October 11, 2022 • 23 mins
This is the 2nd episode of the miniseries dedicated to hearing aid fitting standards. In these podcasts we’re reflecting on the Audiology profession’s commitment to providing evidence-based clinical practises that lead to optimal patient outcomes.
Julia van Huyssteen is joined once again by Dr Gus Mueller, a US based consultant for WSAudiology and Founder of the American Academy of Audiology.
In this episode we talk about pre-fitting considerations including ‘self assessment pre-fitting questionnaires’, ‘uncomfortable loudness levels’, speech recognition tests and ‘speech in noise’ tests. We discuss why they are important, what factors to consider when choosing the test for the patient in front of you and how to incorporate the results into your hearing aid fitting.
Read more about Gus: www.gusmueller.net
Sounding It Out has been produced by Annie Day. A Fresh Air Production for Signia.
See omnystudio.com/listener for privacy information.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Julia van Huyssteen (00:09):
Welcome back to Sounding It Out, a new podcast series
brought to you by Signia UK & Ireland. I'm Julia van
Huyssteen, the Head of Audiology at Cigna. This is the
second of a three- part miniseries about hearing- aid fitting
standards. If you missed part one, you can go back
and download it for free from your podcast provider. Let's
welcome back audiology expert Dr. Gus Mueller. Thanks once again
(00:31):
for your time.
Dr. Gus Mueller (00:33):
Thank you. It's nice to be back. Your life's been going okay
since our last one?
Julia van Huyssteen (00:37):
Absolutely, yes.
Dr. Gus Mueller (00:40):
Oh, good. Good.
Julia van Huyssteen (00:40):
I'm delighted to say that we are also being watched
by a live audience, so welcome to you all, and
we'd love to hear if you've got any questions. So
Dr. Mueller, just before I ask our first question, I'm
just going to explain to the audience that the hearing-
aid fitting standards you've helped put together in the States
last year is divided into 15 standards. The first half
focuses on documentation and communicating with your patient as well
(01:02):
as some pre- fitting standards. Today, for this episode, we
will concentrate on three pre- fitting assessments, which should make,
actually, for quite interesting discussion. So we'll be looking at pre-
fitting self- assessments, UCLs or ULLs, and also, speech- in-
noise testing. So Dr. Mueller, let's start with reasons to
(01:23):
use pre- fitting self- assessment scales. And with this, I
mean any type of questionnaire completed by the patient prior
to the hearing aid fitting. Can you please list a
few areas where self- assessment pre- fitting tests may be
useful for the overall hearing- aid fitting process?
Dr. Gus Mueller (01:40):
Oh, wow. There's a lot of them. I guess just
to define what we're talking about here, this would be
a self- assessment scale that the person would complete a
lot of times. Well, I shouldn't say a lot of
times. Some of the times, they're actually mailed to the
patient in advance. Other times, they're completed in the waiting
room. Most of them can be done on an iPad
(02:01):
today. So it's a simple scale. The usefulness is really
twofold. The first is there's normative data, so you know
how your patient compares to other patients with similar types
of hearing loss. A second reason that they're useful is
if you have a pre- fitting measure, this then down
(02:22):
the road gives you a very easy way to determine
if the hearing- aid fitting has been successful, because most
of these scales, they can be administered before the hearing-
aid fitting, and again after the fitting, and you can
determine benefit. The third reason of doing these scales is...
Just think of it as a very good case history.
(02:44):
We all probably have a history form, but sometimes we
get a little lazy in going through all the questions.
These scales certainly give you a good background of what
the patient's doing, and they actually can predict, in some
cases, who might benefit with hearing aids. A good example
(03:06):
is a scale that I think is actually used here,
which is the HHIE. It was developed in the US,
but it's pretty popular around the world. A very easy
test to do. There are data that show that the
HHIE is as good or better at predicting who will
benefit from hearing aids than the audiogram, simply because it
tells you if the patient is buying into having a
(03:29):
hearing loss, which of course is critical for it to
be successful. So this is information that one easily can
gather before the actual fitting, and makes your life much
easier when you're then going down the road of selecting
hearing aids.
Julia van Huyssteen (03:43):
You've actually answered my next question. I was going to
say, what are your thoughts on using a validated self- assessment
questionnaire versus a good set of open- ended questions? But
I think what I've heard from your answer is it's
about having that normative data for you to compare your
patient with, and it's also about being able to show
improvement from where we are today.
Dr. Gus Mueller (04:00):
Yeah, and the one thing I could add relative to that
is that you wouldn't want to use two scales that
measure the same thing. So you would want to pick
your scales carefully. This is then when you ask, " What
scales would you pick?"
Julia van Huyssteen (04:13):
Mm- hmm.
Dr. Gus Mueller (04:14):
Okay, good. Because that's what I want to answer. So
here's what I'd pick. I think the HHIE is great
because it tells you the emotional and social feelings of
the person about their hearing loss. I would pick something
like the APHAB, the Abbreviated Performance of Hearing Aid Benefit
because it tells you how well the person is actually
(04:34):
doing out in the real world for listening in quiet,
listening in reverberation, listening in background noise, and aversiveness to
loud sounds, as a second scale. And then I would
pick three. Three's enough, I think. The third scale would
be, of course, the famous COSI
Julia van Huyssteen (04:54):
Improvement.
Dr. Gus Mueller (04:54):
Improvement. Thank you. Thank you. Developed by Harvey Dillon. I
remember Harvey Dillon got an award in one of the
journals in the US. It was written up that the main
reason he was getting this award was for development of
the COSI, which is a blank piece of paper. Wow,
that's a cool way to get an award. Harvey, obviously,
has done tons and tons of important research, but including
(05:16):
the COSI. The COSI is good because it's like a
contract that you develop with the patient, and it's very
personal. So the problem with some self- assessment scales is
it asks questions that have nothing to do with that
person, where the COSI is designed for that person. It's
a contract that you develop with that person and the
(05:37):
agreement is, " Okay, Bob, these are the four areas where
you're having trouble. You know what I'm going to do?
I'm going to help you in all four of those
areas, and we're going to meet in a couple of
weeks and make sure that I'm doing my job." And
so to me, that's just critical information to have before
you ever get into fitting the hearing aids.
Julia van Huyssteen (05:56):
And hand in hand with that information, or building that picture up
with your patient, goes that critical thing about building rapport
with your patients. And this is where you really form
that relationship with them and the trust, because you listen
to what's important to them. And of course, COSI part
two then moves on to measuring where you were at
the start of your journey to where you end up.
So we've got that validated piece to the COSI two.
Dr. Gus Mueller (06:19):
Another tip that I used to use when I was
in private practice is after the person filled out their
COSI, I would actually have them rate their expectations, and
that gave you a good idea of where you were
going with this fitting, and hopefully you could meet those expectations.
Julia van Huyssteen (06:35):
Perfect. So the next focus for our episode is about
a particular pre- assessment that isn't actually performed routinely, and
that is frequency- specific UCLS or URLs, Uncomfortable Loudness Levels.
So my first question about this is what do you
think are the reasons for audiologists not performing ULLs? Do
you think it is fear of causing discomfort? Do you
(06:57):
think it takes too long? Or is it perhaps this
loudness variability that we see amongst individuals, so what's maybe
too loud to you may not be too loud to
the next person? What do you think it is?
Dr. Gus Mueller (07:08):
Well, for starters, what you just said at the end
is actually the very reason why we should be doing it. If
you go back and look at the largest study ever
done on LDLs... Excuse me, that's the term that I'm
used to using. It's all the same, ULLs, UCLs, LDLs. But the
largest was Ruth Bentler, which was 508 ears, and on
(07:29):
her data, you can look and say somebody who has
a 50 dB hearing loss, which is very common at
2K, we'll say, very common when you're fitting hearing aids,
their LDLs varied in her study from around 80 to 120. Okay?
So tell me you're going to predict from the audiogram?
You're going to have trouble. In fact, she went back
(07:50):
and looked at her data to see what was the (inaudible)
if you predict it, and she did then a
mean and a regression analysis and a median and all
that. The answer was that you would get it within
5 dB 30% of the time, meaning you would be wrong
70% of the time.
Julia van Huyssteen (08:08):
Wow.
Dr. Gus Mueller (08:09):
To me, that's reason enough right there that I want
to have those measurements. Part two of the answer to
your question is, unfortunately, I believe that people fitting hearing
aids think that the manufacturer will do the job for
them and set the MPO correctly. You said, why don't
some people do it? I think they have an unwarranted
(08:32):
belief that a manufacturer magically will know what the loudness
discomfort level is if that patient sitting there, who, any
given day, has a range of 40 dB.
Julia van Huyssteen (08:44):
That's crazy, isn't it, that variation? Now, moving on from
that, the next question is then
don't get it right? What happens in terms of the MPA?
What's the implications, therefore?
Dr. Gus Mueller (08:54):
Well, the thing we often talk about is make sure
that loud sounds are not too loud, but there's also
a downside of not making loud sounds loud enough, which,
interestingly, in recent years, has become more of a problem
than making it too loud. Because if we have wide
dynamic range compression on all hearing aids with a relatively
low knee- point, compression ratios of 2
(09:19):
like that, and hearing aids tend to be under- fit
gainwise, well what that'll also do then is under- fit
the output. And so you're putting a ceiling... Take a
person who has an LDL of 110. It's very probable
that the maximum output will be 80, 85. You're cheating that
(09:40):
person out of 20 dB of fun. Loud music is
fun at certain times of the day and we like
to hear it, but they're not going to hear it because
there's a ceiling there. It's never going to get there.
So that's the one side of it. The other side,
of course, is that if a person has a very
low LDL, you could be exceeding it, and how are
they going to fix that? They can't go in and
(10:01):
change their AGCO knee- points. The only way they can
fix it is turn down gain, and then they come
back to you and say the hearing aid doesn't work
because they had to turn down gain, because you made
the output too loud. So it can work either way.
It's Goldilocks and the porridge
too cold, and you eat the porridge from the little
(10:21):
bear. That's my thought.
Julia van Huyssteen (10:23):
So it seems to me that it is one of those
tests that it actually only takes what, maybe two, three
minutes to do that? But it's really quite-
Dr. Gus Mueller (10:32):
You need to do two frequencies, and on both ears
it might be five minutes.
Julia van Huyssteen (10:37):
But critical really to not cheat our patients out of
the dynamic range that they need for their hearing loss.
Dr. Gus Mueller (10:41):
Well, yeah, exactly. And you say dynamic range. It's really
critical in a sense if anybody's using the DSL prescriptive
method. The DSL calculates target by first calculating the dynamic
range and then going back and determining fitting targets. So
if one patient's LDL is 90 and another patient's LDL is 110,
(11:05):
if you enter those, the fitting targets will be different
for those two people, even though they have exactly the
same hearing loss. Because you want to fill up the
dynamic range. So gain for average is in the middle.
So if a person has a higher LDL, you'll give
them more gain for average, because everything is spread out
more from threshold to LDL. So it not only changes
(11:27):
the maximum output; it changes gain for average, which is
a good thing. That doesn't happen with the (inaudible) ,
I don't think, but you could do it on your
own, if you wanted, a little bit. If a person
has a high LDL, you could move gain for average
up a little above target. So that's yet another reason
why we need that information and enter it into the software.
Julia van Huyssteen (11:51):
So again, making that a fitting standard.
Dr. Gus Mueller (11:52):
Well, it is in the standard, yes, exactly, which I
guess is why we're talking about it. Yeah. We felt
that that was just a routine part of doing the
fitting. Again, all you need is probably two frequencies per
ear. Critical to use a loudness chart for them to
do the ratings and to use the right instructions. The
right instructions would be when it's first uncomfortable and you
(12:16):
would use an ascending method. So one of the other
things you mentioned about a fear of, " Oh, gee, it's
going to be too loud," I mean, it's going to
be too loud when they get out in the real
world using the hearing aids too, so why not fix
it in your clinic? And yes, there will be one
beeping tone that might be just a hair uncomfortable, but
it isn't like you're going to painfully loud or anything
(12:38):
like that. That's a non- issue, I think.
Julia van Huyssteen (12:40):
Yeah, exactly. So you do it very gradually and you
do it with the right instructions.
Dr. Gus Mueller (12:43):
Exactly. Exactly.
Julia van Huyssteen (12:43):
And therefore, as you say, it's only going to be for a
tiny bit in the clinic, but you do the right
setup for the hearing aid as a consequence. Okay, so
the next question is about speech recognition in noise. Now,
it is best practice, it's within the standards, but we
still don't see these done routinely. However, there are several
(13:04):
reasons why these tests are important, and that's besides the
obvious fact that speech recognition in quiet is a very
poor predictor of a patient's performance in noise. Could you please
talk our audience through some of the reasons why performing
speech recognition in noise is essential; is a standard?
Dr. Gus Mueller (13:20):
Well, I'll start with a very practical thing. Imagine if
you were going for some kind of healthcare, whatever it
might be, and you walk into your family practice doctor
and describe what the problem is, you have a problem
with your right elbow, and that practitioner never even once
looks at your elbow. That would be pretty weird. In
(13:41):
fact, you'd probably get a new practitioner. Well, let's take
it to hearing- aid fitting. The patient walks in and says, "
Hey, doc, my problem is understanding in background noise." And
you know what? A lot of people never test them
in background noise. That's pretty weird. And if I'm that
patient, I'm going to say, " I'm going to go to
somebody who actually tests me in background noise, because that's
(14:02):
what my problem is. I don't have a problem mirroring
tones. In fact, there's no tones in my house anywhere."
So from a very practical standpoint, it gives you immediately
a tie- in with the patient. They walk in complaining
of a problem. You test to see if they really
have that problem. It's also, along those same lines, a
great way to find what is so- called hidden hearing
(14:24):
loss. The fact is, they aren't hidden. They're only hidden
because we aren't doing the right tests. Now, maybe some
of them are, but there's considerable data to show that
many of these people who have normal audiograms do indeed
have problems understanding speech in background noise. It's a legitimate
complaint. It's not like they're just strange or they're whiny
(14:45):
or whatever the case may be. They have a legitimate
problem, but we need to do the testing. Now, directly
related to the hearing- aid fitting itself, where it really
is essential, is for counseling purposes. I'm not sure it's
going to change your fitting tremendously, because regardless if their
speech recognition in noise is good or if it's bad,
(15:08):
we're still going to fit them with directional and noise
reduction and all these kind of things. That's the way we
do business today. But it gives us a lot of
information relative to counseling. You have two patients
an SRT... I'll call it SRT 50, where they're getting 50%
correct of words in background noise. One of them has
(15:28):
a score of + 2 and the other one has a
score of + 12. They both come back and complain of
problems in background noise. I'd be really concerned about the
guy with + 2. The guy with + 12, I would expect
it, and I probably would have told him that before,
because the average restaurant or pub is about + 5. Well,
(15:49):
if he needs it up at + 12, he's not going
to do well, not with the best directional technology. He's
going to need a remote mic. The person who's + 2,
I got some work to do and I'm going to start thinking, " Okay, what went
wrong? Did I need to change something in programming? Is
he going into a restaurant that's 0 dB?" It's very
(16:10):
useful for counseling, and that's the main reason, I think.
Julia van Huyssteen (16:13):
Absolutely, and I think going back to your example of +
2 versus + 2, when somebody comes back really struggling with +
2 and you think that you've set the hearing aids
up as best as you can, that to me would
be a trigger to think, " What else? Do I need
to do some more testing? Do I need to do
maybe some more word recognition scores, see if there's some
(16:34):
roll off? Is there retrocochlear? What else is going on here?"
Dr. Gus Mueller (16:37):
Or did they just get their Visa card bill, which
also brings them back sometimes? But yeah, there's a lot
of things that go on. Yeah, it changes the whole picture of that
particular patient.
Julia van Huyssteen (16:48):
Absolutely. So my next question is about speech testing in
noise. There's a lot of variables when we talk about
this. We're talking words versus sentences; the type of competing
noise that we use; considering adaptive versus fixed signal- to-
noise ratio, just to name a few. So I know
for your everyday audiologist, this can get really quite complex.
(17:10):
Do you have any specific recommendations for our audience how
to keep speech in noise testing as simple as possible?
Dr. Gus Mueller (17:15):
Sure. Well, first of all, I realize that these tests
are somewhat country- and language- specific, and so I can
really only say what we're doing in the US, other
than to say that the HINT, hearing in noise test,
has been translated, I think, into 22 different languages. I
don't know if that's commonly used here. It is not
(17:37):
commonly used in the US, I might say, except in
research. A test that has gained popularity over the past
20 years is something called the QuickSIN. Partly, who doesn't
like the word quick, if you're a busy clinician? And
it is fairly quick. The other nice thing about it
is that the SNRs are prerecorded so you don't have
to fiddle around and try to set things at + 5, +
(18:00):
10, 0 and that. It's all prerecorded on the file
that you would get, which now on most audiometers, the
QuickSIN file comes along. It used to be you had
to have the CD and the CD attachment, but now
the QuickSIN file, I think, is on most computer- based
audiometers these days. So relative to what you're saying about
(18:20):
fixed versus variable and all that, that is an issue
where some people might just take a given test that
was designed to be administered in quiet and present it at
a fixed SNR. The problem then is it might be
too difficult for some people and too easy. You might
get people scoring too well, and that's not what you
want. You want to differentiate people. So I think an
(18:42):
adaptive test works very well. The QuickSIN is indeed an
adaptive test because it tests at six different SNRs, and
then you do some averaging when you score it. The
QuickSIN is actually scored not an SRT 50, but an
SNR loss. The way Mead Killion designed it is... Well,
because normal- hearing people do not score 100% on this.
(19:03):
So the test then means how different is this person's
score than somebody with normal hearing? So if you had
an SNR loss of 5, that means that you need
the signal- to- noise ratio 5 dB better to someone
with normal hearing to perform the same as them. It's
an easy test to give, easy test to score, and
(19:24):
I would say it's the most commonly used in the
US for clinicians. There are certainly other good ones. Coming
out of Oldenberg, Germany is a test that's gaining steam.
It is called the Matrix Test, and it gives you
scores you can pick. Do you want an SRT 50, SRT 80? It's computerized,
very easy to use. I think that test will become
(19:47):
more popular as it becomes more commercially available. And that's
the Matrix. Some people just call it the Oldenberg Speech
Test, or it used to be called ELSA, OLSA?
Julia van Huyssteen (20:00):
Yes, I've heard that. Oldenberg SATS or something like that.
Dr. Gus Mueller (20:00):
Yeah. But because now it's being used in, I think,
12 different countries, I think it's called the Matrix Test.
So that would be another one to look into.
Julia van Huyssteen (20:08):
So you mentioned about the different languages there too. Something
worth mentioning is that we need to be mindful of
accents too. So sometimes we get patients that come into
the clinic and one of the first things they say is, "
I struggle in background noise. I struggle with accents." And
I know that some of these tests do have quite
heavy accents. The QuickSIN, for example, has quite a strong
American accent, but it's been standardized for use in the
(20:28):
UK. So going back to the basics, isn't it? Counsel
your patients about what to expect.
Dr. Gus Mueller (20:33):
And I don't follow that literature a lot, but I
mean, it wouldn't be that hard to norm the QuickSIN
on different types of English. You're right. It could be
that scores SNR loss of 4 here might not be
as bad as an SNR loss of 4 in the
US. I don't know. I haven't really looked at that.
But that's always a concern.
Julia van Huyssteen (20:55):
Yeah, yeah. And I think it's just about that point that
you made about standardization. As long as we know that it's
been standardized for our population, which it has been, it's
a very easy, quick, as you said, quick- to- use
test. So my next question is, you've talked about a
few there. You talked about the QuickSIN, you talked about
the HINT, the Oldenberg. Have we got any evidence on how
closely the results of all these different speech in noise
(21:17):
tests correlate, meaning, can we be confident in the accuracy
with whichever tests we use? Do they correlate at all?
Dr. Gus Mueller (21:25):
Well, they do turn out fairly similar, and there has
been some limited studies. I recall Rich Wilson from the
US, he has a test that he developed called the
Words In Noise, the WIN. He compared the HINT to
the QuickSIN, to the WIN. The same people took all three
tests. And as you would guess, if you do poorly
in one, you'll do poorly in the other. They differed,
(21:48):
I think, when you looked at means; they differed by
about 3 dB. You would use that when you interpret.
So that's really not an issue. You wouldn't use the
same norm. They each have their own norms. I think
the general idea is, is this person close to normal
or are they quite a ways from normal? And any
of these tests, I think, will give you that answer.
(22:09):
It's just the act of doing them was where the
problem was.
Julia van Huyssteen (22:11):
Great. That's really good to hear. So thank you very
much, Dr. Mueller, for another very insightful discussion on hearing-
aid fitting standards. Today we talked about a few pre-
assessments, and we often think we follow the golden rules,
but sometimes we don't. So it was really good to
(22:32):
remind ourselves of some of the reasons why hearing- aid
fitting standards should exist. We'd love to start a conversation
on this, so if you have any comments to share,
get in touch via the links on the episode page.
Please join us for our third episode about hearing- aid
fitting standards, and in the meantime, remember you can find
really useful links on the episode page. If you found
(22:52):
these episodes useful, we'd love it if you could share
it with your friends and colleagues so as many people
as possible benefit from Dr. Mueller's expertise.
Welcome back to Sounding It Out, a new podcast series
brought to you by Signia UK & Ireland. I'm Julia van
Huyssteen, the Head of Audiology at Cigna. This is the
second of a three- part miniseries about hearing- aid fitting
standards. If you missed part one, you can go back
and download it for free from your podcast provider. Let's
welcome back audiology expert Dr. Gus Mueller. Thanks once again
(00:31):
for your time.
Dr. Gus Mueller (00:33):
Thank you. It's nice to be back. Your life's been going okay
since our last one?
Julia van Huyssteen (00:37):
Absolutely, yes.
Dr. Gus Mueller (00:40):
Oh, good. Good.
Julia van Huyssteen (00:40):
I'm delighted to say that we are also being watched
by a live audience, so welcome to you all, and
we'd love to hear if you've got any questions. So
Dr. Mueller, just before I ask our first question, I'm
just going to explain to the audience that the hearing-
aid fitting standards you've helped put together in the States
last year is divided into 15 standards. The first half
focuses on documentation and communicating with your patient as well
(01:02):
as some pre- fitting standards. Today, for this episode, we
will concentrate on three pre- fitting assessments, which should make,
actually, for quite interesting discussion. So we'll be looking at pre-
fitting self- assessments, UCLs or ULLs, and also, speech- in-
noise testing. So Dr. Mueller, let's start with reasons to
(01:23):
use pre- fitting self- assessment scales. And with this, I
mean any type of questionnaire completed by the patient prior
to the hearing aid fitting. Can you please list a
few areas where self- assessment pre- fitting tests may be
useful for the overall hearing- aid fitting process?
Dr. Gus Mueller (01:40):
Oh, wow. There's a lot of them. I guess just
to define what we're talking about here, this would be
a self- assessment scale that the person would complete a
lot of times. Well, I shouldn't say a lot of
times. Some of the times, they're actually mailed to the
patient in advance. Other times, they're completed in the waiting
room. Most of them can be done on an iPad
(02:01):
today. So it's a simple scale. The usefulness is really
twofold. The first is there's normative data, so you know
how your patient compares to other patients with similar types
of hearing loss. A second reason that they're useful is
if you have a pre- fitting measure, this then down
(02:22):
the road gives you a very easy way to determine
if the hearing- aid fitting has been successful, because most
of these scales, they can be administered before the hearing-
aid fitting, and again after the fitting, and you can
determine benefit. The third reason of doing these scales is...
Just think of it as a very good case history.
(02:44):
We all probably have a history form, but sometimes we
get a little lazy in going through all the questions.
These scales certainly give you a good background of what
the patient's doing, and they actually can predict, in some
cases, who might benefit with hearing aids. A good example
(03:06):
is a scale that I think is actually used here,
which is the HHIE. It was developed in the US,
but it's pretty popular around the world. A very easy
test to do. There are data that show that the
HHIE is as good or better at predicting who will
benefit from hearing aids than the audiogram, simply because it
tells you if the patient is buying into having a
(03:29):
hearing loss, which of course is critical for it to
be successful. So this is information that one easily can
gather before the actual fitting, and makes your life much
easier when you're then going down the road of selecting
hearing aids.
Julia van Huyssteen (03:43):
You've actually answered my next question. I was going to
say, what are your thoughts on using a validated self- assessment
questionnaire versus a good set of open- ended questions? But
I think what I've heard from your answer is it's
about having that normative data for you to compare your
patient with, and it's also about being able to show
improvement from where we are today.
Dr. Gus Mueller (04:00):
Yeah, and the one thing I could add relative to that
is that you wouldn't want to use two scales that
measure the same thing. So you would want to pick
your scales carefully. This is then when you ask, " What
scales would you pick?"
Julia van Huyssteen (04:13):
Mm- hmm.
Dr. Gus Mueller (04:14):
Okay, good. Because that's what I want to answer. So
here's what I'd pick. I think the HHIE is great
because it tells you the emotional and social feelings of
the person about their hearing loss. I would pick something
like the APHAB, the Abbreviated Performance of Hearing Aid Benefit
because it tells you how well the person is actually
(04:34):
doing out in the real world for listening in quiet,
listening in reverberation, listening in background noise, and aversiveness to
loud sounds, as a second scale. And then I would
pick three. Three's enough, I think. The third scale would
be, of course, the famous COSI
Julia van Huyssteen (04:54):
Improvement.
Dr. Gus Mueller (04:54):
Improvement. Thank you. Thank you. Developed by Harvey Dillon. I
remember Harvey Dillon got an award in one of the
journals in the US. It was written up that the main
reason he was getting this award was for development of
the COSI, which is a blank piece of paper. Wow,
that's a cool way to get an award. Harvey, obviously,
has done tons and tons of important research, but including
(05:16):
the COSI. The COSI is good because it's like a
contract that you develop with the patient, and it's very
personal. So the problem with some self- assessment scales is
it asks questions that have nothing to do with that
person, where the COSI is designed for that person. It's
a contract that you develop with that person and the
(05:37):
agreement is, " Okay, Bob, these are the four areas where
you're having trouble. You know what I'm going to do?
I'm going to help you in all four of those
areas, and we're going to meet in a couple of
weeks and make sure that I'm doing my job." And
so to me, that's just critical information to have before
you ever get into fitting the hearing aids.
Julia van Huyssteen (05:56):
And hand in hand with that information, or building that picture up
with your patient, goes that critical thing about building rapport
with your patients. And this is where you really form
that relationship with them and the trust, because you listen
to what's important to them. And of course, COSI part
two then moves on to measuring where you were at
the start of your journey to where you end up.
So we've got that validated piece to the COSI two.
Dr. Gus Mueller (06:19):
Another tip that I used to use when I was
in private practice is after the person filled out their
COSI, I would actually have them rate their expectations, and
that gave you a good idea of where you were
going with this fitting, and hopefully you could meet those expectations.
Julia van Huyssteen (06:35):
Perfect. So the next focus for our episode is about
a particular pre- assessment that isn't actually performed routinely, and
that is frequency- specific UCLS or URLs, Uncomfortable Loudness Levels.
So my first question about this is what do you
think are the reasons for audiologists not performing ULLs? Do
you think it is fear of causing discomfort? Do you
(06:57):
think it takes too long? Or is it perhaps this
loudness variability that we see amongst individuals, so what's maybe
too loud to you may not be too loud to
the next person? What do you think it is?
Dr. Gus Mueller (07:08):
Well, for starters, what you just said at the end
is actually the very reason why we should be doing it. If
you go back and look at the largest study ever
done on LDLs... Excuse me, that's the term that I'm
used to using. It's all the same, ULLs, UCLs, LDLs. But the
largest was Ruth Bentler, which was 508 ears, and on
(07:29):
her data, you can look and say somebody who has
a 50 dB hearing loss, which is very common at
2K, we'll say, very common when you're fitting hearing aids,
their LDLs varied in her study from around 80 to 120. Okay?
So tell me you're going to predict from the audiogram?
You're going to have trouble. In fact, she went back
(07:50):
and looked at her data to see what was the (inaudible)
if you predict it, and she did then a
mean and a regression analysis and a median and all
that. The answer was that you would get it within
5 dB 30% of the time, meaning you would be wrong
70% of the time.
Julia van Huyssteen (08:08):
Wow.
Dr. Gus Mueller (08:09):
To me, that's reason enough right there that I want
to have those measurements. Part two of the answer to
your question is, unfortunately, I believe that people fitting hearing
aids think that the manufacturer will do the job for
them and set the MPO correctly. You said, why don't
some people do it? I think they have an unwarranted
(08:32):
belief that a manufacturer magically will know what the loudness
discomfort level is if that patient sitting there, who, any
given day, has a range of 40 dB.
Julia van Huyssteen (08:44):
That's crazy, isn't it, that variation? Now, moving on from
that, the next question is then
don't get it right? What happens in terms of the MPA?
What's the implications, therefore?
Dr. Gus Mueller (08:54):
Well, the thing we often talk about is make sure
that loud sounds are not too loud, but there's also
a downside of not making loud sounds loud enough, which,
interestingly, in recent years, has become more of a problem
than making it too loud. Because if we have wide
dynamic range compression on all hearing aids with a relatively
low knee- point, compression ratios of 2
(09:19):
like that, and hearing aids tend to be under- fit
gainwise, well what that'll also do then is under- fit
the output. And so you're putting a ceiling... Take a
person who has an LDL of 110. It's very probable
that the maximum output will be 80, 85. You're cheating that
(09:40):
person out of 20 dB of fun. Loud music is
fun at certain times of the day and we like
to hear it, but they're not going to hear it because
there's a ceiling there. It's never going to get there.
So that's the one side of it. The other side,
of course, is that if a person has a very
low LDL, you could be exceeding it, and how are
they going to fix that? They can't go in and
(10:01):
change their AGCO knee- points. The only way they can
fix it is turn down gain, and then they come
back to you and say the hearing aid doesn't work
because they had to turn down gain, because you made
the output too loud. So it can work either way.
It's Goldilocks and the porridge
too cold, and you eat the porridge from the little
(10:21):
bear. That's my thought.
Julia van Huyssteen (10:23):
So it seems to me that it is one of those
tests that it actually only takes what, maybe two, three
minutes to do that? But it's really quite-
Dr. Gus Mueller (10:32):
You need to do two frequencies, and on both ears
it might be five minutes.
Julia van Huyssteen (10:37):
But critical really to not cheat our patients out of
the dynamic range that they need for their hearing loss.
Dr. Gus Mueller (10:41):
Well, yeah, exactly. And you say dynamic range. It's really
critical in a sense if anybody's using the DSL prescriptive
method. The DSL calculates target by first calculating the dynamic
range and then going back and determining fitting targets. So
if one patient's LDL is 90 and another patient's LDL is 110,
(11:05):
if you enter those, the fitting targets will be different
for those two people, even though they have exactly the
same hearing loss. Because you want to fill up the
dynamic range. So gain for average is in the middle.
So if a person has a higher LDL, you'll give
them more gain for average, because everything is spread out
more from threshold to LDL. So it not only changes
(11:27):
the maximum output; it changes gain for average, which is
a good thing. That doesn't happen with the (inaudible) ,
I don't think, but you could do it on your
own, if you wanted, a little bit. If a person
has a high LDL, you could move gain for average
up a little above target. So that's yet another reason
why we need that information and enter it into the software.
Julia van Huyssteen (11:51):
So again, making that a fitting standard.
Dr. Gus Mueller (11:52):
Well, it is in the standard, yes, exactly, which I
guess is why we're talking about it. Yeah. We felt
that that was just a routine part of doing the
fitting. Again, all you need is probably two frequencies per
ear. Critical to use a loudness chart for them to
do the ratings and to use the right instructions. The
right instructions would be when it's first uncomfortable and you
(12:16):
would use an ascending method. So one of the other
things you mentioned about a fear of, " Oh, gee, it's
going to be too loud," I mean, it's going to
be too loud when they get out in the real
world using the hearing aids too, so why not fix
it in your clinic? And yes, there will be one
beeping tone that might be just a hair uncomfortable, but
it isn't like you're going to painfully loud or anything
(12:38):
like that. That's a non- issue, I think.
Julia van Huyssteen (12:40):
Yeah, exactly. So you do it very gradually and you
do it with the right instructions.
Dr. Gus Mueller (12:43):
Exactly. Exactly.
Julia van Huyssteen (12:43):
And therefore, as you say, it's only going to be for a
tiny bit in the clinic, but you do the right
setup for the hearing aid as a consequence. Okay, so
the next question is about speech recognition in noise. Now,
it is best practice, it's within the standards, but we
still don't see these done routinely. However, there are several
(13:04):
reasons why these tests are important, and that's besides the
obvious fact that speech recognition in quiet is a very
poor predictor of a patient's performance in noise. Could you please
talk our audience through some of the reasons why performing
speech recognition in noise is essential; is a standard?
Dr. Gus Mueller (13:20):
Well, I'll start with a very practical thing. Imagine if
you were going for some kind of healthcare, whatever it
might be, and you walk into your family practice doctor
and describe what the problem is, you have a problem
with your right elbow, and that practitioner never even once
looks at your elbow. That would be pretty weird. In
(13:41):
fact, you'd probably get a new practitioner. Well, let's take
it to hearing- aid fitting. The patient walks in and says, "
Hey, doc, my problem is understanding in background noise." And
you know what? A lot of people never test them
in background noise. That's pretty weird. And if I'm that
patient, I'm going to say, " I'm going to go to
somebody who actually tests me in background noise, because that's
(14:02):
what my problem is. I don't have a problem mirroring
tones. In fact, there's no tones in my house anywhere."
So from a very practical standpoint, it gives you immediately
a tie- in with the patient. They walk in complaining
of a problem. You test to see if they really
have that problem. It's also, along those same lines, a
great way to find what is so- called hidden hearing
(14:24):
loss. The fact is, they aren't hidden. They're only hidden
because we aren't doing the right tests. Now, maybe some
of them are, but there's considerable data to show that
many of these people who have normal audiograms do indeed
have problems understanding speech in background noise. It's a legitimate
complaint. It's not like they're just strange or they're whiny
(14:45):
or whatever the case may be. They have a legitimate
problem, but we need to do the testing. Now, directly
related to the hearing- aid fitting itself, where it really
is essential, is for counseling purposes. I'm not sure it's
going to change your fitting tremendously, because regardless if their
speech recognition in noise is good or if it's bad,
(15:08):
we're still going to fit them with directional and noise
reduction and all these kind of things. That's the way we
do business today. But it gives us a lot of
information relative to counseling. You have two patients
an SRT... I'll call it SRT 50, where they're getting 50%
correct of words in background noise. One of them has
(15:28):
a score of + 2 and the other one has a
score of + 12. They both come back and complain of
problems in background noise. I'd be really concerned about the
guy with + 2. The guy with + 12, I would expect
it, and I probably would have told him that before,
because the average restaurant or pub is about + 5. Well,
(15:49):
if he needs it up at + 12, he's not going
to do well, not with the best directional technology. He's
going to need a remote mic. The person who's + 2,
I got some work to do and I'm going to start thinking, " Okay, what went
wrong? Did I need to change something in programming? Is
he going into a restaurant that's 0 dB?" It's very
(16:10):
useful for counseling, and that's the main reason, I think.
Julia van Huyssteen (16:13):
Absolutely, and I think going back to your example of +
2 versus + 2, when somebody comes back really struggling with +
2 and you think that you've set the hearing aids
up as best as you can, that to me would
be a trigger to think, " What else? Do I need
to do some more testing? Do I need to do
maybe some more word recognition scores, see if there's some
(16:34):
roll off? Is there retrocochlear? What else is going on here?"
Dr. Gus Mueller (16:37):
Or did they just get their Visa card bill, which
also brings them back sometimes? But yeah, there's a lot
of things that go on. Yeah, it changes the whole picture of that
particular patient.
Julia van Huyssteen (16:48):
Absolutely. So my next question is about speech testing in
noise. There's a lot of variables when we talk about
this. We're talking words versus sentences; the type of competing
noise that we use; considering adaptive versus fixed signal- to-
noise ratio, just to name a few. So I know
for your everyday audiologist, this can get really quite complex.
(17:10):
Do you have any specific recommendations for our audience how
to keep speech in noise testing as simple as possible?
Dr. Gus Mueller (17:15):
Sure. Well, first of all, I realize that these tests
are somewhat country- and language- specific, and so I can
really only say what we're doing in the US, other
than to say that the HINT, hearing in noise test,
has been translated, I think, into 22 different languages. I
don't know if that's commonly used here. It is not
(17:37):
commonly used in the US, I might say, except in
research. A test that has gained popularity over the past
20 years is something called the QuickSIN. Partly, who doesn't
like the word quick, if you're a busy clinician? And
it is fairly quick. The other nice thing about it
is that the SNRs are prerecorded so you don't have
to fiddle around and try to set things at + 5, +
(18:00):
10, 0 and that. It's all prerecorded on the file
that you would get, which now on most audiometers, the
QuickSIN file comes along. It used to be you had
to have the CD and the CD attachment, but now
the QuickSIN file, I think, is on most computer- based
audiometers these days. So relative to what you're saying about
(18:20):
fixed versus variable and all that, that is an issue
where some people might just take a given test that
was designed to be administered in quiet and present it at
a fixed SNR. The problem then is it might be
too difficult for some people and too easy. You might
get people scoring too well, and that's not what you
want. You want to differentiate people. So I think an
(18:42):
adaptive test works very well. The QuickSIN is indeed an
adaptive test because it tests at six different SNRs, and
then you do some averaging when you score it. The
QuickSIN is actually scored not an SRT 50, but an
SNR loss. The way Mead Killion designed it is... Well,
because normal- hearing people do not score 100% on this.
(19:03):
So the test then means how different is this person's
score than somebody with normal hearing? So if you had
an SNR loss of 5, that means that you need
the signal- to- noise ratio 5 dB better to someone
with normal hearing to perform the same as them. It's
an easy test to give, easy test to score, and
(19:24):
I would say it's the most commonly used in the
US for clinicians. There are certainly other good ones. Coming
out of Oldenberg, Germany is a test that's gaining steam.
It is called the Matrix Test, and it gives you
scores you can pick. Do you want an SRT 50, SRT 80? It's computerized,
very easy to use. I think that test will become
(19:47):
more popular as it becomes more commercially available. And that's
the Matrix. Some people just call it the Oldenberg Speech
Test, or it used to be called ELSA, OLSA?
Julia van Huyssteen (20:00):
Yes, I've heard that. Oldenberg SATS or something like that.
Dr. Gus Mueller (20:00):
Yeah. But because now it's being used in, I think,
12 different countries, I think it's called the Matrix Test.
So that would be another one to look into.
Julia van Huyssteen (20:08):
So you mentioned about the different languages there too. Something
worth mentioning is that we need to be mindful of
accents too. So sometimes we get patients that come into
the clinic and one of the first things they say is, "
I struggle in background noise. I struggle with accents." And
I know that some of these tests do have quite
heavy accents. The QuickSIN, for example, has quite a strong
American accent, but it's been standardized for use in the
(20:28):
UK. So going back to the basics, isn't it? Counsel
your patients about what to expect.
Dr. Gus Mueller (20:33):
And I don't follow that literature a lot, but I
mean, it wouldn't be that hard to norm the QuickSIN
on different types of English. You're right. It could be
that scores SNR loss of 4 here might not be
as bad as an SNR loss of 4 in the
US. I don't know. I haven't really looked at that.
But that's always a concern.
Julia van Huyssteen (20:55):
Yeah, yeah. And I think it's just about that point that
you made about standardization. As long as we know that it's
been standardized for our population, which it has been, it's
a very easy, quick, as you said, quick- to- use
test. So my next question is, you've talked about a
few there. You talked about the QuickSIN, you talked about
the HINT, the Oldenberg. Have we got any evidence on how
closely the results of all these different speech in noise
(21:17):
tests correlate, meaning, can we be confident in the accuracy
with whichever tests we use? Do they correlate at all?
Dr. Gus Mueller (21:25):
Well, they do turn out fairly similar, and there has
been some limited studies. I recall Rich Wilson from the
US, he has a test that he developed called the
Words In Noise, the WIN. He compared the HINT to
the QuickSIN, to the WIN. The same people took all three
tests. And as you would guess, if you do poorly
in one, you'll do poorly in the other. They differed,
(21:48):
I think, when you looked at means; they differed by
about 3 dB. You would use that when you interpret.
So that's really not an issue. You wouldn't use the
same norm. They each have their own norms. I think
the general idea is, is this person close to normal
or are they quite a ways from normal? And any
of these tests, I think, will give you that answer.
(22:09):
It's just the act of doing them was where the
problem was.
Julia van Huyssteen (22:11):
Great. That's really good to hear. So thank you very
much, Dr. Mueller, for another very insightful discussion on hearing-
aid fitting standards. Today we talked about a few pre-
assessments, and we often think we follow the golden rules,
but sometimes we don't. So it was really good to
(22:32):
remind ourselves of some of the reasons why hearing- aid
fitting standards should exist. We'd love to start a conversation
on this, so if you have any comments to share,
get in touch via the links on the episode page.
Please join us for our third episode about hearing- aid
fitting standards, and in the meantime, remember you can find
really useful links on the episode page. If you found
(22:52):
these episodes useful, we'd love it if you could share
it with your friends and colleagues so as many people
as possible benefit from Dr. Mueller's expertise.
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