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Wednesday, March 7, 2018


By Chun-Yi Lin, and Kuei-Ju Lin
 
Anyone with no experience with hearing loss may not know exactly how a child’s hearing is affected, what makes hearing easier, or how to get along with the hearing-impaired individuals. However, as long as we are willing to understand the facts about hearing loss, each of us can assist in improving the lives of people with hearing loss.  

Hearing loss ≠ myopia: Patients with these conditions need to wear assistive technology, but the aided performances are quite different!
"You cannot hear me even when I am next to you?" The teacher asked Huang (an 8-year-old boy who wears bilateral hearing aids) with sarcastic voices in front of all the classmates. The teacher apparently believes that Huang has been wearing hearing aids, and he should be able to hear well like a normal-hearing person. Therefore, the teacher refused to wear FM system in class. Huang was frightened by the scenes of chaos and he refused to go to school again.
 
Hearing loss is often compared to myopia (shortsightedness), in that hearing aids (HAs) and cochlear implants (CIs), like glasses, can correct sensory function. However, this comparison often leads to misunderstanding of hearing impairment; corrected hearing is not always the same as corrected vision. Particularly, hearing-impaired people sometimes have difficulty achieving fluent communication because of environmental sounds, reverberation, and sounds coming from varying distances, to cite a few (Fleming, Giordano, Caldara & Belin, 2014).
 
Even if the HA or CI is adjusted appropriately, these devices are still not the same as the normal-functioning ears. The individual differences and learning demands of hearing-impaired listeners are not simply measured or predicted in decibels.
 
“Hearing” ≠ “listening clearly” ≠ “comprehending” or “communicating”
“My child had already worn his hearing aids, why he cannot understand my words?” a mother asked, and she thought her child should understand everything she said.
 
“When my student wears hearing aids, he seems aware I am talking to him, but he still cannot give me the correct answer for what I am asking. Are the hearing aids useful?” A teacher wonders.
 
HAs or CIs adjustments mainly depend on the individual's detection of sounds. However, the ability to hear is not the same as hearing clearly. For example, when a person with hearing impairment can hear the words “white” and “wine” at 50 dB HL, he or she cannot necessarily distinguish these two words correctly at 50 dB HL. That’s why, we can observe some children to be able to detect sounds but unable to identify the right word/s spoken.
 
Comprehension is the reception of information, meaning, and intent, and communication is the two-way transfer of meaningful information (Kiessling et al., 2003). Although daily communication seems straightforward, people with hearing loss need to grapple with many factors like the effectiveness of HAs or CIs, their hearing and speech abilities, a speaker's accent, intelligibility, rate of speech, and noise and distance, which can make communication more challenging (Howell, 2008; Kilman, Zekveld, Hällgren & Rönnberg, 2014).
 
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Hearing voices and listening to the messages they convey clearly are the basic elements of comprehension and communication (as shown in Fig. 1). For instance, in school, if a student says "fidget spinner" to a hearing-impaired child, words that the latter may have never heard before, the hearing-impaired child may have trouble communicating because he or she does not comprehend the meaning of the words.
 
Language develops quickly and many new vocabularies emerge in our daily lives. Listening clearly is never enough for hearing-impaired people. The essential step is to comprehend the meaning of the content. Building up a two-way communication requires that the speaker and the listener both understand their conversation content. Thus, it’s vital to make sure that people with hearing loss could communicate with others by expressing thoughts and feelings that they deem important.  

Hearing level cannot fully represent hearing performance
“You are severe hearing loss, and your senior has the same hearing level as you do. If he can pass the English listening exam, so do you.” An undergraduate student encountered the difficulties of listening to the electrical signals of listening exam. He wishes he could apply for the exemption for examination. However, the school teacher believed that if the senior student who has the same hearing level could participate and pass the exam, this undergraduate is no exception without questioning.
 
Even two people with the same hearing level might have different learning and hearing needs. For example, student A and B both have average hearing threshold at 60 dB HL. Their teacher may expect for them to hear at same levels. However, student A has hearing threshold at 60 dB HL in three different frequencies (500 Hz, 1k Hz, and 2k Hz). On the other hand, student B has hearing threshold at 30 dB HL for 500 Hz, 60 dB HL for 1k Hz, and 90 dB HL for 2k Hz. To compare with student A, the student B’s high frequency is apparently poorer, but the low frequency is better. Consequently, we should be aware the student B may have more difficulties in perceive high frequency sounds (e.g., /s, sh, f, t/ etc.), and hearing level cannot fully represent hearing performance. So, it is recommended to always consider the hearing thresholds at different frequencies when providing hearing rehabilitation goals.
 
Every individual is unique, but there is one thing we all have in common: we all want to be treated with respect. We can show our respect for people with hearing loss by breaking down the myths and preconceived ideas to better understand their unique challenges.

Author information: Chun-Yi Lin is an audiologist at the Children’s Hearing Foundation in Taiwan, where Kuei-Ju Lin is assistant research fellow while working as a primary school teacher. Both are completing their PhD in Special Education.   
 
References
Edwards, A. (2016). The difference between “normal” hearing vs hearing with hearing aids. Retrieved from: http://www.starkey.com/blog/2016/11/ normal-hearing-or-hearing-loss.
Fleming, D., Giordano, B. L., Caldara, R., & Belin, P. (2014). A language-familiarity effect for speaker discrimination without comprehension. Proceedings of the National Academy of Sciences of the United States of America, 111(38), 13795-13798. doi: 10.1073/pnas.1401383111
Howell, P. (2008). Effect of speaking environment on speech production and perception. Journal of the Human-Environment System, 11(1), 51–57. doi.org/10.1618/jhes.11.51
Kaland, M., & Salvatore, K. (2002). The psychology of hearing loss. The ASHA Leader, 7(5), 4–15.
Kiessling. J., Pichora-Fuller, M. K., Gatehouse, S., Stephens, D., Arlinger. S., Chisholm, T. H., Davis, A. C., Erber, N. P., Hickson, L., Holmes, A. E., Rosenhall, U., von Wedel, H. (2003). Candidature for and delivery of audiological services: special needs of older people. International Journal of Audiology, 42(2), 92–101.
Kilman, L., Zekveld, A., Hällgren, M., & Rönnberg, J. (2014). The influence of non-native language proficiency on speech perception performance. Frontiers in Psychology, 5, 651. doi:  10.3389/fpsyg.2014.00651
Lederberg, A. R., & Golbach, T. (2002). Parenting stress and social support in hearing mothers of deaf and hearing children: A longitudinal study. The journal of Deaf Studies and Deaf Education, 7(4), 330-345. doi: doi.org/10.1093/deafed/7.4.330
Tye-Murray, N. (2015). Foundations of aural rehabilitation: children, adults, and their family members: 4th Edition. Clifton Park, NY: Delmar Cengage Learning.

Wednesday, March 7, 2018

​Missed our #HearingChat on World Hearing Day 2018? We've got you covered! Check out this recap of our lively conversation with ​Barbara Kelley, Executive Director of  the Hearing Loss Association of America (HLAA), and Clifford Olson, AuD, of  Applied Hearing Solutions​ and host of The Hearing Journal’s upcoming podcast. Click here

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Thursday, February 22, 2018

Enjoyed our February cover story about athletes with hearing loss? You might want to check out these inspiring books as well.

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Longshot: The Adventures of a Deaf Fundamentalist Mormon kid 
and his Journey to the NBA
by Lance Allred (basketball )





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Catch a Star: Shining Through Adversity to Become a Champion 
by Tamika Catchings (basketball) with Ken Petersen










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No Excuses: Growing Up Deaf and Achieving Super Bowl Dreams 
by Derrick Coleman (football)






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Kicking Up Dirt: A True Story of Determination, Deafness, and Daring 
by Ashley Fiolek (motocross) with Caroline Ryder








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In Quest of Gold: The Jim Ryun Story 
by Jim Ryun (track) with Mike Phillips










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A Reason to Believe: The Blaise Winter Story 
by Blaise Winter (football)
 






Sunday, February 4, 2018

By Gordon Glantz

When you are an athlete–particularly one competing in contact sports (football, ice hockey, boxing, etc.)–saying "I got my bell rung" is understood.

It is part of the common vernacular as "it's gut-check time" or "we need to leave it all out on the field."

While "getting your bell rung" is recognized as a concussion that at least causes temporary issues with one's senses, this whole "bell-ringing" issue in sports seems to be in the early stages of being fully comprehended.

After outside pressure from the medical community, the National Football League–followed by the National Hockey League and others–has been more cognizant of head injuries, initiating protocols and setting concussion standards about if and when a player can return to action.

"It's night and day," said Jim Kyte, who played in the NHL from 1983 to 1996, and one more year in the minor leagues, when asked about concussion protocol.

Kyte's war stories are first-hand. A frequent fighter, he was knocked out cold by frequent co-combatant Joey Kocur on the night of Nov. 25, 1988.

What the hundreds of thousands of YouTube viewers of the fracas don't realize is that the following night, in a 4-4 road tie against the St. Louis Blues, Kyte was back in the lineup.

"(Kocur) put a four-inch crack in my helmet," said Kyte. "I needed assistance to get off the ice. I played the very next night in St. Louis and had a headache for six weeks. If that happened today, I would not see the arena for at least six weeks. At the beginning of every season, players do neurological testing to establish a baseline. After a concussion, players are forbidden to step on the ice again until they can meet the established baseline test. Treatment has come a long way, too. They used to put people recovering from concussions in a dark room and keep brain stimulation to a minimum. Now they do the opposite. It is an ever-evolving field."

While that may be the case, the damage is often already done, as long-term effects of multiple concussions may not reveal themselves for decades.

Along with early dementia and ALS, there is a burgeoning concern by some in the medical community that hearing loss–which can be confused with, and just as easily dismissed as, age-related hearing loss–is another long-term effect.

John P. Leonetti, MD, of Loyola University Medical Center, is currently one of the leading voices at the forefront of the theory, adding that he has spoken to several former NFL players at the meeting arranged through the NFL players association "about their issues with tinnitus and hearing loss."

Lamenting the lack of specific studies in this area, Leonetti said: "Any athlete who has had a concussion will describe a buzzing or ringing in the ears. Typically referred to as 'having your bell rung.' This is a symptom of inner ear trauma that will increase the risk of hearing loss in a delayed fashion and will be most often seen with multiple concussions. The mechanism is thought to be related to direct blunt trauma to the inner ear organ (cochlea) or a stretch or pull on the hearing nerve (cochlear nerve). Usually, the issue is a delayed but progressive occurrence."

Blaise Winter played his whole NFL career with hearing loss related to being born with a cleft lip and palate, and now says his hearing has gotten worse since retiring from football in 1994 after 11 seasons.

Deaf in one ear and with diminished hearing in the other, Winter cannot say for sure that football affected his hearing, post-career.

"To be honest, man, I really don't know. I have no clue, but I wouldn't rule it out," said Winter, who recently had a benign brain tumor removed. "I suffered from infections, and you slowly lose your hearing. It's the way the world is. It's not yes or no, or all black and white. I don't know a person on earth who can say, 100 percent, that collisions to the head don't create something."

Like a lot of athletes, sports gave Winter a place in the world that he still would not have surrendered in exchange for post-career complications.

"I made my choices," he said. "I knew football was violent. I never ever left a game–ever. Football players are weird. We need to sweat and bleed. If I could sign up again, I would. It was the most exciting part of my life. It gave me a place, and nobody judged me. What am I supposed to do, curl up in a ball and die? Am I supposed to live in fear, wondering if this is related to this or that is related to that?

"I'm not looking to blame anybody. There's too much of that. I'm not going down that road. We all knew we were going to get the crap beat out of us, and that two-hand touch was over. It'll never be perfect. It'll never be violent but safe. If they eliminate the violence, there would be no one in the stands. No one is going to watch two-hand-touch football."

Still, Winter has added his name to class-action lawsuits of ex-players against the league, saying: "You automatically do those things because you have to. Most of us, all we want is to have our families taken care of if we can't care for them."

Going forward, Leonetti hopes a new kind of bell will ring—that of an alarm clock awakening the medical community up to the auditory issues connected to head injuries in sports.

He sees ways to at least prevent the side effects of sports-related head injuries. It begins with the recognition that it is an issue, and then some proactive approaches can follow.

"Better head and cervical spine protection are needed," said Leonetti, who recommends avoiding noise exposure in after-football life. "There should be a mandatory hearing screening of all players when they enter the NFL and 3-6 months following any confirmed concussion. The hearing level should be documented for all players at the end of their NFL careers."

 *Gordon Glantz is a freelance writer based in PA.

 

Friday, December 1, 2017

2017 has been a transformative year for audiology, with OTC hearing aids moving the game to a whole new batt​​lefield. How do the recent changes impact the hearing industry and its stakeholders? The Hearing Journal spoke with select industry representatives and here's what they have to say. 

“OTCs are coming and the obvious questions are what impact they will have on the established distribution system for hearing aids, and what opportunities/challenges they present to the hearing health care provider. One of the likely effects is a downward pressure on the average selling price (ASP) of a hearing aid. This will obviously impact overall revenue and profitability. There have been many discussions regarding how to stay price-competitive by using strategies such as unbundling. I am sure we will see a lot more of this. However, I will focus on a few other areas.

So what options are available for countering the effect of a lower ASP? First is operational efficiency. If service is key to patient satisfaction, what percentage of your practice cost is going toward patient facing interaction? Reduce costs not related to providing patient service. Go paperless and reduce data redundancy. Increase efficiency measures for common administrative tasks and clinical activities like charting and medical report writing.

Second is increase patient retention. Only about half of patients purchase their next set of hearing aids from the same practice. Increasing the hearing aid re-purchase rate can have a significant revenue impact on a practice. Develop a strategy for making sure your patients continue to come back to see you for hearing healthcare services. Make sure your practice has an efficient recall system in place, and a communication plan, for creating patient touch-points such as newsletters, birthday cards, etc.

Finally, leverage more revenue opportunities. Target your existing patient base for re-sell opportunities. This can be done with extended warranty sales, annual hearing evaluations, clean and check services, accessory sales, and most importantly by moving up the hearing aid re-sell point.

- Henrik Nielsen, MsC, President of Blueprint Solutions

“As OTC devices become available, there is no doubt the potential to bring new players into the market, outside the traditional suppliers, increasing competition and likely driving down costs to consumers. That said, we continue to see cases where companies unfamiliar with the complexities of treating hearing loss overestimate the ease by which they can access the market, the latest example being the reported closure of Doppler Labs. Whether or not decreased costs will result in increased use of amplification is up for debate. For instance, as discussed by Valente and Amlani (2017), we see that those markets providing hearing aids at little to no cost have similar adoption rates as those markets where hearing aids cost significantly more. No doubt, hearing aid adoption is a complicated issue and cost is but one factor. While the positives potentially include improved access to hearing aids and lower cost alternatives than have been traditionally available, there is also the potential of mistakenly shifting the focus of hearing healthcare towards the product as the sole solution for hearing difficulties.

This new OTC reality provides an opportunity to highlight the value of professional service in the treatment of hearing loss to the community at large. Research has repeatedly shown that patient outcomes with amplification are dependent on how a product is fitted (e.g., Leavitt and Flexer, 2012; Abrams, et al., 2012). Similarly, a soon-to-be published article by Valente and colleagues highlights the importance of verified audibility via real-ear measurements versus a ‘quick fit’ approach in both lab-based and real-world environments on speech recognition, sound quality, hearing aid benefit, and patient preference. I believe these factors will rise in importance with the advent of OTC devices because consumers will have no professional fitting assistance provided to them. Amlani and colleagues (2016; 2017) recently showed the positive impact that clinician services have on patient loyalty, satisfaction, willingness to pay, and perceived value of the provider. To the extent that OTC devices underperform relative to patient expectations, one might envision new business opportunities for clinicians to reach patients who might have otherwise simply lived with their mild to moderate hearing loss. These patients may look for value-added clinical services sooner, given a lower initial cost barrier and improved accessibility to their first amplification experience. Through objective measurements provided by modern audiometric and verification equipment, clinicians will have new opportunities to demonstrate and deliver superior amplification options.”

- John Pumford, AuD, Director of Audiology and Education at Audioscan

“First off, AuDStandard fully supports the independent practice owners and was strongly opposed to the legislation. Every week, I speak with a seasoned practice owner who is frustrated and looking for advice. Add OTC to this decade’s list of disruptors (corporate-owned retail, internet resellers, big box stores, and third-party referral companies), and you can imagine why owners are nervously raising their hands. The good news is that there are places for independent owners to turn.

Practice management groups will continue to grow as a distribution channel. To clarify, I am referring to organizations like AuDStandard that offer value added services that grow member practice’s revenue, while strengthening their foundations for future successes. While lower price is a basic premise of joining a group, it is a short-term benefit. 

Lastly, I see manufacturers strengthening their partnerships with practice management groups. They too see this segment growing as they allocate additional resources in staff (sometimes teams), event sponsorship, and price concessions to support their group partners.”

- Tucker Worster, Managing Director at AuDStandard, LLC

“The movement from traditional amplification towards a consumer electronics model will result in a large expansion of hearing care clients. In addition to our current “clinical clients/patients,” OTCs invite people who prefer to be treated as a consumer. This group may have had either limited access or even resistance to a clinical environment. The “consumer client” will now have hearing care products marketed and designed to appeal to them. For this group, audiologists and dispensers can play a role, not only as a provider of clinical hearing care, but also as an expert reseller of a consumer product. This new business model requires careful consideration of managing consumer expectations, while at the same time controlling touch points and time management. 

This field will quickly fill with new entrants, including well-known audio brands. Staking a position and remaining visible to all prospects is crucial. Ideally, audiologists and dispensers will find marketing messages that support the newly broadened range of available products. New consumers and traditional prospects alike will likely be drawn to familiar brands. Careful selection of OTC products, with focus on rounding out traditional offerings, could be one way to capture interest while also promoting advanced clinical care and performance. 

From there, differentiation can focus on the individualized and customized care that is only available from a hearing care provider. Only hearing care professionals exhibit long-term commitment to success that goes beyond the immediate transaction of an OTC delivery.
In addition to the business model shift from traditional care provider to reseller, the hearing care community will need to meet the needs of consumers who have greater choice than ever before. This will require a blending of both health care and retail approaches - ensuring accessibility, choice, and convenience in addition to the expertise that already exists.

On the instrumentation front, hearing care providers need access to objective tools that facilitate meaningful comparisons between devices. Verification and validation tools are now more important than ever. This is not limited to highlighting the benefit of a specific fitting, but also for objective comparison between the wide array of options, many of which may look similar but perform entirely differently. Design and development of hearing care tools that provide validation, optimal workflow efficiency, and ease-of-use in a hearing care environment, that’s where our focus lies as an audiologic instrumentation provider.”

- Peter Kossek, Senior Product Manager for Fitting Solutions, and Wendy Switalski, Sr. Market Development Manager for Fitting Solutions at Otometrics

“Time will reveal any lasting impacts of OTC hearing aids. In the near-term, competition will increase at the low end of market. This will motivate the audiology community to accelerate product and service innovation for people with mild hearing challenges or tight budgets. Since OTC hearing aids will appeal to some consumers, overall market penetration might increase, too. Most notably, however, OTC hearing aids could anchor consumers.

We are anchored when our decision-making is biased by previous information. With awareness of incumbent hearing aid brands being low outside the audiology community, mass marketing of OTC hearing aids by more familiar brands could anchor consumers on price and performance. Audiologists may see more patients who reject traditional amplification based on price as OTC hearing aids enter the market. They may also see more patients who expect specific product features or are skeptical of aid performance because of their OTC experiences.

Regardless of these impacts, the audiology community has the tools it needs to stay ahead. Audiologists can itemize their products and services, and unbundle them when appropriate, to make pricing transparent and professional value propositions clear. They can dispense hearing aids with open technology that allow competitive pricing today and upgradeability later when patient needs require or budgets allow. In addition, they can employ assistants and other staff to increase efficiency and margins. Most importantly the audiology community can emphasize patient experience.

Patient experience is affected by all products and interactions, both real and virtual, in the hearing healthcare continuum. A great experience includes robust, evidence-based technologies that help people hear better plus remarkable interactions from beginning to end. Increasingly patients expect a no-obligation hearing aid trial, for example, as other consumer industries have raised the bar. Today hearing aids must be respectfully dispensed with pricing transparency and flexibility, timeliness and perceived expertise. By emphasizing patient experience in this way, making value propositions clear and working efficiently, the audiology community can thrive.”

- Aaron C. Jones, Director of In-Clinic Success at Unitron


To hear from the leaders of AAA, ADA and ASHA, read our ​December covery story
To hear from ​AuD student leaders, read our online exclusive ​