March 5, 2025 • 33 mins
Are you or someone you know struggling to hear in noisy environments, yet are told your hearing is normal? This episode of the Hearing Matters podcast focuses on the often overlooked yet critical concept of subclinical hearing loss. Experts Dr. Christina Roup and Dr. Douglas L. Beck discuss the limitations of traditional pure-tone audiometry, revealing how it fails to capture the full spectrum of auditory challenges faced by many individuals today.
This episode provides valuable insights into the best practices for evaluating auditory processing and exploring the implications of extended high-frequency hearing on speech comprehension. If you're a hearing healthcare provider, this episode is a must-listen for improving your approach to evaluating and supporting patients experiencing hearing loss and auditory processing disorder.
We invite you to share this episode, subscribe, and join the conversation on the vital topic of hearing health. Have you ever struggled to hear, even with normal test results? Your experience matters, and we would love to hear from you!
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Blaise M. Delfino, M.S. - (00:19):
Thank you.
You to our partners.
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(00:41):
Welcome back to another episodeof the Hearing Matters podcast.
I'm founder and host BlaiseDelfino and, as a friendly
reminder, this podcast isseparate from my work at Starkey
.
Dr. Douglas L. Beck (00:56):
Good afternoon.
This is Dr Douglas Beck withthe Hearing Matters podcast, and
I am here today with my friendand associate and colleague, Dr
Christina Rupp.
Dr Rupp holds a BA and an MA incommunicative disorders from
California State University atLong Beach and her PhD is in
communicative disorders from theUniversity of Wisconsin at
Madison.
Dr Rupp is an associateprofessor at the Ohio State
(01:19):
University.
Her research focuses on theeffects of aging, traumatic
brain injury and functionalhearing difficulties on binaural
auditory processing.
Her secondary research examinesthe benefits of low gain
amplification for adults withfunctional hearing difficulties
who have normal pure tonethresholds.
Dr Root, welcome, Good to seeyou again.
Dr. Christina M. Roup (01:41):
Good to see you again.
Thank you for having me.
Dr. Douglas L. Beck (01:43):
My pleasure indeed.
Good to see you again.
Good to see you again.
Thank you for having me.
My pleasure indeed.
Let's talk about people whohave normal thresholds, yet
they're having difficultyhearing a noise, or classically
hearing difficulty, and theydon't show any hearing loss.
What do you do?
Dr. Christina M. Roup (01:59):
I think you pay attention to their
complaints right.
So one of the things that Ireally encourage is the use of
standardized questionnaires orthe self-report from your
patient.
Listen to their complaints,because the pure tone audiogram,
we know, does not correlatewell with self-perception.
Dr. Douglas L. Beck (02:19):
Yeah, I'm so glad you said that We'll come
back to audiograms.
Dr. Christina M. Roup (02:22):
Tell me step two Step two is do more
than just test pure tonethresholds.
So I think we need to betesting speech and noise, and I
know you're an advocate for thatas well.
So listen to their complaintsand test.
Use our test measures thatdirectly address their
complaints, and then I think theother thing we can do is go
(02:44):
beyond 8,000 hertz on our puretone audiometry right.
So there's a wealth of evidencethat's demonstrating that
extended high frequency hearingreally matters when it comes to
speech and noise deficits.
Dr. Douglas L. Beck (02:56):
So if I were going to be snarky I would
say well, this must be a newfinding that extended high
frequencies matter, because,gosh, we've only known about
that since World War II.
Just, you know, probably 5% ofus do it right.
And it's so important becausewhen you think about the eighth
nerve, the auditory vestibularnerve, going to the brainstem,
it is tonotopically ortopographically oriented.
(03:18):
So the extreme high frequenciesare on the outside.
And many people would say that,as degradation occurs over time
, through noise-induced hearingloss, through presbycusis,
through ototoxic drugs, throughtraumatic brain injury, which I
know you've studied as wellthrough these things, the first
damage point in the auditorysystem is going to be those
extended high-frequency neurons.
Dr. Christina M. Roup (03:40):
Exactly exactly.
And I think what we may see ifwe continue to do this and I
think we should is that if youhave that patient who has pure
tone thresholds within ourclassically defined normal range
, if you keep going and measureoutside that range, you're going
to see threshold elevation inthose extended high frequencies.
And I think that's you know.
The research has shown thatfrom the past, but also from the
(04:04):
very recent past as well.
I think this's you know.
The research has shown thatfrom the past, but also from the
very recent past as well.
Dr. Douglas L. Beck (04:06):
I think this is so important.
We just did a podcast onextended high frequencies and
we'll put a link to that in theweb version of this one because
it is such an important topic.
And you'll see that so many ofthe patients with normal
thresholds, you know, between250 and 8K, will have extended
high frequency difficulty andyou know they may complain that
(04:27):
they can't understand speech andnoise.
They may complain abouttinnitus, they may complain
about a million things and we'renot catching it because we're
not testing for it.
You know you don't know whatyou don't test.
There was a wonderful articlethat came out, I think since you
and I last spoke.
This is by Dr Charles Lieberman.
Are you familiar with this?
Do you know where I'm going?
Okay, so noise damage andhidden hearing loss, cochlear
(04:49):
synaptopathy in animals andhumans.
And what Dr Lieberman says iswhen thinking about
sensorineural hearing loss, it'svery important to differentiate
problems with audibility,that's, you know, the ability to
hear, from problems withintelligibility, the ability to
extract meaning.
And he says for decades it wasbelieved that hair cells were
the primary target of damage inmost forms of sensorineural
(05:11):
hearing loss and that auditorynerve fibers degenerated mainly
as a secondary effect if, andonly if the hair cells were
already destroyed.
These ideas were challengedwhen our lab meaning his lab in
both noise-induced andage-related hearing loss of mice
, the most vulnerable elementsin the inner ear were not the
hair cells but the synapticconnections between hair cells
(05:32):
and auditory nerve fibers, andthat type of synoptasy could
silence 50% of the neuronswithout hair cells changing
thresholds.
Dr. Christina M. Roup (05:42):
Powerful, powerful words.
Dr. Douglas L. Beck (05:45):
So how do we get the profession to take
this seriously and do somethingabout it?
Dr. Christina M. Roup (05:49):
If I had the answer to that, we would
both be millionaires, wouldn'twe?
Well, at least you would be,yeah.
Dr. Douglas L. Beck (05:56):
I mean, we're in the stall mode.
There's a couple of things hereto unpack.
Number one now this is a goodtime to go back to pure tones.
Tell me your perspective onpure tones being what we all
refer to not you and I, but mostof us refer to audiograms as
the gold standard of hearingmeasuring.
You know what's on youraudiogram and I'd like you to
speak about that and thecategories of convenience.
Dr. Christina M. Roup (06:18):
I love that phrase that you use
categories of convenience or thetraditional classification for
degree of hearing loss, right?
So if we go back in time, weknow that normal hearing has
been classified as thresholdsbetween zero and 25 dB HL, but
many of us argue that that istoo wide of a range, right, that
we really need to tighten thatup, and there's numerous
(06:42):
researchers, professionals whoare arguing for that right.
It's not just you and I.
Dr. Douglas L. Beck (06:47):
Oh, and in 1929, almost 100 years ago,
fletcher showed 15 was the outerlimits of normal.
Exactly, but I digress, pleasecontinue.
Dr. Christina M. Roup (06:55):
No, you hit the nail right on the head,
right, that that 15 dBdemarcation is a much better
place to separate, quote-unquote, normal hearing from threshold
elevation or impaired hearing,and I think, um, that is a great
place for us to, um, what's agood way to say that?
That is a really for us tocontinue to advocate for that
(07:18):
change in.
Dr. Douglas L. Beck (07:19):
So yeah, I absolutely 100.
So.
So let me ask you if you wereempowered by triple a IHS, ada,
all of our acronyms to design aperfect audiogram?
We're absolutely willing tohave people just download it and
use it and take it for free.
But you know, we're not anacademic institution, we're a
(07:55):
podcast.
So tell me your preferences.
How would you define each ofthese categories?
Dr. Christina M. Roup (08:01):
Yeah, I think if you consider normal
hearing, 0 to 15 dB HL, I thinkthat's a great place to start.
I think we already have thatcategory of slight hearing loss
that has been introduced, but itwas classified as only use for
children, right?
And I think if we go away fromthat, we can say that is still a
slight hearing loss for anybody, right it?
(08:22):
doesn't have to be just children.
It's tough because these I willjust say that these words that
we use to classify these rangescan be really misleading.
Right, you know slight and mild.
You know it's like having amild traumatic brain injury.
It's not mild for the personwho has it right.
Mild hearing loss Is it mildfor that person?
Dr. Douglas L. Beck (08:45):
You know this is such a great point so I
almost want to throw away theseterminologies entirely.
And with all due respect to mycolleagues at Johns Hopkins, I'm
not a fan of the hearingnumbers.
Problem with that to me is thatthey only represent loudness.
They don't tell you anythingabout processing or clarity or
speech and noise or hearingdifficulty.
They're just measuring puretones.
Now the thing about that twothings.
(09:06):
Number one you only need 50% ofthe auditory fibers intact to
press the button when you hearthe beep.
So you can have verysignificant damage and have zero
dB thresholds or two, three,four, five, six, seven, eight,
nine, 10, et cetera.
So that's one thing.
And then the other thing isthat people can handle two
numbers.
You know, they know their bloodpressure is 115 over 80.
You know vision is 20-20.
(09:27):
They know they have 32 teeth inone mouth.
That's almost too.
But you know, I don't thinkthat it's going too far if we
design a very, very simplenumber.
Now here's the other thing thatI don't like about the
categories.
If we said 15 to 30 is slight,then that's based on a puritron
average, whether it's threefrequency or four, and many of
(09:50):
us use four frequencies, many ofus use three, and it depends do
you use interactives?
So none of these numbers arenecessarily repeatable
universally.
And then you look at the WorldHealth Organization numbers on
hearing loss and they're very,very different.
I'm not saying right or wrong,but a very different mindset for
a very different purpose.
And so I almost wonder if thesimplest thing to do is just we
(10:12):
know that hearing loss isdecibels.
There's rarely a patient who cantell you what a decibel is, and
we don't really have the timeto teach that class to a patient
.
And I don't mean thatdisrespectfully, it's just it's
not part of their life, right?
So what if we just said youknow what, for the purpose of
patients, why don't we have zeroto a hundred percent?
Just whatever the DB pure toneaverage is, make that a percent
(10:33):
Patient says, well, I have a 45DB loss or I have a 45%.
Okay, good enough for a patient, isn't it?
I mean, would that add moreconfusion, or does that?
Dr. Christina M. Roup (10:44):
Yeah, that's a tricky one.
I think a percentage issomething that's very easy for
patients, or just individuals ingeneral, to latch on to,
because we use percentage in somany different ways.
So it's an easy thing to grabhold of or it's tangible right,
it's tangible for an individualgrab hold of, or it's tangible,
(11:06):
right, it's tangible for anindividual and we all know it.
Dr. Douglas L. Beck (11:09):
Yeah, we all know it's wrong, but it's
probably close enough forconsumers and for the general
public, like a speech banana.
There's nothing on a speechbanana, that's right, not one
thing.
And yet we use that tocommunicate to patients.
A grand piano is 80 dB at 2000Hertz.
Really, because I'm a musician,I got to tell you something
that ain't even close, you know.
Really, because I'm a musician,I gotta tell you something that
ain't even close, you know.
And and a motorcycle is 90 dbat 8 000 hertz.
Are you kidding you know?
Nothing on a speech banana iscorrect.
(11:30):
Yet we use that to try to makethings simple.
Why don't we just usepercentage and get rid of I mean
?
Dr. Christina M. Roup (11:35):
I, you know, I don't disagree with you,
doug, I don't disagree make itsimple.
You know this is.
You know, even if you just usea pure tone average, or if it's
three frequency, four frequency,it's a single number.
You have a 45 dB loss or 45percentage loss or whatever that
means, or whatever term youwant to use, and then add to it
so that second number.
(11:56):
So what would that secondnumber be?
Is it your signal to noiseratio loss?
Is it your speech and noisepercent?
Dr. Douglas L. Beck (12:04):
correct.
Yeah Well, you know, there's somuch information out showing
that word recognition in quietisn't really telling us anything
.
And many people have proposed ifyou do a Google Scholar search
or a PubMed search, many peopleby many I mean five or six that
I've seen in peer-reviewedliterature, or six that I've
seen in peer-reviewed literaturethat say you know, instead of
doing well, in addition to doingSRTs and word recognition in
(12:28):
quiet, we should be doing wordrecognition in noise, and I like
that a lot because I thinkthat's where the most clearly,
90% of the patients that we allsee complain about speech and
noise, yet very few of us testthat.
Now I want to go back tosomething you said earlier,
which is you know, you and I arespeech and noise advocates, but
then again, so is AAA and ASHAand IHS.
It's in every one of their bestpractice models and yet again,
(12:53):
it's not being done on a regularbasis by the majority.
And I think that's that'sterrible, because when, when I
go to see somebody for my visionor or my hearing or whatever it
is, and I tell them, my problemis that I, you know, when I'm
reading a paper up close, Ican't focus without glasses, and
they give me all these distantthings to do.
We haven't addressed the reasonI came in, you know, and I
(13:15):
think that this is a glaringmistake in many of our clinical
protocols.
Dr. Christina M. Roup (13:20):
No, I completely agree.
And it doesn't.
You know what kind of trust isthe patient going to have in you
when you're not testing whatthey've complained about?
Dr. Douglas L. Beck (13:30):
Right, yeah , fair enough.
Dr. Christina M. Roup (13:31):
And we know you know you can have up to
a moderate to moderately severehearing loss and still perform
in quiet above 80% just simplydoesn't give you any additional
information about your patientif you are not addressing the
complaint that they have or theproblems that they experience,
(13:51):
which is listening or trying tounderstand in background noise.
And there's so many great toolsfor us to use that are quick
and easy right, I mean thespeech and noise tests that are
out there that are commerciallyavailable, are quick and easy,
like you know.
For example, the quick sin, thequick speech and noise tests
that are out there that arecommercially available are quick
and easy, like you, know forexample, the quick sin, the
quick speech and noise test.
I mean one minute per list.
(14:11):
How much faster can it get?
Dr. Douglas L. Beck (14:14):
You know your point is very well taken.
I won't go into too much detailthere, but I absolutely, if you
only had one test to do on apatient.
Patient comes to see you andthey say Dr Roop, I'm having
difficulty understanding speechand noise.
I'm 70 years old, I don't haveany extreme noise exposure and
you only had one test that youcould give them.
What would that?
Dr. Christina M. Roup (14:35):
be.
Depending on their age, itwould be a speech and noise test
and then, depending on theirage, I might choose the Quixin
as a quick screener, or or Imight.
I love the revised speech andnoise test.
Yeah, it's an oldie, but youknow it has the high
predictability versus the lowpredictability and it's a.
You can use that as a reallygreat counseling tool like hey,
look these high predictabilitysentences.
Dr. Douglas L. Beck (14:57):
You did great with that low
predictability yeah, yeah, andthat's that's the revised spin,
right, and I'm I'm blanking onwho wrote that originally.
It came out like in themid-'80s.
Dr. Christina M. Roup (15:07):
I want to say so in the mid-'80s it was
Bob Bilger, oh right.
Dr. Douglas L. Beck (15:12):
Who did the ?
Dr. Christina M. Roup (15:12):
revision of that.
So it came out in the 70s right.
So 1977 was the originalarticle from Calico.
Dr. Douglas L. Beck (15:19):
Oh, that's right, calico, that was the name
I was looking for.
Yeah, yep, that was the name Iwas looking for.
Dr. Christina M. Roup (15:23):
Yeah, yep .
Dr. Douglas L. Beck (15:23):
Wow.
Dr. Christina M. Roup (15:24):
So it's an old test, it's an old
recording and you can tell itsounds like it's an old
recording, but I do like it andyou can still get it from your
colleagues.
Right, it is not somethingthat's commercially available,
but you can get rush hughes.
Do you know where I'm going?
Dr. Douglas L. Beck (15:46):
with this, so one of the original
recordings that we used back in,I want to say from the 40s, was
the rush hughes monosyllabicword test.
Rush was the um, the I don'twant to say dj, but he was the
voice that recorded it and itwas a terrible quality test and
and I remember jack katz tellingme back in the little uh I want
to say the late 70s, early 80sthat you could still use.
It was a terrible quality testand I remember Jack Katz telling
(16:06):
me back in the I want to saythe late 70s, early 80s, that
you could still use it as a testof central function because it
was so bad.
But if the patient could put itall together and make sense of
it they were probably fine.
If the people couldn't, youknow it didn't mean you had a
tumor, of course it doesn't, butit correlated with people who
had other regular stuff and sobad recordings aren't
necessarily useless.
(16:26):
Rush Hughes I haven't thoughtof that name in a few decades.
Anyway, listen, I want to talkabout there's somebody called
Sarah Haisley.
I remember her paper I don't, Ihave it in front of me the
relationship betweenself-perceived hearing ability
and listening related fatigue,and she covered so many cool
things.
Let me just in her abstract,and I'll ask you to comment on
(16:47):
this.
Many adults experience hearingproblems despite a diagnosis of
normal hearing.
An invalidation ofself-perceived hearing problems
can be emotionally distressing.
Previous research describes anormal hearing test with
perceived trouble understandingspeech and noise as hearing
difficulties.
And then she goes on to sayrecent studies investigated
(17:11):
factors that contribute todeficits in speech and noise
performance, a common symptom ofHD.
Specifically, adults withpoorer working memory and poorer
extended high frequency hearingexhibited poorer speech and
noise performance than adultswith better working memory and
(17:32):
better extended high frequencies.
So I read this, I guess two orthree years ago, and I was so
impressed that I thought youknow.
Given the opportunity to speakwith you, I would like to get
your current thoughts on this.
She concludes with results fromthe present study suggest it is
essential to apply morerigorous tests of auditory
function than those thatrepresent everyday hearing tests
(17:57):
to more accurately assess anindividual's hearing ability and
validate their self-perceptionof hearing difficulty HD.
Tell me your thoughts on that,because now we're two years
later.
Dr. Christina M. Roup (18:08):
Yeah, two years later, so we're still
looking at that relationship.
So, if I can just digress alittle bit, sarah's study was
really based on a study thatcame out of National Acoustics
Laboratories, so Ingrid Yeand in2018 published a study that
looked at all these differentfactors that might predict
speech and noise performance.
(18:28):
So she had like over 100participants and she sort of
categorized them as you knowthey did well in speech and
noise or they did poor in speechand noise, and then what
predicted whether or not you did?
You did poor with speech andnoise and it was working memory
and it was extendedhigh-frequency hearing.
So the working memory test thatthey used in that study was a
(18:51):
reading working memory test.
It was visual.
So, what Sarah Haisley and Iwere working with is the
auditory working memory test and, if you're familiar with Sherry
Smith's and Kathy McCoyFuller's WARM or the word
auditory recognition and recallmeasure, so we were using that.
So, yeah, I think we see inindividuals with hearing
(19:15):
functional hearing difficulties,subjective hearing difficulties
whatever terminology you wantto use because there's a
thousand terms to describe thispopulation but that working
memory and listening-relatedfatigue are symptoms of that
hearing difficulty and wecontinue to use auditory working
memory as a measure ofcognitive processing or
(19:39):
executive function that isrelated to speech and noise
deficits or difficulties.
Dr. Douglas L. Beck (19:46):
Right, right.
And so when you talk aboutpeople with normal hearing who
may have extended high frequencydeficits they may have working
memory issues.
To me, I tend to group all ofthese things into something
other people refer to and I hateto use a word that's not
well-defined, but I refer tothese now, in 2025, as
subclinical hearing loss.
The reason I do that?
(20:07):
I think physicians are muchmore comfortable with that, I
think ENT, I think familydoctors, I think GPs, internal
medicine, you know, when theysee a test result, if it happens
to be a patient they're alsoworking with, that says normal
thresholds.
It's so important to stilldocument all this other stuff
and I think we can just startmaybe calling it subclinical
(20:27):
hearing loss, because I thinkwhen we use terms like super
threshold hearing loss orcentral auditory processing
disorder or you know any ofthose things which are central
hearing loss, it puts it out inthe ether for the mainstream,
and I think that if we saysubclinical, it seems more
(20:49):
relatable to me.
What's your thought?
What's the best term to usewhen it's not airbone and speech
, when it's not, you know,conductive or sensorineural?
Dr. Christina M. Roup (20:57):
Right.
I don't know that I have a goodanswer because there are a lot
of different terms.
Subclinical is something thatI've seen a lot of and I would
argue that the way it's beingused by Justin Gullup's group,
where it is thresholds 1 to 24or 1 to 25, I would argue that
(21:20):
that's a little too wide of arange.
So, subclinical I think you runthe same difficulty with
subclinical that you do withslight or mild, right?
So if it's subclinical, it'snot clinically relevant, right?
So I think you can run intothat issue with subclinical.
Dr. Douglas L. Beck (21:36):
So I guess my answer is I don't know if
there's a perfect term.
Yeah, I don't think there is aperfect term, but I'm glad for
your reflections on subclinical.
I think I struggle with thebest thing and I know that some
people use the term auditoryprocessing disorder to say it's
not hearing, it's.
You know what we do with whatwe hear.
Dr. Christina M. Roup (21:56):
Yeah, I think you have to be careful
with that.
Dr. Douglas L. Beck (21:59):
You know, I study auditory processing.
Dr. Christina M. Roup (22:01):
I study binaural processing, I believe
that people have processingdeficits that you could
categorize as disordered.
But when it comes to thispopulation, you know what you
and I are talking about rightnow.
Is this threshold elevation,you know, beyond 15 dbhl right,
and we know that?
Or I've had studies that haveshown that if you have threshold
(22:23):
elevation between 15 and 25,that that strongly correlates
with speech and noiseperformance.
Now, do you have a speech andnoise deficit?
Maybe not, but your performanceis definitely poorer than
someone who has thresholdsbetween zero and 15.
(22:56):
So I think audibility orthreshold, minimal threshold
yeah, fair point works togetherright.
Dr. Douglas L. Beck (23:02):
Of course, and it's so hard to characterize
these things because, asaudiologists doing comprehensive
audiometric evaluations, we runinto this all the time and it's
very hard to communicate it tothe family or to the rest of the
healthcare team withoutconfusing people, because they
don't know what a centralhearing or central listening
issue is, they don't know whatauditory processing is.
(23:24):
So I'm just trying to find auniversal term, which obviously
I did not find.
Dr. Christina M. Roup (23:28):
Yeah, we should brainstorm this further.
Dr. Douglas L. Beck (23:31):
Yeah, absolutely so.
Then you had this paper thatcame out about a year ago it was
May, june 2024, with Lander andShang, I think and you were
writing about mild traumaticbrain injury.
I wrote a paper on that about10 or 15 years ago and I found
it to be fascinating.
But you went further in yourconclusions and you say the
(23:52):
present study suggestsconventional clinical
audiometric battery alone maynot provide enough information
about auditory processingdeficits in individuals with a
history of mild traumatic braininjury.
So tell me about that.
I mean, I think you're exactlyright.
And I remember when I was at atrauma center St Louis
University, I was there forseven or eight years or
(24:12):
something like that and you'dhave people who would be in car
accidents or you'd have peoplewho had fallen off a ladder
because we were a trauma center.
And you know, sometimessomebody was clever enough to
order an audiometric evaluation,but you know it was really just
250 to 8K and temps and let theENT take a look at the ear.
You know, and I've alwaysthought well, that's not really
(24:33):
a thorough, comprehensiveaudiometric evaluation for
somebody, given, you know,traumatic or even mild traumatic
brain injury.
And yet you know that's what wedid.
Dr. Christina M. Roup (24:44):
Yeah, it's a fascinating group, you
know I was involved.
I've had colleagues who werereally interested in this in the
veteran population you know,glass exposure, but even just
close head injury, we know hasan impact on the central
auditory nervous system.
But it doesn't necessarilyimpact pure tone thresholds.
(25:05):
So you look at that data thatwe published in that paper, the
pure tone thresholds were allwithin the classically defined
normal range.
So nobody had thresholds outsideof that range.
So if you have a patient comingin and they're complaining
about hearing problems or speechand noise deficits, whatever
(25:26):
their complaint is, and then youfind out they have a history of
concussion or brain injury,whatever that looks like or
whatever term they're using, youknow, pay attention to their
complaints because you need todo more testing and just the
pure tone, audiogram and wordsin quiet, because they're going
to perform beautifully on thosemeasures, yeah Right.
(25:53):
And you know we I havecolleagues in our clinic at Ohio
state who have these stories ofpatients who make it to our
clinic.
So they have a history of braininjury and they've seen five,
six, 10 audiologists who saywell, you have normal hearing,
but all they did was test theirpure tone thresholds.
And then they come to us.
We measure their auditoryprocessing abilities with speech
and noise with an auditoryprocessing evaluation or test
(26:15):
battery like the scan, which Ithink is a very easy
implementable test battery in aclinic, and they perform
abnormally.
And so their complaints arebased on something real right.
Something is happeningcentrally.
Dr. Douglas L. Beck (26:30):
Dr Roof, before I let you go, I want to
talk a little bit about what isa difficult discussion for many
professionals.
So you have a patient who hassubclinical or central or
auditory processing somethinggoing on.
Has subclinical or central orauditory processing something
going on?
Thresholds are normal.
Would you or would you not tryhearing aids?
Dr. Christina M. Roup (26:52):
I would Yep, so I think that is a viable
option.
I think we can do that safelyand effectively, and we have
data to demonstrate that thispopulation will benefit from
mild or low gain amplificationand the digital signal
processing that comes along withadvanced hearing technology.
So, absolutely, I think it isworth trying.
Dr. Douglas L. Beck (27:15):
And so I get this question when I'm out
lecturing are you saying thatpeople with normal hearing
should wear hearing aids?
(27:37):
And the answer is no, nobody'ssaying that.
What we're saying is peoplewith auditory deficits which, by
the way, you have to test inorder to find them might improve
their situation by having abetter signal to noise ratio.
And this is exactly what we'vebeen doing, I think, since 1950s
, with children with auditoryprocessing disorders.
Right, we give them an FMtrainer, we give them a headset.
(28:01):
Now we don't have to use quiteso clunky tools, but we can give
them Bluetooth, we can givethem a digital remote mics, we
can give them a FM, we can givethem, and sometimes we just give
them hearing aids with very lowgain.
So you're not going to causedamage.
But I want to caution people,and I think you would share the
same caution that if you'regoing to do a low gain fitting
for somebody with normaltraditional thresholds but
(28:22):
hearing difficulty, it's almostmandatory in my mind that you
have to do real ear measuresjust to make sure that hearing
aid is not malfunctioning andpotentially causing a problem.
Dr. Christina M. Rou (28:31):
Absolutely , you have to do that.
That is an excellent point andI would never do a fitting like
this without real earverification.
And I would also cautionindividuals to not solely rely
on a prescriptive method or aprescriptive target, because
most prescriptive targets, likeNAL or DSL, they weren't
(28:53):
designed for thresholds you knowbetter than 20 dB HL and in
fact if you enter that into yoursoftware it's probably not
going to turn on the irrigate.
Dr. Douglas L. Beck (29:01):
You won't get any gain at all.
Dr. Christina M. Roup (29:03):
It's minimal at best right.
So I think you have to decidewhat your protocol is.
There's a couple of papers outthere that have done it slightly
differently.
But you know I'm an advocatefor measuring insertion gain.
Know how much gain you want toprovide your patient, whether
that is a flat 5 dB, like some,5 to 6 dBs, like some research
(29:23):
has done, or a more, you know,nuanced 5 to 10, depending on
you.
Know a little bit more gain inthe high frequencies.
But measuring insertion gain, Ithink is a much, much better
approach than relying on aprescriptive target that would
be inappropriate for thataudiogram.
Dr. Douglas L. Beck (29:41):
I like that a lot because if my insertion
gain is 5, 6, 7, 8, 9, 10 dB andI have noise reduction maxed
out and I have beam formers onin a cocktail party situation, a
restaurant, an airport, a groupdiscussion, most of the
amplification will be comingfrom the person that I am
looking at right, becausethey're in front of me, and most
(30:04):
of the attenuation of noisewill occur behind me and mostly
still, you know, for steadystate noise, but some low
rumbling and things will also beeliminated.
The bottom line is, yes, we canmake it clearer, and actually
people don't really want thingslouder.
I know I don't want thingslouder and, and you know, I want
to clear it and it's the samething in vision.
(30:24):
You know people don't wantbigger, they want it more
focused.
You know they want to be able to, to read it up close and at a
distance, and it's the same inhearing healthcare.
So I think that there's a longway to go before the entire
profession starts to adapt bestpractices, because we're not
even talking about anythingextreme here, changing we're
(30:46):
just talking about doing what'salready in best practices.
And I loved what you said, thatyou know we're not in charge of
the pricing.
We are right.
And here's the thing I mean.
We're doctors and are we gonnado what the insurance company
says to do that, what we need tobuild for, or are we gonna
practice appropriate audiologyand do what's in the best
(31:09):
interest of the patient?
And I've been saying this foryears and I've been burned for
saying it for years, but I don'treally care how much we get
reimbursed, even when I was inmy own private practice.
The reason my practice thrivedis because we always did what
was best for the patient andmade all the difference.
If we just did what we couldbill for in 92557 and not go
(31:32):
beyond that, I don't think wewould have been an outstanding
practice.
But I think we were anoutstanding practice because we
use comprehensive audiometricevaluation, which is perfect
Best practice.
Dr. Christina M. Roup (31:42):
Perfect.
Dr. Douglas L. Beck (31:43):
All right.
Well, dr Rupp, it is always apleasure.
I'm so glad to see you and Iappreciate all the work you're
doing in all these areas, and Iwill look forward to the next
time.
Maybe we can do something.
End of 2025.
Dr. Christina M. Roup (31:55):
Sounds great.
Thank you for having me.
Dr. Douglas L. Beck (31:58):
Thank you so much.
You're entirely welcome.
Thank you.
You to our partners.
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(00:41):
Welcome back to another episodeof the Hearing Matters podcast.
I'm founder and host BlaiseDelfino and, as a friendly
reminder, this podcast isseparate from my work at Starkey
.
Dr. Douglas L. Beck (00:56):
Good afternoon.
This is Dr Douglas Beck withthe Hearing Matters podcast, and
I am here today with my friendand associate and colleague, Dr
Christina Rupp.
Dr Rupp holds a BA and an MA incommunicative disorders from
California State University atLong Beach and her PhD is in
communicative disorders from theUniversity of Wisconsin at
Madison.
Dr Rupp is an associateprofessor at the Ohio State
(01:19):
University.
Her research focuses on theeffects of aging, traumatic
brain injury and functionalhearing difficulties on binaural
auditory processing.
Her secondary research examinesthe benefits of low gain
amplification for adults withfunctional hearing difficulties
who have normal pure tonethresholds.
Dr Root, welcome, Good to seeyou again.
Dr. Christina M. Roup (01:41):
Good to see you again.
Thank you for having me.
Dr. Douglas L. Beck (01:43):
My pleasure indeed.
Good to see you again.
Good to see you again.
Thank you for having me.
My pleasure indeed.
Let's talk about people whohave normal thresholds, yet
they're having difficultyhearing a noise, or classically
hearing difficulty, and theydon't show any hearing loss.
What do you do?
Dr. Christina M. Roup (01:59):
I think you pay attention to their
complaints right.
So one of the things that Ireally encourage is the use of
standardized questionnaires orthe self-report from your
patient.
Listen to their complaints,because the pure tone audiogram,
we know, does not correlatewell with self-perception.
Dr. Douglas L. Beck (02:19):
Yeah, I'm so glad you said that We'll come
back to audiograms.
Dr. Christina M. Roup (02:22):
Tell me step two Step two is do more
than just test pure tonethresholds.
So I think we need to betesting speech and noise, and I
know you're an advocate for thatas well.
So listen to their complaintsand test.
Use our test measures thatdirectly address their
complaints, and then I think theother thing we can do is go
(02:44):
beyond 8,000 hertz on our puretone audiometry right.
So there's a wealth of evidencethat's demonstrating that
extended high frequency hearingreally matters when it comes to
speech and noise deficits.
Dr. Douglas L. Beck (02:56):
So if I were going to be snarky I would
say well, this must be a newfinding that extended high
frequencies matter, because,gosh, we've only known about
that since World War II.
Just, you know, probably 5% ofus do it right.
And it's so important becausewhen you think about the eighth
nerve, the auditory vestibularnerve, going to the brainstem,
it is tonotopically ortopographically oriented.
(03:18):
So the extreme high frequenciesare on the outside.
And many people would say that,as degradation occurs over time
, through noise-induced hearingloss, through presbycusis,
through ototoxic drugs, throughtraumatic brain injury, which I
know you've studied as wellthrough these things, the first
damage point in the auditorysystem is going to be those
extended high-frequency neurons.
Dr. Christina M. Roup (03:40):
Exactly exactly.
And I think what we may see ifwe continue to do this and I
think we should is that if youhave that patient who has pure
tone thresholds within ourclassically defined normal range
, if you keep going and measureoutside that range, you're going
to see threshold elevation inthose extended high frequencies.
And I think that's you know.
The research has shown thatfrom the past, but also from the
(04:04):
very recent past as well.
I think this's you know.
The research has shown thatfrom the past, but also from the
very recent past as well.
Dr. Douglas L. Beck (04:06):
I think this is so important.
We just did a podcast onextended high frequencies and
we'll put a link to that in theweb version of this one because
it is such an important topic.
And you'll see that so many ofthe patients with normal
thresholds, you know, between250 and 8K, will have extended
high frequency difficulty andyou know they may complain that
(04:27):
they can't understand speech andnoise.
They may complain abouttinnitus, they may complain
about a million things and we'renot catching it because we're
not testing for it.
You know you don't know whatyou don't test.
There was a wonderful articlethat came out, I think since you
and I last spoke.
This is by Dr Charles Lieberman.
Are you familiar with this?
Do you know where I'm going?
Okay, so noise damage andhidden hearing loss, cochlear
(04:49):
synaptopathy in animals andhumans.
And what Dr Lieberman says iswhen thinking about
sensorineural hearing loss, it'svery important to differentiate
problems with audibility,that's, you know, the ability to
hear, from problems withintelligibility, the ability to
extract meaning.
And he says for decades it wasbelieved that hair cells were
the primary target of damage inmost forms of sensorineural
(05:11):
hearing loss and that auditorynerve fibers degenerated mainly
as a secondary effect if, andonly if the hair cells were
already destroyed.
These ideas were challengedwhen our lab meaning his lab in
both noise-induced andage-related hearing loss of mice
, the most vulnerable elementsin the inner ear were not the
hair cells but the synapticconnections between hair cells
(05:32):
and auditory nerve fibers, andthat type of synoptasy could
silence 50% of the neuronswithout hair cells changing
thresholds.
Dr. Christina M. Roup (05:42):
Powerful, powerful words.
Dr. Douglas L. Beck (05:45):
So how do we get the profession to take
this seriously and do somethingabout it?
Dr. Christina M. Roup (05:49):
If I had the answer to that, we would
both be millionaires, wouldn'twe?
Well, at least you would be,yeah.
Dr. Douglas L. Beck (05:56):
I mean, we're in the stall mode.
There's a couple of things hereto unpack.
Number one now this is a goodtime to go back to pure tones.
Tell me your perspective onpure tones being what we all
refer to not you and I, but mostof us refer to audiograms as
the gold standard of hearingmeasuring.
You know what's on youraudiogram and I'd like you to
speak about that and thecategories of convenience.
Dr. Christina M. Roup (06:18):
I love that phrase that you use
categories of convenience or thetraditional classification for
degree of hearing loss, right?
So if we go back in time, weknow that normal hearing has
been classified as thresholdsbetween zero and 25 dB HL, but
many of us argue that that istoo wide of a range, right, that
we really need to tighten thatup, and there's numerous
(06:42):
researchers, professionals whoare arguing for that right.
It's not just you and I.
Dr. Douglas L. Beck (06:47):
Oh, and in 1929, almost 100 years ago,
fletcher showed 15 was the outerlimits of normal.
Exactly, but I digress, pleasecontinue.
Dr. Christina M. Roup (06:55):
No, you hit the nail right on the head,
right, that that 15 dBdemarcation is a much better
place to separate, quote-unquote, normal hearing from threshold
elevation or impaired hearing,and I think, um, that is a great
place for us to, um, what's agood way to say that?
That is a really for us tocontinue to advocate for that
(07:18):
change in.
Dr. Douglas L. Beck (07:19):
So yeah, I absolutely 100.
So.
So let me ask you if you wereempowered by triple a IHS, ada,
all of our acronyms to design aperfect audiogram?
We're absolutely willing tohave people just download it and
use it and take it for free.
But you know, we're not anacademic institution, we're a
(07:55):
podcast.
So tell me your preferences.
How would you define each ofthese categories?
Dr. Christina M. Roup (08:01):
Yeah, I think if you consider normal
hearing, 0 to 15 dB HL, I thinkthat's a great place to start.
I think we already have thatcategory of slight hearing loss
that has been introduced, but itwas classified as only use for
children, right?
And I think if we go away fromthat, we can say that is still a
slight hearing loss for anybody, right it?
(08:22):
doesn't have to be just children.
It's tough because these I willjust say that these words that
we use to classify these rangescan be really misleading.
Right, you know slight and mild.
You know it's like having amild traumatic brain injury.
It's not mild for the personwho has it right.
Mild hearing loss Is it mildfor that person?
Dr. Douglas L. Beck (08:45):
You know this is such a great point so I
almost want to throw away theseterminologies entirely.
And with all due respect to mycolleagues at Johns Hopkins, I'm
not a fan of the hearingnumbers.
Problem with that to me is thatthey only represent loudness.
They don't tell you anythingabout processing or clarity or
speech and noise or hearingdifficulty.
They're just measuring puretones.
Now the thing about that twothings.
(09:06):
Number one you only need 50% ofthe auditory fibers intact to
press the button when you hearthe beep.
So you can have verysignificant damage and have zero
dB thresholds or two, three,four, five, six, seven, eight,
nine, 10, et cetera.
So that's one thing.
And then the other thing isthat people can handle two
numbers.
You know, they know their bloodpressure is 115 over 80.
You know vision is 20-20.
(09:27):
They know they have 32 teeth inone mouth.
That's almost too.
But you know, I don't thinkthat it's going too far if we
design a very, very simplenumber.
Now here's the other thing thatI don't like about the
categories.
If we said 15 to 30 is slight,then that's based on a puritron
average, whether it's threefrequency or four, and many of
(09:50):
us use four frequencies, many ofus use three, and it depends do
you use interactives?
So none of these numbers arenecessarily repeatable
universally.
And then you look at the WorldHealth Organization numbers on
hearing loss and they're very,very different.
I'm not saying right or wrong,but a very different mindset for
a very different purpose.
And so I almost wonder if thesimplest thing to do is just we
(10:12):
know that hearing loss isdecibels.
There's rarely a patient who cantell you what a decibel is, and
we don't really have the timeto teach that class to a patient
.
And I don't mean thatdisrespectfully, it's just it's
not part of their life, right?
So what if we just said youknow what, for the purpose of
patients, why don't we have zeroto a hundred percent?
Just whatever the DB pure toneaverage is, make that a percent
(10:33):
Patient says, well, I have a 45DB loss or I have a 45%.
Okay, good enough for a patient, isn't it?
I mean, would that add moreconfusion, or does that?
Dr. Christina M. Roup (10:44):
Yeah, that's a tricky one.
I think a percentage issomething that's very easy for
patients, or just individuals ingeneral, to latch on to,
because we use percentage in somany different ways.
So it's an easy thing to grabhold of or it's tangible right,
it's tangible for an individualgrab hold of, or it's tangible,
(11:06):
right, it's tangible for anindividual and we all know it.
Dr. Douglas L. Beck (11:09):
Yeah, we all know it's wrong, but it's
probably close enough forconsumers and for the general
public, like a speech banana.
There's nothing on a speechbanana, that's right, not one
thing.
And yet we use that tocommunicate to patients.
A grand piano is 80 dB at 2000Hertz.
Really, because I'm a musician,I got to tell you something
that ain't even close, you know.
Really, because I'm a musician,I gotta tell you something that
ain't even close, you know.
And and a motorcycle is 90 dbat 8 000 hertz.
Are you kidding you know?
Nothing on a speech banana iscorrect.
(11:30):
Yet we use that to try to makethings simple.
Why don't we just usepercentage and get rid of I mean
?
Dr. Christina M. Roup (11:35):
I, you know, I don't disagree with you,
doug, I don't disagree make itsimple.
You know this is.
You know, even if you just usea pure tone average, or if it's
three frequency, four frequency,it's a single number.
You have a 45 dB loss or 45percentage loss or whatever that
means, or whatever term youwant to use, and then add to it
so that second number.
(11:56):
So what would that secondnumber be?
Is it your signal to noiseratio loss?
Is it your speech and noisepercent?
Dr. Douglas L. Beck (12:04):
correct.
Yeah Well, you know, there's somuch information out showing
that word recognition in quietisn't really telling us anything
.
And many people have proposed ifyou do a Google Scholar search
or a PubMed search, many peopleby many I mean five or six that
I've seen in peer-reviewedliterature, or six that I've
seen in peer-reviewed literaturethat say you know, instead of
doing well, in addition to doingSRTs and word recognition in
(12:28):
quiet, we should be doing wordrecognition in noise, and I like
that a lot because I thinkthat's where the most clearly,
90% of the patients that we allsee complain about speech and
noise, yet very few of us testthat.
Now I want to go back tosomething you said earlier,
which is you know, you and I arespeech and noise advocates, but
then again, so is AAA and ASHAand IHS.
It's in every one of their bestpractice models and yet again,
(12:53):
it's not being done on a regularbasis by the majority.
And I think that's that'sterrible, because when, when I
go to see somebody for my visionor or my hearing or whatever it
is, and I tell them, my problemis that I, you know, when I'm
reading a paper up close, Ican't focus without glasses, and
they give me all these distantthings to do.
We haven't addressed the reasonI came in, you know, and I
(13:15):
think that this is a glaringmistake in many of our clinical
protocols.
Dr. Christina M. Roup (13:20):
No, I completely agree.
And it doesn't.
You know what kind of trust isthe patient going to have in you
when you're not testing whatthey've complained about?
Dr. Douglas L. Beck (13:30):
Right, yeah , fair enough.
Dr. Christina M. Roup (13:31):
And we know you know you can have up to
a moderate to moderately severehearing loss and still perform
in quiet above 80% just simplydoesn't give you any additional
information about your patientif you are not addressing the
complaint that they have or theproblems that they experience,
(13:51):
which is listening or trying tounderstand in background noise.
And there's so many great toolsfor us to use that are quick
and easy right, I mean thespeech and noise tests that are
out there that are commerciallyavailable, are quick and easy,
like you know.
For example, the quick sin, thequick speech and noise tests
that are out there that arecommercially available are quick
and easy, like you, know forexample, the quick sin, the
quick speech and noise test.
I mean one minute per list.
(14:11):
How much faster can it get?
Dr. Douglas L. Beck (14:14):
You know your point is very well taken.
I won't go into too much detailthere, but I absolutely, if you
only had one test to do on apatient.
Patient comes to see you andthey say Dr Roop, I'm having
difficulty understanding speechand noise.
I'm 70 years old, I don't haveany extreme noise exposure and
you only had one test that youcould give them.
What would that?
Dr. Christina M. Roup (14:35):
be.
Depending on their age, itwould be a speech and noise test
and then, depending on theirage, I might choose the Quixin
as a quick screener, or or Imight.
I love the revised speech andnoise test.
Yeah, it's an oldie, but youknow it has the high
predictability versus the lowpredictability and it's a.
You can use that as a reallygreat counseling tool like hey,
look these high predictabilitysentences.
Dr. Douglas L. Beck (14:57):
You did great with that low
predictability yeah, yeah, andthat's that's the revised spin,
right, and I'm I'm blanking onwho wrote that originally.
It came out like in themid-'80s.
Dr. Christina M. Roup (15:07):
I want to say so in the mid-'80s it was
Bob Bilger, oh right.
Dr. Douglas L. Beck (15:12):
Who did the ?
Dr. Christina M. Roup (15:12):
revision of that.
So it came out in the 70s right.
So 1977 was the originalarticle from Calico.
Dr. Douglas L. Beck (15:19):
Oh, that's right, calico, that was the name
I was looking for.
Yeah, yep, that was the name Iwas looking for.
Dr. Christina M. Roup (15:23):
Yeah, yep .
Dr. Douglas L. Beck (15:23):
Wow.
Dr. Christina M. Roup (15:24):
So it's an old test, it's an old
recording and you can tell itsounds like it's an old
recording, but I do like it andyou can still get it from your
colleagues.
Right, it is not somethingthat's commercially available,
but you can get rush hughes.
Do you know where I'm going?
Dr. Douglas L. Beck (15:46):
with this, so one of the original
recordings that we used back in,I want to say from the 40s, was
the rush hughes monosyllabicword test.
Rush was the um, the I don'twant to say dj, but he was the
voice that recorded it and itwas a terrible quality test and
and I remember jack katz tellingme back in the little uh I want
to say the late 70s, early 80sthat you could still use.
It was a terrible quality testand I remember Jack Katz telling
(16:06):
me back in the I want to saythe late 70s, early 80s, that
you could still use it as a testof central function because it
was so bad.
But if the patient could put itall together and make sense of
it they were probably fine.
If the people couldn't, youknow it didn't mean you had a
tumor, of course it doesn't, butit correlated with people who
had other regular stuff and sobad recordings aren't
necessarily useless.
(16:26):
Rush Hughes I haven't thoughtof that name in a few decades.
Anyway, listen, I want to talkabout there's somebody called
Sarah Haisley.
I remember her paper I don't, Ihave it in front of me the
relationship betweenself-perceived hearing ability
and listening related fatigue,and she covered so many cool
things.
Let me just in her abstract,and I'll ask you to comment on
(16:47):
this.
Many adults experience hearingproblems despite a diagnosis of
normal hearing.
An invalidation ofself-perceived hearing problems
can be emotionally distressing.
Previous research describes anormal hearing test with
perceived trouble understandingspeech and noise as hearing
difficulties.
And then she goes on to sayrecent studies investigated
(17:11):
factors that contribute todeficits in speech and noise
performance, a common symptom ofHD.
Specifically, adults withpoorer working memory and poorer
extended high frequency hearingexhibited poorer speech and
noise performance than adultswith better working memory and
(17:32):
better extended high frequencies.
So I read this, I guess two orthree years ago, and I was so
impressed that I thought youknow.
Given the opportunity to speakwith you, I would like to get
your current thoughts on this.
She concludes with results fromthe present study suggest it is
essential to apply morerigorous tests of auditory
function than those thatrepresent everyday hearing tests
(17:57):
to more accurately assess anindividual's hearing ability and
validate their self-perceptionof hearing difficulty HD.
Tell me your thoughts on that,because now we're two years
later.
Dr. Christina M. Roup (18:08):
Yeah, two years later, so we're still
looking at that relationship.
So, if I can just digress alittle bit, sarah's study was
really based on a study thatcame out of National Acoustics
Laboratories, so Ingrid Yeand in2018 published a study that
looked at all these differentfactors that might predict
speech and noise performance.
(18:28):
So she had like over 100participants and she sort of
categorized them as you knowthey did well in speech and
noise or they did poor in speechand noise, and then what
predicted whether or not you did?
You did poor with speech andnoise and it was working memory
and it was extendedhigh-frequency hearing.
So the working memory test thatthey used in that study was a
(18:51):
reading working memory test.
It was visual.
So, what Sarah Haisley and Iwere working with is the
auditory working memory test and, if you're familiar with Sherry
Smith's and Kathy McCoyFuller's WARM or the word
auditory recognition and recallmeasure, so we were using that.
So, yeah, I think we see inindividuals with hearing
(19:15):
functional hearing difficulties,subjective hearing difficulties
whatever terminology you wantto use because there's a
thousand terms to describe thispopulation but that working
memory and listening-relatedfatigue are symptoms of that
hearing difficulty and wecontinue to use auditory working
memory as a measure ofcognitive processing or
(19:39):
executive function that isrelated to speech and noise
deficits or difficulties.
Dr. Douglas L. Beck (19:46):
Right, right.
And so when you talk aboutpeople with normal hearing who
may have extended high frequencydeficits they may have working
memory issues.
To me, I tend to group all ofthese things into something
other people refer to and I hateto use a word that's not
well-defined, but I refer tothese now, in 2025, as
subclinical hearing loss.
The reason I do that?
(20:07):
I think physicians are muchmore comfortable with that, I
think ENT, I think familydoctors, I think GPs, internal
medicine, you know, when theysee a test result, if it happens
to be a patient they're alsoworking with, that says normal
thresholds.
It's so important to stilldocument all this other stuff
and I think we can just startmaybe calling it subclinical
(20:27):
hearing loss, because I thinkwhen we use terms like super
threshold hearing loss orcentral auditory processing
disorder or you know any ofthose things which are central
hearing loss, it puts it out inthe ether for the mainstream,
and I think that if we saysubclinical, it seems more
(20:49):
relatable to me.
What's your thought?
What's the best term to usewhen it's not airbone and speech
, when it's not, you know,conductive or sensorineural?
Dr. Christina M. Roup (20:57):
Right.
I don't know that I have a goodanswer because there are a lot
of different terms.
Subclinical is something thatI've seen a lot of and I would
argue that the way it's beingused by Justin Gullup's group,
where it is thresholds 1 to 24or 1 to 25, I would argue that
(21:20):
that's a little too wide of arange.
So, subclinical I think you runthe same difficulty with
subclinical that you do withslight or mild, right?
So if it's subclinical, it'snot clinically relevant, right?
So I think you can run intothat issue with subclinical.
Dr. Douglas L. Beck (21:36):
So I guess my answer is I don't know if
there's a perfect term.
Yeah, I don't think there is aperfect term, but I'm glad for
your reflections on subclinical.
I think I struggle with thebest thing and I know that some
people use the term auditoryprocessing disorder to say it's
not hearing, it's.
You know what we do with whatwe hear.
Dr. Christina M. Roup (21:56):
Yeah, I think you have to be careful
with that.
Dr. Douglas L. Beck (21:59):
You know, I study auditory processing.
Dr. Christina M. Roup (22:01):
I study binaural processing, I believe
that people have processingdeficits that you could
categorize as disordered.
But when it comes to thispopulation, you know what you
and I are talking about rightnow.
Is this threshold elevation,you know, beyond 15 dbhl right,
and we know that?
Or I've had studies that haveshown that if you have threshold
(22:23):
elevation between 15 and 25,that that strongly correlates
with speech and noiseperformance.
Now, do you have a speech andnoise deficit?
Maybe not, but your performanceis definitely poorer than
someone who has thresholdsbetween zero and 15.
(22:56):
So I think audibility orthreshold, minimal threshold
yeah, fair point works togetherright.
Dr. Douglas L. Beck (23:02):
Of course, and it's so hard to characterize
these things because, asaudiologists doing comprehensive
audiometric evaluations, we runinto this all the time and it's
very hard to communicate it tothe family or to the rest of the
healthcare team withoutconfusing people, because they
don't know what a centralhearing or central listening
issue is, they don't know whatauditory processing is.
(23:24):
So I'm just trying to find auniversal term, which obviously
I did not find.
Dr. Christina M. Roup (23:28):
Yeah, we should brainstorm this further.
Dr. Douglas L. Beck (23:31):
Yeah, absolutely so.
Then you had this paper thatcame out about a year ago it was
May, june 2024, with Lander andShang, I think and you were
writing about mild traumaticbrain injury.
I wrote a paper on that about10 or 15 years ago and I found
it to be fascinating.
But you went further in yourconclusions and you say the
(23:52):
present study suggestsconventional clinical
audiometric battery alone maynot provide enough information
about auditory processingdeficits in individuals with a
history of mild traumatic braininjury.
So tell me about that.
I mean, I think you're exactlyright.
And I remember when I was at atrauma center St Louis
University, I was there forseven or eight years or
(24:12):
something like that and you'dhave people who would be in car
accidents or you'd have peoplewho had fallen off a ladder
because we were a trauma center.
And you know, sometimessomebody was clever enough to
order an audiometric evaluation,but you know it was really just
250 to 8K and temps and let theENT take a look at the ear.
You know, and I've alwaysthought well, that's not really
(24:33):
a thorough, comprehensiveaudiometric evaluation for
somebody, given, you know,traumatic or even mild traumatic
brain injury.
And yet you know that's what wedid.
Dr. Christina M. Roup (24:44):
Yeah, it's a fascinating group, you
know I was involved.
I've had colleagues who werereally interested in this in the
veteran population you know,glass exposure, but even just
close head injury, we know hasan impact on the central
auditory nervous system.
But it doesn't necessarilyimpact pure tone thresholds.
(25:05):
So you look at that data thatwe published in that paper, the
pure tone thresholds were allwithin the classically defined
normal range.
So nobody had thresholds outsideof that range.
So if you have a patient comingin and they're complaining
about hearing problems or speechand noise deficits, whatever
(25:26):
their complaint is, and then youfind out they have a history of
concussion or brain injury,whatever that looks like or
whatever term they're using, youknow, pay attention to their
complaints because you need todo more testing and just the
pure tone, audiogram and wordsin quiet, because they're going
to perform beautifully on thosemeasures, yeah Right.
(25:53):
And you know we I havecolleagues in our clinic at Ohio
state who have these stories ofpatients who make it to our
clinic.
So they have a history of braininjury and they've seen five,
six, 10 audiologists who saywell, you have normal hearing,
but all they did was test theirpure tone thresholds.
And then they come to us.
We measure their auditoryprocessing abilities with speech
and noise with an auditoryprocessing evaluation or test
(26:15):
battery like the scan, which Ithink is a very easy
implementable test battery in aclinic, and they perform
abnormally.
And so their complaints arebased on something real right.
Something is happeningcentrally.
Dr. Douglas L. Beck (26:30):
Dr Roof, before I let you go, I want to
talk a little bit about what isa difficult discussion for many
professionals.
So you have a patient who hassubclinical or central or
auditory processing somethinggoing on.
Has subclinical or central orauditory processing something
going on?
Thresholds are normal.
Would you or would you not tryhearing aids?
Dr. Christina M. Roup (26:52):
I would Yep, so I think that is a viable
option.
I think we can do that safelyand effectively, and we have
data to demonstrate that thispopulation will benefit from
mild or low gain amplificationand the digital signal
processing that comes along withadvanced hearing technology.
So, absolutely, I think it isworth trying.
Dr. Douglas L. Beck (27:15):
And so I get this question when I'm out
lecturing are you saying thatpeople with normal hearing
should wear hearing aids?
(27:37):
And the answer is no, nobody'ssaying that.
What we're saying is peoplewith auditory deficits which, by
the way, you have to test inorder to find them might improve
their situation by having abetter signal to noise ratio.
And this is exactly what we'vebeen doing, I think, since 1950s
, with children with auditoryprocessing disorders.
Right, we give them an FMtrainer, we give them a headset.
(28:01):
Now we don't have to use quiteso clunky tools, but we can give
them Bluetooth, we can givethem a digital remote mics, we
can give them a FM, we can givethem, and sometimes we just give
them hearing aids with very lowgain.
So you're not going to causedamage.
But I want to caution people,and I think you would share the
same caution that if you'regoing to do a low gain fitting
for somebody with normaltraditional thresholds but
(28:22):
hearing difficulty, it's almostmandatory in my mind that you
have to do real ear measuresjust to make sure that hearing
aid is not malfunctioning andpotentially causing a problem.
Dr. Christina M. Rou (28:31):
Absolutely , you have to do that.
That is an excellent point andI would never do a fitting like
this without real earverification.
And I would also cautionindividuals to not solely rely
on a prescriptive method or aprescriptive target, because
most prescriptive targets, likeNAL or DSL, they weren't
(28:53):
designed for thresholds you knowbetter than 20 dB HL and in
fact if you enter that into yoursoftware it's probably not
going to turn on the irrigate.
Dr. Douglas L. Beck (29:01):
You won't get any gain at all.
Dr. Christina M. Roup (29:03):
It's minimal at best right.
So I think you have to decidewhat your protocol is.
There's a couple of papers outthere that have done it slightly
differently.
But you know I'm an advocatefor measuring insertion gain.
Know how much gain you want toprovide your patient, whether
that is a flat 5 dB, like some,5 to 6 dBs, like some research
(29:23):
has done, or a more, you know,nuanced 5 to 10, depending on
you.
Know a little bit more gain inthe high frequencies.
But measuring insertion gain, Ithink is a much, much better
approach than relying on aprescriptive target that would
be inappropriate for thataudiogram.
Dr. Douglas L. Beck (29:41):
I like that a lot because if my insertion
gain is 5, 6, 7, 8, 9, 10 dB andI have noise reduction maxed
out and I have beam formers onin a cocktail party situation, a
restaurant, an airport, a groupdiscussion, most of the
amplification will be comingfrom the person that I am
looking at right, becausethey're in front of me, and most
(30:04):
of the attenuation of noisewill occur behind me and mostly
still, you know, for steadystate noise, but some low
rumbling and things will also beeliminated.
The bottom line is, yes, we canmake it clearer, and actually
people don't really want thingslouder.
I know I don't want thingslouder and, and you know, I want
to clear it and it's the samething in vision.
(30:24):
You know people don't wantbigger, they want it more
focused.
You know they want to be able to, to read it up close and at a
distance, and it's the same inhearing healthcare.
So I think that there's a longway to go before the entire
profession starts to adapt bestpractices, because we're not
even talking about anythingextreme here, changing we're
(30:46):
just talking about doing what'salready in best practices.
And I loved what you said, thatyou know we're not in charge of
the pricing.
We are right.
And here's the thing I mean.
We're doctors and are we gonnado what the insurance company
says to do that, what we need tobuild for, or are we gonna
practice appropriate audiologyand do what's in the best
(31:09):
interest of the patient?
And I've been saying this foryears and I've been burned for
saying it for years, but I don'treally care how much we get
reimbursed, even when I was inmy own private practice.
The reason my practice thrivedis because we always did what
was best for the patient andmade all the difference.
If we just did what we couldbill for in 92557 and not go
(31:32):
beyond that, I don't think wewould have been an outstanding
practice.
But I think we were anoutstanding practice because we
use comprehensive audiometricevaluation, which is perfect
Best practice.
Dr. Christina M. Roup (31:42):
Perfect.
Dr. Douglas L. Beck (31:43):
All right.
Well, dr Rupp, it is always apleasure.
I'm so glad to see you and Iappreciate all the work you're
doing in all these areas, and Iwill look forward to the next
time.
Maybe we can do something.
End of 2025.
Dr. Christina M. Roup (31:55):
Sounds great.
Thank you for having me.
Dr. Douglas L. Beck (31:58):
Thank you so much.
You're entirely welcome.
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