The relationship between hearing status and the participation in different categories of work: demographics.

OBJECTIVE: To investigate the association between hearing status, socioeconomic status and work status. PARTICIPANTS: Cross-sectional data of 18-64 year old participants (N=1888) from the National Longitudinal Study on Hearing (NL-SH) were used. Both normal hearing and hearing impaired subjects participated. METHODS: Hearing ability in noise was measured with the National Hearing test, an online speech-in-noise test. Educational level, monthly income, being primary income earner and working status (i.e. paid employment, unemployed and looking for work, unfit for work, voluntary work, household work, being a student, or taking early retirement, and the type of work contract) were assessed with a questionnaire. Logistic regression analyses were applied. RESULTS: Participants with poorer hearing ability were less likely to be found in the upper categories of educational level and income, having paid work > 12 hours per week, being a student, or taking early retirement. On the other hand they were more likely to look for work or to be unfit for work. No associations were found with voluntary work and household work. DISCUSSION: Hearing ability seems to be related to both socioeconomic status and being employed. Our findings underline the importance of rehabilitation programs in audiology, aimed at supporting people with hearing impairment to help them to successfully enter or re-enter the workforce.

Analysis of failure of voice production by a sound-producing voice prosthesis.

OBJECTIVE: To analyse the cause of failing voice production by a sound-producing voice prosthesis (SPVP). METHODS: The functioning of a prototype SPVP is described in a female laryngectomee before and after its sound-producing mechanism was impeded by tracheal phlegm. This assessment included: perceptual voice evaluation of read-aloud prose by an expert listener; inspection of the malfunctioning SPVP; and aero-acoustical in vivo registrations using a computer-based data acquisition system. RESULTS: Sound-producing voice prosthesis speech is higher pitched, stronger, contains less aperiodic noise and requires a lower airflow rate than the patient's regular tracheoesophageal (TE) shunt speech. Tracheal phlegm caused malfunction of the vibrating silicone lip of the SPVP by causing it to stick to its stainless steel container in an opened position, thereby reducing the SPVP to no more than a regular TE shunt valve from a functional point of view. Tracheal phonatory pressure and dynamic vocal intensity range were not affected by the functional status of the SPVP. CONCLUSIONS: To exploit the advantages an SPVP could offer female laryngectomees with an atonic or severely hypotonic pharyngoesophageal segment, the sound-producing mechanism of the SPVP needs to be less vulnerable to tracheal phlegm.

Assessment of alaryngeal speech using a sound-producing voice prosthesis in relation to sex and pharyngoesophageal segment tonicity.

BACKGROUND: A pneumatic artificial sound source incorporated in a regular tracheoesophageal shunt valve may improve alaryngeal voice quality. METHODS: In 20 laryngectomees categorized for sex and pharyngoesophageal segment tonicity, a prototype sound-producing voice prosthesis (SPVP) is evaluated for a brief period and compared with their regular tracheoesophageal shunt speech. RESULTS: Perceptual voice evaluation by an expert listener and acoustical analysis demonstrate a uniform rise of vocal pitch when using the SPVP. Female laryngectomees with an atonic pharyngoesophageal segment gain vocal strength with the SPVP. Exerted tracheal pressure and airflow rate are equivalent to those required for regular tracheoesophageal shunt valves. However, communicative suitability and speech intelligibility deteriorate by the SPVP for most patients. Tracheal phlegm clogging the SPVP is a hindrance for most patients. CONCLUSIONS: The SPVP raises vocal pitch. Female laryngectomees with an atonic or severely hypotonic pharyngoesophageal segment can benefit from a stronger voice with the SPVP.

A speech enhancement scheme incorporating spectral expansion evaluated with simulated loss of frequency selectivity.

Hearing-impaired listeners often suffer from supra-threshold speech perception deficits. One such deficit is reduced frequency selectivity. We applied a speech enhancement scheme that incorporated spectral expansion in an attempt to reduce the effects of this deficit. The speech processing could contain up to three stages, a first in which the peak-valley ratio of the speech spectrum was enlarged to counteract the broadening of the auditory filtering, and a second in which the overall speech spectrum was modified to counteract the effects of upward-spread-of-masking, using a linear filter. The third stage was a noise suppression stage, applied before the spectral enhancement. The effectiveness of the speech processing with and without noise suppression was evaluated for various parameter settings by measuring the speech reception threshold (SRT) in noise, i.e., the signal-to-noise ratio at which listeners repeat 50% of presented sentences correctly. We used normal-hearing subjects. To simulate the loss of frequency selectivity we applied spectral smearing to the stimuli presented to the subjects. The speech material of the SRT tests was mixed with the noise before processing, and, when present, the smearing was applied last. The results indicated that for one specific parameter setting the SRT values decreased (i.e., improved) by approximately 1 dB when incorporating the spectral expansion together with the linear filtering. Employing either of these two stages separately did not improve the SRT. The application of the noise suppression stage did not further improve the SRT. A pilot study using hearing-impaired listeners showed more promising results for a female than for a male speaker.

Female-pitched sound-producing voice prostheses--initial experimental and clinical results.

In order to improve voice quality in female laryngectomees and/or laryngectomees with a hypotonic pharyngo-oesophageal segment, a sound-producing voice prosthesis was designed. The new source of voice consists of either one or two bent silicone lips which perform an oscillatory movement driven by the expired pulmonary air that flows along the outward-striking lips through the tracheo-oesophageal shunt valve. Four different prototypes of this pneumatic sound source were evaluated in vitro and in two female laryngectomees, testing the feasibility and characteristics of this new mechanism for alternative alaryngeal voice production. In vivo evaluation included acoustic analyses of both sustained vowels and read-aloud prose, videofluoroscopy, speech rate, and registration of tracheal phonatory pressure and vocal intensity. The mechanism proved feasible and did not result in unacceptable airflow resistance. The average pitch of voice increased and clarity improved in female laryngectomees. Pitch regulation of this prosthetic voice is possible with sufficient modulation to avoid monotony. The quality of voice attained through the sound-producing voice prostheses depends on a patient's ability to let pulmonary air flow easily through the pharyngo-oesophageal segment without evoking the low-frequency mucosal vibrations that form the regular tracheo-oesophageal shunt voice. These initial experimental and clinical results provide directions for the future development of sound-producing voice prostheses. A single relatively long lip in a container with a rectangular lumen that hardly protrudes from the voice prosthesis may have the most promising characteristics.

Deviant vocal fold vibration as observed during videokymography: the effect on voice quality.

Videokymographic images of deviant or irregular vocal fold vibration, including diplophonia, the transition from falsetto to modal voice, irregular vibration onset and offset, and phonation following partial laryngectomy were compared with the synchronously recorded acoustic speech signals. A clear relation was shown between videokymographic image sequences and acoustic speech signals, and the effect of irregular or incomplete vocal fold vibration patterns was recognized in the amount of perceived breathiness and roughness and by the harmonics-to-noise ratio in the speech signal. Mechanisms causing roughness are the presence of mucus, phase differences between the left and right vocal fold, and short-term frequency and amplitude modulation. It can be concluded that the use of simultaneously recorded videokymographic image sequences and speech signals contributes to the understanding of the effect of irregular vocal fold vibration on voice quality.

Effects of degradation of intensity, time, or frequency content on speech intelligibility for normal-hearing and hearing-impaired listeners.

Many hearing-impaired listeners suffer from distorted auditory processing capabilities. This study examines which aspects of auditory coding (i.e., intensity, time, or frequency) are distorted and how this affects speech perception. The distortion-sensitivity model is used: The effect of distorted auditory coding of a speech signal is simulated by an artificial distortion, and the sensitivity of speech intelligibility to this artificial distortion is compared for normal-hearing and hearing-impaired listeners. Stimuli (speech plus noise) are wavelet coded using a complex sinusoidal carrier with a Gaussian envelope (1/4 octave bandwidth). Intensity information is distorted by multiplying the modulus of each wavelet coefficient by a random factor. Temporal and spectral information are distorted by randomly shifting the wavelet positions along the temporal or spectral axis, respectively. Measured were (1) detection thresholds for each type of distortion, and (2) speech-reception thresholds for various degrees of distortion. For spectral distortion, hearing-impaired listeners showed increased detection thresholds and were also less sensitive to the distortion with respect to speech perception. For intensity and temporal distortion, this was not observed. Results indicate that a distorted coding of spectral information may be an important factor underlying reduced speech intelligibility for the hearing impaired.

The effect of intensity perturbations on speech intelligibility for normal-hearing and hearing-impaired listeners.

Hearing-impaired listeners are known to suffer from reduced speech intelligibility in noise, even if sounds are above their hearing thresholds. This study examined the possible contribution of reduced acuity of intensity coding to this problem. The "distortion-sensitivity model" was used: the effect of reduced acuity of auditory intensity coding on intelligibility was mimicked by an artificial distortion of the speech intensity coding, and the sensitivity to this distortion for hearing-impaired listeners was compared with that for normal-hearing listeners. Stimuli (speech plus noise) were wavelet coded using a Gaussian wavelet (1/4-octave bandwidth). The intensity coding was distorted by multiplying the modulus of each wavelet coefficient by a random factor. Speech-reception thresholds (SRTs) were measured for various degrees of intensity perturbation. Hearing-impaired listeners were classified as suffering from suprathreshold deficits if intelligibility of undistorted speech was worse than predicted from audibility by the speech intelligibility index model [ANSI, ANSI S3.5-1997 (1997)]. Hearing-impaired listeners without suprathreshold deficits were as sensitive to the intensity distortion as the normal-hearing listeners. Hearing-impaired listeners with suprathreshold deficits appeared to be less sensitive. Results indicate that reduced acuity of auditory intensity coding may be a factor underlying reduced speech intelligibility in noise for the hearing impaired.

Relations between intelligibility of narrow-band speech and auditory functions, both in the 1-kHz frequency region.

Relations between perception of suprathreshold speech and auditory functions were examined in 24 hearing-impaired listeners and 12 normal-hearing listeners. The speech intelligibility index (SII) was used to account for audibility. The auditory functions included detection efficiency, temporal and spectral resolution, temporal and spectral integration, and discrimination of intensity, frequency, rhythm, and spectro-temporal shape. All auditory functions were measured at 1 kHz. Speech intelligibility was assessed with the speech-reception threshold (SRT) in quiet and in noise, and with the speech-reception bandwidth threshold (SRBT), previously developed for investigating speech perception in a limited frequency region around 1 kHz. The results showed that the elevated SRT in quiet could be explained on the basis of audibility. Audibility could only partly account for the elevated SRT values in noise and the deviant SRBT values, suggesting that suprathreshold deficits affected intelligibility in these conditions. SII predictions for the SRBT improved significantly by including the individually measured upward spread of masking in the SII model. Reduced spectral resolution, reduced temporal resolution, and reduced frequency discrimination appeared to be related to speech perception deficits. Loss of peripheral compression appeared to have the smallest effect on the intelligibility of suprathreshold speech.

Alternative voice after laryngectomy using a sound-producing voice prosthesis.

OBJECTIVE: To improve the voice quality of female laryngectomees and/or laryngectomees with a hypotonic pharyngoesophageal (PE) segment by means of a pneumatic artificial source of voice incorporated in a regular tracheoesophageal (TE) shunt valve. STUDY DESIGN: Experimental, randomized, crossover trial. METHODS: The new sound source consists of a single silicone lip, which performs an oscillatory movement driven by expired pulmonary air flowing along the outward-striking lip through the TE shunt valve. A prototype of this pneumatic sound source is evaluated in vitro and in six laryngectomees. In vivo evaluation includes speech rate, maximal phonation time, perceptual voice evaluation of read-aloud prose by an expert listener, speech intelligibility measurements with 12 listeners, and self-assessment by the patients. Moreover, extensive acoustical and aerodynamic in vivo registrations are performed using a newly developed data acquisition system. RESULTS: The current prototype seems beneficial in female laryngectomees with a hypotonic PE segment only. For them the sound-producing voice prosthesis improves voice quality and increases the average pitch of voice, without decreasing intelligibility or necessitating other pressure and airflow rates than regular TE shunt speech. Pitch regulation of this prosthetic voice is possible, yet limited. CONCLUSIONS: The mechanism is feasible and does not result in unacceptable airflow resistance. For this new mechanism of alaryngeal voice to become an established technique for postlaryngectomy voice restoration, a voice suitably pitched for male laryngectomees has to be generated and a large part of the melodic and dynamic range of the sound source has to be attainable within physiological airflow rates.

Aero-acoustics of silicone rubber lip reeds for alternative voice production in laryngectomees.

To improve voice quality after laryngectomy, a small pneumatic sound source to be incorporated in a regular tracheoesophageal shunt valve was designed. This artificial voice source consists of a single floppy lip reed, which performs self-sustaining flutter-type oscillations driven by the expired pulmonary air that flows through the tracheoesophageal shunt valve along the outward-striking lip reed. In this in vitro study, aero-acoustic data and detailed high-speed digital image sequences of lip reed behavior are obtained for 10 lip configurations. The high-speed visualizations provide a more explicit understanding and reveal details of lip reed behavior, such as the onset of vibration, beating of the lip against the walls of its housing, and chaotic behavior at high volume flow. We discuss several aspects of lip reed behavior in general and implications for its application as an artificial voice source. For pressures above the sounding threshold, volume flow, fundamental frequency and sound pressure level generated by the floppy lip reed are almost linear functions of the driving force, static pressure difference across the lip. Observed irregularities in these relations are mainly caused by transitions from one type of beating behavior of the lip against the walls of its housing to another. This beating explains the wide range and the driving force dependence of fundamental frequency, and seems to have a strong effect on the spectral content. The thickness of the lip base is linearly related to the fundamental frequency of lip reed oscillation.

Measuring the threshold for speech reception by adaptive variation of the signal bandwidth. II. Hearing-impaired listeners.

In a previous study [Noordhoek et al., J. Acoust. Soc. Am. 105, 2895-2902 (1999)], an adaptive test was developed to determine the speech-reception bandwidth threshold (SRBT), i.e., the width of a speech band around 1 kHz required for a 50% intelligibility score. In this test, the band-filtered speech is presented in complementary bandstop-filtered noise. In the present study, the performance of 34 hearing-impaired listeners was measured on this SRBT test and on more common SRT (speech-reception threshold) tests, namely the SRT in quiet, the standard SRT in noise (standard speech spectrum), and the spectrally adapted SRT in noise (fitted to the individual's dynamic range). The aim was to investigate to what extent the performance on these tests could be explained simply from audibility, as estimated with the SII (speech intelligibility index) model, or require the assumption of suprathreshold deficits. For most listeners, an elevated SRT in quiet or an elevated standard SRT in noise could be explained on the basis of audibility. For the spectrally adapted SRT in noise, and especially for the SRBT, the data of most listeners could not be explained from audibility, suggesting that the effects of suprathreshold deficits may be present. Possibly, such a deficit is an increased downward spread of masking.

Method for the selection of sentence materials for efficient measurement of the speech reception threshold.

A method is described to select sentence materials for efficient measurement of the speech reception threshold (SRT). The first part of the paper addresses the creation of the sentence materials, the recording procedure, and a listening experiment to evaluate the new speech materials. The result is a set of 1272 sentences, where every sentence has been uttered by two male and two female speakers. In the second part of the paper, a method is described to select subsets with properties that are desired for an efficient measurement of the SRT. For two speakers, this method has been applied to obtain two subsets for measurement of the SRT in stationary noise with the long-term average spectrum of speech. Lastly, a listening experiment has been conducted where the two subsets (each comprising 39 lists of 13 sentences each) are directly compared to the existing sets of Plomp and Mimpen [Audiology 18, 43-52 (1979)] and Smoorenburg [J. Acoust. Soc. Am. 91, 421-437 (1992)]. One of the outcomes is that the newly developed sets can be considered as equivalent to these existing sets.

Preference judgments of artificial processed and hearing-aid transduced speech.

In order to assess the relative importance of various signal processing algorithms and distortions on hearing-aid preference, male and female speech was manipulated in a number of ways and subsequently presented to normal-hearing and hearing-impaired subjects (the latter having a mild sensorineural high-frequency hearing loss). Signal manipulations were artificial (e.g., filtering, compression, peak clipping, or adding noise) or were actual dummy-head recordings of five different hearing aids. Listeners judged the sounds in a pairwise-comparison format. Their task was to indicate the "hearing aid" they would prefer assuming they had to wear it all day. The data were analyzed with multidimensional scaling techniques; Principal Components Analysis revealed that the first two dimensions on which preference judgments were based, can be interpreted as (1) intelligibility or clarity, and (2) distinction between signal distortion and added background distortion. Furthermore, the results showed that normal-hearing subjects generally preferred the original signal, whereas hearing-impaired subjects were inclined to choose the signals with a high-frequency emphasis. Severe band-pass filtering or low-frequency emphasis were disliked, as was to be expected. Surprisingly, however, a soft background noise (S/N ratio of 25 dB) was often among the least preferred of all signals. The differences in preference between the five hearing aids were small, but consistent. For hearing-impaired subjects, hearing-aid ordering could be accounted for by the amount of low-frequency cutoff; for normal-hearing subjects both high- and low-frequency cutoff played a role. Results of a retest experiment with normal-hearing subjects, about one year later, showed that subjects' criteria remain remarkably stable.

Intensity discrimination of Gaussian-windowed tones: indications for the shape of the auditory frequency-time window.

The just-noticeable difference in intensity jnd(I) was measured for 1-kHz tones with a Gaussian-shaped envelope as a function of their spectro-temporal shape. The stimuli, with constant energy and a constant product of bandwidth and duration, ranged from a long-duration narrow-band "tone" to a short-duration broadband "click." The jnd(I) was measured in three normal-hearing listeners at sensation levels of 0, 10, 20, and 30 dB in 35 dB(A) SPL pink noise. At intermediate sensation levels, jnd(I) depends on the spectro-temporal shape: at the extreme shapes (tones and clicks), intensity discrimination performance is best, whereas at intermediate shapes the jnd(I) is larger. Similar results are observed at a higher overall sound level, and at a higher carrier frequency. The maximum jnd(I) is observed for stimuli with an effective bandwidth of about 1/3 octave and an effective duration of 4 ms at 1 kHz (1 ms at 4 kHz). A generalized multiple-window model is proposed that assumes that the spectro-temporal domain is partitioned into "internal" auditory frequency-time windows. The model predicts that intensity discrimination thresholds depend upon the number of windows excited by a signal: jnd(I) is largest for stimuli covering one window.

Measuring the threshold for speech reception by adaptive variation of the signal bandwidth. I. Normal-hearing listeners.

An adaptive test has been developed to determine the minimum bandwidth of speech that a listener needs to reach 50% intelligibility. Measuring this speech-reception bandwidth threshold (SRBT), in addition to the more common speech-reception threshold (SRT) in noise, may be useful in investigating the factors underlying impaired suprathreshold speech perception. Speech was bandpass filtered (center frequency: 1 kHz) and complementary bandstop filtered noise was added. To obtain reference values, the SRBT was measured in 12 normal-hearing listeners at four sound-pressure levels, in combination with three overall spectral tilts. Plotting SRBT as a function of sound-pressure level resulted in U-shaped curves. The most narrow SRBT (1.4 octave) was obtained at an A-weighted sound-pressure level of 55 dB. The required bandwidth increases with increasing level, probably due to upward spread of masking. At a lower level (40 dBA) listeners also need a broader band, because parts of the speech signal will be below threshold. The SII (Speech Intelligibility Index) model reasonably predicts the data, although it seems to underestimate upward spread of masking.

Compression and expansion of the temporal envelope: evaluation of speech intelligibility and sound quality.

Sensorineural hearing loss is accompanied by loudness recruitment, a steeper-than-normal rise of perceived loudness with presentation level. To compensate for this abnormality, amplitude compression is often applied (e.g., in a hearing aid). Alternatively, since speech intelligibility has been modeled as the perception of fast energy fluctuations, enlarging these (by means of expansion) may improve speech intelligibility. Still, even if these signal-processing techniques prove useful in terms of speech intelligibility, practical application might be hindered by unacceptably low sound quality. Therefore, both speech intelligibility and sound quality were evaluated for syllabic compression and expansion of the temporal envelope. Speech intelligibility was evaluated with an adaptive procedure, based on short everyday sentences either in noise or with a competing speaker. Sound quality was measured by means of a rating-scale procedure, for both speech and music. In a systematic setup, both the ratio of compression or expansion and the number of independent processing bands were varied. Individual hearing thresholds were compensated for by a listener-specific filter and amplification. Both listeners with normal hearing and listeners with sensorineural hearing impairment participated as paid volunteers. The results show that, on average, both compression and expansion fail to show better speech intelligibility or sound quality than linear amplification.

The self-reported handicapping effect of hearing disabilities.

This study investigates the extent to which individuals see themselves as being handicapped by a hearing disability. Self-reports were obtained with the Amsterdam Inventory for Auditory Disability and Handicap which distinguishes five basic disabilities: intelligibility in noise, intelligibility in quiet, localization of sounds, distinction of sounds and detection of sounds. Responses of 239 hearing-impaired people with varying types of hearing loss have been examined. The occurrence of the five disabilities in the population as well as the self-reported limiting and annoying effect per disability has been examined. This study shows that the handicapping effects of the disabilities do not have equal weights. Handicap resulting from the inability to understand speech in noise is most strongly felt. This paper argues that the type of disability jointly determines the severity of a person's handicap.

Assessing aspects of auditory handicap by means of pupil dilatation.

The demand on extra effort and concentration during listening are notorious handicapping effects of hearing impairment as is shown by self-assessment studies. In an attempt to explore new ways of assessing hearing handicap, the present study focuses on an objective measure of mental effort during listening. Pupil dilatation is used as the index of mental effort. Results for 14 hearing-impaired and 14 normal hearing listeners show a relation between pupil dilatation and difficulty in speech reception in noise, as manipulated by the speech-to-noise ratio. In addition the study shows that, with regard to effort and concentration, hearing-impaired subjects benefit less than normals from easier listening situations (e.g. at 5 dB above the individual speech-reception threshold). The results show a significant correlation between self-rated handicap and pupil dilatation.