Frustration with so-called “minimal” hearing loss (updated)

UPDATE 1: Please see the new item below about an audiologist for a hearing aid manufacturer

UPDATE 2: Please see the Consensus Statement from the 1990 Vanderbilt/VA Hearing Aid Conference

Better Hearing Institute  director Dr Sergei Kochkin had an interesting reply to Jason Galsters’ What motivates hearing aid use:

So many of the people with hearing loss have mild hearing loss and are simply not candidates for amplification.

We don’t buy that statement, for two reasons:

(1) When a person walks through the Hearing Aid Professionals’ doorway, this individual realizes they have an issue with understanding spoken communications. We give them a free, quick hearing threshold test & speech test in quiet, discover they have 10-15dB average thresholds, and then send them on their way with a pat on the head, telling them “too bad, your hearing loss isn’t bad enough to qualify for hearing aids” …And who can blame them, as there’s a fear of a reprimand from a licensing board for selling hearing aids when there’s no benefit? (But, more on this in a few moments).

But wait a minute! The person has a problem communicating, and the salient question should be, does the minimal peripheral screening test detect the cause of the difficulty? And the answer is a resounding NO: Do we screen for auditory neuropathy (ANSD) by running a stapedial reflex threshold (SRT) test, or at least a speech-in-noise (QuickSIN or HINT) test? Do we screen for auditory processing disorders (CAPD)?  Do we screen for outer hair cell integrity using otoacoustic emissions (OAE)?

Bueller? …Bueller? …Bueller?…

(2) Led by the surprisingly good Songbird FlexFit hearing instrument Songbird Hearing ceased operations in March 2012 and followed up by the Beltone First Step  program  and Starkey with the AMP micro canal hearing aid (nice work, Jason!), these people are bypassing the barrier thrown up by the dispenser or audiologist and getting the help they need.

Sergei, here is my question for you, as the “Keeper of the MarkeTrak industry statistics:” Of the many thousands of Songbird instruments sold every month, I wonder what percentage of people are motivated to buy who have already had “free” screenings & have been told “Sorry, your hearing loss isn’t bad enough for hearing aids?” I have actually seen people with a PTA of almost 20dB with thresholds @3-4k of 30dB being told those dreaded words. [And parenthetically to our severely deaf readers, how many have you been told that you aren’t “deaf enough” to qualify for cochlear implants, and left to struggle with the help you need but is just out of reach?]

Many years ago at the NJHAA convention  (during my first stint as a Hearing Care Professional 1985-95), Dr Bob Martin alerted me to these issues, and he raised the points above. In addition, he pointed out that some of the problem goes back to the the whole concept of “Audiometric Zero,” which is no more than a statistical average of what “normal” hearing is, based on the landmark work by Bell Labs of Fletcher & Munson at the 1939 Chicago World’s Fair. But, as any of us who has tested kids & teens knows, we often see -5 & -10dB thresholds, and as “Dr Bob” pointed out, if a person had a -10dB threshold at, say, 1kHz & it’s now +15dB, that’s a 25dB drop that the brain has to deal with.

BENEFIT:

Now, let’s circle back around to the issue of benefit I raised early on in section (1): What do we do with this population with a communication handicap more severe than the screening audiogram indicates, like with my colleague, speech pathologist Martha, who was having all sorts of problems in restaurants & meetings? (Some of you may have met Martha at the Hearing Loss Ass’n of America 2010 Convention in Milwaukee, as she was my co-presenter on (class)room acoustics). Her thresholds are in the 10-15dB range, not “deaf enough” for hearing aids. She knew, however, from her audiology training she has a problem, and that it needed addressing. Same for my friend Jenifer, whom I counseled to go to the nearest Miracle-Ear: The audiologist told her the same thing: “She doesn’t qualify.” But for both ladies, it left their communication problems unaddressed.

Noted longtime audiologist and textbook author  Wayne Staab PhD weighs in with this quote in Hearing aids: Who needs ’em?  in Hearing Health Matters:

Dr. Staab, who’s been practicing audiology since the 1960s, points out that a person’s decision to get hearing aids is “never based on the degree of hearing loss, but only on the degree of ‘hurt. If the hurt is not great enough psychologically, emotionally, economically, or socially, there is no justification for hearing aid use.”

Elaborating, Wayne says that in the farming and ranching country where he comes from, older people often have treatable hearing losses as defined by their audiometric thresholds. However, they but don’t hurt enough to feel the need for hearing help. Why is that? It’s often a matter of lifestyle, he explains. For example, he says, “Many farmers live with their spouses, they speak with them from fairly close distances, and they use their television volume controls as their hearing aids.” In other words, they hear well enough for the way they live.

Sometimes, it works the other way, Wayne adds. He has fitted people with “normal” hearing thresholds because they weren’t satisfied with their unaided hearing. [Emphasis added: DLS]

What I counseled both ladies to do was order a Songbird (1 for Martha, 2 for Jen), as they have a 45 day free trial, take it out for a spin in meetings, restaurants and  the cafeterias, and see if it actually helps clear up their communications problems. [I believe this is ethical, because both ladies had been screened for diseases by the school district audiologist & Miracle-Ear audiologist, respectively. Also, I felt comfortable because I had no financial interest in the initial Songbird trials to determine if there’s indeed benefit.]

What happened with these two ladies?

Martha, who had audiology schooling, was so pleased, she went to a local audiologist & bought an Oticon Vigo, complete with the Streamer, which you saw her strutting around the Milwaukee HLAA convention, purchased even before the battery on her disposable Songbird died;

Jen was having an issue with fitting¹ but she was so surprised at what she was missing, she returned them in the 45 day free trial period, instead purchasing a pair of Starkey AMP micro canal hearing instruments to try, programmed at gain family 2, -4db in lows & +6dB in highs� And she immediately liked it right at the default volume of 3, of 5 volume steps. What’s more, I love the ability to remotely tweak her programs over the phone, which is a Really Nice Feature.

THE SALIENT QUESTIONS:

A) How many more people like Martha & Jen are there out there, who have a communications handicap that is missed by what the hearing aid professional checks for in the screening audiogram & speech-in-quiet tests?

B) How many of these people have purchased Songbird hearing aids²  or personal sound amplifier products  (PSAPs) to address their handicap after “passing” the dealer screening?

C) How many of these people are, in fact, part of the statistic of 33 million Americans with hearing problems? This has Major Implications for Market Trak, as if these people are in the universe of 33 million, the HA dispensing profession may indeed be *reducing* the universe of (33-8.4 = 24.6 million) candidates;

D) On a related note, this affects children as well as adults, as how many schoolchildren fall into this crack, and would benefit from FM or low gain HA’s in school, even if the classroom meets ANSI/ASA S12.60-2009 acoustical standards for reverberation time & background noise? For more on this, please see my comment about the twin problems of tinnitus  & “I can’t hear what the teacher is saying” that the supposedly “normal” hearing six year old daughter of my author friend Shanna Bartlett Groves‘  faces every day in Test The Ears You Love  on her Lip Reading Mom  blog.

CONCLUSIONS:

Many Americans with auditory communication challenges are taking the steps necessary to overcome them, but are being met by hearing aid professionals who rely solely on the screening audiogram and basic speech audiometry, which do not fully address the challenges the patients face, especially with respect to listening ease, and are turned away as not being “deaf enough.” Some of these people are resorting to over-the-counter hearing aids and other PSAPs with mixed results, while a few hearing aid professionals will go ahead & fit hearing aids; but as we’ve documented above, even when the audiogram says the patient won’t benefit from amplification, the patient deigns to disagree.

UPDATE 1:

After this article was published, we had the following e-mail conversation with a support audiologist for a hearing aid manufacturer after she read this article. Here is the exchange:

Audiologist: On a side note, I read your blog and couldn’t agree with you more.  In fact, I am one of those people whose perceived handicap does not match my “normal” hearing thresholds.

DLS: Incidentally, since you are “one of those people whose perceived handicap does not match my ‘normal’ hearing thresholds,”  do you (proverbally) “eat your own dog food?” Hitch up your NOAHlink, slip on a pair of [redacted] instruments, and play around some on yourself, especially with your streamer!

Audiologist: I have had the same thought, but have never actually used hearing aids.  Text messaging and closed captioning are my friend.  Your suggestion is a good one.  I just might try it.

 DLS: Ummm, if you’re using text messaging, that’s one thing; but if you’re using closed captioning, that’s a whole new ballgame. I’ll bet if you used Bob Sweetows’ LACE you’ll find yourself already a good speechreader.
What are your ipsi & contra reflex thresholds? Your QuickSIN (or HINT) scores? Have you ever been evaluated for ANSD? For CAPD?!
Hmmm, this could get interesting, especially if you plug in hearing aids & things do NOT improve.

See, this can happen to even a hearing care professional…

UPDATE 2: We were made aware of the Consensus Statement from the 1990 Vanderbilt/VA Hearing Aid Conference, as follows:

Hearing Aid Candidacy: The first decision that must be addressed is whether a person is a candidate for hearing aids. It is inappropriate to determine hearing aid candidacy by referring only to hearing sensitivity as represented by thresholds of pure-tone signals or scores on work recognition tests. Anyone who describes hearing difficulties in communicative situations should be considered a potential candidate for hearing aids or other assistive devices. Unless clear contraindications exist, binaural hearing aids should be considered the preferred fitting for the prospective hearing aid user. [Added January 8th, 2014]

 

FOOTNOTES:

(1) Jen also had a minor issue related to eartip size vs need for venting, and needing more gain, which caused feedback. If she were local, I would have made a custom earmold with proper venting and use it instead.

(2) If it seems like I’m a fan of the Songbird FlexFit  hearing aids built right here in New Jersey, you’re right: Unlike the other over-the-counter “listening devices” from China you see on eBay & at WalMart with poor high frequency response, the FlexFit is unique in that when you look at the specifications  it is a real digital hearing aid with an ANSI S3.22-2003 response to 8kHz and an AGCi kneepoint of 67dB (click to enlarge):

Songbird FlexFit acoustical performance, with annotated graphs

Songbird FlexFit hearing aid acoustical performance. Please note my annotations on the graphs

 

(3) Here’s why I’m a Big Fan of the Songbird family… And it’s due to their RCA Sarnoff Labs connection.  As many of you who know, I was a Georgia Tech co-op Electrical Engineer at RCA-Camden in 1979 & 80; and while I was in the IRR project I had the privilege of spending time at the RCA David Sarnoff Research Center in Princeton, opened in 1942. Some of you who are older may have learned acoustics from the Labs’ Harry Olson, whom along with Leo Beranek wrote the textbook you used. The first time I walked into the lobby, I saw in a glass case the 1955 Emmy® trophy awarded to the labs for Color TVOne of twelve Emmy® Awards the Lab have received for everything from stereo TV audio to H.264 Digital TV. [If you’re a technology buff, watch this amazing December1953 YouTube clip].  So, the next time you see a Songbird commercial, know that you can draw a straight line between the technology in that hearing aid and the TV you’re watching it on.~

 

Comment problems:

It’s been brought to our attention from several of our readers that they were having their comments rejected by the Akismet plug-in for WordPress as spam. This is unacceptable to us; and we are soliciting suggestions for a replacement. Unfortunately, we have to use something to screen for spam, as we were receiving over 100 spam comments per day at its’ peak. In the interim, to save retyping, we recommend selecting & copying all of your text to the clipboard: If your comment is accidentally rejected, simply paste it into an e-mail message, put “Rejected Comment” in the subject line, and send it to us at Dan@Snip.Net and we’ll manually post it for you~

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About the author

Dan Schwartz

Electrical Engineer, via Georgia Tech

7 Comments

  1. Audiologist
    February 8, 2012 at 3:02 pm

    Hi Dan (I’m assuming it’s just you, despite your use of “we”),

    You raise a number of important issues here, but in a rush to criticize hearing healthcare providers, you’re missing the point of Dr. Kochkin’s comment and oversimplifying a very complex issue surrounding hearing aid acceptance. My experience as an audiologist has never been to turn someone away who had a communication problem because their audiogram didn’t match some predetermined definition of hearing loss. Much more often, we see individuals with significant hearing losses, are excellent audiological candidates, who do not want to use amplification. Dr. Kochkin’s comment was that many individuals with hearing loss do not experience a communication problem despite having mild hearing loss, so we probably shouldn’t assume that they are people who could benefit from hearing aids and just aren’t using them. To put it another way, the barrier to amplification here is not the provider or their assessment technique, but the cost of devices and the patient’s motivation. Audiologists should do more advanced testing as you suggest, but this point is lost in your attempt to shoot the messenger. You’re suggesting that hearing healthcare providers don’t want to sell hearing aids, and that’s not likely to be a very successful business model.


    • Dan Schwartz
      February 9, 2012 at 9:28 am

      @Audiologist: That’s not the point of the article; and you would miss it since you’re in South Asia, and not in the United States.

      The problem we have here is the State hearing aid dispensing and audiologist licensing boards, and consumer complaints. The Very Last Thing that a dispenser or audiologist wants to happen is a complaint to their governing licensing board for misconduct… And in many (if not all) States, fitting a hearing aid to a minimal hearing loss, i.e. where there isn’t a real need, can be grounds for disciplinary action — And it is this rational fear that holds back many Hearing Aid Professionals from fully addressing the patient needs, leaving them frustrated & still in the lurch~


  2. Dan Schwartz
    April 4, 2012 at 1:22 pm

    Francis Kuk PhD has weighed in with his guest article titled Hearing aids for children (and adults) with auditory processing disorder: thinking outside the box? which deals with the technical issues of using hearing aids, FM, and the two combined when (C)APD has been diagnosed.


  3. Sara
    April 26, 2012 at 12:37 pm

    I am a mom of 3 children who fall into these cracks. 2 of my boys have records all the way back to birth showing minimal to mild hearing impairments. A 3rd child shows 10dB at birth, 15dB at 6 years old, and 8 years old he is in the minimal catagory. All 3 of these boys had horribly delayed speech, though the 3rd had speech developing on time, just sounded muffled and distorted. ALl of them have gone to speech therapy 3x a week since about 2 or younger. The older 2 never showed improvement due to speech therapy. After 4 years of extreme effort on my part and going to audiologist after audiologist (at least 5) we finally got my oldest fit with aids when he was 8 years old. Shortly after my 2 year old got hearing aids too. When my oldest got his aids at 8 his speech was largely unitelligible by outsiders. Family understood him well and his closest friend and speech therapists could understand him. Now it is 2 years later his speech is still a little rough, BUT he is understood by mostly everyone! Usually a stranger needs a repeat, just because they are taken by surprise, but on repeating he is ALWAYS understood. The audiologist was so impressed 2 weeks ago at his yearly cuz she understood him with out my help. After one year his school scores have increased by 25% on mathematical standard measures and 17% on language based standard measures!

    Our now 3 year old who also got the hearing aids was doing wonderfully in the first 6 weeks gaining so many words, but then he figured out how to get the battery out and swallowed one. We had to cut back on use to being only when an adult could supervise. He lost all of his words shortly after we are still in the process of getting him back into full time use, and after 6 months of speech therapy he is almost where he was after the first 6 weeks of use. The sad part is, even after all the growth that our children have shown in speech, education, and the obvious genetic link, our audiologist told me this last Monday that she wished she never perscribed the aids! I was in absolute shock- could not believe what I was hearing! even after she had witnessed all the benefit and improvement in speech! I don’t know what to do, we worked SO hard for them! I wish that Audiologists would present the information and leave it up to the parents to decide what is right for their children- and in the case of delayed speech, H.A.’s should ALWAYS be an option!


    • Dan Schwartz
      April 26, 2012 at 11:37 pm

      Sara, I just pulled you up on Facebook. Per chance, do your kids go to Central Park Elementary? If you’d like, I have superb resources in your very town: Send me a friend request on Facebook at http://www.facebook.com/profile.php?id=100001173406335


    • Dan Schwartz
      April 27, 2012 at 10:42 am

      Sara, on further review, what your 3 year old son needs are hearing aids with rechargeable batteries, that are sealed inside the case. There are three manufacturers I know who have this available: Audiotoniq, which will start shipping in June or July (they have a very good instrument — I saw it at their factory), Persona Medical (formerly Magnatone), which has had rechargeables for over 20 years, and now the Siemens family, which are the Siemens, Rexton and Hansaton brands, and they also private label for Miracle Ear.

      In any event, I’m doing some checking for you.


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