Efficacy of 3 commonly used hearing aid circuits: A crossover trial. NIDCD/VA Hearing Aid Clinical Trial Group.

CONTEXT: Numerous studies have demonstrated that hearing aids provide significant benefit for a wide range of sensorineural hearing loss, but no carefully controlled, multicenter clinical trials comparing hearing aid efficacy have been conducted. OBJECTIVE: To compare the benefits provided to patients with sensorineural hearing loss by 3 commonly used hearing aid circuits. DESIGN: Double-blind, 3-period, 3-treatment crossover trial conducted from May 1996 to February 1998. SETTING: Eight audiology laboratories at Department of Veterans Affairs medical centers across the United States. PATIENTS: A sample of 360 patients with bilateral sensorineural hearing loss (mean age, 67.2 years; 57% male; 78.6% white). INTERVENTION: Patients were randomly assigned to 1 of 6 sequences of linear peak clipper (PC), compression limiter (CL), and wide dynamic range compressor (WDRC) hearing aid circuits. All patients wore each of the 3 hearing aids, which were installed in identical casements, for 3 months. MAIN OUTCOME MEASURES: Results of tests of speech recognition, sound quality, and subjective hearing aid benefit, administered at baseline and after each 3-month intervention with and without a hearing aid. At the end of the experiment, patients ranked the 3 hearing aid circuits. RESULTS: Each circuit markedly improved speech recognition, with greater improvement observed for soft and conversationally loud speech (all 52-dB and 62-dB conditions, P

An individualized, sensitive frequency range for early detection of ototoxicity.

OBJECTIVE: The aim of this study was to identify auditory frequencies at which serial threshold testing would provide the greatest sensitivity for early detection of ototoxicity. The overall objective is to develop a more time-efficient ototoxicity monitoring protocol. DESIGN: Threshold data were analyzed from 370 hospitalized patients treated with aminoglycoside antibiotics (AMGs) or cisplatin (CDDP) who received serial auditory monitoring before, during, and after treatment at conventional (0.25 to 8 kHz) and high (9 to 20 kHz) frequencies. RESULTS: For patients showing hearing changes due to ototoxicity, a frequency range was identified for its apparent high sensitivity to initial ototoxicity. This sensitive range is identified according to an individual's hearing threshold configuration, and is, therefore, unique for each patient. The range consists of five frequencies, generally separated by 1/6 octave, e.g., 8, 9, 10, 11.2, and 12.5 kHz. To determine frequencies and combinations of frequencies that were most often involved in ototoxicity detection, threshold data in the sensitive range were analyzed in detail. This analysis suggests that patients receiving treatment with AMG or CDDP can be monitored for hearing thresholds at only five frequencies, resulting in an 84% detection rate for AMG and 94% for CDDP compared with monitoring at all conventional and high frequencies. CONCLUSIONS: This comprehensive analysis supports earlier observations that a sensitive, limited frequency range exists in which serial threshold monitoring will provide early warning of ototoxicity before effects in the speech frequency range. This finding is now being evaluated in a prospective investigation.

High-frequency audiometric monitoring strategies for early detection of ototoxicity.

Therapeutic drugs such as the aminoglycoside antibiotics (AMG) and the chemotherapy agent cisplatin (CDDP) are known to cause irreversible hearing loss, typically affecting highest frequency hearing first with progression of loss to the lower frequency regions. Conventional (0.25-8 kHz) and high-frequency (9-20 kHz) serial hearing threshold monitoring was done in 123 hospitalized patients (222 ears) administered AMG or CDDP. Of ears showing a decrease in sensitivity corresponding with treatment, 62.5% demonstrated initial hearing loss solely in the high-frequency range, 13.5% first showed loss only in the conventional-frequency range, and 24.0% showed loss in both frequency ranges concurrently. Thus, if only high frequencies had been monitored, early change in auditory sensitivity would have been detected in 86.5% of these patients. Further analysis revealed a range of five frequencies, specific to each individual's hearing threshold configuration, in which initial ototoxicity appeared most likely to be detected. Testing only these five frequencies would have identified 89.2% of ears that showed change. The results of this study confirm the need to serially monitor auditory thresholds, especially in the high-frequency range, of patients receiving ototoxic drugs. A shortened five-frequency monitoring protocol is presented and suggested for use with patients unable to tolerate lengthy audiometric testing procedures.

Quantifying ear-canal geometry with multiple computer-assisted tomographic scans.

Several audiological tests require knowledge of the sound-pressure spectrum at the eardrum. However, microphone readings are typically made at another, more-accessible position in the auditory canal. Recordings are then "adjusted" to the plane of the eardrum via mathematical models of the ear canal and eardrum. As bandwidths of audiological instruments have increased, ear-canal models have, by necessity, become more precise geometrically. Reported herein is a noninvasive procedure for acquiring geometry of the ear canal in fine detail. The method employs a computer-assisted tomographic (CAT) scanner in two steps to make radiographic images of parasagittal cross sections at uniform intervals along the lateral length of the canal. Accuracy was evaluated by comparing areas of cross sections appearing in radiographic images of a cadaver ear canal to cross sectional areas of corresponding michrotome slices of an injection mold of the same canal. Percent differences between these two areas had a mean value of 9.65% for 26 different cross sections of the one ear canal studied. Ear canal volume estimated from the CAT images was 6.12% different from the estimated volume of the injection mold: an improvement over the reported 39% maximum error of conventional acoustic volume measurements.

Measurements of acoustic impedance at the input to the occluded ear canal.

Multi-frequency (multi-component) acoustic impedance measurements may evolve into a sensitive technique for the remote detection of aural pathologies. Such data are also relevant to models used in hearing aid design and could be an asset to the hearing aid prescription and fitting process. This report describes the development and use of a broad-band procedure which acquires impedance data in 20 Hz intervals and describes a comparison of data collected at two sites by different investigators. Mean data were in excellent agreement, and an explanation for a single case of extreme normal variability is presented.

Occluded-ear simulator with variable acoustic properties.

Ear simulators were designed to replicate acoustical characteristics of the average adult ear. Due to variability of ear-canal geometry and eardrum impedance among individuals, the possibility of any one person exhibiting such "average" characteristics--especially if that person is a child and/or has a conductive pathology--is remote. Thus, ear simulators have been of only peripheral value when prescribing a hearing aid (a high output impedance device) to fit the acoustical requirements of a particular patient. Reported herein is development of a programmable artificial ear (PAE) that can account for individual differences in ear-canal geometry and eardrum impedance. It consists of a 2.0-cc coupler, microphone, amplifier, computer, PAE code, and a computer card and/or software for digitization and Fourier transformation. Required input data includes ear-canal dimensions, eardrum impedance, and output impedance of the hearing aid being tested. Sound-pressure recordings produced in the 2.0-cc coupler by the hearing aid are adjusted by the computer to what they would have been had the recordings been made at the eardrum of a particular patient wearing the same hearing aid. Good agreement was observed between experiment and theory for one test case involving a totally occluding miniature earphone.

A comparison of three HA-1 couplers.

The use of 2-cm3 couplers for measuring the output of an ER-3A earphone has been recommended. The purpose of this study was to compare the acoustic output of three commonly available couplers and to study the intra- and inter-examiner reliability with which those measurements may be performed. While the repeatability of measurements, at least for clinical purposes, was good even for hand-held coupling of the earphone to the couplers, differences between couplers were observed. These differences were influenced by the positioning of the sound-outlet orifice relative to the interior, top wall of the couplers' cavities. A recommendation for 2-cm3 coupler calibration of the ER-3A earphone using a commonly available adapter was made.

Simulated hearing loss and phrase dictation.

The effect of simulated high frequency hearing loss in young adult speakers was examined. Subjects were native English speakers with normal hearing sensitivity. There were three listening conditions, two filtered conditions simulating high frequency hearing losses similar to those often occurring in the geriatric population and one unfiltered, or normal condition. Subjects listened to the Phrase Repetition subtest of the Boston Diagnostic Aphasia Examination. There were significant differences in the number of errors across the three conditions, with the most errors occurring during the greater simulated hearing loss. Such errors may be attributed to expressive language impairments when errors may instead be the result of a high frequency hearing loss.

Simulating the open-loop transfer function as a means for understanding acoustic feedback in hearing aids.

Suppressing unstable acoustic feedback in hearing aids will first require knowledge of the open-loop transfer functions of such systems. Reported herein is a mathematical technique for simulating the open-loop transfer function of an in situ eyeglass-type hearing aid. In particular, a computer program was developed that characterized the hearing aid as a serial connection of two-port blocks, each representing one individual component of a hearing aid. Included, for example, were two-port blocks representing the microphone, amplifier, receiver, sound tubes leading to the eardrum (including the ear canal itself), earmold vent, and external pathway from the vent outlet back to the microphone. The computer program was validated by replicating laboratory data derived from an experiment involving a nonstandard manikin fitted with a nonstandard artificial ear. Next, the open-loop transfer function of an eyeglass-type hearing aid in situ on the manikin was simulated via the computer program. Unfortunately, those computer-generated data were not replicated in the laboratory due to the difficulty encountered in actually measuring the open-loop transfer function. Nevertheless, investigators were able to utilize those data to predict, within +/- 25 Hz, the "squeal" frequency of unstable acoustic feedback.

Effect of simulated hearing loss on speech sounds perception.

This study examined the effect of simulated hearing loss on the Speech-Sounds Perception Test (SSPT) performance of a sample of 24 young volunteers with normal hearing sensitivity. Bilateral air conduction thresholds were obtained on all participants. The SSPT was recorded on tape by a professional radio announcer. The tape-recorded stimuli were filtered through a calibrated audiometer and spectrum shaper to simulate two high-frequency losses. Results show a significant effect of simulated high-frequency hearing loss on SSPT performance. Clinicians are advised to exercise caution in attributing poor SSPT performance of their patients with suspected hearing loss solely to a central auditory processing deficit.

A technique for simulating the amplifier-to-eardrum transfer function of an in situ hearing aid.

There are numerous articles wherein mathematical models of various parts of an in situ hearing aid have been reported. Such parts include, for example, the microphone, receiver, cylindrical tubes carrying sound to the eardrum and out through the earmold vent, and the external path from the vent back to the microphone. This article extends these earlier works to include the hearing-aid amplifier. In particular, a mathematical technique for characterizing the amplifier in combination with the receiver is reported. Cascade parameters of a two-port model of one particular amplifier/receiver combination are obtained by this method. The cascade-parameter data and the method of obtaining this data are verified by two different experimental procedures. One procedure involves both computing and measuring the input driving-point impedance of the amplifier/receiver combination. In the second procedure, the amplifier-to-eardrum transfer function of a hearing aid incorporating this same amplifier/receiver combination and mounted on an artificial ear is both computed and measured. Experimental and computed values of this transfer function for three different earmold geometries are in reasonably close agreement. The amplifier/receiver model reported herein will be used in future studies of acoustic feedback in hearing aids.

Reference threshold sound-pressure levels for the TDH-50 and ER-3A earphones.

Reference threshold sound-pressure levels were established for a new insert earphone, the ER-3A tubephone, and for the TDH-50 earphone. In test-retest comparisons, the tubephone produced estimates of auditory threshold as reliable as the thresholds produced by the supraaural earphone. Reference thresholds were developed for the two earphones from data contributed by three laboratories. While the TDH-50 data are in good agreement with the provisional ANSI 6-cc coupler reference levels (ASHA, 1982), the ER-3A data are at variance with the manufacturer's provisional recommendation for 2-cc coupler reference thresholds for frequencies below 1 kHz. The differences are attributed to physiologic noise that masked the lower frequency thresholds.

Experimental determination of cascade parameters of a hearing-aid microphone via the two-load method.

Presented in this article is a computer-aided experimental method for obtaining the cascade parameters of the two-port model of a miniature hearing-aid microphone. The method is an adaptation of the "two-load" method [D.P. Egolf and R.G. Leonard, J. Acoust. Soc. Am. 62, 1013-1023 (1977)] to acoustoelectric, rather than electroacoustic, transducers. The cascade parameters of a particular microphone, determined by this method, were within 2.5 dB of the manufacturer's published open-circuit sensitivity data. In an attempt to further verify the numerical cascade-parameter data, a two-port model of the microphone was used to simulate experimental voltages developed across two different complex electrical load impedances attached to the microphone. The results showed experimental/simulation differences of no greater than 3.0 dB at any frequency. The two-port microphone model and associated cascade parameters are currently being incorporated into a computer-based plan for mathematical simulation of an entire in situ hearing aid.

The constant-volume-velocity nature of hearing aids: conclusions based on computer simulations.

In the literature there are several references which imply that various parts of a hearing aid are sources of constant volume velocity. Reported herein are the findings of an investigation of the validity of such statements. A computer scheme, referenced elsewhere, for modeling in situ hearing aids was utilized to test the constant-volume-velocity hypothesis. In particular, capabilities of the receiver, ear hook, and earmold tip to deliver constant volume velocity were investigated via a computer. To facilitate such an investigation, a universal receiver/earmold model was created. This model was broken down into "source" and "load"at three locations: the receive output, output of the ear hook, and medial tip of the earmold. At each location comparisons were made between computed values of source and load impedance. The constant-volume-velocity hypothesis was assumed to be valid for those cases where source impedance was much, much greater than load impedance. Plots of such impedances show that, for the cases investigated, this rarely occurred, except over certain frequency bands. With the exception of in-the-ear hearing aids, these results appear to contradict inferences made in the literature about the constant-volume-velocity nature of hearing aids.

Spectral characteristics of air and bone conduction transducers used to record the auditory brain stem response.

This study sought to determine differences in the acoustic spectra of five different transducers commonly used for stimulus presentation to record the auditory brain stem response (ABR). The outputs of three commercially available bone conduction vibrators (Radioear B-70A, B-71 and B-72), a TDH-49 earphone, and an insert receiver were measured by applying a 0.1 msec rectangular electrical pulse to each transducer. The resultant output for each transducer was converted to one-third octave band data and plotted against reference threshold levels. Results demonstrated relatively flat acoustic spectra and high output levels for the two air conduction receivers. In contrast, each of the bone oscillators had its greatest concentration of energy in the 2000 Hz region with the spectrum characterized by a precipitous decrease in output at frequencies above and below this resonance peak. Maximum output never exceeded 35 dB HL for any of the three bone conduction devices. Of the three oscillators, however, the B-70A appeared to provide the highest output before reaching saturation. Results are discussed relative to the limitations for recording the auditory brain stem response to bone conducted transient signals.

Sound levels in a 2-cc cavity, a Zwislocki coupler, and occluded ear canals.

Probe-tube measurements of the differences in sound levels at three locations in ear canals were compared to the differences in levels measured at analogous positions in a Zwislocki coupler and a 2-cc cavity. The results support the recommendation of Sachs and Burkhard that probe tube measurements should not be made with the probe tube flush with the earmold tip and close to the sound inlet bore. In real ear canals the transfer functions to the eardrum presented by Bruel, Frederikson, and Rasmussen and by Studebaker agree well with each other but differ somewhat from the one used by Sachs and Burkhard. In agreement with Bruel et al., the data of this study reveal a plateau in the relationship between real ear and 2-cc cavity responses between about 1.6 and 4.0 kHz, the relative intensity level of which may depend upon residual ear canal volume.

Split-half reliability of two word discrimination tests as a function of primary-to-secondary ratio.

Two clinical word discrimination tests, the Northwestern University Auditory Test No. 6 (NU-6) and the Modified Rhyme Test (MRT), were examined for internal consistency and for split-half reliability under varying primary-to-secondary ratios (P:S) in normal hearers. Although the statistical analysis indicated that half-lists could be used reliably for both discrimination tests at most P:S conditions, the wide variability found among individual listeners does not support the clinical practice of half-list testing in noise--at least not for normal-hearing listeners.

A comparison of three hearing aid evaluation procedures for young children.

The evaluation of hearing aid performance with young, nonverbal children traditionally consists of a comparison between aided and unaided thresholds. Alternative evaluation procedures include those that provide an estimate of the speech spectrum area that is potentially audible to the child with amplification. This study compared the hearing aid performance results for ten hearing impaired children evaluated with a sound field procedure and two speech spectrum methods. Results obtained for three hearing aids demonstrated no differences in hearing aid recommendation between procedures for children with only mild-moderate hearing loss. For children with severe to profound losses, however, the sound-field audiogram was found to overestimate what is potentially audible to the child.