2. 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

3. 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

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

5. 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.

6. 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

7. What SNR’s do children need?
Depends on age of child
SNR (dB) required to achieve 95% speech intelligibility
Grade 1:
Grade 3:
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.

8. 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

9. 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.

10. 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….

11. 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 dB of noise to the classroom
Reverberation time is the time it takes for sound to be reflected back to its source.

12. 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

13. 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

14. 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.

15. 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…..

16. 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): 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

17. Types of Signal Technologies

18. 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)

19. 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

20. 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

21. 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

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

23. 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

24. 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

25. 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.​

26. 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.

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

28. COCHLEAR CORPORATION/RESOUND
Why You’re Here

29. ADVANCED BIONICS/PHONAK
Understanding Hearing Loss

30. ADVANCED BIONICS/PHONAK
Understanding Hearing Loss

31. So which system is best?

32. 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

33. 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.

34. 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

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

36. 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.

37. 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

38. 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.

39. 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).

40. 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

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

42. QUESTIONS?
CONTACT INFORMATION:
USC Speech & Hearing Research Center
1224 Sumter Street, Suite Columbia, SC 29201
T: – F:

43. 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),