

After a month of healing, I went for my initial programming session.  I thought that I would be well prepared for this appointment.  After all, I am a trained Audiologist.  I have counseled patients myself about not having unrealistic expectations, especially on the first day.  But I knew there were some patients who could hear speech even on the first day of activation.  I wanted to be one of those people.  I felt I was entitled to be one of those people.  I was wrong.

After the initial Mapping was done, I listened to speech for this first time.  And it sounded like…GARBAGE.  Specifically, it sounded like R2D2.  It was just all a bunch of beeps and chirps.  I drove home that day and decided a nice bottle of single malt Scotch was needed.  I was feeling every emotion from anger, to bewilderment, to sadness.

But to make a long story short, the changes that occur over the next 6 months were rapid.  After about 2 weeks, the implant started sounding like Sammy the Snake hissing sentences into my head.  That’s better than R2D2.  Then it changed to Alvin from the Chipmunks.  Next it started to sound like a young Jerry Lewis.  Now it sounds pretty normal, at least to me.

My word identification score started to rapidly improve.  I cannot recall all of my scores, but after about 6 months I was understanding about 70% of monosyllabic words in isolation and 100% of words in sentences.  After one year, my monosyllabic word identification score for words in quiet improved to 96%.  I was and continue to be completely blown away by this.  After all, I started hearing just beeps and chirps.

Given that I recall having much better hearing, I can describe the difference between hearing through a CI vs a hearing aid.  Basically, when I had enough hearing to benefit from a hearing aid, speech and music sounded full and rich.  But as my hearing loss progressed, all I heard from the hearing aid were low pitches.  Everyone sounded like they had mashed potatoes in their mouths.

The CI sounds very crisp and precise.  I hear all the high frequency fricatives (s, sh, f, th etc) quite well.  I have been told that my speech has improved immensely, although I never realized that my speech production was deteriorating with my progressive hearing loss.  In hindsight, it makes sense.

Music and hearing in noise remained problematic.  To help with hearing in noise, we can get the same improvements hearing aid users get from the use of Directional Microphones or FM systems.  I use both with my CI and it helps.

For me personally, the use of a hearing aid in my non-implanted ear has helped with music perception.  Without a hearing aid, I can barely hear any bass at all. Bass makes music sound full and rich.  On the other hand, the treble I get from the CI makes speech and music sound clear and crisp.  Thus the CI on its own is fine for speech, but makes music sound like it is coming out of a small radio rather than a big stereo.  The hearing aid on its own sounds pretty bad for any type of sound, speech or music.  Combined with the CI, it does not help with speech, but does give music a richer deeper sound.

For those of you considering a Cochlear Implant, my single best word of advice to you is be patient.  Do not expect miracles, especially on the first day.  The improvements will come as your brain relearns to makes sense of these electrical signals.

Please remember too, that everyone is unique.  While my experiences are not uncommon, your pace of improvements and the final levels you reach could be better or worse than me.

I am so glad I took the step of getting a Cochlear Implant and would do it all over again in a heartbeat.

10 New Years Resolutions for People with Hearing Loss


Here we go again…its that time of year where we make all sorts of cliche New Years resolutions.  We all make the typical “lose weight” “exercise more” types.  Those are permanently affixed to every year’s list of resolutions for me.

As a person with significant hearing loss, there are some things which we can do that will make our lives more enjoyable.  So here are some suggestions for New Years Resolutions.

  1. Develop and Enjoy a Hobby.  As people with hearing loss, our communication challenges affect us in so many ways.  Its easy to let this dominate our lives.  So this is why I put this one at the top of the list of resolutions, because I feel it critical to develop and nurture our entire person.  For me, I have taken up Archery.  I love how archery calms me.  In addition, It requires much practice and skill, so it challenges me.  And it completely takes my mind off my hearing loss.
  2. Learn to use a new Communication Device.  Have you tried captioning on your TV?  Have you tried an FM system?  Do you use your different programs on your hearing aid?  This year, make it a goal to pick a device and learn to use it well.
  3. Learn a New Communication Technique.  There are all sorts of behavioral ways we can learn to communicate better.  Technology is only part of the story.  Ask yourself questions such as “Do I always make sure I sit with the light behind me so I can see other people’s faces better for lip-reading?”, or “Do I use a specific clarification rather than just saying what or pardon me?”.  Pick just one technique and try to apply this as much as you can.
  4. Take Action. This involves learning to be assertive, but not aggressive.  I need to work on being a bit more assertive.  For example, when I sit in a restaurant, sometimes I do not pick the best seat.  The best seat would be one in which I can see as many faces as possible and where the background noise is behind me.  All I need to do is just say to my dinner party “Do you mind if I sit there?  It would help me communicate better.”
  5. Learn to Accept Things.  Even with all the best technology and communication techniques, there are certain situations that may still be too challenging.  For example, even though I may go out to a bar with friends, I cannot hear all the communication from all the people in my group.  With the use of my FM system, I can, however, have conversations with one person at a time.  Therefore I have learned to accept this limitation.  I wish I could hear all the jokes zipping around me, but I can’t.
  6. Develop Calmness.  Again, another one I need to work on.  I am getting better, but sometimes I do get frustrated by my limitations.  Normally, this drive I have to not let this hearing loss limit me is a good thing.  It has driven me to become an audiologist, and learn to use all sorts of technologies and strategies to communicate better.  But sometimes, we might hit a brick wall.  I can get worked up by this and boil inside and its not healthy.  This year, when I get that feeling, I will try to draw upon the calmness I am learning from Archery. (See how this all ties in together?)
  7. Teach a Loved One Communication Strategies.  Communication is a two way street.  I would say that perhaps unlike other disabilities, hearing loss always affects your love ones.  Talking always involves at least one other person and as such, requires changes from communication partners.  So take some time to teach one “significant other” some techniques.  For example, my niece is likely the fastest talking teenager on planet earth.  It is incredible how many words per minute she can say.  I have worked on getting her to slow down when talking with me. Interestingly, she is now working as a waitress saving money for University next year and she has found that she does her job better when she slows down her speech for her customers.  Win win!!
  8. Plan a Dinner with Good Communication Techniques.  This one is a fun project.  Scout out a restaurant that is low noise and has good lighting.  Pick out a table that also fits these two criteria.  Pick out a seat that allows you to see everyone and where your back is towards the background noise.  Decide the number of people in the dinner party that you comfortably can communicate with.  Think about the communication devices you will be using, such as an FM system.  Think about the request for clarification techniques you will employ. And then make a reservation and enjoy!
  9. Read.  For the majority of us, our sense of vision is just fine.  Our eyes are an unimpaired portal to information.  The more we read, the more we keep in touch with the world around us.  Topics become more familiar, which assists greatly in lip-reading and hearing.
  10. Take Time for Family.  Here’s another one for me.  I get so wrapped up in dealing with my own hearing loss issues, that I sometimes do not see how things are with my family.  Be sensitive to how your hearing loss affects your other family members.  Be thankful for the things they are already doing to help you.  Also, your family members have things happening to them, both good and bad.  Make sure we take time to listen to them, rejoice in their successes, and help them with their challenges.  Its not always just about us.

Hearing during the Holidays.


The Holiday Season is now upon us.  There are work Holiday parties, Christmas parties in the neighborhood, Christmas or Hanukkah family dinners, you name it.  And they all have a couple of things in common:

  • It is noisy
  • Alcohol is usually served
  • The main activity is talking and listening.

These functions are not easy for people with hearing loss.  We function best in quiet settings and smaller groups where there is no competing noise.  Moreover we need to concentrate harder to communicate, so remaining sober and unintoxicated is a must.

You don't want to be like this guy.

Given that you will be going to places in which there is a high noise level, you need equipment and strategies on how to communicate in this environment.

So here is the Stelma Survival Christmas Guide for People with Hearing Loss.

  1. If you have a mild loss of hearing, you must use a hearing aid with a good Directional Microphone.  As I discussed in a previous blog entry, these microphones will pick up the person talking in front of you and reduce the noise behind you.
  2. Due to the high noise level of these functions, people with moderate, moderate-severe, severe, or profound  losses of hearing will definitely require an FM system attached to the hearing device (hearing aid or cochlear implant).
  3. You need to set your FM system microphone to the SuperZoom position for maximum noise reduction.
  4. If it is a cocktail party type of event, you will be standing and talking.  So you will place the FM transmitter in your left hand and your refreshing beverage in your right hand.
  5. When conversing, you will point the transmitter at the person you wish to communicate with.  We call this the Reporter Style of using an FM system.  Also make sure you hold the transmitter correctly.  See this video clip for more details.
  6. Remember to use Specific Requests for Clarification if you misunderstand.  For example instead of “what?”, say “Can you repeat the last part you said?”.  See my earlier blog entry on “What’s Wrong with Saying What
  7. Try to position yourself in areas with lower noise.  So if the music is blasting in the living room, move to the kitchen or dining room where these is less noise.
  8. Try to position yourself in areas with better lighting.  Again, if the living room is dark, stay in the kitchen where there is better lighting.
  9. Keep your alcohol consumption to a minimum.  It takes a lot of concentration for us people with hearing loss to communicate and alcohol gets in the way.  Not to mention drinking and driving is illegal.  I typically drink Gin and Tonics, but I alternate with mineral water and lime.  That way nobody bugs me about not having a drink in my hand.

If anyone else has some strategies that they use for coping with Holiday Parties, I would love to hear from you.

Happy Holidays everyone!

Strategies for Communicating in Restaurants


Dining plays in an important role in many cultures.  I think we can all agree that we do not eat simply to nourish our bodies.  It is the human connection that seems to be the most important part of dining.  We propose marriage, celebrate birthdays and anniversaries, close business deals, and simply connect with friends and family while dining.

Unfortunately, many people with hearing loss cannot enjoy the social benefits of dining due to their reduced ability to communicate in this noisy environment.  Indeed, many simply accept that they will only be there to consume the food and not much else.  Others simply choose to eliminate this social activity from their lives altogether.  This is very sad.

There are solutions, however.  These will depend partly on your degree of hearing loss, and partly on how noisy the restaurant is.  In the chart below I list the possible solutions for the various environments for different hearing loss levels.  Note that I am assuming that you have a hearing aid.  The last line is suggestions for CI users.

Degree of Hearing Loss Cafe(SNR @ 5 – 0) Restaurant (SNR @ 0 to -5) Bar (SNR @-10) 
Mild Hearing Aid with Directional Microphones Hearing Aid with Directional Microphones FM system in Zoom
Moderate Hearing Aid with Directional Microphones Either FM system in Zoom or hearing aid directional mic FM system in Zoom.
Moderate-Severe Either FM system in Zoom or hearing aid directional mic FM System in Zoom FM system in SuperZoom
Severe FM system in Zoom FM system in Zoom or SuperZoom FM system in SuperZoom
Profound FM system in Zoom FM System in SuperZoom FM system in SuperZoom
Cochlear Implant Directional mic on CI or FM system in Zoom Directional mic on CI or FM system in Zoom FM system in SuperZoom

So what are these microphone positions I am referring to?  Well, on the SmartLink and ZoomLink there are three different microphones.  The Omni mic is at the bottom and it picks up sound in all directions.  I never use this position in a noisy restaurant.  The middle microphone is called the Zoom position.  This picks up sound from the front, but not from behind.  The top microphone is referred to as the SuperZoom position.  This is a beam forming microphone that only picks up sound directly in front, but not from the sides or behind.

The SuperZoom and the Zoom microphones are the most effective in noisy environments like a restaurant

The trick to getting the most out of your directional microphone or FM system is getting the correct seat. You want to have the noise that you don’t want to hear BEHIND you.  A lot of people make the mistake of getting a table in the corner and having the person with hearing loss sit in the corner facing the entire restaurant.  This is the WRONG seat.  You want the background noise in your back.  This way your directional microphones, either on the hearing aid or the FM system, cancel out this noise and only pick up the person in front.

So here are the steps I take when going our for dinner.

  1. Try to find restaurants that are already quieter.  Choose restaurants that don’t blast music during dinner.
  2. Ask for a table in a quiet section of the restaurant if possible.
  3. Seat yourself with your back towards the background noise.  The waiter will try to seat you in the corner with your back to the wall.  He means well, but ignore him and seat yourself correctly.
  4. If you are a small group, seat the other people in front of you.  Ideally you should see the people you wish to hear in front of you and that’s it.  This way your microphones are only picking up those you wish to hear.  I then place my FM system on the table about half a meter away from the people I want to hear.
  5. If you are a larger dinner party, this presents a challenge.  You will still seat yourself as I described.  But your microphones will not always be pointing at the person who is talking.  You need to move your microphone towards the person you wish to converse with.

A couple more points to consider.

  1. If I am having dinner with just one other person, I may get his person to wear the transmitter.  But I do so after the waiter finishes blabbing about all the specials and takes my order.  (Some of these waiters seem to love the sound of their own voice because they talk way too much.  Hint to waiters: Less talk and better service = bigger tip from me).
  2. The FM microphones work best when they are as close to the talker as possible.  So place the transmitter on the table no more than half a meter away.
  3. When the waiter brings the food, grab your microphone off the table, then reposition it.
  4. When having Sushi, keep the microphone away from your Soya Sauce.  I have killed a few transmitters from spills.
  5. In large dinner parties, you will still miss out on some conversation because the microphone is only pointing at one or two people at a time.  Yes, this is still a limitation.  But you can either sit at home and sulk, or you can still be partially engaged.