Assessment of the American Medical Association guide to the evaluation of binaural hearing impairment.

OBJECTIVE: To assess the American Medical Association (AMA) guide to the evaluation of binaural hearing impairment (BHI) as a procedure for estimating severity of hearing loss from audiograms. DESIGN: The BHIs of Australian war veterans were calculated from their hearing threshold levels (HTLs) and compared with their scores on a hearing questionnaire, the hearing measurement scale (HMS). STUDY SAMPLE: The HTLs of 282 Australian war veterans were measured at frequencies from 0.25 to 8 kHz and scores on the HMS were obtained from 154 of those veterans. RESULTS: No grounds could be found for altering the frequencies included in the average HTL or the high fence of 92 dB HL used in calculating the monaural hearing impairments (MHIs) of the veterans, and no grounds could be found for altering the ratio of 5:1 used in determining the BHI from the MHIs of the better and worse ears. However, agreement between HMS score and BHI was improved by reducing the low fence used in calculating MHI from 25 to 15 dB HL. CONCLUSION: A modified version of BHI provided an improved procedure for estimating severity of hearing loss from audiograms but would not be suitable for compensation purposes.

High levels of untreated distress and fatigue in cancer patients.

The purpose of the study was to assess a large representative sample of cancer patients on distress levels, common psychosocial problems, and awareness and use of psychosocial support services. A total of 3095 patients were assessed over a 4-week period with the Brief Symptom Inventory-18 (BSI-18), a common problems checklist, and on awareness and use of psychosocial resources. Full data was available on 2776 patients. On average, patients were 60 years old, Caucasian (78.3%), and middle class. Approximately, half were attending for follow-up care. Types of cancer varied, with the largest groups being breast (23.5%), prostate (16.9%), colorectal (7.5%), and lung (5.8%) cancer patients. Overall, 37.8% of all patients met criteria for general distress in the clinical range. A higher proportion of men met case criteria for somatisation, and more women for depression. There were no gender differences in anxiety or overall distress severity. Minority patients were more likely to be distressed, as were those with lower income, cancers other than prostate, and those currently on active treatment. Lung, pancreatic, head and neck, Hodgkin's disease, and brain cancer patients were the most distressed. Almost half of all patients who met distress criteria had not sought professional psychosocial support nor did they intend to in the future. In conclusion, distress is very common in cancer patients across diagnoses and across the disease trajectory. Many patients who report high levels of distress are not taking advantage of available supportive resources. Barriers to such use, and factors predicting distress and use of psychosocial care, require further exploration.

An equivalent input noise level criterion for hearing aids.

The purpose of this project was to establish a maximum acceptable equivalent input noise level (EINL) for hearing aids. It was found that, if the version of the National Acoustic Laboratories (NAL) procedure for selecting the gain and frequency response of hearing aids, which includes modifications for severe and profound hearing loss is used, the EINL criterion can be relaxed for higher gain hearing aids, as a function of the gain of the aid. The relationship between relaxation of the criterion and 2-cc coupler gain is nonlinear, in different amounts, at the various frequencies, so no simple rule can be used to describe the manner in which the criterion can be relaxed.

Gain, frequency response, and maximum output requirements for hearing aids.

This article applies the gain and frequency response and maximum output selection procedures currently recommended by the National Acoustic Laboratories (NAL) of Australia to the audiograms of a representative group of adult and child clients of Australian Hearing Services (AHS) to specify the performance that is required of various types of hearing aids in order to ensure that they can provide adequate gain, frequency response, and maximum output levels for at least 90% of the AHS client population. Cumulative frequency distributions of required 2-cc coupler gain slopes were calculated for each type of aid and used to design required frequency response variations. Coupler slope requirements in different octaves were found to be independent of one another. The required range of gain-maximum output combinations was determined for each type of aid.

Temporary and permanent threshold shift caused by hearing aid use.

Excessive amplification by hearing aids causes temporary threshold shift (TTS) and permanent threshold shift (PTS). This investigation addressed the question whether it might be possible to predict the eventual amount of PTS caused by excessive amplification from the amount of TTS it causes after a day of hearing aid use. Asymptotic TTS (ATS) to be expected as a result of hearing aid use was predicted for 8 children with sensorineural hearing loss and the predicted ATS was compared with observed permanent deterioration of their thresholds attributed to hearing aid use. There was good agreement between the predicted ATS and observed PTS at 500 to 2000 Hz. It follows that, for prediction of PTS caused by hearing aid use, the mean of the sound levels produced in the ear by the hearing aid is the correct equivalent continuous level (ECL) to use and that the Modified Power Law (MPL) is the appropriate method of adjusting the predictions for sensorineural hearing loss, because these have been shown to be appropriate for prediction of TTS caused by hearing aid use. Predictions of the PTS to be expected for the children that were carried out using the MPL and the mean level as the ECL were in good agreement with the observed PTS at 500 to 2000 Hz, whereas predictions of PTS based on an alternative method of correction for sensorineural hearing loss (the Continuation Hypothesis) were significantly less than the observed amounts. The results of the PTS predictions therefore confirmed the conclusions drawn from the results of the ATS predictions.

Prediction of asymptotic threshold shift caused by hearing aid use.

This study used a well-verified mathematical model to predict asymptotic temporary threshold shift (ATS) caused by hearing aid use. The model determined the amounts of ATS to be expected if real ear insertion gains (REIGs) recommended by the current National Acoustic Laboratories (NAL) procedure are used. It also determined the consequences of use of excess REIG and of high input levels to hearing aids. If recommended REIGs are used and input levels are normal (average A-weighted input levels of about 61 dB SPL), ATS is unlikely to occur for clients who have typical audiograms with three-frequency average pure-tone thresholds (PTAs) less than 60 dB HL. For people with PTAs greater than 60 dB HL, small amounts of ATS can be expected to occur during hearing aid use, but these amounts of ATS are safe, that is, unlikely to be associated with permanent threshold shift (PTS) for individuals with all PTAs except those greater than about 100 dB HL. If REIGs are 15 dB greater than those recommended, the amounts of ATS will be unsafe for people with PTAs greater than about 80 dB HL. It appears unwise for clients who have this degree of hearing loss to use excess REIG. The use of excess REIG in high ambient levels of sound (average A-weighted input levels of about 75 dB SPL) is likely to cause PTS for hearing aid users with PTAs of about 50 dB HL or greater. Clients who prefer to use excess REIG should therefore avoid high ambient sound levels.(ABSTRACT TRUNCATED AT 250 WORDS)

An investigation of temporary threshold shift caused by hearing aid use.

Temporary threshold shift (TTS) caused by hearing aid use was measured by Bekesy audiometry in a group of individuals with severe sensorineural hearing loss. The accuracy with which a mathematical model consisting of the Modified Power Law (MPL) (Humes & Jesteadt, 1991) combined with equations for predicting TTS in normal listeners (Mills, Gilbert, & Adkins, 1979) could predict the TTS was evaluated. When the exponent of the MPL was set to 0.15, the predicted TTS was significantly greater than the observed TTS at two out of six frequencies. When the exponent was increased to 0.20, there were no significant differences between the predictions and the observations. With this value of the exponent, the mathematical model was able to predict the observed TTS as accurately as it could be measured. The MPL was used to derive safety limits for TTS, and gain reduction was recommended as the best method of reducing TTS to the safety limits.

Temporary threshold shift caused by hearing aid use.

Temporary threshold shift (TTS) over a wide range of frequencies was found after 4 hours of hearing aid use by a 15-year-old student with severe sensorineural hearing loss who was using real-ear insertion gains 10 to 20 dB greater than those recommended by the current National Acoustic Laboratories (NAL) procedure for selecting the gain and frequency response of hearing aids. Measurements were made of her noise exposure during hearing aid use with a noise dosimeter. The real-ear insertion response and input-output function of her hearing aid were measured with a real-ear gain analyzer and were used to calculate in-ear noise levels from the noise levels measured by the dosimeter. The amount of TTS could be predicted from the in-ear noise levels and the student's hearing levels (HLs) by means of a mathematical model consisting of the Modified Power Law (MPL) of Humes and Jesteadt (1991) combined with equations for predicting TTS in listeners with normal hearing published by Mills, Gilbert, and Adkins (1979). The mean of the instantaneous A-weighted in-ear noise levels proved to be the appropriate equivalent continuous level (ECL) for use in the predictions. The MPL was also used to determine safety limits for TTS due to hearing aid use. The observed TTS exceeded the safety limits at all frequencies up to and including 2000 Hz. It was therefore considered desirable for the girl to use less gain at frequencies from 500 to 1500 Hz.

Presbycusis and noise-induced permanent threshold shift.

Bies and Hansen [J. Acoust. Soc. Am. 88, 2743-2754 (1990)] have proposed an alternative formulation of the relationship between noise exposure and noise-induced hearing impairment to that presented in International Standard ISO 1999, in which they assume that presbycusis and noise-induced permanent threshold shift (NIPTS) are additive on an antilogarithm basis. Data concerning deterioration in hearing threshold levels at 4000 Hz due to aging in war veterans with NIPTS do not support the Bies and Hansen assumption but provide support for the formula for combining presbycusis and NIPTS incorporated in International Standard ISO 1999.

A comparison of the effects of different methods of impression build-up on earmoulds.

An investigation was carried out into effects of three types of impression build-up (patting down of impressions, special earmould-maker build-up and the multistage impression technique) on the dimensions, static pressure seal, degree of acoustic seal and the subjective tightness and comfort of earmoulds. Patting down the impression significantly improved the degree of acoustic seal provided by earmoulds without making them feel tighter or less comfortable. However, special build-up was much more effective than patting down and the multistage impression technique was slightly more effective than special build-up in improving the degree of acoustic seal. The improvement in acoustic seal provided by both multistage and specially built-up earmoulds can usually be obtained without an unacceptable level of discomfort. Patting down the impression did not improve the chance of obtaining a static pressure seal. Special build-up of the impression by the earmould-maker significantly increased the proportion of earmoulds which provided a static pressure seal but an even higher proportion of earmoulds made from multistage impressions provided a seal. Dimension results indicated that an increase in earmould-maker build-up of the minor axis at the beginning of the canal segment of the impression would improve the acoustic seal provided by specially built-up earmoulds and that earmoulds with rounder tips are more likely to provide a static pressure seal than earmoulds with more elliptical tips. The better the impression material fills the ear canal, the rounder the tip of the impression, and the rounder the tip of the earmould made from the impression.

Prediction of deterioration in hearing due to hearing aid use.

There is a definite risk of overamplification by hearing aids. Guidelines should therefore be established that will minimize the risk of damage to hearing involved in hearing aid use. A mathematical model that can be used for this purpose is derived from equations for predicting noise-induced permanent threshold shift given in International Standard ISO 1999 combined with the Modified Power Law. The model implies that any noise exposure that would cause deterioration of the hearing threshold levels of a person with normal hearing would also be harmful to the hearing of a person with sensorineural hearing impairment. It follows that, in order to ensure that no deterioration occurs in the hearing of a hearing aid user, the output levels from the aid must be such that they would not cause any damage to a person with normal hearing. This constraint can be met for hearing aid users with mild-to-moderate sensorineural hearing loss but cannot be met for users with severe-to-profound loss because it would result in the provision of insufficient gain, particularly at the higher frequencies. If the model is valid, then for this group, some appropriately small amount of hearing damage must be accepted as the cost of the advantages gained from the use of a hearing aid. Verification of the model is essential before the model is used in clinical practice to determine the risk of deterioration in hearing due to hearing aid use.

Permanent threshold shift associated with overamplification by hearing aids.

Humes and Jesteadt have proposed that the Modified Power Law (MPL) provides a means of predicting permanent threshold shift (PTS) due to noise exposure in subjects with preexisting sensorineural hearing loss. Data concerning PTS attributed to overamplification by hearing aids in 8 children with severe sensorineural hearing loss were used to evaluate the MPL hypothesis. The excessive amplification was partly due to use by the children of very high volume-control settings instead of mid-range volume-control settings. The PTS tended to be flat across frequency. Its course in time was a miniature version of the time course of PTS that would be induced by a similar noise exposure in a person with normal hearing. It began to occur soon after the start of hearing aid use and its rate of development was slower than that which would occur in a person with normal hearing. The growth of PTS could be predicted from the estimated real ear output levels of the children's hearing aids by means of the MPL combined with the logarithmic equation proposed by Kraak for predicting the effect of noise exposure on hearing.