Maximizing Communication with Hearing Aids and Implantable Devices Utilizing Wireless Accessories USC Speech & Hearing Research Center Jason P. Wigand, Au.D., CCC-A, ABA Clinical Director, Cochlear Implant Program H. Nicole Herrod-Burrows, Au.D.,CCC-A Clinical Assistant Professor Beth I. Hulvey, Au.D.,CCC-A Clinical Assistant Professor

Disclosures Jason P. Wigand, AuD, CCC-A, ABA Financial: Jason is an Assistant Clinical Professor and Clinical Director of the Cochlear Implant Team in the COMD Department at the University of South Carolina for which he receives a salary. He is a paid consulting audiologist for 360 Care, Inc. in Louisville, KY. Nonfinancial: Jason the President Elect of the South Carolina Academy of Audiology and a board member of the SC AG Bell Association for the Deaf and Hard of Hearing. H. Nicole Herrod-Burrows, AuD, CCC-A Financial: Nicole is an Assistant Clinical Professor member of the Cochlear Implant Team in the Department of Communication Sciences and Disorders at the University of South Carolina for which she receives a salary. Non-financial: Nicole is the Secretary-Elect of the South Carolina Academy of Audiology Beth I. Hulvey, AuD, CCC-A Financial: Beth is an Assistant Clinical Professor member of the Cochlear Implant Team in the Department of Communication Sciences and Disorders at the University of South Carolina for which she receives a salary. Non-financial: None

Consistent & appropriate ACCESS TO SOUND The Hearing Impaired Individual Needs, above all else… Consistent & appropriate ACCESS TO SOUND

Intelligibility vs. Audibility Audibility - the ability to detect the presence of speech but not identify the individual components. Intelligibility - the ability to discriminate individual phonemes and to hear word distinctions. Speech sounds must be consistently INTELLIGIBLE for optimal learning to occur.

What is a “Signal-to-Noise Ratio” “Signal-to-Noise Ratio”, SNR, is the relationship between the primary signal of interest and the background noise. Hearing impaired individuals need a +10 to +15 dB signal-to-noise for optimal speech understanding

What SNR’s do children need? Depends on age of child SNR (dB) required to achieve 95% speech intelligibility Grade 1: +15.5 Grade 3: +12.5 Grade 6: +8.5 Young adults (lab): +1 SNR of +10 dB 1 in 10 words not understood by Grade 1’s on average - Bradley, 2005 The younger the child the greater need for a higher signal to noise ratio.

Speech understanding in younger children Auditory system still developing Children’s auditory system not fully developed until late teens (+ 15 yrs) Children do not process sound as well as older children/adults Knowledge base of language not fully developed Don’t have language skills/knowledge to fill in the missing pieces Children rely more on “bottom-up” processing Younger children require better signal quality to understand speech well

Double Jeopardy Noise has more detrimental effect on Children learning in non-native language ESL, immersion Children with learning disabilities Children with behavioral, attentional difficulties Hard-of-hearing children (temporary, permanent) These kids are already struggling in quiet and now noise is added to the mix.

Ideal listening environment Teacher’s voice is clearly audible Little background noise Good room acoustics Good attenuation of sound from outside noise sources Reverberation (“echo”) in the classroom Examples? Good room acoustics includes attenuation of sound from outside the classroom and reduced reverberation. Carpet, Curtains, pictures, tennis balls on chairs, etc….

Acoustic characteristics of the ideal listening environment Recommended noise level of unoccupied classroom: ANSI S12.60: 35 dBA Teacher’s voice (relaxed) 60 dBA Reverberation time (RT) between 0.4 and 0.6 sec SNR > +15 dB Children may add another 10-20 dB of noise to the classroom Reverberation time is the time it takes for sound to be reflected back to its source.

Effects of poor SNR Students Teacher Other Poor understanding Decreased attention/Fatigue Decreased performance Reading deficiencies Reduced motivation Delayed language acquisition Teacher Contributes to increased vocal strain by teachers Other Fewer verbal interactions between teachers, students More time spent repeating instructions/information and less material covered

The “Listening Bubble” Every hearing impaired individual with hearing aids or a cochlear implant has a listening bubble The instrument’s microphone(s) has a limited pickup range Microphone sensitivity decreases as distance increases

The Distance Problem As the distance from a speaker INCREASES, audibility and intelligibility DECREASE NOTE: Inverse Square Law: For every doubling of distance, sound pressure level falls 6 decibels At a certain distance, the background noise can effectively mask a speaker’s voice.

Auditory Access Students will experience decreased speech perception abilities: with greater degree of hearing loss with increased amount of frequencies affected with both ears affected with increased distance between speaker and listener with presence of noise with group conversation Hearing loss of any kind decreases the amount of speech understanding a person can achieve. Speech understanding through listening is harder with…..

Are the acoustic conditions of our classrooms adequate? In general, no! Noise, reverberation time & estimated speech intelligibility (RaSTI) in most occupied classrooms are unacceptable (ASHA, 1990; Pekkarinen & Viljanen, 1990) Average levels from 43 classrooms (Bradley, 2005) Teacher’s voice (signal): 59.5 dBA (+ 5.5 )* Noise: 49 dBA (+ 7.3)* Mean SNR: +11 dB Bradley study: Eastern Canadian classrooms Measured in 43 Cdn classrooms mostly in small towns, rural settings Urban settings – likely higher outdoor noise levels Warmer climate – open windows, more outdoor noise in class

Types of Signal Technologies

Types of Signal Technologies What type of signal is being used to carry the message? FM – Frequency Modulation Infrared/wireless streaming (2.4GHz, 5.0GHz) Electromagnetic Induction (telecoil)

FM system Transmitter (w/ audio source) Teacher wears transmitter with microphone Sends signal to receiver Receiver Personal or Soundfield/whole classroom Helps improve the signal to noise ratio, reduce reverberation, and close the distance between the teacher and student

Types of Receivers Soundfield Signal sent to speakers around the classroom All students take advantage of better signal to noise ratio May not be as beneficial to hearing impaired student Neck Loop – moves with the individual Worn around hearing impaired student’s neck Utilizes a mixing ratio Interacts with device (hearing aid or cochlear implant) using the telecoil DEVICE MUST BE IN TELECOIL MODE! Plug-in – moves with the individual Plugs directly into hearing impaired student’s device (hearing aid or cochlear implant) Receiver Microphone Speakers Transmitter

Connecting with hearing devices (HAs/CIs): Neck loop FM systems Place loop around neck Activate telecoil mode Change to telecoil program using push button or remote

Connecting with hearing devices: (HAs/CIs) Plug in FM systems Plug the receiver into the port Switch into FM program, if needed

Connecting with Cochlear Implants and Hearing Aids: Wireless Streaming FM systems Need streamer and wireless program Plug in receiver to streamer Switch to wireless streaming program

Wireless Streaming Devices Streamer provides an interface with wireless inputs from landline and cell phones, TV, and Remote Microphones. In addition, new capabilities include Teleloop reception, FM receiver input, and compatibility with digital office phones and internet-based video chat programs. Streamer can also function as a remote control

Telecoil The telecoil (also called a T-coil) is a circuit in your hearing aid designed to pick up a magnetic signal. ​  The magnetic signal is created by an induction field from hearing aid compatible telephones, neckloops, silhouettes, and loop systems.​

T-Coils: Magnetic Connection Using Neckloops A neckloop converts a sound signal from an audio device (assistive listening device) into a magnetic signal.​ The telecoil (in the hearing device) picks up this magnetic signal and converts it into sound; the device amplifies the signal according to its prescriptive gain.

Telecoil uses With a T-coil, you can use​ Neckloop​ Silhouette​s

COCHLEAR CORPORATION/RESOUND Why You’re Here

ADVANCED BIONICS/PHONAK Understanding Hearing Loss

ADVANCED BIONICS/PHONAK Understanding Hearing Loss

So which system is best?

So which system is best? There is no single solution that is best for all individuals Must consider age of the individual hearing loss hearing aids or not individuals ability to use system and operate control educational placement school personnel who will “own” the system motivation of student and parents

Considerations The assistive system may or may not allow the student to also hear the environmental sounds along with the teacher’s voice the student may miss out on incidental language if the teacher’s voice is the only input Device settings allow the child to hear the teacher’s voice louder than the background noise Environmental sounds depend on the program-settings of the device Teacher can choose the directionality of the microphone to allow more or less background noise There may be electromagnetic interference from fluorescent lighting and computer equipment Troubleshooting may be difficult and confusing Have resources from parents, device mfg, or audiologist #44: Need one person on teach who is familiar with fm and feels comfortable troubleshooting. Students need to advocate. Often may not want to wear it. Vain.

Mixing ratio and assistive systems The ratio of sound from the accessory to sound from the environment / HA or CI microphone 1:1 or 50/50 ratio-equal sound from accessory and environment Allows individual to hear signal of interest, but also input from surroundings 2:1 or 75/25 ratio-more sound from the accessory than the environment Allows individual to hear signal of interest, still aware of input from surroundings; however streaming signal will be the dominant signal Aux/Accessory Only Individual only hears accessory signal Auto Connect/Plug-N-Play Hearing aid or cochlear implant switched automatically into accessory mode when accessory is plugged in

Additional Auditory Strategies Decrease distance to child Use short phrases Repetition Ask, “what did you hear?” Use a closed-set Auditory highlighting (stress, inflection)

Auditory Fatigue Alternate heavy listening demands with quiet activities Allow downtime privileges (quiet place) Reduce background noise like music Give extra processing time (e.g. pausing) Keep directions clear and short #21: Very common. Here from our adults that they just have to go “silent” Takes a lot more energy for a student with HL to function that child with normal hearing. When we suspect fatigue or even teach student to recognize their fatigue the following strategies maybe used.

Some Things to Have on Hand For each type of processor or hearing aid: Microphone tester and/or Lapel microphone Charged or new batteries New body cables and headpiece cables, BTE Cable, and Cable/Coils New Coil or Headpiece New specialty earhooks (t-mics, direct connections, etc) or accessories Remote Assistant or Remote Control Show items in box Invite people to come look at components at the end

Maintenance and Troubleshooting of the Speech Processor The speech processor needs to be checked daily to ensure optimal sound quality batteries charged, cables good, microphone clear, volume settings appropriate If any part of the system is malfunctioning, the recipient will not hear properly hear intermittently, distortion, static, not at all Don’t forget to try the spare speech processor and parts to compare to the “broken” one Need to know if it is an equipment issue or a mapping issue #22: Listening mic> having backup batteries. Really helps if student carries extra parts. If not, quick communication with parent so that parent can come in and troubleshoot or make an appt. with audiologist.

Use of a remote-microphone accessory designed for a CI sound processor provides superior speech recognition in quiet and in noise when compared with performance obtained with the CI sound processor alone (Wolfe et al., 2015). As [providers], we should do everything in our power to ensure that every child we serve is equipped with wireless remote microphone technology (Smith & Wolfe, 2014).

Children School (ADD WHICH TYPE OF CONNECTIVITY TO USE OPTIMALLY FOR EACH SETTING) Educational Technology FMs Home/Personal Headphones Personal Technology Computers Cell phones Tablets Social/sports activities Wireless Accessories

Adults Work FM Systems Work Technology Computer Landline/Office Phone Social Wireless Accessories Personal Headphones Personal Technology Computers Cell phones Tablets

QUESTIONS? CONTACT INFORMATION: USC Speech & Hearing Research Center 1224 Sumter Street, Suite 300 - Columbia, SC 29201 T: 803.777.2642 – F: 803.253.4143 Email: jwigand@mailbox.sc.edu

References Wolfe, J., Morais, M., & Schafer, E. (2015). Improving Hearing Performance for Cochlear Implant Recipients with Use of a Digital, Wireless, Remote-Microphone, Audio-Streaming Accessory. Journal of the American Academy of Audiology, 26(6), 532–539(8). Ciprut, A., Derinsu, U., Cesur, S., Çiçek, B., Özkan, B., & Yücel, E. (2015). Speech intelligibility with the phone clip in experienced cochlear implant recipients. Journal of International Advanced Otology, 11. Kolberg, E. R., Sheffield, S. W., Davis, T. J., Sunderhaus, L. W., & Gifford, R. H. (2015). Cochlear implant microphone location affects speech recognition in diffuse noise. Journal of the American Academy of Audiology,26(1), 51-8. Smith, J., & Wolfe, J. (2014). Counting Down the Highlights in CI Technology for Children. The Hearing Journal, 67(12), 26-28.