single’sideddeafness: clientimpact* and ... · evidencefromliterature •...

Single-‐sided deafness: Client Impact

and Management op6ons Phil Gomersall

Lecturer in Audiology

The plan…

•  What is SSD? •  Evidence of handicap from literature Take home message: •  UHL can be very handicapping in some individuals

•  What can we do to help?

Evidence from literature

•  Approximately 7500 new cases per year (2003 UK popula6on 48m) •  Equivalent to 9800 (Es6mated 2012 popula6on 63m)

Clin Otolaryngol. 2006 The evidence base for the applica8on of contralateral bone anchored hearing aids in acquired unilateral sensorineural hearing loss in adults. 31(1):6-‐14.Baguley DM, Bird J, Humphriss RL, Prevost AT.

Evidence from literature General SSDC popula6on • 73% (31/43 pa6ents) with unilateral SNHL experienced significant audiological handicap (HHI-‐A) • High variance in scores – wide range of handicaps •  Items related to feeling frustrated, upset, and le= out had the three highest scores • Range of thresholds Newman et al. 1997 Perceived hearing handicap of pa8ents with unilateral or mild hearing loss. Ann. Otol. Rhinol. Laryngol. 106, 210–214

Evidence from literature Sudden-‐onset hearing loss • 86% (18/21) pa6ents who had previously experienced sudden SNHL indicated severe audiological handicap.

Chiossoine-‐Kerdel J.A., Baguley D.M., Stoddart R.L. et al. (2000) An inves8ga8on of the audiological handicap associated with unilateral sudden sensorineural hearing loss. Am. J. Otol. 21, 645–651

High co-‐incidence of troubling 6nnitus • 76% described 6nnitus (42% ‘annoying’) • Ti was significant predictor of greater anxiety and poorer QoL

Carlsson et al (2011) Quality of life, psychosocial consequences, and audiological rehabilita6on aher sudden sensorineural hearing loss. IJA 50,(2) 139-‐144

Evidence from literature Handicap in Meniere’s: • Significant hearing handicap in this popula6on (but emo6onal handicap > physical) Factors Influencing Quality of Life in Pa8ents with Meniere's Disease, Iden8fied by a Mul8dimensional Approach Söderman, Anne-‐Charloke Hessén*; Bagger-‐Sjöbäck, Dan*; Bergenius, Johan†; Langius, Ann‡ Otology & Neurotology: 23(6) pp941-‐948

Middle ear surgery: • Significant hearing handicap (along with ves6bular handicap) in sample of two individuals Pa8ents’ Lives following Stapedectomy Complica8ons. Arnold W, Häusler R (eds): Otosclerosis and Stapes Surgery. Adv Otorhinolaryngol. Basel, Karger, 2007, vol 65, pp 348-‐352

Mechanism of auditory impairment


Audibility / Loudness


loss of binaural summa6on: Loudness reduced by 3 dB at threshold, 6 dB at 30 dB > threshold 10 dB at 90 dB > threshold (Hirsh, 1948; Licklider, 1948; Reynolds & Stevens, 1960).



loss of binaural summa6on: Loudness reduced by 3 dB at threshold, 6 dB at 30 dB > threshold 10 dB at 90 dB > threshold (Hirsh, 1948; Licklider, 1948; Reynolds & Stevens, 1960). Loss of ‘direc6onal audibility’ : Head Shadow Time-‐average speech akenuated by 6.4 dB averaged across frequencies (Tillman et al, 1963). Affects frequencies > 1KHz more severely – reduces audibility of consonsants


Tillman T., Kasten R. & Horner J. 1963. Effect of headshadow on recep6on of speech. ASHA, 5, 7789.


-‐Reduced source segrega6on

CuQng your binaural benefits


-‐Reduced source segrega6on -‐No binaural masking release (3db-‐13dB, Levik and Rabiner 1967)


Levik H, Rabiner LR. 1967 Predic6ng binaural gain in intelligibility and release from masking for speech. J Acoust Soc Am. Oct;42(4):820-‐9


-‐Reduced source segrega6on -‐No more binaural masking release (3db-‐13dB, Levik and Rabiner 1967)



-‐Reduced source segrega6on -‐No more binaural masking release (3db-‐13dB, Levik and Rabiner 1967)


The result of losing these benefits is that a significantly higher signal-‐to-‐noise ra8o is required in order for speech discrimina8on to occur


-‐Reduced source segrega6on -‐No more binaural masking release (3db-‐13dB, Levik and Rabiner 1967) -‐Reduced localisa6on (Van Wanrooij and Van Opstal 2006)


≈1 degree

Van Wanrooij MM, Van Opstal AJ. 2007 Sound Localiza6on Under Perturbed Binaural Hearing J Neurophysiol. Jan; 97(1):715-‐26




≈16 degree

Summary of impairments of ‘normal’ binaural auditory func6on

•  Reduced source segrega6on •  Reduced release from binaural masking •  Reduced localisa6on

Take care of the SSD pa6ent •  Ae6ologies of unilateral hearing loss include sudden hearing loss

•  This may provide different challenges to the dispenser

•  Shock/grief/anger •  Important factors in rehabilita6on process •  Consider the “pa6ent journey model” before considering devices

Manchaiah et al 2013:hkp://www.trialsjournal.com/content/14/1/25

hkp://lostandsound.org/

Approaches to Management: “Sudden onset” popula6on

•  Counselling and support •  Listening tac6cs •  Assis6ve listening devices (safety) •  Tinnitus management •  Clinical anxiety and/or depression •  Diagnos6cs: ULLs and speech tes6ng

Amplifica6on op6ons: Contralateral Rou6ng of Signal

•  CROS aids •  BiCROS aid Transcranial CROS •  Candidacy •  Evidence base for effec6veness •  Technology •  Fi{ng and verifica6on •  Future developments

Discussed in context of maximising Outcomes

CROS

Receiver

Microphone

Contralateral Rou6ng Of Signal

CROS

Receiver

Microphone

CROS

Receiver

Microphone SOUND

BiCROS

Receiver

Microphone

BiCROS

Microphone

Receiver

CROS vs BiCROS

•  CROS 1x microphone (poor ear) + 1x speaker (beker ear)

•  BiCROS 2x microphones (poor ear + beker ear) + 1x speaker (beker ear)

(Bi)CROS aids •  Different types (BTE vs ITE, wired vs Specs vs wireless)

Wireless Transmission

spectaclehearingaids.wordpress.com

Transcranial CROS •  High-‐powered amplifier •  Deep, occluding earmould (reaching bony por6on of auditory

meatus)

Transcranial CROS •  High-‐powered amplifier •  Deep, occluding earmould (reaching bony por6on of auditory

meatus) •  Sound energy transmiked via bone conduc6on to contralateral

cochlea •  Feedback? •  Comfort? Deep mould + vibrotac6le sensa6on •  Not suitable for ‘problem ears’

Evidence-‐base for CROS use “Success rate” < 50% Harford E, Barry j A rehabilita6ve approach to the problem of unilateral hearing impairment: the contralateral rou6ng of signals (CROS) J Speech Hear Disord 196; 30:121-‐138 Harford E, Dodds E. The clinical applica6on of CROS. A hearing aid for unilateral deafness Arch Otolaryngol 1966; 83(5):455-‐464 Valente et al, Fi{ng Op6ons for Adult Pa6ents with Single Sided Deafness (SSD), Audiology online (2006)

Higher success rate in cases with a mild high-‐frequency hearing loss on beker hearing ear Taylor R, Contralateral Rou6ng of the Signal Amplifica6on Strategies Semin Hear 2010; 31(4): 378-‐392

Beker outcomes linked to high levels of mo6va6on Punch J, CROS revisited ASHA 1988; 30 (2) 35-‐37 Issues with the above: Candidacy – use correct tool for correct purpose Improvements in technology (verifica6on, valida6on and devices)

Candidacy: (Bi)CROS

•  Suitable hearing losses = one ‘unaidable’ ear -‐Dead / Severe-‐Profound -‐Poor speech discrimina6on -‐Hasn’t tolerated unilateral aiding (hyperacusis) -‐Infec6on risk •  Candidate iden6fies difficul6es of ‘offside listening’

Candidacy: (Bi)CROS

•  Suitable hearing losses = one ‘unaidable’ ear -‐Dead / Severe-‐Profound -‐Poor speech discrimina6on -‐Hasn’t tolerated unilateral aiding (hyperacusis) -‐Infec6on risk •  Candidate iden8fies difficul8es of ‘offside listening’

Candidacy: (Bi)CROS

•  Assessment of needs Use of relevant validated ques6onnaires: -‐  Client Orientated Scale Improvement (COSI) -‐  Speech Spa6al Quali6es (SSQ) •  Counselling (expecta6on monitoring) Honest appraisal of benefits. How much to wear?

Technological improvements

•  Verifica6on •  Valida6on •  Devices •  Direc6onality and beamforming •  Assis6ve listening devices / Bluetooth compa6bility

Fi{ng, Verifica6on and Valida6on

Valida6on

•  (spa6ally separated) Speech in noise tes6ng

Words-‐in-‐Noise (WIN;Wilson, 2003) test. The WIN test involved the presenta6on of monosyllabic words in mul6-‐talker babble at seven signal-‐to-‐noise ra6os (SNRs) from 24 to 0 dB in 4dB decrements.

Technology:Devices •  Wireless vs wired devices Advantages: wireless -‐ obvious cosme8c and prac8cal advantage Advantages:wired -‐ Signal quality (interference and loss of signal) -‐ Bakery drain •  Digital wireless (small packets of digital data uses FM) vs analogue wireless (AM) Advantages: digital -‐Interference resistant (frequency hopping spread spectrum) -‐Output not linked to separa6on between devices (up to limits of range) -‐Can be encrypted (can’t listen-‐in to other people’s CROS aids) Disadvantages:digital -‐AD conversion takes 6me-‐ introduces a lag -‐Can reduce by reducing informa6on sent (reduces quality) -‐Can reduce by improving chipset (increases cost) -‐Full Audiosignal transfer at 300kb/s -‐Bakery drain

Direc6onality and beamforming Signal-‐to-‐noise ra6o can be improved through direc6onal microphones – modest improvements in speech understanding in noise

Dual microphones (+hence direc6onality) are now available on CROS transmikers Binaurally-‐linked signal processing (between two devices) allows quite significant ‘beamforming’ of gain profile

Assis6ve listening devices and bluetooth compa6bility

•  Use of remote microphones or inputs from devices TV/media players can significantly improve signal to noise ra6o

•  Might help alleviate loss of binaural benefits Contemporary wireless CROS aids have capability of high levels of connec6vity via a ‘streamer’

Bone anchored hearing aid vs CROS

Inser6on of permanent fixture into skull bones Akachment of device that drives sound waves efficiently into skull Transfers efficiently via bone conduc6on to hearing ear Overcomes head shadow, but no different to CROS aid, except -‐  Poorer frequency response -‐  Surgical interven6on (greater costs, maintenance and risk) -‐  Abutment not easily removed -‐  Limited power output -‐  Harder to verify fi{ng

Future developments: Cochlear Implant for SSD

A true ‘binaural’ solu6on Some implants have been inserted primarily for relief of chronic 6nnitus Research ongoing to determine what se{ngs might return the greatest degree of binaural benefit

Maximising CROS Outcomes •  My opinion: Some individuals will definitely benefit from use of CROS aid. With current technology this is significantly more than previously reported. Some will definitely not benefit. Try and use suitable assessment and counselling to triage

•  Mo6va6on is the key to success. The wearer must recognize some situa6on or situa6ons where his/her unaidable ear is degrading an aspect of his/her performance

•  Don’t oversell the aid – honesty about the limita6ons (as well as demonstra6ons of poten6al benefits)

•  To use full 6me or not? Users will pick and choose their situa6ons

•  The most successful user will be a well-‐informed BiCROS user – mul6ple programs to maximise spa6al benefit, perhaps verified, demonstrated and prac6ced in suitable soundfield set-‐up.

•  Remember that we are not fi{ng a cochlear hearing loss in the case of a CROS fi{ng – think carefully about prescrip6on formula and compression se{ngs. As likle gain as possible, low MPOs

Thanks Again!

Evidence-‐base: CROS vs BiCROS

Future research

Summary of Williams 2012 ar6cle

ability to hear speech in noise (1x source)

hearing performance in reverberant environments (church, Pizza Express)

ability to locate sta6onary , and track moving, sounds (e.g. mobile , traffic)

Disability Welsh LW et al 2004 Func8onal impairments due to unilateral deafness Ann Otol Rhinol Laryngol. (12):987-‐93.

ability to hear speech in noise (1x source)

hearing performance in reverberant environments (church, Pizza Express)

ability to locate sta6onary , and track moving, sounds (e.g. mobile , traffic)

Disability

Handicap

Exclusion from conversa6on: not part of group Restric6on of social life Avoidance of novel situa6ons Isola6on ‘Communica6on stress’: 6redness, irritability.

Difficul6es ‘naviga6ng the world’ Risk of physical injury Fear Restric6on of ac6vity

Compromises rela6onships with significant others

Anxiety Depression Effect on Employment

Welsh LW et al 2004 Func8onal impairments due to unilateral deafness Ann Otol Rhinol Laryngol. (12):987-‐93.

Stephens D, Gianopoulos I, Kerr P. Determina6on and classifica6on of the problems experienced by hearing-‐impaired elderly people. 2001 Audiology. ;40:294-‐300.

Disability

Handicap

Not feeling part of the auditory world Loss/change of iden6ty

Loss of enjoyment of rich stereo sounds, in par6cular music

Anxiety Depression

Speaker (receiver)

Microphone

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