Effectiveness of the HEAR-Aware App for Adults Not Ready for Hearing Aids, but Open to Self-Management Support: Results of a Randomized Controlled Trial.

INTRODUCTION: Recently, the HEAR-aware app was developed to support adults who are eligible for hearing aids (HAs) but not yet ready to use them. The app serves as a self-management tool, offering assistance for a range of target behaviors (TBs), such as communication strategies and emotional coping. Using ecological momentary assessment and intervention, the app prompts users to complete brief surveys regarding challenging listening situations they encounter in their daily lives (ecological momentary assessment). In response, users receive educational content in the form of "snippets" (videos, texts, web links) on the TBs, some of which are customized based on the reported acoustic environmental characteristics (ecological momentary intervention). The primary objective of this study was to assess the effectiveness of the HEAR-aware app in enhancing readiness to take action on various TBs and evaluate its impact on secondary outcomes. The secondary objective was to examine the app's usability, usefulness, and user satisfaction. METHODS: A randomized controlled trial design with two arms was used. Participants with hearing loss aged 50 years and over were recruited via an HA retailer and randomly assigned to the intervention group (n = 42, mean age = 65 years [SD = 9.1]) or the control group (n = 45, mean age = 68 years [SD 8.7]). The intervention group used the app during 4 weeks. The control group received no intervention. All participants completed online questionnaires at baseline (T0), after 4 weeks (T1), and again 4 weeks later (T2). Participants' readiness to take action on five TBs was measured with The Line Composite. A list of secondary outcomes was used. Intention-to-treat analyses were performed using Linear Mixed effect Models including group (intervention/control), time (T0/T1/T2), and Group × Time Interactions. In addition, a per protocol analysis was carried out to explore whether effects depended on app usage. For the secondary aim the System Usability Scale (SUS), the Intrinsic Motivation Inventory, item 4 of the International Outcome Inventory-Alternative Intervention (IOI-AI), and a recommendation item were used (intervention group only at T1). RESULTS: For objective 1, there was no significant group difference for The Line Composite over the course of T0, T1, and T2. However, a significant (p = 0.033) Group × Time Interaction was found for The Line Emotional coping, with higher increase in readiness to take action on emotional coping in the intervention group than in the control group. The intention-to-treat analyses revealed no other significant group differences, but the per protocol analyses showed that participants in the intervention group were significantly more ready to take up Assistive Listening Devices (The Line Assistive Listening Devices) and less ready to take up HAs (Staging Algorithm HAs) than the control group (p = 0.049). Results for objective 2 showed that on average, participants rated the app as moderately useful (mean Intrinsic Motivation Inventory score 5 out of 7) and its usability as "marginal" (mean SUS score 68 out of 100) with about half of the participants rating the app as "good" (SUS score >70) and a minority rating is as "unacceptable" (SUS score ≤50). DISCUSSION/CONCLUSIONS: This study underscores the potential of self-management support tools like the HEAR-aware app in the rehabilitation of adults with hearing loss who are not yet ready for HAs. The range in usability scores suggest that it may not be a suitable intervention for everyone.

Experienced Adult Cochlear Implant Users Show Improved Speech Recognition When Target Fitting Parameters Are Applied.

OBJECTIVES: The aim of the present study was to investigate whether prediction models built by de Graaff et al. (2020) can be used to improve speech recognition in experienced adult postlingual implanted Cochlear CI users. de Graaff et al. (2020) found relationships between elevated aided thresholds and a not optimal electrical dynamic range (<50 CL or >60 CL), and poorer speech recognition in quiet and in noise. The primary hypothesis of the present study was that speech recognition improves both in quiet and in noise when the sound processor is refitted to match targets derived from the prediction models from de Graaff et al. (2020). A second hypothesis was that subjectively, most of the CI users would find the new setting too loud because of an increase in C levels, and therefore, prefer the old settings. DESIGN: A within-participant repeated measures design with 18 adult Cochlear CI users was used. T- and C-levels were changed to "optimized settings," as predicted by the model of de Graaff et al. (2020). Aided thresholds, speech recognition in quiet, and speech recognition in noise were measured with the old settings and after a 4-week acclimatization period with the optimized settings. Subjective benefit was measured using the Device Oriented Subjective Outcome Scale questionnaire. RESULTS: The mean electrical dynamic range changed from 41.1 (SD = 6.6) CL to 48.6 (SD = 3.0) CL. No significant change in aided thresholds was measured. Speech recognition improved for 16 out of 18 participants and remained stable for 2 participants. Average speech recognition scores in quiet significantly improved by 4.9% (SD = 3.8%). No significant change for speech recognition in noise was found. A significant improvement in subjective benefit was found for one of the Device Oriented Subjective Outcome subscales (speech cues) between the old and optimized settings. All participants chose to keep the optimized settings at the end of the study. CONCLUSIONS: We were able to improve speech recognition in quiet by optimizing the electrical dynamic range of experienced adult CI users, according to the prediction models built by de Graaff et al. (2020). There was no significant change in aided thresholds nor in speech recognition in noise. The findings of the present study suggest that improved performance for speech recognition in quiet in adult Cochlear CI users can be achieved by setting the dynamic range as close as possible to values between 50 and 60 CL when the volume level is at 10.

Manual switching between programs intended for specific real-life listening environments by adult cochlear implant users: do they use the intended program?

OBJECTIVE: The aim of the current study was to investigate the use of manually and automatically switching programs in everyday day life by adult cochlear implant (CI) users. DESIGN: Participants were fitted with an automatically switching sound processor setting and 2 manual programs for 3-week study periods. They received an extensive counselling session. Datalog information was used to analyse the listening environments identified by the sound processor, the program used and the number of program switches. STUDY SAMPLES: Fifteen adult Cochlear CI users. Average age 69 years (range: 57-85 years). RESULTS: Speech recognition in noise was significantly better with the "noise" program than with the "quiet" program. On average, participants correctly classified 4 out of 5 listening environments in a laboratory setting. Participants switched, on average, less than once a day between the 2 manual programs and the sound processor was in the intended program 60% of the time. CONCLUSION: Adult CI users switch rarely between two manual programs and leave the sound processor often in a program not intended for the specific listening environment. A program that switches automatically between settings, therefore, seems to be a more appropriate option to optimise speech recognition performance in daily listening environments.

Measurement and optimisation of the perceptual equivalence of the Dutch consonant-vowel-consonant (CVC) word lists using synthetic speech and list pairs.

OBJECTIVES: (1) to determine whether the standard Dutch word lists for speech audiometry are equally intelligible in normal-hearing listeners (Experiment 1), (2) to investigate whether synthetic speech can be used to create word lists (Experiment 1) and (3) to determine whether the list effect found in Experiment 1 can be reduced by combining two lists into pairs (Experiment 2). DESIGN: Participants performed speech tests in quiet with the original (natural) and synthetic word lists (Experiment 1.). In Experiment 2, new participants performed speech tests with list pairs from the original lists constructed from the results of Experiment 1. STUDY SAMPLES: Twenty-four and twenty-eight normal-hearing adults. RESULTS: There was a significant list effect in the natural speech lists; not in the synthetic speech lists. Variability in intelligibility was significantly higher in the former, with list differences up to 20% at fixed presentation levels. The 95% confidence interval of a list with a score of approximately 70% is around 10%-points wider than of a list pair. CONCLUSIONS: The original Dutch word lists show large variations in intelligibility. List effects can be reduced by combining two lists per condition. Synthetic speech is a promising alternative to natural speech in speech audiometry in quiet.

Digits in noise testing in a multilingual sample of Asian adults.

OBJECTIVE: Appropriate speech-in noise assessment is challenging in multilingual populations. This study aimed to assess whether first preferred language affected performance on an English Digits-in-noise (DIN) test in the local Asian multilingual population, controlling for hearing threshold, age, sex, English fluency and educational status. A secondary aim was to determine the association between DIN test scores and hearing thresholds. DESIGN: English digit-triplets in noise testing and pure-tone audiometry were conducted. Multiple regression analysis was performed with DIN scores and hearing thresholds as dependent variables. Correlation analysis was performed between DIN-SRT and hearing thresholds. STUDY SAMPLE: 165 subjects from the Singapore Longitudinal Ageing Study, a population-based longitudinal study of community-dwellers over 55 years of age. RESULTS: Mean DIN speech reception threshold (DIN-SRT) was -5.7 dB SNR (SD 3.6; range 6.7 to -11.2). Better ear pure tone average and English fluency were significantly associated with DIN-SRT. CONCLUSIONS: DIN performance was independent of first preferred language in a multilingual ageing Singaporean population after adjusting for age, gender and education. Those with poorer English fluency had a significantly lower DIN-SRT score. The DIN test has the potential to provide a quick, uniform method of testing speech in noise in this multilingual population.

Feasibility of the HEAR-aware App for Hearing Loss Self-Management: A Nonrandomized Intervention Study to Examine Intervention Acceptability and the Stages-of-Change Concept.

OBJECTIVES: The HEAR-aware project targets adults ≥50 years who were recently diagnosed with hearing loss and declined hearing aids, but were open for support via a smartphone app on different target behaviors (TBs). The HEAR-aware app, based on Ecological Momentary Assessment and Ecological Momentary Intervention (EMA, EMI), contains educational materials ("snippets") tailored partly to the user's experienced listening situations. The app aims to increase adults' TB-specific readiness to take action on hearing problems. The present study focused on examining feasibility regarding three novel aspects: (1) the app's acceptability, mainly regarding its EMA and EMI elements (compliance, usability, usefulness, satisfaction), (2) psychometric properties of 10 new TB-specific stages-of-change (SoC) measures (test-retest reliability, construct validity), and (3) the potential of tailoring snippets on a person's SoC. DESIGN: A nonrandomized intervention study including four measurements with 2-week intervals (T0-T3). (1) The intervention period lasted 4 weeks. App usage data were collected throughout (T1-T3). Usability, usefulness, and satisfaction were measured at T3 (n = 26). (2) Reliability concerned T0 and T1 data, in between which no intervention occurred. Intraclass correlation coefficients (ICCs) were calculated (n = 29). Construct validity was examined by calculating correlations between the different TB-specific scales (at T0), and also between each of them and self-reported hearing disability (n = 29). (3) Person-tailoring by SoC was examined using T0 and T1 data. Linear mixed models were applied to test whether users rated snippets corresponding to their SoC as more interesting and useful than noncorresponding snippets (n = 25). RESULTS: (1) The percentage of participants that complied with the intended usage varied across the five predefined compliance criteria (lowest: 8%; highest: 85%). Median snippet satisfaction scores were reasonably positive (3.5 to 4.0 of 5). Usability was good (System Usability Score, mean = 72.4, SD = 14.3) and usefulness satisfactory (Intrinsic Motivation Inventory, mean = 4.4, SD = 1.4), but showed large variance. (2) The 10 TB-specific scales showed fair-to-excellent reliabilities (range ICCs = 0.51 to 0.80). Correlations between the TB-specific scales ranged between -0.17 ( p > 0.05) and 0.74 ( p < 0.001), supporting only partly overlap between their underlying constructs. Only the correlation between TB-specific readiness for hearing aid uptake and self-reported hearing disability was significant. (3) Correspondence of a snippet's SoC with the person's SoC significantly related to "interesting" ratings ( p = 0.006). Unexpectedly, for snippets with a lower SoC than the participant's, further deviation of the snippet's SoC from the participant's SoC, increased the participant's interest in the snippet. The relationship with "usefulness" was borderline significant. CONCLUSIONS: (1) Overall usability, usefulness, and satisfaction scores indicated sufficient app acceptability. The high variance and fairly low compliance showed room for improving the app's EMA/EMI parts for part of the participants. (2) The 10 new TB-specific SoC measures showed sufficient reliability, supporting that they measured different types of readiness to take action on hearing problems (construct validity). (3) The unexpected findings regarding tailoring educational app materials to individuals' SoC deserve further study.

The International Standard Set of Outcome Measures for the Assessment of Hearing in People with Osteogenesis Imperfecta.

OBJECTIVE: The aim is to recommend a minimum standard set of clinician-reported outcome measures (CROMs) and patient-reported outcome measures (PROMs) on hearing for people with osteogenesis imperfecta (OI). This project is part of the larger "Key4OI" project initiated by the "Care4BrittleBones foundation" of which the goal is to improve quality of life of people with OI. Key4OI provides a standard set of outcome measures and covers a large set of domains affecting the well-being of people with OI. METHODS: An international team of experts in OI, comprising specialists in audiological science, medical specialists, and an expert patient representative, used a modified Delphi consensus process to select CROMs and PROMs to evaluate hearing problems in people with OI. In addition, focus groups of people with OI identified key consequences of their hearing loss. These criteria were matched to categories of preselected questionnaires to select a PROM that matched their specific hearing-related concerns best. RESULTS: Consensus on PROMs for adults and CROMs for adults and children was reached. The focus of the CROMs was on specific audiological outcome measures and standardized follow-up. CONCLUSIONS: This project resulted in a clear consensus statement for standardization of hearing-related PROMs and CROMs and follow-up management of patients with OI. This standardization of outcome measurements will facilitate comparability of research and easier international cooperation in OI and hearing loss. Furthermore, it can improve standard of care in people with OI and hearing loss by incorporating the recommendations into care pathways.

Cohort profile: Netherlands Longitudinal Study on Hearing (NL-SH).

PURPOSE: The Netherlands Longitudinal Study on Hearing (NL-SH) was set up to examine associations of hearing ability with psychosocial, work and health outcomes in working age adults. PARTICIPANTS: Inclusion started in 2006 and is ongoing. Currently the sample comprises 2800 adults with normal and impaired hearing, aged 18-70 years at inclusion. Five-year follow-up started in 2011, 10-year follow-up in 2016 and 15-year follow-up in 2021. All measurements are web-based. Participants perform a speech-in-noise recognition test to measure hearing ability and fill out questionnaires about their hearing status, hearing aid use, self-reported hearing disability and coping, work status and work-related outcomes (work performance, need for recovery), physical and psychosocial health (depression, anxiety, distress, somatisation, loneliness), healthcare usage, lifestyle (smoking, alcohol), and technology use. FINDINGS TO DATE: The NL-SH has shown the vast implications of reduced hearing ability for the quality of life and health of working-age adults. A selection of results published in 27 papers is presented. Age-related deterioration of hearing ability accelerates after the age of 50 years. Having a history of smoking is associated with a faster decline in hearing ability, but this relationship is not found for other cardiovascular risk factors. Poorer hearing ability is associated with increased distress, somatisation, depression and loneliness. Adults with impaired hearing ability are more likely to be unemployed or unfit for work, and need more time to recuperate from work effort. FUTURE PLANS: Participant data will be linked to a national database to enable research on the association between hearing ability and mortality. Linking to environmental exposure data will facilitate insight in relations between environmental factors, hearing ability and psychosocial outcomes. The unique breadth of the NL-SH data will also allow for further research on other functional problems, for instance, hearing ability and fall risk. TRIAL REGISTRATION NUMBER: NL12015.029.06.

Distinct disease mechanisms may underlie cognitive decline related to hearing loss in different age groups.

BACKGROUND: Hearing loss in older adults is associated with increased dementia risk. Underlying mechanisms that connect hearing loss with dementia remain largely unclear. METHODS: We studied the association of hearing loss and biomarkers for dementia risk in two age groups with normal cognition: 65 participants from the European Medical Information Framework (EMIF)-Alzheimer's disease (AD) 90+ study (oldest-old; mean age 92.7 years, 56.9% female) and 60 participants from the EMIF-AD PreclinAD study (younger-old; mean age 74.4, 43.3% female). Hearing function was tested by the 'digits-in-noise test' and cognition by repeated neuropsychological evaluation. Regressions and generalised estimating equations were used to test the association of hearing function and PET-derived amyloid burden, and linear mixed models were used to test the association of hearing function and cognitive decline. In the oldest-old group, mediation analyses were performed to study whether cognitive decline is mediated through regional brain atrophy. RESULTS: In oldest-old individuals, hearing function was not associated with amyloid pathology (p=0.7), whereas in the younger-old individuals hearing loss was associated with higher amyloid burden (p=0.0034). In oldest-old individuals, poorer hearing was associated with a steeper decline in memory, global cognition and language, and in the younger-old with steeper decline in language only. The hippocampus and nucleus accumbens mediated the effects of hearing loss on memory and global cognition in the oldest-old individuals. CONCLUSIONS: Hearing loss was associated with amyloid binding in younger-old individuals only, and with cognitive decline in both age groups. These results suggest that mechanisms linking hearing loss with risk for dementia depends on age.

Sensitivity of the antiphasic digits-in-noise test to simulated unilateral and bilateral conductive hearing loss.

OBJECTIVES: The objective of this study is (1) to assess whether the presentation level of the antiphasic digits-in-noise (DIN) test affects the speech recognition threshold (SRT), (2) to evaluate how accurately simulated unilateral and bilateral conductive hearing loss is detected (CHL) and (3) to determine whether increasing the presentation level normalises the antiphasic DIN SRT. DESIGN: Participants performed antiphasic and diotic DINs at different presentation levels with unilateral, bilateral or no earplugs. STUDY SAMPLE: Twenty-four and twelve normal hearing adults. RESULTS: Without earplugs, antiphasic DIN SRTs did not differ between 60 and 80 dB SPL. At 60 dB SPL, the antiphasic DIN correctly classified 92% of the unilateral earplug cases; the diotic DIN 25%. The binaural intelligibility level difference did not differ between the no-earplug condition and the condition with bilateral earplugs when the presentation was increased with the attenuation level. CONCLUSIONS: In normal hearing participants, diotic and antiphasic DIN SRTs are independent of presentation level above a minimum level of 60 dB SPL. The antiphasic DIN is more sensitive than the diotic DIN for detecting unilateral CHL; not for bilateral CHL. The effect of CHL on DIN SRTs can be largely compensated by increasing the presentation level. Audibility plays an important role in the antiphasic and diotic DIN.

The one-up one-down adaptive (staircase) procedure in speech-in-noise testing: Standard error of measurement and fluctuations in the track.

The one-up one-down adaptive (staircase or up-down) procedure is often used to estimate the speech recognition threshold (SRT) in speech-in-noise testing. This article provides a brief historical overview of the one-up one-down procedure in psychophysics, discussing the groundbreaking early work that is still relevant to clinical audiology and scientific research. Next, this article focuses on two aspects of the one-up one-down adaptive procedure: first, the standard error of measurement (SEM) and, second, the fluctuations in the track [i.e., the standard deviation of the signal-to-noise ratios of the stimuli within the track (SDtrack)]. Simulations of ideal and non-ideal listeners and experimental data are used to determine and evaluate different relationships between the parameters slope of the speech recognition function, SRT, SEM, and SDtrack. Hearing loss and non-ideal behavior (inattentiveness, fatigue, and giving up when the task becomes too difficult) slightly increase the average value of SDtrack. SDtrack, however, poorly discriminates between reliable and unreliable SRT estimates.

Global use and outcomes of the hearWHO mHealth hearing test.

Objectives: The objective of this study was to examine the uptake, user characteristics, and performance of the free WHO smartphone hearing screening test (hearWHO) as a global hearing health promotion initiative. Method: We retrospectively examined the data of 242 626 tests conducted by adults (> 18 years) on the hearWHO app between February 2019 and May 2021. Test uptake was evaluated by country, WHO world region, test date, and demographics of age and gender. Results: The hearWHO test was completed in nearly every country globally (n = 179/195), with the greatest uptake seen in China and India. Uptake was greatest in the Western Pacific (32.9%) and European (24.8%) WHO regions. There was a high uptake of tests (44%) by young adults under the age of 30 years. Referral rates were typically higher for older age groups in most WHO regions, except for the African and Eastern Mediterranean regions, where overall hearWHO test uptake was lowest. Most testing (49%) took place in March (2019-2021) coinciding with World Hearing Day (3rd of March) each year. Conclusions: Digital mhealth tools provide many benefits in healthcare, including health promotion, access to information, and services for hearing loss. The hearWHO test was mainly reaching younger adults, positioning it as an important measure for public health advocacy to prevent hearing loss. Since hearing loss is primarily age related, more targeted campaigns or community-based initiatives should be directed toward older adults.

Factors Associated With the Development of Tinnitus and With the Degree of Annoyance Caused by Newly Developed Tinnitus.

OBJECTIVES: Tinnitus is highly prevalent, but only a few risk factors for developing tinnitus are known and little is known about factors associated with the degree of annoyance of new-onset tinnitus. Longitudinal analysis can reveal risk factors associated with the development of tinnitus and might lead to targeted prevention. The aim of this study is twofold. (1) To identify risk factors that are longitudinally associated with the odds of developing tinnitus 5 years later. (2) To identify factors that are cross-sectionally associated with tinnitus annoyance in adults with new-onset tinnitus. METHODS: Baseline, 5-year, and 10-year follow-up data of participants in the Netherlands Longitudinal Study on Hearing (NL-SH) were used. The NL-SH is a web-based prospective cohort study, which started in 2006 and includes both normal hearing and hearing-impaired adults aged 18 to 70 years at baseline. The NL-SH uses an online digit-triplet speech-in-noise test to asses speech recognition ability in noise, and online questionnaires on various aspects of life. At follow-up, participants are asked (1) if they suffer from tinnitus and (2) to rate tinnitus annoyance on a 0 to 100 numeric rating scale. We investigated whether demographic (age, sex, living arrangement, educational level), lifestyle (history of tobacco smoking, alcohol use), health (asthma, severe heart disease, hypertension, history of stroke, osteoarthritis, rheumatoid arthritis, epilepsy, multiple sclerosis, and migraine), hearing (speech recognition ability in noise, hyperacusis, and occupational noise exposure), and psychological variables (distress, somatization, depression, and anxiety) were potential risk factors for new-onset tinnitus, or associated with annoyance caused by new-onset tinnitus. Generalized estimating equations were used to longitudinally analyze the association between potential risk factors and new-onset tinnitus measured 5 years later. A multivariable association model was constructed using a forward selection procedure with p < 0.05 for model entry. Linear regression analysis was used to cross-sectionally analyze the association between potential factors and tinnitus annoyance in new-onset tinnitus. For this purpose, a multivariable association model was constructed using a forward selection procedure with p <0.05 for model entry. RESULTS: In total, 734 participants without tinnitus at baseline were included, from which 137 participants reported to suffer from new-onset tinnitus 5 or 10 years later. Risk factors for new-onset tinnitus were history of smoking (odds ratio 1.5, 95% confidence interval [CI] 1.0 to 2.2, p = 0.027) and higher levels of somatization (odds ratio 2.0, 95% CI 1.2 to 3.3, overall p = 0.024). Factors associated with the degree of tinnitus annoyance were increased levels of anxiety (ß = 11.6, 95% CI 2.3-20.8, overall p = 0.035) and poor speech recognition ability in noise (ß = 13.5, 95% CI, 4.4 to 22.6, overall p = 0.014). CONCLUSIONS: Higher levels of somatization and a history of smoking were found to be risk factors for new-onset tinnitus 5 years later. Anxiety and poor speech recognition ability in noise were associated with higher degrees of tinnitus annoyance in new-onset tinnitus. Somatization deserves to be addressed in future research and clinical practice as it might provide part of a model for the development of chronic tinnitus.

The Importance of Extended High-Frequency Speech Information in the Recognition of Digits, Words, and Sentences in Quiet and Noise.

OBJECTIVES: In pure-tone audiometry, hearing thresholds are typically measured up to 8 kHz. Recent research has shown that extended high-frequency (EHF; frequencies >8 kHz) speech information improves speech recognition. However, it is unclear whether the EHF benefit is present for different types of speech material. This study assesses the added value of EHF information for speech recognition in noise for digit triplets, consonant-vowel-consonant (CVC) words, and sentences; and for speech recognition in quiet for CVC. DESIGN: Twenty-four young adults with normal-hearing thresholds up to 16 kHz performed a listening experiment in quiet and in noise in a within-subject repeated measures design. Stimuli were presented monaurally. Steady state speech-shaped noise at a fixed signal to noise ratio was used for measurements in noise. Listening conditions varied only in terms of available EHF information. Stimuli were presented in three different conditions: (1) both speech and noise broadband, (2) speech broadband and noise low-pass filtered at 8 kHz, and (3) both speech and noise low-pass filtered at 8 kHz. In the speech-in-quiet experiment, stimuli (CVC) were high-pass filtered at 3 kHz and presented in two conditions: (1) with EHF information and (2) without EHF information. RESULTS: In the speech-in-noise experiment, for all speech material, the highest scores were achieved in the condition where the noise was low-pass filtered at 8 kHz and speech unfiltered; the lowest scores were obtained in the condition where both speech and noise were low-pass filtered at 8 kHz. Adding speech frequencies above 8 kHz improved the median recognition scores by 75.0%, 21.8%, and 23.8% for digit triplets, words, and sentences, respectively, at a fixed signal to noise ratio. In the speech-in-quiet experiment, median recognition scores were 7.8% higher in the condition where the EHF information was available, as opposed to when it was not. CONCLUSIONS: Speech information for frequencies above 8 kHz contributes to speech recognition in noise. It also contributes to speech recognition in quiet when information below 3 kHz is absent. Our results suggest that EHFs may be relevant in challenging listening conditions and should be measured in pure-tone audiometry to get a complete picture of a person's hearing. Further, results of speech recognition tests may vary when different recording and/or measurement equipment is used with different frequency responses above 8 kHz.

Diotic and Antiphasic Digits-in-noise Testing as a Hearing Screening and Triage Tool to Classify Type of Hearing Loss.

OBJECTIVES: The digits-in-noise test (DIN) is a popular self-test measure that has traditionally been used to screen for hearing loss by providing either a pass or refer result. Standard approaches either tested each ear monaurally or used a binaural diotic version where identical digits and noise were presented simultaneously to both ears. Recently, a dichotic, antiphasic version was developed, increasing sensitivity of the DIN to unilateral or asymmetric sensorineural hearing loss (SNHL) and conductive hearing loss (CHL). The purpose of this study was to determine predictors and normative ranges of the antiphasic and diotic DIN and to determine if a combination of diotic and antiphasic DIN could accurately categorize hearing into (1) normal, (2) bilateral SNHL, or (3) unilateral SNHL or CHL. DESIGN: The analytical sample consisted of 489 participants between the ages of 18 and 92 years with varying types, symmetry, and degrees of hearing loss. Degree and type of hearing loss were determined based on standard clinical four-frequency (0.5-4 kHz) pure-tone air and bone conduction threshold averages. The sample consisted of bilateral normal hearing (n = 293), bilateral SNHL (n = 172), unilateral SNHL (n = 42), and CHL (n = 32). All participants (n = 489) first completed an antiphasic DIN (digit stimuli 180° out-of-phase between ears), while 393 of the sample also completed a diotic DIN. Two procedures were assessed for their ability to categorize hearing into one of the three hearing groups. The first used a fixed antiphasic cutoff combined with a cutoff formed by a linear combination of antiphasic and diotic speech recognition threshold (SRT) or binaural intelligibility-level difference. RESULTS: Poorer ear pure-tone average was the strongest predictor of antiphasic DIN score, whereas better ear pure-tone average explained more of the variance in diotic SRT. The antiphasic DIN sensitivity and specificity was 90% and 84%, respectively, for detecting hearing loss, with outstanding area under the receiver operating characteristics values exceeding 0.93 to identify hearing loss in the poorer ear. The first fixed SRT cutoff procedure could categorize 75% of all participants correctly, while the second procedure increased correct categorization to 79%. False negative rates for both procedures were below 10%. CONCLUSIONS: A sequential antiphasic and diotic DIN could categorize hearing to a reasonable degree into three groups of (1) normal hearing; (2) bilateral SNHL; and (3) unilateral asymmetric SNHL or CHL. This type of approach could optimize care pathways using remote and contactless testing, by identifying unilateral SNHL and CHL as cases requiring medical referral. In contrast, bilateral SNHL cases could be referred directly to an audiologist, or nontraditional models like OTC hearing aids.

Improving the Efficiency of the Digits-in-Noise Hearing Screening Test: A Comparison Between Four Different Test Procedures.

PURPOSE: This study compared the test characteristics, test-retest reliability, and test efficiency of three novel digits-in-noise (DIN) test procedures to a conventional antiphasic 23-trial adaptive DIN (D23). METHOD: One hundred twenty participants with an average age of 42 years (SD = 19) were included. Participants were tested and retested with four different DIN procedures. Three new DIN procedures were compared to the reference D23 version: (a) a self-selected DIN (DSS) to allow participants to indicate a subjective speech recognition threshold (SRT), (b) a combination of self-selected and adaptive eight-trial DIN (DC8) that utilized a self-selected signal-to-noise ratio (SNR) followed by an eight-trial adaptive DIN procedure, and (c) a fixed SNR DIN (DF) approach using a fixed SNR value for all presentations to produce a pass/fail test result. RESULTS: Test-retest reliability of the D23 procedure was better than that of the DSS and DC8 procedures. SRTs from DSS and DC8 were significantly higher than SRTs from D23. DSS was not accurate to discriminate between normal-hearing and hard of hearing listeners. The DF and DC8 procedures with an adapted cutoff showed good hearing screening test characteristics. All three novel DIN procedure durations were significantly shorter (< 70 s) than that of D23. DF showed a reduction of 46% in the number of presentations compared to D23 (from 23 presentations to an average of 12.5). CONCLUSIONS: The DF and DC8 procedures had significantly lower test durations than the reference D23 and show potential to be more time-efficient screening tools to determine normal hearing or potential hearing loss. Further studies are needed to optimize the DC8 procedure. The reference D23 remains the most reliable and accurate DIN hearing screening test, but studies in which the potentially efficient new DIN procedures are compared to pure-tone thresholds are needed to validate these procedures.

French Version of the Antiphasic Digits-in-Noise Test for Smartphone Hearing Screening.

In France 58% of persons with hearing loss still do not wear hearing aids. Pure-tone audiometry is the traditional gold standard in assessment and screening of hearing impairment, but it requires the use of calibrated devices and soundproof booth. The antiphasic digits-in-noise (DIN) test does not require calibrated material and can run on a standard headset or earbuds connected to a smartphone or a computer. The DIN test is highly correlated with pure tone audiometry and has already shown to be effective in hearing loss screening in its English version promoted by the WHO. The aim of the present study was to develop and validate a French version of the antiphasic DIN test for implementation on a national screening test offered as a smartphone app. The audio files recorded from a French native female speaker were selected and normalized in intensity according to their recognition probability. The French DIN test application was then tested on normal hearing- and hearing-impaired subjects. Based on the strong correlation between pure tone audiometry (PTA) and DIN SRT, we calculated ROC curves and Z-score. For PTA > 20 dB HL, a SNR cutoff of 12.9 dB corresponds to a sensitivity and specificity of 0.96 and 0.93, respectively. To detect moderate and more severe hearing loss (PTA > 40 dB HL), the SNR cutoff was -10.9 dB, corresponding to a sensitivity and specificity of 0.99 and 0.83, respectively. The Z-score was calculated to define statistical criteria of normality for speech-in-noise evaluation. While a score of 0 roughly corresponds to the normality (DIN SRT = -15.4 dB SNR), a subject with DIN SRT > -12.2 (Z-score > 2) is ranked in the hearing loss population. Next, the French antiphasic DIN test was implemented in the Höra iOS and Android apps. In total, 19,545 Höra tests were completed and analyzed. Three quarters of them were classified as normal (74 %) and one quarter presented mild (9%) or more severe loss (17%). Together, results argue for the use of the French version of antiphasic DIN test in the general population to improve the screening of hearing-impaired individuals.

An analytical method to convert between speech recognition thresholds and percentage-correct scores for speech-in-noise tests.

Speech-in-noise tests use fixed signal-to-noise ratio (SNR) procedures to measure the percentage of correctly recognized speech items at a fixed SNR or use adaptive procedures to measure the SNR corresponding to 50% correct (i.e., the speech recognition threshold, SRT). A direct comparison of these measures is not possible yet. The aim of the present study was to demonstrate that these measures can be converted when the speech-in-noise test meets specific criteria. Formulae to convert between SRT and percentage-correct were derived from basic concepts that underlie standard speech recognition models. Information about the audiogram is not being used in the proposed method. The method was validated by comparing the direct conversion by these formulae with the conversion using the more elaborate Speech Intelligibility Index model and a representative set of 60 audiograms (r = 0.993 and r = 0.994, respectively). Finally, the method was experimentally validated with the Afrikaans sentence-in-noise test (r = 0.866). The proposed formulae can be used when the speech-in-noise test uses steady-state masking noise that matches the spectrum of the speech. Because pure tone thresholds are not required for these calculations, the method is widely applicable.

Speech Recognition in Noise Using Binaural Diotic and Antiphasic Digits-in-Noise in Children: Maturation and Self-Test Validity.

BACKGROUND: Digits-in-noise (DIN) tests have become popular for hearing screening over the past 15 years. Several recent studies have highlighted the potential utility of DIN as a school-aged hearing test. However, age may influence test performance in children due to maturation. In addition, a new antiphasic stimulus paradigm has been introduced, allowing binaural intelligibility level difference (BILD) to be measured by using a combination of conventional diotic and antiphasic DIN. PURPOSE: This study determined age-specific normative data for diotic and antiphasic DIN, and a derived measure, BILD, in children. A secondary aim evaluated the validity of DIN as a smartphone self-test in a subgroup of young children. RESEARCH DESIGN: A cross-sectional, quantitative design was used. Participants with confirmed normal audiometric hearing were tested with a diotic and antiphasic DIN. During the test, arrangements of three spoken digits were presented in noise via headphones at varying signal-to-noise ratio (SNR). Researchers entered each three-digit spoken sequence repeated by the participant on a smartphone keypad. STUDY SAMPLE: Overall, 621 (428 male and 193 female) normal hearing children (bilateral pure tone threshold of ≤ 20 dB hearing level at 1, 2, and 4 kHz) ranging between the ages of 6 and 13 years were recruited. A subgroup of 7-year-olds (n = 30), complying with the same selection criteria, was selected to determine the validity of self-testing. DATA COLLECTION AND ANALYSIS: DIN testing was completed via headphones coupled to a smartphone. Diotic and antiphasic DIN speech recognition thresholds (SRTs) were analyzed and compared for each age group. BILD was calculated through subtraction of antiphasic from diotic SRTs. Multiple linear regressions were run to determine the effect of age on SRT and BILD. In addition, piecewise linear regressions were fit across different age groups. Wilcoxon signed-rank tests were used to determine differences between self- and facilitated tests. RESULTS: Age was a significant predictor, of both diotic and antiphasic DIN SRTs (p < 0.05). SRTs improved by 0.15 dB and 0.35 dB SNR per year for diotic and antiphasic SRTs, respectively. However, age effects were only significant up to 10 and 12 years for antiphasic and diotic SRTs, respectively. Age significantly (p < 0.001) predicted BILD, which increased by 0.18 dB per year. A small SRT advantage for facilitated over self-testing was seen but was not significant (p > 0.05). CONCLUSIONS: Increasing age was significantly associated with improved SRT and BILD using diotic and antiphasic DINs. DIN could be used as a smartphone self-test in young children from 7 years of age with appropriate quality control measures to avoid potential false positives.

Binaural summation, binaural unmasking and fluctuating masker benefit in bimodal and bilateral adult cochlear implant users.

OBJECTIVES: The number of bilateral adult cochlear implant (CI) users and bimodal CI users is expanding worldwide. The addition of a hearing aid (HA) in the contralateral non-implanted ear (bimodal) or a second CI (bilateral) can provide CI users with some of the benefits associated with listening with two ears. Our was to examine whether bilateral and bimodal CI users demonstrate binaural summation, binaural unmasking and a fluctuating masker benefit. METHODS: Direct audio input was used to present stimuli to 10 bilateral and 10 bimodal CochlearTM CI users. Speech recognition in noise (speech reception threshold, SRT) was assessed monaurally, diotically (identical signals in both devices) and dichotically (antiphasic speech) with different masking noises (steady-state and interrupted), using the digits-in-noise test. RESULTS: Bilateral CI users demonstrated a trend towards better SRTs with both CIs than with one CI. Bimodal CI users showed no difference between the bimodal SRT and the SRT for CI alone. No significant differences in SRT were found between the diotic and dichotic conditions for either group. Analyses of electrodograms created from bilateral stimuli demonstrated that substantial parts of the interaural speech cues were preserved in the Advanced Combination Encoder, an n-of-m channel selection speech coding strategy, used by the CI users. Speech recognition in noise was significantly better with interrupted noise than with steady-state masking noise for both bilateral and bimodal CI users. CONCLUSION: Bilateral CI users demonstrated a trend towards binaural summation, but bimodal CI users did not. No binaural unmasking was demonstrated for either group of CI users. A large fluctuating masker benefit was found in both bilateral and bimodal CI users.