The Ling 6(HL) Test: Typical Pediatric Performance Data and Clinical Use Evaluation

Hearing Rehabilitation With a Chat-Based Mobile Auditory Training Program in Experienced Hearing Aid Users: Prospective Randomized Controlled Study

Background

Hearing rehabilitation with auditory training (AT) is necessary to improve speech perception ability in patients with hearing loss. However, face-to-face AT has not been widely implemented due to its high cost and personnel requirements. Therefore, there is a need for the development of a patient-friendly, mobile-based AT program.

Objective

In this study, we evaluated the effectiveness of hearing rehabilitation with our chat-based mobile AT (CMAT) program for speech perception performance among experienced hearing aid (HA) users.

Methods

A total of 42 adult patients with hearing loss who had worn bilateral HAs for more than 3 months were enrolled and randomly allocated to the AT or control group. In the AT group, CMAT was performed for 30 minutes a day for 2 months, while no intervention was provided in the control group. During the study, 2 patients from the AT group and 1 patient from the control group dropped out. At 0-, 1- and 2-month visits, results of hearing tests and speech perception tests, compliance, and questionnaires were prospectively collected and compared in the 2 groups.

Results

The AT group (n=19) showed better improvement in word and sentence perception tests compared to the control group (n=20; P=.04 and P=.03, respectively), while no significant difference was observed in phoneme and consonant perception tests (both P>.05). All participants were able to use CMAT without any difficulties, and 85% (17/20) of the AT group completed required training sessions. There were no changes in time or completion rate between the first and the second month of AT. No significant difference was observed between the 2 groups in questionnaire surveys.

Conclusions

After using the CMAT program, word and sentence perception performance was significantly improved in experienced HA users. In addition, CMAT showed high compliance and adherence over the 2-month study period. Further investigations are needed to validate long-term efficacy in a larger population.

Speech Perception Training in Children: The Retention of Benefits and Booster Training

OBJECTIVES

Speech perception training can be a highly effective intervention to improve perception and language abilities in children who are deaf or hard of hearing. Most studies of speech perception training, however, only measure gains immediately following training. Only a minority of cases include a follow-up assessment after a period without training. A critical unanswered question was whether training-related benefits are retained for a period of time after training has stopped. A primary goal of this investigation was to determine whether children retained training-related benefits 4 to 6 weeks after they completed 16 hours of formal speech perception training. Training was comprised of either auditory or speechreading training, or a combination of both. Also important is to determine if "booster" training can help increase gains made during the initial intensive training period. Another goal of the study was to investigate the benefits of providing home-based booster training during the 4- to 6-week interval after the formal training ceased. The original investigation ( Tye-Murray et al. 2022 ) compared the effects of talker familiarity and the relative benefits of the different types of training. We predicted that the children who received no additional training would retain the gains after the completing the formal training. We also predicted that those children who completed the booster training would realize additional gains.

DESIGN

Children, 6 to 12 years old, with hearing loss who had previously participated in the original randomized control study returned 4 to 6 weeks after the conclusion to take a follow-up speech perception assessment. The first group (n = 44) returned after receiving no formal intervention from the research team before the follow-up assessment. A second group of 40 children completed an additional 16 hours of speech perception training at home during a 4- to 6-week interval before the follow-up speech perception assessment. The home-based speech perception training was a continuation of the same training that was received in the laboratory formatted to work on a PC tablet with a portable speaker. The follow-up speech perception assessment included measures of listening and speechreading, with test items spoken by both familiar (trained) and unfamiliar (untrained) talkers.

RESULTS

In the group that did not receive the booster training, follow-up testing showed retention for all gains that were obtained immediately following the laboratory-based training. The group that received booster training during the same interval also maintained the benefits from the formal training, with some indication of minor improvement.

CONCLUSIONS

Clinically, the present findings are extremely encouraging; the group that did not receive home-based booster training retained the benefits obtained during the laboratory-based training regimen. Moreover, the results suggest that self-paced booster training maintained the relative training gains associated with talker familiarity and training type seen immediately following laboratory-based training. Future aural rehabilitation programs should include maintenance training at home to supplement the speech perception training conducted under more formal conditions at school or in the clinic.

Teaching Children With Hearing Loss to Recognize Speech: Gains Made With Computer-Based Auditory and/or Speechreading Training

OBJECTIVES

Transfer appropriate processing (TAP) refers to a general finding that training gains are maximized when training and testing are conducted under the same conditions. The present study tested the extent to which TAP applies to speech perception training in children with hearing loss. Specifically, we assessed the benefits of computer-based speech perception training games for enhancing children's speech recognition by comparing three training groups: auditory training (AT), audiovisual training (AVT), and a combination of these two (AT/AVT). We also determined whether talker-specific training, as might occur when children train with the speech of a next year's classroom teacher, leads to better recognition of that talker's speech and if so, the extent to which training benefits generalize to untrained talkers. Consistent with TAP theory, we predicted that children would improve their ability to recognize the speech of the trained talker more than that of three untrained talkers and, depending on their training group, would improve more on an auditory-only (listening) or audiovisual (speechreading) speech perception assessment, that matched the type of training they received. We also hypothesized that benefit would generalize to untrained talkers and to test modalities in which they did not train, albeit to a lesser extent.

DESIGN

Ninety-nine elementary school aged children with hearing loss were enrolled into a randomized control trial with a repeated measures A-A-B experimental mixed design in which children served as their own control for the assessment of overall benefit of a particular training type and three different groups of children yielded data for comparing the three types of training. We also assessed talker-specific learning and transfer of learning by including speech perception tests with stimuli spoken by the talker with whom a child trained and stimuli spoken by three talkers with whom the child did not train and by including speech perception tests that presented both auditory (listening) and audiovisual (speechreading) stimuli. Children received 16 hr of gamified training. The games provided word identification and connected speech comprehension training activities.

RESULTS

Overall, children showed significant improvement in both their listening and speechreading performance. Consistent with TAP theory, children improved more on their trained talker than on the untrained talkers. Also consistent with TAP theory, the children who received AT improved more on the listening than the speechreading. However, children who received AVT improved on both types of assessment equally, which is not consistent with our predictions derived from a TAP perspective. Age, language level, and phonological awareness were either not predictive of training benefits or only negligibly so.

CONCLUSIONS

The findings provide support for the practice of providing children who have hearing loss with structured speech perception training and suggest that future aural rehabilitation programs might include teacher-specific speech perception training to prepare children for an upcoming school year, especially since training will generalize to other talkers. The results also suggest that benefits of speech perception training were not significantly related to age, language level, or degree of phonological awareness. The findings are largely consistent with TAP theory, suggesting that the more aligned a training task is with the desired outcome, the more likely benefit will accrue.

Development of the Mandarin Phoneme Detection Score Sheet as a Screening Tool

Background and Objectives

Hearing thresholds across frequencies must be obtained for hearing aid fitting. Narrow-band noise (NBN) and speech sounds are often used as stimuli in pediatric audiologic assessments to elicit children’s attention due to their wider frequency ranges as compared to pure tones. However, obtaining complete responses across frequency ranges is challenging in pediatric practice. Therefore, we developed a frequency-specific phoneme screening tool, the Mandarin Phoneme Detection Score Sheet, to help clinicians evaluate aided performance in pediatric practice.

Subjects and Methods

A total of 30 adults with typical hearing and 30 children aged 3-12 years with hearing loss were recruited. Threshold ranges for the aided detection of Mandarin phonemes and NBN were measured using 95% confidence intervals. A stepwise regression analysis was then performed to identify the Mandarin phonemes that can predict NBN detection performance.

Results

The Mandarin Phoneme Detection Score Sheet was developed based on the results of the regression analysis. It was shown that the phonemes /ɤ, a, tɕ^h/ could predict detection performance at different frequencies.

Conclusions

The Mandarin Phoneme Detection Score Sheet can allow audiologists and early intervention professionals to determine the benefits of hearing aids for pediatric patients in the early stage of hearing loss conditions.

Calibrated Ling Sounds Test for Cochlear Implant fitting in children

The Implanted children audiometric evaluation inaccuracies may lead to an extended period of the time to achieve proper cochlear implant (CI) electric stimulation. In this work we hypothesized that the relationship between implanted patient hearing thresholds estimation based on the Electrical Cochlear Response (ECR) and detection thresholds to Ling Sounds intensity calibrated according to higher energy spectral component allow electrical current stimulation adjustment of intracochlear electrodes. ECR is an objective test which is performed while patient is asleep and using the CI in everyday operation mode. Stimulus are variable intensity pip tones whose frequency is coincident with the central frequency of the band frequencies in which incoming sound is divided. The ECR Hearing Threshold is determinate by initial ECR detection and is defined as the minimum intensity level which auditory nerve portion involved with test electrode responds to electric stimulation hence producing an auditive experience to subject. Correlation observed between ECR Hearing Thresholds and Calibrated Ling Sounds detection thresholds is high enough (r²= 0.99) for electrodes electric current adjustment based on patient detection thresholds obtained in a Calibrated Ling Sound Test.

Auditory testing outcomes with hearing aids in patients with auditory neuropathy spectrum disorder

OBJECTIVE

The objective of this study is to evaluate the audiologic outcomes with hearing aids in pediatric patients with auditory neuropathy spectrum disorder (ANSD) using the Infant Toddler-Meaningful Auditory Integration Scale (IT-MAIS), and the Ling 6 Sound Test (Ling 6).

STUDY DESIGN

Case series.

SETTING

Single tertiary care academic medical center.

SUBJECTS AND METHODS

All pediatric patients with a confirmed diagnosis of ANSD on Auditory Brainstem Response (ABR) testing who presented to a single tertiary medical center between September 2008 and September 2018 were included. Only patients that underwent Infant Toddler-Meaningful Auditory Integration Scale (IT-MAIS) and/or Ling 6 Sound Test (Ling 6) were included in the study. Audiologic testing performed after cochlear implantation was excluded.

RESULTS

60 pediatric patients with ANSD were analyzed. There were 10 patients included in the study with documented hearing aid use who underwent IT-MAIS and/or Ling 6 testing. Average IT-MAIS score improved by 20.4% after initial or extended trial of amplification. Similarly, average Ling 6 score improved from 3.6 to 4.8 after initial or extended trial of amplification. The four patients who did not receive amplification had higher average IT-MAIS and Ling 6 scores.

CONCLUSION

In most children with ANSD, IT-MAIS and Ling 6 Sound Test scores improved with initial hearing aid use and over time with extended hearing aid use. Long-term prospective, multi-institutional studies are needed to determine the impact of the natural history of ANSD, comorbidities, and socioeconomic variables on auditory function testing results in children with ANSD using hearing aids.

Vocabulary Acquisition as a By-Product of Meaning-Oriented Auditory Training for Children Who Are Deaf or Hard of Hearing

Purpose A meaning-oriented auditory training program for children who are deaf or hard of hearing (d/hh) was assessed with regard to its efficacy in promoting novel word learning. Method While administering the auditory training program, one of the authors (Elizabeth Mauzé) observed that children were learning words they previously did not know. Therefore, we systematically assessed vocabulary gains among 16 children. Most completed pretest, posttest, and retention versions of a picture-naming task in which they attempted to verbally identify 199 color pictures of words that would appear during training. Posttest and retention versions included both pictures used and not used during training in order to test generalization of associations between words and their referents. Importantly, each training session involved meaning-oriented, albeit simple, activities/games on a computer. Results At posttest, the percentage of word gain was 27.3% (SD = 12.5; confidence interval [CI] of the mean: 24.2-30.4) using trained pictures as cues and 25.9% (CI of the mean: 22.9-29.0) using untrained pictures as cues. An analysis of retention scores (for 13 of the participants who completed it weeks later) indicated strikingly high levels of retention for the words that had been learned. Conclusions These findings favor auditory training that is meaning oriented when it comes to the acquisition of different linguistic subsystems, lexis in this case. We also expand the discussion to include other evidence-based recommendations regarding how vocabulary is presented (input-based effects) and what learners are asked to do (task-based effects) as part of an overall effort to help children who are d/hh increase their vocabulary knowledge.

Speech Intelligibility Index and the Ling 6(HL) test: correlations in pediatric hearing aid users

PURPOSE

To evaluate speech audibility in schoolchildren hearing aids users and correlate the Speech Intelligibility Index to phonemes detecion.

METHODS

22 children and adolescents hearing aids users, underwent audiological evaluation, in situ verification (and consequent obtaining the Speech Intelligibility Index - SII - for conditions with and without hearing aids) and detection thresholds for phonemes by Ling-6 (HL) test.

RESULTS

The average value for the SII was 25.1 without hearing aids and 68.9 with amplification (p <0.001 *). The phoneme detection thresholds in free field, in dBHL, were, without amplification /m/ = 29.9, /u/ = 29.5, /a/ = 35.5, /i/ = 30.8, /∫/ = 44.2 e /s/ = 44.9, and with amplification /m/ = 13.0, /u/ = 11.5 /a/ = 14.3, /i/ = 15.4, /∫/ = 20.4 e /s/ = 23.1 (p<0.001*). There was a negative correlation between SII and the thresholds of all phonemes in the condition without hearing aids (p≤0.001*) and between SII and the /s/ threshold with hearing aids (p = 0.036*).

CONCLUSION

The detection thresholds for all phonemes are lower than without hearing aids. There is a negative correlation between SII and the thresholds of all phonemes in the situation without hearing aids and between SII and the detection threshold of the phoneme / s / in the situation with hearing aids.

The Accuracy of Envelope Following Responses in Predicting Speech Audibility

OBJECTIVES

The present study aimed to (1) evaluate the accuracy of envelope following responses (EFRs) in predicting speech audibility as a function of the statistical indicator used for objective response detection, stimulus phoneme, frequency, and level, and (2) quantify the minimum sensation level (SL; stimulus level above behavioral threshold) needed for detecting EFRs.

DESIGN

In 21 participants with normal hearing, EFRs were elicited by 8 band-limited phonemes in the male-spoken token /susa∫i/ (2.05 sec) presented between 20 and 65 dB SPL in 15 dB increments. Vowels in /susa∫i/ were modified to elicit two EFRs simultaneously by selectively lowering the fundamental frequency (f0) in the first formant (F1) region. The modified vowels elicited one EFR from the low-frequency F1 and another from the mid-frequency second and higher formants (F2+). Fricatives were amplitude-modulated at the average f0. EFRs were extracted from single-channel EEG recorded between the vertex (Cz) and the nape of the neck when /susa∫i/ was presented monaurally for 450 sweeps. The performance of the three statistical indicators, F-test, Hotelling's T, and phase coherence, was compared against behaviorally determined audibility (estimated SL, SL ≥0 dB = audible) using area under the receiver operating characteristics (AUROC) curve, sensitivity (the proportion of audible speech with a detectable EFR [true positive rate]), and specificity (the proportion of inaudible speech with an undetectable EFR [true negative rate]). The influence of stimulus phoneme, frequency, and level on the accuracy of EFRs in predicting speech audibility was assessed by comparing sensitivity, specificity, positive predictive value (PPV; the proportion of detected EFRs elicited by audible stimuli) and negative predictive value (NPV; the proportion of undetected EFRs elicited by inaudible stimuli). The minimum SL needed for detection was evaluated using a linear mixed-effects model with the predictor variables stimulus and EFR detection p value.

RESULTS

of the 3 statistical indicators were similar; however, at the type I error rate of 5%, the sensitivities of Hotelling's T (68.4%) and phase coherence (68.8%) were significantly higher than the F-test (59.5%). In contrast, the specificity of the F-test (97.3%) was significantly higher than the Hotelling's T (88.4%). When analyzed using Hotelling's T as a function of stimulus, fricatives offered higher sensitivity (88.6 to 90.6%) and NPV (57.9 to 76.0%) compared with most vowel stimuli (51.9 to 71.4% and 11.6 to 51.3%, respectively). When analyzed as a function of frequency band (F1, F2+, and fricatives aggregated as low-, mid- and high-frequencies, respectively), high-frequency stimuli offered the highest sensitivity (96.9%) and NPV (88.9%). When analyzed as a function of test level, sensitivity improved with increases in stimulus level (99.4% at 65 dB SPL). The minimum SL for EFR detection ranged between 13.4 and 21.7 dB for F1 stimuli, 7.8 to 12.2 dB for F2+ stimuli, and 2.3 to 3.9 dB for fricative stimuli.

CONCLUSIONS

EFR-based inference of speech audibility requires consideration of the statistical indicator used, phoneme, stimulus frequency, and stimulus level.

Test-Retest Variability in the Characteristics of Envelope Following Responses Evoked by Speech Stimuli

OBJECTIVES

The objective of the present study was to evaluate the between-session test-retest variability in the characteristics of envelope following responses (EFRs) evoked by modified natural speech stimuli in young normal hearing adults.

DESIGN

EFRs from 22 adults were recorded in two sessions, 1 to 12 days apart. EFRs were evoked by the token /susa∫ i/ (2.05 sec) presented at 65 dB SPL and recorded from the vertex referenced to the neck. The token /susa∫ i/, spoken by a male with an average fundamental frequency [f0] of 98.53 Hz, was of interest because of its potential utility as an objective hearing aid outcome measure. Each vowel was modified to elicit two EFRs simultaneously by lowering the f0 in the first formant while maintaining the original f0 in the higher formants. Fricatives were amplitude-modulated at 93.02 Hz and elicited one EFR each. EFRs evoked by vowels and fricatives were estimated using Fourier analyzer and discrete Fourier transform, respectively. Detection of EFRs was determined by an F-test. Test-retest variability in EFR amplitude and phase coherence were quantified using correlation, repeated-measures analysis of variance, and the repeatability coefficient. The repeatability coefficient, computed as twice the standard deviation (SD) of test-retest differences, represents the ±95% limits of test-retest variation around the mean difference. Test-retest variability of EFR amplitude and phase coherence were compared using the coefficient of variation, a normalized metric, which represents the ratio of the SD of repeat measurements to its mean. Consistency in EFR detection outcomes was assessed using the test of proportions.

RESULTS

EFR amplitude and phase coherence did not vary significantly between sessions, and were significantly correlated across repeat measurements. The repeatability coefficient for EFR amplitude ranged from 38.5 nV to 45.6 nV for all stimuli, except for /∫/ (71.6 nV). For any given stimulus, the test-retest differences in EFR amplitude of individual participants were not correlated with their test-retest differences in noise amplitude. However, across stimuli, higher repeatability coefficients of EFR amplitude tended to occur when the group mean noise amplitude and the repeatability coefficient of noise amplitude were higher. The test-retest variability of phase coherence was comparable to that of EFR amplitude in terms of the coefficient of variation, and the repeatability coefficient varied from 0.1 to 0.2, with the highest value of 0.2 for /∫/. Mismatches in EFR detection outcomes occurred in 11 of 176 measurements. For each stimulus, the tests of proportions revealed a significantly higher proportion of matched detection outcomes compared to mismatches.

CONCLUSIONS

Speech-evoked EFRs demonstrated reasonable repeatability across sessions. Of the eight stimuli, the shortest stimulus /∫/ demonstrated the largest variability in EFR amplitude and phase coherence. The test-retest variability in EFR amplitude could not be explained by test-retest differences in noise amplitude for any of the stimuli. This lack of explanation argues for other sources of variability, one possibility being the modulation of cortical contributions imposed on brainstem-generated EFRs.

Audiological Considerations for Managing Mild Bilateral or Unilateral Hearing Loss in Infants and Young Children

Purpose This clinical focus article describes considerations for recommending assistive hearing technology to infants and young children who have mild bilateral or unilateral hearing loss. These conditions present special challenges compared to bilateral permanent hearing losses that are moderate to profound in their degree in that the recommendation to proceed with technology is not as clear. Conclusion Current clinical practice guidelines and protocols for pediatric hearing aid fitting recommend managing these conditions on a case-by-case basis. Descriptions of key considerations for recommending assistive hearing technology for infants and young children with mild bilateral hearing loss or unilateral hearing loss are offered herein.

Auditory Skills following Cochlear Implantation in Children with the Charge Syndrome

OBJECTIVES

To assess the auditory outcomes and skills of pediatric cochlear implant (CI) users with the CHARGE syndrome. To determine the influence of inner ear malformations on the surgical procedure and speech understanding outcomes in this population.

STUDY DESIGN

Observational, retrospective study.

MATERIALS AND METHODS

Imaging, auditory testing, intraoperative findings, complications, and postoperative auditory skills and outcomes of pediatric CI users with CHARGE syndrome were recorded.

RESULTS

6 children (8 ears) were included, 5 of whom had prelingual deafness. Their mean age at implantation was 37 months. Six of the 8 ears presented cochlear malformation; the most frequent was hypoplasia type III. Intraoperatively, the transmastoid facial recess approach was used in 5 ears, and abnormalities of facial nerve anatomy were found in 5 ears. All electrode insertions were complete. All children were, to a varying degree, able to detect and identify sound. Verbalization skills were developed by 2 children, 1 of whom used oral language as his primary mode of communication.

CONCLUSIONS

Cochlear implantation performed by an experienced surgeon in patients with the CHARGE syndrome is a safe procedure with adequate treatment planning. All children had improved auditory skills although the improvement was variable.

The Use of Frequency Lowering Technology in the Treatment of Severe-to-Profound Hearing Loss: A Review of the Literature and Candidacy Considerations for Clinical Application

This article provides a review of the current literature on the topic of frequency lowering hearing aid technology specific to the treatment of severe and profound levels of hearing impairment in child and adult listeners. Factors to consider when assessing listener candidacy for frequency lowering technology are discussed. These include factors related to audiometric assessment, the listener, the type of hearing aid technology, and the verification and validation procedures that can assist in determining candidacy for frequency lowering technology. An individualized candidacy assessment including the use of real-ear verification measures and carefully chosen validation tools are recommended for listeners requiring greater audibility of high-frequency sounds, when compared with amplification via conventional hearing aid technology.

Validation of the Chinese Sound Test: Auditory Performance of Hearing Aid Users

PURPOSE

The Chinese Sound Test (Hung, Lin, Tsai, & Lee, 2016) has been recently developed as a modified version of the Ling Six-Sound Test (Ling, 2012). By incorporating Chinese speech sounds, this test should be able to estimate whether the listener can hear across the Chinese speech spectrum. To establish the clinical validity of the test, this study examined the relationship between the aided audiometric thresholds and the distance thresholds.

METHOD

Sixty children with bilateral hearing aids were recruited. The aided sound-field thresholds at 250, 500, 1000, 2000, 4000, and 6000 Hz were compared with the distance thresholds of six sounds, /u, ə, a, i, tɕʰ, and s/, which encompass the entire Chinese speech frequency range from low to high.

RESULTS

Partial correlation and stepwise regression analyses revealed that the Chinese testing sounds are frequency specific and that the audibility of each sound could be predicted by a specific frequency threshold.

CONCLUSIONS

The results confirm the validity of the Chinese Sound Test, indicating that the testing sounds can be reliably used to assess the perception of frequency-specific information. Crucially, these data also demonstrate that the Chinese Sound Test is a useful tool to identify red flags of poor auditory access in daily environment to monitor device malfunctions and possible hearing fluctuations.