Division of Audiology, Department of Otolaryngology University of California, San Francisco School of Medicine presents

UCSF Audiology Amplification Update XI

November 1– 2, 2013 Holiday Inn, Fisherman’s Wharf San Francisco, California

Course Chair Robert W. Sweetow, PhD University of California, San Francisco

University of California, San Francisco School of Medicine Acknowledgement of Commercial Support

This CME activity was supported in part by educational grants from the following:

Oticon, Inc

Starkey Hearing Technologies

Exhibitors

Audiology Systems Inc. – an Otometrics partner

CaptionCall

Cochlear Americas

Elite Hearing Network

Health Care Instruments (HCI)/Audiometrics

Fuel Medical

Lyric by Phonak

MED EL

Neurotone

Oticon Medical

Oticon USA

Phonak

ReSound

Siemens Hearing Instruments

Starkey Hearing Technologies

Unitron

Widex

Table of Contents

Educational Objectives ...... 5 Accreditation ...... 5 General Information ...... 6 Linguistic Competency Information ...... 7 Course Faculty ...... 9 Disclosures ...... 10 Course Program ...... 11

Friday, November 1, 2013 Evidence base for hearing aid features, the 'What, How ...... 12 -30 and Why' of Technology Selection, Fitting, and Assessment J. Andrew "Drew" Dundas, PhD Evaluating New Technology ...... 31 -57 Ruth Bentler, PhD Cochlear Implants: Where we’ve been; where we are ...... 58 -70 Colleen Polite, AuD Basal Ganglia Neuromodulation for Tinnitus Suppression ...... 71-78 Steven W. Cheung, MD

Saturday, November 2, 2013 Assessment and Interventions for Hearing Loss-related Fatigue ...... 79-83 Benjamin W.Y. Hornsby, PhD Techniques and Challenges Related to Participation and ...... 84-103 Compliance with Aural Rehabilitation Robert W. Sweetow, PhD Pediatric Bone Anchored Implants: Protocols and Strategies ...... 104-123 Lisa Christensen, AuD Registrant List ...... 124-126

University of California, San Francisco School of Medicine Presents

UCSF Audiology Amplification Update XI

This course is designed as a state-of-the-art course is designed as a state-of-the-art update of contemporary audiological practice, including evidence-based fitting and verification of hearing aids, pediatric use of bone anchored implants, listener effort and fatigue from amplification, as well as techniques and challenges associated with aural rehabilitation, tinnitus, and cochlear implants. Although it is intended as a course for practicing audiologists, professionals engaged in hearing aid dispensing, audiology graduate students, physicians, and others involved in the management of adults and children with hearing disorders will also benefit. The program consists of four primary components: lectures presented by renowned faculty from around the country, moderated question and answer periods at the conclusion of each morning and afternoon session, moderated panel discussions, and updates on new technology presented by manufacturer representatives.

Educational Objectives

An attendee completing this course will be able to: • Compare evidence-based research for current hearing aid fitting and verification; • Assess information regarding listener fatigue and how to minimize it; • Distinguish best practice guidelines for pediatric bone anchored implants; • Illustrate new strategies for cochlear implant patients; • Analyze recent research findings on the generation of tinnitus; • Practice new approaches to aural rehabilitation; • Solve challenges to participation and compliance in auditory rehabilitation.

Accreditation

University of California, San Francisco is a Speech-Language Pathology and Audiology and Hearing Aid Dispensers Board (SLPAHADB) approved provider for continuing professional development courses. This live activity meets the qualifications for 12 hours of continuing professional development credit for audiologists as required by SLPAHADB for hearing-aid related and non-hearing aid related. Provider #PDP313.

This educational activity is approved for up to 1.2 CEUs and up to 1.2 Tier 1 CEUs from the American Academy of Audiology: Program number 13UCA-100. General Information

Attendance / Sign-In Sheet / Certificates

Please return your Attendance Verification Record (AVR) form by the end of the course along with your evaluation. Certificates will be mailed to you, at the address you registered with, in approximately 3-4 weeks post course.

Each participant is required to sign-in and claim the number of credits in order to receive a certificate. The sign-in sheet will be located at the UCSF Registration Desk.

Evaluation Your opinion is important to us. Please complete and return the course evaluation as it is important to future course planning. The evaluation is the colored sheet you received with your course syllabus. Please turn in the evaluation with your AVR form.

Security We urge caution with regard to your personal belongings. Please do not leave any personal belongings unattended in the meeting room during lunch or breaks or overnight.

Exhibits Industry exhibits will be available outside the ballroom on the Mezzanine level during breakfasts and breaks, and lunches.

Course Reception: Friday, November 1 A course reception will be held directly after the lecture on Friday, November 1 from 5:30 pm -7:00 pm on the Mezzanine level. This is open to all attendees.

Final Presentations PowerPoint presentations will be available on our website, www.cme.ucsf.edu, approximately 3 – 4 weeks post course. Only presentations that have been authorized for inclusion by the presenter will be included

Federal and State Law Regarding Linguistic Access and Services for Limited English Proficient Persons

I. Purpose. This document is intended to satisfy the requirements set forth in California Business and Professions code 2190.1. California law requires physicians to obtain training in cultural and linguistic competency as part of their continuing medical education programs. This document and the attachments are intended to provide physicians with an overview of federal and state laws regarding linguistic access and services for limited English proficient (“LEP”) persons. Other federal and state laws not reviewed below also may govern the manner in which physicians and healthcare providers render services for disabled, hearing impaired or other protected categories

II. Federal Law – Federal Civil Rights Act of 1964, Executive Order 13166, August 11, 2000, and Department of Health and Human Services (“HHS”) Regulations and LEP Guidance. The Federal Civil Rights Act of 1964, as amended, and HHS regulations require recipients of federal financial assistance (“Recipients”) to take reasonable steps to ensure that LEP persons have meaningful access to federally funded programs and services. Failure to provide LEP individuals with access to federally funded programs and services may constitute national origin discrimination, which may be remedied by federal agency enforcement action. Recipients may include physicians, hospitals, universities and academic medical centers who receive grants, training, equipment, surplus property and other assistance from the federal government.

HHS recently issued revised guidance documents for Recipients to ensure that they understand their obligations to provide language assistance services to LEP persons. A copy of HHS’s summary document entitled “Guidance for Federal Financial Assistance Recipients Regarding Title VI and the Prohibition Against National Origin Discrimination Affecting Limited English Proficient Persons – Summary” is available at HHS’s website at: http://www.hhs.gov/ocr/lep/ .

As noted above, Recipients generally must provide meaningful access to their programs and services for LEP persons. The rule, however, is a flexible one and HHS recognizes that “reasonable steps” may differ depending on the Recipient’s size and scope of services. HHS advised that Recipients, in designing an LEP program, should conduct an individualized assessment balancing four factors, including: (i) the number or proportion of LEP persons eligible to be served or likely to be encountered by the Recipient; (ii) the frequency with which LEP individuals come into contact with the Recipient’s program; (iii) the nature and importance of the program, activity or service provided by the Recipient to its beneficiaries; and (iv) the resources available to the Recipient and the costs of interpreting and translation services.

Based on the Recipient’s analysis, the Recipient should then design an LEP plan based on five recommended steps, including: (i) identifying LEP individuals who may need assistance; (ii) identifying language assistance measures; (iii) training staff; (iv) providing notice to LEP persons; and (v) monitoring and updating the LEP plan.

A Recipient’s LEP plan likely will include translating vital documents and providing either on-site interpreters or telephone interpreter services, or using shared interpreting services with other Recipients. Recipients may take other reasonable steps depending on the emergent or non- emergent needs of the LEP individual, such as hiring bilingual staff who are competent in the skills required for medical translation, hiring staff interpreters, or contracting with outside public or private agencies that provide interpreter services. HHS’s guidance provides detailed examples of the mix of services that a Recipient should consider and implement. HHS’s guidance also establishes a “safe harbor” that Recipients may elect to follow when determining whether vital documents must be translated into other languages. Compliance with the safe harbor will be strong evidence that the Recipient has satisfied its written translation obligations.

In addition to reviewing HHS guidance documents, Recipients may contact HHS’s Office for Civil Rights for technical assistance in establishing a reasonable LEP plan.

III. California Law – Dymally-Alatorre Bilingual Services Act. The California legislature enacted the California’s Dymally-Alatorre Bilingual Services Act (Govt. Code 7290 et seq.) in order to ensure that California residents would appropriately receive services from public agencies regardless of the person’s English language skills. California Government Code section 7291 recites this legislative intent as follows:

“The Legislature hereby finds and declares that the effective maintenance and development of a free and democratic society depends on the right and ability of its citizens and residents to communicate with their government and the right and ability of the government to communicate with them.

The Legislature further finds and declares that substantial numbers of persons who live, work and pay taxes in this state are unable, either because they do not speak or write English at all, or because their primary language is other than English, effectively to communicate with their government. The Legislature further finds and declares that state and local agency employees frequently are unable to communicate with persons requiring their services because of this language barrier. As a consequence, substantial numbers of persons presently are being denied rights and benefits to which they would otherwise be entitled.

It is the intention of the Legislature in enacting this chapter to provide for effective communication between all levels of government in this state and the people of this state who are precluded from utilizing public services because of language barriers.”

The Act generally requires state and local public agencies to provide interpreter and written document translation services in a manner that will ensure that LEP individuals have access to important government services. Agencies may employ bilingual staff, and translate documents into additional languages representing the clientele served by the agency. Public agencies also must conduct a needs assessment survey every two years documenting the items listed in Government Code section 7299.4, and develop an implementation plan every year that documents compliance with the Act. You may access a copy of this law at the following url: http://www.spb.ca.gov/bilingual/dymallyact.htm

Faculty List

Course Chair

Robert W. Sweetow, PhD Professor of Otolaryngology

Guest Faculty

Ruth A. Bentler, PhD Professor Department of Speech Pathology & Audiology University of Iowa Iowa City, IA

Lisa Christensen, AuD Pediatric Audiologist Outreach Support Services Program Arkansas School for the Deaf Little Rock, AK

Benjamin W.Y. Hornsby, PhD Assistant Professor Department of Hearing and Speech Sciences Vanderbilt University

Course Faculty (University of California, San Francisco)

Steven W. Cheung, MD, FACS Professor, Department of Otolaryngology-Head and Neck Surgery

J. Andrew “Drew” Dundas, PhD Director, Audiology Assistant Professor, Department of Otolaryngology-Head and Neck Surgery

Colleen Polite, AuD Assistant Director, Cochlear Implant Center Department of Otolaryngology-Head and Neck Surgery

; Disclosures

The following faculty speakers, moderators, and planning committee members have disclosed they have no financial interest/arrangement or affiliation with any commercial companies who have provided products or services relating to their presentation(s) or commercial support for this continuing medical education activity:

Ruth A. Bentler, PhD Benjamin W.Y. Hornsby, PhD Steven W. Cheung, MD, FACS Colleen Polite, AuD J. Andrew “Drew” Dundas, PhD

The following faculty speakers have disclosed a financial interest/arrangement or affiliation with a commercial company who has provided products or services relating to their presentation(s) or commercial support for this continuing medical education activity. All conflicts of interest have been resolved in accordance with the ACCME Standards for Commercial Support:

Robert Sweetow Consultant and stock shareholder Neurotone, Inc. Lisa Christensen Consultant Cochlear Americas

This UCSF CME educational activity was planned and developed to: uphold academic standards to ensure balance, independence, objectivity, and scientific rigor; adhere to requirements to protect health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA); and, include a mechanism to inform learners when unapproved or unlabeled uses of therapeutic products or agents are discussed or referenced.

This activity has been reviewed and approved by members of the UCSF CME Governing Board in accordance with UCSF CME accreditation policies. Office of CME staff, planners, reviewers, and all others in control of content have disclosed no relevant financial relationships.

UCSF Audiology Amplification Update XI COURSE AGENDA Holiday Inn Fisherman’s Wharf, San Francisco, CA FRIDAY, NOVEMBER 1, 2013

7:30 am Registration/Continental Breakfast

8:00 Welcome Robert W. Sweetow, PhD

8:05 Updates on New Technology Manufacturer Representatives

9:05 *Evidence base for hearing aid features - J. Andrew "Drew" Dundas, PhD, the 'What, How and Why' of Technology Selection, Fitting, and Assessment

10:35 Break, Exhibits Open

11:00 *Evaluating New Technology Ruth Bentler, PhD

12:30 pm *Question and Answer Panel

1:00 Lunch on your own - Exhibits Open

2:30 *Cochlear Implants: Where we’ve been; where we are Colleen Polite, AuD

3:30 Break, Exhibits Open

4:00 *Basal Ganglia Neuromodulation for Steven W. Cheung, MD Tinnitus Suppression

5:00 *Question and Answer Panel

5:30 pm Adjourn

5:30-7;00 pm Reception and Exhibits

SATURDAY, NOVEMBER 2, 2013

7:30 am Registration and Continental Breakfast

8:00 Welcome Robert W. Sweetow, PhD

8:05 Updates on New Technology Manufacturer Representatives

9:05 *Assessment and Interventions for Benjamin W.Y. Hornsby, PhD Hearing Loss-related Fatigue

10:35 Break, Exhibits Open

11:00 *Auditory Training and Challenges Associated Robert W. Sweetow, PhD with Participation and Compliance 12:30 pm *Question and Answer Panel

1:00 Lunch on your own - Exhibits Open

2:30 *Pediatric Bone Anchored Implants: Lisa Christensen, AuD Protocols and Strategies

4:00 Break and Exhibits

4:30 *Panel on Current Hearing Aid Dispensing Issues Conference Speakers

5:30 pm Adjourn

(Maximum 12 SLPAHADB Audiology Hours; 12 SLPAHADB Dispenser Hours; 1.2 AAA Credits; 1.2 ABA Tier 1 Credits)

10/21/2013

Evidence base for  HI Industry research background – Starkey hearing aid features: Hearing Technologies, 2010‐2012  Realities of hearing aid features don’t always fit with marketing spin, conventional wisdom or the ʹwhat, how and whyʹ of published research technology selection, { fitting and assessment.

Drew Dundas, PhD Director of Audiology, Clinical Assistant Professor of Disclosure Otolaryngology UCSF Medical Center

 Directional  What the technology is  Assessing benefit: microphones intended to accomplish D‐Mics  Objective  Digital Noise  How it actually works  Subjective Reduction  Why you might want to  The take home message DNR  Frequency Lowering recommend it

Frequency Lowering What, How, Why… Today’s Topics

1 10/21/2013

 “an abnormally rapid growth of loudness for  Abnormally rapid?  Critical terms and concepts sounds presented at levels greater than the  Growth of loudness? threshold of detection”

Foundations… Recruitment

 Perceptual correlate of intensity  Sound must be  Change in loudness is audible to have affected by: loudness  Magnitude of intensity change  Duration of intensity change Loudness Loudness

2 10/21/2013

The compressor of a hearing aid can be thought of as a loudness control Objective Subjective system. Why do we care?

 Real Ear Insertion Gain  Real Ear Aided Response  REIG ≠ Audibility  REAR > Threshold = Audibility  Gain = (Output –Input)  Device gain ≠ change in audibility  Response = Intensity

Gain vs. Response REIG vs. REAR

3 10/21/2013

 We need both gain and  Channel = A subset of the audibility to produce benefit that is: bandwidth for signal analysis and processing Objective and  Band = A subset of the bandwidth Subjective where you can control gain

Why do we care? Channels vs. Bands

The compressor of a hearing aid can be thought of as a loudness control system. Signal processing features are gain control systems.

Loudness and Gain The main course

4 10/21/2013

 Directional What? microphones D‐Mics  Digital Noise Reduction Why?  Frequency Lowering DNR How?

Frequency Lowering Directional Microphone Today’s Topics Technology

 Noise is an unwanted competitor.  It can also drive the compressor level estimate.  This can result in decreased signal audibility, as well as poor SNR.

The theory

5 10/21/2013

 Displays relative sensitivity of the mic at different angles.  Convention: Up is the ‘look’ direction.  Convention: Where the line gets close to the center, the mic is less sensitive. How do they work? Polar Response Pattern

 Fixed directional  Automatic directional  Adaptive directional  Automatic adaptive directional

A little like this… The implementations

6 10/21/2013

 Switches between omnidirectional and fixed directional  When to switch is governed by sound environment analysis

Automatic directional Dual Omni‐directional

 Vary the time delay, vary the polar response pattern  Adjust response pattern to maximize overall SNR

Change time delay, Adaptive Directional change response

7 10/21/2013

 Adds the low noise  When conditions are benefit of an appropriate – e.g., high omnidirectional SNR, low level response pattern listening. Automatic Adaptive Directional Adaptive Null‐Steering

Typically 20% ‐35% when:  The sound source of interest is in front and nearby  Competing noise is mainly behind or surrounds the listener  Reverberation is moderate or less  The instrument has a high average directivity index (DI) (3.5 –5.5 dB)

DI on the head Directional Benefit (Ricketts, 2008)

8 10/21/2013

Caveat: Microphone Drift  Directional Mics are Normal Hypercardioid Pattern Degraded Pattern due to good for almost 0.6‐dB Sensitivity Mismatch everyone, but…  They are not magic  If you don’t have audibility, DI = 6.0 dB DI = 4.0 dB they can’t help.  if there is a vent, they cannot provide benefit if you are not at least 0dB insertion gain Nulls are lost. The take home message DI drops by 2 dB.

What?  Identify which parts of sound are speech, and  Simple, right? which parts are noise. Why?  …um, no.  Don’t amplify the noise. How?

Digital Noise Reduction The theory

9 10/21/2013

10

8

6

4

2  Fast vs. Slow acting 2

0  Noise reduction vs. Speech preservation -2 SIGNAL VALUE SIGNAL SIGNAL VALUE SIGNAL -4

-6

-8

-10 0 0.5 1 1.5 2 2.5 The implementation TIME, s What it does

30

20

10

0

 Identify Noise -10 SNR, dB SNR,  Calculate Noise spectrum  For a given Time & Frequency: -20  Turn gain up when Speech -30  Turn gain down when Noise

-40 0 0.5 1 1.5 2 2.5 Identify NoiseTIME, s

10 10/21/2013

TC = 0.02; Slope = 0.45; Offset = 10 30 30

20 20

10 10

0 0

-10 -10 SNR, dB SNR, dB SNR,

-20 -20

-30 -30

-40 -40 0 0.5 1 1.5 2 2.5 0 0.5 1 1.5 2 2.5 Identify SpeechTIME, s Apply Gain TIME,Rules s

“Strict” Detection

Noise Speech Reduction Preservation

“Lenient” Detection In Running Speech A Balancing Act

11 10/21/2013

* *

Acceptance of Comfort and Annoyance (Palmer, Bentler, Mueller, 2006) Background Noise (Mueller, Weber, Hornsby, 2006)

Cognitive Benefits DNR makes noise more acceptable (Sarampalis et al., 2009)

12 10/21/2013

 Effects of DNR:  Enhanced comfort What?  Some listeners may  May free up cognitive experience enhanced resources for other speech understanding in Why? noise tasks  May make HAs more acceptable How?

The take home message Frequency Lowering

 Some listeners may not benefit from HF audibility

The theory

13 10/21/2013

 Off‐frequency listening  ‘Sensory overload’  Distortion /S/  Adverse effects on speech understanding

Theory Frequency Lowering

 Frequency Compression  Three Current  Transposition Implementations Non‐Linear Frequency Compression  Feature Synthesis

The implementations 1 2 3 44 5 65 6

14 10/21/2013

Increased audibility Decreased bandwidth at all times Reduced sound quality

Frequency Compression Frequency (Hz)

Frequency Transposition

Technique1 2 3 4 5 6 Frequency Transposition

15 10/21/2013

 Preserve bandwidth  Identify HF consonant sounds  Generate a spectral analogue at a lower • Increased audibility frequency • Speech cue confusion  Provide appropriate audibility of the analogue • Reduced sound quality re: concurrent speech sounds

Frequency Transposition Feature Synthesis

• Consonant sounds replicated in real time • Bandwidth preserved • Quality usually preserved Feature Synthesis The evidence

16 10/21/2013

Frequency Lowering: Adults

*

Frequency Lowering: Adults (Frequency Compression) (Glista et al., 2009) (Glista, Scollie, Bagatto, Seewald, Johson, 2009)

Consonant Recognition

Frequency Lowering: Adults (Frequency Transposition)

(Kuk, Peeters, Keenan, & Lau, 2007) (Galster, Valentine, Dundas & Fitz, 2011)

17 10/21/2013

 Recent research  Probe mic measures  Provides measurable  Problem: how much suggests that can be useful with real‐world benefit audibility is preserving bandwidth bandwidth limited  appropriate? Tuning for listener is preferred even in techniques preference is necessary  What targets do you patients with suspected  Demonstrates change  aim for? Like fitting targets, one dead regions in audibility size does not fit all  Sound quality matters

Assessing benefit The take home message

 Directional  microphones  Directionality All can provide D‐Mics measurable benefit for  Digital Noise  DNR appropriately selected Reduction  Frequency lowering and fit patients DNR  Frequency Lowering

Frequency Lowering Positive effects Summary

18 10/21/2013

1. Have to be applying gain with D‐Mics and DNR to change  Choose settings the output signal carefully, using  Can occur 2. Must be audible to be perceptible verification and patient The 3 concepts are linked perceptions as guides 3. Magnitude of perception is dependent on the loudness growth curve Gain, Audibility & Negative Effects? Magnitude of Perceptual effects

Questions?

 Direct sound arriving through the vent may [email protected]  Comparing sealed reduce signal processing coupler measurements effects to real‐world is not  In challenging cases, and always realistic more severe hearing losses, consider less open fittings to maximize effect

Direct vs. Amplified Path

19 11/1/2013

Levels of Evidence* APFs (Catherine Palmer, 2009) ◦ What does the algorithm do? ◦ What are the parameters that impact the doing? Evaluating New Efficacy of the design ◦ In a well-controlled (contrived?) environment, do we get an effect? Technologies ◦ Or, what is the effect of the feature in the lab? Effectiveness of the design RUTH BENTLER ◦ In the real-world use of this design, do we get an effect? UNIVERSITY OF IOWA ◦ Or, what is the effect of the feature in the real world?

*Ala Bentler 1

http://www.uiowa.edu/~neuroerg/siren.html

1 11/1/2013

Levels of Evidence* APFs (Catherine Palmer, 2009) ◦ What does the algorithm do? ◦ What are the parameters that impact the doing? Efficacy of the design ◦ In a well-controlled (contrived?) environment, do we get an Directional Microphones effect? ◦ Or, what is the effect of the feature in the lab? Effectiveness of the design ◦ In the real-world use of this design, do we get an effect? Or, what is the effect of the feature in the real world? Efficiency (not studied in my lab)

*Ala Bentler 8

APFs THE FIRST STEP IS TO UNDERSTANDING THE BLACK BOX….

9 10

11 12

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15 16

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Theoretical FF (BTE) KEMAR (BTE)

Cardioid 4.8 4.0 2.3

Hypercardioid 6.0 5.1 3.0

Supercardioid 5.7 5.0 3.3

45

0 350 20 10 340 20 330 30 15 320 40 Theoretical FF (ITE) KEMAR (ITE) 10 310 50 5 300 60 0 Cardioid 290 70 4.8 4.1 2.7 -5

280 -10 80 500 1000 270 -15 90 2000 Hypercardioid 6.0 5.6 3.3 260 100 4000 250 110

240 120 Supercardioid 5.7 5.4 3.5 230 130 220 140 210 150 200 160 190 170 180

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8 11/1/2013

Polargram And so… oWe are able to measure the acoustic and physical facts (APFs) for all possible scenarios of test; oSuch APF testing is necessary to develop our hypotheses; oNewer technique for quantifying polar response patterns and directivity indices (DI) helps us understand static function in a dynamic world of noise Wu & Bentler, 2009, 2010, 2012)!

50

Data? Test Booth Field Ratings 100 10 Very Good Plenty of efficacy data for all designs depending upon OMNI 80 DIR 8 ◦ Baseline used p < .0001 p < .0001 ◦ Speaker arrangement 60 6

◦ Noise type 40 4 ◦ Etc Percent Correct 20 2 Effectiveness data a bit harder to come by… 0 0 Very Poor 60 / 0 75 / +2 Speech CST Test Condition Understanding in Noise

Walden, Surr, & Cord, 2003

9 11/1/2013

Research Question of Study #1 Laboratory

• How do visual cues affect DIR benefit?

Real world

Speech recognition test

Speech Recognition Performance

100

80 DIR 60 Auditory-Only

40 OMNI 20 OMNI-AO OMNI-AV

Speech Recognition (%) Recognition Speech DIR-AO 0 DIR-AV

-10 -6 -2 2 6 10 SNR (dB) Wu & Bentler, 2010, Ear Hear

10 11/1/2013

Speech Recognition Performance Summary of Study 1

• The advantage (benefit) of visual cues can overshadow 100 Audiovisual the measured benefit of directional mic schemes in real

80 world environments.

60 Auditory-Only

40

20 OMNI-AO OMNI-AV

Speech Recognition (%) Recognition Speech DIR-AO 0 DIR-AV

-10 -6 -2 2 6 10 SNR (dB) Wu & Bentler, 2010, Ear Hear

Research Question of Study #2 25 F(1, 21) = 1.21 p = 0.29 • How does age impact DIR benefit? 20

• Laboratory 15 • Real world 10

Laboratory 5

DIR Benefit (%)

0

-5 30 40 50 60 70 80 90 Age

Wu, 2010, JAAA

100 Summary of Study #2 F(1, 21) = 11.78 p = 0.003 80 • Listeners of different ages obtain comparable benefits from DIR in the laboratory. 60 • Older users tend to perceive less DIR benefit than do younger users in the real world. 40 • Due to lifestyle differences, primarily

Real World • The focus of future efforts in the lab 20

DIR Preference (%) 0

30 40 50 60 70 80 90 Age

Wu, 2010, JAAA

11 11/1/2013

Example of unexpected function…

Front Forward DIR Forward DIR

Backward DIR Backward DIR Back

7

Front 6

5 p < 0.05

4

3 Backward DIR Backward DIR 2 p = 0.17 Back

Directional Benefit (dB) 1

0 Big dogs can be ConversationOur Data Manufacturer’sListening dangerous. Condition Data Wu, Stangl & Bentler, 2013 http://www.despicableme.com/

Big dogs can be dangerous. Front Front Forward DIR Forward DIR Forward DIR Forward DIR

Backward DIR Backward DIR Back Back

The boy fell from the window.

12 11/1/2013

7 Briefly, for DIR 6 ◦APFs are clear as to expected impact 5 p < 0.05 ◦Efficacy has been demonstrated 4 repeatedly; newer algorithms take 3 special consideration 2 p = 0.17 ◦Effectiveness depends on many

Directional Benefit (dB) Benefit Directional 1 factors ◦ Environment, age, etc 0 ◦ …crud ConversationOur Data Manufacturer’sListening Data Condition Wu, Stangl & Bentler, 2013

Analog NR (1980-90s) Early spectral approaches ◦ Switch ◦ ASP (means low frequency compression) Digital Noise Reduction ◦ Adaptive filtering ◦ Frequency dependant input compression ◦ Adaptive compressionTM ◦ Zeta Noise BlockerTM

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Today’s versions oMost are modulation-based with some algorithm for where and how much gain reduction should occur; oAt least one other (Oticon) first introduced a strategy called “synchronous morphology” treating harminic inputs like speech; oMany are now implementing Wiener filters as well; oMany are now implementing impulse noise APFs reduction; THE FIRST STEP IS TO UNDERSTANDING oMany also use some mic noise reduction, expansion, THE wind noise reduction, and even directional mics as part of the strategy they promote. BLACK BOX….

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Siemens (TRIANO 3) 2 GN ReSound (CANTA 770-D)

5 0

0 -2

-5 -4

-10 -6

-8 -15

Difference (dB, 1/3 Octave) SIREN Difference (dB,1/3octave) -20 -10 TRAFFIC DINING a -12 -25 250 500 1000 2000 4000 8000 125 250 500 1000 2000 4000 8000 Frequency (Hz) Frequency (Hz)

Starkey (AXENT II AV MM) 70dB 5 2

0 0 -2

-5 -4

OFF -6 -10

-8

versus -15 -10

ON (output change) SNR00

Difference (dB,1/3octave) -20 -12 SNR05 SNR10 b -14 SNR15 -25 125 250 500 1000 2000 4000 8000 -16 125 250 500 1000 2000 4000 8000 Frequency (Hz) Frequency (Hz) ICRA Speech Random Noise Babble

Starkey J13 Axent AV 75 dB --SPEECH,RANDOM, MUSIC-- 85dB 5

2 0 0

-2 -5

-4 -10 OFF -6

-8 -15

versus

-10 DIFFERENCE(dB,1/3octave) ON (output change) -20 SNR00 -12 SNR05 SNR10 -25 -14 SNR15 125 250 500 1000 2000 4000 8000

-16 Frequency(Hz) 125 250 500 1000 2000 4000 8000 Guitar Frequency (Hz) Piano Saxophone with background music Random Noise Plain Speech

14 11/1/2013

What happens in the time domain?

Siemens (Triano)

APFs…10 years later

Starkey (Axent)

88

Any reason to expect SNR-50

would change?

Output SNR (re: Linear) (re: SNR Output

Miller et al. 2012

15 11/1/2013

Data? Briefly, for DNR • Still, plenty of efficacy and effectiveness data for all designs if you are asking the right question: ◦APFs are clear as to expected impact • Walden et al (2000) ◦Efficacy and Effectiveness have been • Boymans and Dreschler (2000) • Alcantara et al (2003) demonstrated…if you are asking the right • Ricketts & Hornsby (2005) question • Marcoux et al (2006) • Mueller et al (2008) • Bentler et al (2009) • Sarampalis et al (2009) • Bentler et al (2010) • Stelmachowicz et al (2010) • Pittman et al (2011): • And those are good outcomes

Not really a new concept

Four (sort of) choices on the market: ◦ Frequency compression ◦ Frequency transposition Frequency Lowering ◦ Frequency “cueing” ◦ Combination of above Concept makes sense ◦ Providing the widest input bandwidth possible ◦ Data suggest this may be most important for children re: speech and language development

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What is happening here?

Frequency compression hearing aid Default settings Steeply sloping loss Freq compression: OFF APFs Assessed on 11/23/09 SN:0906H109W THE FIRST STEP IS TO UNDERSTANDING Input: 1s pure tones 100 Hz spaced with 500ms THE intervals (~75dB SPL) BLACK BOX…. Upper graph: output of Hearing aid

95 96

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1st peak: 3468 Hz, 2nd peak: 4091 Hz, 3rd peak: 4700 Hz 1st peak: 3661 Hz, 2nd peak: 4306 Hz, 3rd peak: 4927 Hz Input: 4091 Hz Input: 4306 Hz

97 98

st nd 1 peak: 3765 Hz, 2 peak: 4392 Hz 1st peak: 4070 Hz, 2nd peak: 4694 Hz, 3rd peak: 5336 Hz Input 4392 Hz Input 4694 Hz

99 100

1st peak: 5490 Hz 1st peak: 5598 Hz Input 5490 Hz Input 5598 Hz

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1st peak: 5457 Hz, 2nd peak: 6093 Hz 1st peak: 5553 Hz, 2nd peak: 6201 Hz Input: 6093 Hz Input: 6201 Hz

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st nd 1 peak: 5665 Hz, 2 peak: 5603 Hz 1st peak: 1937 Hz, 2nd peak: 2562 Hz Input 6309 Hz Input 6395 Hz

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1st peak: 1071 Hz, 2nd peak: 1701 Hz, 3rd peak: 2346 Hz Input: 4091 Hz What is happening here?

Frequency compression hearing aid Default settings Steeply sloping loss Freq compression: ON Assessed on 11/23/09 SN:0906H109W Input: 1s pure tones 100 Hz spaced with 500ms intervals (~75dB SPL) Upper graph: output of Hearing aid

107 108

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st nd rd th th 1st peak: 1894 Hz, 2nd peak: 1538 Hz 1 peak: 1207 Hz, 2 peak: 1359 Hz, 3 peak: 2851 Hz, 4 peak: 2001 Hz, 5 Input: 4306 Hz peak: 2482 Hz – Input 4392 Hz

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1st peak: 1343 Hz, 2nd peak: 1656 Hz, 3rd peak: 1981 Hz, 4th peak: 2626 Hz – 1st peak: 1351 Hz, 2nd peak: 1672 Hz, 3rd peak: 1981 Hz, 4th peak: 2626 Hz – Input 4694 Hz Input 5490 Hz

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1st peak: 1287 Hz, 2nd peak: 1916 Hz, 3rd peak: 2410 Hz, 4th peak: 2562 – Input 1st peak: 1624 Hz, 2nd peak: 2260 Hz, 3rd peak: 2907 Hz 5598 Hz Input: 6093 Hz

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1st peak: 1720 Hz, 2nd peak: 2368 Hz 1st peak: 1830 Hz, 2nd peak: 2466 Hz Input: 6201 Hz Input 6309 Hz

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1st peak: 1937 Hz, 2nd peak: 2562 Hz Input 6395 Hz

7500

6500 Uncompressed CF6.0; CR1.5 CF5.9; CR2.1 5500 CF4.7; CR2.0

CF3.8; CR1.9 4500 CF3.2; CR1.8 CF2.6; CR1.7 CF2.2; CR1.7 CF1.9; CR1.5 3500 CF1.7; CR1.6 CF1.5; CR1.5

CF1.5; CR2.0 Output (frequency inHz) (frequency Output 2500 CF1.5; CR2.5 CF1.5; CR3.2 CF1.5; CR4.1 1500

500 500 1500 2500 3500 4500 5500 6500 7500 Input (frequency in Hz)

Graph from A Perreau dissertation, 2011 117 118

Output of frequency-lowering hearing aids as a function of input frequency 2500 High-pass filter

2250 Processing of data blocks 2000 1787.26 1744.19 1750 FFT Σ Oscillators 1550.39 1765.72 Cutoff 1507.32 1528.86 Bin 1 Bin 1 Output Output 1500 Frequency Bin 2 Bin 2 1550.39 (frequency in Hz)(frequency Bin 3 Bin 3 Σ 1250 1356.59 * . . Microphone . . Receiver 1000 990.53 . . Bin 24 Bin 24

750 *N=7/11: Lowered Output <1500Hz

500 500 1000 1500 2000 2500 3000 3500 4000 4500 5000 Input (frequency in Hz) Low-pass filter delay = 9 ms

Graph from A Perreau dissertation, 2011 119 Graph from A Perreau dissertation,120 2011

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Evidence (efficacy here): Sound quality • Better speech-sound perception • Simpson et al (2005) 8/17 improvement phoneme recognition • Simpson et al (2006) 1/7 (words) 1/5 (sentences) improved speech perception; 1/6 better APHAB • Kuk et al (2007; 2009) improved consonant recognition (group) • Gifford et al (2007): 2/6 improved sentence recognition in Q and N; more (group) Guitar Original Guitar Max Comp benefit on EC, BN and RV subscales of APHAB • Robinson et al (2007) 4/7 improved affricates; 5/7 improved /s and /z/ • Nyffeler (2008) improved (group) satisfaction (11 adults) • Singer Original Singer Compressed Robinson et al (2009) 1/5 improved affricates; 1/5 improved /s and /z/ • Glista et al (2009) 5/11 children, 5/13 adults benefit for /s/ and /z/ detection • O’Brien et al (2010) initial improvement in speech perception (23 adults) • Wolfe at al (2010) group improvement for tokens /asa/ and /ada/ in quiet (15 children)

Piano Original Piano Compressed • Wolfe et al (2011) group improvement for tokens /asa/, /ata/ and /ada/ in quiet; after 6 mo. of use improvement on nonsense syllable SRT in quiet, 13/15 improved on plural test

Evidence: Evidence:

• Better speech perception/satisfaction • Better speech perception/satisfaction • Simpson et al (2005) 8/17 improvement phoneme recognition • Simpson et al (2005) 8/17 improvement phoneme recognition • Simpson et al (2006) 1/7 (words) 1/5 (sentences) improved speech • Simpson et al (2006) 1/7 (words) 1/5 (sentences) improved speech perception; perception; 1/6 better APHAB 1/6 better APHAB • Kuk et al (2007; 2009) improved consonant recognition (group) • Kuk et al (2007; 2009) improved consonant recognition (group) • Gifford et al (2007): 2/6 improved sentence recognition in Q and N; more (group) • Gifford et al (2007): 2/6 improved sentence recognition in Q and N; more (group) benefit on EC, BN and RV subscales of APHAB benefit on EC, BN and RV subscales of APHAB • Robinson et al (2007) 4/7 improved affricates; 5/7 improved /s and /z/ • Robinson et al (2007) 4/7 improved affricates; 5/7 improved /s and /z/ • Nyffeler (2008) improved (group) satisfaction (11 adults) • Nyffeler (2008) improved (group) satisfaction (11 adults) • Robinson et al (2009) 1/5 improved affricates; 1/5 improved /s and /z/ • Robinson et al (2009) 1/5 improved affricates; 1/5 improved /s and /z/ • Glista et al (2009) 5/11 children, 5/13 adults benefit for /s/ and /z/ detection • Glista et al (2009) 5/11 children, 5/13 adults benefit for /s/ and /z/ detection • O’Brien et al (2010) initial improvement in speech perception (23 adults) • O’Brien et al (2010) initial improvement in speech perception (23 adults) • Wolfe at al (2010) group improvement for tokens /asa/ and /ada/ in quiet (15 • Wolfe at al (2010) group improvement for tokens /asa/ and /ada/ in quiet (15 children) children) • Wolfe et al (2011) group improvement for tokens /asa/, /ata/ and /ada/ in quiet; • Wolfe et al (2011) group improvement for tokens /asa/, /ata/ and /ada/ in quiet; after 6 mo. of use improvement on nonsense syllable SRT in quiet, 13/15 after 6 mo. of use improvement on nonsense syllable SRT in quiet, 13/15 improved on plural test improved on plural test

Evidence: Evidence:

• Better speech perception/satisfaction • Better speech perception/satisfaction • Simpson et al (2005) 8/17 improvement phoneme recognition • Simpson et al (2005) 8/17 improvement phoneme recognition • Simpson et al (2006) 1/7 (words) 1/5 (sentences) improved speech perception; • Simpson et al (2006) 1/7 (words) 1/5 (sentences) improved speech perception; 1/6 better APHAB 1/6 better APHAB • Kuk et al (2007; 2009) improved consonant recognition (group) • Kuk et al (2007; 2009) improved consonant recognition (group) • Gifford et al (2007): 2/6 improved sentence recognition in Q and N; more • Gifford et al (2007): 2/6 improved sentence recognition in Q and N; more (group) (group) benefit on EC, BN and RV subscales of APHAB benefit on EC, BN and RV subscales of APHAB • Robinson et al (2007) 4/7 improved affricates; 5/7 improved /s and /z/ • Robinson et al (2007) 4/7 improved affricates; 5/7 improved /s and /z/ • Nyffeler (2008) improved (group) satisfaction (11 adults) • Nyffeler (2008) improved (group) satisfaction (11 adults) • Robinson et al (2009) 1/5 improved affricates; 1/5 improved /s and /z/ • Robinson et al (2009) 1/5 improved affricates; 1/5 improved /s and /z/ • Glista et al (2009) 5/11 children, 5/13 adults benefit for /s/ and /z/ detection • Glista et al (2009) 5/11 children, 5/13 adults benefit for /s/ and /z/ detection • O’Brien et al (2010) initial improvement in speech perception (23 adults) • O’Brien et al (2010) initial improvement in speech perception (23 adults) • Wolfe at al (2010) group improvement for tokens /asa/ and /ada/ in quiet (15 • Wolfe at al (2010) group improvement for tokens /asa/ and /ada/ in quiet (15 children) children) • Wolfe et al (2011) group improvement for tokens /asa/, /ata/ and /ada/ in quiet; • Wolfe et al (2011) group improvement for tokens /asa/, /ata/ and /ada/ in quiet; after 6 mo. of use improvement on nonsense syllable SRT in quiet, 13/15 after 6 mo. of use improvement on nonsense syllable SRT in quiet, 13/15 improved on plural test improved on plural test

21 11/1/2013

Evidence: Evidence:

• Better speech perception/satisfaction • Better speech perception/satisfaction • Simpson et al (2005) 8/17 improvement phoneme recognition • Simpson et al (2005) 8/17 improvement phoneme recognition • Simpson et al (2006) 1/7 (words) 1/5 (sentences) improved speech perception; • Simpson et al (2006) 1/7 (words) 1/5 (sentences) improved speech perception; 1/6 better APHAB 1/6 better APHAB • Kuk et al (2007; 2009) improved consonant recognition (group) • Kuk et al (2007; 2009) improved consonant recognition (group) • Gifford et al (2007): 2/6 improved sentence recognition in Q and N; more (group) • Gifford et al (2007): 2/6 improved sentence recognition in Q and N; more (group) benefit on EC, BN and RV subscales of APHAB benefit on EC, BN and RV subscales of APHAB • Robinson et al (2007) 4/7 improved affricates; 5/7 improved /s and /z/ • Robinson et al (2007) 4/7 improved affricates; 5/7 improved /s and /z/ • Nyffeler (2008) improved (group) satisfaction (11 adults) • Nyffeler (2008) improved (group) satisfaction (11 adults) • Robinson et al (2009) 1/5 improved affricates; 1/5 improved /s and /z/ • Robinson et al (2009) 1/5 improved affricates; 1/5 improved /s and /z/ • Glista et al (2009) 5/11 children, 5/13 adults benefit for /s/ and /z/ detection • Glista et al (2009) 5/11 children, 5/13 adults benefit for /s/ and /z/ detection • O’Brien et al (2010) initial improvement in speech perception (23 adults) • O’Brien et al (2010) initial improvement in speech perception (23 adults) • Wolfe at al (2010) group improvement for tokens /asa/ and /ada/ in quiet (15 • Wolfe at al (2010) group improvement for tokens /asa/ and /ada/ in quiet (15 children) children) • Wolfe et al (2011) group improvement for tokens /asa/, /ata/ and /ada/ in quiet; • Wolfe et al (2011) group improvement for tokens /asa/, /ata/ and /ada/ in quiet; after 6 mo. of use improvement on nonsense syllable SRT in quiet, 13/15 after 6 mo. of use improvement on nonsense syllable SRT in quiet, 13/15 improved on plural test improved on plural test

And now for the conflicting evidence: More recent data (still efficacy)

• Worse performance or no change • Mussoi pre-dissertation project: • Simpson et al (2005) 8/17 no improvement phoneme recognition; 1/17 poorer • Simpson et al (2006) 4/7 (words) 4/5 (sentences) no improvement speech perception; 2/7 (words) • Less is more poorer; 4/6 APHAB preference for conventional amplification, 1/6 APHAB no preference • Musical training makes the distortion more negative • Kuk et al (2007; 2009): no change in vowel recognition (group data; n=13, 8) • Gifford et al (2007): 4/6 no diff in sentence recognition in Q and N; more (group) aversiveness on No compression Moderate compression Max. compression APHAB 60 Slight preference • Robinson et al (2007) 3/7 no effect affricates; 2/7 no improvement /s and /z/ Moderate preference 50 Strong preference • Nyffeler (2008) no improvement (group) in sentence recognition in noise

• Robinson et al (2009) 2/5 decreases performance affricates; 4/5 no improvement /s/ and /z/; 4/5 40 preferred control (no compression) condition 1/5 had no clear preference • Glista et al (2009) 5/11 children, 6/13 adults no benefit for /s/ and /z/ detection; 1/11, 1/13 showed 30 poorer performance

% Preference 20 • O’Brien et al (2010) initial improvement in speech perception (23 adults) disappeared after 8 weeks. No difference/improvement on SSQ. 10 • Wolfe at al (2010) no improvement (group) for sentence recognition in noise or for tokens /afa/, /aka/, /asha/ or /ata/ in quiet 0 • Wolfe et al (2011) no improvement (group) for sentence recognition in noise or for tokens /afa/, NH-NT NH-THL-NT HL-T NH-NT NH-THL-NT HL-T NH-NT NH-THL-NT HL-T Group /aka/, or /asha/, no effect for 2/15 who performed at ceiling on plural test

More recent data (still efficacy) More recent data (still efficacy)

• Perreau dissertation • Perreau dissertation • Adults tend to opt for conventional technology as the bimodal • Adults tend to opt for conventional technology as the bimodal option to CI option to CI • No objective evidence of better localization • No objective evidence of improved speech perception

Perreau, Bentler & Tyler, 2013 Perreau, Bentler & Tyler, 2013

22 11/1/2013

Effectiveness data “OCHL” Study (real effectiveness data) NIH/NIDCD R01 DC009560 • Perreau dissertation • Adults tend to opt for conventional technology as the bimodal • Outcomes of Children with Hearing Loss option to CI….. • Co-PIs Mary Pat Moeller, J Bruce Tomblin

• Multi-site (UIowa, UNC, Boys Town) • Using accelerated longitudinal design • Recruited children 6 mos-7 years of age • Follow same children for 3+ years • Lengthy burden tables resulting in many data points!

Perreau, Bentler & Tyler, 2013

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Recruitment Sample • Sampling Regions • Iowa, Nebraska, Eastern Kansas/Northern Missouri, • 321 children with hearing loss Illinois, Southern Virginia, • 182 children with normal hearing North Carolina, Minnesota • Sampling Method • Ages 6 months to 7 years, 3 months • Referral from Newborn • Speaks English in the home Hearing Screening • Children identified in EHDI via • No major secondary disabilities follow up clinics • Permanent Bilateral Mild to Severe Hearing • Children identified via Loss audiology or medical service providers – PTA of 25-75 dB HL (500, 1k, 2k, 4 kHz) • Children identified through school screening

137

Domains of Study Opportunity to observe:

Language Skills • What hearing aids children wear; Speech Academic Production Abilities • How they are fit; • How long they wear them (i.e., use time);

Hearing & Psychosoci • What kind of audibility is provided; Speech al and Perception Behavioral • If any of the above impact outcomes in speech and language.

Interventions Background Child and (clinical, characteristics Family educational, of child/family Outcomes audiological)

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This Data Set Questions

• Three age levels (3-, 4- and 5-yr olds) • Are children using nonlinear frequency compression • All children had 1+ yrs. experience with aids and ~equal (NLFC) in their hearing aids getting better access to the number in each group: speech signal than children using conventional • Nonlinear Frequency Compression (NLFC) processing schemes? • Conventional signal processing • Data from one site only since that site fit majority of subjects using NLFC, using “best-practice” verification protocol.

Questions Questions

• Are children using nonlinear frequency compression • Are speech and language skills different for children who (NLFC) in their hearing aids getting better access to the have been fit with the two different technologies; if so, in speech signal than children using conventional what areas? processing schemes? • We hypothesized that children whose hearing aids provided wider input bandwidth would have more access to the speech signal, as measured by an adaptation of the Speech Intelligibility Index (SII, ANSI S3.5-1997, R2007)

Questions Demographics

• Are speech and language skills different for children who • No significant differences between groups (NLFC and have been fit with the two different technologies; if so, in conventional processing) at any age (3, 4, 5): what areas? • Age loss confirmed • We hypothesized that if the children were getting • Age began intervention increased access to the speech signal as a result of their • Months using hearing aids NLFC hearing aids (Question 1), we would see improved • Reported daily use time performance in areas of speech production, • Datalogged use time morphosyntax, and speech perception compared to the • Mother’s education group with conventional processing. • Family income • All children wore current hearing aids > 1 year

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Outcome Measures, Age 3 Outcome Measures, Age 4

• Goldman-Fristoe Test of Articulation-2 (GFTA-2, • VABS-II also administered in the 4-year old protocol; Goldman & Fristoe, 2000) is a standardized measure of • Test of Preschool Early Literacy (TOPEL; Lonigan et speech production; al., 2007), standardized measure of early literacy, • Vineland Adaptive Behavior Scales-II (VABS-II; specifically phonological processing and print knowledge; Sparrow, Cicchetti, & Balla, 2005), parent-report • CASL 3-4 also administered in the 4-year old protocol; questionnaire of personal/social behavior; • Wechsler Preschool and Primary Scales of • Comprehensive Assessment of Spoken Language Intelligence-III (WPPSI-III; Wechsler, 2002), standardized (CASL 3-4; Carrow-Woolfolk, 1999), standardized measure of verbal and nonverbal intelligence measure of global language development.

Outcome Measures, Age 5 Three-year olds -10 • Goldman-Fristoe Test of Articulation-2 also administered in the 5- 0 year old protocol; Non-Compressed 10 Compressed • Peabody Picture Vocabulary Test-4 (PPVT-4; Dunn & Dunn, 2007), 20 standardized measure of receptive vocabulary; 30 • TOPEL also administered in the 5-year old protocol; 40 • CELF-4 Word Structure. Subtest of the Clinical Evaluation of 50 Language Fundamentals-4 (CELF-4; Semel, Wiig, & Secord, 2003), 60 assesses morphological development using picture stimuli; 70 80 • Comprehensive Test of Phonological Processing (CTOPP; (dB) Hearing Level Wagner, Torgesen, & Rashotte, 1999), standardized measure of 90 phonological processing; 100 110 • Preschool Language Assessment Instrument (PLAI-2; Blank et al, 250 500 1000 2000 4000 8000 2003), standardized measure of expressive and receptive discourse; Frequency (Hz) • PBKs for speech perception

Four-year olds 3 year olds -10 NLFC Conventional P value 0 10 GFTA 88.9 99.6 .07 20 30 Vineland 94.8 97.1 .66 40 CASL 82.1 95.5 .02 50 60 Better ear PTA 56.5 50.8 .23 70 80

Hearing Level (dB) Hearing Level Better ear aided SII (50) .52 .59 .37 90 Non-Compressed 100 .70 .78 .16 Compressed Better ear aided SII (65) 110 250 500 1000 2000 4000 8000 Better ear unaided SII .21 .20 .44 Frequency (Hz)

25 11/1/2013

Five-year olds 4-year olds -10 NLFC Conventional P value 0 10 Vineland 90.29 95.39 .31 20 30 CASL 99.77 102.16 .74 40 TOPEL Phono 85.55 91.67 .40 50 60 WPPSI Block 10.67 9.81 .55 70 80

Hearing Level (dB) Hearing Level WPPSI Reasoning 11.89 10.53 .40 90 Non-Compressed 100 WPPSI Vocab 7.44 8.13 .60 Compressed 110 Better Ear PTA 53.0 47.9 .29 250 500 1000 2000 4000 8000 Frequency (Hz)

5-year olds Limitations

NLFC Conventional P value • Not a true comparison of impact of NLFC on bandwidth (i.e., audibility) in that this was a between-groups GFTA 93.7 95.0 .84 analysis; 100.8 100.3 .94 PPVT • Reflects best-case fitting methods, which may not be TOPEL 104.2 105.7 .74 representative of other clinics; CELF 9.1 8.2 .57 • The audiometric data of the subjects did not support assumption that NLFC would be more readily fit to 110.9 106.4 .54 PLAI children with more sloping configuration of loss. PBK 79.0 78.6 .93 Better Ear PTA 52.4 51.6 .85

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Summary of OCHL findings OCHL Team Members

• In this study, audiograms and unaided audibility (ala SII) University of Iowa BTNRH J. Bruce Tomblin, Ph.D. (Co-PI) Mary Pat Moeller, Ph.D. (Co-PI) same for both groups at each age; Marlea O’Brien, Program Coordinator Patricia Stelmachowicz, Ph.D. • Aided audibility was not different for the two groups Rick Arenas (IT) Meredith Spratford, Au.D. Lauren Berry, M.S., CCC-SLP (NLFC and Conventional) for soft or average inputs; Ruth Bentler, Ph.D. Lenore Holte, Ph.D. Emilie Sweet, M.S., CCC-SLP • As an expected consequence, speech and language Elizabeth Walker, Ph.D., CCC-A/SLP Sophie Ambrose, Ph.D. (LENA) outcomes were not different for the two groups. Connie Ferguson, M.S., CCC-SLP Marcia St. Clair, SLP Examiner University of North Carolina-Chapel Hill • Emerging data suggest that detection may be enhanced Wendy Fick Melody Harrison, Ph.D. Jacob Oleson, Ph.D. (biostatistics) for some children, but there is still little evidence of Patricia A. Roush, Au.D. broader advantage for children of this audiometric profile. Shana Jacobs, Au.D. M. Thomas Page, M.S., CCC-SLP • More longitudinal data of this sort necessary.

26 11/1/2013

Briefly, for frequency lowering

◦APFs are manageable, but different for different algorithms; What can we ◦Efficacy has been demonstrated repeatedly in terms of sibilant detection & do? discrimination for adults and children; ◦Little effectiveness data not very i.e., we as in clinicians, not me as in encouraging. researcher

What can we do? Buzz words… Know the black box (APFs) ◦ DIR/DNR: test it! Evidence-based design ◦ Frequency Lowering: Verify it! Evidence-based practice Look at efficacy measures: ◦ Have high ecological validity Evidence ◦ Represent individual’s listening environments ◦ Include a variety of test situations Evidence Look at effectiveness ◦ COSI, e.g. Evidence ◦ Self-report measures ..and the “evidence” will have the strength (both in level and grade) to impact decision-making in the clinics.

So, how does this all go? Acknowledgements Three prongs ◦ Empirical evidence National Institute on Disability and Rehabilitation Research (NIDRR) ◦ Clinician experience/evidence National Institute on Health (NIH/NIDCD) ◦ Patient needs and characteristics ASHFoundation AAA Foundation Starkey laboratories, Inc. Siemens Hearing Instruments, Inc. Research participants

27 10/31/2013

• No disclosures

Cochlear Implants: Where we’ve been, Where we are Colleen Polite, AuD Assistant Director Cochlear Implant Center Otolaryngology Head and Neck Surgery University of California, San Francisco

November 1, 2013

2

Objectives

• Candidacy Criteria • Cases Warranting Referral • Emerging Indications

3 Poll: I work with CIs in my practice

1 10/31/2013

Poll: How many CI candidates have you seen in ... Poll: How many patients have you referred for ...

AudiologyNOW 2008 Survey Population Statistics

60 • 1,000,000 potential CI candidates in US 50 • 7.5% of people who could benefit from CI have one 40 • 3% of audiograms met FDA criteria for CI 30

20

10

0 Saw None Saw 1‐4Ref'd None Ref'd 1‐4

Huart, 2009

7 8

2 10/31/2013

Consumer Survey Market

• Average time from onset of severe-profound hearing loss to CI = 12 years • Average time from learning about CI and discovering eligibility to surgery <1 year • Almost 80% of CI recipients said they would have gotten a CI earlier if they had known about it

ENT-VSL-3.2 Increase the proportion of persons who are deaf or very hard of hearing and who have cochlear implants

9 10

Baseline: 76.8 per 10,000 persons Target: 84.7 per 10,000 persons

10 percent improvement

www.healthypeople.gov/2020

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Where we’ve been

Bilger Report, 1977

• Benefits lipreading • Environmental sound awareness • Better modulation of voice • Possibilities of improvement

13 14

Where we’ve been Where we’ve been Candidacy: Adult Candidacy: Adult 1985 • First outcomes reported pre-op vs. post-op • Comparisons of HA users and CI users Age: 18 yrs+ Hearing loss: bilateral profound post-lingual • Results on CI outcomes in patients with more hearing pre-op Speech recognition: 0% words or sentences with HAs Hearing aid use: 6 months

15 16

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Where we are Candidacy: Adult Candidacy: Adult Today Age: 18 yrs+ Hearing loss: bilateral MODERATE – PROFOUND, post-, peri- or pre-lingual Speech recognition: ≤50% on sentences in ear to be implanted and ≤60% best aided/contralateral ear

Figure 2. Advances in technology and signal processing in cochlear implants have resulted in improved performance outcomes. Shown are group mean scores for CUNY and HINT sentences in quiet and CNC monosyllabic words from multiple sources: Skinner et al. (1994), Skinner et al. (1991);Pijl et al. (2009).

Huart, 2009

17 18

Where we are Candidacy: Adult

• Speech scores can approximate normal hearers • Near ceiling performance at 3 - 6 months experience • Updated speech battery (MSTB 2011)

Gifford, 2008

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Candidacy: Pediatric Candidacy: Pediatric

1990 Today Minimum age: 2 yrs Minimum age: 12 – 23 mos Hearing loss: profound Hearing loss: <24 mos prof HL; ≥24 mos sev-prof Communication: 0% words or sentences with HAs Communication: 30-40% word or sentence scores Hearing aid use: 6 months Hearing aid use: 3-6 months

21 22

Candidacy: Pediatric Word Learning

• Lower minimum age – Higher communication performance – Higher scores on all language measures

Houston, et al. 2012

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6 10/31/2013

Will Older Children Catch Up? Candidacy: Pediatric

• More hearing – Children with poorer hearing pre-CI had lower language skills at 3.5 yrs – Accounted for almost 60% of variance in language performance

Nicholas and Geers, 2006 Nicholas & Geers, 2007

25 26

Where we are Candidacy: Pediatric Referral Warranted

• Reduced HA trial period • Fluctuating hearing loss • Children diagnosed and using hearing aids at the earliest ages experienced longer periods of hearing aid use before implantation. • Children with greater aided residual hearing also experienced longer hearing aid trials before implantation. • These data suggest long periods of hearing aid use prior to cochlear implantation may not always be the most beneficial course of action for young children who may be CI candidates.

27 28

7 10/31/2013

Enlarged Vestibular Aqueduct Audiogram (Pre-Eval)

• Most common imaging finding • Excellent candidates for CI Word Recognition RE: 4% – Early referral for patients with progressive/fluctuating loss LE: 84% • Variable outcomes when associated with other PTA cochlear malformations RE: 72 dB HL LE: 105 dB HL • Surgical risk of CSF gusher – Managed intra-operatively – Has no significant effect on speech outcomes (Adunka, et al., 2012) Drop in RE hrg 1 mo ago following head injury Increased tinnitus since drop in hrg

29

Audiogram (CI Eval) Audiogram (CI)

Aided Speech Speech Perception 1 mo CNC AzBio-Q/+10 CNC AzBio-Q/+10 RE: 0% CI: 56% 75% / 32% LE: 60% Speech Perception 3 mos B: 50% 58% / 42% CNC AzBio-Q/+10/+5 CI: 74% 71%/57%/17% CI+ HA: 96% 100%/88%/73%

8 10/31/2013

Where we are Ménière’s Disease Referral Warranted

• Significant improvement • Fluctuating hearing loss – Even with previous chemical or surgery treatment – EVAS • Results similar to other post-lingually deaf – Meniere’s adults • Asymmetrical hearing loss • Improvement in tinnitus – Implant poorer ear • Most achieve stable hearing – Bimodal listeners

Lustig, et al., 2003

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Where we are Auditory Neuropathy Referral Warranted

• Fluctuating hearing loss • No progress with auditory or language skills – EVAS – refer for CI evaluation – CI may offer neural synchronization – Meniere’s • Outcomes are variable • Asymmetrical hearing loss – Comparable to SNHL in those without other – Implant poorer ear medical/cognitive issues – Bimodal listeners – ? Contraindicated in hypoplasia/aplasia of cochlear nerve • Auditory Neuropathy Spectrum Disorder – Counseling is key

35 36

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Where we are Where we are Referral Warranted Referral Warranted

• Fluctuating hearing loss • Fluctuating hearing loss – EVAS – EVAS – Meniere’s – Meniere’s • Asymmetrical hearing loss • Asymmetrical hearing loss – Implant poorer ear – Implant poorer ear – Bimodal listeners – Bimodal listeners • Auditory Neuropathy Spectrum Disorder • Auditory Neuropathy Spectrum Disorder • WRS ≤ 50% • WRS ≤ 50% • Ski-slope hearing loss – Hybrid/EAS – Improved hearing in noise, music quality

37 38

Cochlear Malformations: CI Ski-slope Hearing Loss Candidacy • Not candidate • Candidate – Complete labyrinthine – Common cavity aplasia – Cochlear hypoplasia – Cochlear aplasia – Incomplete partition – Absent auditory nerve – SCC dysplasia – Enlarged Vestibular Aqueduct

39 40

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Where we are going Where we are going Emerging Indications Emerging Indications

• <12 months • <12 months • SSD/Unilateral – What happens when there is no access to auditory information in the first year of life? – Cognitive mechanisms/language processes – Sensitive periods

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Emerging indications/Expanding Where we are going Criteria Emerging Indications

• <12 months • <12 months – Improved phonological skills • SSD/Unilateral – Superior speech understanding – Language skills growth rate similar to normal-hearing peers – Support non-verbal cognitive development (Coletti, 2011) • Risks – Minimalized by experienced pediatric surgeons and anesthesiologists

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Where we are going Success Emerging Indications

• <12 months • SSD/Unilateral – Less difficulty hearing in noise – Some benefit for localization – Reduced tinnitus – ? Hearing quality – ? Binaural benefits

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Summary

• Patients may have complex issues that need to be fully evaluated in the CI work-up • Early referral of children for CI is best • Moderate to profound HL indicates referral Thank you! • Less than fair WRS warrants referral • Refer any patient with PTA and WRS discrepancy

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References

• available upon request

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Basal Ganglia Neuromodulation for Disclosure Tinnitus Suppression • No personal financial or institutional interest in any of the drugs, materials, or devices discussed in this presentation.

Audiology Amplification Update XI Steven W. Cheung University of California, San Francisco 1 November 2013

Agenda Tinnitus – Auditory Phantoms Auditory Percept Without an External Source

. Background Pathophysiology  Aberrant Activity Originating from the Auditory System . New Onset Tinnitus Clinical Course  Hyperactivity; Synchronized Oscillations; Reorganized Cortical Maps . Basal Ganglia Overview  Brain Networks Acting in Concert . Target Selection for Deep Brain Stimulation (DBS) Tinnitus‐Related Distress . DBS of the Striatum: Two Experiments  Auditory Phantom Qualia Uncorrelated with Tinnitus Severity . Tinnitus Conceptual Model  Loudness Level; Sound Character . Phase I Clinical Trial  Modulators  Limbic System: Reinforcement, Mood, Behavior  Others: Eye, Facial, Cervical Movements; Sounds

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Tinnitus Functional Index (0 – 100 score) Therapeutic Modalities ≤ 10 (not a problem), 10-20 (small problem), 30-40 (moderate problem), 40-60 (big problem), and 60-90 (very big problem)

Reduce Contrast Reclassify Phantom Percept Mask Phantom Percept Reduce Saliency Suppress Hyperactivity Mitigate Emotional Distress Examples Examples o Hearing Aids o Tinnitus Retraining o Maskers o Cognitive-behavioral therapy o Cochlear Implants o Neuromonics o Cortical Stimulation o Fractal tones o Vagal N Stimulation o Antidepressants

Auditory-Striatal-Limbic Connectivity

Disrupt Information Conveyance Examples o Transcranial Magnetic Stimulation o Direct Electrical Stimulation o Basal Ganglia Neuromodulation

‘Natural History’ of New Auditory Phantoms Investigational Therapies Initial Complaints (≤ 3 months) ▫ Unfamiliar ▫ Relatively loud ▫ Commands attention ▫ Intrusive and annoying Typical Course (6 –12 months; 80%) ▫ Familiar ▫ Much softer ▫ Easy to ignore ▫ Not particularly noticeable Atypical Course (≥ 1 year; 20%) ▫ Familiar ▫ Remains relatively loud ▫ Still commands attention ▫ Drives associated emotional and behavioral reactions

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General Role of the Basal Ganglia Medial Surface of the Basal Ganglia

1. Head of Caudate Nucleus 2. Body of Caudate Nucleus A multisensory integration system that: 3. Caudatolenticular Gray Bridge 4. Putamen • Detects interpretations of sensory patterns 5. Tail of Caudate Nucleus • Releases responses 6. External segment of Globus Pallidus 7. Internal segment of Globus Pallidus 8. Amygdaloid Body 9. Nucleus Accumbens

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Corticobasal Loops and Interconnectivity Functional Loops of the Basal Ganglia Limbic to Sensorimotor Connections Sensorimotor ▫ Sensorimotor (Auditory) and Premotor Cortices ▫ Tectum (Colliculi) Associative DLS – Dorsolateral Striatum ▫ Dorsolateral Prefrontal Cortex ▫ Lateral Orbitofrontal Cortex IL - Infralimbic ▫ Higher Order Auditory Cortex Limbic ▫ Limbic and Paralimbic Cortices ▫ Hippocampus ▫ Amygdala

Diffuse Basal Ganglia Lesion

63 year old otolaryngologist with 40 year history of mostly constant, high‐pitched tinnitus. Tinnitus was mostly louder in the left ear, with episodic increases in loudness. Audiogram showed right moderate and left moderate‐to‐ severe sensorineural hearing losses.

Left hemispheric stroke involving ‘the more dorsal part of Basal Ganglia Target Selection the corona radiata. In addition there is involvement of the neostriatum, including the body of the caudate and the caudodorsal aspect of the putamen. As such it most likely involves thalamocortical radiations and corticothalamic projection in addition to corticocortical fibers running in the superior longitudinal fasciculus.’

o Tinnitus Suppressed Completely o Hearing Remained Unchanged

Lowry et al (2004) Otol Neurotol

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Focal Basal Ganglia Lesion Deep Brain Stimulation System 56 year old woman underwent deep brain stimulation (DBS) for implantation of the left subthalamic nucleus for medically refractory Parkinson’s disease. Baseline ‘hissing’ tinnitus Anchor Secures was reported to be reduced on the first postoperative day. Long‐term data showed Probe to the skull enduring outcomes. Connector Establishes Probe Delivers stimulation link to the Controller to deep brain nuclei

Controller Determines parameters for brain stimulation and houses the Programmer Communicates power source with the Controller to customize o Tinnitus Suppressed Substantially therapy o Hearing Remained Unchanged

Larson and Cheung (2012) J Neurosurgery

Caudate Nucleus (Area LC) –DBS Target TWO ELECTRICAL STIMULATION EXPERIMENTS IN THE CAUDATE NUCLEUS • The caudate is routinely traversed during deep brain stimulation surgery for movement disorders. ▫ Opportunity to perform acute caudate stimulation Neuromodulation of Auditory Phantoms experiments without altering the surgical procedure. ▫ Loudness Level ▫ Study population with known nigrostriatal dysfunction. ▫ Sound Quality • IRB approval obtained.

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Loudness Level Modulation

Caudate Nucleus Confirmed by Stealth Trajectory and Microelectrode Recordings

Sound Quality Modulation Summary of Deep Brain Stimulation in Area LC Tinnitus Loudness & Sound Qualia Modulation

Subject Stimulation Stimulation Tinnitus Tinnitus Tinnitus Area LC (age/gender) parameters in threshold to baseline baseline loudness at Neuromodulation effect & side of frequency & effect in volts quality loudness stimulation stimulation pulse width (range) (0‐10 scale) threshold A (63/m) Microlesion 5Left 0Left Suppress Tonal Right/Left effect 1Right 1Right existing phantom B (51/m) 185 Hz 5V 5Left 0Left Suppress Noise‐like Right 90 µsec (0 ‐ 8) 5Right 0Right existing phantom C (57/m) 180 Hz 10V 5Left 1Left Suppress Cricket‐like Right 90 µsec (0 ‐ 10) 5Right 1Right existing phantom D(67/m) 150 Hz 4V 4Left 2Left Suppress Musical Right 60 µsec (0 ‐ 8) 4Right 2Right existing phantom E (66/m) 185 Hz 3V 3Left 2Left Suppress Tonal Right 90 µsec (0 ‐ 8) 7Right 2Right existing phantom F (61/m) 180 Hz 4V 0Left 2Left Trigger None Right 60 µsec (0 ‐ 10) 0Right 0Right click sequences G (50/f) 10 Hz 2V 0Left 6Left Trigger None Right 60 µsec (0 ‐ 10) 0Right 0Right jet takeoff sounds H (67/f) 10 Hz 4V 0Left 1Left Trigger None Left 60 µsec (0 ‐ 10) 0Right 1Right creaking sounds

Cheung and Larson (2010) Neuroscience Larson and Cheung (2012) Neurosurgery

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Tinnitus Conceptual Framework Striatal Neuromodulation Effects on Tinnitus Key Features • Baseline loudness of auditory phantoms was modulated, to higher and lower perceptual levels.  Instruction on details of phantom percepts are represented in the central auditory system. ▫ Mostly Bilateral • New auditory phantoms may be triggered in a  Permission to gate candidate phantom percepts for conscious awareness is controlled by the controllable manner. dorsal striatum. ▫ Mostly Contralateral  Action to attend, reject or accept phantom • No changes to hearing with acute stimulation. percepts, and form perceptual habits is decided by the ventral striatum. • No seizures up to 10V stimulation.  Determination of tinnitus distress severity is mediated through the limbic and paralimbic system‐nucleus accumbens‐ventral striatum loop.

Phase I Clinical Trial Study Flowchart

o NIH/NIDCD Funded (8 –10 Subjects) o Key Inclusion Criterion: TFI > 50 o Enrollment Starts Winter 2013 o Specific Aims  To estimate the treatment effect size of DBS in area LC on tinnitus severity (TFI score).  To assess preliminary safety and tolerability of DBS in area LC (neuropsychological assays). o Enrollment Starts Winter 2013

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Basal Ganglia Neuromodulation for Tinnitus Suppression

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Acknowledgements and Disclosures • Research collaborators – Dan Ashmead, PhD – Erin Picou, PhD Hearing Loss and Fatigue: – Fred Bess, PhD – Aaron Kipp, PhD • Lab members Assessment and Intervention – Zoe Doss – Julie Fix Alissa Harbin – Katie Makowiec Benjamin W.Y. Hornsby, Ph.D. – – Amanda Headly – Bridget Stone  Funding for the works described here was provided by  NIH R21 DC012865-01A1  Phonak, Inc.,  IES #R324A110266  Starkey Inc., and  the ASHFoundation  the Dan Maddox Foundation

What is Fatigue? Consequences of Fatigue • Fatigue is a complex construct that can occur • Decreased attention, concentration, in both the physical and mental domains. mental processing, and decision‐making van der Linden et al. 2003; DeLuca, 2005 – Our focus is on mental fatigue – • Less productive and more prone to • Subjectively, defined as a mood or feeling of accidents tiredness, exhaustion or lack of “energy” – Ricci et al. 2007 • Often associated with a lack of, or decline in, • Less active, more isolated, less able to – Focus, concentration, alertness and/or mental monitor own self‐care, and more prone energy and efficiency to depression • Kennedy, 1988; O’Conner, 2006; Lieberman, 2007; – Amato, et al. 2001; Eddy and Cruz, 2007 Boksem and Tops, 2008

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Who has Fatigue? Hearing Loss and Fatigue • Everybody! • Fatigue is a common accompaniment of hearing loss – Complaints of transient fatigue are common even with severe consequences on quality of life in healthy populations – Listening IS exhausting!!! • Post on hearingaidforums.com • Recurrent fatigue is common in many chronic – “…since I lost most of my hearing…, I've had periodic bouts health conditions of tiredness that are deeper and of a different quality than I ever experienced before.” Cancer, HIV AIDs, Parkinson’s, Multiple Sclerosis – • Copithorne, 2006 – Very little work specifically looking at hearing loss – “I go to bed most nights with nothing left. It takes so much and fatigue energy to participate in conversations all day, that I’m often asleep within minutes.” • Blog post http://hearingelmo.wordpress.com/2008/06/17/fatigue‐fear‐ and‐coping/

Quantifying Fatigue Subjectively Subjective Measures of Fatigue • Fatigue can be measured many ways • Profile of Mood States (POMS) – Subjectively using surveys, rating scales and – 65 items used to derive six mood scores questionnaires that ask about mood or feelings including fatigue and vigor (uni‐dimensional) • Many options, none specific to hearing loss • Sensitive to effects of multiple variables on fatigue

Below is a list of words that describe feelings that people have. Please • Fatigue scales may be read each word carefully. Then circle the number that best describes – Uni‐dimensional: Assess “general” fatigue how you have been feeling during the PAST WEEK, including today. Not at all A little Moderately Quite a bit Extremely • a composite fatigue measure Item # Item 0 1 2 3 4 Construct 4Worn Out Fatigue 7Lively Vigor – Multidimensional: Assess various fatigue constructs 11 Listless Fatigue 15 Active Vigor • E.g., General, physical, mental, emotional, sleep, etc… 29 Fatigued Fatigue 51 Alert Vigor – Can also assess frequency and severity McNair et al, 1971

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Subjective Measures of Fatigue Subjective fatigue in adults seeking • Multidimensional Fatigue Symptom Inventory hearing help (MFSI‐short form; Stein et al., 2004) • Participants: Subset of individuals scheduled for a – 30 items; four fatigue scores (General, Physical, hearing test or hearing aid evaluation. Emotional, Mental), a vigor and total score – ≥ 55 years old (mean: 72.3 years; s.d. 10.2 years) Below is a list of statements that describe how people sometimes feel. • range 55‐94 years. Please read each item carefully, then circle the one number next to each N=116 adults (63% males). item which best describes how true each statement has been for you – in the past 7 days. • Participants were mailed two self‐report measures of Not at all A little Moderately Quite a bit Extremely Item # Item 0 1 2 3 4 Construct fatigue and a measure of hearing handicap 2My muscles ache Physical 3I feel upset Emotional – POMS (fatigue and vigor subscales) 7I feel lively Vigor 12I am worn out General – Multidimensional fatigue scale (MFSI) I have trouble 15paying attention Mental – Hearing handicap inventory (HHIE/HHIA)

Severe fatigue and vigor deficits * * • 1.5 st. dev above normative mean is a common “cutpoint” for identifying cases needing additional attention – Expect ~7% of cases • Adults seeking hearing help reported more fatigue based on normative and significantly less vigor than age‐matched adults data recruited from church and community groups • Our group was much more likely to report severe (Nyenhuis et al., 1999) *p<0.01 fatigue and vigor deficits

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Degree of loss and subjective fatigue Hearing handicap and fatigue

30 95% Confidence Interval 100 100 PTA = 75 dB HL Regression Prediction Age: 67 80 Gender: Male 25 Raw Data 60 • As fatigue increases, 80

40 PTA = 25 dB HL 20 hearing handicap • Surprisingly, no 20 60 TotalHHIE/A Score increases 0 15 relationship -20-100 102030405060708090 MFSI Total Score • Suggests between degree 40 10 PTA: 35 consequences of Age: 67 of hearing loss Gender: Male hearing loss and fatigue 5 20

HHIE/A Total Score HHIE/A 95% Confidence Interval are associated POMS Fatigue Score POMS Fatigue and subjective 0 Regression Prediction fatigue or vigor 0 0 1020304050607080 -20-100 102030405060708090 Better Ear PTA MFSI Total Score • Suggests factors other than “increased effort” • Strong relationship between hearing handicap affect fatigue in adults with HL and subjective fatigue (POMS and MFSI)

Hornsby, Werfel, Camarata, and Bess (2013). Subjective Fatigue in Children with Hearing Loss, AJA. Summary Subjective fatigue in children with HL

* p< 0.05 • Fatigue is a complex multidimensional construct that 100 90 CHL can be defined subjectively as a mood or feeling and CNH 80 quantified using various subjective measures 70 – E.g., POMS, MFSI, PedsQL‐MFS 60 ** * More Fatigue 50 • Results using validated, generic, measures confirm 40 – fatigue is increased in adults and children with HL, 30 – risk for more severe fatigue is increased in these groups, PedsQL Score 20 10 – Psychosocial consequences of hearing loss and fatigue are 0 related General Sleep/Rest Cognitive Overall • CHL report significantly more fatigue. Pervasive across domains

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Hornsby, B. (2013). The Effects of Hearing Aid Use on Listening Effort and Mental Fatigue Associated With Sustained Speech Processing Demands. Ear and Hearing Objective Measures of Fatigue Objective fatigue measures Visual Reaction times • Fatigue has also been defined behaviorally 500 • Unaided RTs Unaided Aided Basic slow over time – A decline in cognitive performance due to 450 sustained mental demands consistent with • Kennedy 1988; DeLuca 2005 400 onset of fatigue • Measures of attention, concentration, 350 • Aided RTs are processing speed, and decision‐making have 300 more stable Reactionms) Time (in Error bars = 1 st. error been used as objective markers of fatigue 250 suggesting some – van der Linden et al. 2003; DeLuca, 2005 ST123456Mean Trial Block resistance to • Very limited work in this area in HI persons • Reaction times (RT) during a demanding dual‐task fatigue requiring sustained (~50 minutes)speech processing

Subjective Ratings References Change in POMS Fatigue Scores after sustained listening during a demanding speech task • DeLuca, J. (2005). Fatigue, Cognition, and Mental Effort. In J. DeLuca (Ed.), Fatigue as a window to the brain (pp. 37‐58). Cambridge, Mass.: MIT Press.

More Fatigued 30 • Hetu, R., Riverin, L., Lalande, N., Getty, L. and St‐Cyr, C. (1988). "Qualitative More Fatiguing when Aided Unaided analysis of the handicap associated with occupational hearing loss." British Journal 10 25 Mean Aided of Audiology 22(4): 251‐64. 8 20 • Hornsby, B. W. Y. (2013). The Effects of Hearing Aid Use on Listening Effort and 15 Mental Fatigue Associated With Sustained Speech Processing Demands. Ear and 6 Hearing. doi: 10.1097/AUD.0b013e31828003d8 10 4 • Hornsby, B. W., Werfel, K., Camarata, S., & Bess, F. H. (2013). Subjective Fatigue in 5 Children with Hearing Loss: Some Preliminary Findings. Am J Audiol. doi: 2

Change in Aided FatigueRating More Fatiguing when Unaided Fatigue Subscale Score Subscale Fatigue 0 10.1044/1059‐0889(2013/13‐0017) Less Fatigued 0 0 5 10 15 20 25 30 • Lieberman, H. R. (2007). Cognitive methods for assessing mental energy. Nutr Pre-Test Post-Test Change in Unaided Fatigue Rating Neurosci, 10(5‐6), 229‐242. • Demanding listening IS fatiguing especially unaided! • van der Linden, D., Frese, M., & Meijman, T. F. (2003). Mental fatigue and the control of cognitive processes: effects on perseveration and planning. Acta Psychol • I.e., Aids help consistently across participants (Amst), 113(1), 45‐65. doi: S0001691802001506 [pii]

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Everything we do as audiologists is aural or audiologic rehabilitation (AR) : counseling, hearing aids, ALDs, communication strategies, auditory training)… Auditory Training and Challenges BUT……... Associated with Participation and • less than 20% of new users (and less than 10% of Compliance experienced users) receive any form of audiologic rehabilitation (beyond hearing aids) Robert Sweetow, Ph.D. • only 2 ‐ 5% are provided with formal retraining University of California, San Francisco opportunities

– Kochkin, MarkeTrak VIII, 2009

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Elements of Communication (Kiessling, et al, 2003; Sweetow and Henderson-Sabes, 2004)

Why do patients seek our help?

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Potential impediments to achieving mastery of The biggest mistake we currently make these elements may be…….

• Hearing loss • Making hearing aids the focus of our attention, when the focus should • Neural plasticity and progressive neurodegeneration be…. • Global cognitive decline • Enhancing communication • Maladaptive compensatory behaviors • Loss of confidence

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Current speech perception tests….

• Don’t take the contextual nature of Are we really testing conversation into account communication? • Don’t take the interactive nature of conversation into account • Don’t allow access to conversational repair strategies that occur in real life

Flynn, 2003 7 8

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Communication Needs Assessment Relevant domains for assessment Measures beyond the audiogram that can be used to define residual auditory function.

• Communication expectations and needs Objective procedures • Sentence recognition in noise • QuickSIN – BKB‐SIN • Tolerance of noise • Hearing in Noise Test (HINT) • Ability to handle rapid speech • Listening in Spatialized Noise Sentences (LiSN‐S) • Binaural integration (interference) • Acceptable Noise Levels (ANL) • Cognitive skills (working memory, speed of processing, • Binaural interference executive function) • Dichotic testing • Auditory scene analysis • Listening span (Letter Number Sequencing) • Perceived handicap • TEN • Confidence / self‐efficacy • Rapid (compressed) speech test • Dexterity • Speechreading • Vision • Dual‐tasking • Need for screening measures 9 10

Communication Needs Assessment Measures beyond the audiogram that can be used to define residual auditory function. Communication Confidence Profile

Subjective measures Please circle the number that corresponds most closely with Hearing Handicap Inventory for the Elderly – Screening HHIE‐S • your response for each answer. • Communication Scale for Older Adults (CSOA) • Communication Confidence Profile (CCP) or Listening Self Efficacy Questionnaire If you wear hearing aids, please answer the way that you • Self Assessment and Communication partner subjective scales hear WITH your hearing aids. (SAC and SOAC)

Combined (objective and subjective) methods Sweetow, R and Sabes J. Hearing Journal: • Performance Perceptual Test (PPT) (2010); 63:12 ;17‐18,20,22,24.

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1. Are you confident you can understand conversations when you are 7. Are you confident that you can focus on a conversation when other talking with one or two people in your own home? distractions are present? 2. Are you confident in your ability to understand when you are conversing with friends in a noisy environment, like a restaurant? 8. Are you confident that you can understand a person speaking in large 3. In order to hear better, how likely are you to do things like moving rooms like an auditorium or house of worship? closer to the person speaking to you, changing positions, moving to a 9. In a quiet room, are you secure in your ability to understand people quieter area, finding better lighting, etc? 4. If you are having trouble understanding, how likely are you to ask a with whom you are not familiar? person you are speaking with to alter his or her speech by slowing 10. In a noisy environment, are you confident in your ability to down, repeating, or rephrasing? 5. How sure are you that you are able to tell where sounds are coming understand people speaking with whom you are not familiar? from (for example, if more than one person is talking, can you identify 11. Are you confident that you can switch your attention back and forth the location of the person speaking?) between different talkers or sounds? 6. Are you confident that you are able to follow quickly‐paced conversational material? 12. If you are having difficulty understanding a person talking, how likely 13 are you to continue to stay engaged in the conversation? 14

CCP interpretation Some facts related to aging

• 2/3 of people age 70 and older have hearing loss • Older adults with hearing loss have a 24% higher • 50+ = Confident risk of cognitive impairment • A 25 dB hearing loss equals the reduction in • 40‐50 = Cautiously certain cognitive performance associated with a 6.8 year age difference • 30‐39 = Tentative • Could be related to common cause hypothesis (shared neural pathways) , extra resource • Below 29 = Insecure expenditure; isolation from hearing loss

Lin (2011, 2013)

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• Imaging studies of word identification in unfavorable signal‐to‐noise ratios have revealed greater activation of memory and attention brain regions in older adults compared with younger adults (Neuropsychologia 2009;47[3]:693‐703). To compensate for reduced • Older adults with hearing loss and poor audibility or deficits in temporal processing (J Neurosci working memory are more susceptible to 2012;32[41]:14156‐14164; J Acoust Soc Am 2006;119[4]:2455‐2466), older adults appear to draw hearing aid distortions from signal‐processing more on cognitive resources than younger adults do algorithms, suggesting that cognitive skills (Ear Hear 2010;31[4]:471‐479). • Despite this greater need to rely on cognitive should be taken into account in the hearing resources, older adults often have a diminished aid fitting. cognitive reserve when trying to communicate in a complex listening environment (Trends Amplif 2006;10[1]:29‐59). – Arehart, et al; Ear Hear 2013;34[3]:251‐260)

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Montreal Cognitive Assessment So what’s the point?

• designed to assist in the detection of mild • Like other diagnostic testing, any single cognitive impairment (J Am Ger Soc measure (including speech in noise testing) 2005;53[4]:695‐699). may not provide enough additional • http://www.mocatest.org information to justify the time or cost. • However consideration of a combination of objective and subjective measures beyond the audiogram can supply important rehabilitation data.

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Pilot study –what can busy clinical audiologists fit in?

• UCSF Request – Minimum of 2 objective and 2 subjective measures Is this practical????? – Keep track of time – Keep track of how additional data impacted therapy plan

• Results – 80% received CCP and HHIE/A‐S – 70% performed Quick SIN – 10% performed ANL, PPT‐DIS, etc.

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However……… Why?????

70% provided usable information • a) not enough time above and beyond the “comp • b) inconvenient audio” • c) don’t believe additional data will help • d) all of the above • e) don’t feel it is important to follow the instructions of the boss

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Assessing Motivation and Readiness Expectations vs. Goals for AR • Expectations have a product orientation – Patient assumes passive role • Source : internal vs. external – Whatever goes wrong is the professional’s • Level: fault handicap perception • Goals have a rehabilitation orientation • desire to rehabilitate – Patient assumes active role Patient shares in the process – • Don’t fit an unmotivated patient

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Ida Institute tools

• Circle of change • Line • Decisional Balance Box

……. and don’t forget assessment!!!!!!!!!!!!

(Prochaska and DiClemente, 1984) 27 28

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Benefit does NOT equal satisfaction!

Outcome assessment should relate • Cox (1997) estimated that satisfaction is explicitly to the needs and goals comprised of: determined. • 40% benefit (both psychosocial and acoustic); • 25% personal image; • 19% service and cost; Gatehouse 2003; Cox et al 2000 • and 16% negative features.

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How will your patient (and you) assess outcome? Client Oriented Scale of Improvement

• Hearing soft sounds COSI • Louder perception • Self‐report questionnaire requiring patient to • Understanding speech in noise list 5 listening situations in which help with • Listening effort (elevators don’t make travel from hearing is required. Post‐rehab, the reduction floor 1 to floor 20 more effective, but they do make it easier) !!!!! (Irv Hafter) in disability and the resulting ability to • End of day fatigue communicate in these situations is quantified. • Use of new strategies • Takes less than 5 minutes of patient time, 2 • Quality of life minutes professional time for interpretation • Benefit or satisfaction • RFC

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Characteristics of Amplification Tool Characteristics of Amplification Tool COAT (COAT) Newman and Sandridge • 9‐item measure of non‐audiologic information to determine if technology is required. • Assesses – Motivation Takes 3 minutes of patient time, 2 minutes • – Expectations professional time for interpretation – Preferences – Cosmetics – Cost considerations

http://www.audiologyonline.com/management/uploads/articles/sandridge_COAT.doc

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Look at the pictures of the hearing aids. Please place an X on the picture or pictures of the style you would NOT be willing to use. Your audiologist will discuss with you if your choices are appropriate for you ‐ –given your hearing loss and physical shape of "It doesn't sound normal" your ear. • Normal to the hearing impaired patient may not be normal to the normal listener • What do post‐surgery patients report? • Status quo is what the patient brings to the evaluation

• “If it sounds right, it’s probably wrong”

Mini BTE

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What do we do for a patient receiving an artificial limb?

What do we do for a cochlear implant patient? How can a person be trained to form whole perceptual units from What do we do for a patient with a balance auditory fragments? disorder?

What do we do for a hearing impaired patient?

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Definition of an auditory processing disorder Jerger and Musiek, 2000

• An auditory processing disorder is a deficit in the processing of information in the auditory modality. It may be related to difficulty in listening, speech understanding, language development, and learning. These problems can be exacerbated in unfavorable acoustic environments. • What does a peripheral disorder do?????

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Why should AT be expected to produce benefit? Does peripheral hearing loss lead to central auditory dysfunction • Acuity and sensitivity are lower level functions • Higher level functions (i.e. speech in noise) require more complex (hierarchical) If so, can anything be done to processing (such as temporal analysis) that may utilize multiple channels of perceptual compensate? processing not governed by critical bands

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Training‐related physiological changes have been Physiologic changes post training attributed to…… • MRI shows increases in grey matter (Boyke, et al 2008) • 1) a greater number of neurons responding in the sensory field • Cortical thickening in older adults (Engvig, et al, 2010) • 2) improved neural synchrony (or temporal • Changes in mismatched negativity response for adults trained coherence) on synthetic phoneme discrimination tasks (Kraus (1995); • 3) may be a neural “decorrelative” processes in Recanzone (1995) which training decorrelates activity between neurons, making each neuron as different as • Changes using auditory evoked magnetic fields ‐ possible in its functional specificity relative to the magnetoencephalography (Vasama and Makela (1995) other members of the population. • Enhanced NI‐P2 on novel speech sounds and demonstrated – This process assumes that information common to two training effects (Tremblay, et al (1998, 2001) stimuli is disregarded, while responses to unique features of each stimulus are enhanced. • Physiological changes occur quite rapidly, and precede Tremblay, 2006 changes in perception. (Tremblay, 1998)

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Evidence based review of auditory rehabilitation and training AT Studies since 2000 meeting Evidenced Based criteria in adults (Sweetow and Palmer, 2005) (Sweetow and Palmer, 2005) Henshaw and Ferguson , PLOS 2013; CBAT*

• Group • –Fu and Galvin, 2007 – Beynon, Thornton and Poole, 1997 • –Oba, Fu and Galvin, 2011 – Chisolm, Abrams, and McArdle, 2005 • – Miller, Watson, Kistler, Wightman and • Individual Preminger, 2008 – Kricos and Holmes, 1996 – Montgomery, Walden, Schwartz, and Prosek, 1984 • –Sweetow and Sabes, 2004 – Walden, Erdman, Montgomery, Schwartz, and Prosek, 1981 • –Sweetow and Sabes, 2006 – Rubenstein and Boothroyd , 1987 • –Barcroft, Sommers, Tye‐Murray et al., 2011 – Kricos, Holmes and Doyle, 1992 • –Ingvalson, Lee, Fiebig and Wong, 2013 – Wright, B., Buonomano, Mahncke, and Merzenich, 1997 – Zhang, Dorman, Fu and Spahr, 2012 – Bode and Oyer, 1970 • • –Levitt, Oden, Simon et al., 2011.

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CONCLUSIONS Benefits of AR Programs • 1) less than 5% of studies published on auditory • Reduced return rate (13 vs 3%) of hearing aids training meet rigorous evidenced based criteria (Martin, 2007); 9% ‐ 3% (Northern and Beyert, • 2) auditory training resulted in improved 1999) performance for trained tasks in nearly all the • Increased sale of assistive listening devices articles that met evidenced‐based criteria • Fewer trouble‐shooting visits • 3) although significant generalization of learning was shown to untrained measures of speech • Referrals from friends, co‐workers, and family intelligibility, cognition, and/or self‐reported members hearing abilities, the improvements were • Free advertising provided by satisfied hearing variable, relatively small and not robust, though aid users retention of learning was shown at post‐training • Good community relations

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What happened to Aural Rehabilitation? Examples of good group rehab formats • declined because outcome measures • ACE (Active communication education program) concentrated on auditory training and (Hickson, 2007) speechreading and didn’t consider emotional • Learning to Hear Again (Wayner and Abrahamson, 1996). and psychological by‐products • Mayo Clinic (Hawkins, 2004) • boring? • Kricos • too speech pathology like? • Beynon, et al • too time consuming? • Northern and Meadows • lack of reimbursement • Abrams, Chisholm, et al

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Training is not a new concept…. What we can learn from learning theory? But now we have the means to do it 1. Distribution of practice should be suitable for the effectively……via computer aided auditory task to be learned. 2. Active participation by the learner is superior to rehabilitation….so that….. passive receptivity. • It can be performed in a private, non‐ 3. Practice material should be varied so that the learner can adapt to realistic variation and so that threatening environment his motivation during drill is improved. • It can proceed at the individual’s optimal 4. Accurate performance records need to be maintained in order to evaluate progress and pace effects of training. • Progress assessment can be done 5. The most useful single contribution of learning automatically theory is the provision for immediate knowledge given to learners regarding their performance. Wolfle (1951) 51

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Many available Computer‐based Auditory Training Programs What we can learn from neuroscience…? • Baldi • Computer‐Assisted Speech Perception Testing and Training (CASPER) • CogMed • Appropriate feedback (Holroyd et al. 2004, Birdsong • Computer Assisted Speech Training (CAST/TigerSpeech) studies) – Sound and WAY Beyond – Seeing and Hearing Speech • Motivation (Kilgard and Merzenich, 1998) – Sound Express • eARena • Reward (Benenger and Miller, 1998) • FastForWord • Training near threshold (Blake et al., 2002) • I Hear What You Mean • IMPACT • Incremental training: Go slow and steady • LACE (Listening And Communication Enhancement) (Linkenhoker and Knudsen, 2002) • Read My QUIPs • Speed and spacing of the training (Hairston and • SoundScape Knight, 2004, Marquet, 2001) • Speech Perception Assessment and Training System (SPATS) • The Listening Room 54

Music Training OPERA • Kraus’ lab (Northwestern) has shown: • Overlap: in the anatomy and physiology for speech and • Better understanding of speech in noise across music age groups • Precision: more precision is required for music processing than speech • Shorter brainstem timing delays • Emotions “ strong emotions evoked by music may induce • Neurobio Aging 2012:33(7):1483 plasticity via brain’s reward centers • Repetition: extensive practice tunes the auditory system • Attention: focused attention to details of sound is required when playing an instrument

Aniruddh D. Patel (Nat Rev Neurosci 2010;11(8):599

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LACE (Listening and Communication Enhancement) Note: Even a 1 • Cognitive dB reduction – Auditory Working Memory in SNR has – Speed of Processing been equated • Degraded and competing speech with a 6‐8% improvement – Background noise in sentence – Compressed speech recognition Competing speaker (Crandell, 1991; – Wilson et al, 2007) • Context / Linguistics • Interactive communication

All of the above are designed to enhance listening and communication skills and improve confidence levels

Sweetow and Henderson‐Sabes, 2006 Note: Henderson‐Sabes (2012) separated the 3410 20‐lesson finishers into groups according to their initial QuickSIN SNR loss tested at MCL 57 58

• On average, normal hearing people require a +2 Good news dB signal to noise ratio for 50% recognition of • Higher benefit from training is significantly correlated words in sentences while people with hearing with reduced listening effort (Olsen and Preminger, loss require a 8 dB signal to noise ratio (Killion, 2002). 2012) • Even a 1 dB reduction in SNR has been estimated • New hearing aid users in the training group experience to be commensurate with a 6‐8% improvement in the largest improvement (Preminger, 2011) percent correct scores for sentence recognition • Patients with more severe handicap show greater (Crandell, 1991; Wilson et al, 2007) benefit (Henderson‐Sabes and Sweetow, 2007; Kuk et • 5 dB SNR loss = 20% quality estimation (Killion (2011) al, 2009; Hickson et al, 2011) • Patients with more severe handicap are more likely to comply with therapeutic recommendations (Sweetow and Sabes, 2007) • Reduced return rate (13 vs. 3%) of hearing aids (Martin, 2007); 9% ‐ 3% (Northern and Beyer, 1999) 59 60

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The biggest unresolved questions

Difference in Average S/B Score Difference in Average CS Score Difference in Average TC Score 1st to 4th Quarter 1st to 4th Quarter 1st to 4th Quarter 5 10 10 • Will audiologists recommend it? 5 5 0 0 0 -5 -5 – Impact on return for credit rate? -5 -10 -10 -15 (dB SNR) (dB (dB SNR) (dB SNR) (dB -10 -15 -20 • Will patients do it? -20 -25 -15 -25 -30 0 10 20 30 40 50 60 70 0 10 20 30 40 50 60 70 0 10 20 30 40 50 60 70 Cost of effort Subject Subject Subject –

Difference in Average TW Score DifferenceDifference in in Average Average TWMW Score 1st to 4th Quarter Score 1st– 1st toto 4th 4th Quarterquarter – They do for physical therapy

3 1 • Why? 2 0 – MD recommendation 1 -1

0 -2 – Immediate modeling of therapy after surgery (dB SNR) (dB (dB SNR) (dB -3 -1 -4 -2 0 10 20 30 40 50 60 70 0 10 20 30 40 50 60 70 Subject Subject

62

Why audiologists don’t recommend AR Something to consider • Results from a counseling‐based group AR • Belief that hearing aids alone are adequate program indicated that hearing aid users that • Lack of belief in outcome measures participated in the program performed better on • Belief that additional resources (time, money) are the Communication Profile of the Hearing required Impaired than hearing aid users with no group • Lack of confidence regarding who needs AT AR experience at the conclusion of the program. • Lack of reimbursement • However, there were no significant differences between the groups after one year. • Reluctance to ask patients to spend more time or money Chisolm TH, Abrams HB, McArdle, R. (2004) Short‐ and long‐term • Inertia outcomes of adult audiological rehabilitation. Ear Hear 25:464‐477. • Laziness • So what does this imply? 63 64

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AT Studies from 2000 – 2012 meeting Evidenced Based Compliance criteria • Clinical data from over 3,000 individuals reported that (Sweetow and Palmer, 2005) adherence (defined as completion of at least half of the Henshaw and Ferguson , PLOS 2013; CBAT* recommended number of training sessions) was less than –Fu and Galvin, 2007 30%. (Sweetow and Sabes, 2010) • • –Oba, Fu and Galvin, 2011 • Similarly, in a study of home‐based computerized AT for cochlear implant users, Stacey and Summerfield (2005) • – Miller, Watson, Kistler, Wightman and reported that about 1/3 of their users completed less Preminger, 2008 than 1/3 of the recommended training. • –Sweetow and Sabes, 2004 • Non‐compliance with prescribed medication regimens • –Sweetow and Sabes, 2006 for hypotensive treatment ranges from 5% to 80% among • –Barcroft, Sommers, Tye‐Murray et al., 2011 glaucoma patients (Olthoff et al, 2005). • –Ingvalson, Lee, Fiebig and Wong, 2013 • Vincent (1971) reported that 43% of glaucoma patients refused to take the physician‐ordered measures • – Zhang, Dorman, Fu and Spahr, 2012 necessary to prevent blindness, even when that refusal • –Levitt, Oden, Simon et al., 2011. had already led to impairment in one eye. 65 66

CONCLUSIONS Reasons

• 1) less than 5% of studies published on auditory • Denial of the problem training meet rigorous evidenced based criteria • Cost (money, time, risk of failure) of the treatment • 2) auditory training resulted in improved • Difficulty of the regimen performance for trained tasks in nearly all the • Unpleasant outcomes or side‐effects of the articles that met evidenced‐based criteria treatment • 3) although generalization of learning was shown • Lack of trust to untrained measures of speech intelligibility, cognition, and/or self‐reported hearing abilities, • Apathy the improvements were variable, relatively small • Previous negative experience and not robust, though retention of learning was • Failure to persuade that compliance is in their best shown at post‐training interest • Lack of “rewards” or recognition for effort

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Six predictors of positive compliance Suggestions

• Higher socioeconomic status • Compliance generally increases if patients are • Greater initial self reported hearing disability given clear and understandable information • Lower pre‐contemplation stage (denial) about their condition and progress in a sincere • Greater action stage of change and responsive way • Lower chance locus of control • Do the first session face to face • Greater hearing disability perceived by others Simplify instructions and treatment regimen and self • as much as possible. – Laplante‐Levesque, Hickson, and Worrall (Ear & • Have systems in place to generate treatment Hearing, 2012) and appointment reminders

69 70

LACE CE and Compliance 50 How should success be measured?

40 * Patients training at home may choose not to upload data • On‐task improvement 30 • Generalized speech recognition performance (%)

20 • Quality of life • Subjective communication confidence 10 Percent of patients uploading at least 10 sessions 0 • Individual vs group mean data In Clinic At H ome Where Patient Completed Session 1

71 72

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Summary Attitude of the Professional • Identify and manage patient’s emotional status • Help the patient feel safe and free to express his/her • Audiologists sell a process, not a product feelings • Manage emotional barriers • Patients will not regard listening programs to • Select appropriate amplification in accordance with be important unless the clinician appears to the patient’s personality and needs • Teach and orient the patient regarding adaptation and believe it is important the use of the hearing aids • Radical changes in technology have immediate • Help the patient manage telephone use • Help the patient attain realistic expectations impact • Make the patient understand that hearing aid use is only one component of the hearing rehabilitation • Changes in practice or procedures must process overcome the hurdle of inertia • Document your work • Provide a rehabilitation plan

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Challenges Aural (auditory, audiologic) rehab…… • Convince MDs / audiologists / patients of importance • Large scale studies on AR/AT Should NOT be considered an add‐on! • Better diagnostic/prognostic assessments • Establish optimal training parameters • Raise acceptance to level of acceptance of “Brain games” (e.g. Lumosity, Brain HQ, Posit Science) Incorporate it at the very beginning • More enjoyable AT (e.g. enhanced LACE with videos) • More mobile apps (e.g. Hear Coach) • More “fun” games (e.g. Read My Quips) • Non‐speech, i.e. music training (e.g. Kraus and Anderson) Above all……….. Do something!!!!! • Incentives • Determine appropriate outcome measures

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Thanks for listening

[email protected]

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PEDIATRIC BONE ANCHORED IMPLANTS: DISCLOSURE PROTOCOLS AND STRATEGIES

Consultant for Cochlear Americas BAS

Lisa Christensen, Au.D. Arkansas School for the Deaf

BONE ANCHORED IMPLANTS CANDIDACY

¡ Osseointegrated devices have treating conductive and mixed hearing loss since 1977. ¡ Softbands • No age restrictions ¡ Works through direct bone conduction. • Bilateral CHL ¡ Sound is conducted through the skull bone bypassing the outer and • Bilateral MHL middle ear and stimulating the cochlea. • SSD or unilateral losses ¡ Contains three parts: • Unilateral or bilateral softbands available § titanium implant § external abutment § detachable sound processor ¡ Implants • FDA - age 5 years old or older

§ BAHA – Entific Medical Systems • FDA: Bilateral implants (can be simultaneously implanted) must be § Baha ™ Cochlear Americas symmetric bone conduction thresholds less than 10 dB difference on § Ponto – Oticon Medical average (500, 1000, 2000, and 3000 Hz) or less than 15 dB at § Osseointegrated implants individual frequencies § Bone Anchored Implants – BAI § Aided testing - B

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CANDIDACY SOFTBAND FITTING

¡ Conductive Hearing Loss • TCS • Placement of Baha Softband • Atresia/microtia § Infants - not always on mastoid

§ Toddlers ¡ MHL implants § Preschoolers • Bilateral with BC PTA or 35 dB or less for children (Christensen)

• Power devices • 5 years of age as other implantation guidelines • Fitting the Softband § Helping parents find the perfect fit ¡ Single sided deafness (SSD) • Unilateral hearing loss profound SNHL, MHL, or CHL • Functional gain/aided audiogram • Normal (15 dB or less) in the “good ear” • Softband

SOFTBANDS: WHEN TO FIT SOFTBAND VERIFICATION

¡ Bilateral CHL/MHL will be fit ASAP ¡ For bilateral CHL/MHL most common • Just like traditional hearing aid fittings verification is Functional Gain • Some will be implanted when they are 5 years old • under 6 months of age – BOA • Some will receive other surgical intervention § Testing Babies: You Can Do It! Behavioral Observation Audiometry (BOA) by Jane R. Madell Perspectives on Hearing and Hearing Disorders in Childhood December ¡ Unilateral losses (SNHL/MHL/CHL) 2011 21:59-65. • fit at 9 to 12 months of age when we can get a Softband near the • over 6 months – VRA, CPA, etc affected ear on a full time basis

¡ Outcome measures

¡ SLPs/AV Therapists

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SOFTBAND VALIDATION RULES

Any validation measure you currently use for other traditional BTE fittings with children will work well with softband validation for bilateral CHL/MHL.

Karen Anderson - Success for Kids with Hearing Loss § https://successforkidswithhearingloss.com/tests ¡ When in doubt…follow the rules

¡ ELF - Early Listening Function § State licensure laws for verification and validation of hearing aids ¡ CHILD - Children’s Home Inventory of Listening Difficulties ¡ Preschool SIFTER – Preschool Screening Instrument For Targeting Educational Risk and implantable devices ¡ SIFTER – Screening Instrument For Targeting Educational Risk of Elementary School Children ¡ Secondary SIFTER - Secondary Screening Instrument For Targeting Educational Risk ¡ LIFE-R – Revised Listening Inventory For Education § Clinical practice guidelines (AAA, ASHA, etc) ¡ LIFE – Learning Inventory For Education ¡ LIFE Student Appraisal ¡ LIFE Student Appraisal Pictures ¡ LIFE Teacher Appraisal ¡ CHAPS- Children’s Auditory Performance Scale ¡ SAC-A-Self Assessment of Communication-Adolescent ¡ SOAC-A– Significant Other Assessment of Communication – Adolescent ¡ FLE – Functional Listening Evaluation ¡ Childrens Peer Relationship Scale ¡ Minnesota Social Skills Checklist for Students who are Deaf - Hard of Hearing ¡ PARC– Placement Readiness Checklists for Children who are Deaf or Hard of Hearing (Colorado)

AAA CLINICAL PRACTICE GUIDELINES ARKANSAS LICENSURE LAW PEDIATRIC AMPLIFICATION JUNE 2013

Evaluation of hearing aids must be performed with the hearing 3. AUDIOLOGIC CANDIDACY CRITERIA (page 12) aids on the patient. This shall be accomplished EITHER in sound field OR with instruments which objectively measure hearing aid performance with appropriate prescriptive techniques to Recommendations for Determining Candidacy account for the different means of programming the hearing aid (linear versus nonlinear, digital versus analog). The preferred Children with permanent conductive hearing loss should be fit verification method of fitting is to use probe microphone measures in conjunction with the patient’s ear, ear mold, and with air conduction hearing aids when anatomically possible personal amplification system. A real ear to coupler difference (sufficient external ear and canal anatomy to support the (RECD) can be obtained and probe tube measurement performed coupling of an earmold and retention of the device), or bone in a coupler if a patient is unwilling to tolerate probe conduction hearing aids if anatomy is insufficient for coupling microphone measurement in the ear. A prescriptive measure (atresia, chronically draining ears, or other significant addressing gain should be in place to address the possibility of anatomical malformations). over- or underestimating gain until the patient is five (5) years of age.

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AAA CLINICAL PRACTICE GUIDELINES SOFTBAND VERIFICATION PEDIATRIC AMPLIFICATION JUNE 2013

6.2.3 Aided Thresholds in the Sound Field (pp 39-40)

2. In cases of bone conduction hearing aids, real-ear probe microphone measures cannot be conducted (when there is no acoustic signal in an ear canal), and the aided audiogram may be the most readily available verification option. In spite of its limitations, the aided audiogram can provide information, and in the case of bone conduction and frequency transposition/ compression hearing aids, may be the most valid way to quantify the aided response with currently available technologies.

SOFTBAND CASE 1

¡ DOB 3/30/2010 SOFTBAND CASES ¡ Female ¡ 36 weeks gestational age ¡ 3 lbs.15 oz. ¡ Failed NBHS in rural part of Arkansas ¡ No family history of hearing loss

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SOFTBAND CASE 1 SOFTBAND CASE 1

¡ Seen at 4 months of age for follow up NBHS ¡ ENT examination – Stenosis and No TM identified in the clinic ¡ Tech notes ear pit right ear ¡ ABR at 7 months - During possible PET ¡ Type B high frequency tymps AU placement was consistent with a Moderate CHL AU

¡ Failed OAEs AU

SOFTBAND CASE 1 SOFTBAND CASE 2

¡ Cleft palate ¡ Chromosome deletion 18p ¡ Loaner device fit at ¡ Failed NBHS and follow up screenings 8 months old § NO atresia § NO stenosis ¡ Personal Softband fit at 9 months 22 days ¡ Behavioral testing at 6 months consistent with moderate/severe CHL

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SOFTBAND CASE 2 SOFTBAND CASE 2

¡ Fit with BP100 at 2 years of age ¡ Fit with loaner device 6 months § Titanium ¡ Personal Baha fitting at 8 months § Lockable battery door § Moisture resistant ¡ Numerous repairs … • Importance of pediatric features • Softbands • loaners

SOFTBAND CASE 3 SOFTBAND CASE 3

¡ Down Syndrome

¡ 8 years old at the time of initial fitting

¡ Raised by great grandparents at the time and due to dexterity issues a Softband was the best option for the family

¡ Also allowed for less adjustments by the audiologist

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SOFTBAND FUNDING SOFTBAND DATA

Reimbursement for Softbands? ¡ Hol et al 2005 • Two subjects § 3 y/o and 29 months 1. Key phrases • Compared Baha Compact, Baha Classic, and Oticon E 300 P § Cannot benefit from traditional BTEs • The electro-acoustic measurements showed minor § Malformation differences in gain between the three devices • Both children showed speech and language § Congenital development that was in accordance with their cognitive development. ¡ Conclusions: The BAHA Softband was a valid 2. Provide data intervention in children with congenital bilateral aural atresia who were too young for percutaneous BAHA application

SOFTBAND DATA SOFTBAND DATA

¡ Arkansas Children’s Hospital § A retrospective study of Baha charts of 20 infants and children 2002 to 2006 § 20 infants and children § 8 months to 16 years (mean age = 5.04 years) § Inclusion criteria was: (a) bilateral symmetrical conductive hearing loss (b) fit with Baha at ACH (c) consistent full-time Baha use on a Softband (d) followed at ACH for 6 months or longer Nicholson, N. Christensen, L, Dornhoffer, J. Martin, P, Smith-Olinde, L. (2011).Verification of speech spectrum audibility for pediatric baha softband users with craionfacial anomalies. Cleft Palate-Craniofacial Journal, (48)1: 56-65.

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IMPLANTATION

IMPLANTATION ¡ Surgical procedures § FDA recommendations - 5 years and older § 1 stage vs. 2 stage surgeries § Osseointegration § Wait times § New surgical techniques § New technology

PRE-SURGICAL CONSIDERATIONS IMPLANT CASE 1

¡ History § Progressive HL? § Sudden HL? ¡ 7 years old ¡ Wore BTEs for bilateral moderate CHL ¡ CT ¡ Normal pinnas AU § EVAS? ¡ Chronic otitis externa § Other middle or inner ear anomalies? ¡ Family and child must be motivated ¡ Implanted bilaterally with a two stage surgery 6 ¡ Hygiene/ability to care for abutment by family months osseointegration period between two stages and/or child § Complications happen and should be discussed

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IMPLANT CASE 1 IMPLANT CASE 1

¡ Family choice Unaided ¡ Aided thresholds were similar

¡ Never wore a Softband

¡ Chronic otitis externa was their priority BTE Aided

Bilateral Baha Implants ¡ Still uses FM as she did with the BTEs

TRADITIONAL BC AIDS VS. BAHA SYSTEM HEADBAND VS. IMPLANTATION

¡ Verstraeten et al (2008) ¡ Why choose bone anchored implants over traditional ¡ 3 conditions: bone conduction aids? § Baha implanted unilaterally § Baha coupled to a headband ¡ Is it worth the money? § Baha coupled to the test band ¡ How does a traditional bone conduction aid compare to the Softband? To a implanted Baha? ¡ Results § Headband vs. test band were similar § Implantation was superior to both headband and test band

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BAHA VS. TRADITIONAL BC AID FUNCTIONAL GAIN RESULTS

Retrospective study of 10 subjects (a) 6 months to 18 years of age (b) congenital bilateral conductive hearing loss (c) initially fit with a traditional bone conduction hearing aid (d) fit unilaterally with a Baha Compact or Divino via the Softband (e) implanted unilaterally with the Baha system (f) unaided and aided soundfield thresholds available for four frequencies from 500 Hz to 4000 Hz (g) consistent full-time use of amplification

¡ Ear and frequency specific thresholds obtained via supra aural headphones at 500, 1000, 2000, and 4000 Hz were recorded on datasheets and transferred to an Excel®

¡ Audiometric data for frequency specific unaided and aided sound field thresholds obtained with the speaker positioned at a 90° azimuth to the target ear were also transferred to an Excel sheet

RESULTS

• Bone conduction transducer provides the most gain of any device tested • The implanted Baha system provided second highest amount of functional gain • Softband results provided the third amount of highest functional gain. • Traditional bone conduction hearing aids provided the least amount of functional gain. • There is some overlap among devices at 1000 Hz, but at no other frequency. BILATERAL ¡ Implanted Baha has statistically as much gain as a bone conduction transducer at all frequencies tested;

¡ Implanted Baha provides statistically more gain at 500 Hz than the Baha attached to a Softband

¡ Traditional bone conduction hearing aid provides significantly less gain than all the other devices at all frequencies with the exception of the Baha with Softband at 2000 Hz.

Christensen L, Smith-Olinde L, Kimberlain J, Richter G, Dornhoffer J (2010). Comparison of traditional bone-conduction hearing aids with the Baha system. 20:3.

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PREVIOUS RESEARCH BOSMAN ET AL RESULTS

¡ Bosman, A.J. et al (2001) ¡ Results: ¡ ‘Audiometric Evaluation of Bilaterally Fitted Bone- § Better localization skills § Better speech in noise anchored Hearing Aids’ § Better Binaural Masking Level Difference (BMLD) • 25 adults § The masked threshold of a signal can sometimes be lower • Aged 12 to 69 years of age when listening with two ears rather than one § The detection of a signal in noise is improved when either • Required at least 3 months experience with bilateral the phase or level differences of the signal at the two ears Baha implants are not the same as the masker. • All had symmetrical bone conduction thresholds across ¡ Conculsions: 0.5, 1, 2, and 4 kHz § Results for localization, speech in noise and BMLD measurements indicate that bilateral Baha “do indeed • Baha Classic (no longer manufactured) result in binaural hearing” to an extent.

BILATERAL CASE 1 BILATERAL CASE 1

¡ 18 year old female

¡ TCS

¡ First implanted unilaterally in another state

¡ Received second implant approximately 2 years after the first implant

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BILATERAL CASE 1 BILATERAL CASE 2

¡ Hearing In Noise Test (HINT) ¡ Di George Syndrome § 10 sentences that are scored based on the number of words repeated correctly. ¡ Mixed Hearing Loss ¡ Malformed outer, middle, and inner ear ¡ Wore BTEs since shortly after birth § Left Baha ¡ Terrible balance/vestibular problems…Tons of repairs!!! § + 10 dB S/N ratio = 80% ¡ Used Bilateral Softband prior to implantation § Right Baha ¡ Bilateral Implants § + 10 dB S/N ratio = 82%

§ Bilateral Baha § + 10 dB S/N ratio = 91%

BILATERAL CASE 2

Unaided

SINGLE SIDED DEAFNESS (SSD)

BTE Aided

Baha Aided

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SINCE 1986…UNILATERAL HEARING LOSS… UNILATERAL LOSSES

¡ Judith Lieu, MD ¡ 35% failed at least one grade § Washington University

¡ 13.3% were in need of some special resource ¡ 70% of children with unilateral loss have IEP assistance ¡ Unilateral loss IS associated with worse speech and ¡ 20% were described by teachers as having language scores in children behavioral problems Lieu, J., (2004). Speech-language and educational consequences of unilateral hearing loss in children. Arch Otolaryngol Head Neck Surg. 130 (5):524-530. ¡ 50% showed some difficulty in educational progress Lieu, J., Tye-Murray, N, Karzon, R., Piccirillo, J. (2010). Unilateral hearing loss is associated with worse speech-language scores in children. Pediatrics. 125(6); 1348-1355. (Bess & Tharpe,1986)

AAA CLINICAL PRACTICE GUIDELINES UHL TREATMENTS PEDIATRIC AMPLIFICATION JUNE 2013

AUDIOLOGIC CANDIDACY CRITERIA (p 12)

1. FM systems Recommendations for Determining Candidacy § Personal or soundfield § Works well for elementary grades 1. Children with aidable unilateral hearing loss should be considered candidates for amplification in the impaired ear due to 2. Preferential classroom seating evidence for potential developmental and academic delays. 3. Counsel it away Children with unilateral hearing loss are at greater risk than children with normal hearing for speech and language delays and 4. Hearing aids academic difficulties. For children with severe or profound § 50% parents report “never” wearing it (Davis et al 2004) unilateral hearing losses and normal hearing in the other ear, Contralateral Routing of Signal (CROS) or bone conduction devices 5. CROS may be considered depending on the child’s age and ability to 6. BAI control their environment. Currently there is a paucity of data available to inform these decisions.

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AAA CLINICAL PRACTICE GUIDELINES CROS PEDIATRIC AMPLIFICATION JUNE 2013

PRINCIPLES UNDERLYING EFFECTIVE AMPLIFICATION (pp14-16) • Shapiro 1997 Archives of Otolaryngology

Unilateral Hearing Loss • 10 children (7 to 17 years) fit with CROS • Results based on teacher report and parent report (how much use? Contralateral routing of the signal (CROS) and Bilateral routing of the Was child forced to use it?) signal (BICROS) fittings are specially designed for patients having either • 7 of 10 children were considered successful with CROS unilateral hearing loss or bilateral asymmetrical hearing loss where one ear is unaidable, respectively. Currently, wired and wireless configurations are available. For the child with unilateral deafness, an • Kenworthy 1990 Ear & Hearing FM system with the wireless remote microphone receiver portion coupled to the open, good ear may be preferable in classroom situations to the § Speech recognition abilities of children with unilateral SNHL – goal CROS arrangement to give the benefit of increased signal to noise ratio, § Compared unaided; CROS and personal FM a benefit in a noisy classroom. The transcranial CROS is an option for § FM system was the only audiological recommendation that did not individuals who have no auditory response in one ear. In this produce a marked reduction in speech recognition in at least one configuration, a powerful hearing aid is fit to the non-responsive ear so interaural attenuation is overcome and sound is perceived by the listening environment functioning cochlea. This is not a common fitting for children and again, • Updike 1994 JAAA an appropriately fit assistive listening device may be a better communication solution in the classroom. The osseointegrated hearing • 6 children amplification and CROS did not improve speech device described earlier also can be used as an implanted transcranial understanding in noise and had detrimental results in noisy CROS; evidence supporting benefit of this arrangement in children is situations. limited.

BAHA & SSD SSD GUIDELINES

¡ Is anyone really doing this? • CHL or SNHL – unaidable by traditional amplification ¡ Why are we doing it? options • Normal ear must be NORMAL and without known risk ¡ Does it really work? or progression ¡ How do you know if it really works? • Testing using “power” device coupled to a metal ¡ Do these kids really wear that? headband ¡ Is this a one hit wonder? • Ability by family and/or child to care for abutment properly • Counseling pre-implant to verify the family and child knows the benefits and limitations of the Baha This is NOT a cure for their hearing loss.

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WAIT…WHAT IF IT’S AN INFANT OR SSD EVALUATION TODDLER?

¡ Speech in noise testing ¡ Speech in noise § Testing with and without noise § Body parts § Hearing in Noise Test (HINT) (Nilsson, Soli, and Sullivan, 1994); § WIPI Words in Noise (WIN) (Wilson, 2003; Wilson and Burks, 2005); QuickSIN (Etymotic Research, 2001; Killion et al., 2004), § SRT/SAT Bamford-Kowal-Bench SIN (BKB-SIN) (Etymotic Research, 2005; § Spondee Picture Cards Bench, Kowal, and Bamford, 1979; Niquette et al., 2003). ¡ Outcome Measures ¡ Outcome Measures § Must be parent measures § Use testing that looks at “listening skills” also not just “hearing” § SLP evaluations § CHILD (5 to 12 year olds) § SSQ (13 years and older) § LIFE

SSD CASE 1 SSD CASE 1

Pre-implant Testing Post Implant Testing

¡ 17 Y 6M female ¡ HINT ¡ HINT § Normal hearing left ear; Profound (no response) right ear § +10 SNR = 100% § +10 SNR = 100% § Seen yearly to monitor loss § +5 SNR = 100% § +5 SNR = 100% § In office trial and testing § 0 SNR = 68% § 0 SNR = 100% § Single stage surgery § - 5 SNR = 23% § - 5 SNR = 36%

¡ SSQ ¡ SSQ § Speech = 4.29 § Speech = 9.07 § Spatial = 1.47 § Spatial = 9.06 § Quality = 5.61 § Quality = 8.89

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SSD CASE 2 SSD CASE 2

Pre-implant Testing 3 Months Post Implant

¡ 13 year old female ¡ HINT ¡ HINT § +10 SNR = 79% § +10 SNR = 100% § +5 SNR = 60% § +5 SNR = 100% § Normal hearing right ear § 0 SNR = 23% § 0 SNR = 96% § Profound left ear – absent VIIIth nerve § - 5 SNR = 96% § Yearly monitor of hearing loss ¡ SSQ ¡ SSQ § Speech = 6.86 § Speech = 9.79 § Spatial = 5.06 § Spatial = 9.59 § Quality = 7.76 § Quality = 9.00

SSD REIMBURSEMENT HINT RESULTS

1. Catch Phrases § Congenital ¡ Average scores for all 26 subjects § Cannot benefit from traditional amplification ¡ Pre-Implant 0 SNR = 41% 2. Show HINT and CHILD/SSQ scores +5 SNR = 76% § Everyone gets percentages +10 SNR = 95%

¡ Post-Implant 3. Provide the data 0 SNR = 82% +5 SNR = 97% +10 SNR = 99%

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CHILD RESULTS SSD DATA

Scores 1 to 10 on 15 situations Average scores for all 25 subjects ¡ Christensen, Richter, Dornhoffer (2010). Update on bone- anchored hearing aids in pediatric patients with profound Parent Version Pre-Implant unilateral sensorineural hearing loss, Archives of = 4.58 Otolaryngology, 136(2): 175-177. Child Version Pre-Implant = 4.50 ¡ Christensen L, Dornhoffer JL, Bone-Anchored Hearing Aids for Parent Version Post-Implant Unilateral Hearing Loss in Teenagers, Otology Neurotology, = 7.19 2008;29:1120-1122. Child Version Post-Implant = 7.24

UNPUBLISHED SSQ RESULTS

¡ SSQ Pre-Implant (N=9) Speech = 4.20 Spatial = 2.41 Quality = 5.40 UNILATERAL CHL ¡ SSQ Post-Implant 3 months (N=9) Speech = 7.87 Spatial = 6.60 Quality = 7.70

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UNILATERAL CHL CASE UNILATERAL CHL CASE

Pre-implant Testing 3 months ¡ 16 year old male ¡ HINT ¡ HINT § Atresia right ear; Normal hearing left ear § +10 SNR = 100% § +10 SNR = 100% § +5 SNR = 92% § +5 SNR = 98% § 0 SNR = 73% § 0 SNR = 91% § - 5 SNR = 12% § - 5 SNR = 11%

¡ SSQ ¡ SSQ § Speech = 5.60 § Speech = 8.14 § Spatial = 7.18 § Spatial = 8.69 § Quality = 7.76 § Quality = 8.58

WHAT ABOUT COCHLEAR IMPLANTS?

¡ Prosper Meniere Society Meeting, Austria § Japan § Adults only

¡ Audiology Today, Jennifer Torres & Daniel Zeitier, September/October 2013 § 10 year old with UHL THE FUTURE: “By all accounts, the patient was noted to be a bright student and was not having any noticeable trouble hearing in the classroom, in after school or social activities, or in the home. In fact, the patient reports that many of her SSD AND BAI friends didn’t realize she had hearing loss until she decided to tell them “so they would not think I was ignoring them.” However, her family admits they made some significant lifestyle modifications to adapt to the patient’s UHL as well as to preserve the hearing she had left (i.e., infrequent restaurant dining, no live sporting events, no firework shows).” § Tried CROS but did not like wearing a device in her hearing ear § Used BAI with softband, which she liked (and had slightly better test results) but insurance denied § CI (which insurance approved) ¡ At 3 months post-op testing SNR loss with the CI was increased to 3 dB SNR (from 7.5 dB SNR) indicating that the patient did not perform any better with the CI than she did with the CROS or the BAI during preoperative testing conditions. ¡ However subjectively the patient greatly preferred the CI

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WILL WE STILL NEED BAI FOR SSD?

¡ Cochlear malformations ¡ Absent VIII nerves COMPLICATIONS

COMPLICATIONS COMPLICATIONS

¡ Retrospective study on extrusion rate ¡ 57 children ¡ Complication rates ¡ 20 adults in Arkansas ¡ 3mm and 4mm implants used

§ 21% for children ¡ Mean age § 12 years 3 months for the children § 52 years for the adults

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COMPLICATIONS FUTURE

§ Young age § Syndromic status ¡ SSD and CI § Possible failure to penetrate the inner cranium ¡ Softbands will remain… § Soft tissue infections § Local trauma ¡ Complications ¡ New Technology § All of these factors are assumed to be the cause of the complication rate in children.

Lee C, Christensen L, Richter G, Dornhoffer J. (2011). Arkansas BAHA Experience: Transcalvarial fixture placement using osseointegration surgical hardware. Otology Neurotology. 32:444-447.

20 University of California San Francisco 11/2/2013 MMH14004: Audiology Amplification

UCSF OCME Registrant List Page 1 of 3

Name City, State 1Aldred Joyce E. Santa Rosa, CA 2Ama Lais HAD Palo Alto, CA 3Amornpongchai Aunyaporn Napa, CA 4Andrus Gary Wyatt AuD Ukiah, CA 5Apilado Benjamin MA Porterville, CA 6Arnst Dennis PhD Fresno, CA 7Ashley Debra MS Palo Alto, CA 8Athey Joseph T. MA Vallejo, CA 9Barga Patrick AuD Davis, CA 10Barrett Jillian G. PhD Danville, CA 11Barry Michelle Sacramento, CA 12Bass Roberta AuD Redding, CA 13Baxter Jane H. AuD Menlo Park, CA 14Belt Donald PhD Hollister, CA 15Benko Kay Lynn MS, CCC-A Salinas, CA 16Bentler Ruth PhD Iowa City, IA 17Bigler Stephanie Gold River, CA 18Billheimer Kenneth San Francisco, CA 19Blazek Barbara L. AuD San Bruno, CA 20Burt Phyllis J. MA Petaluma, CA 21Chalmers Crystal L. AuD Chico, CA 22Cheung Steven W. MD, FACS San Francisco, CA 23Christensen Lisa V. AuD Little Rock, AR 24Clark Debbie AuD Los Altos, CA 25Cohen Beth R. MS Oakland, CA 26Conley Judith MA Santa Rosa, CA 27Crookston Ray G. AuD Alameda, CA 28Dias Maria M. AuD San Jose, CA 29Donohue Sally Jo MD Bainbridge Island, WA 30Duguay Brian AuD Napa, CA 31Dundas Drew PhD San Francisco, CA 32Dundas Lisa AuD Greenbrae, CA 33Epter David D. MD Emeryville, CA 34Everson Megan Greenya Huntington Beach, CA 35Ewing Kelly E. Palo Alto, CA 36Fellores Jayme Santa Rosa, CA 37Fitzgibbons Gregory MA Walnut Creek, CA 38Fitzgibbons Valerie Walnut Creek, CA UCSF OCME Registrant List Page 2 of 3

Name City, State 39Fitzke Jeanette MD Peoria, AZ 40Fitzsimmons Nelson San Diego, CA 41Flowers Jeremy San Diego, CA 42Gholami Honey Palo Alto, CA 43Gibson Keiko Oceano, CA 44Griffin Cari San Jose, CA 45Griffin Michelle San Francisco, CA 46Hanson Judy Sacramento, CA 47Harrigan Erin Los Altos, CA 48Harris Caton A San Diego, CA 49Havard Joan MED, CCC/A Saratoga, CA 50Havard Jovina Walnut Creek, CA 51Hightower Nichole M. Elk Grove, CA 52Hoche Antoine Montcenis, France 53Hornsby Benjamin PhD Nashville, TN 54Jarvis John PhD Penngrove, CA 55Johnston Laura Sacramento, CA 56Joseph Michal AuD Novato, CA 57Kelly Julie Eureka, CA 58Khetrapal Tara F. MA Santa Clara, CA 59Kinder Molly San Jose, CA 60Knudsen Kimberly Sacramento, CA 61Lampert Jeffrey San Francisco, CA 62Larky Jannine MA Stanford, CA 63Lee Shui-lan San Francisco, CA 64Lim Shu-En AuD Menlo Park, CA 65Lind Richard C. MA Yuba City, CA 66Lisi Margaret AuD Menlo Park, CA 67Little Heather San Francisco, CA 68Looper Louis (Tony) AuD Oakley, CA 69Makeig Heidi Oakland, CA 70Marculescu Rebecca AuD San Mateo, CA 71McNamara Betty L. AuD Davis, CA 72Molin Lisa MD Los Osos, CA 73Montgomery Pat San Jose, CA 74Moore Dawn Salinas, CA 75Musko Sally San Jose, CA 76Nelson Amy AuD San Jose, CA 77Novick Marni AuD Palo Alto, CA 78Oza Kalindi AuD Fremont, CA 79Payne Lonnie Mark AuD Shingle Springs, CA 80Pepin Nancy T. MA Rancho Murieta, CA UCSF OCME Registrant List Page 3 of 3

Name City, State 81Perro Jamie Travis AFB, CA 82Pfau Elly MA Napa, CA 83Polite Colleen AuD, MS, CCC-A San Francisco, CA 84Price Melissa Palo Alto, CA 85Pumford John MD San Mateo, CA 86Raguskus Brook AuD Los Altos, CA 87Rammaha Haifa A. AuD Santa Clara, CA 88Ramsey Robin Salinas, CA 89Reed Analisa AuD Carmichael, CA 90Reilly Kathy AuD Larkspur, CA 91Root Allison Townsend Chico, CA 92Sanchez Keleigh AuD Santa Clara, CA 93Schreuder Wendy MS Napa, CA 94Schwaderer Nonie Napa, CA 95Shalles Jennifer L. MA San Francisco, CA 96Simpson Roberta J. MA Algodones, NM 97Sliheet Jane T. MS Alameda, CA 98Sostarich Mary E Hercules, CA 99Spencer Raymond E. MA Amador City, CA 100Stong Mont San Francisco, CA 101Sturm Arthur G. BSC Harbor City, CA 102Sweetow Robert W. PhD San Francisco, CA 103Tannenbaum Melissa MS San Francisco, CA 104Toney Ronald Eugene Fresno, CA 105Tu Clara AuD San Carlos, CA 106Weissman Lee San Rafael, CA 107Will Toni AuD Mill Valley, CA 108Williams Kelle P Sacramento, CA 109Wright Lorna MA Benicia, CA 110Yee Jenny AuD San Francisco, CA 111Ziarati Roya MS Davis, CA

Total Number of Attendees for MMH14004: 111