Evolutionary changes occur across health care, including within the hearing care delivery system. At times, the change is driven by external forces and thus elicits a reactive response. In contrast, developing a vision o...Evolutionary changes occur across health care, including within the hearing care delivery system. At times, the change is driven by external forces and thus elicits a reactive response. In contrast, developing a vision of a future state, and subsequently the strategies to achieve that vision, is a proactive and a preferred process. Using the reactive versus proactive framework, a future state built around the emergence of genetics as both an assessment tool and a treatment option is presented. In addition, a broad, consumer-centric vision for access to affordable and contemporary hearing care is presented that would result in an expanded and positive future state for hearing care services.
Children with hearing loss require early access to sound in both ears to support their development. In this article, we describe barriers to providing bilateral hearing and developmental consequences of delays during ear...Children with hearing loss require early access to sound in both ears to support their development. In this article, we describe barriers to providing bilateral hearing and developmental consequences of delays during early sensitive periods. Barriers include late identification of hearing loss in one or both ears and delayed access to intervention with hearing devices such as cochlear implants. Effects of delayed bilateral input on the auditory pathways and brain are discussed as well as behavioral effects on speech perception and other developmental outcomes including language and academics. Evidence for these effects has supported an evolution in cochlear implant candidacy in children that was started with unilateral implantation in children with profound deafness bilaterally to bilateral implantation to implantation of children with asymmetric hearing loss including children with single-side deafness. Opportunities to enhance the developmental benefits of bilateral hearing in children with hearing loss are also discussed including efforts to improve binaural/spatial hearing and consideration of concurrent vestibular deficits which are common in children with hearing loss.
Children require greater access to sound than adults as they are learning to communicate using hearing and spoken language. Yet when it comes to cochlear implant candidacy, currently approved Food and Drug Administration...Children require greater access to sound than adults as they are learning to communicate using hearing and spoken language. Yet when it comes to cochlear implant candidacy, currently approved Food and Drug Administration (FDA) criteria for adults are much less restrictive than those for children, allowing for greater levels of residual hearing and aided speech recognition in adults. Cochlear implant guidelines for children have changed very little in the 30 years since cochlear implants have been approved for pediatrics, and this lack of change has proven to be a barrier to implantation. Using evidence-based practice, centers have been providing off-label implantation for children who fall outside of current FDA criteria, including children with more residual hearing, children with single-side deafness younger than 5 years, and infants with bilateral profound loss younger than 9 months. The purpose of this article is to outline how these restrictions impede access to implants for children and describe the evidence supporting cochlear implantation in children who fall outside of current criteria.
Potential cochlear implant (CI) candidates arrive to the clinic with a variety of hearing loss configurations, hearing aid history, and aided capabilities. CI candidacy is primarily determined based on aided speech recog...Potential cochlear implant (CI) candidates arrive to the clinic with a variety of hearing loss configurations, hearing aid history, and aided capabilities. CI candidacy is primarily determined based on aided speech recognition capability, which relies on benefit derived from use of hearing aids. Therefore, contemporary evaluation for CI candidacy should incorporate a battery of testing to determine abilities and limitations and must be predicated on appropriate verification of the hearing aid fitting. However, recent reports, including a retrospective chart review of patients presenting to Cleveland Clinic for CI evaluation, suggest that a significant subset of patients may be using inappropriately fit or programmed amplification. Thus, a combination of simulated real-ear measurements and aided speech recognition testing is essential for fully assessing the effect of amplification and ultimately determination of CI candidacy. Furthermore, waiting to incorporate these tools until CI candidacy is suspected may delay timely identification of problems or need to change technology. Utilization of evidence-based decision drivers ultimately leads clinicians to timely patient-specific interventions which may include surgical intervention or other amplification options. As audiology moves into a healthcare era in which payers consider the benefit of our services to overall health and well-being, demonstrating timely, optimal outcomes using thorough, multifactorial evaluation is essential.
Cochlear implantation (CI) is the preferred method of hearing rehabilitation when patients cannot perform well with traditional amplification. Unfortunately, there are still significant misconceptions around this life-ch...Cochlear implantation (CI) is the preferred method of hearing rehabilitation when patients cannot perform well with traditional amplification. Unfortunately, there are still significant misconceptions around this life-changing intervention. The goal of this article is to address some of the most common myths around CI surgery. After reading this article, the learner will be able to explain the utility of CI in patients with residual hearing and recognize that insurance coverage is widespread. The reader will be able to list common risks associated with this well-tolerated procedure including anesthetic risk and the risk of vestibular dysfunction. Additionally, the reader will be able to identify the significant positive impact of CI on patients' quality of life. Finally, the reader will identify that many patients can safely have an MRI scan after implantation, including nearly all contemporary recipients.
This review examines the relationship between cochlear implantation and cognition and quality of life in older adults, as well as how frailty affects outcomes for older patients with cochlear implants. A growing body of...This review examines the relationship between cochlear implantation and cognition and quality of life in older adults, as well as how frailty affects outcomes for older patients with cochlear implants. A growing body of evidence suggests that there is a strong association between hearing loss and cognitive impairment. Preliminary studies suggest that cochlear implantation in older adults may be protective against cognitive decline. While studies have observed a positive impact of cochlear implantation on quality of life, currently it is unclear what factors contribute the most to improved quality of life. Frailty, as a measurement of general health, likely plays a role in complication rates and quality-of-life outcomes after cochlear implantation, though larger prospective studies are required to further elucidate this relationship.
The safety, efficacy, and success of cochlear implants (CIs) are well established and have led to changes in criteria used by clinicians to determine who should receive a CI. Such changes in clinical decision-making have...The safety, efficacy, and success of cochlear implants (CIs) are well established and have led to changes in criteria used by clinicians to determine who should receive a CI. Such changes in clinical decision-making have out-paced the slower-occurring changes that have taken place with regulatory bodies' and insurers' indications. We review the historical development of indications for CIs, including those of the U.S. Food and Drug Administration (FDA), Medicare, Medicaid, and private insurers. We report on expansion to include patients with greater residual hearing, such as those who receive Hybrid and EAS devices, and report on recent FDA approvals that place less emphasis on the patient's best-aided condition and greater emphasis on the ear to be treated. This includes expansion of CIs to patients with single-side deafness and asymmetric hearing loss. We review changes in the test materials used to determine candidacy, including transition from sentences in quiet to sentences in noise to the recent use of monosyllabic words and cognitive screening measures. Importantly, we discuss the recent trend to recommend CIs despite a patient not meeting FDA or insurers' indications (a practice known as "off-label"), which serves as attestation that current indications need to be updated.
Hearing loss is a global public health problem with high prevalence and profound impacts on health. Cochlear implantation (CI) is a well-established evidence-based treatment for hearing loss; however, there are significa...Hearing loss is a global public health problem with high prevalence and profound impacts on health. Cochlear implantation (CI) is a well-established evidence-based treatment for hearing loss; however, there are significant disparities in utilization, access, and clinical outcomes among different populations. While variations in CI outcomes are influenced by innate biological differences, a wide array of social, environmental, and economic factors significantly impact optimal outcomes. These differences in hearing health are rooted in inequities of health-related socioeconomic resources. To define disparities and advance equity in CI, there is a pressing need to understand and target these social factors that influence equitable outcomes, access, and utilization. These factors can be categorized according to the widely accepted framework of social determinants of health, which include the following domains: healthcare access/quality, education access/quality, social and community context, economic stability, and neighborhood and physical environment. This article defines these domains in the context of CI and examines the published research and the gaps in research of each of these domains. Further consideration is given to how these factors can influence equity in CI and how to incorporate this information in the evaluation and management of patients receiving cochlear implants.
Persistent underutilization of cochlear implants (CIs) in the United States is in part a reflection of a lack of hearing health knowledge and the complexities of care delivery in the treatment of sensorineural hearing lo...Persistent underutilization of cochlear implants (CIs) in the United States is in part a reflection of a lack of hearing health knowledge and the complexities of care delivery in the treatment of sensorineural hearing loss. An evaluation of the patient experience through the CI health care delivery process systematically exposes barriers that must be overcome to undergo treatment for moderate-to-severe hearing loss. This review analyzes patient-facing obstacles including diagnosis of hearing loss, CI candidate identification and referral to surgeon, CI evaluation and candidacy criteria interpretation, and lastly CI surgery and rehabilitation. Pervasive throughout the process are several themes which demand attention in addressing inequities in hearing health disparities in the United States.
This article details ways that machine learning and artificial intelligence technologies are being integrated in modern hearing aids to improve speech understanding in background noise and provide a gateway to overall he...This article details ways that machine learning and artificial intelligence technologies are being integrated in modern hearing aids to improve speech understanding in background noise and provide a gateway to overall health and wellness. Discussion focuses on how Starkey incorporates automatic and user-driven optimization of speech intelligibility with onboard hearing aid signal processing and machine learning algorithms, smartphone-based deep neural network processing, and wireless hearing aid accessories. The article will conclude with a review of health and wellness tracking capabilities that are enabled by embedded sensors and artificial intelligence.
Hearing aid gain and signal processing are based on assumptions about the average user in the average listening environment, but problems may arise when the individual hearing aid user differs from these assumptions in g...Hearing aid gain and signal processing are based on assumptions about the average user in the average listening environment, but problems may arise when the individual hearing aid user differs from these assumptions in general or specific ways. This article describes how an artificial intelligence (AI) mechanism that operates continuously on input from the user may alleviate such problems by using a type of machine learning known as Bayesian optimization. The basic AI mechanism is described, and studies showing its effects both in the laboratory and in the field are summarized. A crucial fact about the use of this AI is that it generates large amounts of user data that serve as input for scientific understanding as well as for the development of hearing aids and hearing care. Analyses of users' listening environments based on these data show the distribution of activities and intentions in situations where hearing is challenging. Finally, this article demonstrates how further AI-based analyses of the data can drive development.
Hearing aids continue to acquire increasingly sophisticated sound-processing features beyond basic amplification. On the one hand, these have the potential to add user benefit and allow for personalization. On the other...Hearing aids continue to acquire increasingly sophisticated sound-processing features beyond basic amplification. On the one hand, these have the potential to add user benefit and allow for personalization. On the other hand, if such features are to benefit according to their potential, they require clinicians to be acquainted with both the underlying technologies and the specific fitting handles made available by the individual hearing aid manufacturers. Ensuring benefit from hearing aids in typical daily listening environments requires that the hearing aids handle sounds that interfere with communication, generically referred to as "noise." With this aim, considerable efforts from both academia and industry have led to increasingly advanced algorithms that handle noise, typically using the principles of directional processing and postfiltering. This article provides an overview of the techniques used for noise reduction in modern hearing aids. First, classical techniques are covered as they are used in modern hearing aids. The discussion then shifts to how deep learning, a subfield of artificial intelligence, provides a radically different way of solving the noise problem. Finally, the results of several experiments are used to showcase the benefits of recent algorithmic advances in terms of signal-to-noise ratio, speech intelligibility, selective attention, and listening effort.
Many hearing aid users are negatively impacted by wind noise when spending time outdoors. Turbulent airflow around hearing aid microphones caused by the obstruction of wind can result in noise that is not only perceived...Many hearing aid users are negatively impacted by wind noise when spending time outdoors. Turbulent airflow around hearing aid microphones caused by the obstruction of wind can result in noise that is not only perceived as annoying but may also mask desirable sounds in the listening environment, such as speech. To mitigate the adverse effects of wind noise, hearing aid developers have introduced several technological solutions to reduce the amount of wind noise at the hearing aid output. Some solutions are based on mechanical modifications; more recently, sophisticated signal processing algorithms have also been introduced. By offering solutions to the wind noise problem, these signal processing algorithms can promote more optimal use of hearing aids during outdoor activities. This article reviews how wind noise is generated in hearing aids, outlines the technological challenges in wind noise management, and summarizes the technological solutions that have been proposed and/or implemented in modern hearing aids.
A requirement for modern hearing aids is to evaluate a listening environment for the user and automatically apply appropriate gain and feature settings for optimal hearing in that listening environment. This has been pre...A requirement for modern hearing aids is to evaluate a listening environment for the user and automatically apply appropriate gain and feature settings for optimal hearing in that listening environment. This has been predominantly achieved by the hearing aids' acoustic sensors, which measure acoustic characteristics such as the amplitude and modulation of the incoming sound sources. However, acoustic information alone is not always sufficient for providing a clear indication of the soundscape and user's listening needs. User activity such as being stationary or being in motion can drastically change these listening needs. Recently, hearing aids have begun utilizing integrated motion sensors to provide further information to the hearing aid's decision-making process when determining the listening environment. Specifically, accelerometer technology has proven to be an appropriate solution for motion sensor integration in hearing aids. Recent investigations have shown benefits with integrated motion sensors for both laboratory and real-world ecological momentary assessment measurements. The combination of acoustic and motion sensors provides the hearing aids with data to better optimize the hearing aid features in anticipation of the hearing aid user's listening needs.
Directionality is the only hearing aid technology - in addition to amplification - proven to help hearing aid users hear better in noise. Hearing aid directionality has been documented to improve speech intelligibility i...Directionality is the only hearing aid technology - in addition to amplification - proven to help hearing aid users hear better in noise. Hearing aid directionality has been documented to improve speech intelligibility in multiple laboratory studies. In contrast, real-world studies have shown a disconnect between the potential of the technology and what hearing aid users experience in their daily life. This article describes the real-world studies that inspired ReSound to take a different approach to applying directional microphone technology. This approach is based on the idea that hearing aid directionality can leverage natural binaural hearing and inherent listening strategies. The directional strategy includes three listening modes that will be explained. These are the Spatial Cue Preservation mode, the Binaural Listening mode, and the Speech Intelligibility mode. The strategy and the advantages it provides in terms of sound quality, spatial hearing, and improved signal-to-noise ratio with maintained awareness of surroundings are explained.
For many years, clinicians have understood the advantages of listening with two ears compared with one. In addition to improved speech intelligibility in quiet, noisy, and reverberant environments, binaural versus monaur...For many years, clinicians have understood the advantages of listening with two ears compared with one. In addition to improved speech intelligibility in quiet, noisy, and reverberant environments, binaural versus monaural listening improves perceived sound quality and decreases the effort listeners must expend to understand a target voice of interest or to monitor a multitude of potential target voices. For most individuals with bilateral hearing impairment, the body of evidence collected across decades of research has also found that the provision of two compared with one hearing aid yields significant benefit for the user. This article briefly summarizes the major advantages of binaural compared with monaural hearing, followed by a detailed description of the related technological advances in modern hearing aids. Aspects related to the communication and exchange of data between the left and right hearing aids are discussed together with typical algorithmic approaches implemented in modern hearing aids.
There are two parts to this article. The first is a general overview of how hearing aid classification works, including a comparison study of normal-hearing listeners and multiple manufacturers' hearing aids while listen...There are two parts to this article. The first is a general overview of how hearing aid classification works, including a comparison study of normal-hearing listeners and multiple manufacturers' hearing aids while listening to a sound parkour composed of a multitude of acoustic scenes. Most hearing aids applied nearly identical classification for simple listening environments. But differences began to appear across manufacturers' products when the listening environments became more complex. The second section reviews the results of a study of the acoustic ecology (listening environments) experienced by several cohorts of hearing aid users over a 4-month period. The percentages of time people spent in seven different listening environments were mapped. It was learned that they spent an average of 57% of their time in conversation and that age is not a good predictor of the amount of time spent in most listening environments. This is because, when grouped by age, there was little to no difference in the distribution of time spent in the seven listening environments, whereas there was tremendous variability within each age group.
Understanding speech in noise is difficult for individuals with normal hearing and is even more so for individuals with hearing loss. Difficulty understanding speech in noise is one of the primary reasons people seek hea...Understanding speech in noise is difficult for individuals with normal hearing and is even more so for individuals with hearing loss. Difficulty understanding speech in noise is one of the primary reasons people seek hearing assistance. Despite amplification, many hearing aid users still struggle to understand speech in noise. In response to this persistent problem, hearing aid manufacturers have invested significantly in developing new solutions. Any solution is not without its tradeoffs, and decisions must be made when optimizing and implementing them. Much of this happens behind the scenes, and casual observers fail to appreciate the nuances of developing new hearing aid technologies. The difficulty of communicating this information to clinicians may hinder the use or the fine-tuning of the various technologies available today. The purpose of this issue of is to educate professionals and students in audiology, hearing science, and engineering about different approaches to combat problems related to environmental and wind noise using technologies that include classification, directional microphones, binaural signal processing, beamformers, motion sensors, and machine learning. To accomplish this purpose, some of the top researchers and engineers from the world's largest hearing aid manufacturers agreed to share their unique insights.
The demand for telehealth services will continue to grow alongside an increased need for audiology services among both children and adults. Insurance coverage policies for audiologic services are specific to each payer a...The demand for telehealth services will continue to grow alongside an increased need for audiology services among both children and adults. Insurance coverage policies for audiologic services are specific to each payer and vary widely in the level of coverage provided for both in-person and telehealth-based audiology services. While benefits for children are fairly comprehensive, coverage for audiology services for adults is generally poor. Traditional Medicare does not cover hearing aids or other rehabilitative audiologic services, and other payer policies vary widely. Lack of benefits for hearing and balance services is inconsistent with the evidence base and leaves many beneficiaries without access to meaningful care for hearing and balance disorders, which are highly prevalent among and disproportionately affect Medicare beneficiaries. The purpose of this article is to discuss regulatory and reimbursement considerations for telehealth provision in audiology and elucidate opportunities to influence related health policy at both state and federal levels.