UCSF CME · Table of Contents . Educational Objectives ....................................................................................................... 5 . Accreditation

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

mailto:[email protected]

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

http://www.cme.ucsf.edu/

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.

http://www.hhs.gov/ocr/lep/

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

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 Steven W. Cheung, MD, FACS J. Andrew “Drew” Dundas, PhD

Benjamin W.Y. Hornsby, PhD Colleen Polite, AuD

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

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

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


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


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

10/21/2013

1

{

Evidence base for hearing aid features:

the ʹwhat, how and whyʹ of technology selection, fitting and assessment.

Drew Dundas, PhDDirector of Audiology, Clinical Assistant Professor of OtolaryngologyUCSF Medical Center

HI Industry research background – Starkey Hearing Technologies, 2010‐2012

Realities of hearing aid features don’t always fit with marketing spin, conventional wisdom or published research

Disclosure

Today’s Topics

Frequency Lowering

DNR

D‐Mics

Directional microphones

Digital Noise Reduction

Frequency Lowering

What, How, Why…

What the technology is intended to accomplish

How it actually works

Why you might want to recommend it

Assessing benefit:

Objective

Subjective

The take home message

10/21/2013

2

Foundations…

Critical terms and concepts

Recruitment

“an abnormally rapid growth of loudness for sounds presented at levels greater than the threshold of detection”

Abnormally rapid?

Growth of loudness?

Loudness

Perceptual correlate of intensity

Sound must be audible to have loudness

Change in loudness is affected by:

Magnitude of intensity change

Duration of intensity change

Loudness

10/21/2013

3

The compressor of a hearing aid can be thought of as a loudness control

system. Why do we care?

Objective Subjective

Gain vs. Response

Gain = (Output – Input)

Device gain ≠ change in audibility

Response = Intensity

REIG vs. REAR

Real Ear Insertion Gain

REIG ≠ Audibility

Real Ear Aided Response

REAR > Threshold = Audibility

10/21/2013

4

Why do we care?

We need both gain and audibility to produce benefit that is:

Objective

and

Subjective

Channels vs. Bands

Channel = A subset of the bandwidth for signal analysis and processing

Band = A subset of the bandwidth where you can control gain

Loudness and Gain

The compressor of a hearing aid can be thought of as a loudness control system.

Signal processing features are gain control systems.

The main course

10/21/2013

5

Today’s Topics

Frequency Lowering

DNR

D‐Mics



Frequency Lowering

Directional Microphone Technology

How?

Why?

What?

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

10/21/2013

6

How do they work? Polar Response Pattern

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.

A little like this…

Fixed directional

Automatic directional

Adaptive directional

Automatic adaptive directional

The implementations

10/21/2013

7

Switches between omnidirectional and fixed directional

When to switch is governed by sound environment analysis

Automatic directional Dual Omni‐directional

Change time delay, change response

Vary the time delay, vary the polar response pattern

Adjust response pattern to maximize overall SNR

Adaptive Directional

10/21/2013

8

Adaptive Null‐Steering

Automatic Adaptive Directional

Adds the low noise benefit of an omnidirectional response pattern

When conditions are appropriate – e.g., high SNR, low level listening.

DI on the head Directional Benefit

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)

(Ricketts, 2008)

10/21/2013

9

Caveat: Microphone Drift

Degraded Pattern due to 0.6‐dB Sensitivity Mismatch

Normal Hypercardioid Pattern

DI = 6.0 dB DI = 4.0 dB

Nulls are lost.DI drops by 2 dB.


Directional Mics are good for almost everyone, but… They are not magic

If you don’t have audibility, they can’t help.

if there is a vent, they cannot provide benefit if you are not at least 0dB insertion gain


How?

Why?

What?

The theory

Identify which parts of sound are speech, and which parts are noise.

Don’t amplify the noise.

Simple, right?

…um, no.

10/21/2013

10

Fast vs. Slow acting

Noise reduction vs. Speech preservation

The implementationWhat it does

0 0 .5 1 1 .5 2 2 .5-1 0

-8

-6

-4

-2

0

2

4

6

8

1 0

T IM E , s

SIG

NA

L V

ALU

E

0 0 .5 1 1 .5 2 2 .5-1 0

-8

-6

-4

-2

0

2

4

6

8

1 0

T IM E , s

SIG

NA

L V

ALU

E

Identify Noise

Calculate Noise spectrum

For a given Time & Frequency: Turn gain up when Speech

Turn gain down when Noise

0 0.5 1 1.5 2 2.5-40

-30

-20

-10

0

10

20

30

TIME, s

SN

R, d

B

Identify Noise

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Identify Speech0 0.5 1 1.5 2 2.5

-40

-30

-20

-10

0

10

20

30

TIME, s

SN

R, d

B

0 0.5 1 1.5 2 2.5-40

-30

-20

-10

0

10

20

30

TIME, s

SN

R, d

B

TC = 0.02; Slope = 0.45; Offset = 10

Apply Gain Rules

In Running Speech

Noise Reduction

Speech Preservation

“Strict” Detection

“Lenient” Detection

A Balancing Act

10/21/2013

12

Comfort and Annoyance(Palmer, Bentler, Mueller, 2006)

*

Acceptance of Background Noise

(Mueller, Weber, Hornsby, 2006)

*

DNR makes noise more acceptableCognitive Benefits

(Sarampalis et al., 2009)

10/21/2013

13


Effects of DNR:

Enhanced comfort

Some listeners may experience enhanced speech understanding in noise

May make HAs more acceptable

May free up cognitive resources for other tasks

Frequency Lowering

How?

Why?

What?

The theory

Some listeners may not benefit from HF audibility

10/21/2013

14

Theory

Off‐frequency listening

‘Sensory overload’

Distortion

Adverse effects on speech understanding

Frequency Lowering

/S/

The implementations

Three Current Implementations

Frequency Compression

Transposition

Feature Synthesis

1 2 3 4 5 64 5 6

Non‐Linear Frequency Compression

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15

Frequency (Hz)

Frequency Compression

Increased audibilityDecreased bandwidth at all timesReduced sound quality

Technique

Frequency Transposition

1 2 3 4 5 6 Frequency Transposition

10/21/2013

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Frequency Transposition

• Increased audibility• Speech cue confusion• Reduced sound quality

Preserve bandwidth

Identify HF consonant sounds

Generate a spectral analogue at a lower frequency

Provide appropriate audibility of the analogue re: concurrent speech sounds

Feature Synthesis

Feature Synthesis

• Consonant sounds replicated in real time

• Bandwidth preserved

• Quality usually preserved

The evidence

10/21/2013

17

Frequency Lowering: Adults(Frequency Compression)

(Glista et al., 2009)

*

Frequency Lowering: Adults

(Glista, Scollie, Bagatto, Seewald, Johson, 2009)

Frequency Lowering: Adults(Frequency Transposition)

(Kuk, Peeters, Keenan, & Lau, 2007)

Consonant Recognition

(Galster, Valentine, Dundas & Fitz, 2011)

10/21/2013

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Assessing benefit

Probe mic measures can be useful with bandwidth limited techniques

Demonstrates change in audibility

Problem: how much audibility is appropriate?

What targets do you aim for?


Provides measurable real‐world benefit

Tuning for listener preference is necessary

Like fitting targets, one size does not fit all

Recent research suggests that preserving bandwidth is preferred even in patients with suspected dead regions

Sound quality matters

Summary

Frequency Lowering

DNR

D‐Mics



Frequency Lowering

Positive effects

Directionality

DNR

Frequency lowering

All can provide measurable benefit for appropriately selected and fit patients

10/21/2013

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Negative Effects?

Can occur

Choose settings carefully, using verification and patient perceptions as guides

1. Have to be applying gain with D‐Mics and DNR to change the output signal

2. Must be audible to be perceptible

3. Magnitude of perception is dependent on the loudness growth curve

Gain, Audibility & Magnitude of Perceptual effects

The 3 concepts are linked

Direct vs. Amplified Path

Comparing sealed coupler measurements to real‐world is not always realistic

Direct sound arriving through the vent may reduce signal processing effects

In challenging cases, and more severe hearing losses, consider less open fittings to maximize effect

Questions?

[email protected]

11/1/2013

1

Evaluating New Technologies

RUTH BENTLER

UNIVERSITY OF IOWA

1

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 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?

*Ala Bentler

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

11/1/2013

2

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

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

Directional Microphones

8

APFs THE FIRST STEP IS TO UNDERSTANDING THE

BLACK BOX….

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11 12

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45

4.8 4.0 2.3

6.0 5.1 3.0

5.7 5.0 3.3

Theoretical FF (BTE) KEMAR (BTE)

Cardioid

Hypercardioid

Supercardioid

4.8 4.1 2.7

6.0 5.6 3.3

5.7 5.4 3.5

Theoretical FF (ITE) KEMAR (ITE)

Cardioid

Hypercardioid

Supercardioid

-15

-10

-5

0

5

10

15

20

010

2030

40

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60

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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)!

Polargram

50

Data? Plenty of efficacy data for all designs depending upon

◦ Baseline used

◦ Speaker arrangement

◦ Noise type

◦ Etc

Effectiveness data a bit harder to come by…

0

20

40

60

80

100

60 / 0 75 / +2 Speech

Understanding in

Noise

Pe

rcen

t C

orr

ect

OMNI

DIR

CST Test Condition

Test Booth Field Ratings 10 Very Good

0 Very Poor

p < .0001

p < .0001

8

6

4

2

Walden, Surr, & Cord, 2003

0

20

40

60

80

100

60 / 0 75 / +2 Speech

Understanding in

Noise

Pe

rcen

t C

orr

ect

OMNI

DIR

CST Test Condition

Test Booth Field Ratings 10 Very Good

0 Very Poor

p < .0001

p < .0001

8

6

4

2

11/1/2013

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Research Question of Study #1

• How do visual cues affect DIR benefit?

Laboratory

Real world

Speech recognition test

Speech Recognition Performance

SNR (dB)

1062-2-6-10

Speech R

ecognitio

n (

%)

0

20

40

60

80

100

OMNI-AO

OMNI-AV

DIR-AO

DIR-AV

Auditory-Only

Wu & Bentler, 2010, Ear Hear

OMNI

DIR

11/1/2013

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Speech Recognition Performance

SNR (dB)

1062-2-6-10

Spe

ech

Re

cognitio

n (

%)

0

20

40

60

80

100

OMNI-AO

OMNI-AV

DIR-AO

DIR-AV

Audiovisual

Auditory-Only

Wu & Bentler, 2010, Ear Hear

Summary of Study 1

• The advantage (benefit) of visual cues can overshadow

the measured benefit of directional mic schemes in real

world environments.

Research Question of Study #2

• How does age impact DIR benefit?

• Laboratory

• Real world

Age

30 40 50 60 70 80 90

Lab

ora

tory

DIR

Benefit

(%)

-5

0

5

10

15

20

25

F(1, 21) = 1.21 p = 0.29

Wu, 2010, JAAA

Age

30 40 50 60 70 80 90

Real

Wo

rld

DIR

Pre

fere

nce (

%)

0

20

40

60

80

100

F(1, 21) = 11.78 p = 0.003

Wu, 2010, JAAA

Summary of Study #2

• Listeners of different ages obtain comparable benefits

from DIR in the laboratory.

• Older users tend to perceive less DIR benefit than do

younger users in the real world.

• Due to lifestyle differences, primarily

• The focus of future efforts in the lab

11/1/2013

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Example of unexpected function…

Front

Back

Backward DIR Backward DIR

Forward DIR Forward DIR

Condition

Conversation Listening

Dir

ectio

na

l B

en

efit

(dB

)

0

1

2

3

4

5

6

7

p = 0.17

p < 0.05

Wu, Stangl & Bentler, 2013

Our Data Manufacturer’s Data

http://www.despicableme.com/

Front

Back

Big dogs can be dangerous.


Front

Back

Big dogs can be dangerous.



Front

Back

The boy fell from the window.


11/1/2013

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Condition

Conversation Listening

Directio

nal B

enefit

(dB

)

0

1

2

3

4

5

6

7

p = 0.17

p < 0.05

Wu, Stangl & Bentler, 2013

Our Data Manufacturer’s Data

Briefly, for DIR ◦APFs are clear as to expected impact ◦Efficacy has been demonstrated repeatedly; newer algorithms take special consideration

◦Effectiveness depends on many factors

◦ Environment, age, etc

◦ …crud


75

Analog NR (1980-90s) Early spectral approaches

◦ Switch

◦ ASP (means low frequency compression)

◦ Adaptive filtering

◦ Frequency dependant input compression

◦ Adaptive compressionTM

◦ Zeta Noise BlockerTM

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

reduction; oMany also use some mic noise reduction, expansion,

wind noise reduction, and even directional mics as part of the strategy they promote.


BLACK BOX….

78

11/1/2013

14

Siemens (TRIANO 3)

Frequency (Hz)

250 500 1000 2000 4000 8000

Diffe

ren

ce

(dB

, 1

/3 O

cta

ve)

-12

-10

-8

-6

-4

-2

0

2

SIREN

TRAFFIC

DINING

Frequency (Hz)

125 250 500 1000 2000 4000 8000

Diffe

ren

ce

(d

B,1

/3o

cta

ve

)

-25

-20

-15

-10

-5

0

5

GN ReSound (CANTA 770-D)

a

Frequency (Hz)

125 250 500 1000 2000 4000 8000

Diffe

rence (

dB

,1/3

octa

ve)

-25

-20

-15

-10

-5

0

5

ICRA

Speech

Random Noise

Babble

Starkey (AXENT II AV MM)

b

Frequency (Hz)

125 250 500 1000 2000 4000 8000

ON

ve

rsu

s O

FF

(ou

tpu

t ch

an

ge

)

-16

-14

-12

-10

-8

-6

-4

-2

0

2

SNR00

SNR05

SNR10

SNR15

70dB

Frequency (Hz)

125 250 500 1000 2000 4000 8000

ON

vers

us O

FF

(outp

ut change)

-16

-14

-12

-10

-8

-6

-4

-2

0

2

SNR00

SNR05

SNR10

SNR15

85dB

Starkey J13 Axent AV75 dB

--SPEECH,RANDOM, MUSIC--

Frequency(Hz)

125 250 500 1000 2000 4000 8000

DIF

FE

RE

NC

E (

dB

,1/3

octa

ve)

-25

-20

-15

-10

-5

0

5

Guitar

Piano

Saxophone with background music

Random Noise

Plain Speech

11/1/2013

15

What happens in the time domain?

Siemens (Triano)

Starkey (Axent)

APFs…10 years later

88

Any reason to expect SNR-50 would change?

Ou

tpu

t S

NR

(re

: L

inea

r)

Miller et al. 2012

11/1/2013

16

Data?

• Still, plenty of efficacy and effectiveness data for all

designs if you are asking the right question: • Walden et al (2000)

• Boymans and Dreschler (2000)

• Alcantara et al (2003)

• Ricketts & Hornsby (2005)

• 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

Briefly, for DNR ◦APFs are clear as to expected impact

◦Efficacy and Effectiveness have been demonstrated…if you are asking the right question

Frequency Lowering

93

Not really a new concept

Four (sort of) choices on the market:

◦ Frequency compression

◦ Frequency transposition

◦ 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


BLACK BOX….

95

What is happening here?

Frequency compression hearing aid

Default settings

Steeply sloping loss

Freq compression: OFF

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

96

11/1/2013

17

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

97


98

1st peak: 3765 Hz, 2nd peak: 4392 Hz Input 4392 Hz

99

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

100

1st peak: 5490 Hz Input 5490 Hz

101

1st peak: 5598 Hz Input 5598 Hz

102

11/1/2013

18

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

103


104


105


106

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

11/1/2013

19


109

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

110

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

111

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

112

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

113


114

11/1/2013

20


115


116


117

500

1500

2500

3500

4500

5500

6500

7500

500 1500 2500 3500 4500 5500 6500 7500

Input (frequency in Hz)

Ou

tpu

t (f

req

ue

ncy in

Hz)

CF2.6; CR1.7

CF1.7; CR1.6

Uncompressed

CF6.0; CR1.5

CF5.9; CR2.1

CF4.7; CR2.0

CF3.8; CR1.9

CF3.2; CR1.8

CF2.2; CR1.7CF1.9; CR1.5

CF1.5; CR1.5

CF1.5; CR2.0

CF1.5; CR2.5

CF1.5; CR3.2

CF1.5; CR4.1

Graph from A Perreau dissertation, 2011 118

Output of frequency-lowering hearing aids

as a function of input frequency

990.53

1528.861507.32

1356.59

1550.39

1550.39

1744.19

1765.72

1787.26

500

750

1000

1250

1500

1750

2000

2250

2500

500 1000 1500 2000 2500 3000 3500 4000 4500 5000

Input (frequency in Hz)

Outp

ut

(fre

quency in H

z)

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

*


Microphone

Low-pass filter

High-pass filter

FFT Bin 1 Bin 2 Bin 3

.

.

. Bin 24

Σ Oscillators Bin 1 Bin 2 Bin 3

.

.

. Bin 24

Processing of data blocks

delay = 9 ms

Σ

Receiver

Cutoff Frequency

Microphone


11/1/2013

21

Sound quality

Guitar Original Guitar Max Comp

Singer Original Singer Compressed

Piano Original Piano Compressed

Evidence (efficacy here):

• 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) 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)


• 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)

• 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:

• Better speech perception/satisfaction • Simpson et al (2005) 8/17 improvement phoneme recognition











Evidence:












Evidence:












Evidence:












11/1/2013

22

Evidence:












Evidence:












And now for the conflicting evidence:

• Worse performance or no change

• 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)

poorer; 4/6 APHAB preference for conventional amplification, 1/6 APHAB no preference

• 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

APHAB

• Robinson et al (2007) 3/7 no effect affricates; 2/7 no improvement /s and /z/

• 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

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

poorer performance

• O’Brien et al (2010) initial improvement in speech perception (23 adults) disappeared after 8

weeks. No difference/improvement on SSQ.

• Wolfe at al (2010) no improvement (group) for sentence recognition in noise or for tokens /afa/,

/aka/, /asha/ or /ata/ in quiet

• Wolfe et al (2011) no improvement (group) for sentence recognition in noise or for tokens /afa/,

/aka/, or /asha/, no effect for 2/15 who performed at ceiling on plural test

More recent data (still efficacy)

• Mussoi pre-dissertation project:

• Less is more

• Musical training makes the distortion more negative

NH-NTNH-T

HL-NTHL-T

Moderate compression

NH-NTNH-T

HL-NTHL-T

Max. compression

Slight preference

Moderate preference

Strong preference

NH-NTNH-T

HL-NTHL-T

No compression

% P

refe

ren

ce

0

10

20

30

40

50

60

Group


• Perreau dissertation

• Adults tend to opt for conventional technology as the bimodal

option to CI

• No objective evidence of better localization

Perreau, Bentler & Tyler, 2013




option to CI

• No objective evidence of improved speech perception


11/1/2013

23

Effectiveness data



option to CI…..


“OCHL” Study (real effectiveness data)

• Outcomes of Children with Hearing Loss

• 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!

NIH/NIDCD R01 DC009560

Recruitment • Sampling Regions

• Iowa, Nebraska, Eastern Kansas/Northern Missouri, Illinois, Southern Virginia, North Carolina, Minnesota

• Sampling Method

• Referral from Newborn Hearing Screening

• Children identified in EHDI via follow up clinics

• Children identified via audiology or medical service providers

• Children identified through school screening

135

Sample

• 321 children with hearing loss

• 182 children with normal hearing

• Ages 6 months to 7 years, 3 months

• Speaks English in the home

• No major secondary disabilities

• Permanent Bilateral Mild to Severe Hearing Loss

– PTA of 25-75 dB HL (500, 1k, 2k, 4 kHz)

136

Domains of Study

137

Child and Family

Outcomes

Background characteristics of child/family

Hearing & Speech

Perception

Speech Production

Language Skills

Academic Abilities

Psychosocial and

Behavioral

Interventions (clinical,

educational, audiological)

Opportunity to observe:

• What hearing aids children wear;

• How they are fit;

• How long they wear them (i.e., use time);

• What kind of audibility is provided;

• If any of the above impact outcomes in speech and

language.

11/1/2013

24

This Data Set

• Three age levels (3-, 4- and 5-yr olds)

• All children had 1+ yrs. experience with aids and ~equal

number in each group:

• Nonlinear Frequency Compression (NLFC)

• Conventional signal processing

• Data from one site only since that site fit majority of

subjects using NLFC, using “best-practice” verification

protocol.

Questions

• Are children using nonlinear frequency compression

(NLFC) in their hearing aids getting better access to the

speech signal than children using conventional

processing schemes?

Questions

• Are children using nonlinear frequency compression

(NLFC) in their hearing aids getting better access to the

speech signal than children using conventional

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

• Are speech and language skills different for children who

have been fit with the two different technologies; if so, in

what areas?

Questions

• Are speech and language skills different for children who

have been fit with the two different technologies; if so, in

what areas?

• We hypothesized that if the children were getting

increased access to the speech signal as a result of their

NLFC hearing aids (Question 1), we would see improved

performance in areas of speech production,

morphosyntax, and speech perception compared to the

group with conventional processing.

Demographics

• No significant differences between groups (NLFC and

conventional processing) at any age (3, 4, 5):

• Age loss confirmed

• Age began intervention

• Months using hearing aids

• Reported daily use time

• Datalogged use time

• Mother’s education

• Family income

• All children wore current hearing aids > 1 year

11/1/2013

25

Outcome Measures, Age 3

• Goldman-Fristoe Test of Articulation-2 (GFTA-2,

Goldman & Fristoe, 2000) is a standardized measure of

speech production;

• Vineland Adaptive Behavior Scales-II (VABS-II;

Sparrow, Cicchetti, & Balla, 2005), parent-report

questionnaire of personal/social behavior;

• Comprehensive Assessment of Spoken Language

(CASL 3-4; Carrow-Woolfolk, 1999), standardized

measure of global language development.

Outcome Measures, Age 4

• VABS-II also administered in the 4-year old protocol;

• Test of Preschool Early Literacy (TOPEL; Lonigan et

al., 2007), standardized measure of early literacy,

specifically phonological processing and print knowledge;

• CASL 3-4 also administered in the 4-year old protocol;

• Wechsler Preschool and Primary Scales of

Intelligence-III (WPPSI-III; Wechsler, 2002), standardized

measure of verbal and nonverbal intelligence

Outcome Measures, Age 5 • Goldman-Fristoe Test of Articulation-2 also administered in the 5-

year old protocol;

• Peabody Picture Vocabulary Test-4 (PPVT-4; Dunn & Dunn, 2007),

standardized measure of receptive vocabulary;

• TOPEL also administered in the 5-year old protocol;

• CELF-4 Word Structure. Subtest of the Clinical Evaluation of

Language Fundamentals-4 (CELF-4; Semel, Wiig, & Secord, 2003),

assesses morphological development using picture stimuli;

• Comprehensive Test of Phonological Processing (CTOPP;

Wagner, Torgesen, & Rashotte, 1999), standardized measure of

phonological processing;

• Preschool Language Assessment Instrument (PLAI-2; Blank et al,

2003), standardized measure of expressive and receptive discourse;

• PBKs for speech perception Frequency (Hz)

250 500 1000 2000 4000 8000

He

ari

ng

Le

ve

l (d

B)

-10

0

10

20

30

40

50

60

70

80

90

100

110

Non-Compressed

Compressed

Three-year olds

3 year olds NLFC Conventional P value

GFTA 88.9 99.6 .07

Vineland 94.8 97.1 .66

CASL 82.1 95.5 .02

Better ear PTA 56.5 50.8 .23

Better ear aided SII (50) .52 .59 .37

Better ear aided SII (65) .70 .78 .16

Better ear unaided SII .21 .20 .44 Frequency (Hz)

250 500 1000 2000 4000 8000

He

ari

ng

Le

ve

l (d

B)

-10

0

10

20

30

40

50

60

70

80

90

100

110

Non-Compressed

Compressed

Four-year olds

11/1/2013

26

NLFC Conventional P value

Vineland 90.29 95.39 .31

CASL 99.77 102.16 .74

TOPEL Phono 85.55 91.67 .40

WPPSI Block 10.67 9.81 .55

WPPSI Reasoning 11.89 10.53 .40

WPPSI Vocab 7.44 8.13 .60

Better Ear PTA 53.0 47.9 .29

4-year olds

Frequency (Hz)

250 500 1000 2000 4000 8000

Heari

ng L

evel (d

B)

-10

0

10

20

30

40

50

60

70

80

90

100

110

Non-Compressed

Compressed

Five-year olds

5-year olds NLFC Conventional P value

GFTA 93.7 95.0 .84

PPVT 100.8 100.3 .94

TOPEL 104.2 105.7 .74

CELF 9.1 8.2 .57

PLAI 110.9 106.4 .54

PBK 79.0 78.6 .93

Better Ear PTA 52.4 51.6 .85

Limitations

• Not a true comparison of impact of NLFC on bandwidth

(i.e., audibility) in that this was a between-groups

analysis;

• Reflects best-case fitting methods, which may not be

representative of other clinics;

• The audiometric data of the subjects did not support

assumption that NLFC would be more readily fit to

children with more sloping configuration of loss.

Summary of OCHL findings

• In this study, audiograms and unaided audibility (ala SII)

same for both groups at each age;

• Aided audibility was not different for the two groups

(NLFC and Conventional) for soft or average inputs;

• As an expected consequence, speech and language

outcomes were not different for the two groups.

• Emerging data suggest that detection may be enhanced

for some children, but there is still little evidence of

broader advantage for children of this audiometric profile.

• More longitudinal data of this sort necessary.

OCHL Team Members

156

University of Iowa

J. Bruce Tomblin, Ph.D. (Co-PI)

Marlea O’Brien, Program Coordinator

Rick Arenas (IT)

Ruth Bentler, Ph.D.

Lenore Holte, Ph.D.

Elizabeth Walker, Ph.D., CCC-A/SLP

Connie Ferguson, M.S., CCC-SLP

Marcia St. Clair, SLP Examiner

Wendy Fick

Jacob Oleson, Ph.D. (biostatistics)

BTNRH

Mary Pat Moeller, Ph.D. (Co-PI)

Patricia Stelmachowicz, Ph.D.

Meredith Spratford, Au.D.

Lauren Berry, M.S., CCC-SLP

Emilie Sweet, M.S., CCC-SLP

Sophie Ambrose, Ph.D. (LENA)

University of North Carolina-Chapel Hill

Melody Harrison, Ph.D.

Patricia A. Roush, Au.D.

Shana Jacobs, Au.D.

M. Thomas Page, M.S., CCC-SLP

11/1/2013

27

Briefly, for frequency lowering

◦APFs are manageable, but different for different algorithms;

◦Efficacy has been demonstrated repeatedly in terms of sibilant detection & discrimination for adults and children;

◦Little effectiveness data not very encouraging.

What can we do?

i .e., we as in cl inicians, not me as in researcher

What can we do? Know the black box (APFs)

◦ DIR/DNR: test it!

◦ Frequency Lowering: Verify it!

Look at efficacy measures: ◦ Have high ecological validity

◦ Represent individual’s listening environments

◦ Include a variety of test situations

Look at effectiveness ◦ COSI, e.g.

◦ Self-report measures

..and the “evidence” will have the strength (both in level and grade) to impact decision-making in the clinics.

Buzz words… Evidence-based design

Evidence-based practice

Evidence

Evidence

Evidence

So, how does this all go? Three prongs

◦ Empirical evidence

◦ Clinician experience/evidence

◦ Patient needs and characteristics

Acknowledgements

National Institute on Disability and Rehabilitation Research (NIDRR)

National Institute on Health (NIH/NIDCD)

ASHFoundation

AAA Foundation

Starkey laboratories, Inc.

Siemens Hearing Instruments, Inc.

Research participants

http://www.bing.com/images/search?q=University of Iowa&FORM=KADOMI

10/31/2013

1

Cochlear Implants:Where we’ve been,Where we are

Colleen Polite, AuDAssistant DirectorCochlear Implant CenterOtolaryngology Head and Neck SurgeryUniversity of California,San Francisco

November 1, 2013

• No disclosures

2

3

Objectives

• Candidacy Criteria

• Cases Warranting Referral

• Emerging Indications

Poll: I work with CIs in my practice

10/31/2013

2

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

AudiologyNOW 2008 Survey

7

0

10

20

30

40

50

60

Saw None Saw 1‐4 Ref'd None Ref'd 1‐4

Population Statistics

• 1,000,000 potential CI candidates in US

• 7.5% of people who could benefit from CI have one

• 3% of audiograms met FDA criteria for CI

8

Huart, 2009

10/31/2013

3

Consumer Survey

• 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

9

Market

10

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

11

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

10 percent improvement

www.healthypeople.gov/2020

12

10/31/2013

4

13

Where we’ve been

Bilger Report, 1977

14

• Benefits lipreading

• Environmental sound awareness

• Better modulation of voice

• Possibilities of improvement

Where we’ve beenCandidacy: Adult

15

1985Age: 18 yrs+Hearing loss: bilateral profound post-lingualSpeech recognition: 0% words or sentences with HAsHearing aid use: 6 months

• First outcomes reported pre-op vs. post-op• Comparisons of HA users and CI users • Results on CI outcomes in patients with more

hearing pre-op

16

Where we’ve beenCandidacy: Adult

10/31/2013

5

Candidacy: Adult

17

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

Where we areCandidacy: Adult

18

TodayAge: 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

19

• Speech scores can approximate normal hearers

• Near ceiling performance at 3 - 6 months experience

• Updated speech battery (MSTB 2011)

20

Where we areCandidacy: Adult

Gifford, 2008

10/31/2013

6

Candidacy: Pediatric

1990Minimum age: 2 yrsHearing loss: profoundCommunication: 0% words or sentences with HAsHearing aid use: 6 months

21


22

TodayMinimum age: 12 – 23 mos

Hearing loss: <24 mos prof HL; ≥24 mos sev-prof

Communication: 30-40% word or sentence scores

Hearing aid use: 3-6 months


• Lower minimum age

– Higher communication performance– Higher scores on all language measures

23

Word Learning

24

Houston, et al. 2012

10/31/2013

7

Will Older Children Catch Up?

25

Nicholas & Geers, 2007


• 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

26

Nicholas and Geers, 2006


• Reduced HA trial period• 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

Where we areReferral Warranted

• Fluctuating hearing loss

28

10/31/2013

8

29

Enlarged Vestibular Aqueduct

• Most common imaging finding

• Excellent candidates for CI

– Early referral for patients with progressive/fluctuating loss• Variable outcomes when associated with other

cochlear malformations

• Surgical risk of CSF gusher– Managed intra-operatively– Has no significant effect on speech outcomes (Adunka, et

al., 2012)

Audiogram (Pre-Eval)

Word Recognition RE: 4%LE: 84%PTARE: 72 dB HLLE: 105 dB HL

Drop in RE hrg 1 mo ago following head injury

Increased tinnitus since drop in hrg

Audiogram (CI Eval)

Aided Speech CNC AzBio-Q/+10

RE: 0% LE: 60% B: 50% 58% / 42%

Audiogram (CI)

Speech Perception 1 moCNC AzBio-Q/+10

CI: 56% 75% / 32%Speech Perception 3 mos

CNC AzBio-Q/+10/+5CI: 74% 71%/57%/17%CI+HA: 96% 100%/88%/73%

10/31/2013

9

Méniere’s Disease

• Significant improvement

– Even with previous chemical or surgery treatment

• Results similar to other post-lingually deaf adults

• Improvement in tinnitus

• Most achieve stable hearing

33

Lustig, et al., 2003



– EVAS– Meniere’s

• Asymmetrical hearing loss

– Implant poorer ear– Bimodal listeners

34






• Auditory Neuropathy Spectrum Disorder

35 36

Auditory Neuropathy

• No progress with auditory or language skills

– refer for CI evaluation– CI may offer neural synchronization

• Outcomes are variable

– Comparable to SNHL in those without other medical/cognitive issues

– ? Contraindicated in hypoplasia/aplasia of cochlear nerve– Counseling is key

10/31/2013

10







• WRS ≤ 50%

37







• WRS ≤ 50%

• Ski-slope hearing loss

– Hybrid/EAS– Improved hearing in noise, music quality

38

Ski-slope Hearing Loss

39

Cochlear Malformations: CI Candidacy

• Candidate– Common cavity– Cochlear hypoplasia– Incomplete partition– SCC dysplasia– Enlarged Vestibular

Aqueduct

40

• Not candidate– Complete labyrinthine

aplasia– Cochlear aplasia– Absent auditory nerve

10/31/2013

11

Where we are goingEmerging Indications

• <12 months• SSD/Unilateral

41


• <12 months– What happens when there is no access to auditory

information in the first year of life?– Cognitive mechanisms/language processes– Sensitive periods

42

Emerging indications/Expanding Criteria

• <12 months– Improved phonological skills – 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

43


• <12 months

• SSD/Unilateral

44

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12


• <12 months• SSD/Unilateral

– Less difficulty hearing in noise– Some benefit for localization– Reduced tinnitus– ? Hearing quality– ? Binaural benefits

45

Success

46

47

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

• Less than fair WRS warrants referral

• Refer any patient with PTA and WRS discrepancy

Thank you!

10/31/2013

13

References

• available upon request

49

9/4/2013

1

Basal Ganglia Neuromodulation for Tinnitus Suppression

Audiology Amplification Update XI

Steven W. CheungUniversity of California, San Francisco

1 November 2013

Disclosure

• No personal financial or institutional interest in any of the drugs, materials, or devices discussed in this presentation.

Agenda

Background

New Onset Tinnitus Clinical Course

Basal Ganglia Overview

Target Selection for Deep Brain Stimulation (DBS)

DBS of the Striatum: Two Experiments

Tinnitus Conceptual Model

Phase I Clinical Trial

Tinnitus – Auditory PhantomsAuditory Percept Without an External Source

Pathophysiology

Aberrant Activity Originating from the Auditory System

Hyperactivity; Synchronized Oscillations; Reorganized Cortical Maps

Brain Networks Acting in Concert

Tinnitus‐Related Distress

Auditory Phantom Qualia Uncorrelated with Tinnitus Severity

Loudness Level; Sound Character

Modulators

Limbic System: Reinforcement, Mood, Behavior

Others: Eye, Facial, Cervical Movements; Sounds

9/4/2013

2

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

Therapeutic Modalities

Reduce ContrastMask Phantom PerceptSuppress Hyperactivity

Exampleso Hearing Aidso Maskerso Cochlear Implantso Cortical Stimulationo Vagal N Stimulation

Reclassify Phantom PerceptReduce SaliencyMitigate Emotional Distress

Exampleso Tinnitus Retrainingo Cognitive-behavioral therapyo Neuromonicso Fractal toneso Antidepressants

Disrupt Information ConveyanceExampleso Transcranial Magnetic Stimulationo Direct Electrical Stimulationo Basal Ganglia Neuromodulation

Auditory-Striatal-Limbic Connectivity

‘Natural History’ of New Auditory Phantoms

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

Investigational Therapies

9/4/2013

3

General Role of the Basal Ganglia

A multisensory integration system that:

• Detects interpretations of sensory patterns

• Releases responses

Medial Surface of the Basal Ganglia

1. Head of Caudate Nucleus

2. Body of Caudate Nucleus

3. Caudatolenticular Gray Bridge

4. Putamen

5. Tail of Caudate Nucleus

6. External segment of Globus Pallidus

7. Internal segment of Globus Pallidus

8. Amygdaloid Body

9. Nucleus Accumbens

9/4/2013

4

Functional Loops of the Basal GangliaSensorimotor ▫ Sensorimotor (Auditory) and Premotor Cortices

▫ Tectum (Colliculi)

Associative▫ Dorsolateral Prefrontal Cortex

▫ Lateral Orbitofrontal Cortex

▫ Higher Order Auditory Cortex

Limbic▫ Limbic and Paralimbic Cortices

▫ Hippocampus

▫ Amygdala

Limbic to Sensorimotor Connections

DLS – Dorsolateral Striatum

IL - Infralimbic

Corticobasal Loops and Interconnectivity

Basal Ganglia Target Selection

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 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 Completelyo Hearing Remained Unchanged

Lowry et al (2004) Otol Neurotol

Diffuse Basal Ganglia Lesion

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5

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 was reported to be reduced on the first postoperative day. Long‐term data showed enduring outcomes.

Larson and Cheung (2012) J Neurosurgery

o Tinnitus Suppressed Substantiallyo Hearing Remained Unchanged

Focal Basal Ganglia Lesion

Probe Delivers stimulation to deep brain nuclei

Anchor SecuresProbe to the skull

Connector Establisheslink to the Controller

Programmer Communicates with the Controller to customize therapy

Controller Determines parameters for brain stimulation and houses the power source

Deep Brain Stimulation System

Caudate Nucleus (Area LC) – DBS Target

• The caudate is routinely traversed during deep brain stimulation surgery for movement disorders.

▫ Opportunity to perform acute caudate stimulation experiments without altering the surgical procedure.

▫ Study population with known nigrostriatal dysfunction.

• IRB approval obtained.

TWO ELECTRICAL STIMULATION EXPERIMENTS IN THE CAUDATE NUCLEUS

Neuromodulation of Auditory Phantoms▫ Loudness Level

▫ Sound Quality

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6

Caudate Nucleus Confirmed by Stealth Trajectory and Microelectrode Recordings

Loudness Level Modulation

Sound Quality Modulation

Subject (age/gender) & side of stimulation

Stimulation parameters in frequency & pulse width

Stimulation threshold to effect in volts

(range)

Tinnitus baseline quality

Tinnitus baseline loudness

(0‐10 scale)

Tinnitus loudness at stimulation threshold

Area LC Neuromodulation effect

A (63/m)Right/Left

Microlesion effect

Tonal5 Left1 Right

0 Left1 Right

Suppressexisting phantom

B (51/m)Right

185 Hz90 µsec

5V(0 ‐ 8)

Noise‐like5 Left5 Right

0 Left0 Right


C (57/m)Right

180 Hz90 µsec

10V(0 ‐ 10)

Cricket‐like5 Left5 Right

1 Left1 Right


D(67/m)Right

150 Hz60 µsec

4V(0 ‐ 8)

Musical4 Left4 Right

2 Left2 Right


E (66/m)Right

185 Hz90 µsec

3V(0 ‐ 8)

Tonal3 Left7 Right

2 Left2 Right


F (61/m)Right

180 Hz60 µsec

4V(0 ‐ 10)

None0 Left0 Right

2 Left0 Right

Triggerclick sequences

G (50/f)Right

10 Hz60 µsec

2V(0 ‐ 10)

None0 Left0 Right

6 Left0 Right

Triggerjet takeoff sounds

H (67/f)Left

10 Hz60 µsec

4V(0 ‐ 10)

None0 Left0 Right

1 Left1 Right

Triggercreaking sounds

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

Summary of Deep Brain Stimulation in Area LCTinnitus Loudness & Sound Qualia Modulation

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7

Striatal Neuromodulation Effects on Tinnitus

• Baseline loudness of auditory phantoms was modulated, to higher and lower perceptual levels.▫ Mostly Bilateral

• New auditory phantoms may be triggered in a controllable manner.▫ Mostly Contralateral

• No changes to hearing with acute stimulation.

• No seizures up to 10V stimulation.

Key Features

Instruction on details of phantom percepts are represented in the central auditory system.

Permission to gate candidate phantom percepts for conscious awareness is controlled by the dorsal striatum.

Action to attend, reject or accept phantom percepts, and form perceptual habits is decided by the ventral striatum.

Determination of tinnitus distress severity is mediated through the limbic and paralimbic system‐nucleus accumbens‐ventral striatum loop.

Tinnitus Conceptual Framework

Phase I Clinical Trial

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

Study Flowchart

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8

Basal Ganglia Neuromodulation for Tinnitus Suppression

10/21/2013

1

Hearing Loss and Fatigue: Assessment and Intervention

Benjamin W.Y. Hornsby, Ph.D.

Acknowledgements and Disclosures• Research collaborators

– Dan Ashmead, PhD

– Fred Bess, PhD

• Lab members

– Zoe Doss

– Alissa Harbin

– Amanda Headly

– Julie Fix

– Katie Makowiec

– Bridget Stone

Funding for the works described here was provided by NIH R21 DC012865-01A1 IES #R324A110266 the ASHFoundation

– Erin Picou, PhD

– Aaron Kipp, PhD

Phonak, Inc., Starkey Inc., and the Dan Maddox Foundation

What is Fatigue?

• Fatigue is a complex construct that can occur in both the physical and mental domains.

– Our focus is on mental fatigue

• Subjectively, defined as a mood or feeling of tiredness, exhaustion or lack of “energy”

• Often associated with a lack of, or decline in,

– Focus, concentration, alertness and/or mental energy and efficiency

• Kennedy, 1988; O’Conner, 2006; Lieberman, 2007; Boksem and Tops, 2008

Consequences of Fatigue• Decreased attention, concentration, mental processing, and decision‐making

– van der Linden et al. 2003; DeLuca, 2005

• Less productive and more prone to accidents

– Ricci et al. 2007

• Less active, more isolated, less able to monitor own self‐care, and more prone to depression

– Amato, et al. 2001; Eddy and Cruz, 2007

10/21/2013

2

Who has Fatigue?

• Everybody!

– Complaints of transient fatigue are common even in healthy populations

• Recurrent fatigue is common in many chronic health conditions

– Cancer, HIV AIDs, Parkinson’s, Multiple Sclerosis

– Very little work specifically looking at hearing loss and fatigue

Hearing Loss and Fatigue• Fatigue is a common accompaniment of hearing loss with severe consequences on quality of life

– Listening IS exhausting!!!• Post on hearingaidforums.com

– “…since I lost most of my hearing…, I've had periodic bouts of tiredness that are deeper and of a different quality than I ever experienced before.”

• Copithorne, 2006

– “I go to bed most nights with nothing left. It takes so much 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/

• Fatigue can be measured many ways

– Subjectively using surveys, rating scales and questionnaires that ask about mood or feelings

• Many options, none specific to hearing loss

• Fatigue scales may be

– Uni‐dimensional: Assess “general” fatigue

• a composite fatigue measure

– Multidimensional: Assess various fatigue constructs

• E.g., General, physical, mental, emotional, sleep, etc…

– Can also assess frequency and severity

Quantifying Fatigue Subjectively Subjective Measures of Fatigue

• Profile of Mood States (POMS)

– 65 items used to derive six mood scores including fatigue and vigor (uni‐dimensional)

• Sensitive to effects of multiple variables on fatigue

Below is a list of words that describe feelings that people have. Please read each word carefully. Then circle the number that best describes how you have been feeling during the PAST WEEK, including today.

McNair et al, 1971

Not at all A little Moderately Quite a bit Extremely

Item # Item 0 1 2 3 4 Construct4 Worn Out Fatigue

7 Lively Vigor

11 Listless Fatigue

15 Active Vigor

29 Fatigued Fatigue

51 Alert Vigor

10/21/2013

3

Subjective Measures of Fatigue

• Multidimensional Fatigue Symptom Inventory (MFSI‐short form; Stein et al., 2004)

– 30 items; four fatigue scores (General, Physical, Emotional, Mental), a vigor and total score

Below is a list of statements that describe how people sometimes feel. Please read each item carefully, then circle the one number next to each item which best describes how true each statement has been for you in the past 7 days.

Not at all A little Moderately Quite a bit Extremely

Item # Item 0 1 2 3 4 Construct

2My muscles ache Physical3 I feel upset Emotional

7 I feel lively Vigor

12 I am worn out General

15I have trouble paying attention Mental

Subjective fatigue in adults seeking hearing help

• Participants: Subset of individuals scheduled for a hearing test or hearing aid evaluation.

– ≥ 55 years old (mean: 72.3 years; s.d. 10.2 years)

• range 55‐94 years.

– N=116 adults (63% males).

• Participants were mailed two self‐report measures of fatigue and a measure of hearing handicap

– POMS (fatigue and vigor subscales)

– Multidimensional fatigue scale (MFSI)

– Hearing handicap inventory (HHIE/HHIA)

• Adults seeking hearing help reported more fatigue and significantly less vigor than age‐matched adults recruited from church and community groups (Nyenhuis et al., 1999) *p<0.01

* *

• Our group was much more likely to report severe fatigue and vigor deficits

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 based on normative data

10/21/2013

4

Degree of loss and subjective fatigue

• Suggests factors other than “increased effort” affect fatigue in adults with HL

Better Ear PTA0 10 20 30 40 50 60 70 80

POM

S Fa

tigue

Sco

re

0

5

10

15

20

25

3095% Confidence IntervalRegression PredictionRaw Data

• Surprisingly, no relationship between degree of hearing loss and subjective fatigue or vigor

Age: 67Gender: Male

Hearing handicap and fatigue

• Strong relationship between hearing handicap and subjective fatigue (POMS and MFSI)

MFSI Total Score-20 -10 0 10 20 30 40 50 60 70 80 90

HH

IE/A

Tot

al S

core

0

20

40

60

80

100

95% Confidence IntervalRegression Prediction

MFSI Total Score-20 -10 0 10 20 30 40 50 60 70 80 90

HH

IE/A

Tot

al S

core

0

20

40

60

80

100

PTA = 25 dB HL

PTA = 75 dB HL

• As fatigue increases, hearing handicap increases

• Suggests consequences of hearing loss and fatigue are associated

PTA: 35Age: 67Gender: Male

Subjective fatigue in children with HL

• CHL report significantly more fatigue. Pervasive across domains

General Sleep/Rest Cognitive Overall

Peds

QL

Scor

e

0102030405060708090

100CHL CNH

Mor

e Fa

tigue

* * *

* p< 0.05

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

• Fatigue is a complex multidimensional construct that can be defined subjectively as a mood or feeling and quantified using various subjective measures

– E.g., POMS, MFSI, PedsQL‐MFS

• Results using validated, generic, measures confirm

– fatigue is increased in adults and children with HL,

– risk for more severe fatigue is increased in these groups,

– Psychosocial consequences of hearing loss and fatigue are related

10/21/2013

5

• Fatigue has also been defined behaviorally

– A decline in cognitive performance due to sustained mental demands

• Kennedy 1988; DeLuca 2005

• Measures of attention, concentration, processing speed, and decision‐making have been used as objective markers of fatigue

– van der Linden et al. 2003; DeLuca, 2005

• Very limited work in this area in HI persons

Objective Measures of Fatigue

Trial BlockST 1 2 3 4 5 6 Mean

Rea

ctio

n Ti

me

(in m

s)

250

300

350

400

450

500Unaided Aided Basic

Error bars = 1 st. error

Objective fatigue measures• Unaided RTs slow over time consistent with onset of fatigue

• Aided RTs are more stable suggesting some resistance to fatigue

Visual Reaction times

• Reaction times (RT) during a demanding dual‐task requiring sustained (~50 minutes)speech processing

Hornsby, B. (2013). The Effects of Hearing Aid Use on Listening Effort and Mental Fatigue Associated With Sustained Speech Processing Demands. Ear and Hearing

Subjective Ratings

• Demanding listening IS fatiguing especially unaided!

• I.e., Aids help consistently across participants

Pre-Test Post-Test

Fatig

ue S

ubsc

ale

Sco

re

0

2

4

6

8

10Unaided Aided

More Fatigued

Less Fatigued

Change in POMS Fatigue Scores after sustained listening during a demanding speech task

Change in Unaided Fatigue Rating0 5 10 15 20 25 30

Cha

nge

in A

ided

Fat

igue

Rat

ing

0

5

10

15

20

25

30

Mean

More Fatiguing when Aided

More Fatiguing when Unaided

References

• 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.

• Hetu, R., Riverin, L., Lalande, N., Getty, L. and St‐Cyr, C. (1988). "Qualitative analysis of the handicap associated with occupational hearing loss." British Journal of Audiology 22(4): 251‐64.

• Hornsby, B. W. Y. (2013). The Effects of Hearing Aid Use on Listening Effort and Mental Fatigue Associated With Sustained Speech Processing Demands. Ear and Hearing. doi: 10.1097/AUD.0b013e31828003d8

• Hornsby, B. W., Werfel, K., Camarata, S., & Bess, F. H. (2013). Subjective Fatigue in Children with Hearing Loss: Some Preliminary Findings. Am J Audiol. doi: 10.1044/1059‐0889(2013/13‐0017)

• Lieberman, H. R. (2007). Cognitive methods for assessing mental energy. NutrNeurosci, 10(5‐6), 229‐242.

• 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(Amst), 113(1), 45‐65. doi: S0001691802001506 [pii]

10/14/2013

1

Auditory Training and Challenges Associated with Participation and

Compliance

Robert Sweetow, Ph.D.

University of California, San Francisco

1

Everything we do as audiologists is aural or audiologicrehabilitation (AR) : counseling, hearing aids, ALDs, communication strategies, auditory training)…

BUT……...

• less than 20% of new users (and less than 10% of experienced users) receive any form of audiologicrehabilitation (beyond hearing aids)

• only 2 ‐ 5% are provided with formal retraining opportunities

– Kochkin, MarkeTrak VIII, 2009

2

Why do patients seek our help?

3

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

4

10/14/2013

2

Potential impediments to achieving mastery of these elements

• Hearing loss

• Neural plasticity and progressive neurodegeneration

• Global cognitive decline

• Maladaptive compensatory behaviors

• Loss of confidence

5

The biggest mistake we currently make may be…….

• Making hearing aids the focus of our attention, when the focus should be….

• Enhancing communication

6

Are we really testing communication?

7

Current speech perception tests….

• Don’t take the contextual nature of conversation into account

• Don’t take the interactive nature of conversation into account

• Don’t allow access to conversational repair strategies that occur in real life

Flynn, 20038

10/14/2013

3

Relevant domains for assessment

• Communication expectations and needs• Sentence recognition in noise• Tolerance of noise• Ability to handle rapid speech• Binaural integration (interference)• Cognitive skills (working memory, speed of processing,

executive function)• Auditory scene analysis• Perceived handicap• Confidence / self‐efficacy• Dexterity• Vision

9

Measures beyond the audiogram that can be used to define residual auditory function.

Objective procedures• QuickSIN

– BKB‐SIN

• Hearing in Noise Test (HINT)• Listening in Spatialized Noise Sentences (LiSN‐S) • Acceptable Noise Levels (ANL)• Binaural interference • Dichotic testing• Listening span (Letter Number Sequencing)• TEN• Rapid (compressed) speech test• Speechreading• Dual‐tasking

• Need for screening measures

Communication Needs Assessment

10

Measures beyond the audiogram that can be used to define residual auditory function.

Subjective measures• Hearing Handicap Inventory for the Elderly – Screening HHIE‐S• Communication Scale for Older Adults (CSOA)• Communication Confidence Profile (CCP) or Listening Self

Efficacy Questionnaire• Self Assessment and Communication partner subjective scales

(SAC and SOAC)

Combined (objective and subjective) methods• Performance Perceptual Test (PPT)

Communication Needs Assessment

11

Communication Confidence Profile

Please circle the number that corresponds most closely with your response for each answer.

If you wear hearing aids, please answer the way that you hear WITH your hearing aids.

Sweetow, R and Sabes J. Hearing Journal: (2010); 63:12 ;17‐18,20,22,24.

12

10/14/2013

4

1. Are you confident you can understand conversations when you are

talking with one or two people in your own home?

2. Are you confident in your ability to understand when you are

conversing with friends in a noisy environment, like a restaurant?

3. In order to hear better, how likely are you to do things like moving

closer to the person speaking to you, changing positions, moving to a

quieter area, finding better lighting, etc?

4. If you are having trouble understanding, how likely are you to ask a

person you are speaking with to alter his or her speech by slowing

down, repeating, or rephrasing?

5. How sure are you that you are able to tell where sounds are coming

from (for example, if more than one person is talking, can you identify

the location of the person speaking?)

6. Are you confident that you are able to follow quickly‐paced

conversational material?13

7. Are you confident that you can focus on a conversation when other

distractions are present?

8. Are you confident that you can understand a person speaking in large

rooms like an auditorium or house of worship?

9. In a quiet room, are you secure in your ability to understand people

with whom you are not familiar?

10. In a noisy environment, are you confident in your ability to

understand people speaking with whom you are not familiar?

11. Are you confident that you can switch your attention back and forth

between different talkers or sounds?

12. If you are having difficulty understanding a person talking, how likely

are you to continue to stay engaged in the conversation? 14

CCP interpretation

• 50+ = Confident• 40‐50 = Cautiously certain• 30‐39 = Tentative• Below 29 = Insecure

15

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 risk of cognitive impairment

• A 25 dB hearing loss equals the reduction in cognitive performance associated with a 6.8 year age difference

• Could be related to common cause hypothesis (shared neural pathways) , extra resource expenditure; isolation from hearing loss

Lin (2011, 2013)

16

10/14/2013

5

• 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 (Neuropsychologia2009;47[3]:693‐703). To compensate for reduced audibility or deficits in temporal processing (J Neurosci2012;32[41]:14156‐14164; J Acoust Soc Am 2006;119[4]:2455‐2466), older adults appear to draw more on cognitive resources than younger adults do (Ear Hear 2010;31[4]:471‐479).

• Despite this greater need to rely on cognitive resources, older adults often have a diminished cognitive reserve when trying to communicate in a complex listening environment (Trends Amplif2006;10[1]:29‐59).

17

• Older adults with hearing loss and poor working memory are more susceptible to hearing aid distortions from signal‐processing algorithms, suggesting that cognitive skills should be taken into account in the hearing aid fitting.

– Arehart, et al; Ear Hear 2013;34[3]:251‐260)

18

Montreal Cognitive Assessment

• designed to assist in the detection of mild cognitive impairment (J Am Ger Soc 2005;53[4]:695‐699).

• http://www.mocatest.org

19

So what’s the point?

• Like other diagnostic testing, any single measure (including speech in noise testing) may not provide enough additional 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.

20

10/14/2013

6

Is this practical?????

21

Pilot study – what can busy clinical audiologists fit in?

• UCSF Request

– Minimum of 2 objective and 2 subjective measures

– 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.

22

However………

70% provided usable information above and beyond the “comp audio”

23

Why?????

• a) not enough time

• b) inconvenient

• 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

24

10/14/2013

7

Expectations vs. Goals

• Expectations have a product orientation–Patient assumes passive role

–Whatever goes wrong is the professional’s fault

• Goals have a rehabilitation orientation–Patient assumes active role

–Patient shares in the process

25

Assessing Motivation and Readiness for AR

• Source : internal vs. external• Level:

handicap perception• desire to rehabilitate

• Don’t fit an unmotivated patient

26

Ida Institute tools

• Circle of change

• Line

• Decisional Balance Box

27

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

28

(Prochaska and DiClemente, 1984)

10/14/2013

8

Outcome assessment should relate explicitly to the needs and goals

determined.

Gatehouse 2003; Cox et al 2000

29

Benefit does NOT equal satisfaction!

• Cox (1997) estimated that satisfaction is comprised of:

• 40% benefit (both psychosocial and acoustic);

• 25% personal image;

• 19% service and cost;

• and 16% negative features.

30

How will your patient (and you) assess outcome?

• Hearing soft sounds• Louder perception• Understanding speech in noise• Listening effort (elevators don’t make travel from floor 1 to floor 20 more effective, but they do make it easier) !!!!! (Irv Hafter)

• End of day fatigue• Use of new strategies• Quality of life• Benefit or satisfaction• RFC

31

Client Oriented Scale of ImprovementCOSI

• Self‐report questionnaire requiring patient to list 5 listening situations in which help with hearing is required. Post‐rehab, the reduction in disability and the resulting ability to communicate in these situations is quantified.

• Takes less than 5 minutes of patient time, 2 minutes professional time for interpretation

32

10/14/2013

9

Characteristics of Amplification Tool COAT

• 9‐item measure of non‐audiologic information to determine if technology is required.

• Takes 3 minutes of patient time, 2 minutes professional time for interpretation

33

Characteristics of Amplification Tool(COAT)

Newman and Sandridge

• Assesses

– Motivation

– Expectations

– Preferences

– Cosmetics

– Cost considerations

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

34

Mini BTE

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

your ear.

35

"It doesn't sound normal"

• 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”

36

10/14/2013

10

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

What do we do for a cochlear implant patient?

What do we do for a patient with a balance disorder?

What do we do for a hearing impaired patient?

How can a person be trained to form whole perceptual units from

auditory fragments?

38

39

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?????

40

10/14/2013

11

Does peripheral hearing loss lead to central auditory dysfunction

If so, can anything be done to compensate?

41

Why should AT be expected to produce benefit?

• Acuity and sensitivity are lower level functions

• Higher level functions (i.e. speech in noise) require more complex (hierarchical) processing (such as temporal analysis) that may utilize multiple channels of perceptual processing not governed by critical bands

42

Training‐related physiological changes have been attributed to……

• 1) a greater number of neurons responding in the sensory field

• 2) improved neural synchrony (or temporal coherence)

• 3) may be a neural “decorrelative” processes in which training decorrelates activity between neurons, making each neuron as different as possible in its functional specificity relative to the other members of the population. – This process assumes that information common to two stimuli is disregarded, while responses to unique features of each stimulus are enhanced.

Tremblay, 2006

43

Physiologic changes post training

• MRI shows increases in grey matter (Boyke, et al 2008)

• Cortical thickening in older adults (Engvig, et al, 2010)

• Changes in mismatched negativity response for adults trained on synthetic phoneme discrimination tasks (Kraus (1995); Recanzone (1995)

• Changes using auditory evoked magnetic fields ‐magnetoencephalography (Vasama and Makela (1995)

• Enhanced NI‐P2 on novel speech sounds and demonstrated training effects (Tremblay, et al (1998, 2001)

• Physiological changes occur quite rapidly, and precede changes in perception. (Tremblay, 1998)

44

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Evidence based review of auditory rehabilitation and training in adults

(Sweetow and Palmer, 2005)

• Group– Beynon, Thornton and Poole, 1997

– Chisolm, Abrams, and McArdle, 2005

• Individual– Kricos and Holmes, 1996

– Montgomery, Walden, Schwartz, and Prosek, 1984

– Walden, Erdman, Montgomery, Schwartz, and Prosek, 1981

– Rubenstein and Boothroyd , 1987

– Kricos, Holmes and Doyle, 1992

– Wright, B., Buonomano, Mahncke, and Merzenich, 1997

– Bode and Oyer, 1970

45

AT Studies since 2000 meeting Evidenced Based criteria(Sweetow and Palmer, 2005)

Henshaw and Ferguson , PLOS 2013; CBAT*

• – Fu and Galvin, 2007• – Oba, Fu and Galvin, 2011• – Miller, Watson, Kistler, Wightman and

Preminger, 2008• – Sweetow and Sabes, 2004• – Sweetow and Sabes, 2006• – Barcroft, Sommers, Tye‐Murray et al., 2011• – Ingvalson, Lee, Fiebig and Wong, 2013• – Zhang, Dorman, Fu and Spahr, 2012• – Levitt, Oden, Simon et al., 2011.

46

CONCLUSIONS

• 1) less than 5% of studies published on auditory training meet rigorous evidenced based criteria

• 2) auditory training resulted in improved performance for trained tasks in nearly all the articles that met evidenced‐based criteria

• 3) although significant generalization of learning was shown to untrained measures of speech intelligibility, cognition, and/or self‐reported hearing abilities, the improvements were variable, relatively small and not robust, though retention of learning was shown at post‐training

47

Benefits of AR Programs

• Reduced return rate (13 vs 3%) of hearing aids (Martin, 2007); 9% ‐ 3% (Northern and Beyert, 1999)

• Increased sale of assistive listening devices• Fewer trouble‐shooting visits • Referrals from friends, co‐workers, and family members

• Free advertising provided by satisfied hearing aid users

• Good community relations

48

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Examples of good group rehab formats

• ACE (Active communication education program) (Hickson, 2007)

• Learning to Hear Again (Wayner and Abrahamson, 1996).

• Mayo Clinic (Hawkins, 2004)

• Kricos

• Beynon, et al

• Northern and Meadows

• Abrams, Chisholm, et al

49

What happened to Aural Rehabilitation?

• declined because outcome measures concentrated on auditory training and speechreading and didn’t consider emotional and psychological by‐products

• boring?• too speech pathology like?• too time consuming?

• lack of reimbursement

50

Training is not a new concept….

But now we have the means to do it effectively……via computer aided auditory rehabilitation….so that…..

• It can be performed in a private, non‐threatening environment

• It can proceed at the individual’s optimal pace

• Progress assessment can be done automatically

51

What we can learn from learning theory?

1. Distribution of practice should be suitable for the task to be learned.

2. Active participation by the learner is superior to passive receptivity.

3. Practice material should be varied so that the learner can adapt to realistic variation and so that his motivation during drill is improved.

4. Accurate performance records need to be maintained in order to evaluate progress and effects of training.

5. The most useful single contribution of learning theory is the provision for immediate knowledge given to learners regarding their performance.

Wolfle (1951)

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What we can learn from neuroscience…?

• Appropriate feedback (Holroyd et al. 2004, Birdsong studies)

• Motivation (Kilgard and Merzenich, 1998)

• Reward (Benenger and Miller, 1998)

• Training near threshold (Blake et al., 2002)

• Incremental training: Go slow and steady (Linkenhoker and Knudsen, 2002)

• Speed and spacing of the training (Hairston and Knight, 2004, Marquet, 2001)

Many available Computer‐based Auditory Training Programs

• Baldi• Computer‐Assisted Speech Perception Testing and Training (CASPER)• CogMed• Computer Assisted Speech Training (CAST/TigerSpeech)– Sound and WAY Beyond– Seeing and Hearing Speech– Sound Express• eARena• FastForWord• I Hear What You Mean• IMPACT• LACE (Listening And Communication Enhancement)• Read My QUIPs• SoundScape• Speech Perception Assessment and Training System (SPATS)• The Listening Room

54

Music Training

• Kraus’ lab (Northwestern) has shown:

• Better understanding of speech in noise across age groups

• Shorter brainstem timing delays• Neurobio Aging 2012:33(7):1483

55

OPERA

• Overlap: in the anatomy and physiology for speech and music

• Precision: more precision is required for music processing than speech

• Emotions “ strong emotions evoked by music may induce 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

56

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LACE(Listening and Communication Enhancement)

• Cognitive– Auditory Working Memory– Speed of Processing

• Degraded and competing speech– Background noise– Compressed speech– Competing speaker

• 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

57

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

58

Note: Even a 1 dB reduction in SNR has been equated with a 6‐8% improvement in sentence recognition (Crandell, 1991; Wilson et al, 2007)

• On average, normal hearing people require a +2 dB signal to noise ratio for 50% recognition of words in sentences while people with hearing loss require a 8 dB signal to noise ratio (Killion, 2002).

• Even a 1 dB reduction in SNR has been estimated to be commensurate with a 6‐8% improvement in percent correct scores for sentence recognition (Crandell, 1991; Wilson et al, 2007)

• 5 dB SNR loss = 20% quality estimation (Killion (2011)

59

Good news• Higher benefit from training is significantly correlated with reduced listening effort (Olsen and Preminger, 2012)

• New hearing aid users in the training group experience the largest improvement (Preminger, 2011)

• Patients with more severe handicap show greater benefit (Henderson‐Sabes and Sweetow, 2007; Kuk et 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)

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Difference in Average S/B Score1st to 4th Quarter

0 10 20 30 40 50 60 70-15

-10

-5

0

5

Subject

(dB

SN

R)

Difference in Average CS Score1st to 4th Quarter

0 10 20 30 40 50 60 70-25

-20

-15

-10

-5

0

5

10

Subject

(dB

SN

R)

Difference in Average TC Score1st to 4th Quarter

0 10 20 30 40 50 60 70-30-25-20-15-10-505

10

Subject

(dB

SN

R)

Difference in Average TW Score1st to 4th Quarter

0 10 20 30 40 50 60 70-2

-1

0

1

2

3

Subject

(dB

SN

R)

Difference in Average TW Score1st to 4th Quarter

0 10 20 30 40 50 60 70

-4

-3

-2

-1

0

1

Subject

(dB

SN

R)

MWDifference in Average MW Score – 1st to 4th quarter

The biggest unresolved questions

• Will audiologists recommend it?

– Impact on return for credit rate?

• Will patients do it?

– Cost of effort

– They do for physical therapy

• Why? – MD recommendation

– Immediate modeling of therapy after surgery

62

Why audiologists don’t recommend AR

• Belief that hearing aids alone are adequate

• Lack of belief in outcome measures

• Belief that additional resources (time, money) are required

• Lack of confidence regarding who needs AT

• Lack of reimbursement

• Reluctance to ask patients to spend more time or money

• Inertia

• Laziness

63

Something to consider

• Results from a counseling‐based group AR program indicated that hearing aid users that participated in the program performed better on the Communication Profile of the Hearing Impaired than hearing aid users with no group AR experience at the conclusion of the program.

• However, there were no significant differences between the groups after one year.

Chisolm TH, Abrams HB, McArdle, R. (2004) Short‐ and long‐term outcomes of adult audiological rehabilitation. Ear Hear 25:464‐477.

• So what does this imply?64

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Compliance• Clinical data from over 3,000 individuals reported that

adherence (defined as completion of at least half of the recommended number of training sessions) was less than 30%. (Sweetow and Sabes, 2010)

• Similarly, in a study of home‐based computerized AT for cochlear implant users, Stacey and Summerfield (2005) reported that about 1/3 of their users completed less than 1/3 of the recommended training.

• Non‐compliance with prescribed medication regimens for hypotensive treatment ranges from 5% to 80% among glaucoma patients (Olthoff et al, 2005).

• Vincent (1971) reported that 43% of glaucoma patients refused to take the physician‐ordered measures necessary to prevent blindness, even when that refusal had already led to impairment in one eye.

65

AT Studies from 2000 – 2012 meeting Evidenced Based criteria

(Sweetow and Palmer, 2005)Henshaw and Ferguson , PLOS 2013; CBAT*

• – Fu and Galvin, 2007• – Oba, Fu and Galvin, 2011• – Miller, Watson, Kistler, Wightman and

Preminger, 2008• – Sweetow and Sabes, 2004• – Sweetow and Sabes, 2006• – Barcroft, Sommers, Tye‐Murray et al., 2011• – Ingvalson, Lee, Fiebig and Wong, 2013• – Zhang, Dorman, Fu and Spahr, 2012• – Levitt, Oden, Simon et al., 2011.

66

CONCLUSIONS

• 1) less than 5% of studies published on auditory training meet rigorous evidenced based criteria

• 2) auditory training resulted in improved performance for trained tasks in nearly all the articles that met evidenced‐based criteria

• 3) although generalization of learning was shown to untrained measures of speech intelligibility, cognition, and/or self‐reported hearing abilities, the improvements were variable, relatively small and not robust, though retention of learning was shown at post‐training

67

Reasons

• Denial of the problem

• Cost (money, time, risk of failure) of the treatment

• Difficulty of the regimen

• Unpleasant outcomes or side‐effects of the treatment

• Lack of trust

• Apathy

• Previous negative experience• Failure to persuade that compliance is in their best interest

• Lack of “rewards” or recognition for effort68

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Six predictors of positive compliance

• Higher socioeconomic status• Greater initial self reported hearing disability• Lower pre‐contemplation stage (denial)• Greater action stage of change• Lower chance locus of control• Greater hearing disability perceived by others and self

– Laplante‐Levesque, Hickson, and Worrall (Ear & Hearing, 2012)

69

Suggestions

• Compliance generally increases if patients are given clear and understandable information about their condition and progress in a sincere and responsive way

• Do the first session face to face

• Simplify instructions and treatment regimen as much as possible.

• Have systems in place to generate treatment and appointment reminders

70

LACE CE and Compliance

In Clinic At Home0

10

20

30

40

50

* Patients training at home maychoose not to upload data

Where Patient Completed Session 1

Perc

ent o

f pat

ient

s up

load

ing

at le

ast 1

0 se

ssio

ns(%

)

71

How should success be measured?

• On‐task improvement

• Generalized speech recognition performance

• Quality of life

• Subjective communication confidence

• Individual vs group mean data

72

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Attitude of the Professional

• Audiologists sell a process, not a product

• Patients will not regard listening programs to be important unless the clinician appears to believe it is important

• Radical changes in technology have immediate impact

• Changes in practice or procedures must overcome the hurdle of inertia

73

Summary

• Identify and manage patient’s emotional status• Help the patient feel safe and free to express his/her feelings

• Manage emotional barriers• Select appropriate amplification in accordance with the patient’s personality and needs

• Teach and orient the patient regarding adaptation and the use of the hearing aids

• Help the patient manage telephone use• Help the patient attain realistic expectations• Make the patient understand that hearing aid use is only one component of the hearing rehabilitation process

• Document your work• Provide a rehabilitation plan

74

Challenges

• Convince MDs / audiologists / patients of importance• Large scale studies on AR/AT• Better diagnostic/prognostic assessments• Establish optimal training parameters• Raise acceptance to level of acceptance of “Brain games” (e.g. Lumosity, Brain HQ, Posit Science)

• 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)• Incentives• Determine appropriate outcome measures

75

Aural (auditory, audiologic) rehab……

Should NOT be considered an add‐on!

Incorporate it at the very beginning

Above all……….. Do something!!!!!

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Thanks for listening

[email protected]

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10/24/13

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

PEDIATRIC BONE ANCHORED IMPLANTS:

PROTOCOLS AND STRATEGIES

Consultant for Cochlear Americas BAS

DISCLOSURE

¡  Osseointegrated devices have treating conductive and mixed hearing loss since 1977.

¡  Works through direct bone conduction.

¡  Sound is conducted through the skull bone bypassing the outer and middle ear and stimulating the cochlea.

¡  Contains three parts: §  titanium implant §  external abutment §  detachable sound processor §  BAHA – Entific Medical Systems §  Baha ™ Cochlear Americas §  Ponto – Oticon Medical §  Osseointegrated implants §  Bone Anchored Implants – BAI

§  Aided testing - B

BONE ANCHORED IMPLANTS

¡  Softbands •  No age restrictions •  Bilateral CHL •  Bilateral MHL •  SSD or unilateral losses •  Unilateral or bilateral softbands available

¡  Implants •  FDA - age 5 years old or older •  FDA: Bilateral implants (can be simultaneously implanted) must be

symmetric bone conduction thresholds less than 10 dB difference on average (500, 1000, 2000, and 3000 Hz) or less than 15 dB at individual frequencies

CANDIDACY

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¡  Conductive Hearing Loss •  TCS •  Atresia/microtia

¡ MHL implants

•  Bilateral with BC PTA or 35 dB or less for children (Christensen) •  Power devices •  5 years of age as other implantation guidelines

¡  Single sided deafness (SSD)

•  Unilateral hearing loss profound SNHL, MHL, or CHL •  Normal (15 dB or less) in the “good ear” •  Softband

CANDIDACY

•  Placement of Baha Softband § Infants - not always on mastoid § Toddlers § Preschoolers

•  Fitting the Softband § Helping parents find the perfect fit

•  Functional gain/aided audiogram

SOFTBAND FITTING

¡ Bilateral CHL/MHL will be fit ASAP •  Just like traditional hearing aid fittings •  Some will be implanted when they are 5 years old •  Some will receive other surgical intervention

¡ Unilateral losses (SNHL/MHL/CHL)

•  fit at 9 to 12 months of age when we can get a Softband near the affected ear on a full time basis

SOFTBANDS: WHEN TO FIT

¡ For bilateral CHL/MHL most common verification is Functional Gain •  under 6 months of age – BOA

§  Testing Babies: You Can Do It! Behavioral Observation Audiometry (BOA) by Jane R. Madell

Perspectives on Hearing and Hearing Disorders in Childhood December 2011 21:59-65.

•  over 6 months – VRA, CPA, etc

¡ Outcome measures ¡ SLPs/AV Therapists

SOFTBAND VERIFICATION

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SOFTBAND VALIDATION

Any va l idat ion measure you cur rent l y use fo r other t rad i t iona l BTE f i t t ings wi th ch i ld ren wi l l work we l l w i th sof tband va l idat ion fo r b i la tera l CHL/MHL. Karen Ander son - Success fo r K ids w i th Hear ing Loss

§  https://successforkidswithhearingloss.com/tests ¡  ELF - Ear l y L is ten ing Funct ion ¡  CHILD - Ch i ld ren ’s Home Inventor y o f L is ten ing D i f f i cu l t ies ¡  Preschoo l S IFTER – Preschoo l Screen ing Ins t rument For Target ing Educat iona l R isk ¡  SIFTER – Screen ing Ins t rument For Target ing Educat iona l R isk o f E lementar y School Ch i ld ren ¡  Secondar y S IFTER - Secondar y Screen ing Ins t rument For Target ing Educat iona l R isk ¡  LIFE -R – Rev ised L is ten ing Inventor y For Educat ion ¡  LIFE – Learn ing Inventor y For Educat ion ¡  LIFE Student Appra isa l ¡  LIFE Student Appra isa l P ic tures ¡  LIFE Teacher Appra isa l ¡  CHAPS- Ch i ld ren ’s Audi tor y Per formance Sca le ¡  SAC- A -Se l f Assessment o f Communicat ion - Ado lescent ¡  SOAC- A– S ign i f i cant Other Assessment o f Communicat ion – Adolescent ¡  FLE – Funct iona l L is ten ing Eva luat ion ¡  Chi ldrens Peer Re lat ionsh ip Sca le ¡  Minnesota Soc ia l Sk i l l s Check l i s t fo r Students who are Deaf - Hard o f Hear ing ¡  PARC– P lacement Readiness Check l is ts fo r Ch i ld ren who are Deaf o r Hard o f Hear ing

(Co lorado)

¡ When in doubt…follow the rules

§  State licensure laws for verification and validation of hearing aids and implantable devices

§  Clinical practice guidelines (AAA, ASHA, etc)

RULES

ARKANSAS LICENSURE LAW

Evaluation of hearing aids must be performed with the hearing 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 account for the dif ferent means of programming the hearing aid (linear versus nonlinear, digital versus analog). The preferred verification method of fitting is to use probe microphone measures in conjunction with the patient’s ear, ear mold, and personal amplification system. A real ear to coupler dif ference (RECD) can be obtained and probe tube measurement performed in a coupler if a patient is unwilling to tolerate probe microphone measurement in the ear. A prescriptive measure addressing gain should be in place to address the possibility of over- or underestimating gain until the patient is five (5) years of age.

3. AUDIOLOGIC CANDIDACY CRITERIA (page 12) Recommendations for Determining Candidacy Children with permanent conductive hearing loss should be fit with air conduction hearing aids when anatomically possible (sufficient external ear and canal anatomy to support the coupling of an earmold and retention of the device), or bone conduction hearing aids if anatomy is insufficient for coupling (atresia, chronically draining ears, or other significant anatomical malformations).

AAA CLINICAL PRACTICE GUIDELINES PEDIATRIC AMPLIFICATION JUNE 2013

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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.

AAA CLINICAL PRACTICE GUIDELINES PEDIATRIC AMPLIFICATION JUNE 2013 SOFTBAND VERIFICATION

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

SOFTBAND CASE 1

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¡ Seen at 4 months of age for follow up NBHS

¡ Tech notes ear pit right ear

¡ Type B high frequency tymps AU

¡ Failed OAEs AU

SOFTBAND CASE 1

¡ ENT examination – Stenosis and No TM identified in the clinic

¡ ABR at 7 months - During possible PET placement was consistent with a Moderate CHL AU

SOFTBAND CASE 1

¡ Loaner device fit at 8 months old ¡ Personal Softband fit at

9 months 22 days

SOFTBAND CASE 1

¡ Cleft palate ¡ Chromosome deletion 18p ¡ Failed NBHS and follow up screenings

§ NO atresia § NO stenosis

¡ Behavioral testing at 6 months consistent with moderate/severe CHL

SOFTBAND CASE 2

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¡ Fit with loaner device 6 months

¡ Personal Baha fitting at 8 months

¡ Numerous repairs …

SOFTBAND CASE 2

¡ Fit with BP100 at 2 years of age

§ Titanium § Lockable battery door § Moisture resistant

• Importance of pediatric features • Softbands • loaners

SOFTBAND CASE 2

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

SOFTBAND CASE 3

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Reimbursement for Softbands?

1.  Key phrases § Cannot benefit from traditional BTEs § Malformation § Congenital

2. Provide data

SOFTBAND FUNDING

¡ Hol et al 2005 •  Two subjects

§  3 y/o and 29 months •  Compared Baha Compact, Baha Classic, and Oticon E 300 P •  The electro-acoustic measurements showed minor

differences in gain between the three devices •  Both children showed speech and language

development that was in accordance with their cognitive development.

¡ Conclusions: The BAHA Softband was a valid intervention in children with congenital bilateral aural atresia who were too young for percutaneous BAHA application

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

SOFTBAND DATA

Nicholson, N. Christensen, L, Dornhof fer, J . Mart in, P, Smith-Ol inde, L. (2011).Verif ication of speech spectrum audibi l i ty for pediatr ic baha sof tband users with craionfacial anomalies. Clef t Palate-Craniofacial Journal , (48)1: 56-65.

SOFTBAND DATA

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IMPLANTATION ¡ Surgical procedures

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

IMPLANTATION

PRE-SURGICAL CONSIDERATIONS

¡ History § Progressive HL? § Sudden HL?

¡ CT § EVAS? § Other middle or inner ear anomalies?

¡ Family and child must be motivated ¡ Hygiene/ability to care for abutment by family

and/or child §  Complications happen and should be discussed

¡ 7 years old ¡ Wore BTEs for bilateral moderate CHL ¡ Normal pinnas AU ¡ Chronic otitis externa

¡ Implanted bilaterally with a two stage surgery 6 months osseointegration period between two stages

IMPLANT CASE 1

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IMPLANT CASE 1

Unaided

BTE Aided

Bilateral Baha Implants

¡ Family choice

¡ Aided thresholds were similar

¡ Never wore a Softband

¡ Chronic otitis externa was their priority

¡ Still uses FM as she did with the BTEs

IMPLANT CASE 1

¡ Why choose bone anchored implants over traditional bone conduction aids?

¡ Is it worth the money?

¡ How does a traditional bone conduction aid compare to the Softband? To a implanted Baha?

TRADITIONAL BC AIDS VS. BAHA SYSTEM

¡ Verstraeten et al (2008) ¡ 3 conditions:

§ Baha implanted unilaterally § Baha coupled to a headband § Baha coupled to the test band

¡ Results §  Headband vs. test band were similar §  Implantation was superior to both headband and test

band

HEADBAND VS. IMPLANTATION

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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

BAHA VS. TRADITIONAL BC AID FUNCTIONAL GAIN RESULTS

•  Bone conduct ion t ransducer prov ides the most gain of any dev ice tested

•  The implanted Baha system prov ided second h ighest amount of funct ional gain

•  Sof tband resul ts prov ided the th i rd amount of h ighest funct ional gain .

•  Tradi t ional bone conduct ion hear ing a ids prov ided the least amount of funct ional gain .

•  There is some over lap among dev ices at 1000 Hz , but at no other f requency . ¡  Implanted Baha has stat is t ica l ly as much gain as a bone conduct ion t ransducer at

a l l f requencies tested;

¡  Implanted Baha prov ides stat is t ica l ly more gain at 500 Hz than the Baha at tached to a Sof tband

¡  Tradi t ional bone conduct ion hear ing a id prov ides s igni f icant ly less gain than a l l the other dev ices at a l l f requencies wi th the except ion of the Baha with Sof tband 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.

RESULTS

BILATERAL

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¡ Bosman, A.J. et al (2001) ¡  ‘Audiometric Evaluation of Bilaterally Fitted Bone-

anchored Hearing Aids’ •  25 adults •  Aged 12 to 69 years of age •  Required at least 3 months experience with bilateral

Baha implants •  All had symmetrical bone conduction thresholds across

0.5, 1, 2, and 4 kHz •  Baha Classic (no longer manufactured)

PREVIOUS RESEARCH

¡ Results: § Better localization skills § Better speech in noise § Better Binaural Masking Level Difference (BMLD)

§ The masked threshold of a signal can sometimes be lower when listening with two ears rather than one

§ The detection of a signal in noise is improved when either the phase or level differences of the signal at the two ears are not the same as the masker.

¡ Conculsions: § Results for localization, speech in noise and BMLD

measurements indicate that bilateral Baha “do indeed result in binaural hearing” to an extent.

BOSMAN ET AL RESULTS

¡ 18 year old female

¡ TCS

¡ First implanted unilaterally in another state

¡ Received second implant approximately 2 years after the first implant

BILATERAL CASE 1

BILATERAL CASE 1

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¡ Hearing In Noise Test (HINT) § 10 sentences that are scored based on the number of words

repeated correctly.

§ Left Baha § + 10 dB S/N ratio = 80%

§ Right Baha § + 10 dB S/N ratio = 82%

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

BILATERAL CASE 1

¡  Di George Syndrome ¡ Mixed Hearing Loss ¡ Malformed outer, middle, and inner ear ¡ Wore BTEs since shortly after birth ¡  Terrible balance/vestibular problems…Tons of repairs!!! ¡  Used Bilateral Softband prior to implantation ¡  Bilateral Implants

BILATERAL CASE 2

BILATERAL CASE 2

Unaided

BTE Aided

Baha Aided

SINGLE SIDED DEAFNESS (SSD)

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¡ 35% failed at least one grade

¡ 13.3% were in need of some special resource assistance

¡ 20% were described by teachers as having behavioral problems

¡ 50% showed some difficulty in educational progress

(Bess & Tharpe,1986)

SINCE 1986…UNILATERAL HEARING LOSS…

¡ Judith Lieu, MD § Washington University

¡ 70% of children with unilateral loss have IEP

¡ Unilateral loss IS associated with worse speech and language scores in children

Lieu, J . , (2004). Speech- language and educat ional consequences of uni lateral hearing loss in chi ldren. Arch Otolar yngol Head Neck Surg. 130 (5) :524-530. L ieu, J . , Tye-Murray, N, Karzon, R. , Piccir i l lo , J . (2010) . Uni lateral hear ing loss is associated with worse speech- language scores in chi ldren. Pediatr ics . 125(6) ; 1348-1355.

UNILATERAL LOSSES

1.  FM systems § Personal or soundfield § Works well for elementary grades

2.  Preferential classroom seating 3.  Counsel it away 4.  Hearing aids

§ 50% parents report “never” wearing it (Davis et al 2004) 5.  CROS 6.  BAI

UHL TREATMENTS

AUDIOLOGIC CANDIDACY CRITERIA (p 12) Recommendations for Determining Candidacy 1. Children with aidable unilateral hearing loss should be considered candidates for amplification in the impaired ear due to evidence for potential developmental and academic delays. Children with unilateral hearing loss are at greater risk than children with normal hearing for speech and language delays and academic dif ficulties. For children with severe or profound unilateral hearing losses and normal hearing in the other ear, Contralateral Routing of Signal (CROS) or bone conduction devices may be considered depending on the child’s age and ability to control their environment. Currently there is a paucity of data available to inform these decisions.


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PRINCIPLES UNDERLYING EFFECTIVE AMPLIFICATION (pp14-16) Uni lateral Hearing Loss Contralateral routing of the signal (CROS) and Bilateral routing of the signal (BICROS) fittings are specially designed for patients having either 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 FM system with the wireless remote microphone receiver portion coupled to the open, good ear may be preferable in classroom situations to the CROS arrangement to give the benefit of increased signal to noise ratio, a benefit in a noisy classroom. The transcranial CROS is an option for individuals who have no auditory response in one ear. In this configuration, a powerful hearing aid is fit to the non-responsive ear so interaural attenuation is overcome and sound is perceived by the functioning cochlea. This is not a common fitting for children and again, an appropriately fit assistive l istening device may be a better communication solution in the classroom. The osseointegrated hearing device described earlier also can be used as an implanted transcranial CROS; evidence supporting benefit of this arrangement in children is l imited.


•  Shapiro 1997 Archives of Otolaryngology •  10 children (7 to 17 years) fit with CROS •  Results based on teacher report and parent report (how much use?

Was child forced to use it?) •  7 of 10 children were considered successful with CROS

•  Kenworthy 1990 Ear & Hearing §  Speech recognition abilities of children with unilateral SNHL – goal §  Compared unaided; CROS and personal FM §  FM system was the only audiological recommendation that did not

produce a marked reduction in speech recognition in at least one listening environment

•  Updike 1994 JAAA •  6 children amplification and CROS did not improve speech

understanding in noise and had detrimental results in noisy situations.

CROS

¡ Is anyone really doing this? ¡ Why are we doing it? ¡ Does it really work? ¡ How do you know if it really works? ¡ Do these kids really wear that? ¡ Is this a one hit wonder?

BAHA & SSD

•  CHL or SNHL – unaidable by traditional amplification options

•  Normal ear must be NORMAL and without known risk or progression

•  Testing using “power” device coupled to a metal headband

•  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.

SSD GUIDELINES

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¡  Speech in noise testing §  Testing with and without noise §  Hearing in Noise Test (HINT) (Nilsson, Soli, and Sullivan, 1994);

Words in Noise (WIN) (Wilson, 2003; Wilson and Burks, 2005); QuickSIN (Etymotic Research, 2001; Killion et al., 2004), Bamford-Kowal-Bench SIN (BKB-SIN) (Etymotic Research, 2005; Bench, Kowal, and Bamford, 1979; Niquette et al., 2003).

¡  Outcome Measures

§  Use testing that looks at “listening skills” also not just “hearing” §  CHILD (5 to 12 year olds) §  SSQ (13 years and older) §  LIFE

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

¡  Speech in noise § Body parts § WIPI § SRT/SAT § Spondee Picture Cards

¡  Outcome Measures § Must be parent measures § SLP evaluations

¡ 17 Y 6M female § Normal hearing left ear; Profound (no response) right ear § Seen yearly to monitor loss § In office trial and testing § Single stage surgery

SSD CASE 1

Pre-implant Testing

¡ HINT § +10 SNR = 100% § +5 SNR = 100% § 0 SNR = 68% § - 5 SNR = 23%

¡ SSQ

§ Speech = 4.29 § Spatial = 1.47 § Quality = 5.61

Post Implant Testing


¡ SSQ § Speech = 9.07 § Spatial = 9.06 § Quality = 8.89

SSD CASE 1

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¡ 13 year old female

§ Normal hearing right ear § Profound left ear – absent VIIIth nerve § Yearly monitor of hearing loss

SSD CASE 2

Pre-implant Testing

¡ HINT § +10 SNR = 79% § +5 SNR = 60% § 0 SNR = 23%

¡ SSQ


3 Months Post Implant


¡ SSQ


SSD CASE 2

1.  Catch Phrases § Congenital § Cannot benefit from traditional amplification

2.  Show HINT and CHILD/SSQ scores § Everyone gets percentages

3. Provide the data

SSD REIMBURSEMENT

¡  Average scores for all 26 subjects

¡  Pre-Implant

0 SNR = 41% +5 SNR = 76% +10 SNR = 95%

¡  Post-Implant 0 SNR = 82% +5 SNR = 97% +10 SNR = 99%

HINT RESULTS

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Scores 1 to 10 on 15 situations Average scores for all 25 subjects Parent Version Pre-Implant = 4.58 Child Version Pre-Implant = 4.50

Parent Version Post-Implant = 7.19 Child Version Post-Implant = 7.24

CHILD RESULTS

¡  Christensen, Richter, Dornhoffer (2010). Update on bone-anchored hearing aids in pediatric patients with profound unilateral sensorineural hearing loss, Archives of Otolaryngology , 136(2): 175-177.

¡  Christensen L, Dornhoffer JL, Bone-Anchored Hearing Aids for Unilateral Hearing Loss in Teenagers, Otology Neurotology, 2008;29:1120-1122.

SSD DATA

¡ SSQ Pre-Implant (N=9)

Speech = 4.20 Spatial = 2.41 Quality = 5.40

¡ SSQ Post-Implant 3 months (N=9) Speech = 7.87 Spatial = 6.60 Quality = 7.70

UNPUBLISHED SSQ RESULTS

UNILATERAL CHL

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¡ 16 year old male

§ Atresia right ear; Normal hearing left ear

UNILATERAL CHL CASE

Pre-implant Testing


¡ SSQ


3 months


¡ SSQ


UNILATERAL CHL CASE

THE FUTURE: SSD AND BAI

¡  Prosper Meniere Society Meeting, Austr ia §  Japan §  Adults only

¡  Audiology Today, Jennifer Torres & Daniel Zeit ier, September/October 2013

§  10 year old with UHL “By al l accounts, the patient was noted to be a bright student and was not having any noticeable trouble hearing in the classroom, in af ter school or social activ it ies, or in the home. In fact, the patient repor ts that many of her fr iends didn’t real ize she had hearing loss unti l she decided to tel l them “so they would not think I was ignoring them.” However, her family admits they made some signif icant l i festyle modifications to adapt to the patient’s UHL as well as to preserve the hearing she had lef t ( i .e. , infrequent restaurant dining, no l ive spor t ing 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 per form any better with the CI than she did with the CROS or the BAI during preoperative test ing condit ions.

¡  However subjectively the patient greatly preferred the CI

WHAT ABOUT COCHLEAR IMPLANTS?

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¡ Cochlear malformations ¡ Absent VIII nerves

WILL WE STILL NEED BAI FOR SSD?

COMPLICATIONS

¡ Retrospective study on extrusion rate ¡ 57 children ¡ 20 adults ¡ 3mm and 4mm implants used ¡ Mean age

§ 12 years 3 months for the children § 52 years for the adults

COMPLICATIONS

¡ Complication rates in Arkansas

§ 21% for children

COMPLICATIONS

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§ Young age § Syndromic status § Possible failure to penetrate the inner cranium § Soft tissue infections § Local trauma

§ 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.

COMPLICATIONS

¡ SSD and CI ¡ Softbands will remain… ¡ Complications ¡ New Technology

FUTURE

MMH14004: Audiology Amplification

11/2/2013University of California San Francisco

City, StateName

Registrant ListUCSF OCME Page 1 of 3

1 Santa Rosa, CAAldred Joyce E.

2 HAD Palo Alto, CAAma Lais

3 Napa, CAAmornpongchai Aunyaporn

4 AuD Ukiah, CAAndrus Gary Wyatt

5 MA Porterville, CAApilado Benjamin

6 PhD Fresno, CAArnst Dennis

7 MS Palo Alto, CAAshley Debra

8 MA Vallejo, CAAthey Joseph T.

9 AuD Davis, CABarga Patrick

10 PhD Danville, CABarrett Jillian G.

11 Sacramento, CABarry Michelle

12 AuD Redding, CABass Roberta

13 AuD Menlo Park, CABaxter Jane H.

14 PhD Hollister, CABelt Donald

15 MS, CCC-A Salinas, CABenko Kay Lynn

16 PhD Iowa City, IABentler Ruth

17 Gold River, CABigler Stephanie

18 San Francisco, CABillheimer Kenneth

19 AuD San Bruno, CABlazek Barbara L.

20 MA Petaluma, CABurt Phyllis J.

21 AuD Chico, CAChalmers Crystal L.

22 MD, FACS San Francisco, CACheung Steven W.

23 AuD Little Rock, ARChristensen Lisa V.

24 AuD Los Altos, CAClark Debbie

25 MS Oakland, CACohen Beth R.

26 MA Santa Rosa, CAConley Judith

27 AuD Alameda, CACrookston Ray G.

28 AuD San Jose, CADias Maria M.

29 MD Bainbridge Island, WADonohue Sally Jo

30 AuD Napa, CADuguay Brian

31 PhD San Francisco, CADundas Drew

32 AuD Greenbrae, CADundas Lisa

33 MD Emeryville, CAEpter David D.

34 Huntington Beach, CAEverson Megan Greenya

35 E. Palo Alto, CAEwing Kelly

36 Santa Rosa, CAFellores Jayme

37 MA Walnut Creek, CAFitzgibbons Gregory

38 Walnut Creek, CAFitzgibbons Valerie

City, StateName


39 MD Peoria, AZFitzke Jeanette

40 San Diego, CAFitzsimmons Nelson

41 San Diego, CAFlowers Jeremy

42 Palo Alto, CAGholami Honey

43 Oceano, CAGibson Keiko

44 San Jose, CAGriffin Cari

45 San Francisco, CAGriffin Michelle

46 Sacramento, CAHanson Judy

47 Los Altos, CAHarrigan Erin

48 San Diego, CAHarris Caton A

49 MED, CCC/A Saratoga, CAHavard Joan

50 Walnut Creek, CAHavard Jovina

51 Elk Grove, CAHightower Nichole M.

52 Montcenis, FranceHoche Antoine

53 PhD Nashville, TNHornsby Benjamin

54 PhD Penngrove, CAJarvis John

55 Sacramento, CAJohnston Laura

56 AuD Novato, CAJoseph Michal

57 Eureka, CAKelly Julie

58 MA Santa Clara, CAKhetrapal Tara F.

59 San Jose, CAKinder Molly

60 Sacramento, CAKnudsen Kimberly

61 San Francisco, CALampert Jeffrey

62 MA Stanford, CALarky Jannine

63 San Francisco, CALee Shui-lan

64 AuD Menlo Park, CALim Shu-En

65 MA Yuba City, CALind Richard C.

66 AuD Menlo Park, CALisi Margaret

67 San Francisco, CALittle Heather

68 AuD Oakley, CALooper Louis (Tony)

69 Oakland, CAMakeig Heidi

70 AuD San Mateo, CAMarculescu Rebecca

71 AuD Davis, CAMcNamara Betty L.

72 MD Los Osos, CAMolin Lisa

73 San Jose, CAMontgomery Pat

74 Salinas, CAMoore Dawn

75 San Jose, CAMusko Sally

76 AuD San Jose, CANelson Amy

77 AuD Palo Alto, CANovick Marni

78 AuD Fremont, CAOza Kalindi

79 AuD Shingle Springs, CAPayne Lonnie Mark

80 MA Rancho Murieta, CAPepin Nancy T.

City, StateName


81 Travis AFB, CAPerro Jamie

82 MA Napa, CAPfau Elly

83 AuD, MS, CCC-A San Francisco, CAPolite Colleen

84 Palo Alto, CAPrice Melissa

85 MD San Mateo, CAPumford John

86 AuD Los Altos, CARaguskus Brook

87 AuD Santa Clara, CARammaha Haifa A.

88 Salinas, CARamsey Robin

89 AuD Carmichael, CAReed Analisa

90 AuD Larkspur, CAReilly Kathy

91 Chico, CARoot Allison Townsend

92 AuD Santa Clara, CASanchez Keleigh

93 MS Napa, CASchreuder Wendy

94 Napa, CASchwaderer Nonie

95 MA San Francisco, CAShalles Jennifer L.

96 MA Algodones, NMSimpson Roberta J.

97 MS Alameda, CASliheet Jane T.

98 Hercules, CASostarich Mary E

99 MA Amador City, CASpencer Raymond E.

100 San Francisco, CAStong Mont

101 BSC Harbor City, CASturm Arthur G.

102 PhD San Francisco, CASweetow Robert W.

103 MS San Francisco, CATannenbaum Melissa

104 Fresno, CAToney Ronald Eugene

105 AuD San Carlos, CATu Clara

106 San Rafael, CAWeissman Lee

107 AuD Mill Valley, CAWill Toni

108 Sacramento, CAWilliams Kelle P

109 MA Benicia, CAWright Lorna

110 AuD San Francisco, CAYee Jenny

111 MS Davis, CAZiarati Roya

111Total Number of Attendees for MMH14004:

Documents

UCSF CME · Table of Contents . Educational Objectives ....................................................................................................... 5 . Accreditation