Improving Sensitivity of the Digits-In-Noise Test Using Antiphasic Stimuli

Automatic development of speech-in-noise hearing tests using machine learning

Understanding speech in noisy environments is a primary challenge for individuals with hearing loss, affecting daily communication and quality of life. Traditional speech-in-noise tests are essential for screening and diagnosing hearing loss but are resource-intensive to develop, making them less accessible in low and middle-income countries. This study introduces an artificial intelligence-based approach to automate the development of these tests. By leveraging text-to-speech and automatic speech recognition (ASR) technologies, the cost, time, and resources required for high-quality speech-in-noise testing could be reduced. The procedure, named "Aladdin" (Automatic LAnguage-independent Development of the digits-in-noise test), creates digits-in-noise (DIN) hearing tests through synthetic speech material and uses ASR-based level corrections to perceptually equalize the digits. Traditional DIN tests were compared with newly developed Dutch and English Aladdin tests in listeners with normal hearing and hearing loss. Aladdin tests showed 84% specificity and 100% sensitivity, similar to the reference DIN tests (87% and 100%). Aladdin provides a universal guideline for developing DIN tests across languages, addressing the challenge of comparing test results across variants. Aladdin's approach represents a significant advancement in test development and offers an efficient enhancement to global screening and treatment for hearing loss.

The Influence of Semantic Context on the Intelligibility Benefit From Speech Glimpses in Younger and Older Adults

PURPOSE

Speech is often masked by background sound that fluctuates over time. Fluctuations in masker intensity can reveal glimpses of speech that support speech intelligibility, but older adults have frequently been shown to benefit less from speech glimpses than younger adults when listening to sentences. Recent work, however, suggests that older adults may leverage speech glimpses as much, or more, when listening to naturalistic stories, potentially because of the availability of semantic context in stories. The current study directly investigated whether semantic context helps older adults benefit from speech glimpses released by a fluctuating (modulated) masker more than younger adults.

METHOD

In two experiments, we reduced and extended semantic information of sentence stimuli in modulated and unmodulated speech maskers for younger and older adults. Speech intelligibility was assessed.

RESULTS

We found that semantic context improves speech intelligibility in both younger and older adults. Both age groups also exhibit better speech intelligibility for a modulated than an unmodulated (stationary) masker, but the benefit from the speech glimpses was reduced in older compared to younger adults. Semantic context amplified the benefit gained from the speech glimpses, but there was no indication that the amplification by the semantic context led to a greater benefit in older adults. If anything, younger adults benefitted more.

CONCLUSIONS

The current results suggest that the deficit in the masking-release benefit in older adults generalizes to situations in which extended speech context is available. That previous research found a greater benefit in older than younger adults during story listening may suggest that other factors, such as thematic knowledge, motivation, or cognition, may amplify the benefit from speech glimpses under naturalistic listening conditions.

Reliability Analysis of the Arabic Speech Matrix Test

Objective

Speech matrix tests offer information about a person's capacity to comprehend speech in noisy environments, which is an essential component of everyday communication, in contrast to pure tone audiometry, which primarily assesses hearing sensitivity. This study aimed to assess the test-retest reliability of the Arabic Speech Matrix test.

Methods

This is a prospective cohort study that included three groups: normal hearing individuals, cochlear implant users, and those using hearing aids. Seventy-five participants were included in the study. The test was administered in two different settings with noise presented from various angles. The test was re-administered to participants after a 7-14 days interval, and Intra-class Correlation Coefficient (ICC) and Bland-Altman plots were used to evaluate reliability.

Results

Moderate to excellent reliability was demonstrated, with higher consistency observed among hearing-impaired groups using cochlear implants and other devices. Minor learning effects were noted in the normal hearing group, with better reliability observed in the left setting.

Conclusion

The Arabic Speech Matrix test demonstrated strong test-retest reliability overall, indicating that it can be successfully incorporated into regular clinical audiological evaluations.

Level of Evidence

4.

Validation of a smartphone-based digits-in-noise hearing test in Mandarin Chinese

OBJECTIVE

This study aimed to provide normative ranges of Chinese smartphone-based digits-in-noise (DIN) test results, to explore the association between speech reception threshold (SRT) and pure-tone average (PTA) threshold, and to verify the effectiveness and feasibility of the Chinese DIN.

DESIGN

Chinese-speaking adult subjects with varying types, symmetry and degrees of hearing loss, were recruited. All participants completed a pure-tone audiometric hearing test and DIN test with dichotic and antiphasic stimulus presentation.

STUDY SAMPLE

The overall sample consisted of 191 subjects, 24 with normal hearing and 167 with hearing loss.

RESULTS

There was a positive correlation between antiphasic DIN SRTs and PTA thresholds. Receiver operating characteristic curves (ROC) were calculated based on the classification of poorer ears. When SRT was ≥ -15.8 dB, it suggested the possible presence of mild or more severe hearing loss; when SRT was ≥ -14.2 dB, it suggested the possible presence of moderate or more severe hearing loss.

CONCLUSION

The Chinese DIN SRT showed a highly positive correlation with PTA and exhibited high sensitivity and specificity in detecting hearing loss. Poorer ear PTA was the primary predictor of the antiphasic DIN SRT. The present results verify the validity of the Chinese DIN in its purpose of hearing screening.

Digit-in-Noise Test as a Hearing Screening Test for Individuals With Intellectual Disability

BACKGROUND

Diagnosis of intellectual disability (ID) may overshadow, or co-occur with, hearing impairment, but screening is frequently inaccessible due to various factors that prevent successful test execution. There is a pressing need for easily, locally administered hearing tests. This study aimed to assess the efficacy of the digit-in-noise (DIN) test, as well as three variations of it, as a hearing screening for individuals with mild to moderate ID. Additionally, we explored correlations between participant characteristics and cognitive-linguistic abilities, with DIN test performance.

METHOD

Forty participants with ID aged 21-40 were recruited from two supported employment centres, 31 of whom met full inclusion criteria. Controls were 20 typically developed (TD) participants, aged 21-40. The original DIN test (DIN(3)) was administered, and those unable to recall the three digits were administered a version with two digits (DIN(2)). Participants unable to successfully complete DIN(3) or DIN(2) were administered versions with added visual and verbal performance feedback.

RESULTS

A significant difference in speech receptive threshold in noise (SRTn) between DIN(2) and DIN(3) was only present for the ID group. A moderate negative relationship between DIN(2) SRTn and vocabulary and a positive relationship with age was found for the ID group; no correlation was found with digit span or matrices. The DIN(2) SRTn was correlated with the average hearing level of pure tones measured by audiometry.

CONCLUSIONS

Our findings highlight the DIN(2) as the most effective version, as its signal-to-noise ratio (SRTn) threshold was closest to the typically developed (TD) control group. This study is the first step towards developing a hearing screening test for individuals with ID who are at elevated risk of impairment and who have insufficient evaluation access. Our findings suggest that adults with mild to moderate ID can sufficiently perform the adapted DIN(2) as a hearing screening test.

Development and evaluation of the Digit Triplet Test in Swahili language

BACKGROUND

 The development of a Digit Triplet Test in the Swahili language is an essential step towards providing accurate hearing assessment for Swahili-speaking populations.

OBJECTIVES

 This study aimed to develop a Digit Triplet Test in Swahili through a two-part procedure consisting of an optimisation phase and an evaluation phase using normal hearing participants.

METHOD

 A total of 34 subjects participated in the study. During the optimisation phase, a psychometric intelligibility function was determined for each recorded digit, allowing for volume adjustments to standardise the threshold across all digits. This resulted in a lower threshold and a steeper psychometric function for both the triplets and the test lists. Using the optimised speech material, four test lists were created, each containing 27 triplets composed of digits between 1 and 9. The finalised material was then evaluated.

RESULTS

 In the final version, the mean Speech Reception Threshold (SRT) for the participants was -8.9 ± 0.6 dB Signal-to-Noise Ratio (SNR), and the mean slope was 24.7 ± 3.5%/dB using triplet scoring.

CONCLUSION

 The psychometric function for normal listeners shows a steep slope with little variation between subjects and across test lists.Contribution: The test results are comparable to those of Digit Triplet Tests developed in other languages, indicating the effectiveness and reliability of the Swahili Digit Triplet Test for hearing assessments.

Impaired Prosodic Processing but Not Hearing Function Is Associated with an Age-Related Reduction in AI Speech Recognition

BACKGROUND/OBJECTIVES

Voice artificial intelligence (AI) technology is becoming increasingly common. Recent work indicates that middle-aged to older adults are less able to identify modern AI speech compared to younger adults, but the underlying causes are unclear.

METHODS

The current study with younger and middle-aged to older adults investigated factors that could explain the age-related reduction in AI speech identification. Experiment 1 investigated whether high-frequency information in speech-to which middle-aged to older adults often have less access due sensitivity loss at high frequencies-contributes to age-group differences. Experiment 2 investigated whether an age-related reduction in the ability to process prosodic information in speech predicts the reduction in AI speech identification.

RESULTS

Results for Experiment 1 show that middle-aged to older adults are less able to identify AI speech for both full-bandwidth speech and speech for which information above 4 kHz is removed, making the contribution of high-frequency hearing loss unlikely. Experiment 2 shows that the ability to identify AI speech is greater in individuals who also show a greater ability to identify emotions from prosodic speech information, after accounting for hearing function and self-rated experience with voice-AI systems.

CONCLUSIONS

The current results suggest that the ability to identify AI speech is related to the accurate processing of prosodic information.

Arabic Digits-in-Noise Tests: Relations to Hearing Loss and Comparison of Diotic and Antiphasic Versions

The study set out to acquire validation data for Arabic versions of the Digits-in-Noise (DIN) test, measured using browser-based software suitable for home hearing screening. DIN and pure-tone audiometric (PTA) thresholds were obtained from a sample of 155 Arabic-speaking participants, varying widely in age and in degree and type of hearing loss. DIN thresholds were measured using both diotic and antiphasic stimuli, with the goal of determining whether antiphasic testing provides superior prediction of poorer-ear hearing loss. A comprehensive study protocol was publicly pre-registered via the Open Science Framework. Both types of DIN threshold correlate with poorer-ear PTA thresholds after controlling for age, but the correlation is significantly stronger for antiphasic than diotic stimuli. Antiphasic DIN thresholds increase more steeply than diotic DIN thresholds as poorer-ear PTA thresholds increase, and are superior binary classifiers of hearing loss. Combined with previous results based on DIN data measured in participants' homes, the present findings suggest that the browser-based Arabic DIN test may be effective in remote hearing screening, when combined with antiphasic digit presentation.

Neural tracking of the speech envelope predicts binaural unmasking

Binaural unmasking is a remarkable phenomenon that it is substantially easier to detect a signal in noise when the interaural parameters of the signal are different from those of the noise - a useful mechanism in so-called cocktail party scenarios. In this study, we investigated the effect of binaural unmasking on neural tracking of the speech envelope. We measured EEG in 8 participants who listened to speech in noise at a fixed signal-to-noise ratio, in two conditions: one where speech and noise had the same interaural phase difference (both speech and noise having an opposite waveform across ears, SπNπ), and one where the interaural phase difference of the speech was different from that of the noise (only the speech having an opposite waveform across ears, SπN). We measured a clear benefit of binaural unmasking in behavioural speech understanding scores, accompanied by increased neural tracking of the speech envelope. Moreover, analysing the temporal response functions revealed that binaural unmasking also resulted in decreased peak latencies and increased peak amplitudes. Our results are consistent with previous research using auditory evoked potentials and steady-state responses to quantify binaural unmasking at cortical levels. Moreover, they confirm that neural tracking of speech is associated with speech understanding, even if the acoustic signal-to-noise ratio is kept constant. From a clinical perspective, these results offer the potential for the objective evaluation of binaural speech understanding mechanisms, and the objective detection of pathologies sensitive to binaural processing, such as asymmetric hearing loss, auditory neuropathy and age-related deficits.

Evaluating psychometric properties of the Cantonese integrated Digit-in-Noise Test: perhaps the 2-digit sequence can also be used for hearing screening

OBJECTIVE

This study developed and validated the Cantonese integrated Digit-in-Noise Test (iDIN) for speech-in-noise measurement and hearing screening.

DESIGN

The development of the Cantonese iDIN followed the International Collegium of Rehabilitative Audiology guidelines. Its psychometric properties, including normative data, psychometric function, test-retest reliability, and criterion validity, were established. Additionally, a preliminary comparison of the effectiveness of 2- and 3-digit SRTs in hearing screening was conducted.

STUDY SAMPLE

The sample included 40 young adults with normal hearing and 65 older adults, with and without hearing loss.

RESULTS

Mean SRTs for 2-, 3-, and 5-digit with forward recall were -11.5 ± 1.3, -12.0 ± 1.0, and -11.3 ± 0.9 dB SNR in young adults, respectively. The slopes for the psychometric functions of these sequences were 20.26, 18.61, and 19.10 %/dB, respectively, and measurement errors were 0.80, 0.61, and 0.71 dB. The area under the receiver operating characteristic curves for the 2- and 3-digit SRTs were .941 and .974, indicating high discriminative ability in hearing screening.

CONCLUSIONS

The Cantonese iDIN shows robust psychometric properties. Despite the 3-digit test's slightly better screening performance, shorter test during associated with the 2-digit suggests its potential for hearing screening.

Kids are not just small adults: An attempt to validate pediatric tablet-based digits in noise testing

Objective

The objective of this study is to investigate whether conductive hearing loss (CHL) can be differentiated from sensorineural hearing loss in children ages 3-18 using a diotic and antiphasic digits-in-noise (DIN) tablet-based test using existing adult cut-off criteria.

Methods

A blinded multi-institutional prospective cohort of 64 children aged 3-18 scheduled for an audiometric soundbooth evaluation with a pediatric audiologist and a same-day otolaryngologist examination were recruited for the study. Following a conventional audiogram, the subjects underwent diotic (same-phased stimuli) and antiphasic (out-of-phase stimuli) DIN testing on a HearX Samsung Galaxy tablet with over-the-ear headphones, for a total of 128 measurements. DIN test results were compared with soundbooth audiometry using known adult "cut off criteria."

Results

A logistic regression analysis adjusted for demographics (age, sex) and race was performed to compare CHL determination from DIN testing to CHL determination with soundbooth audiometry. The results showed 50% agreement with a p-value of .753. The determinations based on combined DIN testing agreed with each other 33% of the time and had a p-value of .373. Otologic pathology and age were not predictive of outcome.

Conclusion

This preliminary analysis of DIN testing indicated that DIN and audiometric testing completed in a soundbooth were not significantly predictive of one another in the population of children aged 3-18 when using the adult cut-off criteria for CHL differentiation. Given these findings, further testing is required in children to determine pediatric specific cut-off values.

A Multi-Sample Comparison and Rasch Analysis of the Evaluation of Children's Listening and Processing Skills Questionnaire

OBJECTIVES

Assessing listening difficulties and associated complaints can be challenging. Often, measures of peripheral auditory functions are within normal ranges, making clinicians feel unsure about proper management strategies. The range and nature of observed or experienced difficulties might be better captured using a qualitative measure. The Evaluation of Children's Listening and Processing Skills (ECLiPS) questionnaire was designed to broadly profile the auditory and cognitive problems often present in children with listening difficulties. This 38-item questionnaire was initially standardized in British children aged 6 to 11 years, was subsequently modified for use with North-American children, and was recently translated into Flemish-Dutch. This study aimed to compare typical scores of the Flemish version with the UK and US versions, and to evaluate and compare its psychometric quality based on Rasch analysis.

DESIGN

We selected 112 Flemish children aged 6 to 11 years with verified normal hearing and typical development, and asked two caregivers of every child to fill out the ECLiPS. Data from two comparator samples were analyzed, including responses for 71 North-American children and 650 British children. Typical values for ECLiPS factors and aggregates were determined as a function of age and gender, and meaningful differences across samples were analyzed. Rasch analyses were performed to evaluate whether ECLiPS response categories work as intended, and whether item scores fit a linear equal interval measurement scale that works the same way for everyone. Item and person metrics were derived, including separation and reliability indices. We investigated whether items function similarly across linguistically and culturally different samples.

RESULTS

ECLiPS scores were relatively invariant to age. Girls obtained higher scores compared with boys, mainly for items related to memory and attention, and pragmatic and social skills. Across ECLiPS versions, the most pronounced differences were found for items probing social skills. With respect to its psychometric quality, ECLiPS response categories work as intended, and ECLiPS items were found to fit the Rasch measurement scale. Cultural differences in responses were noted for some items, belonging to different factors. Item separation and reliability indices generally pointed toward sufficient variation in item difficulty. In general, person separation (and reliability) metrics, quantifying the instrument's ability to distinguish between poor and strong performers (in a reproducible manner), were low. This is expected from samples of typically developing children with homogeneous and high levels of listening ability.

CONCLUSIONS

Across the languages assessed here, the ECLiPS caregiver questionnaire was verified to be a psychometrically valid qualitative measure to assess listening and processing skills, which can be used to support the assessment and management of elementary school children referred with LiD.

The multilingual digits-in-noise (DIN) test: development and evaluation

OBJECTIVE

To develop a methodologically uniform digits-in-noise (DIN) test in 17 different languages.

DESIGN

The DIN test was developed for Android devices as an extension to the open-access Hearing Test™ app, available on the Google Play store. It utilised professionally recorded female speech, speech-shaped noise, a digit scoring method and a variable step size. The test was adaptively optimised and evaluated as the results of tests taken online by users of the app became available.

STUDY SAMPLE

Optimisation using 35,534 ears, evaluation using 6012 ears.

RESULTS

Optimisation improved the slopes of the psychometric functions for all languages by an average of 6.8%/dB. Evaluation included calculation of normative speech reception thresholds (SRTs) and estimation of test-retest standard deviations. Normative values for SRTs ranged from -14.2 dB SNR (95% CI -14.3 to -14.0) for Chinese to -11.2 dB SNR (95% CI -11.3 to -11.1) for Japanese, with reliability estimates ranging from 0.48 dB (95% CI 0.36-0.64) for Portuguese to 0.91 dB (95% CI 0.73-1.21) for Romanian.

CONCLUSIONS

The optimisation of each language version was confirmed by the improvement in the slopes of the psychometric functions. The normative values obtained from the test evaluation were in agreement with literature data.

TRIAL REGISTRATION

Science Support Centre of Wroclaw Medical University BW-59/2020.

Digits in noise testing in a multilingual sample of Asian adults

OBJECTIVE

Appropriate speech-in noise assessment is challenging in multilingual populations. This study aimed to assess whether first preferred language affected performance on an English Digits-in-noise (DIN) test in the local Asian multilingual population, controlling for hearing threshold, age, sex, English fluency and educational status. A secondary aim was to determine the association between DIN test scores and hearing thresholds.

DESIGN

English digit-triplets in noise testing and pure-tone audiometry were conducted. Multiple regression analysis was performed with DIN scores and hearing thresholds as dependent variables. Correlation analysis was performed between DIN-SRT and hearing thresholds.

STUDY SAMPLE

165 subjects from the Singapore Longitudinal Ageing Study, a population-based longitudinal study of community-dwellers over 55 years of age.

RESULTS

Mean DIN speech reception threshold (DIN-SRT) was -5.7 dB SNR (SD 3.6; range 6.7 to -11.2). Better ear pure tone average and English fluency were significantly associated with DIN-SRT.

CONCLUSIONS

DIN performance was independent of first preferred language in a multilingual ageing Singaporean population after adjusting for age, gender and education. Those with poorer English fluency had a significantly lower DIN-SRT score. The DIN test has the potential to provide a quick, uniform method of testing speech in noise in this multilingual population.

Reported Hearing Outcome Measures Following Stereotactic Radiosurgery for Vestibular Schwannoma: A Scoping Review

Background  Evidence on hearing outcome measures when assessing hearing preservation following stereotactic radiosurgery (SRS) for adults with vestibular schwannoma (VS) has not previously been collated in a structured review. Objective  The objective of the present study was to perform a scoping review of the evidence regarding the choice of hearing outcomes and other methodological characteristics following SRS for adults with VS. Methods  The protocol was registered in the International Platform of Registered Systematic Review and Meta-Analysis Protocols (INPLASY) and reported according to the Preferred Reporting Items for Systematic Review and Meta-Analyses extension guidelines for scoping reviews. A systematic search of five online databases revealed 1,591 studies, 247 of which met the inclusion criteria. Results  The majority of studies ( n  = 213, 86%) were retrospective cohort or case series with the remainder ( n  = 34, 14%) prospective cohort. Pure-tone audiometry and speech intelligibility were included in 222 (90%) and 158 (64%) studies, respectively, often summarized within a classification scheme and lacking procedural details. Fifty-nine (24%) studies included self-report measures. The median duration of follow-up, when reported, was 43 months (interquartile range: 29, 4-150). Conclusion  Evidence on hearing disability after SRS for VS is based on low-quality studies which are inherently susceptible to bias. This review has highlighted an urgent need for a randomized controlled trial assessing hearing outcomes in patients with VS managed with radiosurgery or radiological observation. Similarly, consensus and coproduction of a core outcome set to determine relevant hearing and communication outcome domains is required. This will ensure that patient priorities, including communication abilities in the presence of background noise and reduced participation restrictions, are addressed.

The Chinese Zodiac-in-Noise Test: An Internet-Based Speech-in-Noise Test for Large-Scale Hearing Screening

OBJECTIVES

Motivated by the growing need for hearing screening in China, the present study has two objectives. First, to develop and validate a new test, called the Chinese Zodiac-in-noise (ZIN) test, for large-scale hearing screening in China. Second, to conduct a large-scale remote hearing screening in China, using the ZIN test developed.

DESIGN

The ZIN test was developed following a similar procedure as the digits-in-noise test but emphasizes the importance of consonant recognition by employing the 12 zodiac animals in traditional Chinese culture as speech materials. It measures the speech reception threshold (SRT) using triplets of Chinese zodiac animals in speech-shaped noise with an adaptive procedure.

RESULTS

Normative data of the test were obtained in a group of 140 normal-hearing listeners, and the performance of the test was validated by comparisons with pure-tone audiometry in 116 listeners with various hearing abilities. The ZIN test has a reference SRT of -11.0 ± 1.6 dB in normal-hearing listeners with a test-retest variability of 1.7 dB and can be completed in 3 minutes. The ZIN SRT is highly correlated with the better-ear pure-tone threshold ( r = 0.82). With a cutoff value of -7.7 dB, the ZIN test has a sensitivity of 0.85 and a specificity of 0.94 for detecting a hearing loss of 25 dB HL or more at the better ear.A large-scale remote hearing screening involving 30,552 participants was performed using the ZIN test. The large-scale study found a hearing loss proportion of 21.0% across the study sample, with a high proportion of 57.1% in the elderly study sample aged over 60 years. Age and gender were also observed to have associations with hearing loss, with older individuals and males being more likely to have hearing loss.

CONCLUSIONS

The Chinese ZIN test is a valid and efficient solution for large-scale hearing screening in China. Its remote applications may improve access to hearing screening and enhance public awareness of hearing health.

A language-independent hearing screening self-test at school-entry

The usage of a tablet-based language-independent self-test involving the recognition of ecological sounds in background noise, the Sound Ear Check, was investigated. The results of 692 children, aged between 5 and 9 years and 4 months, recruited in seven different countries, were used to analyze the validity and the cultural independence of test. Three different test procedures, namely a monaural adaptive procedure, a procedure presenting the sounds dichotically in diotic noise, and a procedure presenting all the sounds with a fixed signal-to-noise ratio and a stopping rule were studied. Results showed high sensitivity and specificity of all three procedures to detect conductive, sensorineural and mixed hearing loss > 30 dB HL. Additionally, the data collected from different countries were consistent, and there were no clinically relevant differences observed between countries. Therefore, the Sound Ear Check can offer an international hearing screening test for young children at school entry, solving the current lack of hearing screening services on a global scale.

A Perspective on Auditory Wellness: What It Is, Why It Is Important, and How It Can Be Managed

During the last decade, there has been a move towards consumer-centric hearing healthcare. This is a direct result of technological advancements (e.g., merger of consumer grade hearing aids with consumer grade earphones creating a wide range of hearing devices) as well as policy changes (e.g., the U.S. Food and Drug Administration creating a new over-the-counter [OTC] hearing aid category). In addition to various direct-to-consumer (DTC) hearing devices available on the market, there are also several validated tools for the self-assessment of auditory function and the detection of ear disease, as well as tools for education about hearing loss, hearing devices, and communication strategies. Further, all can be made easily available to a wide range of people. This perspective provides a framework and identifies tools to improve and maintain optimal auditory wellness across the adult life course. A broadly available and accessible set of tools that can be made available on a digital platform to aid adults in the assessment and as needed, the improvement, of auditory wellness is discussed.

User characteristics associated with use of wrist-worn wearables and physical activity apps by adults with and without impaired speech-in-noise recognition: a cross-sectional analysis

OBJECTIVE

To study weekly use of smartwatches, fitness watches and physical activity apps among adults with and without impaired speech-in-noise (SIN) recognition, to identify subgroups of users.

DESIGN

Cross-sectional study.

STUDY SAMPLE

Adults (aged 28-80 years) with impaired (n = 384) and normal SIN recognition (n = 341) as measured with a web-based digits-in-noise test, from the Netherlands Longitudinal Study on Hearing. Multiple logistic regression analyses were used to study differences and to build an association model.

RESULTS

Employed adults in both groups are more likely to use each type of fitness technology (all ORs >3.4, all p-values < 0.004). Specific to fitness watch use, adults living with others use it more (OR 2.5, 95%CI 1.1;5.8, p = 0.033) whereas those abstaining from alcohol (OR 0.3, 95%CI 0.1;0.6) or consuming >2 glasses/week (OR 0.4, 95%CI 0.2;0.81, overall p = 0.006) and hearing aid users (OR 0.5, 95%CI 0.2;0.9, p = 0.024) make less use.

CONCLUSIONS

Subgroups of adults more and less likely to use fitness technology exist, but do not differ between adults with and without impaired SIN recognition. More research is needed to confirm these results and to develop interventions to increase physical activity levels among adults with hearing loss.

Testing the Informativeness of Diverse Measures of Auditory Processing for Clinical Audiological Practice in Middle-Aged Adults in Mexico

PURPOSE

Standard clinical audiologic assessment is limited in its ability to capture variance in self-reported hearing difficulty. Additionally, the costs associated with clinical testing in audiology create financial barriers for hearing health care in developing countries like Mexico. This study used an open-source Spanish-language tool called PART (Portable Automated Rapid Testing) to test the hypothesis that a battery of assessments of auditory processing can complement standard clinical audiological assessment to better capture the variance of self-reported hearing difficulty.

METHOD

Forty-three adults between 40 and 69 years of age were tested in Mexico City using a traditional clinical pure-tone audiogram, cognitive screening, and a battery of PART-based auditory processing assessments including a speech-on-speech competition spatial release from masking task. Results were compared to self-reported hearing difficulty, assessed with a Spanish-language adaptation of the Hearing Handicap Inventory for the Elderly-Screening Version (HHIE-S).

RESULTS

Several measures from the PART battery exhibited stronger correlations with self-reported hearing difficulties than the pure-tone audiogram. The spatial release from masking task best captured variance in HHIE-S scores and remained significant after controlling for the effects of age, audibility, and cognitive score.

CONCLUSIONS

The spatial release from masking task can complement traditional clinical measures to better account for patient's self-reported hearing difficulty. Open-source access to this test in PART supports its implementation for Spanish speakers in clinical settings around the world at low cost.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.24470140.

Sensitivity of the antiphasic digits-in-noise test to simulated unilateral and bilateral conductive hearing loss

OBJECTIVES

The objective of this study is (1) to assess whether the presentation level of the antiphasic digits-in-noise (DIN) test affects the speech recognition threshold (SRT), (2) to evaluate how accurately simulated unilateral and bilateral conductive hearing loss is detected (CHL) and (3) to determine whether increasing the presentation level normalises the antiphasic DIN SRT.

DESIGN

Participants performed antiphasic and diotic DINs at different presentation levels with unilateral, bilateral or no earplugs.

STUDY SAMPLE

Twenty-four and twelve normal hearing adults.

RESULTS

Without earplugs, antiphasic DIN SRTs did not differ between 60 and 80 dB SPL. At 60 dB SPL, the antiphasic DIN correctly classified 92% of the unilateral earplug cases; the diotic DIN 25%. The binaural intelligibility level difference did not differ between the no-earplug condition and the condition with bilateral earplugs when the presentation was increased with the attenuation level.

CONCLUSIONS

In normal hearing participants, diotic and antiphasic DIN SRTs are independent of presentation level above a minimum level of 60 dB SPL. The antiphasic DIN is more sensitive than the diotic DIN for detecting unilateral CHL; not for bilateral CHL. The effect of CHL on DIN SRTs can be largely compensated by increasing the presentation level. Audibility plays an important role in the antiphasic and diotic DIN.

Simplified cochlear frequency selectivity measure for sensorineural hearing loss screening: comparison with digit triplet test (DTT) and shortened speech, spatial and qualities of hearing scale (SSQ) questionnaire

PURPOSE

Pure-tone audiometry (PTA) is the gold standard for screening and diagnosis of hearing loss but is not always accessible. This study evaluated a simplified cochlear frequency selectivity (FS) measure as an alternative option to screen for early frequency-specific sensorineural hearing loss (SNHL).

METHODS

FS measures at 1 and 4 kHz center frequencies were obtained using a custom-made software in normal-hearing (NH), slight SNHL and mild-to-moderate SNHL subjects. For comparison, subjects were also assessed with the Malay Digit Triplet Test (DTT) and the shortened Malay Speech, Spatial and Qualities of Hearing Scale (SSQ) questionnaire.

RESULTS

Compared to DTT and SSQ, the FS measure at 4 kHz was able to distinguish NH from slight and mild-to-moderate SNHL subjects, and was strongly correlated with their thresholds in quiet determined separately in 1-dB step sizes at the similar test frequency. Further analysis with receiver operating characteristic (ROC) curves indicated area under the curve (AUC) of 0.77 and 0.83 for the FS measure at 4 kHz when PTA thresholds of NH subjects were taken as ≤ 15 dB HL and ≤ 20 dB HL, respectively. At the optimal FS cut-off point for 4 kHz, the FS measure had 77.8% sensitivity and 86.7% specificity to detect 20 dB HL hearing loss.

CONCLUSION

FS measure was superior to DTT and SSQ questionnaire in detecting early frequency-specific threshold shifts in SNHL subjects, particularly at 4 kHz. This method could be used for screening subjects at risk of noise-induced hearing loss.

Effects of Adding Monaural and Binaural Noise to a Dichotic Listening Task

BACKGROUND

 The Dichotic Digits Test (DDT) evaluates central auditory nervous system (CANS) dysfunction. The DDT is widely used in audiology clinics worldwide, because it is clinically efficient and has good sensitivity and specificity for CANS lesions. However, the DDT shows a strong ceiling effect, which can mitigate its ability to detect subtle CANS dysfunction.

PURPOSE

 This study examines the effects of adding monaural and binaural speech-spectrum noise to the DDT in an effort to make the test more taxing to the CANS and thereby reduce the observed ceiling effect.

RESEARCH DESIGN

 This was an experimental repeated measures study.

STUDY SAMPLE

 The participants were 20 adults aged 18 to 50 years with bilaterally symmetric speech-reception thresholds and pure-tone thresholds (250-8000 Hz) of 25 dB HL or better.

DATA COLLECTION AND ANALYSIS

 Each participant was administered one standard DDT test list (no noise added) and DDT test lists with binaural, monaural right, and monaural left noise added. For each of the noise-added conditions, lists were administered at two different signal-to-noise ratios, for a grand total of seven DDT test lists per participant, presented in randomized order. Monaural and binaural noise effects on DDT scoring indices (Right and Left Ear Percent Correct Scores, Combined Total Percent Correct Scores, and Dichotic Difference Scores), as well as noise effects on the right ear advantage for speech, were examined. Mixed model analyses of variance were used to examine fixed effects and interactions of Noise Condition and Ear.

RESULTS

 Adding noise to the standard DDT systematically reduced Right and Left Ear Percent Correct Scores and Combined Total Percent Correct Scores. Statistically significant differences on all indices were found between monaural and binaural noise-added conditions, suggesting a possible advantage for binaural listening in noise.

CONCLUSIONS

 These findings suggest that adding noise to tests of dichotic listening increases the difficulty of the task, and that further investigation of dichotic listening patterns in noise could potentially lead to more sensitive clinical evaluations of CANS integrity and function.

Cohort profile: Netherlands Longitudinal Study on Hearing (NL-SH)

PURPOSE

The Netherlands Longitudinal Study on Hearing (NL-SH) was set up to examine associations of hearing ability with psychosocial, work and health outcomes in working age adults.

PARTICIPANTS

Inclusion started in 2006 and is ongoing. Currently the sample comprises 2800 adults with normal and impaired hearing, aged 18-70 years at inclusion. Five-year follow-up started in 2011, 10-year follow-up in 2016 and 15-year follow-up in 2021. All measurements are web-based. Participants perform a speech-in-noise recognition test to measure hearing ability and fill out questionnaires about their hearing status, hearing aid use, self-reported hearing disability and coping, work status and work-related outcomes (work performance, need for recovery), physical and psychosocial health (depression, anxiety, distress, somatisation, loneliness), healthcare usage, lifestyle (smoking, alcohol), and technology use.

FINDINGS TO DATE

The NL-SH has shown the vast implications of reduced hearing ability for the quality of life and health of working-age adults. A selection of results published in 27 papers is presented. Age-related deterioration of hearing ability accelerates after the age of 50 years. Having a history of smoking is associated with a faster decline in hearing ability, but this relationship is not found for other cardiovascular risk factors. Poorer hearing ability is associated with increased distress, somatisation, depression and loneliness. Adults with impaired hearing ability are more likely to be unemployed or unfit for work, and need more time to recuperate from work effort.

FUTURE PLANS

Participant data will be linked to a national database to enable research on the association between hearing ability and mortality. Linking to environmental exposure data will facilitate insight in relations between environmental factors, hearing ability and psychosocial outcomes. The unique breadth of the NL-SH data will also allow for further research on other functional problems, for instance, hearing ability and fall risk.

TRIAL REGISTRATION NUMBER

NL12015.029.06.

A Critique of the National Academies of Sciences, Engineering, and Medicine Report (2021) and the Diagnostic Accuracy of Measurements of Functional Hearing Ability

PURPOSE

The Social Security Administration (SSA) asked the National Academies of Sciences, Engineering, and Medicine (NASEM, 2021) to make recommendations for tests of functional hearing ability. These tests include speech perception measures administered in quiet and in background noise. Such tests are required to make disability determinations for adults and children following cochlear implantation. The test review required an evaluation of the diagnostic accuracy of the speech perception measures. Following a review of the literature, NASEM wrote that the evidence needed to support such a recommendation was lacking. They resorted to "professional judgment" and recommended a monosyllabic word recognition test, presumably in quiet, along with a measure of self-report or parent report. The primary purpose of this article was to critically review the committee's report. The secondary purpose was to critique the committee's recommendation of a monosyllabic word test as a measure of functional hearing ability for disability determinations. The third purpose was to provide a review of diagnostic accuracy studies not included in NASEM (2021) with an emphasis on speech recognition in noise (SRN) tests.

CONCLUSIONS

In contrast to the committee's recommendation, studies have shown that a monosyllabic word test is a poor predictor of SRN ability. Contrary to the conclusion of NASEM (2021), diagnostic accuracy studies have been conducted for a few SRN tests. The Hearing in Noise Test and the AzBio SRN test have published data demonstrating their ability to correctly identify the presence and absence of an SRN disorder.

Binaural temporal coding and the middle ear muscle reflex in audiometrically normal young adults

Noise exposure may damage the synapses that connect inner hair cells with auditory nerve fibers, before outer hair cells are lost. In humans, this cochlear synaptopathy (CS) is thought to decrease the fidelity of peripheral auditory temporal coding. In the current study, the primary hypothesis was that higher middle ear muscle reflex (MEMR) thresholds, as a proxy measure of CS, would be associated with smaller values of the binaural intelligibility level difference (BILD). The BILD, which is a measure of binaural temporal coding, is defined here as the difference in thresholds between the diotic and the antiphasic versions of the digits in noise (DIN) test. This DIN BILD may control for factors unrelated to binaural temporal coding such as linguistic, central auditory, and cognitive factors. Fifty-six audiometrically normal adults (34 females) aged 18 - 30 were tested. The test battery included standard pure tone audiometry, tympanometry, MEMR using a 2 kHz elicitor and 226 Hz and 1 kHz probes, the Noise Exposure Structured Interview, forward digit span test, extended high frequency (EHF) audiometry, and diotic and antiphasic DIN tests. The study protocol was pre-registered prior to data collection. MEMR thresholds did not predict the DIN BILD. Secondary analyses showed no association between MEMR thresholds and the individual diotic and antiphasic DIN thresholds. Greater lifetime noise exposure was non-significantly associated with higher MEMR thresholds, larger DIN BILD values, and lower (better) antiphasic DIN thresholds, but not with diotic DIN thresholds, nor with EHF thresholds. EHF thresholds were associated with neither MEMR thresholds nor any of the DIN outcomes, including the DIN BILD. Results provide no evidence that young, audiometrically normal people incur CS with impacts on binaural temporal processing.

Speech-in-noise testing: Innovative applications for pediatric patients, underrepresented populations, fitness for duty, clinical trials, and remote services

Speech perception testing, defined as providing standardized speech stimuli and requiring a listener to provide a behavioral and scored response, has been an integral part of the audiologic test battery since the beginning of the audiology profession. Over the past several decades, limitations in the diagnostic and prognostic validity of standard speech perception testing as routinely administered in the clinic have been noted, and the promotion of speech-in-noise testing has been highlighted. This review will summarize emerging and innovative approaches to speech-in-noise testing with a focus on five applications: (1) pediatric considerations promoting the measurement of sensory and cognitive components separately; (2) appropriately serving underrepresented populations with special attention to racial, ethnic, and linguistic minorities, as well as considering biological sex and/or gender differences as variables of interest; (3) binaural fitness for duty assessments of functional hearing for occupational settings that demand the ability to detect, recognize, and localize sounds; (4) utilization of speech-in-noise tests in pharmacotherapeutic clinical trials with considerations to the drug mechanistic action, the patient populations, and the study design; and (5) online and mobile applications of hearing assessment that increase accessibility and the direct-to-consumer market.

Factors Affecting the Use of Speech Testing in Adult Audiology

OBJECTIVE

The aim of this study was to evaluate hearing health care professionals' (HHPs) speech testing practices in routine adult audiology services and better understand the facilitators and barriers to speech testing provision.

DESIGN

A cross-sectional questionnaire study was conducted.

STUDY SAMPLE

A sample (N = 306) of HHPs from the public (64%) and private (36%) sectors in the United Kingdom completed the survey.

RESULTS

In the United Kingdom, speech testing practice varied significantly between health sectors. Speech testing was carried out during the audiology assessment by 73.4% of private sector HHPs and 20.4% of those from the public sector. During the hearing aid intervention stage, speech testing was carried out by 56.5% and 26.5% of HHPs from the private and public sectors, respectively. Recognized benefits of speech testing included (a) providing patients with relatable assessment information, (b) guiding hearing aid fitting, and (c) supporting a diagnostic test battery. A lack of clinical time was a key barrier to uptake.

CONCLUSIONS

Use of speech testing varies in adult audiology. Results from this study found that the percentage of U.K. HHPs making use of speech tests was low compared to that of other countries. HHPs recognized different benefits of speech testing in audiology practice, but the barriers limiting uptake were often driven by factors derived from decision makers rather than clinical rationale. Privately funded HHPs used speech tests more frequently than those working in the public sector where time and resources are under greater pressure and governed by guidance that does not include a recommendation for speech testing. Therefore, the inclusion of speech testing in national clinical guidelines could increase the consistency of use and facilitate the comparison of practice trends across centers.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20044457.

Telehealth solutions for assessing auditory outcomes related to noise and ototoxic exposures in clinic and research

Nearly 1.5 billion people globally have some decline in hearing ability throughout their lifetime. Many causes for hearing loss are preventable, such as that from exposure to noise and chemicals. According to the World Health Organization, nearly 50% of individuals 12-25 years old are at risk of hearing loss due to recreational noise exposure. In the occupational setting, an estimated 16% of disabling hearing loss is related to occupational noise exposure, highest in developing countries. Ototoxicity is another cause of acquired hearing loss. Audiologic assessment is essential for monitoring hearing health and for the diagnosis and management of hearing loss and related disorders (e.g., tinnitus). However, 44% of the world's population is considered rural and, consequently, lacks access to quality hearing healthcare. Therefore, serving individuals living in rural and under-resourced areas requires creative solutions. Conducting hearing assessments via telehealth is one such solution. Telehealth can be used in a variety of contexts, including noise and ototoxic exposure monitoring, field testing in rural and low-resource settings, and evaluating auditory outcomes in large-scale clinical trials. This overview summarizes current telehealth applications and practices for the audiometric assessment, identification, and monitoring of hearing loss.

Remote Monitoring of Adult Cochlear Implant Recipients Using Digits-in-Noise Self-Testing

PURPOSE

The COVID-19 pandemic has accelerated the uptake and scope of telehealth. This study determined the accuracy and reliability of a smartphone digits-in-noise (DIN) test when conducted by adult cochlear implant (CI) recipients in a simulated home environment compared with a clinic setup. Perceptions of remote monitoring using speech-in-noise (SIN) testing were also explored.

METHOD

Thirty-three adult CI recipients between 18 and 78 years of age (M = 46.7, SD = ±20.4) conducted the DIN test in a simulated home environment and a clinic setup. Test-retest reliability across the two environments and comparisons between test settings were evaluated. A survey explored the perceptions of adult CI recipients regarding remote monitoring and use of the DIN self-test.

RESULTS

Mean-aided speech reception thresholds (SRTs) in the clinic and simulated home environment test conditions and clinic and simulated home environment retest conditions did not differ significantly. Mean test-retest SRTs in the clinic and simulated home environment were significantly different (p < .05). High intraclass correlation coefficient and low standard error of measurement scores reflected good and excellent reliability between test-retest measures and between clinic and simulated home environment measures. Most participants were positive about the possibility of using the DIN test at home to self-assess speech perception, although some test adjustments such as including training items and a less adverse starting signal-to-noise ratio may be required.

CONCLUSION

Adult CI recipients can use the smartphone DIN test to self-assess aided SIN performance in a home environment with accuracy and reliability relatively similar to clinic testing.

SUPPLEMENTAL MATERIAL

https://doi.org/10.23641/asha.20044418.

Online Assessment of Speech Perception and Auditory Spectrotemporal Processing in Spanish-English Bilinguals

PURPOSE

There is limited access to audiology services for the growing population of Spanish-English bilinguals in the United States. Online auditory testing can potentially provide a cost-effective alternative to in-person visits. However, even for bilinguals with high English proficiency, age of English acquisition may affect speech perception accuracy. This study used a comprehensive test battery to assess speech perception and spectrotemporal processing abilities in Spanish-English bilinguals and to evaluate susceptibility of different tests to effects of native language.

METHOD

The online battery comprised three tests of speech in quiet (vowel and consonant identification and words in sentences), four tests of speech perception in noise (two for intelligibility and two for comprehension), and three tests of spectrotemporal processing (two tests of stochastically modulated pattern discrimination and one test of spectral resolution). Participants were 28 adult Spanish-English bilinguals whose English acquisition began either early (≤ 6 years old) or late (≥ 7 years old) and 18 English monolingual speakers.

RESULTS

Significant differences were found in six of the 10 tests. The differences were most pronounced for vowel perception in quiet, speech-in-noise test, and two tests of speech comprehension in noise. Late bilinguals consistently scored lower than native English speakers or early bilinguals. In contrast, no differences between groups were observed for digits-in-noise or three tests of spectrotemporal processing abilities.

CONCLUSION

The findings suggest initial feasibility of online assessment in this population and can inform selection of tests for auditory assessment of Spanish-English bilinguals.

Accuracy of smartphone-based hearing screening tests: a systematic review

PURPOSE

To verify the accuracy of smartphone apps to identify hearing loss.

RESEARCH STRATEGIES

A systematic review followed the PRISMA-DATA checklist. The search strategies were applied across four databases (Lilacs, PubMed, Scopus and Web of Science) and grey literature (Google Scholar, OpenGrey, and ProQuest Dissertations and Thesis).

SELECTION CRITERIA

The acronym PIRD was used in review. This included populations of any gender and all age groups. The Index test is the smartphone-based hearing screening test; the Reference test is the pure-tone audiometry, which is considered the gold reference for hearing diagnostics; the diagnosis was performed via validity data (sensitivity and specificity) to identify hearing loss and diagnostic studies.

DATA ANALYSIS

Two reviewers selected the studies in a two-step process. The risk of bias was assessed according to the criteria of the QUADAS-2.

RESULTS

Of 1395 articles, 104 articles were eligible for full-text reading and 17 were included. Only four met all criteria for methodological quality. All of the included studies were published in English between 2015 and 2020. The applications Digits-in noise Test (5 articles), uHear (4 articles), HearScreen (2 articles), hearTest (2 articles) and Hearing Test (2 articles) were the most studied. All this application showed sensitivity and specificity values between 75 and 100%. The other applications were EarScale, uHearing Test, Free field hearing (FFH) and Free Hearing Test.

CONCLUSION

uHear, Digit-in-Noise Test, HearTest and HearScreen have shown significant values of sensitivity and specificity and can be considered as the most accurate methods for screening of hearing impairment.

Digital Approaches to Automated and Machine Learning Assessments of Hearing: Scoping Review

BACKGROUND

Hearing loss affects 1 in 5 people worldwide and is estimated to affect 1 in 4 by 2050. Treatment relies on the accurate diagnosis of hearing loss; however, this first step is out of reach for >80% of those affected. Increasingly automated approaches are being developed for self-administered digital hearing assessments without the direct involvement of professionals.

OBJECTIVE

This study aims to provide an overview of digital approaches in automated and machine learning assessments of hearing using pure-tone audiometry and to focus on the aspects related to accuracy, reliability, and time efficiency. This review is an extension of a 2013 systematic review.

METHODS

A search across the electronic databases of PubMed, IEEE, and Web of Science was conducted to identify relevant reports from the peer-reviewed literature. Key information about each report's scope and details was collected to assess the commonalities among the approaches.

RESULTS

A total of 56 reports from 2012 to June 2021 were included. From this selection, 27 unique automated approaches were identified. Machine learning approaches require fewer trials than conventional threshold-seeking approaches, and personal digital devices make assessments more affordable and accessible. Validity can be enhanced using digital technologies for quality surveillance, including noise monitoring and detecting inconclusive results.

CONCLUSIONS

In the past 10 years, an increasing number of automated approaches have reported similar accuracy, reliability, and time efficiency as manual hearing assessments. New developments, including machine learning approaches, offer features, versatility, and cost-effectiveness beyond manual audiometry. Used within identified limitations, automated assessments using digital devices can support task-shifting, self-care, telehealth, and clinical care pathways.

Improving the Efficiency of the Digits-in-Noise Hearing Screening Test: A Comparison Between Four Different Test Procedures

PURPOSE

This study compared the test characteristics, test-retest reliability, and test efficiency of three novel digits-in-noise (DIN) test procedures to a conventional antiphasic 23-trial adaptive DIN (D23).

METHOD

One hundred twenty participants with an average age of 42 years (SD = 19) were included. Participants were tested and retested with four different DIN procedures. Three new DIN procedures were compared to the reference D23 version: (a) a self-selected DIN (DSS) to allow participants to indicate a subjective speech recognition threshold (SRT), (b) a combination of self-selected and adaptive eight-trial DIN (DC8) that utilized a self-selected signal-to-noise ratio (SNR) followed by an eight-trial adaptive DIN procedure, and (c) a fixed SNR DIN (DF) approach using a fixed SNR value for all presentations to produce a pass/fail test result.

RESULTS

Test-retest reliability of the D23 procedure was better than that of the DSS and DC8 procedures. SRTs from DSS and DC8 were significantly higher than SRTs from D23. DSS was not accurate to discriminate between normal-hearing and hard of hearing listeners. The DF and DC8 procedures with an adapted cutoff showed good hearing screening test characteristics. All three novel DIN procedure durations were significantly shorter (< 70 s) than that of D23. DF showed a reduction of 46% in the number of presentations compared to D23 (from 23 presentations to an average of 12.5).

CONCLUSIONS

The DF and DC8 procedures had significantly lower test durations than the reference D23 and show potential to be more time-efficient screening tools to determine normal hearing or potential hearing loss. Further studies are needed to optimize the DC8 procedure. The reference D23 remains the most reliable and accurate DIN hearing screening test, but studies in which the potentially efficient new DIN procedures are compared to pure-tone thresholds are needed to validate these procedures.

Language-Independent Hearing Screening - Increasing the Feasibility of a Hearing Screening Self-Test at School-Entry

A tablet-based language-independent self-test involving the recognition of ecological sounds in background noise, the Sound Ear Check (SEC), was adapted to make it feasible for young children. Two experiments were conducted. The first experiment investigated the SEC's feasibility, as well as its sensitivity and specificity for detecting childhood hearing loss with a monaural adaptive test procedure. In the second experiment, the SEC sounds, noise, and test format were adapted based on the findings of the first experiment. The adaptations were combined with three test procedures, one similar to the one used in Experiment 1, one presenting the sounds dichotically in diotic noise, and one presenting all the sounds with a fixed signal-to-noise ratio and a stopping rule. Results in young children show high sensitivity and specificity to detect different grades of conductive and sensorineural hearing loss (70-90%). When using an adaptive, monaural procedure, the test duration was approximately 6 min, and 17% of the results obtained were unreliable. Adaptive staircase analyses showed that the unreliable results probably occur due to attention/motivation loss. The test duration could be reduced to 3-4 min with adapted test formats without decreasing the test-retest reliability. The unreliable test results could be reduced from 17% to as low as 5%. However, dichotic presentation requires longer training, reducing the dichotic test format's feasibility.

Guidelines of the French Society of Otorhinolaryngology-Head and Neck Surgery (SFORL) and the French Society of Audiology (SFA) for Speech-in-Noise Testing in Adults

OBJECTIVES

This document presents the fundamentals of speech audiometry in noise, general requirements for implementation and criteria for choice among the tests available in French according to the health-professional's needs.

MATERIAL AND METHODS

The recommendations are based on a systematic analysis of the literature carried out by a multidisciplinary group of doctors, audiologists and audioprosthetists from all over France. They are graded A, B, C or expert opinion according to decreasing level of scientific evidence.

RESULTS

Eight tests of speech audiometry in noise can be used in France.

CONCLUSION

To be complete, evaluation of hearing status requires testing understanding of speech in noise. The examination must begin with a minimum of two measurements familiarizing the subject with the test procedure. For initial diagnosis, adaptive procedures establishing the 50% speech reception threshold (SRT50) in noise are to be preferred in order to obtain a rapid and standardized measurement of perception of speech in noise. When the aim is to measure real-life speech comprehension, tests based on sentences, cocktail-party noise and free-field stimulation are to be preferred. Prosthetic gain is evaluated exclusively in free field. This is the only way to evaluate the contribution of binaurality and to measure perception in noise in an environment as close as possible to real life. In order to avoid acoustic interference in free field, at least five loudspeakers should be used, in particular for evaluating the effectiveness of directional microphones, CROS devices enabling sounds picked up in the damaged ear to be rerouted to the functional ear, or bimodal fitting (i.e., when hearing is enabled by two modalities: for example, hearing aid for one ear, cochlear implant for the other).

Global use and outcomes of the hearWHO mHealth hearing test

Objectives

The objective of this study was to examine the uptake, user characteristics, and performance of the free WHO smartphone hearing screening test ( hearWHO) as a global hearing health promotion initiative.

Method

We retrospectively examined the data of 242 626 tests conducted by adults (> 18 years) on the hearWHO app between February 2019 and May 2021. Test uptake was evaluated by country, WHO world region, test date, and demographics of age and gender.

Results

The hearWHO test was completed in nearly every country globally ( n = 179/195), with the greatest uptake seen in China and India. Uptake was greatest in the Western Pacific (32.9%) and European (24.8%) WHO regions. There was a high uptake of tests (44%) by young adults under the age of 30 years. Referral rates were typically higher for older age groups in most WHO regions, except for the African and Eastern Mediterranean regions, where overall hearWHO test uptake was lowest. Most testing (49%) took place in March (2019–2021) coinciding with World Hearing Day (3rd of March) each year.

Conclusions

Digital mhealth tools provide many benefits in healthcare, including health promotion, access to information, and services for hearing loss. The hearWHO test was mainly reaching younger adults, positioning it as an important measure for public health advocacy to prevent hearing loss. Since hearing loss is primarily age related, more targeted campaigns or community-based initiatives should be directed toward older adults.

The digit triplet test: a scoping review

OBJECTIVE

This review article presents an overview of all Digit Triplet Tests (DTT) and digits-in-noise tests (DIN) and their variations in language, speech material, masking noise, test procedures, and targeted population. The effects on aspects of validity, reliability, and feasibility are investigated.

DESIGN

Scoping review.

STUDY SAMPLE

All studies referring to the DTT and DIN were collected from Pubmed and Embase. Search terms "digit triplet test" and "digits in noise" were used. Citations of selected articles were scanned backwards in time (the bibliography of the already selected research article) and forward in time (articles that cited the already selected research article). The search terms yielded 95 results in total. Eventually, 39 papers were selected.

RESULTS

Analyses showed psychometric reference-curves with steep slopes and speech reception thresholds with high measurement precision which are strongly associated with pure tone audiometry. High sensitivity and specificity to detect elevated pure tone thresholds were noted for test variants. Certain procedural modifications of the DTT and DIN can further improve the test. Additionally, large-scale application of the DTT and DIN is feasible.

CONCLUSION

The DTT and DIN are a very valuable tool for screening and diagnostics for a wide variety of populations.

Diotic and Antiphasic Digits-in-noise Testing as a Hearing Screening and Triage Tool to Classify Type of Hearing Loss

OBJECTIVES

The digits-in-noise test (DIN) is a popular self-test measure that has traditionally been used to screen for hearing loss by providing either a pass or refer result. Standard approaches either tested each ear monaurally or used a binaural diotic version where identical digits and noise were presented simultaneously to both ears. Recently, a dichotic, antiphasic version was developed, increasing sensitivity of the DIN to unilateral or asymmetric sensorineural hearing loss (SNHL) and conductive hearing loss (CHL). The purpose of this study was to determine predictors and normative ranges of the antiphasic and diotic DIN and to determine if a combination of diotic and antiphasic DIN could accurately categorize hearing into (1) normal, (2) bilateral SNHL, or (3) unilateral SNHL or CHL.

DESIGN

The analytical sample consisted of 489 participants between the ages of 18 and 92 years with varying types, symmetry, and degrees of hearing loss. Degree and type of hearing loss were determined based on standard clinical four-frequency (0.5-4 kHz) pure-tone air and bone conduction threshold averages. The sample consisted of bilateral normal hearing (n = 293), bilateral SNHL (n = 172), unilateral SNHL (n = 42), and CHL (n = 32). All participants (n = 489) first completed an antiphasic DIN (digit stimuli 180° out-of-phase between ears), while 393 of the sample also completed a diotic DIN. Two procedures were assessed for their ability to categorize hearing into one of the three hearing groups. The first used a fixed antiphasic cutoff combined with a cutoff formed by a linear combination of antiphasic and diotic speech recognition threshold (SRT) or binaural intelligibility-level difference.

RESULTS

Poorer ear pure-tone average was the strongest predictor of antiphasic DIN score, whereas better ear pure-tone average explained more of the variance in diotic SRT. The antiphasic DIN sensitivity and specificity was 90% and 84%, respectively, for detecting hearing loss, with outstanding area under the receiver operating characteristics values exceeding 0.93 to identify hearing loss in the poorer ear. The first fixed SRT cutoff procedure could categorize 75% of all participants correctly, while the second procedure increased correct categorization to 79%. False negative rates for both procedures were below 10%.

CONCLUSIONS

A sequential antiphasic and diotic DIN could categorize hearing to a reasonable degree into three groups of (1) normal hearing; (2) bilateral SNHL; and (3) unilateral asymmetric SNHL or CHL. This type of approach could optimize care pathways using remote and contactless testing, by identifying unilateral SNHL and CHL as cases requiring medical referral. In contrast, bilateral SNHL cases could be referred directly to an audiologist, or nontraditional models like OTC hearing aids.

French Version of the Antiphasic Digits-in-Noise Test for Smartphone Hearing Screening

In France 58% of persons with hearing loss still do not wear hearing aids. Pure-tone audiometry is the traditional gold standard in assessment and screening of hearing impairment, but it requires the use of calibrated devices and soundproof booth. The antiphasic digits-in-noise (DIN) test does not require calibrated material and can run on a standard headset or earbuds connected to a smartphone or a computer. The DIN test is highly correlated with pure tone audiometry and has already shown to be effective in hearing loss screening in its English version promoted by the WHO. The aim of the present study was to develop and validate a French version of the antiphasic DIN test for implementation on a national screening test offered as a smartphone app. The audio files recorded from a French native female speaker were selected and normalized in intensity according to their recognition probability. The French DIN test application was then tested on normal hearing- and hearing-impaired subjects. Based on the strong correlation between pure tone audiometry (PTA) and DIN SRT, we calculated ROC curves and Z-score. For PTA > 20 dB HL, a SNR cutoff of 12.9 dB corresponds to a sensitivity and specificity of 0.96 and 0.93, respectively. To detect moderate and more severe hearing loss (PTA > 40 dB HL), the SNR cutoff was -10.9 dB, corresponding to a sensitivity and specificity of 0.99 and 0.83, respectively. The Z-score was calculated to define statistical criteria of normality for speech-in-noise evaluation. While a score of 0 roughly corresponds to the normality (DIN SRT = -15.4 dB SNR), a subject with DIN SRT > -12.2 (Z-score > 2) is ranked in the hearing loss population. Next, the French antiphasic DIN test was implemented in the Höra iOS and Android apps. In total, 19,545 Höra tests were completed and analyzed. Three quarters of them were classified as normal (74 %) and one quarter presented mild (9%) or more severe loss (17%). Together, results argue for the use of the French version of antiphasic DIN test in the general population to improve the screening of hearing-impaired individuals.

Digital Technology for Remote Hearing Assessment—Current Status and Future Directions for Consumers

Globally, more than 1.5 billion people have hearing loss. Unfortunately, most people with hearing loss reside in low- and middle-income countries (LMICs) where traditional face-to-face services rendered by trained health professionals are few and unequally dispersed. The COVID-19 pandemic has further hampered the effectiveness of traditional service delivery models to provide hearing care. Digital health technologies are strong enablers of hearing care and can support health delivery models that are more sustainable. The convergence of advancing technology and mobile connectivity is enabling new ways of providing decentralized hearing services. Recently, an abundance of digital applications that offer hearing tests directly to the public has become available. A growing body of evidence has shown the ability of several approaches to provide accurate, accessible, and remote hearing assessment to consumers. Further effort is needed to promote greater accuracy across a variety of test platforms, improve sensitivity to ear disease, and scale up hearing rehabilitation, especially in LMICs.

The Feasibility and Reliability of a Digits-in-Noise Test in the Clinical Follow-Up of Children With Mild to Profound Hearing Loss

OBJECTIVES

Speech perception in noise is an important aspect of the rehabilitation of children with hearing loss. We aimed to evaluate the feasibility and reliability of the Dutch digits-in-noise (DIN) test in the clinical follow-up of children with hearing aids (HAs) and/or cochlear implants (CIs). A second aim of the study was to gain insight in the speech perception in noise performance of children with different degrees of hearing loss.

DESIGN

We retrospectively analyzed DIN test data of Dutch-speaking children with hearing loss (N = 188; 5 to 18 years old). A free-field version of the DIN-test was used. Children with open-set phoneme recognition in quiet of >70% at 65 dB SPL (best aided condition) were included. Ages ranged from 5 to 18 years old. All were experienced HA or CI users and had used their device(s) for at least 1 year before the measurement in the study. The DIN-test was performed in the framework of a clinical rehabilitation program. During testing, children wore their own devices with normal daily programs.

RESULTS

The average speech reception threshold (SRT) was -3.6 dB (SD 3.6) for the first list and significantly improved to -4.0 dB (SD 3.1) for the second list. HA users had a 4-dB better SRT compared with CI users. The larger the child's hearing loss, the worse the SRT is. However, 15% of the children who completed a first list of 24 trials were unable to complete a second list. Mean adaptive staircase trajectories across trials suggested that learning occurred throughout the first list, and that loss of sustained attention contributed to response variability during the second list.

CONCLUSION

The DIN test can be used to assess speech perception in noise abilities for children with different degrees of hearing loss and using HAs or CIs. The children with hearing loss required a higher signal-to-noise ratio (SNR) than did normal-hearing children and the required SNR is larger as the hearing loss increases. However, the current measurement procedure should be optimized for use in standard pediatric audiological care, as 15% of the children were unable to conduct a second list after the first list to reach a more stable SNR.

Speech Recognition in Noise Using Binaural Diotic and Antiphasic Digits-in-Noise in Children: Maturation and Self-Test Validity

BACKGROUND

 Digits-in-noise (DIN) tests have become popular for hearing screening over the past 15 years. Several recent studies have highlighted the potential utility of DIN as a school-aged hearing test. However, age may influence test performance in children due to maturation. In addition, a new antiphasic stimulus paradigm has been introduced, allowing binaural intelligibility level difference (BILD) to be measured by using a combination of conventional diotic and antiphasic DIN.

PURPOSE

 This study determined age-specific normative data for diotic and antiphasic DIN, and a derived measure, BILD, in children. A secondary aim evaluated the validity of DIN as a smartphone self-test in a subgroup of young children.

RESEARCH DESIGN

 A cross-sectional, quantitative design was used. Participants with confirmed normal audiometric hearing were tested with a diotic and antiphasic DIN. During the test, arrangements of three spoken digits were presented in noise via headphones at varying signal-to-noise ratio (SNR). Researchers entered each three-digit spoken sequence repeated by the participant on a smartphone keypad.

STUDY SAMPLE

 Overall, 621 (428 male and 193 female) normal hearing children (bilateral pure tone threshold of ≤ 20 dB hearing level at 1, 2, and 4 kHz) ranging between the ages of 6 and 13 years were recruited. A subgroup of 7-year-olds (n = 30), complying with the same selection criteria, was selected to determine the validity of self-testing.

DATA COLLECTION AND ANALYSIS

 DIN testing was completed via headphones coupled to a smartphone. Diotic and antiphasic DIN speech recognition thresholds (SRTs) were analyzed and compared for each age group. BILD was calculated through subtraction of antiphasic from diotic SRTs. Multiple linear regressions were run to determine the effect of age on SRT and BILD. In addition, piecewise linear regressions were fit across different age groups. Wilcoxon signed-rank tests were used to determine differences between self- and facilitated tests.

RESULTS

 Age was a significant predictor, of both diotic and antiphasic DIN SRTs (p < 0.05). SRTs improved by 0.15 dB and 0.35 dB SNR per year for diotic and antiphasic SRTs, respectively. However, age effects were only significant up to 10 and 12 years for antiphasic and diotic SRTs, respectively. Age significantly (p < 0.001) predicted BILD, which increased by 0.18 dB per year. A small SRT advantage for facilitated over self-testing was seen but was not significant (p > 0.05).

CONCLUSIONS

 Increasing age was significantly associated with improved SRT and BILD using diotic and antiphasic DINs. DIN could be used as a smartphone self-test in young children from 7 years of age with appropriate quality control measures to avoid potential false positives.

Assessment of hearing screening programmes across 47 countries or regions III: provision of childhood hearing screening after the newborn period

OBJECTIVE

To inventory provision and features of childhood hearing screening after the newborn period (CHS), primarily in Europe.

DESIGN

From each participating country or region, experts provided information through an extensive questionnaire: implementation year, age at screening, test method, pass criteria, screening location, screener profession, and quality indicators: coverage, referral, follow-up and detection rates, supplemented by literature sources.

STUDY SAMPLE

Forty-two European countries or regions, plus Russia, Malawi, Rwanda, India, and China.

RESULTS

CHS was performed universally with pure-tone audiometry screening (PTS) in 17 countries or regions, whereas non-universal CHS was performed in eight with PTS or whisper tests. All participating countries with universal PTS had newborn hearing screening. Coverage rate was provided from three countries, detection rate from one, and referral and follow-up rate from two. In four countries, universal PTS was performed at two ages. Earliest universal PTS was performed in a (pre)school setting by nurses (n = 9, median age: 5 years, range: 3-7), in a healthcare setting by doctors and nurses (n = 7, median age: 4.5 years, range: 4-7), or in both (n = 1).

CONCLUSIONS

Within universal CHS, PTS was mostly performed at 4-6 years by nurses. Insufficient collection of data and monitoring with quality indicators impedes evaluation of screening.

Feasibility of remote assessment of the binaural intelligibility level difference in school-age children

This work evaluated the feasibility and reliability of remotely assessing masked speech recognition and the binaural intelligibility level difference (BILD) in children. Participants were 28 children (6-17 years) and 11 adults (22-45 years) with self-reported normal hearing. A three-alternative forced-choice word recognition task was completed using participants' personal hardware (headphones and computer) and custom software that uploaded results to a central database. Results demonstrate that assessment of masked speech recognition and the BILD is feasible and generally reliable in a remote setting. Variability of results across individuals would likely have been reduced by distributing or specifying appropriate headphones.

Reward Enhances Online Participants' Engagement With a Demanding Auditory Task

Online recruitment platforms are increasingly used for experimental research. Crowdsourcing is associated with numerous benefits but also notable constraints, including lack of control over participants' environment and engagement. In the context of auditory experiments, these limitations may be particularly detrimental to threshold-based tasks that require effortful listening. Here, we ask whether incorporating a performance-based monetary bonus improves speech reception performance of online participants. In two experiments, participants performed an adaptive matrix-type speech-in-noise task (where listeners select two key words out of closed sets). In Experiment 1, our results revealed worse performance in online (N = 49) compared with in-lab (N = 81) groups. Specifically, relative to the in-lab cohort, significantly fewer participants in the online group achieved very low thresholds. In Experiment 2 (N = 200), we show that a monetary reward improved listeners' thresholds to levels similar to those observed in the lab setting. Overall, the results suggest that providing a small performance-based bonus increases participants' task engagement, facilitating a more accurate estimation of auditory ability under challenging listening conditions.

Speech Audiometry at Home: Automated Listening Tests via Smart Speakers With Normal-Hearing and Hearing-Impaired Listeners

Speech audiometry in noise based on sentence tests is an important diagnostic tool to assess listeners’ speech recognition threshold (SRT), i.e., the signal-to-noise ratio corresponding to 50% intelligibility. The clinical standard measurement procedure requires a professional experimenter to record and evaluate the response (expert-conducted speech audiometry). The use of automatic speech recognition enables self-conducted measurements with an easy-to-use speech-based interface. This article compares self-conducted SRT measurements using smart speakers with expert-conducted laboratory measurements. With smart speakers, there is no control over the absolute presentation level, potential errors from the automated response logging, and room acoustics. We investigate the differences between highly controlled measurements in the laboratory and smart speaker-based tests for young normal-hearing (NH) listeners as well as for elderly NH, mildly and moderately hearing-impaired listeners in low, medium, and highly reverberant room acoustics. For the smart speaker setup, we observe an overall bias in the SRT result that depends on the hearing loss. The bias ranges from +0.7 dB for elderly moderately hearing-impaired listeners to +2.2 dB for young NH listeners. The intrasubject standard deviation is close to the clinical standard deviation (0.57/0.69 dB for the young/elderly NH compared with 0.5 dB observed for clinical tests and 0.93/1.09 dB for the mild/moderate hearing-impaired listeners compared with 0.9 dB). For detecting a clinically elevated SRT, the speech-based test achieves an area under the curve value of 0.95 and therefore seems promising for complementing clinical measurements.

Telemedicine in Audiology. Best practice recommendations from the French Society of Audiology (SFA) and the French Society of Otorhinolaryngology-Head and Neck Surgery (SFORL)

Objectives

Access to diagnosis and treatments for auditory disorders and related pathologies has regressed in France during the COVID-19 pandemic, posing a risk to the patient's chance of recovery. This best practice recommendations guide aims to list the existing technological solutions for the remote examination of a patient with hearing complaint, and to outline their benefits and, where applicable, their limitations.

Methods

The recommendations were developed both from the clinical experience of the medical experts who drafted the guide, and from an extensive review of the literature dealing with clinical practice recommendations for tele-audiology. Tele-audiometry solutions were identified on the basis of a search engine query carried out in April 2020, prior to verification of their availability on the European market.

Results

Video otoscopy solutions allow for the teletransmission of images compatible with a high-quality diagnosis, either by connecting via internet to a tele-health platform or using a smartphone or a tablet with an iOS or Android operating system. Using the same telecommunication methods, it is possible to remotely conduct a pure-tone audiometry test in accordance with standard practice, a speech-in-quiet or a speech-in-noise audiometry test, as well as objective measures of hearing. Clinical and paraclinical examinations can be accessed by the physician to be interpreted on a deferred basis (asynchronous tele-audiology). Examinations can also be conducted in real time in a patient, at any age of life, as long as a caregiver can be present during the installation of the transducers or the acoumetry. Tele-audiology solutions also find application in the remote training of future healthcare professionals involved in the management of deafness and hearing impairment.

Conclusion

Under French law, tele-otoscopy is a medical procedure that is either a tele-expertise (asynchronous adive) or a teleconsultation act (synchronous advice). Subjective and objective evaluation of the patient's hearing functions can be done remotely provided that the listed precautions are respected.

Improved Sensitivity of Digits-in-Noise Test to High-Frequency Hearing Loss

OBJECTIVES

Hearing loss is most commonly observed at high frequencies. High-frequency hearing loss (HFHL) precedes and predicts hearing loss at lower frequencies. It was previously shown that an automated, self-administered digits-in-noise (DIN) test can be sensitized for detection of HFHL by low-pass filtering the speech-shaped masking noise at 1.5 kHz. This study was designed to investigate whether sensitivity of the DIN to HFHL can be enhanced further using low-pass noise filters with higher cutoff frequencies.

DESIGN

The US-English digits 0 to 9, homogenized for audibility, were binaurally presented in different noise maskers including one broadband and three low-pass (cutoff at 2, 4, and 8 kHz) filtered speech-shaped noises. DIN-speech reception thresholds (SRTs) were obtained from 60 normal hearing (NH), and 40 mildly hearing impaired listeners with bilateral symmetric sensorineural hearing loss. Standard and extended high-frequency audiometric pure-tone averages (PTAs) were compared with the DIN-SRTs.

RESULTS

Narrower masking noise bandwidth generally produced better (more sensitive) mean DIN-SRTs. There were strong and significant correlations between SRT and PTA in the hearing impaired group. Lower frequency PTALF 0.5,1, 2, 4 kHz had the highest correlation and the steepest slope with SRTs obtained from the 2-kHz filter. Higher frequency PTAHF 4,8,10,12.5 kHz correlated best with SRTs obtained from 4- and 8-kHz filtered noise. The 4-kHz low-pass filter also had the highest sensitivity (92%) and equally highest (with the 8-kHz filter) specificity (90%) for detecting an average PTAHF of 20 dB or more.

CONCLUSIONS

Of the filters used, DIN sensitivity to higher frequency hearing loss was greatest using the 4-kHz low-pass filter. These results suggest that low-pass filtered noise may be usefully substituted for broadband noise to improve earlier detection of HFHL using DIN.

Development and validation of a digits-in-noise hearing test in Persian

OBJECTIVE

The prevalence of unrecognised and late-diagnosed hearing loss is higher in low- and middle-income than in high-income countries, due in part to lack of access to hearing services. Because hearing screening is important for early identification of hearing loss, development of an accessible, self-screening test that can detect hearing loss reliably and quickly would provide significant benefits, especially for underserved populations. This study aimed to develop and validate a new version of the digits-in-noise (DIN) test for Persian speaking countries.

DESIGN

Recordings of Persian digits 0-9 were binaurally presented in broadband speech-shaped noise. Using fitted speech intelligibility functions, digits were homogenised to achieve equal perceptual difficulty across stimuli. The evaluation was established by reference to existing English DIN tests.

STUDY SAMPLE

Thirty Persian speaking young adults with normal hearing thresholds (≤20 dB HL, 0.25-8 kHz).

RESULTS

Speech intelligibility functions produced a mean speech reception threshold (SRT) of -7.7 dB, corresponding closely to previously developed DIN tests. There was no significant difference between test and retest SRTs, indicating high reliability of the test. Our findings suggest that language-specific factors need to be considered for cross-language comparison of DIN-SRTs.

CONCLUSION

This study introduces a convenient tool for future hearing screening in Persian speaking countries with limited access to audiology services.