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Nuts & Bolts: Five Testing Essentials Help Even Those with Profound Hearing Loss

Martin, Robert L. PhD; Asp, Carl W. PhD

doi: 10.1097/01.HJ.0000414381.05364.90
Nuts & Bolts

Dr. Martin has been a dispensing audiologist in private practice in the San Diego area for more than 30 years. He has been writing Nuts & Bolts since 1989. Dr. Asp is a professor emeritus and the director of the Verbotonal Research Laboratory at the Department of Audiology and Speech Pathology at the University of Tennessee, Knoxville.



Conventional hearing tests using pure tones and words are helpful in providing information for patients with moderate hearing loss. Test data will suggest near normal hearing with amplification if a patient has a flat 60-dB hearing loss and a 100 percent word-understanding score. A patient's hearing is poor when pure-tone thresholds are near 90 dB, for example, and the word-understanding scores are approximately 20 percent in both ears, but there is no way to dissect this information to help the patient.



Other tests are needed for a broader picture. We need specific information on techniques that will improve the patient's ability to communicate. We need specific information to decide whether to recommend hearing aids, frequency-modulation systems, cochlear implants, or a combination of these. It should guide us in setting up an auditory rehabilitation program for the patient. We also need to evaluate the social support structures that help patients cope, learn, grow, and thrive.

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“Joyce,” 48, works as a research secretary. She has a sharply sloping, acquired hearing loss configuration: 30 dB at 250 Hz, 40 dB at 500 Hz, 50 dB at 1,000 Hz, 100 dB at 2,000 Hz, and no response at 4,000 Hz.

An audiologist fitted Joyce with a pair of hearing aids, but she could not tolerate them, which was discouraging. Therefore, her audiologist advised against using them because her word-understanding scores were poor — approximately 28 percent bilaterally as measured by standard testing techniques. Joyce was referred to our clinic for auditory rehabilitation and counseling.

Joyce's hearing and communication abilities can be markedly improved. Let's first consider her hearing evaluation: Joyce's conventional hearing tests reveal sharply sloping hearing loss with poor word-understanding ability. Some audiologists would read that and conclude there's little that can be done. This isn't true, there's a great deal we can do for Joyce!

Conventional hearing tests tell us when hearing is poor; in this case they showed large zones of deafness in Joyce's hearing. Newer technology has emerged that help us evaluate dead zones, which Joyce unquestionably has in her hearing profile. We should focus on the zones that not only function, but under ideal situations, function well. Finding the good zones is as important as finding the bad ones. The combination of good zones and other information channels are called the “optimal frequency response” in our clinic. We need tests that show us functional zones, not zones of deafness, and these tests should be performed under ideal situations for Joyce. Can Joyce hear well and communicate better if we stack the odds in her favor?

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We can find Joyce's maximum hearing zone if we modify her hearing test by adding five essentials.

  • Use full sentences instead of individual words such as “yard” and “carve” that are difficult to hear.
  • Allow or remove lip-reading cues. Allowing cues provides large amounts of information in a conversation. Many audiologists don't appreciate how much speech information becomes available by lip reading. In mathematics, 2 + 2 = 4, but the combination of auditory cues and information obtained from the lips and other channels is 2 + 2 = 8 or 2 + 2 + 2 = 12.
  • Deliver speech through a master hearing aid that filters and shapes sounds. This also removes excessive speech energy by notch filtering, avoiding the upward spread of masking and overloading the ear and brain with high-intensity, unnatural speech sounds.
  • Place a vibrotactile stimulator (a speech vibrator) on the head or in the hands. A lot of rhythm and intonation is contained in the lower frequencies (below 300 Hz), and much of this information is passed through the stimulator. Sentences are easier to understand when inflection and rhythm are added.
  • Activate and enhance the neuroplasticity in the brain, inducing motivation. Teach the brain to compensate and make sense of conversational speech presented in a normal (high-speed) manner.

When we use all five essentials, Joyce receives a large amount of speech information, diminishing the effect of her profound hearing loss. A high-quality microphone is held close to her mouth during evaluation, which crams additional information into the communication pathway. I asked her, “Can you hear me?”

She answered, “Yes, I hear you well.”

I covered my face and said, “Good. Listen to me and repeat. ‘It's getting cold. I want a cup of coffee.’”

Joyce smiled and repeated my words. I then asked her, “Did you go to the football game last Saturday?”

She laughed and said, “No,” and then remembers she was supposed to repeat what I said. She responded, “No. I did not go to the football game last Saturday,” adding, “We won, didn't we?”

Joyce is elated that she is communicating. “I can really hear with this system,” she said. “I wish I could hear like this all the time!”

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Joyce's conventional hearing tests indicated that her hearing was poor, and from a traditional diagnostic point of view, it could not be helped. Word-understanding scores as measured by these standardized tests were not far from zero percent.

But we altered the hearing test by incorporating five essentials, and created an ideal listening environment. The amount of speech information presented to her was markedly increased. Some conventional audiologists would say we cheated, but how you define the circumstances isn't important; the results are what matter. Joyce can now engage in live, exciting conversation in this ideal situation, and she's thrilled. This brief, successful, clinical session is the starting point for Joyce's auditory rehabilitation. It's an artificial environment, but it's a great start. Future articles will discuss how to go from this starting point to communicating in normal situations with coworkers, family, and friends.

It is our goal to help Joyce hear like this all the time through long-term treatment, the best amplifying systems, and continuous professional support. This approach is magical when you can show a patient that he can communicate well under ideal circumstances. Many people with severe hearing loss have given up after unsuccessfully trying to communicate over and over. This strategy gives them hope, and revives their motivation. Is there a greater joy than helping people live a better, fuller life? Our lives have been enriched by using this strategy as well.

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