February 28, 2025 • 31 mins
Are you aware of the sounds your ears can’t hear? This episode dives deep into extended high-frequency hearing, a vital but often overlooked component of audiology. Join us to uncover how testing ranges above 8,000 Hz can reveal significant insights into your auditory health.
Dr. Melissa Fling shares her expertise and personal experiences as an audiologist. She explains the science behind high-frequency hearing loss and challenges the traditional limitations of standard audiometric tests. Discover why failing to assess these extended ranges may lead to unseen communication struggles that many individuals face, even while passing regular hearing tests.
Through case studies from Dr. Fling’s practice, we explore how patients often present with "normal" thresholds yet experience complications related to high frequencies. Learn about the patient-centered approach that seeks not only to confirm hearing loss but to enhance quality of life through personalized treatment.
This episode isn't just for audiologists; it’s for anyone who’s ever wondered about the complexities hidden within our hearing capabilities. Engage with us as we discuss the urgent need for a shift in audiological practices and how we can make strides toward comprehensive assessments for everyone. Want to be proactive about your hearing health? Tune in, and let’s start the conversation! Be sure to subscribe and share your thoughts on this crucial topic.
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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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Life is calling CareCredit,here today to help more people
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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
today I'm here with my guest,Dr Melissa Fling.
She is a clinical audiologistand owner and founder of Custom
Ear Solutions, a small privatepractice in Denver, Colorado.
Through Custom Ear Solutions,Dr Fling specializes in hearing
conservation and custom fittedear molds for hearing protection
(01:18):
and other uses.
She is a graduate of CentralMichigan University, one of my
favorite old schools, and shehas been practicing audiology
for almost 10 years in manydifferent settings.
Dr Fling is certified throughthe American Speech-Language
Hearing Association and she islicensed in many states,
including Colorado, California,Arizona, Utah and New Mexico, so
(01:38):
that means you can go almostanywhere.
Anyway, thank you for joiningme.
Dr. Melissa Fling (01:43):
Thank you, Dr Beck.
I'm so excited to be here.
Dr. Douglas L. Beck (01:46):
Our topic for the day is extended
high-frequency hearing andhearing loss and hearing aids
and everything else that couldhave an extended high frequency
but doesn't in general.
So I want to start by askingyou to tell me what is extended
high-frequency hearing.
Dr. Melissa Fling (02:01):
As audiologists, we all know that
humans can hear between 20 hertzand 20,000 hertz and
historically it's been standardto test from about 250 hertz up
to 8,000 hertz, because theresearch, I suppose, in the past
has shown that that's where wepick up the most speech
information, which is what we'remost interested in knowing if
(02:22):
somebody can hear.
But then we're missing out onall this information between
8,000 and 20,000 hertz andthat's what we refer to as
extended high frequency or ultrahigh frequency hearing.
Dr. Douglas L. Beck (02:34):
Right.
And this is so interesting tome because the reason I think
that we do 250 to 8,000 isbecause that aligns very well
with medical diagnosis.
So you know, if I look between250 and 8000 hertz I can see
patterns like presbycusis, likenoise induced hearing loss, like
a car heart notch, like airbone gap, things like that.
(02:56):
So so it's very, very useful tolook there for medical reasons.
But I think what we've learnedover the decades and I do mean
decades since World War Twowe've learned that there's so
much information to be had above8000 hertz and I really think
we're overdue to be testing that.
So what does the literature sayabout extended high frequencies
(03:16):
as far as the sensitivity tothat?
Dr. Melissa Fling (03:19):
Well, it seems like when people start to
lose sensitivity in the extendedhigh frequency range it can
potentially affect theirlocalization.
It's definitely affecting theirspeech perception, particularly
in complex listeningenvironments.
It can affect the perception ofmusic quality.
So obviously with musiciansthey might start to notice
(03:42):
something early on that mightnot show on a standard audiogram
.
So those are the three mainthings that I've come across
localization, music perceptionand speech perception in
complicated listeningenvironments.
Dr. Douglas L. Beck (03:56):
And you know.
The thing about this is, whenyou're looking above 8,000 hertz
, you know there's so muchliterature that shows the
topographic organization of theeighth nerve and the cochlea,
and so when you start to havedamage at 8, 10, 12, 14, 16, 18,
20,000 hertz, that could be anearly warning sign of hearing
loss yet to show up on thestandard audiogram.
(04:18):
And I want to point out thatall you need is about 50% of
those fibers intact in order topress the button when you hear a
beep and have normal responseswhen somebody says they have a
normal audiogram but they can'tunderstand speech and noise,
which is at least 26 millionpeople.
Jeff Danauer and I wrote apaper on that that was peer
reviewed in 2019.
(04:39):
And we identified 26 million.
So now it's six years later.
So I would I would guess it's28 or maybe 30 million people if
we were to redo all that work,but but I think that the point
is that if you're looking above8,000 Hertz, it could be a
precursor to what's about tohappen below 8,000 Hertz.
What are your thoughts on that?
Dr. Melissa Fling (04:57):
I agree and I think just in my experience now
I see that it can validatesomebody's concerns about it
when in the past they've beentold that they have normal
hearing.
I've seen huge asymmetriesbetween 8 and 20,000 hertz.
I've seen significant hearingloss in that range.
That could point to why someonehas tinnitus or that could
(05:19):
point to why someone perceivestheir tinnitus as being louder
in one ear, why someoneperceives their tinnitus as
being louder in one ear.
I was just actually messagingback and forth with someone on
LinkedIn the other day who hasseen a case where there was a
significant extended highfrequency asymmetry and it
turned out that person had avestibular schwannoma on the
side that was worse.
So they probably detected thatway earlier than would have been
(05:44):
detected.
Dr. Douglas L. Beck (05:46):
I mean, symptoms may have shown up, but
yeah, I mean when you go backthrough the literature, you know
, in 1977, 1978, weldon Seltzerand Daryl Brackman looked at the
sensitivity of ABR, using ABRto detect acoustic neuromas or
vestibular schwannomas, and whatthey found was very interesting
, right, they found anelongation between wave one and
(06:07):
wave five, which typicallyshould be 4.0 milliseconds, but
it would be maybe five or six orseven or nothing, no response
at all.
And that turned out to be very,very important in detecting
acoustic tumors.
And I think that the thing hereis that an ABR click is
essentially a square wave andmost of the energy, if I recall,
is going to be around 2,000hertz, 4,000 hertz.
(06:29):
So what you're saying is well,if you looked higher up in the
spectral range, you might seedamage sooner, which might make
sense, because if an acousticneuroma is touching an auditory
nerve, it's mostly impinging onthose high fibers first.
Dr. Melissa Fling (06:43):
So I agree with you.
Dr. Douglas L. Beck (06:44):
And I don't know that anybody's really
looked at this.
Dr. Melissa Fling (06:46):
I don't know that they have either, because
really nobody's testing extendedhigh frequency.
So there's so much researchthat is still that still needs
to be done on it.
Dr. Douglas L. Beck (06:56):
Absolutely so.
Tell me, have you seen anyinteresting patterns that you've
seen through EHF testing?
Do you have any data you canshow us?
I know you work with veteransand you work with active
military now and then, but Iknow you mentioned to me that
you had some interesting casestudies.
Can you show us one?
Dr. Melissa Fling (07:13):
Yeah.
So this first one is a youngman, Air Force veteran, who is a
right-handed shooter.
He worked in water and fuelsystem maintenance, which I
don't know if that's as relevantto the hearing loss as being a
right-handed shooter is.
He perceived worse hearing inhis left ear, but he essentially
shows normal hearing in bothears up to 6,000 hertz.
(07:37):
I'm going to show you what theaudiogram looks like.
So I tested up to 16,000 Hertz.
That day was my capacity, andI've circled 6,000 Hertz, which
is where the militarytechnicians that test hearing
would typically stop for hearingconservation purposes.
And you can see how it dropsway down from.
(07:58):
I'd have to look.
This is 30 is his threshold at6,000 Hertz.
So he has mild hearing lossthere, but it drops down to that
.
Dr. Douglas L. Beck (08:06):
Probably looks like about 60 dB and stays
there, and then it looks likeyou've got five or six data
points that go beyond 8,000Hertz there.
So if you're looking at thefellow's left ear there is a
clear asymmetry, but it wouldn'tshow up in normal audiometry
because they're only testing outto 6K.
In the military and in theregular audiology and hearing
(08:28):
aid dispensing world they testout to 8k, but this really
wouldn't show up.
Dr. Melissa Fling (08:31):
And a little difference at 8 000 hertz
everybody would just say isrelatively insignificant right
and so if he, if he was referredto for a diagnostic with a
military audiologist, then theywould see the drop at 8 000
hertz.
But if, if not, if he didn'tshow a, then they would see the
drop at 8,000 Hertz.
Um, but if, if not, if hedidn't show a significant shift,
they would not necessarilyrefer him for a full diagnostic.
(08:51):
So that would have been, the8,000 Hertz would have been
missed out.
So I'm hoping that in thefuture um the hearing
conservation for you know, thedepartment of defense they will
change their protocol to startincluding not only 8,000 hertz
but extended high frequency,Because I mean that changes the
entire story for him when we seethat.
Dr. Douglas L. Beck (09:13):
Yeah, it really does and it also tells us
.
You'll see that pattern everynow and then in tinnitus
patients, where everything willbe absolutely normal through 8K,
but they'll have an asymmetryor they'll have a high frequency
loss.
That's bilateral, that wouldnot show up below 8K.
Dr. Melissa Fling (09:30):
Right, and then I've got several others
that show hearing loss above 8K.
So here's another 59-year-oldNavy veteran who worked in
construction for the Navy,normal hearing at 8,000 hertz,
which I'm going to circle here.
We're close to it anyway inboth ears.
(09:50):
So I circled the 8,000 hertzthreshold so he's got mild loss
in the left ear at eight.
But then you can see this hugedrop off in the extended high
frequency range.
Dr. Douglas L. Beck (10:00):
What was his primary complaint when he
came in to see you?
Dr. Melissa Fling (10:04):
You know, honestly I don't remember,
because it was over a year agothat I saw him and I didn't make
notes on that, so he may nothave perceived any problem.
I'm not sure.
Dr. Douglas L. Beck (10:13):
Some of these people do, and some don't
have any perception of it, whichis another interesting thing to
look at, but that's what hishearing looks like you as an Air
Force veteran, which I am thechanges that you can expect, you
know, through the military arevery, very slow to happen,
(10:33):
unless there's an immediate need, in a crisis or something you
know that says you must act now.
I wonder have you had anycontact with Military Academy of
Audiology to speak with them orshare ideas to see what they're
, because they're a great groupand I want to give a shout out
to them.
I worked with them many ideasto see what they're, because
they're a great group and um I,I want to give a shout out to
them.
I worked with them many, manyyears ago.
But the military academy ofaudiology would be a great place
(10:55):
to bring this and to startdiscussing it, because if they
say, hey, listen, we need to dothis, um, you know it could get
done the the.
The interesting thing to me alsois that you know we we rarely
we're taught that we don't needto test the mid-tones unless the
difference between the octavesis 20 dB or greater, and I've
(11:15):
always thought that that's anabsolute nonsensical state of
affairs.
That may be true for medicalpurposes Again looking for
medical patterns of the etiologyof hearing loss but I think
there's so much information toget at 750, 1500, 3k and 6K and
when you think about it in themilitary, if they do 255, 124
(11:36):
and 6, that's six data points.
That's all they've got.
If they add in the mid-tones,now they've got 10.
If they add in, let's say, fourspots above 8,000, or five or
six spots, you know now you'regoing, you know up to 14, 15, 16
data points.
That gives you a much clearerimpression of what's actually
going on in that ear than sixdata points.
(11:57):
So I wonder why is it that AAAand ASHA and audiologists and
hearing aid dispensers, why isit they don't do this?
Dr. Melissa Fling (12:06):
Well, I don't know for sure what everybody's
reasoning is, but my guess is,from the places that I've worked
, my guess is time theperception that it will take
significantly more time toinclude six more data points,
let alone 750 and 1500.
So time, you know, we talkedabout this a little bit before
(12:30):
but in an ear, nose and throatoffice that's extremely fast
paced and busy, you have 10minutes from the second you sit
in the room with the patient,get case history and do an audio
and, you know, hand them off tothe physician and they just
have to crank through people.
So there's just not time unlessthey prioritize something like
(12:51):
that.
But insurance reimbursement ispotentially an issue.
There is a modifier forextended high frequency testing
that's been suggested for thepure tone CPT code, but I don't
know how responsive insurancecompanies are to that, If the re
, what the reimbursement is, ifit's consistent.
(13:11):
So it's a time and money issue.
And also I think from justdiscussing it with other
audiologists, some might not seethe purpose in it when we for.
So if somebody has an extendedhigh frequency hearing loss, we
can't yet treat it with hearingaids.
So that's the other obstaclethat's coming up, or the
(13:31):
resistance is.
Ok, I can diagnose it, but Ican't actually treat it.
So what's the point of findingthat information out?
Dr. Douglas L. Beck (13:40):
I'm going to argue that one.
Here's the thing.
So I wrote a paper in 2018 with25 co-authors and we talked
about what do you do withpatients with normal thresholds
who have hearing difficulty orspeech and noise complaints and
things like that.
And the essence of the paper isthat each person has to be
treated as an N of one.
(14:00):
Each has a specific complaint.
That's your primary task ismake sure they're safe and then
address that complaint.
But many of the recommendationswere to try hearing aids.
And, of course, back then inthe 2010s is when the British
Society of Audiology said thatit's totally fine to put hearing
aids on people who have normalhearing but they have tinnitus,
(14:23):
and so you know, I took that andran with it.
I thought that was brilliantand I've always done that anyway
, but I was so glad to see themcome out with it, and now it's
kind of a common thing inaudiology in 2025 in the USA.
To you know, with tinnituspatients, even if they have
normal hearing, you might tryhearing aids and see how that
goes, because you know,habituation, masking, improved
(14:44):
speech and noise, reducedbackground noise all of those
things that you can get with agood quality hearing aid fitting
.
So this is my point on extendedhigh frequencies and I have no
basis for this at all.
But I think if I had a patientwho complained of hearing
difficulty and the only thing Icould find on them is a
difference at 12, 14, 16, 18k,20, 30, 40 dB you know asymmetry
(15:09):
I might try hearing aids andsee if that helps.
Because in essence, you know,what they're complaining about
is lots of things that we can'tmeasure at those high
frequencies and I wouldn't beopposed to trying hearing aids
and I would probably not do thatlightly.
I mean, you got to do real yourmeasures to make sure you're
(15:30):
not getting too noisy.
You have to.
Uh, I would absolutely dospeech and noise aided and
unaided.
And if he or she says to me ohmy gosh, I'm doing so much
better with this hearing aid, um, why wouldn't I suggest that
they wear it?
You know right, yeah, I mean, Iwear hearing aids pretty much
full time.
now, you know I have a mild tomoderate loss and and I can
(15:51):
remember when my hearing losswas only mild every now and then
wearing hearing aids andthinking, oh, this is so much
better, you know.
So you're not trying to fixanything other than their
listening ability, their abilityto make sense and comprehend
the sounds around them.
So I, you know, I don't haveany proof, I can't offer any
proof.
But I think that it's ripe forsomebody to do a study looking
(16:14):
at extended high frequencies,find those people with losses
and with asymmetries and seewhat they respond to, because
you know, I mean, I mean I knowit's been done with small pilot
studies here and there, but Ithink it would be a really
important study, particularlywhen we're talking about the
military, because you know thereare a lot of veterans who will
come home from a tour of dutysomewhere and they'll play I
(16:37):
have difficulty hearing, I don'tunderstand speech noise and
they'll wind up with an FMsystem or a digital remote mic
or hearing aids or a pockettalker and they'll tell you that
life is much better.
And tinnitus is such a greatexample because we can't
directly measure it.
We can use different tools toget a subjective perception of
(16:58):
what their tinnitus is like, butwe physically can't measure it.
And yet we treat it.
And my final word on that isthere's a difference between
treatment and cure, right?
I mean, if I can treat it withhearing aid to make the
patient's quality of life better, I haven't cured it, I haven't
taken it away, I haven't fixedit, but I've given them a tool
(17:18):
that allows them to do betterwith it, to manage with it, and
I think that that's veryworthwhile.
Dr. Melissa Fling (17:33):
Well, and I have a thought about that
because actually some of theresearch has shown that extended
high frequency hearing loss canmimic learning disorders in
children.
So again it's just going backto why wouldn't we want more
data points to investigate whysomebody is having the
difficulty that they are childor adult, More information is
(17:53):
better, but I think it comesdown to a matter of time and
money and cost for adding thatmodule onto an audiometer.
Dr. Douglas L. Beck (17:56):
So it seems to me in my read of the
literature over these last fewweeks prepping for this, it
looks like the modules that youneed.
You need something on youraudiometer that can produce
those sounds at the rightoscillations, and that's an
issue, issue but it's doable formany audiographers.
And then you need heads,headsets that can reproduce it
right, uh, special transducersto accurately, um, deliver that
(18:18):
sound.
So so that runs what like 1500bucks, 2000 bucks yeah, that's.
Dr. Melissa Fling (18:23):
That's what I paid once on a colleague's GSI
61.
It might have been about $1,200to add the module onto that.
And then I also had to buy theDD450 headphones, which were I
can't remember.
Now I want to say $900.
That might be off.
So it was an investment, butworth it to me because I'm
(18:44):
totally fascinated by extendedhigh-frequency hearing loss and
right now I'm not doing anytreatment with it because it's
mostly veterans that I'm doingthis testing on.
But it's so fascinating to seethe patterns that come up and
how they either match or don'tmatch with their perceived
difficulties.
Dr. Douglas L. Beck (19:04):
Yeah, I'm.
I'm really curious.
I will try to get in touch.
Some of my friends who used towork in San Antonio when I was
in San Antonio were taking careof veterans and I'm curious what
the main line of thinking is inthis situation when you have
asymmetries or hearing loss, itextended high frequencies, and
perhaps the answer is they don'ttest it, so they don't know
(19:25):
about that.
So what are the limits of theapplication of EHF test results?
Dr. Melissa Fling (19:30):
Well, kind of like we already talked about.
I think it's a matter of okay.
Now we know that you havehearing loss in this range, what
do we do about it?
Hearing aids receivers can'tproduce that range of sound.
So how do we treat it?
And I think, just like you said, if you feel that it's safe and
appropriate and it's not goingto hurt anything, why not just
(19:53):
try hearing aids and see if justhaving a little bit of a boost
will give somebody help?
That's no different than whatwe have done with people with
auditory processing disorder whoshow normal hearing.
They're often fit with somekind of ear level device.
Dr. Douglas L. Beck (20:07):
Absolutely, and they've been doing that
since World War II.
Blaise M. Delfino, M.S. - HI (20:10):
Fm trainers the old headset.
Dr. Douglas L. Beck (20:13):
And most of those kids didn't have hearing
loss right.
They didn't need things louder,they needed things clearer, and
the way to accomplish that wasto give them an improved
signal-to-noise ratio.
You know, I know that theoriginal audiometers right from
100 years ago the first one outthere went up to whatever it was
20,000 hertz right, and thenthe second one was it
(20:33):
Westinghouse, I think it was20,000 Hertz right, and then the
second one was it Westinghouse,I think it was Westinghouse.
The second one, wa2 or whateverit was called, only went out to
8,000 Hertz, and so we've knownabout the value of measuring
the entire human hearingspectrum for a hundred years,
but commercially it just didn'thappen.
And so I'm wondering when, whenyou have so many manufacturers
(21:01):
now making audiometers and andyou know, pretty small these
days and, and you know, usuallyattached to a computer and all
that good stuff.
So the question is is there onein particular I mean, I hate to
do this because I don't want toget hate mail from the others,
but is there one or two that youmight mention that you know,
offer this, uh, as a regularpart of their audiometry
(21:24):
packaging?
Dr. Melissa Fling (21:25):
yeah, well, there are several.
So I have the med recs awrc,which is a computer-based
audiometer.
Love it, it Interacousticsmakes.
Ehf testing available.
Otometrics GSI Shoebox goes upto 16,000 hertz.
So there's plenty of.
I mean all the main audiometermanufacturers are offering it.
Dr. Douglas L. Beck (21:50):
And so that's great.
I'm glad you mentioned that.
Now tell me about your personalopinion as somebody who's
studied this and been involvedwith this.
When a patient comes in andthey say I have difficulty in a
cocktail party situation, I havedifficulty speech and noise,
are you going to test allfrequencies or do you just see
what you get through 8,000 andthen make a decision?
(22:10):
I mean, what's your standardprotocol is what I'm asking.
Dr. Melissa Fling (22:14):
Yes, so what I've been doing.
So I would like to do it oneverybody, just to see, because
I like seeing the patterns andseeing what comes up, no matter
what the complaints are.
But sometimes, when I'm loweron time, if it's an older person
, that's maybe in their sixties,sevents I already know that
(22:35):
they have hearing loss between250 and 8000 or it's likely that
they do so.
Once I'm doing that testing Isee what that looks like.
If I have extra time I'll doEHF testing on them.
If I don't, then I won't, andit might not be as valuable
information with them as itwould be with somebody who shows
relatively normal hearingbetween 250 and eight.
(22:56):
So I tend to do it.
I tend to stick to my gunsdoing it on younger people that
show normal hearing between 250and eight and less, with older
populations that show hearingloss at that range.
But if I had all the time I'ddo it on yeah, as as at least as
the the first time that I testthem.
Dr. Douglas L. Beck (23:18):
You know this is.
It's more of a politicalstatement that I'm happy to make
.
I'm an old guy.
They say whatever they want, Idon't care, but we're in this
difficult situation where wehave best practices right and
AAA, ash and IHS.
The best practices arebrilliant, they're all excellent
, they all need to be renewed,but they're all excellent.
(23:38):
And my point is that we don'tget paid to do best practices.
We get paid to do 92557 andother little things and it's a
huge problem.
Physicians are in the same boat, nurses are in the same boat,
ots, pts, speech, languagepathology are in the same boat
OTs, pts, speech, languagepathology.
But it sets us up for failurebecause we know so much more
(24:00):
than what we can bill.
We know how to find moreimportant diagnostic information
than what we can bill for.
And I think you're speakinghonestly to the fact that people
don't do the work that we canand probably should do because
we're limited by reimbursementthrough crazy insurance
companies, you know, won'treimburse for the work you did.
You know we all have ICD-10sand CPT codes and it's a
(24:25):
shambles, I you know.
And and it just gets worse andworse the more you look at it.
I wonder if one day we'll goback to fee for service, cause.
If we did, I think everybodycould then do the complete best
practice protocol, which wouldbe always in the patient's best
interest.
And that gets us to oh, that'swhy we do screenings, because
it's more efficient.
No, it's not.
(24:45):
It's not A pure tone screening.
So if I do a pure tone screeningon any of your patients 250,
500, 1k, 2k, maybe throwing 3Kand 4K at 30 dB or 25, you know
all these intricate patternsthat you're finding, all of this
very valuable high frequencyinformation none of it would be
found.
If the patient had asymmetriesthat you know started at 8K and
(25:10):
went above, they would never beseen.
And you know when patients comein for screenings, we're in
this terrible position where wesay well, you know your hearing
is normal through the screeningand nobody tested their speech
and noise and their speech andnoise might be deplorable, which
Rich Wilson made very clear in2011 that um of the 3,500
(25:31):
veterans he tested um in quiet Ithink now I'm going to go off
the top of my head, but I'mgoing to be pretty close About
90% of them had normal wordrecognition scores in quiet and
when he tested them with speechand noise, 70% of those failed.
So the point is yeah 70% of them, but they passed all these
(25:52):
shortcuts, practices, but theypassed because we took all these
shortcuts.
So I don't know, just my ownlittle rant that I've been on
for about 40 years.
Dr. Melissa Fling (26:00):
Well, I'm getting into the same headspace.
I get angry all the timethinking about how we've allowed
insurance to put their handsnot only into our money, but the
way that we decide how wepractice, because they're the
boss of how we get reimbursed,which is not the way that it
should be.
They should not dictate the waythat we practice.
We should.
Dr. Douglas L. Beck (26:21):
Right, and it should be.
You know, not maybe each of usas an individual, but if we're
going to speak theoretically,you know you have a working
group at AAA or ASHA or IHS.
They say this is best practice,this is what we recommend.
That's what you do, Right,chest.
They say this is best practice,this is what we recommend.
That's what you do Right, andthen the evidence back, whatever
their decisions are.
And and that would be great,you know, I I think stuff like
(26:45):
extended high frequency umtesting would be a part of every
test.
Um, so would speech and noise.
But you know, speech and noiseis already in best practices by
every major group, yet only 15%of us do it.
And you're right.
It is time and money, I mean.
I don't think anybody says, oh,it's not worth doing.
I think it's always time andmoney, and you know that puts us
in a tough spot Anyway.
So if listeners were to takeaway one thing about extra high
(27:05):
frequency testing, what wouldyou want that to be?
Dr. Melissa Fling (27:09):
I'm going to kind of steal from a hearing
journal article that I readrecently and at the end they say
to steal from a hearing journalarticle that I read recently
and at the end they say there'salways got to be the first kid
on the block doing it.
So start doing it.
The more of us that do it, themore this will become the
standard.
It should be the standard.
We should be testing the entirecochlea, not a part of it.
(27:29):
And another thing that thismakes me think of I want to give
a shout out to a formersupervisor professor at Central
Michigan, shannon Palmer.
She always said to us in classand in clinic don't be an oddie.
Almost.
Do it the right way, do it thethorough way.
You're getting a doctorate.
(27:52):
There's a reason that you'regetting a doctorate.
There's there's a reason thatyou you know you're getting a
doctorate you need to beperforming at a high level.
So let's do what we should bedoing and and evaluate people
comprehensively.
And the more we all start doingit and diagnosing it, I wonder
if the hearing aid industry willkind of come along and try to
(28:12):
catch up with that, becausethere will be more and more need
for hearing aids to be able toamplify in that range.
So we've just got to startdoing it, that's all.
Dr. Douglas L. Beck (28:22):
Well, the industry frequently does follow
practice and I can tell you Iwrote a paper gosh, I'm going to
say 15 years ago on extendedbandwidths in hearing aids and
at that point the extendedbandwidth was going out to 6,000
to 8,000 hertz and that wasunusual because hearing aids
prior to that only went outreally to about 3,000 or 4,000
(28:42):
hertz.
But I do think that the hearingaid industry responds very, very
well to clinical needs and Ithink if we had enough data to
show how important this is, Ithink they could probably you
know it's not easy because theydon't have the transducers right
now, but they could start doingR&D on them out to, you know,
12,000 hertz or maybe 14,000 ona good day, but 10 to 12,000
(29:06):
hertz Now.
Some of the hearing aidmanufacturers do go out to
10,000 hertz now, but there'sjust not a lot of gain available
there and you know there's somany issues that get involved.
But I do think that if the datasupports that, audiologists and
dispensers are going to starttesting on a regular basis five
or six data points, like you do,beyond 8,000 hertz, it would be
(29:26):
nice to have some products thatcould reach that.
So I think you're exactly right,all right.
Well, listen, melissa, it'sbeen a joy to spend time with
you and I'm so happy that we hadthis discussion, and I will try
to follow up with the MilitaryAcademy of Audiology.
I think this is a greatquestion.
I used to have some friendsthere.
I don't know if they're stillthere, but I'll try and I wish
you a joyous afternoon.
(29:47):
Thank you so much.
Dr. Melissa Fling (29:49):
Thank you, Dr Beck.
Dr. Douglas L. Beck (29:50):
My pleasure .
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
today I'm here with my guest,Dr Melissa Fling.
She is a clinical audiologistand owner and founder of Custom
Ear Solutions, a small privatepractice in Denver, Colorado.
Through Custom Ear Solutions,Dr Fling specializes in hearing
conservation and custom fittedear molds for hearing protection
(01:18):
and other uses.
She is a graduate of CentralMichigan University, one of my
favorite old schools, and shehas been practicing audiology
for almost 10 years in manydifferent settings.
Dr Fling is certified throughthe American Speech-Language
Hearing Association and she islicensed in many states,
including Colorado, California,Arizona, Utah and New Mexico, so
(01:38):
that means you can go almostanywhere.
Anyway, thank you for joiningme.
Dr. Melissa Fling (01:43):
Thank you, Dr Beck.
I'm so excited to be here.
Dr. Douglas L. Beck (01:46):
Our topic for the day is extended
high-frequency hearing andhearing loss and hearing aids
and everything else that couldhave an extended high frequency
but doesn't in general.
So I want to start by askingyou to tell me what is extended
high-frequency hearing.
Dr. Melissa Fling (02:01):
As audiologists, we all know that
humans can hear between 20 hertzand 20,000 hertz and
historically it's been standardto test from about 250 hertz up
to 8,000 hertz, because theresearch, I suppose, in the past
has shown that that's where wepick up the most speech
information, which is what we'remost interested in knowing if
(02:22):
somebody can hear.
But then we're missing out onall this information between
8,000 and 20,000 hertz andthat's what we refer to as
extended high frequency or ultrahigh frequency hearing.
Dr. Douglas L. Beck (02:34):
Right.
And this is so interesting tome because the reason I think
that we do 250 to 8,000 isbecause that aligns very well
with medical diagnosis.
So you know, if I look between250 and 8000 hertz I can see
patterns like presbycusis, likenoise induced hearing loss, like
a car heart notch, like airbone gap, things like that.
(02:56):
So so it's very, very useful tolook there for medical reasons.
But I think what we've learnedover the decades and I do mean
decades since World War Twowe've learned that there's so
much information to be had above8000 hertz and I really think
we're overdue to be testing that.
So what does the literature sayabout extended high frequencies
(03:16):
as far as the sensitivity tothat?
Dr. Melissa Fling (03:19):
Well, it seems like when people start to
lose sensitivity in the extendedhigh frequency range it can
potentially affect theirlocalization.
It's definitely affecting theirspeech perception, particularly
in complex listeningenvironments.
It can affect the perception ofmusic quality.
So obviously with musiciansthey might start to notice
(03:42):
something early on that mightnot show on a standard audiogram
.
So those are the three mainthings that I've come across
localization, music perceptionand speech perception in
complicated listeningenvironments.
Dr. Douglas L. Beck (03:56):
And you know.
The thing about this is, whenyou're looking above 8,000 hertz
, you know there's so muchliterature that shows the
topographic organization of theeighth nerve and the cochlea,
and so when you start to havedamage at 8, 10, 12, 14, 16, 18,
20,000 hertz, that could be anearly warning sign of hearing
loss yet to show up on thestandard audiogram.
(04:18):
And I want to point out thatall you need is about 50% of
those fibers intact in order topress the button when you hear a
beep and have normal responseswhen somebody says they have a
normal audiogram but they can'tunderstand speech and noise,
which is at least 26 millionpeople.
Jeff Danauer and I wrote apaper on that that was peer
reviewed in 2019.
(04:39):
And we identified 26 million.
So now it's six years later.
So I would I would guess it's28 or maybe 30 million people if
we were to redo all that work,but but I think that the point
is that if you're looking above8,000 Hertz, it could be a
precursor to what's about tohappen below 8,000 Hertz.
What are your thoughts on that?
Dr. Melissa Fling (04:57):
I agree and I think just in my experience now
I see that it can validatesomebody's concerns about it
when in the past they've beentold that they have normal
hearing.
I've seen huge asymmetriesbetween 8 and 20,000 hertz.
I've seen significant hearingloss in that range.
That could point to why someonehas tinnitus or that could
(05:19):
point to why someone perceivestheir tinnitus as being louder
in one ear, why someoneperceives their tinnitus as
being louder in one ear.
I was just actually messagingback and forth with someone on
LinkedIn the other day who hasseen a case where there was a
significant extended highfrequency asymmetry and it
turned out that person had avestibular schwannoma on the
side that was worse.
So they probably detected thatway earlier than would have been
(05:44):
detected.
Dr. Douglas L. Beck (05:46):
I mean, symptoms may have shown up, but
yeah, I mean when you go backthrough the literature, you know
, in 1977, 1978, weldon Seltzerand Daryl Brackman looked at the
sensitivity of ABR, using ABRto detect acoustic neuromas or
vestibular schwannomas, and whatthey found was very interesting
, right, they found anelongation between wave one and
(06:07):
wave five, which typicallyshould be 4.0 milliseconds, but
it would be maybe five or six orseven or nothing, no response
at all.
And that turned out to be very,very important in detecting
acoustic tumors.
And I think that the thing hereis that an ABR click is
essentially a square wave andmost of the energy, if I recall,
is going to be around 2,000hertz, 4,000 hertz.
(06:29):
So what you're saying is well,if you looked higher up in the
spectral range, you might seedamage sooner, which might make
sense, because if an acousticneuroma is touching an auditory
nerve, it's mostly impinging onthose high fibers first.
Dr. Melissa Fling (06:43):
So I agree with you.
Dr. Douglas L. Beck (06:44):
And I don't know that anybody's really
looked at this.
Dr. Melissa Fling (06:46):
I don't know that they have either, because
really nobody's testing extendedhigh frequency.
So there's so much researchthat is still that still needs
to be done on it.
Dr. Douglas L. Beck (06:56):
Absolutely so.
Tell me, have you seen anyinteresting patterns that you've
seen through EHF testing?
Do you have any data you canshow us?
I know you work with veteransand you work with active
military now and then, but Iknow you mentioned to me that
you had some interesting casestudies.
Can you show us one?
Dr. Melissa Fling (07:13):
Yeah.
So this first one is a youngman, Air Force veteran, who is a
right-handed shooter.
He worked in water and fuelsystem maintenance, which I
don't know if that's as relevantto the hearing loss as being a
right-handed shooter is.
He perceived worse hearing inhis left ear, but he essentially
shows normal hearing in bothears up to 6,000 hertz.
(07:37):
I'm going to show you what theaudiogram looks like.
So I tested up to 16,000 Hertz.
That day was my capacity, andI've circled 6,000 Hertz, which
is where the militarytechnicians that test hearing
would typically stop for hearingconservation purposes.
And you can see how it dropsway down from.
(07:58):
I'd have to look.
This is 30 is his threshold at6,000 Hertz.
So he has mild hearing lossthere, but it drops down to that
.
Dr. Douglas L. Beck (08:06):
Probably looks like about 60 dB and stays
there, and then it looks likeyou've got five or six data
points that go beyond 8,000Hertz there.
So if you're looking at thefellow's left ear there is a
clear asymmetry, but it wouldn'tshow up in normal audiometry
because they're only testing outto 6K.
In the military and in theregular audiology and hearing
(08:28):
aid dispensing world they testout to 8k, but this really
wouldn't show up.
Dr. Melissa Fling (08:31):
And a little difference at 8 000 hertz
everybody would just say isrelatively insignificant right
and so if he, if he was referredto for a diagnostic with a
military audiologist, then theywould see the drop at 8 000
hertz.
But if, if not, if he didn'tshow a, then they would see the
drop at 8,000 Hertz.
Um, but if, if not, if hedidn't show a significant shift,
they would not necessarilyrefer him for a full diagnostic.
(08:51):
So that would have been, the8,000 Hertz would have been
missed out.
So I'm hoping that in thefuture um the hearing
conservation for you know, thedepartment of defense they will
change their protocol to startincluding not only 8,000 hertz
but extended high frequency,Because I mean that changes the
entire story for him when we seethat.
Dr. Douglas L. Beck (09:13):
Yeah, it really does and it also tells us
.
You'll see that pattern everynow and then in tinnitus
patients, where everything willbe absolutely normal through 8K,
but they'll have an asymmetryor they'll have a high frequency
loss.
That's bilateral, that wouldnot show up below 8K.
Dr. Melissa Fling (09:30):
Right, and then I've got several others
that show hearing loss above 8K.
So here's another 59-year-oldNavy veteran who worked in
construction for the Navy,normal hearing at 8,000 hertz,
which I'm going to circle here.
We're close to it anyway inboth ears.
(09:50):
So I circled the 8,000 hertzthreshold so he's got mild loss
in the left ear at eight.
But then you can see this hugedrop off in the extended high
frequency range.
Dr. Douglas L. Beck (10:00):
What was his primary complaint when he
came in to see you?
Dr. Melissa Fling (10:04):
You know, honestly I don't remember,
because it was over a year agothat I saw him and I didn't make
notes on that, so he may nothave perceived any problem.
I'm not sure.
Dr. Douglas L. Beck (10:13):
Some of these people do, and some don't
have any perception of it, whichis another interesting thing to
look at, but that's what hishearing looks like you as an Air
Force veteran, which I am thechanges that you can expect, you
know, through the military arevery, very slow to happen,
(10:33):
unless there's an immediate need, in a crisis or something you
know that says you must act now.
I wonder have you had anycontact with Military Academy of
Audiology to speak with them orshare ideas to see what they're
, because they're a great groupand I want to give a shout out
to them.
I worked with them many ideasto see what they're, because
they're a great group and um I,I want to give a shout out to
them.
I worked with them many, manyyears ago.
But the military academy ofaudiology would be a great place
(10:55):
to bring this and to startdiscussing it, because if they
say, hey, listen, we need to dothis, um, you know it could get
done the the.
The interesting thing to me alsois that you know we we rarely
we're taught that we don't needto test the mid-tones unless the
difference between the octavesis 20 dB or greater, and I've
(11:15):
always thought that that's anabsolute nonsensical state of
affairs.
That may be true for medicalpurposes Again looking for
medical patterns of the etiologyof hearing loss but I think
there's so much information toget at 750, 1500, 3k and 6K and
when you think about it in themilitary, if they do 255, 124
(11:36):
and 6, that's six data points.
That's all they've got.
If they add in the mid-tones,now they've got 10.
If they add in, let's say, fourspots above 8,000, or five or
six spots, you know now you'regoing, you know up to 14, 15, 16
data points.
That gives you a much clearerimpression of what's actually
going on in that ear than sixdata points.
(11:57):
So I wonder why is it that AAAand ASHA and audiologists and
hearing aid dispensers, why isit they don't do this?
Dr. Melissa Fling (12:06):
Well, I don't know for sure what everybody's
reasoning is, but my guess is,from the places that I've worked
, my guess is time theperception that it will take
significantly more time toinclude six more data points,
let alone 750 and 1500.
So time, you know, we talkedabout this a little bit before
(12:30):
but in an ear, nose and throatoffice that's extremely fast
paced and busy, you have 10minutes from the second you sit
in the room with the patient,get case history and do an audio
and, you know, hand them off tothe physician and they just
have to crank through people.
So there's just not time unlessthey prioritize something like
(12:51):
that.
But insurance reimbursement ispotentially an issue.
There is a modifier forextended high frequency testing
that's been suggested for thepure tone CPT code, but I don't
know how responsive insurancecompanies are to that, If the re
, what the reimbursement is, ifit's consistent.
(13:11):
So it's a time and money issue.
And also I think from justdiscussing it with other
audiologists, some might not seethe purpose in it when we for.
So if somebody has an extendedhigh frequency hearing loss, we
can't yet treat it with hearingaids.
So that's the other obstaclethat's coming up, or the
(13:31):
resistance is.
Ok, I can diagnose it, but Ican't actually treat it.
So what's the point of findingthat information out?
Dr. Douglas L. Beck (13:40):
I'm going to argue that one.
Here's the thing.
So I wrote a paper in 2018 with25 co-authors and we talked
about what do you do withpatients with normal thresholds
who have hearing difficulty orspeech and noise complaints and
things like that.
And the essence of the paper isthat each person has to be
treated as an N of one.
(14:00):
Each has a specific complaint.
That's your primary task ismake sure they're safe and then
address that complaint.
But many of the recommendationswere to try hearing aids.
And, of course, back then inthe 2010s is when the British
Society of Audiology said thatit's totally fine to put hearing
aids on people who have normalhearing but they have tinnitus,
(14:23):
and so you know, I took that andran with it.
I thought that was brilliantand I've always done that anyway
, but I was so glad to see themcome out with it, and now it's
kind of a common thing inaudiology in 2025 in the USA.
To you know, with tinnituspatients, even if they have
normal hearing, you might tryhearing aids and see how that
goes, because you know,habituation, masking, improved
(14:44):
speech and noise, reducedbackground noise all of those
things that you can get with agood quality hearing aid fitting
.
So this is my point on extendedhigh frequencies and I have no
basis for this at all.
But I think if I had a patientwho complained of hearing
difficulty and the only thing Icould find on them is a
difference at 12, 14, 16, 18k,20, 30, 40 dB you know asymmetry
(15:09):
I might try hearing aids andsee if that helps.
Because in essence, you know,what they're complaining about
is lots of things that we can'tmeasure at those high
frequencies and I wouldn't beopposed to trying hearing aids
and I would probably not do thatlightly.
I mean, you got to do real yourmeasures to make sure you're
(15:30):
not getting too noisy.
You have to.
Uh, I would absolutely dospeech and noise aided and
unaided.
And if he or she says to me ohmy gosh, I'm doing so much
better with this hearing aid, um, why wouldn't I suggest that
they wear it?
You know right, yeah, I mean, Iwear hearing aids pretty much
full time.
now, you know I have a mild tomoderate loss and and I can
(15:51):
remember when my hearing losswas only mild every now and then
wearing hearing aids andthinking, oh, this is so much
better, you know.
So you're not trying to fixanything other than their
listening ability, their abilityto make sense and comprehend
the sounds around them.
So I, you know, I don't haveany proof, I can't offer any
proof.
But I think that it's ripe forsomebody to do a study looking
(16:14):
at extended high frequencies,find those people with losses
and with asymmetries and seewhat they respond to, because
you know, I mean, I mean I knowit's been done with small pilot
studies here and there, but Ithink it would be a really
important study, particularlywhen we're talking about the
military, because you know thereare a lot of veterans who will
come home from a tour of dutysomewhere and they'll play I
(16:37):
have difficulty hearing, I don'tunderstand speech noise and
they'll wind up with an FMsystem or a digital remote mic
or hearing aids or a pockettalker and they'll tell you that
life is much better.
And tinnitus is such a greatexample because we can't
directly measure it.
We can use different tools toget a subjective perception of
(16:58):
what their tinnitus is like, butwe physically can't measure it.
And yet we treat it.
And my final word on that isthere's a difference between
treatment and cure, right?
I mean, if I can treat it withhearing aid to make the
patient's quality of life better, I haven't cured it, I haven't
taken it away, I haven't fixedit, but I've given them a tool
(17:18):
that allows them to do betterwith it, to manage with it, and
I think that that's veryworthwhile.
Dr. Melissa Fling (17:33):
Well, and I have a thought about that
because actually some of theresearch has shown that extended
high frequency hearing loss canmimic learning disorders in
children.
So again it's just going backto why wouldn't we want more
data points to investigate whysomebody is having the
difficulty that they are childor adult, More information is
(17:53):
better, but I think it comesdown to a matter of time and
money and cost for adding thatmodule onto an audiometer.
Dr. Douglas L. Beck (17:56):
So it seems to me in my read of the
literature over these last fewweeks prepping for this, it
looks like the modules that youneed.
You need something on youraudiometer that can produce
those sounds at the rightoscillations, and that's an
issue, issue but it's doable formany audiographers.
And then you need heads,headsets that can reproduce it
right, uh, special transducersto accurately, um, deliver that
(18:18):
sound.
So so that runs what like 1500bucks, 2000 bucks yeah, that's.
Dr. Melissa Fling (18:23):
That's what I paid once on a colleague's GSI
61.
It might have been about $1,200to add the module onto that.
And then I also had to buy theDD450 headphones, which were I
can't remember.
Now I want to say $900.
That might be off.
So it was an investment, butworth it to me because I'm
(18:44):
totally fascinated by extendedhigh-frequency hearing loss and
right now I'm not doing anytreatment with it because it's
mostly veterans that I'm doingthis testing on.
But it's so fascinating to seethe patterns that come up and
how they either match or don'tmatch with their perceived
difficulties.
Dr. Douglas L. Beck (19:04):
Yeah, I'm.
I'm really curious.
I will try to get in touch.
Some of my friends who used towork in San Antonio when I was
in San Antonio were taking careof veterans and I'm curious what
the main line of thinking is inthis situation when you have
asymmetries or hearing loss, itextended high frequencies, and
perhaps the answer is they don'ttest it, so they don't know
(19:25):
about that.
So what are the limits of theapplication of EHF test results?
Dr. Melissa Fling (19:30):
Well, kind of like we already talked about.
I think it's a matter of okay.
Now we know that you havehearing loss in this range, what
do we do about it?
Hearing aids receivers can'tproduce that range of sound.
So how do we treat it?
And I think, just like you said, if you feel that it's safe and
appropriate and it's not goingto hurt anything, why not just
(19:53):
try hearing aids and see if justhaving a little bit of a boost
will give somebody help?
That's no different than whatwe have done with people with
auditory processing disorder whoshow normal hearing.
They're often fit with somekind of ear level device.
Dr. Douglas L. Beck (20:07):
Absolutely, and they've been doing that
since World War II.
Blaise M. Delfino, M.S. - HI (20:10):
Fm trainers the old headset.
Dr. Douglas L. Beck (20:13):
And most of those kids didn't have hearing
loss right.
They didn't need things louder,they needed things clearer, and
the way to accomplish that wasto give them an improved
signal-to-noise ratio.
You know, I know that theoriginal audiometers right from
100 years ago the first one outthere went up to whatever it was
20,000 hertz right, and thenthe second one was it
(20:33):
Westinghouse, I think it was20,000 Hertz right, and then the
second one was it Westinghouse,I think it was Westinghouse.
The second one, wa2 or whateverit was called, only went out to
8,000 Hertz, and so we've knownabout the value of measuring
the entire human hearingspectrum for a hundred years,
but commercially it just didn'thappen.
And so I'm wondering when, whenyou have so many manufacturers
(21:01):
now making audiometers and andyou know, pretty small these
days and, and you know, usuallyattached to a computer and all
that good stuff.
So the question is is there onein particular I mean, I hate to
do this because I don't want toget hate mail from the others,
but is there one or two that youmight mention that you know,
offer this, uh, as a regularpart of their audiometry
(21:24):
packaging?
Dr. Melissa Fling (21:25):
yeah, well, there are several.
So I have the med recs awrc,which is a computer-based
audiometer.
Love it, it Interacousticsmakes.
Ehf testing available.
Otometrics GSI Shoebox goes upto 16,000 hertz.
So there's plenty of.
I mean all the main audiometermanufacturers are offering it.
Dr. Douglas L. Beck (21:50):
And so that's great.
I'm glad you mentioned that.
Now tell me about your personalopinion as somebody who's
studied this and been involvedwith this.
When a patient comes in andthey say I have difficulty in a
cocktail party situation, I havedifficulty speech and noise,
are you going to test allfrequencies or do you just see
what you get through 8,000 andthen make a decision?
(22:10):
I mean, what's your standardprotocol is what I'm asking.
Dr. Melissa Fling (22:14):
Yes, so what I've been doing.
So I would like to do it oneverybody, just to see, because
I like seeing the patterns andseeing what comes up, no matter
what the complaints are.
But sometimes, when I'm loweron time, if it's an older person
, that's maybe in their sixties,sevents I already know that
(22:35):
they have hearing loss between250 and 8000 or it's likely that
they do so.
Once I'm doing that testing Isee what that looks like.
If I have extra time I'll doEHF testing on them.
If I don't, then I won't, andit might not be as valuable
information with them as itwould be with somebody who shows
relatively normal hearingbetween 250 and eight.
(22:56):
So I tend to do it.
I tend to stick to my gunsdoing it on younger people that
show normal hearing between 250and eight and less, with older
populations that show hearingloss at that range.
But if I had all the time I'ddo it on yeah, as as at least as
the the first time that I testthem.
Dr. Douglas L. Beck (23:18):
You know this is.
It's more of a politicalstatement that I'm happy to make
.
I'm an old guy.
They say whatever they want, Idon't care, but we're in this
difficult situation where wehave best practices right and
AAA, ash and IHS.
The best practices arebrilliant, they're all excellent
, they all need to be renewed,but they're all excellent.
(23:38):
And my point is that we don'tget paid to do best practices.
We get paid to do 92557 andother little things and it's a
huge problem.
Physicians are in the same boat, nurses are in the same boat,
ots, pts, speech, languagepathology are in the same boat
OTs, pts, speech, languagepathology.
But it sets us up for failurebecause we know so much more
(24:00):
than what we can bill.
We know how to find moreimportant diagnostic information
than what we can bill for.
And I think you're speakinghonestly to the fact that people
don't do the work that we canand probably should do because
we're limited by reimbursementthrough crazy insurance
companies, you know, won'treimburse for the work you did.
You know we all have ICD-10sand CPT codes and it's a
(24:25):
shambles, I you know.
And and it just gets worse andworse the more you look at it.
I wonder if one day we'll goback to fee for service, cause.
If we did, I think everybodycould then do the complete best
practice protocol, which wouldbe always in the patient's best
interest.
And that gets us to oh, that'swhy we do screenings, because
it's more efficient.
No, it's not.
(24:45):
It's not A pure tone screening.
So if I do a pure tone screeningon any of your patients 250,
500, 1k, 2k, maybe throwing 3Kand 4K at 30 dB or 25, you know
all these intricate patternsthat you're finding, all of this
very valuable high frequencyinformation none of it would be
found.
If the patient had asymmetriesthat you know started at 8K and
(25:10):
went above, they would never beseen.
And you know when patients comein for screenings, we're in
this terrible position where wesay well, you know your hearing
is normal through the screeningand nobody tested their speech
and noise and their speech andnoise might be deplorable, which
Rich Wilson made very clear in2011 that um of the 3,500
(25:31):
veterans he tested um in quiet Ithink now I'm going to go off
the top of my head, but I'mgoing to be pretty close About
90% of them had normal wordrecognition scores in quiet and
when he tested them with speechand noise, 70% of those failed.
So the point is yeah 70% of them, but they passed all these
(25:52):
shortcuts, practices, but theypassed because we took all these
shortcuts.
So I don't know, just my ownlittle rant that I've been on
for about 40 years.
Dr. Melissa Fling (26:00):
Well, I'm getting into the same headspace.
I get angry all the timethinking about how we've allowed
insurance to put their handsnot only into our money, but the
way that we decide how wepractice, because they're the
boss of how we get reimbursed,which is not the way that it
should be.
They should not dictate the waythat we practice.
We should.
Dr. Douglas L. Beck (26:21):
Right, and it should be.
You know, not maybe each of usas an individual, but if we're
going to speak theoretically,you know you have a working
group at AAA or ASHA or IHS.
They say this is best practice,this is what we recommend.
That's what you do, Right,chest.
They say this is best practice,this is what we recommend.
That's what you do Right, andthen the evidence back, whatever
their decisions are.
And and that would be great,you know, I I think stuff like
(26:45):
extended high frequency umtesting would be a part of every
test.
Um, so would speech and noise.
But you know, speech and noiseis already in best practices by
every major group, yet only 15%of us do it.
And you're right.
It is time and money, I mean.
I don't think anybody says, oh,it's not worth doing.
I think it's always time andmoney, and you know that puts us
in a tough spot Anyway.
So if listeners were to takeaway one thing about extra high
(27:05):
frequency testing, what wouldyou want that to be?
Dr. Melissa Fling (27:09):
I'm going to kind of steal from a hearing
journal article that I readrecently and at the end they say
to steal from a hearing journalarticle that I read recently
and at the end they say there'salways got to be the first kid
on the block doing it.
So start doing it.
The more of us that do it, themore this will become the
standard.
It should be the standard.
We should be testing the entirecochlea, not a part of it.
(27:29):
And another thing that thismakes me think of I want to give
a shout out to a formersupervisor professor at Central
Michigan, shannon Palmer.
She always said to us in classand in clinic don't be an oddie.
Almost.
Do it the right way, do it thethorough way.
You're getting a doctorate.
(27:52):
There's a reason that you'regetting a doctorate.
There's there's a reason thatyou you know you're getting a
doctorate you need to beperforming at a high level.
So let's do what we should bedoing and and evaluate people
comprehensively.
And the more we all start doingit and diagnosing it, I wonder
if the hearing aid industry willkind of come along and try to
(28:12):
catch up with that, becausethere will be more and more need
for hearing aids to be able toamplify in that range.
So we've just got to startdoing it, that's all.
Dr. Douglas L. Beck (28:22):
Well, the industry frequently does follow
practice and I can tell you Iwrote a paper gosh, I'm going to
say 15 years ago on extendedbandwidths in hearing aids and
at that point the extendedbandwidth was going out to 6,000
to 8,000 hertz and that wasunusual because hearing aids
prior to that only went outreally to about 3,000 or 4,000
(28:42):
hertz.
But I do think that the hearingaid industry responds very, very
well to clinical needs and Ithink if we had enough data to
show how important this is, Ithink they could probably you
know it's not easy because theydon't have the transducers right
now, but they could start doingR&D on them out to, you know,
12,000 hertz or maybe 14,000 ona good day, but 10 to 12,000
(29:06):
hertz Now.
Some of the hearing aidmanufacturers do go out to
10,000 hertz now, but there'sjust not a lot of gain available
there and you know there's somany issues that get involved.
But I do think that if the datasupports that, audiologists and
dispensers are going to starttesting on a regular basis five
or six data points, like you do,beyond 8,000 hertz, it would be
(29:26):
nice to have some products thatcould reach that.
So I think you're exactly right,all right.
Well, listen, melissa, it'sbeen a joy to spend time with
you and I'm so happy that we hadthis discussion, and I will try
to follow up with the MilitaryAcademy of Audiology.
I think this is a greatquestion.
I used to have some friendsthere.
I don't know if they're stillthere, but I'll try and I wish
you a joyous afternoon.
(29:47):
Thank you so much.
Dr. Melissa Fling (29:49):
Thank you, Dr Beck.
Dr. Douglas L. Beck (29:50):
My pleasure .
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