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Hearing Matters Podcast
Welcome to the Hearing Matters Podcast with Blaise Delfino, M.S. - HIS and Dr. Douglas Beck! We combine education, entertainment, and all things hearing aid-related in one ear-pleasing package!
In each episode, we'll unravel the mysteries of the auditory system, decode the latest advancements in hearing technology, and explore the unique challenges faced by individuals with hearing loss. But don't worry, we promise our discussions won't go in one ear and out the other!
From heartwarming personal stories to mind-blowing research breakthroughs, the Hearing Matters Podcast is your go-to destination for all things related to hearing health. Get ready to laugh, learn, and join a vibrant community that believes that hearing matters - because it truly does!
Hearing Matters Podcast
Hearing loss, speech in noise, minimal fittings and more!
Understanding a patient's hearing struggles goes beyond mere numbers on a chart. In this episode, we emphasize the importance of including a primary communication partner during audiological evaluations to capture a fuller picture of the patient's daily challenges. We also critique current hearing screening standards, advocating for a lower threshold and considering ambient noise factors. Learn why comprehensive audiometric evaluations are vital for all age groups and why traditional screenings often fall short, leading to low follow-up rates and misinterpretations.
Discover the hidden depths of auditory processing with our discussion on extended high-frequency hearing tests, especially crucial for individuals exposed to loud noises like veterans and firefighters. These tests can uncover issues such as speech-in-noise difficulties and tinnitus that standard tests might miss. We delve into treatment strategies for extended high-frequency hearing loss, including the use of FM systems and low gain amplification. Finally, we explore the complexities of fitting hearing aids for those with normal to near-normal hearing thresholds, stressing the need for personalized fittings and the broader implications for maintaining high standards in hearing aid customization. Tune in and rethink what you know about hearing loss and auditory health.
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Thank you partners. Redux: faster, drier, smarter, verified. Sycle built for the entire hearing care practice. Otoset, the modern ear cleaning device. Fader Plugs: the world's first custom adjustable ear plug. Welcome back to another episode of the Hearing Matters podcast. I'm your founder and host, Blaise Delfino, and, as a friendly reminder, this podcast is separate from my work at Starkey.
Dr. Douglas L. Beck:Good afternoon, this is Dr Douglas Beck with the Hearing Matters podcast, and today we're interviewing Dr Christina Root. Dr Root received her BA and her MA in communicative disorders from California State University at Long Beach, not far from where I used to live in Seal Beach, and she completed a pre-doctoral fellowship at the Mountain Home VAMC, that's the Veterans Administration Medical Center in Tennessee. She received her PhD in Communicative Disorders from the University of Wisconsin at Madison, where a million excellent, incredibly talented audiologists have come from. Christina worked as a research audiologist at the Martinez VA OPC in Martinez, California, coordinating amplification research. She joined the Ohio State University as an assistant professor in 2004, promoted to associate professor in 2011. Christina is the director of the Speech Recognition and Aging Laboratory and studies age-related changes in binaural speech recognition. She teaches courses on basic audiology, hearing disorders and adult oral rehab. Christina has served on the board of the Ohio Academy of Audiology and on the planning committee for the Ohio Audiology Conference. Dr Roop, welcome Good to have you here.
Dr. Christine Roup:Thank you, thank you for having me my pleasure.
Dr. Douglas L. Beck:You and I we never met until a few weeks ago, but we've been publishing kind of similar stuff for the last 20 or 30 years and we've never met face-to-face. So this is really an honor for me. I have enjoyed your work tremendously. What I'd like to do Same? Oh, thank you, that's kind of you. I would like to start with some pretty basic stuff and then we'll get into the more difficult topics. So let's start with categorizing hearing loss, because the traditional and I refer to these as categories of convenience so we say zero to 25 is normal, 26 to 40 mild, 41 to 70 moderate, 71 to 90 severe, 91 plus profound. Tell me your thoughts on that that. Does that make any sense to you at all?
Dr. Christine Roup:I really like that. What you just said, that it's their categories of convenience, right. I talked to my students about them being fairly arbitrary categories that we use to describe degree of hearing loss. But it becomes, it can become right and that's why we're kind of leading into that a little bit here. They've been around for a long time. Those categories very easy to implement and use, but they do become problematic. They're not perfect. So categories of convenience is a great way to describe that.
Dr. Douglas L. Beck:And the thing about them is that I believe we started using these just after World War II and it was decided, I guess by a working group that said OK, 0 to 25, we'll call that normal. But the problem with that is, if you go back almost 100 years ago, the outer limit of normal in the DBHL scale was determined to be about 13.5, maybe 14. So I guess 0 to 15 as within limits. What are your thoughts on that? What if you got to pick?
Dr. Christine Roup:Yeah, I totally agree with that. I would choose 15 as that, 15 dB HL as the outer limit of normal right and then thresholds above that would be considered clinically significant loss of threshold or hearing right. There's a great article I don't know if we're going to mention articles that we've both read or we have both written, but there's a great one a very brief article from Fred Martin and Craig Champlin from 2000, published in JAAA, and it talks about exactly this issue that you just brought up, doug, this reconsidering the limits of normal hearing. And they give a really nice historical outline of what you just alluded to, where we started and somehow we got to this place of categorizing normal hearing from zero to 25 dBHL. And they propose 15 dB as the cutoff and I totally agree with that. You know, based on work that you've done, based on work that you've done, based on work that I've done and what I've seen clinically, anecdotally, but also in my lab, it really I think would make good sense if we moved in that direction.
Dr. Douglas L. Beck:And you know when I think about this. First of all, these categories of convenience vary and I think it's very confusing and I think it's a terrible disservice to patients because with, you know, a 35, 36, 37 decibel pure tone average, they're told they have a mild hearing loss. And if I can borrow the joke from my friend Dr Keith Darrow, keith says when I think of mild I think of salsa, you know. And so to describe hearing loss as mild or slight minimizes it in the patient's mind and it says no big deal. But that's a total discrepancy with reality. When you have 30, 38, 39 dB of hearing loss, you're not hearing the majority of speech sounds around you.
Dr. Christine Roup:Exactly Well put. It was originally those categories. When you go back to the original article from 1965 and when ASHA published that, it was to describe the impact on communicative function, right, and that was based in quiet and not in noise. So when you and when you're in quiet, you could take advantage of your nonverbal cues or your visual cues, all those things that help you fill in the gaps, but in noise it just all that goes away, right? So we're always in noise, there's always something on, there's always ambient noise, and sometimes it's worse than others.
Dr. Douglas L. Beck:Yeah, absolutely, and so this is the major challenge Now in the literature the last few years and I know you've seen this as well there are many people who are proposing that, instead of measuring word recognition in quiet, which I would call speech in quiet, siq they're saying it's much more sense to just measure if you're only going to do one measure speech at a standardized level. What do you think about that?
Dr. Christine Roup:Yeah, absolutely agree. We've been talking about this what for the last 50 years in clinical audiology. I mean, raymond Carhartt was telling us to measure speech and noise back in the 1970s. So we should be doing that.
Dr. Douglas L. Beck:Yeah, Carhartt and Tillman Carhartt and Tillman, exactly they said every audiometric evaluation should include speech and noise. So that was I really agree.
Dr. Christine Roup:There's the data on speech and noise and especially adults with hearing loss, sensory, neural hearing loss. Whether you have thresholds in the 20 to 30 dB range versus the 60 to 70 dB range, it just tells you so much more about your patient's abilities in their real world environment right.
Dr. Douglas L. Beck:Yeah, and here's an amazing fact that I think, unfortunately, many professionals have missed. When you go back, I think it was 2011, rich Wilson published a paper right 3,600, I think, was the amount of veterans in this study, and he said and I may get this number of a couple of points wrong, but it'll be, it'll be close he said of these three thousand six hundred, something like 70 percent of them had word recognition scores that were good or excellent yes, in quiet. But then he gave them the win. The words in noise test found 70 percent of those patients had abnormal scores in noise. 7% maintained good to excellent speech in noise scores. Did I say that correctly?
Dr. Christine Roup:I think you did. I think that you're really close, if not right on target. That's a great article from Richard, and he's been advocating for speech and noise testing for as long as I've known him. I worked with him in the late 1990s, yeah. And then there was just a recent article published by Matt Fitzgerald from Stanford I don't know if you've seen that, aaron. Hearing that argues for the same thing using the Quixin instead of the Winn. So yeah, great data from both of those labs.
Dr. Douglas L. Beck:I have some issues with it. Number one it's brilliant. Number two Mead Killian should never stop being applauded for thinking of it. It is one of the most important tests ever. But that said and I love Mead and I love his wife Gail I'm not criticizing him at all.
Dr. Douglas L. Beck:But what I'm saying is many people do the adaptive right when it goes from 20 to 15 to 10 to five. It's the most common as far as I can tell. And the problem with that to me is that many people who will have an SNR 50 of about nine, if you improve them tremendously, you bring them down to a six, they're still in the same category, so nobody sees a change, even though there's an enormous change in their ability to communicate. So that's why the other problem is that there are no corrections for age. So you take an 81-year-old patient and you take a 28-year-old patient and you give them the sentence the boy went to the store to get milk and eggs and for the 28-year-old piece of cake, for the 81-year-old they might abbreviate it, they might skip a few words. So there's no correction for aging.
Dr. Douglas L. Beck:I don't like that. And the third thing I don't like about it and again I don't mean any disrespect at all because again, it is one of the most brilliant tests ever devised in audiology. But the other reason I don't like it clinically so much is for many people they do speech and noise out of one speaker and then you have virtually no localization going on. And speech and noise is to a very large degree dependent on your vocalization, your ability to use interaural loudness, interaural timing, head shadow effect and for your brain to put all that together to make sense out of the work. So that's my issue with the quicksand. But I vastly prefer the quicksand to speech in quiet. Yeah for sure.
Dr. Christine Roup:And it's quick and easy, right? I think that's why it's probably one of the most popular tests that's being used right now of the audiologist doing speech and noise. Yeah, I like the quicksand for the same reasons that you just mentioned. I think one of the challenges as a professor who teaches students trying to get them to wrap their head around the concept of SNR loss is tricky. So SNR 50 is a lot easier, but SNR loss if I have a hard time getting my students to understand that, what patient's going to understand that? So interpretation can be a little tricky but it's easily implementable in the clinic. But the whole spatial cue issue is important, right? You're missing that if you only have one speaker.
Dr. Douglas L. Beck:And what do you think about this? And whenever I lecture on this, which turns out to be at least once a week for the last 20 years, some people do speech and noise in a TDAH 39 or an insert and I think, well, that's also. There's no localization brought into that.
Dr. Christine Roup:No, I do that. I've done that in my lab, you do a lateral message or it'silateral noise instead of or I. I do a lot of things binaurally under headphones, sure so yeah, you are missing that localization piece, but there's other tests that you could do if you wanted to right. If you don't have a speaker array, you could do something like the listen or the listening and specialized noise test if you're familiar about that second one second.
Dr. Douglas L. Beck:All right. The listen for people who are not familiar. Also a brilliant test. That was Sharon Cameron and Harvey Dillon. Harvey Dillon, Wasn't it like 2005, 2006?
Dr. Christine Roup:Yeah, they published the first paper in 2007.
Dr. Douglas L. Beck:And it's an abbreviation, it's LISN, listening in Specialized Noise. So now that we've caught everybody up, go ahead, tell me about that noise.
Dr. Christine Roup:So now, that we've caught everybody up. Go ahead and tell me about that. Yeah, it's a great test. I spent three months down at National Acoustic Collaboratories and that's where I was introduced to the Listen and it's under headphones. So they have done the recordings in SoundField and they use head-related transfer functions to create sort of this 3D image under Sennheiser headphones so you can be listening and you'll listen to the target signal and the competing signal and it sounds like they're both right in front of you at zero degrees, and then it'll change conditions and then the competing signal will come out to plus or minus 90 degrees. So you're listening to the target at zero and then the competitor moves, which means you get that spatial separation, so you're able to actually measure spatial benefit with the same test and it all calculates it for you. They've done a brilliant job of making it super easy to use.
Dr. Douglas L. Beck:I always liked that. I thought it was diagnostically very, very useful to understand the situation the patient is in. You know, one of the things that Mike Valente used to talk about was the importance of having the spouse or the loved one or the carer or the significant other in the room while you're doing this so he or she can be exposed to it, and he or she probably doesn't have the same problem. So they're listening and saying how easy it is and then realizing that their partner, loved person, spouse, whomever, how difficult this is for them and it sheds a lot of light. Have you been able to do anything with that? And spatialized speech and noise? Or listening and spatialized noise. Is there any way to bring in the second person?
Dr. Christine Roup:I have not done that. I think that's a great idea though. You know, having that person, that primary communication partner, whoever that is, having them in the room. It really brings home the issues that the patient is having right and it's a great counseling tool to have that person.
Dr. Douglas L. Beck:Well, if you can't do it in the lab, the chance of us doing it in the booth is probably minimal. But Mike used it all the time for hearing aid patients. He would use it to show the difference between speech and noise with your directional mics versus a digital remote mic or an FM, and he'd have the significant other sitting there and their draws would drop when they would see the difference. Anyway, okay. So what I want to talk about if we could, for just a few minutes, let's talk about screening numbers. What are your thoughts on that, because this is a big deal now in clinical audiology is that everybody should know a screening number, and I want to get your thoughts and then I'll share mine.
Dr. Christine Roup:So screening in terms of a pure tone screening where we should be screening at.
Dr. Douglas L. Beck:Yes.
Dr. Christine Roup:So you know, I think most screen at 20 dbHL or 25. That's the current standard. Is that? The ASHA recommendation is 25, I think 25, yeah 20 or 25. And so what do I think about that? That's a great question. I think maybe it might be interesting to lower that to 15.
Dr. Douglas L. Beck:Yeah.
Dr. Christine Roup:But it does depend on where you're doing the. You have to take into consideration where you are and, given the ambient noise, yeah.
Dr. Douglas L. Beck:Well, I agree with you entirely, you know, and one thing I wanted to mention earlier I forgot Marion Downs used to talk about in pediatric audiology any child with a 15 dB or worse threshold needs amplification or needs being seen and managed and treated Right.
Dr. Christine Roup:There's some great data coming out of Boys Town on that exact topic right now so.
Dr. Douglas L. Beck:Ryan McCreary's group. Yes, that group is doing some really great work. So I want to give you an idea that that is radical and that that you know I'm sure I'll be banished from audiology for it. But here's the idea.
Dr. Douglas L. Beck:I don't believe in screenings, with the sole exception of universal newborn screenings. That, I think, is critically important. Other than that, I think all children, all adults, all seniors need a comprehensive audiometric evaluation, and you could say pass or fail, but you can't say what their status is. You know it's a bogus concept that, oh, you're fine. No, that has nothing to do with anything we've already talked about, right, right?
Dr. Christine Roup:Yeah, it's a really great point. You know we have data on that. Patrick Feeney I was on a paper with him that came out of this huge screening study we did in adults.
Dr. Douglas L. Beck:Like 15 years ago. Yeah, I remember, yeah.
Dr. Christine Roup:And then we did the six-month follow the follow up rate was just so low for adults and so if you're doing pure tone screening, it's not meaningful for the person. So I think that's a good point.
Dr. Douglas L. Beck:Well, and Larry Medwetsky, when he was at the Rochester Institute of Technology, right, he did this study about screening and people who failed were told to follow up and virtually, I think, 15 percent of them followed up. So you know, when we do screenings it's worth very, very little to the patient. But you know, I think, that for most people, you know, free screenings are worth exactly what they paid for it. And here's why your dentist doesn't do a free screening, your neurologist doesn't do a free screening. Nobody does free screenings. Why on earth are we saddled with that?
Dr. Christine Roup:I don't know, I don't know where it came from. I honestly don't. I agree. I agree. We need to stop selling ourselves short, selling ourselves that way as a profession.
Dr. Douglas L. Beck:As a profession, I think it's a gross disservice to our patients to tell anybody they passed, because what we just said, with 3,500 veterans from Rich Wilson fewer than you know, was it? 93% of them failed speech and noise, even though they had good you know thresholds and or speech and quiet. I have no issue, by the way, if a school teacher or a school nurse wants to do a screening to see, grossly, is Johnny or Susie normal, that's fine, I have no issue with that. But when Dr Roop does a screening, you know. So I go into the clinic and I get a free screening or a $50 screening or something like that and Dr Roop said I passed the screening. What I'm going to go home and tell my wife is oh, dr Roop said I'm normal, and so we keep getting. We did.
Dr. Christine Roup:Or the opposite, right, you come into the clinic for a free screening thinking you have hearing loss, and then you're told that you passed and you're normal and you go home without your concerns addressed, right. So, go both ways.
Dr. Douglas L. Beck:You could go both ways.
Dr. Christine Roup:The disservice goes both ways.
Dr. Douglas L. Beck:Yeah. So I think we need to stop all screenings. I really do, and I'm not saying don't test, I'm saying test everyone, absolutely. You know anybody who has an auditory issue, whether it's pain, whether it's drainage, whether it's hearing, whether it's listening, whether it's dizziness, whether it's facial nerve, any you know. But comprehensive audiometric evaluations, and these are laid out by AAA, by ASHA, by IHS. We know that they are airborne in speech, but they're also otoacoustic emissions, they're also timps and reflexes, they're also listening in noise. Every single one of those national organizations in best guidelines has speech and noise. Yet I believe fewer than 15% of licensed hearing healthcare professionals.
Dr. Christine Roup:Yeah, I saw that statistic. Yeah, I was just looking at that. I was wondering just for myself, in preparation for how many audiologists are doing that from the recent surveys, recent data, and it's low.
Dr. Douglas L. Beck:It's very low, it's very low.
Dr. Christine Roup:And I go to AAA and I give talks and I'm sure you've had this experience and you ask your audience how many of you are doing speech and noise Like three quarters of the room will raise their hands like okay, well, I'm preaching to the choir here, so I guess I'm preaching to the wrong choir.
Dr. Douglas L. Beck:Right, let's talk about 50 year olds. You know they come in and they see you and they say listen. My problem, dr Rupp, is that I cannot understand. In conversation with multiple people, speech and noise is awful they won't use that word but when I'm at a restaurant, a cocktail party, hanging out with my neighbors, I can't tell what people are saying. I hear them, I know they're speaking and I saw an EIA doctor and his audiologist said my hearing is normal. So it seems that there's really nothing for me to do, right. What would you say at that point?
Dr. Christine Roup:I would say wrong. Thank you for being here, thank you for coming to see me. I would start with a standardized questionnaire, right so a patient reported outcome measure and get at some situationally specific things that the patient is reporting about. We have so many great tools to get at the subjective component of the patient complaint other than just hey, I'm having these problems. Well, let's dive a little deeper into that. I do my standard evaluation, but you know what I would add? I'd add extended high frequency threshold testing.
Dr. Christine Roup:So I would test from 10,000 all the way out to 16,000.
Dr. Christine Roup:If you have the capabilities. At 20, 50 years old you might be able to hear 20,000, maybe not, but certainly out through 16,000 because the data is so rich. Now that's showing us how important those frequencies are to things like speech and noise or localization abilities et cetera. But I would do that super threshold auditory evaluation, whether that is speech and noise. Or maybe I want to do some other auditory tests. You know, if the patient has thresholds in that standard audiometric range up through 8000, and they're in that 15 to 20 dB range, maybe I want to do the scan. You know that is the Scan 3A, which is that auditory processing test battery which includes speech and noise, filtered words, competing words, competing sentences. You know to add some. You know that's a really easy clinical test to implement.
Dr. Douglas L. Beck:And that was by Robert Keith, correct, Robert Keith?
Dr. Christine Roup:right. I in my lab do other tests. You know Frank Music's gaps in noise test. I think is very informative when you have patients who have complaints like this. In my early days I did a lot of dichotic listening testing. And I think that is an underutilized tool as well. So I think those super threshold auditory measures can really get at those patient complaints. That is what I would do.
Dr. Douglas L. Beck:You mentioned a few of the tests along the way the gaps in noise test, the Robert Keith Scan 3A but tell me about your listening test, or listening and communication ability test? I mean, we have things like the International Outcomes Inventory. We have the AFAB, which is the Abbreviated Profile of Hearing Aid Benefit. We have HHIENA Hearing Healthcare Inventory for Elderly Slash Adults. We have the SSQ and that comes in. I don't even know anymore. I think there's four different versions of that. Yeah, so what's your favorite of those listening questionnaires?
Dr. Christine Roup:Yeah, I've not used the SSQ but I've seen that in the literature used quite successfully. I've used the AFAB when I've done hearing aid studies, but when I'm looking at subjective complaints in this population I use a combination of the HHI. So either hearing handicap inventory for adults and elderly, that is very consistently, very informative. It has so much data, it's been around for so long. But then I've been using something else. It's I don't know if you're familiar with the CHAPS, which is the Children's Auditory Performance Scale. A number of years ago I had a student convert that or alter it to be appropriate for use with adults. So we just changed the instructions and we changed the scoring a little bit. But I've been using that. We call it the adult auditory performance scale and it asks questions in a different way, like how much difficulty do you experience when you're in noise and you're listening to X, Y and Z, and so that has been a tool that I have found very useful as well.
Dr. Douglas L. Beck:I love that a lot. I remember the chaps gosh, I think it came out. I'm probably wrong, but I want to say like 90, something, 1990, something like that, and I never thought to use it for adults. So that's, that's really clever. Do you have that available that people can?
Dr. Christine Roup:see I do. How would somebody get a copy of the adult version? It's on my lab website. You can get to it there. You can just download it. Lab website is uosuedu slash S-R-A-L-A-B.
Dr. Douglas L. Beck:So a lot of the tests that you're talking about here have been classically described as auditory processing tests. And so to me and you know I studied under Jack Katz a hundred years ago right when I think of auditory processing disorders, my favorite definition is what Jack said back then in his definition. I think he derived it in the mid-60s when the first version of SSW came out. He said APD auditory processing disorders is defined as what you do with what you hear, and I love that. When I think of some of the tests that you've just mentioned, I think they're classically identified as auditory processing disorder tests. But to me I think of them as standard clinical best practices.
Dr. Douglas L. Beck:That when you're looking at extended high frequencies, we know that when people have asymmetries and particular hearing loss in the high frequencies and I don't mean have asymmetries and particular hearing loss in the high frequencies, and I don't mean 8k, I mean, as you were saying earlier, you know, up to 16k these can lead to all sorts of problems, including tinnitus, including cognitive decline. We've seen that. We've seen patients who have terrible difficulty with speech and noise. And we think also to a large degree that when you're looking at veterans, people have come back from substantial battles and noise experience and even though their thresholds through 8K may be normal, they can have asymmetries and hearing loss higher than that and their main complaint is going to be they can't understand speech and noise. So if you're not checking there, if you're not testing there, you're not going to find it. These problems are invisible.
Dr. Christine Roup:Right, exactly, well said. I just published a paper on firefighters and we looked at this relationship between extended high frequency hearing, because firefighters get their hearing tested all the time, but it's just pure tones 250 through 8,000 Hertz. I haven't found any evidence to suggest that they're getting their hearing tested in the extended high frequencies. So we did, and, sure enough, the longer you're a firefighter, the poorer you're hearing in those extended high frequencies and that's related to their spatial advantage. So the poorer your extended high frequency thresholds, the poorer your ability to take advantage of spatial cues. So you see that in young to middle-aged firefighters who have a history of noise exposure and exposure to toxins and you brought up the veterans data that made me think of that- no, that's great.
Dr. Douglas L. Beck:I'm glad you mentioned that. So let's go back to this 50-year-old and let's suppose that he has been tested. He's been seen, he's otologically normal and you've tested him and now you've found that he does have some extended high frequency loss. He probably complains of a little tinnitus now and then, but he's having a very, very difficult time with speech and noise. So how would you go about treating that?
Dr. Christine Roup:Yeah, I think there's a couple of different ways you could go about that. I think you know Gabby Saunders has some great data to show that the use of an FM or a DM system can be useful. So you know, improving the signal to noise ratio for the patient that type of patient is going to be super important for those situations they struggle in. So FM can work if the patient is willing to use the device. The other option is amplification using hearing aids. We've seen some really good success with using low or mild gain, however you want to describe that. Some people say low gain, some people say mild gain.
Dr. Douglas L. Beck:This is really interesting, One of the things that is always brought to my attention by people who are trying to think this through. That is always brought to my attention by people who are trying to think this through. Well, if the patient has normal thresholds and you enter that into the program not going to get any gain, so what do you do? So let's say they have 10 dB thresholds across the board, but they have asymmetric sensorineural high frequency loss, meaning 12k, 16k.
Dr. Christine Roup:Yeah, the way that I did it. I didn't use a prescriptive method, right, so I didn't use, I didn't enter in an audiogram. I use an unaided response and then I measure, and then an aided response and I measure insertion gain Okay, measure how much gain an individual is getting using real ear measures and so that's how I did it when I did my study that we published back in 2018. We just made sure that the participant in the study was getting 5 to 10 dB of gain insertion gain from about 1,000 to 4,000 hertz. So that's how we did that. So I have a colleague here at Ohio State who does this clinically. She does use real ear measures, she inputs an audiogram, but then she adjusts to ensure that the patient is getting about that much gain. So I think you could do it either way. I think what you hit on, doug, is really important is that the prescriptive methods that we have available to us, so NAL, nl2, or DSL they don't provide gain for those thresholds.
Dr. Christine Roup:So if you have a patient with thresholds from 0 to 15 or say 0 to 20 thresholds and you put in their audiogram, you're not going to get gain Right right and in some cases you can get insertion loss right, sure, from putting the hearing aid in. So it's a great question and it's not an easy one to answer. I think you have to be careful about your fitting protocol.
Dr. Douglas L. Beck:In 2019, I published a paper with Lauren Benitez on a speech and noise test that we came up with. It was a very, very quick, two-minute test. It's free, you don't have to buy anything and it's really a clinical protocol. So it's unaided SNR50 to aided SNR50. And we found the same problem right. So what we did and it's in the paper we published it in AAA. I'm going to make up the numbers, but again they'll be closed. Like at 250, we said okay, put in 30 dB. At 500, put in 25. At 1,000, put in 25. At 2,000, put in 30. At 4,000, put in 30. Because we were just trying to get some gain through the speech frequencies. I like the way you did it better and I think that makes more intuitive sense. And I think we have to underscore the importance of real ear here, because these people who have normal thresholds and you have to be absolutely sure that the HFA SSPL 90 is not too loud that could cause hearing loss. So I would put that to whatever the lowest level you could get.
Dr. Christine Roup:Absolutely.
Dr. Douglas L. Beck:Yeah.
Dr. Christine Roup:Absolutely yeah. I think either approach works. I think we need more research to figure out how we're you know a more standardized approach to this, because I think clinicians are struggling on how to fit these individuals. You know, how do you decide how much gain? There's no standard on that yet, and I say yet because I think we'll get there. We'll get there as researchers, we'll get there as clinicians, we'll get there as a profession. But yeah, there's multiple ways to manage that.
Dr. Douglas L. Beck:So I was recently at one of the hearing aid manufacturers a month or two ago and I needed new hearing aids, and so they took a very, very deep canal impression using a video otoscope that had resolution unlike anything I'd ever seen in my life. I mean, it was so bright and so clear and you could, even though it was just a two-dimensional screen, you got the impression you're looking at 3D. It was that good. It was like having a binocular vision looking through an otoscope or a surgical microscope Fantastic visualization. So I think that for most of us it's very easy to fit RICs and RITs and mini-PTEs and all that with open domes, but I think that's never the patient's best solution. It may be where they start, so that at least they're willing to go into amplification, but I do think that two or three months later when they tell you well, gee, dr Rupp, I did great with you in the office, but I'm still having a terrible time at restaurants, I think rather than adjusting the hearing aid, that's when it would be great to say remember we talked about we should do an owl impression and do it at that point. So they get the advantage of all the technology, because the technology, including directional.
Dr. Douglas L. Beck:Most of the hearing aids being fitted are pointing up like this Well, that's for people who are bird watchers, fantastic. But you're trying to convert with somebody on your horse, right as a man. The hearing is supposed to be fitted like this, right, right. So we? We lose all of these advantages of the technologies by taking shortcuts, and I would say, you know, dumb. Fittings to me are are not ever in the patient's best interest. They may be more comfortable.
Dr. Christine Roup:That's a good point. We should study that, we should make some comparisons, we should look at that and no one's ever done that to my knowledge.
Dr. Douglas L. Beck:You know we've lost this art of making excellent ear canals Right.
Dr. Christine Roup:That's an important consideration, especially for this population. Right, it's what you said. They have such good hearing, especially in the low frequencies, that they're getting the noise through the acoustics of an open ear canal right and one of the things that I should have mentioned earlier.
Dr. Douglas L. Beck:You know, when we're looking at all these people who have relatively normal thresholds according to the categories of convenience, you know, in order to press the button when you hear the beep, of the 15 to 17,000 auditory fibers in each year, you only need about 15% to 20% of them to be intact to perceive that sound. So perceiving or detecting sound such as a pure tone is a relatively easy task and you don't need much of an auditory system intact to do that To process sound, to make sense of speech and noise, to localize, to lateralize much more difficult challenges to the auditory system. In 2019, I wrote a paper with Jeff Danhauer and we said that there were 26 million Americans who have hearing difficulty or speech and noise problems. And then there was a paper in 2023, it came out of the VA and they said I think they said about 22 to 24 million.
Dr. Douglas L. Beck:So, as we're looking at hearing loss in the USA, the most recent paper that I saw was the Global Burden of Disease paper that Ear and Hearing published in early 2024. And they said that one out of five people in the USA has hearing loss. That's kind of shocking One out of five. Now they did justify those numbers, and then Jeff and I said well, there's another 26 million, so do those numbers ring true to you? Do we need to correct those a bit?
Dr. Christine Roup:I think they ring true, I think they're good estimates, I think they're fairly accurate. We see it in our clinic here at Ohio State. We have patients coming in that meet this, meet that criteria right, they have they've been to many audiologists and who they test their pure tone thresholds and are told they're within normal limits or they have normal hearing. And the patient is unsatisfied because these are people who have the other key factor about this population you've just mentioned. These are people who have the other key factor about this population you just mentioned hearing complaints, normal pure tone thresholds. They have help seeking behavior or they exhibit a lot of help seeking behavior right, they go to the ENT, they go to the audiologist. If they're not getting the right answer, they're going to go to another audiologist. So we, I think, have a reputation for seeing these patients, so they come to us or they find us. But yeah, I think I'm able to recruit these individuals into my studies. So they're out there.
Dr. Douglas L. Beck:Well, listen, any final words. Anything you'd like to make sure that we discuss that we haven't yet touched on.
Dr. Christine Roup:I like the addition of the traumatic brain injury population. I think that's a question that audiologists should be asking on their case histories. We see it in the veteran data. You know veterans who are returning from service with blast injuries. You see the data coming out of Portland, va and CRAR, so that brain injury population and the other thing about it is this group that are labeled as mild traumatic brain injury right, it's like being called you have mild hearing loss. Well, what does mild mean? It's that it's just so arbitrary and the symptoms of mild traumatic brain injury can persist and you know we have patients who their injury was 10 years ago and they still have these auditory symptoms. That can be helped.
Dr. Christine Roup:We can help you don't have to send them on their merry way.
Dr. Douglas L. Beck:And, you know, for the other professionals listening to this, in many of the cases we've talked about today, we actually have auditory neuropathy going on, and I think audiology made this so difficult because we started with auditory neuropathy dyss. And I think audiology made this so difficult because we started with auditory neuropathy dyssynchrony, right, right, all of these caveats, and they're important and they're real, but the bottom line is that auditory neuropathy means, you know, the destruction or the deletion or the attenuation of auditory nerve fibers, and they don't have to be between 250 and 8000000 hertz to cause problems, right, why we have so many people walking around with subclinical hearing loss or or hidden hearing loss.
Dr. Christine Roup:You didn't mention hidden hearing loss.
Dr. Douglas L. Beck:All the labels yeah, I mean, it's only hidden if you don't look for it.
Dr. Christine Roup:If you look for it, well, that is an excellent point, right, that's it's only hidden if you don't look for it. Yeah, and we have the tools to look for it. If you look for it, well, that is an excellent point, right, that's it's only hidden. If you don't look for it, yeah, and we have the tools to look for it. So you know. The other thing I tell my patients is not my patients because I don't see patients. I see, I tell my students that they have to listen to their patients. Right, listen to what they're telling you, and if you're only doing pure tone thresholds, did you actually test the problem that they're experiencing? You didn't.
Dr. Douglas L. Beck:And you know, one of the things that I talk to other professionals about is when you're doing pure tones, air, bone and speech sort of things, that is, you know, considered the peripheral.
Dr. Christine Roup:It's diagnostically important, but other than that, it tells you very little about your patient.
Dr. Douglas L. Beck:Right, they don't live with that simple, you know, perception or detection of sound. They're living in a world where they have to process auditory information to make sense of it. And you know when you think that only three to five percent of people with auditory complaints have a medical or a surgical issue, that means 95% of those are our patients.
Dr. Christine Roup:And you know you use the example of a 50-year old. I think what you inadvertently tapped into is middle age. What's happening in middle age that is, things are happening in middle age is the pre senescent changes that are happening in the auditory system, again an emerging area in the research literature about these subtle, subtle auditory deficits that emerge in middle age, that present as these subclinical hearing losses or auditory processing issues or hearing difficulties or whatever you want to call it. You know one of the things that I hear audiologists say about using low gain amplification or using, you know, selling somebody hearing aids to treat, you know subjective complaint. Really right, but people will pay. If they come to your clinic and they exhibit that help seeking behavior, they're willing to pay for the hearing aids that you can provide for them. We see that every day in our clinic. But I'm super curious to see what will happen with the OTC products and if that will actually open up the market like it was intended to do.
Dr. Douglas L. Beck:Yeah, I mean there's a chance it could do that. I want to go back to something you said. It's not necessarily the price of the product, it's the price of the service, right? So if they?
Dr. Christine Roup:were me. Yeah, no, that's a great point. Thank you for correcting me on that.
Dr. Douglas L. Beck:It's really the service that you're providing for them Right, and the expertise and the diagnosis and the rehab. But here's the thing with OTC, and I think they'll continue to get better. I'm sure they will over the next decade or two, but right now, when somebody is self-fitting, it's very, very difficult, because you might take an online test which could be accurate, it might not be accurate. You're buying a product based on its marketing ability, right? How attractive is the box? How attractive is the price? What does the product look like? You know all that stuff that's cool.
Dr. Douglas L. Beck:None of those things are definitively in place to solve your auditory problem. The marketing is to get you to buy it. So once you buy it, you've got it and then you've got to set it up. Now I will tell you, and I won't mention any names, but I have one, two, three. I have four OTC hearing aids given to me by OTC manufacturers to try and I personally cannot endorse any of them, but because they don't sound as good as my custom made and programmed hearing aids. There you go, and the custom made coming with three year parts, labor loss, theft.
Dr. Christine Roup:Right, plus just having the audiologist walk you through that process right, Rather than? Here's a box figure it out. Especially for a patient who has a history of brain injury, here's a box figure it out.
Dr. Douglas L. Beck:Well, anyway, listen, Christine, it is a joy and a pleasure to meet you. I hope to see you on the circuit somewhere over this next year or two. Sounds good. I appreciate your time. You on the circuit somewhere over this next year or two Sounds good. I appreciate your time and your knowledge and your publications. Thank you so much.
Dr. Christine Roup:Thank you, appreciate your time. Thanks for having me.
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