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Managing Adults with Subjective Hearing Difficulties

Roup, Christina M., PhD; Whitelaw, Gail M., PhD; Baxter, Jodi, AuD

doi: 10.1097/01.HJ.0000553580.62101.62
Hearing Assessment

From left: Dr. Roup is an associate professor in the department of speech and hearing science and the director of the Speech Recognition and Aging Laboratory at The Ohio State University. Her research interests include aging, TBI, and binaural processing. Visit her work at Dr. Whitelaw is an audiologist, an associate clinical professor in the department of speech and hearing science, and the director of the Speech-Language-Hearing Clinic at Ohio State. Her research interests are auditory processing, particularly in relation to TBI and concussion. Dr. Baxter is an audiologist and an assistant clinical professor in Ohio State's department of speech and hearing science. Her research interests include adult amplification and audiologic rehabilitation.

An ideal clinical outcome is when a diagnosis of hearing loss agrees with the patient's self-perceived hearing problems and he or she proceeds with appropriate treatment. Not all patients, however, perceive a hearing problem in the face of a diagnosis of sensorineural hearing loss. The same situation can occur in the diagnosis of normal hearing. A patient may perceive clinically significant hearing problems despite presenting with normal pure tone detection thresholds.1 Figure 1 shows the potential relationships between a patient's self-perception and test results. In instances of disconnect between patient perception and pure tone threshold results, is it appropriate to rely solely on a single assessment of auditory detection ability to define an individual's full range of hearing and communication abilities?

Figure 1.

Figure 1.

Figure 2.

Figure 2.

Anecdotal clinical evidence is mounting regarding a population of adults with normal pure-tone detection thresholds who present with substantial hearing-related complaints in audiology clinics. Similarly, a growing body of research supports the categorization of a population that exhibits suprathreshold auditory processing deficits in the presence of normal pure tone thresholds or subjective hearing difficulties.2-6 These difficulties have been reported for middle-aged7,8 and older adults9,10 and for adults with a history of brain pathology (central auditory nervous system lesions,11,12 traumatic brain injury [TBI],13-14 history of noise exposure,15 etc.). Co-morbidities such as depression5 and emotional distress16 have both been associated with subjective hearing difficulties, potentially having a negative impact on a patient's quality of life. Accurate identification and diagnosis of adults with subjective hearing difficulties are therefore essential for the recommendation of appropriate treatment options that can improve a patient's quality of life.

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The assessment of adults with subjective hearing difficulties should include:

  1. a careful case history;
  2. an authentic subjective assessment;
  3. a standard audiometric assessment; and
  4. an extensive suprathreshold audiologic processing assessment.

A careful case history, the first step in any assessment protocol, is particularly important for adults who present with subjective hearing difficulties. The case history should include questions about specific situations where hearing difficulties arise, whether symptoms are new or long-standing, and if the patient has a history of concussion or TBI. For patients with a history of noise exposure, gathering further details about the type and duration of exposure is warranted (i.e., potential presence of hidden hearing loss17). Taking extra time to complete a patient's case history may help identify a potential etiology, and more importantly, ensure that the patient's concerns are being heard.

An authentic subjective assessment is used to further elucidate the symptoms experienced by adults with subjective hearing difficulties. Standardized questionnaires are a straight-forward and time-efficient means of detailing specific situations that patients consider problematic. For example, the Hearing Handicap Questionnaire for Adults18 and the Abbreviated Profile of Hearing Aid Benefit19 are quick and easy to administer and provide extensive normative data. The assessment should also consider the patient's cognitive status. Processing of auditory information is known to be affected by cognitive factors (e.g., working memory) and can be negatively impacted by cognitive impairment. Completing a cognitive screening measure such as the Montreal Cognitive Assessment20 (MoCA) is therefore warranted. The MoCA is a 30-item assessment of visuospatial and executive function, naming, memory, attention, language, abstraction, delayed recall, and orientation. It is also quick and easy to administer, and provides immediate information about the patient's cognitive status (scores <26 indicate cognitive impairment).

The standard audiometric assessment, including pure tone audiometry and word recognition performance in quiet, is important, but it should not conclude the assessment process. According to Erber's hierarchy of auditory skills (Fig. 2), detecting pure tones is the easiest task used in clinical audiology,21 and many adults with subjective hearing difficulties will report being told that “The audiogram says I have normal hearing” or “I have been told I have perfect hearing.” Therefore, assessment of suprathreshold abilities using measures that specifically address the patient's complaints and tax the auditory system are essential to the diagnosis of subjective hearing difficulties. At a minimum, a suprathreshold audiologic assessment should include speech-in-noise testing (i.e., the primary complaint of most patients with hearing difficulties). Many speech-in-noise tests designed for clinical use are commercially available, including the Quick Speech in Noise22 (QSIN) test, Hearing in Noise Test23 (HINT), and Words-in-Noise test24 (WIN).

In addition to speech-in-noise testing, suprathreshold audiologic assessment should include clinical measures of binaural speech recognition, such as dichotic listening (e.g., dichotic digits) or spatial benefit (e.g., Listening in Spatialized Noise test), and a measure of temporal processing, such as gap detection (e.g., Gaps-in-Noise test12) or release from masking (e.g., 500-Hz masking level difference26). Interpretation of the suprathreshold assessment is based on a comparison of the results to published norms. A finding of abnormal performance on one or more tests serves as a confirmation of the patient's complaints and provides the basis for consideration of audiologic treatment.

The sensitivity and specificity of the test battery described above are unknown. Several studies2,13,14 and clinical experience suggest that a majority of patients presenting with subjective hearing difficulties will exhibit abnormal performance on one or more tests. However, not all patients with hearing complaints will exhibit abnormal suprathreshold performance. One possibility for a lack of poor performance may reflect the fact that current tests are not sensitive to the subtle nature of subjective hearing difficulties, and new measures need to be developed. It is also important to acknowledge that subjective hearing difficulties may simply be the manifestation of a deficit in another domain, such as cognition (e.g., working memory, attention, etc.).

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Multiple treatment options are available for adults with subjective hearing difficulties. These can be categorized into bottom-up or top-down options. Bottom-up treatment strategies aim to provide patients with the best possible auditory signal by improving audibility of soft speech and the signal-to-noise ratio (SNR) and managing competing sounds. Examples include the use of hearing technology (e.g., mild-gain hearing aids and/or digital modulation systems) and traditional audiologic rehabilitation training (e.g., environmental management and communication strategies). Top-down strategies target the function of underlying auditory skills and enhance cognitive abilities by creating a highly redundant listening and learning environment. Examples of top-down auditory training programs include Listening and Communication Enhancement 27 (LACE;, Read My Quips (, clEAR 28 (, and Angel Sound (

The use of hearing technology to treat subjective hearing difficulties is gaining traction in clinical audiology. Mild-gain hearing aids enhance the audibility of soft speech and improve the SNR through adaptive directionality and noise reduction algorithms. Promising results for patients with subjective hearing difficulties have been reported in trials at The Ohio State University29 and the Walter Reed National Military Medical Center.30 Significant improvements in speech-in-noise performance and self-perceived hearing handicap have been seen in patients who used mild-gain hearing aids,29 suggesting that the use of amplification is a viable treatment option with this population.

Understanding that auditory complaints and suprathreshold auditory deficits can co-exist in the presence of normal pure tone thresholds is the first step in providing appropriate clinical care for adults with subjective hearing difficulties. An assessment protocol that incorporates standardized questionnaires and clinically validated suprathreshold measures enables audiologists to promptly verify patient complaints. If audiologists are to be essential in the lives of patients, going beyond the statement, “The audiogram says your hearing is normal,” is key. It is critical to listen to patient concerns, assess those concerns clinically, and provide support for treatment. Our own clinical experience and a growing body of research have established an evidence-based rationale for the use of audiological rehabilitation for these patients, including the use of technology such as mild-gain amplification.

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1. Jerger J Why do people without hearing loss have hearing complaints? J Am Acad Audiol. 2011 22 8 490
2. Saunders GH, Haggard MP The clinical assessment of obscure auditory dysfunction-1. Auditory and psychological factors. Ear Hear. 1989 10 200–208
3. Higson JM, Haggard MP, Field DL Validation of parameters for assessing obscure auditory dysfunction – robustness of determinants of OAD status across samples and test methods. Br J Audiol. 1994 28 27–39
4. Badri R, Siegel JH, Wright BA Auditory filter shapes and high-frequency hearing in adults who have impaired speech in noise performance despite clinically normal audiograms. J Acoust Soc Am. 2011 129 2 852–863
5. Tremblay K, Pinto A, Fischer ME, et al Self-reported hearing difficulties among adults with normal audiograms: The Beaver Dam Offspring Study. Ear Hear. 2015 36 6 e290–e299
6. Roup CM The impact of minimal to mild sensorineural hearing loss in adults. Perspectives of the ASHA Special Interest Groups. 2016; SIG 6, Vol. 1 (Part 2):55-64.
    7. Grose JH, Hall JW, Buss E Temporal processing deficits in the pre-senescent auditory system. J Acoust Soc Am. 2006 119 2305–2315
    8. Helfer KS, Vargo M Speech recognition and temporal processing in middle-aged women. J Am Acad Audiol. 2009 20 264–271
    9. Rodriguez GP, DiSarno NJ, Hardiman CJ Central auditory processing in normal-hearing elderly adults. Audiology. 1990 29 85–92
    10. Hannula S, Bloigu R, Majamaa K, Sorri M, Mäki-Torkko E Self-reported hearing problems among older adults: prevalence and comparison to measured hearing impairment. J Am Acad Audiol. 2011 22 550–559
    11. Rappaport JM, Gulliver JM, Phillips DP, Van Dorpe RA, Maxner CE, Bhan V Auditory temporal resolution in multiple sclerosis. J Otolaryngol. 1994 23 5 307–324
    12. Musiek FE, Shinn JB, Jirsa R, Bamiou DE, Baran JA, Zaida E GIN (gaps-in-noise) test performance in subjects with confirmed central auditory nervous system involvement. Ear Hear. 2005 26 6 608–18
    13. Bergemalm P, Lyxell B Appearances are deceptive? Long-term cognitive and central auditory sequelae from closed head injury. Int J Audiol. 2005 44 39–49
    14. Gallun FJ, Diedesch A, Kubli LR, et al Performance on tests of central auditory processing by individuals exposed to high-intensity blasts. J Rehabil Res Dev. 2012 49 7 1005–24
    15. Kumar UA, Ameenudin S, Sangamanatha AV Temporal and speech processing skills in normal hearing individuals exposed to occupational noise. Noise & Health. 2012 14 58 100–105
    16. Gopinath B, Schneider J, Hickson L, et al Hearing handicap, rather than measured hearing impairment, predicts poorer quality of life over 10 years in older adults. Maturitas. 2012 72 2 146–51
    17. Liberman MC, Epstein MJ, Cleveland SS, Wang H, Maison SF Toward a differential diagnosis of hidden hearing loss in humans. PLOS One. 2016 11 9 1–15
      18. Newman CW, Weinstein BE, Jacobson GP, Hug GA The Hearing Handicap Inventory for Adults: psychometric adequacy and audiometric correlates. Ear Hear. 1990 11 6 430–433
      19. Cox RM, Alexander GC The Abbreviated Profile of Hearing Aid Benefit. Ear Hear. 1995 16 176–186
      20. Nassreddine ZS, Phillips NA, Bédirian V, et al The Montreal Cognitive Assessment, MoCA: A brief screening tool for mild cognitive impairment. J Am Geriatrics Soc. 2005 53 695–699
      21. Erber N Communication and Adult Hearing Loss. Melborne, Australia; Clavis Press; 1993
        22. Killion MC, Niquette PA, Gudmundsen GI, Revit LJ, Banerjee S Development of a quick speech-in-noise test for measuring signal-to-noise ratio loss in normal hearing and hearing-impaired listeners. J Acoust Soc Am. 2004 116 2395–2405
        23. Nilsson M, Soli SD, Sullivan JA Development of the Hearing in Noise test for the measurement of speech reception thresholds in quiet and noise. J Acoust Soc Am. 1994 95 2 1085–99
        24. Wilson RH, Abrams HB, Pillion AL A word-recognition task in multitalker babble using a descending presentation mode from 24 dB to 0 dB signal to babble. J Rehabil Res Dev. 2003 40 4 321–328
        25. Cameron S, Dillon H Development of the listening in spatialized noise-sentences test (LiSN-S). Ear Hear. 2007 28 2 196–211
        26. Wilson RH, Moncrieff DW, Townsend EA, Pillion AL Development of a 500 Hz masking-level difference protocol for clinic use. J Am Acad Audiol. 2003 14 1–8
        27. Sweetow RW, Sabes JH The need for and development of an adaptive listening and communication enhancement (LACETM) program. J Am Acad Audiol. 2006 17 538–558
        28. Tye-Murray N, Sommers MS, Mauzé E, Schrow C, Barcroft J, Spehar B Using patient perceptions of relative benefit and enjoymen to assess auditory training. J Am Acad Audiol. 2012 23 623–634
        29. Roup CM, Post E, Lewis J Mild-gain hearing aids as a treatment for adults with self-reported hearing difficulties. J Am Acad Audiol. 2018 29 477–94
        30. Kokx-Ryan M, Nousak JM, Jackson JC, DeGraba T, Brungart DS, Grant KW Improved management of patients with auditory processing deficits fit with low-gain hearing aids. International Hearing Aid Research Conference; Lake Tahoe, CA; 2016.
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