Hearing Aids, Hearing Assistance Technologies & Implants Chapter 3 Hearing Aids, Hearing Assistance Technologies & Implants

Latest Technology Phonak Roger Pen GN ReSound LiNX MED-EL Rondo

Question Which of the following is NOT true? A cochlear implant primarily amplifies sound A hearing primarily amplifies sound Hearing aids can be worn by infants from birth Less than 25% of Americans who could benefit from a hearing aid, wear a hearing aid Children function better with 2 cochlear implants

Purpose of Hearing Devices Make speech audible Make non-speech audible Restore range of loudness Alerting Keep in touch with environment

Hearing Challenges Hearing soft speech Hearing speech clearly Hearing speech in noisy environment Hearing speech in reverberant environment

Question The Augustana Chapel provides a conducive listening environment for persons with a hearing loss? Yes No

Definition of Hearing Aid Hearing Aids (noun, plural) 1 (archaic): electronic devices usually worn by a person for amplifying sound before it reaches the auditory receptor organs. 2 (modern): electronic devices worn by a person for processing sound to provide audibility and improve the signal-to-noise ratio before it reaches the auditory receptor organs. A New Definition for Modern Hearing Aids, Victor Bray, Ph.D. & Michael Nilsson, Ph.D., Auditory Research Department, Sonic Innovations, Inc.

Types of Listening Devices Hearing Aids ALDs/HAT Alerting Devices Brainstem Implants Middle Ear Implant Devices (BAHA & Envoy) Cochlear Implants (CI) Smartphone

Hearing Aid Styles Air conduction Bone Conduction Body Aid Glasses BTE RITE RITA ITE ITC CIC Bone Conduction Middle Ear Implant Devices (BAHA)               

Open Canal Receiver in the Ear RITE Receiver in the Aid RITA

Question A RITA hearing aid has the speaker component in the? Ear canal Hearing aid Middle ear Both ear canal and hearing aid

Bone Conduction HA When a conventional hearing aid cannot be worn due to microtia, atresia, obstruction in EAM, bone conduction hearing aids may be beneficial

BAHA (unisensory conductive loss) Bone Anchored Hearing Aid: Surgically embedded titanium "post" into skull with a small abutment A sound processor sits on abutment The implant vibrates the skull and stimulates the cochlea via bone conduction bypassing outer & middle ear Treatment for: Conductive loss Mixed hearing losses Unilateral sensorineural hearing loss, Chronic ear infections Congenital external auditory canal atresia

Alpha 2 (M) Bone Conduction Hearing System Sophono Inc. Differding Family Story and Sophono

MED-EL BoneBridge BoneBridge

SoundBite Hearing System Single sided deafness or conductive hearing loss No surgery required Removable and totally non-invasive No dental work or alterations to teeth BTE (behind-the-ear) microphone unit, housing receiver, wireless transmitter, and attached microphone Removable ITM (in-the-mouth) hearing device

Question The BAHA is? Air conduction hearing aid Bone conduction hearing aid Cochlear implant Brainstem implant

Envoy Implant Middle Ear Implant Envoy Medical

ESTEEM Implant Criteria at least 18 years of age stable, moderate-to-severe, bilateral sensorineural hearing loss (Range = 40 dB to 70 dB, defined as the average of pure tone thresholds at .5, 1, 2 KHz) speech recognition test score (WRS) greater than, or equal to, 40% in the worst hearing ear normal tympanic membrane & middle ear anatomy normally functioning Eustachian tubes worn properly fit hearing aids for at least one month no history of immune compromise or chronic staphylococcal skin infections room in their mastoid cavity to accept the ESTEEM components able to undergo a 3-4 hours general anesthetic

VIBRANT SOUNDBRIDGE Middle Ear Implant System (Medel) Placement Options: Ossicular RoundWindow

Hearing Aids Analog (conventional) Programmable (analog or digital)

Type of Hearing Aids Analog hearing aids pick up the sound and convert it into electronic signals. These hearing aids have trimmers that are manually adjusted by a hearing healthcare professional using a tiny screwdriver. Analog hearing aids are the least flexible, but also the least expensive, level of hearing aid technology. Programmable Programmable hearing aids must be connected to a computer in order for your hearing healthcare professional to make adjustments. These hearing aids offer more flexibility and can provide more features. Digital Digital hearing aids contain computer chips that convert the electronic signal into digital signals. The digital hearing aid can perform complex processing of the sound, such as reducing the intensity of loud background noise. Typically programmed via a computer, offers the greatest flexibility in its ability to match the hearing aid response to the hearing loss.

Question A receiver is another name for: Microphone Speaker Battery Amplifier

HA Components Microphone The microphone picks up sounds from the air and convert them into electrical signals. Amplifier The amplifier increases the intensity of the signals from the microphone. Filters modify the sounds so that only sounds which are relevant for the person are amplified. 'Loudspeaker' (Receiver) The third basic component is the 'loudspeaker' (receiver). It converts electrical signals into acoustic signals, which the person then hears. Small computer (Digital) (How it works) These three components exist in all hearing aids. Furthermore, in digital hearing aids a small computer can be programmed to manipulate the signals to fit the hearing loss of the individual hearing-impaired person.               

Batteries Various Sizes Chemical

Question Most hearing aid batteries are? Mercury Zinc-air Hallogen Sulfer-free

Earmolds Earmolds direct sound into the ear canal Variety of styles, colors, and other characteristics

Ear Impressions

Thin Tube (Open Canal)

HA Verification Real Ear (probe microphone) Speech tests (HINT, QuickSIN, BKB-SIN, SPIN) Subjective ratings of intelligibility and quality Loudness verification Questionnaires Functional gain ABR—for infants & young children

Probe Microphone Real Ear measures of sound pressure in the ear canal

Speech Tests HINT QuickSIN BKB-SIN SPIN

QuickSIN/BKB-SIN 1.   SNR loss of 0-2 dB: Normal to near-normal.  These patients will probably do well in noise with any hearing aids that provide undistorted output.  With directional microphones, they may hear better than their normal-hearing peers in noisy situations. 2.  SNR loss of 2-7 dB: Mild SNR loss.  Today’s directional microphones provide SNR improvements of 2 to 5 dB; with directional microphones, these patients should be able to hear almost as well as their normal-hearing counterparts in noisy situations. 3.  SNR loss of 7-15 dB: Moderate SNR loss.  While directional microphones will provide benefit for these patients, they cannot provide enough SNR improvement to allow the person to hear as well as their normal-hearing counterparts in noisy situations. Microphone arrays, such as the LinkiT, provide a 7 to 13 dB improvement in SNR. 4.  SNR loss greater than 15 dB: Severe SNR loss.  These patients need the maximum amount of SNR improvement, and FM systems are the technology of choice for these patients. Today’s ear-level FM systems are cosmetically appealing and are available in a wide range of hearing aids. Contact hearing aid manufacturers for more information.

Subjective Ratings Magnitude Production Category Scaling Pt is given a number and instructed to adjust a given parameter such as intensity, SNR, until that number is reached Category Scaling Pt is given a bounded scale such as 1 to 10 and asked to make a judgment of a speech passage based on intelligibility, quality, etc. Paired Comparisons Pt compares 2 different settings or hearing aids Clarity Pt asked to judge if sound is clear, distinct, pure…the opposite is diffuse

Loudness Restoration PAL Soft, comfortable, loud

Questionnaires APHAB SADL IOI SSQ GHABP PAL

Classroom Function Hearing Evaluation Using Clickers

Functional Gain Compare Aided vs. Unaided results In the example, the aided (green) thresholds are compared to the unaided thresholds for the right (red) and left (blue) thresholds

Ling 6 (HL) CD from Phonak

Ling 6 Sound Check Evaluate student at variety of distances to determine maximum distance Ling sounds heard Ling 6 Sound Check Chart Ling 6 Behavioral Daily Checklist Ling 6 Recording Chart

Ling 6 (HL) (free CD from Phonak)

UWO Plurals Test (free CD from Phonak)

UWO Plurals Test (free CD from Phonak)

Phonak Logatom Test Adaptive, computer controlled test Developed by Phonak Female speaker: “My name is…” Software track level in dB SPL that corresponds to 50% correct performance

Functional Listening Evaluation Determine how listening abilities are affected by noise, distance, and visual input in an individual’s natural listening environment Designed to simulate listening ability in situations that represent actual listening conditions in student’s classroom– not sound booth Administration of the evaluation, the student’s teachers, parents, and others gain understanding affects of adverse listening conditions encountered by the student. The evaluation results are also useful in justifying accommodations, such as assistive listening devices, sign language or oral interpreters, notetakers, captioning, special seating, and room acoustic modifications. Functional Listening Evaluation (Ying , 1990), (Ross, Bracken & Maxon, 1992)

FLE (cont.) Test administration takes approximately 30 minutes, including set up, with sentences and 20 minutes with words. 1. Auditory-Visual Close Quiet 2. Auditory Close Quiet 3. Auditory-Visual Close Noise 4. Auditory Close Noise 5. Auditory-Visual Distant Noise 6. Auditory Distant Noise 7. Auditory Distant Quiet 8. Auditory-Visual Distant Quiet

BKB SIN Test 10 sentences presented twice Increasing noise with each sentence SNR loss is the increased S/N ratio required by a listener to understand speech in noise BKB-SIN Test scores are reported in SNR Age normative data Allows audiologist to recommend appropriate assistive technology (e.g., omni-directional microphones, directional microphones, array microphones, FM systems, etc.) for students with HL to function in noisy situations Rich in semantic context, thus individuals with HL may be using top-down processing to improve their performance—does not tax bottom-up processing (Niquette et al 2003)

AB IT-MAIS (free iPad app)

LENA Developmental Snapshots

Hart & Risely

Oticon Hearing Diary App (iOS)

Oticon Functional Auditory Measures

Binaural vs. Monaural Advantage head shadow loudness summation localizing signal to noise ratio

Marvel Superhero HL A 4-year-old boy in Salem, MA who decided he did not want to wear his blue hearing aid to school anymore received some new inspiration after Marvel Comics designed a superhero after him.

Hearing Assistive Technology (HAT) Refers to devices and services that help deaf and hard of hearing people compensate for hearing loss Four primary categories of HAT: assistive listening devices alerting devices telecommunications devices visual communication devices

ALDs/HAT Function Catch the desired sound as cleanly as possibly (using well-selected microphones or a direct audio feed) Carry the sound intact via a specific type of transmission to a receiver (using infrared light waves, radio waves, induction, or wires) Couple the receiver to the hearing device or ear with as little background noise, feedback or distortion as possible (using neckloops, silhouettes, cords, headphones, or earbuds, depending on the user's equipment or lack thereof)

How ALDs/HAT Help Bypassing or minimizing background noise Overcoming the weakening effect of sound traveling through air Reducing the effect of poor room acoustics

HAT in Schools FM (radio frequency) preferred method Loop Induction (best in churches, homes, public meeting places) Infrared (not common in schools)(best in courtrooms) Hardwire systems (rarely found)

ALDS/HAT Loop Induction (Loop)(Electromagnetic) Radio Frequency AM FM (most used system in educational settings) FM plus Video 900 MHz (Starkey) 2.4 GHz (ReSound) Bluetooth Light (Infrared) Hardwire

Loop Induction Systems ALDs/HAT Loop Induction Systems

Looping the World with Audiocoil “The ordinary telecoil is perhaps the most common and most underestimated assistive listening device available for hearing impaired individuals today.” Ross (2002). “By changing the label to something more general—my suggestion is ‘audiocoil’—we do not restrict to a single function the way we think of the coil”. Ross (2006). Telecoils are about more than telephones. The Hearing Journal, 59, 24-28.

Loop Induction Components Microphone Loop amplifier Loop wire Telecoil

Loop Inducton Large area Home area (cushion loop pad)

Loop Options Silhouette: Neckloop: Portable Loop Near telecoil and signal relatively low therefore less susceptible to) most EMI (ElectroMagnetic Interference). Stay aligned relative to the hearing aid, they are less sensitive to head position. Neckloop: Drive both hearing aids (not with true stereo, but with a mono signal into both aids). Does not require wires running up the neck to the hearing aid(s), and can be worn under a shirt or jacket. Portable Loop Portable and able to carry Communicate one on one or in small groups, cars, etc.

Loop Induction Oval Window LI transmits via an electromagnetic field and require no receiver if the hearing aid wearer has a telecoil Oval Window

Loop Induction: Telecoils Inductive/audio loop systems transmit an electro- magnetic field Receivers are not necessary for hearing aid wearers with a telecoil (the telecoil itself is the receiver) Loop receivers can be provided for people who do not have telecoils. Loops are often permanently installed Silhouette inductor Neckloop Direct audio input

ClearSounds Quattro 4.0

Radio Frequency Systems ALDs/Hat Radio Frequency Systems

DAILY EVENT ASSISTIVE DEVICES Wake-up Alarm clock with vibrator and/or flashing light Land lines: home and work HAC phone, texting, built in amplification, ringer connected to visual or vibrator indicator, speech recognition 1:1 conversations Personal communication device (FM or infrared) Small group meetings Portable FM or infrared device placed in the middle of the table, loop, real-time captioning, 1:1 personal communicator Noisy restaurant Personal device with directional mike Large group meetings, Large-area infrared, FM or loop system Cell phone HAC phone, vibrate option, texting, high volume output  Vehicle 1:1 device with directional mike, emergency siren recognizer Family dinner Portable infrared or FM device in middle of table TV Captioning, Infrared, FM or loop connected to TV Door bell Vibrator worn on body and flashing lights Child care Baby monitoring device with vibrating annunciator Fire-alarm Flashing lights and/or vibrating annunciator

Question Radio Frequency can include: AM FM Bluetooth All the above A and B

Question Which is a digital signal for HAT technology? AM FM Bluetooth All the above A and B

Radio Frequency FM (radio frequency) systems transmit radio waves to receivers Used in classrooms and where mobility is required Not affected by light, able to cover 100+ feet, and are portable Systems can be set to different frequencies to allow several uses in same place Miniaturized FM receivers using the 216-217 mhz range are available as an attachment for some BTEs and CI processors Some FM transmitters have built-in microphones that can switch from an omnidirectional, directional and/or super directional setting Susceptible to some radio interference

Radio Frequency Systems Phonak Multi-frequency receivers (MLxS, ML8S and ML9S) synchronized automatically using the WallPilot or directly with Campus S. The MLxS also has a standardized connector that makes it compatible with both Phonak hearing instruments and BTEs from other manufacturers Single-frequency receivers (MLx, ML8, ML3-7) single-frequency receiver which clips to BTE hearing aid MicroLink CI S miniaturized FM receiver for cochlear implant users that attaches directly to the bodyworn speech processor WallPilot hangs at the entrance to a room and performs an Automatic Frequency Synchronization (AFS) and ensures that the multi-frequency receivers of wearers entering the room are automatically set to the correct frequency

Phonak Dynamic FM Inspiro Phonak Dynamic Inspiro Studies show students with Dynamic FM on average improve 50% in loud noisy situations Recommended for students wearing hearing aids or cochlear implants

Phonak Roger Roger Phonak Roger Pen 2.4 GHz

FM Radio Frequency Systems Phonic Ear Sprite BTE FM used by people of all ages who have hearing abilities ranging from normal to profound loss used in the car, at restaurants and parties, watching TV, on tours, and talking with others across a distance. students with ADD or CAPD benefit Toteable

Oticon (FM)

AVR (FM) AVR Sonovation was one of the first companies to develop FM receivers inside the BTE hearing aid.

Audiovisual FM AudiSee Assistive device to facilitate speechreading and hearing, primarily in educational settings Portable Camera and microphone worn by speaker less strain to speechread when teacher moves about the classroom or turns to write on the blackboard

Bluetooth 4.0 LE Bluetooth is a short-range, wireless, digital communication standard. Bluetooth devices send data and voice in a clean, clear, digital format audio signal is not subject to the same sources of signal degradation that sometimes compromise the quality of analog (FM, AM or inductive) transmissions. Radio frequency transmission in the 2.4-gigaHertz range

BlueTooth Advantages Bluetooth signal is extracted from the noise; it alone is transmitted and amplified, while noise is rejected. Minimizes battery consumption for portable devices Also, it places an intentional limit on the range of transmission — the most common version has a range of 10 meters which helps to avoid interference among nearby devices Walls and other obstacles have a negligible effect on Bluetooth transmission

BlueTooth Interference Advantage

ALDs/HAT Infrared Systems

Infrared Infrared systems transmit sound via infrared light waves to receivers worn by users IR commonly used in courtrooms, movies, and live performance theaters, conventions and with TVs (signal contained in room) Infrared systems may be susceptible to interference from bright sunlight or fluorescent lights Requires line-of-sight between the IR transmitter and the receiver, IR waves can effectively reflect off some surfaces, depending upon the power of the transmitter                       

Sound Field Systems Portable or permanently installed speakers placed close to listeners at a distance from the speaker They are most often used in classrooms and are helpful for people with mild to moderate loss They offer a secondary benefit to those who are not HOH Wireless speakers perform the same function. Audio Enhancement Video 1 LightSpeed

Phonak Dynamic Soundfield Phonak Dynamic Soundfield with Inspiro

Vibrotactile Devices Tactaid - small, battery-powered instruments that can help a deaf person understand sounds by allowing the user to feel the unique pattern of vibrations present in every sound

ALDs (HAT) Assistive listening devices and systems (including couplers and accessories for hearing aids and cochlear implants) Alerting devices and systems (weather, doorbell, phone, fire/smoke alerting devices) Amplified telephones (some of which have tone controls and/or audio output jacks) and telephone accessories TTYs (teletypewriters), VCO (Voice Carry Over) phones, CapTel, and telecommunications-related software and services Speech-to-text services and technology, such as CART (Computer Assisted Realtime Transcription), C-Print and CAN; closed caption decoders Videophones and other visual technology to facilitate speechreading and/or the use of sign language or cued speech

Question POTS Perry on teaching science Plain old telephone system Peaches on tea and sun Popular only TV shows None of the above

TELECOMMUNICATIONS Television Telephones POTS (plain old telephone system) Cell Phones

TELECOMMUNICATIONS: TV Television There are two ways to understand communication on TV: hear it or read it: closed captions, a menu option ability built into most TVs (TVs over 13 inches in diameter sold after 1993). HAT Increase volume on a personal receiver, not TV sound across the room Most are cordless and utilize different types of technologies Some devices marketed specifically for TV use Hearing aid users and non hearing aid users can use technologies

TELECOMMUNICATIONS: PHONES Two needs with phones: understanding conversation on the phone knowing phone is ringing There are two ways to understand the conversation on the phone: hear it or read it. There are four basic types of telephone amplifiers: portable, handset, inline and phone set.

TELECOMMUNICATIONS: PHONES Types of telephone amplifiers: Portable Handset Inline phone set

TELECOMMUNICATIONS: PHONES Portable amplifiers Not recommended for regular use Inconvenient--strapped onto a phone handset and need to be turned off after use or the battery runs dead Occasionally helpful with wireless phones that do not have amplification May make a phone hearing aid compatible Peace of mind for use while traveling

TELECOMMUNICATIONS: PHONES In-line amplifiers devices that connect to the jack in the phone where the curly handset cord plugs in may be a good value, as some go as high as 40 dB Compatible with most phones, home and business.

TELECOMMUNICATIONS: PHONES Amplification handsets Replace original phone receiver Less popular Adjustment controls in the handle In some cases, not electrically compatible universal amplifier (battery or A/C powered) used for compatibility

TELECOMMUNICATIONS: PHONES Amplified phones Many features Some provide 50 dB gain. Louder not always helpful for clarity Some provide tone control Additional features (optional) variable ringer sounds built-in ringer light flash big buttons for dialing audio jack HAT may require electrical outlet connection cordless amplified phones

TELECOMMUNICATIONS: PHONES Other telecommunications devices pagers cell phones fax email texting Phone company custom calling helpful features caller ID (for calling back the person through relay distinctive ringing (for differentiating voice and TTY calls) voice mail (to listen to voice messages with amplified phones or via the relay service)

Internet Email Social networks (FaceBook, Twitter, etc.) FaceTime, Google Hangouts and IP Relay IP VRS CapTel Web CapTel/mobile CapTel

Hearing Aids and You!