REHABILITATIVE TECHNOLOGY

PRE-SELECTION
SELECTION

 Selecting prescriptive formula

 Selecting hearing aid features (Vol.
DAI/telecoil Directional mic etc)
 Selecting signal processing schemes
 Selecting hearing aid style
GOAL OF HEARING AID
PRESCRIPTION
 To help meet listening needs (Speech
understanding)
 For localization
 For maximum use of residual hearing
 Should a give a good quality output
 Hearing aid should provide amplification in
the comfortable range
VERIFICATION
 Process by which we see whether the
selected device is meeting the target or
goals. There few methods

 1) Functional gain measurement

 2) Insertion gain measurement
INSERTION GAIN MEASUREMENT
 Is an objective comparison between the
unamplified versus the amplified sound that
“reaches the ear”. Such comparisons are called
Rear-ear Insertion gain (REIG) measurements or
Insertion gain measurements

 REM (Real ear measurements) is used a synonym

used for Insertion gain measurements

 First study in the form of probe microphone

measurement was made by Weiner & Ross (1946)
INSTRUMENTATION
 All REM systems are comprised of the following:
 a sound field speaker,
 a reference microphone,
 a probe-tube microphone and
 a computerized micro processing unit.

 REM system generates its own calibrated sound source. The

loudspeaker delivers the test signal generated by the system to the
sound field.

 The reference (Control) microphone is responsible for calibrating the

sound field and can be positioned just below or above the ear. The
REM system uses the recordings done by reference mic to adjust the
signal source to achieve specified values.
 Used to regulate the sound level near the ear to the required level.

 The probe tube microphone is the main measurement
microphone
 a very soft and slim silicone rubber tube, one end of
which is inserted into the ear canal; and the other end
is connected outside the ear to small microphone
housing
 Earlier small metal tubes were used
 Later A small electret mic itself was placed in the ear
canal (called as Harford-Preves technique).
TEST PARAMETERS
 Stimulus type
 Test Environment
 Signal Level
 Distance
 Azimuth
 Probe tube insertion depth
 Head Restraint
 Varieties of stimulus are available on most real ear probe mic
system. Such as pure tones, warble tones, clicks, NBN etc.
 Pure tone: Continuous sinusoid of a single frequency. But
because of standing wave from reflective surfaces. Pure tone
stimuli are not recommended
 Warble tones: FM of a single frequency of a pure tone. Not
influenced by standing wave.
 NBN: Produced by 1/3rd octave band filtering of white noise.
It can be used as swept frequency or single frequency
measurement.
 Clicks: It is broad band transient signal characterized by
instantaneous onset.
 Clicks are difficult to calibrate precisely because of the
inability to limit or define the spectrum.
 In addition rapid onset of click may activate the automatic
gain suppression circuit of the hearing aids thereby giving
enormous results
 Composite noise: It is composed of large number
of individual sinusoidal signals summed for
simultaneous presentation. The result is “noise
like” stimulus with controlled spectral
characteristics.
 These signals are speech weighted that is high
frequencies having less energy than at the lower
frequencies. The most common speech weighting is
defined by ANSI S3.42-1992. Higher frequencies
continue to decrease in amplitude at a rate of
6dB/octave. Another speech weighting is defined
ICRA (The international Collegium of Rehabilitative
Audiology (1997)) It rolls off the high frequencies
more quickly than ANSI, at a rate of 9 dB per
octave.


ANSI VS ICRA
DIGI SPEECH
 Interrupted composite noise. The pauses
are similar to that of natural speech
 There are two Digital Speech signals
available

Digital Speech ICRA (DIGSP ICRA) and Digital

Speech ANSI (DIGSP ANSI
COMPOSITE
DIGI SPEECH
ISTS
 International Speech Test Signal (ISTS)
 This signal includes natural sentences of six
languages spoken by a female. The ISTS was
developed by a group within EHIMA
(European Hearing Instrument Manufacturers
Association).
 This is more speech-like than the other
existing test stimuli. 
 The signal reflects a female speaker
incorporating and combining six different
mother tongues (American English, Arabic,
Chinese, French, German, and Spanish).  
ISTS
TEST ENVIRONMENT
 Envt. can affect the validity of the results.
 It is suggested to measure the ambient
levels in the proposed test room prior to
initiating IG measures to avoid contamination
 It is advisable to compare IG results obtained
for several subjects in the proposed test
room with those obtained in a sound treated
room.
LEVEL OF THE SIGNAL
 Test level should be high enough to avoid
contamination by ambient noise level
 Test level should not be so great as to send
the hearing aid into saturation or to activate
its compressor circuitry
 Should not cause discomfort
 Level of 60 to 70 dB SPL is suggested

 For a non linear hearing aid testing is done at

multiple levels usually 55, 65 and 80 dB SPL
DISTANCE AND AZIMUTH

 Testing at closer distances of loud speaker creates the risk of entering

into the near field. When this occurs, small changes in the distance
leads to large measurement errors. It also creates discomfort to
patients.

 Keeping the loud speaker too far results in interference of ambient

noise and reverberation

 Jecca (1987) compared two distances, 1m and 1.5 m in two

environments, in an audiometric test room and a non-standard
consultation room. There was no difference between the two
situations and two distances.

 Studies have shown that a distance of 20 cm it was unpleasant for the

patient and distance of 1 m was far more comfortable for the patient.
 Most manufacturers recommend the distance between 0.5 and 1.0
meter.
 As was noted earlier, audiologists should review the documentation
provided with their specific real-ear system to determine the
recommended protocols with their equipment. As an example, Audioscan
recommends placing the patient directly in front of and facing the speaker
(0 degrees azimuth) at a distance of 0.45 m to 0.6 m.
Fonix recommends 12 inches, 45 degrees azimuth

 Killion and Revit (1987) – Reported that reduced variability of repeated

measures is obtained then the loud speaker is placed 45 degrees to the sid
of 45 degrees elevation
 This reduced the average test retest deviations upto 1 dB relative to 0
degree azimuth
 90 degree azimuth has better test retest variability than 0 degree
azimuth. However, this orientation may interact with directional mic, HSE

 Mueller (1992) reported 90 degree results in significant error and should

be avoided
PROBE TUBE INSERTION DEPTH
 It’s a source of greatest variability in RE measures.
Insertion depth should not be so much that it touches
TM
 Place the tip of the probe tube within approximately 5
mm of the eardrum to avoid standing waves and to
assure that the high frequency components of the
response are accurately measured. As Dirks and Kincaid
(1987) illustrated, the closer the probe tube is placed
to the eardrum, the more accurate high frequency
measurements become. For clinical purposes, a
placement within 5 mm of the eardrum is appropriate
as it will provide accuracy within approximately 2 dB of
the true value at the eardrum up to 8 kHz.
  
HEAD RESTRAINT
 Killion and Revit (1987) demonstrated that
the variability associated with different LS
azimuth is due to small head movements.
Head restraint should be expected to reduce
the likelihood of error but its difficult to use
head restraint clinically
 Care should be taken
PRE-MEASUREMENT
PROCEDURES (FACTORS): 
A. Probe Tube Calibration

Probe tube calibration accounts for the acoustic effects the probe tube
introduces as sound travels through it.

In effect, calibration removes the acoustic effects the probe tube during real-ear
measurement.

One has to compare the output form the reference mic to the simultaneously
recorded response of the signal travelling thorugh the probe tube attached to
the test mic.

The difference between these two responses reflect the effect of probe tube.

In most equipments, the acoustical transmission effects of probe tube are stored
and hence the response from two mic should be same.
 B. Otoscopic Examination

Prior to conducting any real-ear measurement, it is important

to perform an otoscopic examination. This serves to provide
information about the presence of cerumen or other debris
which may interfere with placement of the probe tube
and/or block the probe tube.

 If the ear canal appears occluded or if cerumen is located

where it may affect probe tube placement, the cerumen
should be removed prior to conducting real-ear
measurements.

 Otoscopic examination also provides details regarding the

specific anatomy of the ear canal, which is useful when
placing the probe tube.

 C. Location of speaker
D. PROBE TUBE PLACEMENT
METHODS
 One method (visually-assisted positioning) involves inserting
the probe tube a constant insertion depth beyond the tragus or
inter-tragal notch. The guidelines regarding how far to insert
the probe tube can vary, depending on the age and gender of
the patient.


General guidelines suggest: For adult females, insert the probe

tube 28 mm past the inter-tragal notch. For adult males, insert
the probe tube 30-31 mm past the inter-tragal notch.

 For children, insert the probe tube 20-25 mm past the inter-
tragal notch. Certainly normal anatomic variants will prohibit
the placement of the probe tube to these depths in some
patients, while in other patients these locations may not be
deep enough.
'geometrical positioning.‘
 the ridge of the ear mold or hearing instrument
corresponding to the location of the inter tragal
notch is identified.
 Lay the probe tube along the ridge identified above
with the open end of the probe tube extending 5
mm beyond the tip of the ear mold or hearing
instrument.
 Mark the probe tube at the outer edge of the ear
mold or at the faceplate of the hearing aid and
then insert the probe tube into the ear canal until
the mark lies at the rim of the inter tragal notch.
 Probe tube placement can also be assisted via acoustical
positioning procedures (ANSI, 1997; ISO 12124:2001). A simplified
method is through visualization and repositioning based on the
REUG curve, monitoring particularly the frequency region above
4000 Hz.
 a. Insert the probe tube less than half way into the ear canal while
presenting a 65 dB pink noise signal or composite signal.
 b. A notch in the gain curve above 4000 Hz is likely to be observed.
 c. Gently insert the probe tube deeper while keeping an eye on the
notch which is moving towards higher frequencies.
 d. The probe tube is located correctly as soon as the notch is no
longer dragging the gain curve down (-5 dB) in the high-
frequencies.
 e. Once the measurement is stabilized move the probe tube marker
into position or to attach the probe tube to the probe tube support.
E. EQUALIZATION
 It is the process of controlling the acoustic
signal at a specific point in space so that the
amplitude remains at the desired level across
frequencies.
 There have been 2 commonly used methods
of sound field equalization
 a. Substitution method
 b. Modified pressure method (this term was
recently recommended by ANSI) / earlier it
was called as modified comparison method
(Preves, 1987; Preves and Sullivan, 1987).
 a. Substitution method
 The exact position in the room where the person will be
seated is identified
 without the patient in the room, a mic is placed at the
location the person will occupy for measurements.
 A signal is produced by the loud speaker, measured by the
mic and deviation from a flat free field is calculated.
 After that the unoccluded ear testing will be conducted
with the patient in the exact position .The centre of the
patient’s head is placed in the precise location previously
occupied by microphone
 microphone is located in the ear canal.
 Then aided measurement conducted in the similar
manner as unaided testing. It is usually done in off line.
 b. Modified pressure method
 There are two mics, one that measures SPL in the
ear canal and one that is located some place in
the head and regulates the SPL being generated
by the loud speaker and maintain the signal at a
constant level. There are two major differences
between substitution method and this. First,
there is no equalization conducted with the
patient absent. Second, a second regulating mic
will be present for all the measurement. It can be
done either in online /offline.

 Feed in thresholds
 Select prescriptive formula
 Select ear
 Stimuli
 Level
1. REUR (real ear unaided response)
 SPL, as a function of frequency, at a
specified measurement point in the
unoccluded ear canal for a specified sound
field. This can expressed either in absolute
SPL (Response) or again in decibels relative
to the stimulus level (Gain).
 They reflect the resonance characteristics of ear canal, concha,
and also the head and torso.
 The average adult REUR has a primary peak around 2700 Hz of
about 17 dB, and a secondary peaks around 4000 Hz to 5000 Hz
region of 12 – 14 dB. It is the gain provided by the pinna and the
ear canal with consequent head diffraction effects as measured in
the ear canal.
 Procedure:
1. Conduct otoscopic examination.
 2. Place probe tube in the ear canal, with end of tube at
appropriate distance from the inter tragal notch (e.g., within 5
mm of the eardrum).
 3. Place patient at appropriate distance/azimuth from the
loudspeaker.
 4. Select desired input level.
 5. Conduct the measurement.
 Reference value for the calculation of
insertion gain.
 Also reflects the abnormalities of ear canal
or the middle ear.
2. REAR (Real-Ear Aided Response)
 SPL, as a function of frequency, between the
SPL at a specified measurement point in the
ear canal for a specified sound field, with
the hearing aid (and its acoustic coupling) in
place and turned on.
 The gain of the hearing instrument across frequencies,
measured in the ear canal. It is a direct measurement how a
hearing aid will perform in a real ear.
 Procedure:
 1. Conduct otoscopic examination.
 2. Seat the patient at the appropriate distance/azimuth from
the loudspeaker.
 3. Place probe tube in the ear canal, with end of tube at
appropriate distance from the inter tragal notch (e.g., within
5 mm of the eardrum). NOTE: if the REAR/REAG is being used
to calculate insertion gain, be sure to position the probe tube
at the same location as the REUR/REUG measurement.
 4. Insert the hearing instrument into the client's ear while
holding the probe tube so that its position in the ear canal is
not disturbed.
 5. Turn the hearing instrument on and set the user gain
control to the desired setting.
 6. Select desired input level.
 7. Conduct the measurement.
 Clinical applications .
 Serves as a reference for insertion gain
calculation
 To find out inter modulation distortions in
the hearing aid
 Trouble shooting the hearing aids
 Helps in finding out the maximum output in
the real ear of the hearing aid when it is in
saturation.
3. REIG (Real-Ear Insertion Gain) 
 The real ear insertion response (REIR)(ANSI S3.46-
1997): Difference in decibels, as a function of
frequency, between the REAR and the REUR,
obtained with the same measurement point in the
same sound field conditions.
 The REIG is the value, in decibels of the REIR at a
specific frequency. The amount of gain provided by
the hearing instrument alone calculated by
subtracting the REUG from the REAG across
frequencies or by subtracting the REUR from the
REAR across frequencies.
 REIG = REAG – REUG
 Procedure :
 Step 1: Conduct an REUR
 Step 2 : Conduct an REAR, using the same sound field
conditions and measurement point as the REUR (i.e., probe
tube placement and signal level).
 Step 3: Subtract the REUR from the REAR across frequencies
or subtract the REUG from the REAG across frequencies.
 Step 4: Adjust hearing instrument characteristics so that the
REAR (REAG) and thus the subsequent calculation of REIG
provides the best match to the target REIG values across
frequencies.
  REOR (Real era occluded response
 SPL as a function of frequency, at a specified measurement
point in the ear canal for a specified sound field, with the
hearing aid (and its acoustic coupling) in place and turned
off. This can be expressed either in SPL or as gain in decibels
relative to the stimulus level.
 Here the effect of placement of ear mould or hearing aid in
the ear easily can be measured. For open ear fitting REOR
may be very similar to REUR at some frequency region. For
most of the ear mould styles REOR will be substantially below
than REUR. In cases of venting REOR comes higher than that
of REUR at the region around 1500 Hz, because of the
resonance. REOR helps in the estimation of insertion loss.
Tight fitting hearing aid the REOR falls below the input level.
So it becomes very important in the measurement of REIR.
 Procedure:
 REUR measurement (even if it is not necessary)
 Hearing aid will be placed. Make sure the hearing aid is turned off.
 Place probe tube in the ear canal, with end of tube at appropriate
distance from the inter tragal notch (e.g., within 5 mm of the
eardrum).
 Place patient at appropriate distance/azimuth from the
loudspeaker.
 Select desired input level. (usually 60dB SPL)
 Conduct the measurement
 Clinical applications
 Helps in determining appropriate vent size.
 Indirect measure of occlusion effect.
 Helps in selecting an acoustically appropriate sound delivery system
 Real ear saturation response
 Difference in decibels, as a function of
frequency, between the SPL at a specified
measurement point in the ear canal for a
specified sound field, with the hearing aid
(and its acoustic coupling) in place and
turned on. The measurement is obtained
with the stimulus levels sufficiently intense
as to operate the hearing aid at its maximum
output level.
 It is very critical measurement for children
and non responsive patients when the
maximum output of the hearing aid must not
only comfortable but also safe.
 Procedure:
 Same as that of REAR, ensure that the
hearing aid is in saturation. This can be
accomplished by setting the input as 90dBSPL
and by adjusting the hearing aid volume
control to a just below the feedback.
 Clinical applications
 To measure the patient discomfort level
 To make sure that the maximum output of
the hearing aid is both comfortable and safe.
 Real ear coupler difference (RECD) 
 Difference in decibels, as a function of frequency, between the
outputs of the hearing aid measured in a real ear Vs a 2 cm3
coupler. This measure solves the problems of correcting
responses from the 2cm3 coupler to the real ear.
 Procedure
 Measure REAR
 VCW at ½ or 2/3 rotation setting.
 Remove the hearing aid from the ear and a 2cm3 coupler
response is obtained. ( VCW should be in the same position
 2cm3 coupler values are subtracted from the REAR and the
difference is RECD.

 It helps the clinician to select the hearing aid that would

closely approximate the prescriptive target
 Real ear to dial difference (REDD)
 The difference between the outputs measured in dB SPL using a probe
microphone near to the ear drum to the measure made in dB hearing
level (HL) from a calibrated audiometer.

 It usually requires an audiometer to produce the signal in dB HL and the

real ear analyzer and measure the response near the eardrum in dB SPL.

 Here continuous pure tone signal is usually produced from the

audiometer at 70dB HL using headphone or insert as the transducer
(which used to measure the patient threshold values).

 The real ear analyzer measures the response near the ear drum with the
probe microphone. The difference between the SPL value measured by
real ear analyzer and the amplitude produced by the audiometer in dB
HL is the REDD at that frequency.
ADVANTAGES OF IGM
 We obtain information across frequencies
 It is not necessary to mask the other ear.
 REG can be done for whom behavioral
responses are not available.
 The effects of input level are assessed.
SOUND FIELD MEASUREMENTS
 Sound field is any area in which sound waves
are present
 Functional gain: is the dB difference
between aided and unaided behavioral or
neural thresholds
 EQUIPMENT
 The equipment used in sound field
measurements consists of a stimulus
generator, loudspeakers, and calibration
equipment.
 A. Loudspeakers
 The ideal loudspeaker for audio logic testing
should possess the following general
characteristics:
 (a) Broad bandwidth (minimally 100–10,000
Hz);
 (b) Constant output as a function of
frequency (c) low distortion;
 (d) Capability of accurately transducing
transient as well as steady-state signals;
 B.ENVIORNMENT
 Sound field measurements are influenced by
the acoustic characteristics of the
environment in which auditory measures are
to be conducted.
 When pure tones are introduced into the
sound field, the resonances of the room are
evidenced by standing-wave patterns with
resultant variation in measured SPL depending
on measurement location in the room.
 Hence, warble tones
 To achieve a reliable and repeatable
measurements in a sound field, it is
necessary to place the patient in an area
where ambient noise levels are controlled.
 Less reverberant condition
 Good absorbing material that dampens the
sound and reduces standing waves.
 Patient placement in a sound field

 Patient should be placed far enough from

reflecting surfaces so that there is no
disturbance from changes in sound pressure.

 Patient be placed 1 m from the sound field

speaker to reduce the influence of standing
waves. The patients head must be held as
steady as possible.
 Frequency specific stimuli- pure-tones have
problem of standing waves
 Hence, warble tones need to be used

 Speech stimuli should also be used – to assess

the utility to understand conversational
speech under a variety of listening
situations.
 Depending the age Ling sound test or
 Picture Identification testing or Word
Recognition testing should be done
 Its also important to judge the intelligibility
of a paragraph/sentences using paired
comparison procedures.

 Finally, loudness discomfort levels need to

be estimated
FUNCTIONAL GAIN MEASUREMENTS
VS INSERTION GAIN MEASUREMENTS
Functional Gain measurements
 It is a subjective method using sound field
measurements
 Functional gain can also be measured using
other objective methods such as ABR, ASSr
 Subject’s preferences and comfort levels can
be measured using this
INSERTION GAIN
MEASUREMENTS
 It is a Real ear measure
 It is an objective method and less time
consuming
 Subject’s preferences and comfort levels can
not be measured using this
 This can be used to assess at different
stimulus level
VALIDATION
 Verification is an important component of the
hearing aid evaluation, but it does evaluate
whether the matched hearing aid targets are
actually appropriate for the patient with
regard to improvements in speech perception,
or whether the patient will benefit from such
prescribed hearing aid gain.
 Hearing aid validation refers to outcome
measures designed to assess treatment
efficacy, that is, whether the hearing aids are
beneficial.
There are two types of validation/outcome measures
 Subjective outcome measures use questionnaires
and interviews
 There are several questionnaires developed. Some
are:
 The Client Orient Scale of Improvement (COSI)
-Dillon, James, & Ginis, 1997
 The Glasgow hearing aid benefit profile-
Gatehouse, 1998)
 Abbreviated Profile of Hearing Aid Benefit
(APHAB)- Cox & Alexander, 1995

 Objective outcome measures

 Use speech perception and speech in noise tests to
check the improvement.
PAEDIATRIC HEARING AID
FITTING-SELECTION AND
VERIFICATION
 PRE-SELECTON OF AMPLIFICATION SYSTEMS

 SELECTION

 Signal processing options

 Selecting amplification targets: NAL or DSL

 VERIFICATION OF ELECTROACOUSTIC
CHARACTERISTICS

 VALIDATION OF AIDED AUDITORY FUNCTION

 DIFFERENCE BETWEEN CHILDREN AND
ADULTS

 They are physically smaller than adults which leads to

differences in SPL especially at higher frequencies (Voss
& Hermman, 2005)
 The type of assessment is different between the two
group

 Theamount of information available at the time of the

hearing instrument fitting
 PRE-SELECTON OF AMPLIFICATION
SYSTEMS
 Behind-The-Ear hearing aids - comfort, safety and fit
comfortably on the child’s ears

 Select a hearing aid with flexible electro acoustic

characteristics

 Hawkins and Yacullo (1984)

 Reported that binaural hearing aids give a greater SNR
advantage in adverse listening conditions compared to
monaural hearing aid fitting.
 unless medically contraindicated or the other ear is
anacusic.
 Options for accessing assistive devices, i.e., direct
audio input (DAI), telecoil (T) and microphone-
telecoil (M-T) switching option

 Safety features, i.e., tamper resistant battery

compartment, volume controls that can be covered or
deactivated.
 Earmolds - soft material for safety and comfort
 Retention devices include: "Huggies", headbands,
bonnets and caps
 Selection of features: Compression circuits, multi
memory systems, directional microphones, and FM
systems

 WDRC circuits apply more gain to less intense

signals than to more intense signals
 WDRC is found to be better for horizontal sound
localization and consonant perception at 55 dB SPL in
children

 Potential for feedback is higher because of the

increased gain for low input levels.
Directional microphones

 For young children- not as advantageous as they are for

adults

 However, Directional microphone technology does not

significantly disadvantage children of any age.

 Switchable is preferable (directional to omni directional

mode of operation)

 Counseling caregivers and professionals on making the

most of directional advantage by facing the child when
talking by teaching the child to look at the talker is
essential.
 Multi-memory is preferable for school going
children as children may make of induction
loop or FM system.
 It is always preferable to select a hearing aid
which is compatible with FM system.

 Non-traditional amplification should also be

considered (i.e., frequency
transposition/frequency compression hearing
aids, when not able to perceive high
frequency sounds)
 Starting point - prediction of the audiogram from an
evoked potential assessment (Scollie & Bagatto, 2010)

 Different procedures use different stimuli and calibrations

 If this is not considered important, the child might be over
amplified.
 CAUTION when BOA result are considered for fitting
hearing aids.
 Amplification should be fitted based on appropriately
converted ABR thresholds or on behavioral thresholds.
 A correction is applied to the ABR threshold estimates to
better predict the behavioural threshold.

 This corrected ABR is sometimes referred to as Estimated

Hearing Level (eHL) 
SELECTING AMPLIFICATION TARGETS: NAL-NL1 OR DSL I/O
 Both are widely accepted prescriptions.

 DIFFERENCES
 DSL prescribes higher gain than NAL
 DSL prescribes more low-frequency gain for flat loss
 DSL prescribes more high-frequency gain for sloping loss

Preferable to reduce gain for loud sounds in noisy situation

when DSLi/o is used
Preferable to increase gain for soft sounds when NAL-NL1 is
used
VERIFICATION OF ELECTROACOUSTIC
CHARACTERISTICS
EVALUATION OF AIDED PERFORMANCE

Behavioral measures:
 Functional Gain is done: This is the difference, in
decibels between aided and unaided thresholds
 cooperation from the child is required and thus
may require multiple sessions.
Speech tests:
 Level of difficulty has to be appropriate to the age
and degree of hearing loss (either open or closed
set)
 Ling sound test
 Paired comparison:
 This can be done in children aged six or older -two
alternative hearing aids in quick succession can be
given and compared
 Evaluation of discomfort:
 Face icons to represent different loudness categories
when a child’s LDL is measured.
 Age of seven or older can be assessed using this.

Objective measures:
 Insertion Gain Measures:
 These are Individual and objective measures
 If the child is not cooperative, RECD can be performed
6.7 to 17.3 years
Scollie et al, 2010
 If RECD measurements cannot be performed,
applications of DSL v5, there are age appropriate
predicted RECD values.

 At some frequencies, the differences range from

±12 dB

 Recommended is to use individual measurements of

RECD
ELECTROPHYSIOLOGICAL TESTS
WHY ELECTROPHYSIOLOGICAL
TESTS
 Behavioural audiometry is not viable until the age of 5 to
6 months and, in some infants or young children with
developmental delay, not possible at all.

 Difficult-to-test populations, hearing thresholds can be

obtained only through electrophysiological measures that
do not require any voluntary response from the
individual

 Electrophysiological tests can assist research involved in

the adaptation (improvement) of hearing aids, because
these tests can measure auditory function objectively
IMMITTANCE
 By placing the HA on a child and measuring the AR in the contra
lateral ear with a 65 dB SPL speech input, volume control can
be lowered or raised until the reflex is barely observed. The
optimum setting can be made by setting the VC at a level just
below the occurrence of the AR.

 The difference between the aided and unaided reflex threshold

is the real ear or use gain at a particular volume control
setting.

 Can also find out dynamic range (PT threshold-reflex threshold)

 And also LDLS can be predicted using Immittance since the ART
and loudness discomfort level for some types of acoustic stimuli
- especially speech - were at approximately the same levels.
OTOACOUSTIC EMISSION AND
COCHLEAR MICROPHONICS
 Level at which OAE is recorded cannot be used to
predict behavioural thresholds from which to
prescribe amplification.

 However, the presence of OAEs or CMs suggests

normal outer hair cell function (mainly in the cases of
AD), which means amplification may cause noise-
induced hearing loss due to OHC damage.

 As a result it is important to monitor the child for

progressive hearing loss. This could potentially be
achieved using OAE tests.
ABR
Present the signal through the speaker
Carry out unaided ABR
Fit the hearing aid and record the aided ABR
Threshold, amplitude or latency of wave V can be used to fit the hearing
aid

1) Threshold of wave V.
 The hearing aids and/or settings which provide lowest threshold is
selected
Krebs (1976); Cox and Metz (1980) and Kilney (1982)

2) Latency of wave V.
 The hearing aids and/or settings which provide shortest latency is
selected
 L-I function
 The observed patterns could be used to determine
what type of HA would best suit a HL.

 For instance, if Steeper than normal LI function was a

sign of recruitment (i.e., reduced dynamic range) and
that subject would benefit from compression
circuitry.- Hecox (1983)

3) Gain of hearing aid can be adjusted till a

recognizable wave is obtained

 Kiessling (1983) – has given Amplitude projection

procedure based on amplitude- intensity function
 Threshold gives gain, Amplitude growth
function gives DR & Compression.
LIMITATIONS OF ABR FOR HEARING AID EVALUATION

 Click stimulus -brief stimulus can be distorted and create

ringing in the hearing aid

 Click stimuli are broadband and thus do not represent accurate

measures of hearing thresholds for any specific frequency

 Hearing aids reacts differently to rapidly changing stimuli than

to continuous stimulus which leads to distortion of the stimulus

 Brief stimuli may not activate the hearing instruments

compression circuitry in the same way as longer duration
 There has not been much success in discovering valid ABR
measures to assess HAs
 Even tone bursts can create a large artifacts with hearing aids
ASSR
 Studies (for example Picton et al (1998)) suggested that
it would be possible to measure functional gain of
hearing aids on the basis of ASSR threshold.

 Damarla & Manjula, 2007

 studied the relationship between the real ear insertion
gain (REIG) and ASSR gain (unaided ASSR threshold vs.
aided ASSR threshold).

 that ASSR gain and REIG were highly correlated and there
was no significant difference at all test frequencies.
Amplitude Projection Procedure has been applied on
the ASSR data and ASSR could be used for selection
of gain and compression ratio.

LIMITATION OF ASSR

 The estimation error of hearing thresholds

from ASSR can be very large
LLR
It has been found that aided LLR responses are larger than
unaided responses when stimuli were presented at the same
input level.

The cortical responses are present reliably with speech stimuli

in aided infants with moderate and severe hearing losses.
However, can be present even in children with profound hearing
loss cases

the cortical responses’ shape changes consistently with changes

in the gain-frequency response of hearing aids.

Hence, LLR can be used to ensure that the hearing aid is useful
or not.

Presence of LLR indicates that the signal is audible and

perceived at the cortical level (verification)

It also monitors the change in neural processing of speech

(Validation)
ADVANTAGES
 The stimuli can be longer than the brief clicks or
tone pips that are needed to measure an ABR. This
means the hearing aid has time to react to the
sound

 It can be done with speech stimuli and provide

information regarding speech processing.

 It assesses almost the entire auditory system

Limitation: Arousal state affects the results.

MISMATCH NEGATIVITY (MMN)
AND P3

 Aided MMN and P300 have been studied

 The results of this tell us about the

improvements in speech discrimination
ability with hearing aids.
 Counseling and training
VALIDATION OF AIDED
AUDITORY FUNCTION
Direct measurements of the child's performance in clinical and
natural environments may include:
1) aided sound field responses
2) aided speech perception measures
3) parent report measures/questionnaires
 Infant –Toddler Meaningful Auditory Integration Scale (IT-
MAIS) (Zimmerman, Osberfer & Robbins, 1998).
 Children’s home inventory for listening difficulties (CHILD)

 It is also important to test in Binaural presentation mode

SUMMARY
 BTE
 WDRC , Directional Microphones
 Binaural hearing aids- always test two ears seperately
 Subjective and Objective tools
 Subjective – age specific
 Older age- speech tests (in noise), paired comparison,
Loudness judgments
 Always have insertion gain measurements
 Need to have average RECD developed
A well defined protocol is important
HEARING AID FITTING FOR
CONDUCTIVE HEARING LOSS
 Surgical correction is the primary and preferred treatment
option by most patients
 Hearing aid is the next option
 AC hearing aid or BC hearing aid
 Some considerations while fitting AC hearing to conductive
hearing loss:
 Prescriptive formula apply correction while calculating gain for
conductive hearing loss – usually 25% of ABG is added (NAL and
Berger)
 In case of linear hearing aids the toe control setting is in N or L as
mostly CDHL is of flat or rising configuration
 Hearing aid with flexible electro acoustic characteristics as the
hearing may improve incase of infection resolving
 Compression is seldom required as they don’t have recruitment or
tolerance problem except in an advanced stages of otosclerosis.
 Based on needs assessment select features
 Venting is an option to be considered for cases
with ear discharge, preferably external vent.
Parallel or diagonal vent is generally not
preferred as it will reduce low frequencies. Even
if they are given a very small diameter vent is
recommended.

 Verification: functional and insertion gain

measurements can be done.
If there is active frequent ear discharge, infection
in the outer ear, skin allergy, atresia or stenosis,
then BC hearing aid can be considered.
 Two main types of bone conduction hearing aid are
available; the traditional bone conduction hearing
aid and the implanted bone anchored hearing aid.
 Conductive or mixed with good BC thresholds can
be fitted with BC hearing aid.
 Verification strategies for fitting traditional BC
hearing aids:
 Its mainly functional gain measurements
 However, output hearing aid can be measured with
real ear analyzer. The probe microphone is placed
at the position of the bone conductor, with the
patient absent.
BAHA
 The Baha is a surgically implantable system for treatment of hearing loss that
works through direct bone conduction.

Candidates for the Baha System

 The Baha is used to rehabilitate people with conductive and mixed loss hearing
impairment. This includes people with chronic infection of the ear canal, people
with absence of or a very narrow ear canal as a result of a congenital ear
malformation, infection, or surgery
 People with a single sided hearing loss
 The bone conduction thresholds should be up to, on average, 55 dB (FDA
indication states 45 dB)
 If ABG is 30 or higher, improvement may be better
 Age of candidates 5 yrs or older
 Bilateral fitting can be done
 SIS more than 30%
 SSD (normal hearing should have 20-25 dB HL)
 pre-operatively assess the effectiveness of this
device by putting the device onto a headband or
soft band and perform sound field age appropriate
testing.
 Some skin damping occurs in this demonstration
scenario, but patients are able to listen to the
device and make some judgment as to whether
they want the device or not.
 Aided and unaided speech-in-noise testing in the
sound field can be done
 The same test are performed to look at post-
operative benefit and outcomes with this device. 
 Advantage of BAHA
 This is placed behind the ear leaving the canal open.
 It is worn under the hair and is not perceptible to
others.
 Because it is held in place by a clip and directly
integrated with the skull bone, there is no need for a
head band and pressure against the skin of the head.
 In recent clinical trials patients prefer the sound and
speech clarity achieved with the Baha versus the CROS
and versus the unaided condition.
HEARING AID FITTING IN
GERIATRIC POPULATION
 Hearing aid prescription depends majorly on
their motivation to use the hearing aids. Since
most of them don’t accept of having hearing
problem, counseling is important regarding the
need for hearing aid, benefits form hearing aid,
other modes of communication etc.

 Initially they may use the hearing aid but may

stop later since they find that the benefit is
lesser than their expectation. Hence, counseling
on what to expect is very important and close
monitoring and follow –up is essential.
 There are a number of easily administered
self-assessment measures, such as the
Hearing Handicap for the Elderly (HHIE;
Ventry and Weinstein, 1982) questionnaire.
These take minutes to administer and help
delineate the older adult’s perception of
communication difficulties
SELECTING AN AID (HEARING AID STYLE,
ARRANGEMENT, CATEGORY)
Selection of Hearing-aid style
  Manual dexterity may be a problem for
many older adults and hence needs to
considered while selecting hearing aids
 BTEs are ideal.
 Additional advantages include their
flexibility, compatibility with direct audio
input microphones, powerful telecoils, ease
of insertion of unit, and larger batteries.
 For the most part, however, smaller custom
ITE aids are preferred for cosmetic appeal.
 Hearing aid arrangement (Monaural vs.
Binaural)
 Hearing level in conjunction with word-
recognition scores can be used to decide on
hearing aid arrangement or in the case of a
monaural unit, the ear to be fit. It is now
commonly accepted that binaural fittings are
preferable to monaural fittings because of
advantages associated with a binaural fitting
 Binaural amplification may not be appropriate
for older adults with dexterity problems on a
particular side
 More automatic better, as the need to manipulate controls
reduce.
 Other features selection is similar to adults.

 However, cognitive abilities of geriatric population needs

to be considered. It has been found that persons with poor
working memory longer time constants resulted in better
performance than short time constants
Ear mold fitting for elderly
 Fitting the elderly can create some special concerns. One
of these concerns is manual dexterity and its effect on
ease of insertion of the ear mold.
Hearing aid fitting:
 Have short sessions of testing

 Give them ample time for responding

 ALDs help to address communication problems by
amplifying sounds and are typically stand-alone
devices; i.e., no hearing aids are required.
Assistive listening devices have been found to
provide improvement in hearing along with the
hearing aids. Some of them are-
 Personal listening systems 
 TV listening systems 
 Direct audio input hearing
 Telephone amplifying devices. 
 Mobile phone amplifying devices. 
 Auditorium-type assistive listening systems. 
 Counseling
 Appropriate expectations of the benefits of
hearing aid use are imperative for successful
hearing fit. Clients need to realize that the
devices are aids to hearing and not hearing
restorers. Patients need to understand that
they will experience an adjustment period
after the fitting.
 Post-Fitting Interventions
 Group programs
 Formal listening training: The Listening and
Communication Enhancement (LACE;
Sweetow, 2005; Sweetow and Henderson-
Sabes , 2004)
 Communication strategies
 Speech reading: (Different analytic and
synthetic approaches)