About Kristin Banach, Senior Marketing Manager

Senior Marketing Manager

Talking Hearing Aids with Brian Taylor and H. Gustav Mueller

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Fitting and Dispensing Hearing Aids, a popular introductory textbook, has just been published in its second edition in September. We managed to listen in to a conversation between its two authors, Brian Taylor and H. Gustav Mueller, who were exchanging some thoughts regarding their new 2nd Edition.

BT:  You know Gus, when we wrote the first edition of this book, I remember us talking about the fact that there seemed to a fair number of professionals who maybe weren’t following Best Practice when they were fitting hearing aids.  We thought that it might simply be because they didn’t exactly know what was called for in Best Practice, or maybe it never had been laid out for them in an orderly manner.

HGM:  And we thought a book like ours might help . . .

BT:  Right.  Do you think it did?

HGM:  I’d certainly like to think so.  We sold a lot of copies, so that’s a good start!  But honestly, when I travel around, I don’t see as much change over the past five years as I thought might happen.  Let’s take pre-fitting testing for instance.  We have some great speech-in-noise tests available for clinical use like the QuickSIN, the BKB-SIN and the WIN.  We talked about all of these in the book, provided step-by-step guidelines, yet I just don’t really see an uptake—for some reason, audiologists and hearing instrument specialists seem to have a love affair with monosyllables in quiet, which really have little use for the fitting of hearing aids.

BT:  Maybe we’re expecting things to happen too fast.  I think it’s good we expanded that section on pre-fitting speech recognition testing in the current book—hopefully more readers will take notice.  And as you know Gus, I’ve always been a fan of the ANL.  I just saw that there has been over 40 articles published on that test in the past 12 years!  That’s another easy-to-do test, and it really provides information that you cannot learn by doing speech recognition testing.

HGM:  Part of Best Practice is picking the right technology for the right person.  I recall you spent a lot of time researching all the new technology that has come out in recent years for this 2nd Edition.

BT:  Things change pretty fast in that area.  I think we’ve added some great new sections on wireless connectivity, frequency lowering, and audio data transfer between hearing aids. Like the first edition, rather than getting into the intricate technical details of various features, we focus on how this technology benefits the patient. For example, in the chapter that covers wireless connectivity and audio data transfer between hearing aids, we write about how these new features enhance benefit in background noise, and how candidates are identified.

HGM:  And, of course, verification of the fitting is critical.  The best hearing aid in the world is no better than a PSAP if it’s programmed wrong.  I think our new section on speechmapping will be extremely helpful for people who are just getting started using probe-mic measures.  As we described, recent research clearly has shown that you can’t simply rely on what you see simulated on the software fitting screen.  As, of course, all those special features that you talked about, such as frequency lowering, need to be verified in the real ear too!

With all that said, however, we also know that verification alone is not enough to demonstrate to patients, their families, and even third-party payers that a new set of hearing aids is worth the investment—so, we can’t forget about outcome measures.

BT: Yes, Gus, it seems there are always a couple of new outcome measures to talk about. With all of the recent research on the impact of untreated hearing loss on other conditions, like cognitive function, social isolation, and overall mental health, we added a section on validated self-reports to measure the impact hearing aid use may have on these common conditions.  Even if you’re not inclined to measure those types of downstream outcomes, we added more detail on using the International Outcome Inventory for Hearing Aids (IOI-HA). As you know, many audiologists and hearing instrument specialists neglect to conduct any outcome measures. We cover the reasons this is a bad idea, and suggest, if you are only going to use one measure, it ought to be the IOI-HA.

HGM:  And you know, some people suggested that it was a little silly for us to use our chapter themes of country music, movies, wine tasting, baseball, and all the others, but I’m glad we kept that going in this 2nd Edition.

BT:  Me too.  Who said you can’t have fun and learn about hearing aid fitting at the same time?  After all, it’s worked all these years for the two of us!


Cultivating an Awareness of Generational Differences for Effective Communication

By A. Embry Burrus and Laura B. Willis
Authors of Professional Communication in Speech Language Pathology: How to Write, Talk, and Act Like a Clinician, Third Edition


Popular literature is filled with descriptions of the term, “generational differences,” and for good reason. There are distinct differences among individuals based on when they were born, and the political, social, and economic environment in which they have grown up. This post will address the various communication styles of individuals who are currently in the workforce. Although there are differences among the generations, according to the Center for Creative Leadership, there are also similarities; namely, most people have the same basic core values: “family, integrity, achievement, love, competence, happiness, self-respect, wisdom, balance and responsibility.”

The Millennial Generation, born between 1982 and 1994 (estimate), represents a cohort distinct from their parents of the Baby Boom generation (1945–1964 [estimate]), and their predecessors, Generation X (1961–1981 [estimate]). Millennials have been generally described as optimistic, team-oriented, high-achieving rule-followers. In addition, aptitude test scores for this group have risen across all grade levels, and with the higher aptitude has come a greater pressure to succeed. It is noteworthy to mention that Millennials are the most racially and ethnically diverse generation in U.S. history. As of 2012, individuals of Hispanic origin accounted for 26.9% of the 21-and-under population (http://www.census.gov), and Asians accounted for 25.6%. Interestingly enough, this generation has been described as more accepting of diversity than past generations.

Research has shown that children of the Millennial Generation were encouraged to “befriend” their parents, as well as their parents’ friends, and as teens they became comfortable expressing their opinions to adults; therefore, they are not hesitant to challenge authority, assert themselves, or ask for preferential treatment. Studies have shown that Millennials view strong relationships with supervisors to be a crucial factor in their satisfaction with their role as supervisee, and that they expect communication with supervisors to be frequent, positive, and affirming.

In today’s society, we are taught that to be successful, we need to be self-confident. Some of the characteristics assigned to the Millennials are that they are self-assured, assertive, and perfectionistic, which, when used constructively, can be very positive attributes. It is important that Millennials are aware that to members of the older generations, this can sometimes be misconstrued as overconfidence. If a supervisor or colleague perceives you to be overconfident, this could create a number of opportunities for miscommunication and misunderstanding. You do not want to communicate to others that you have more ambition than skill, or that you already “know it all” and therefore do not need or want their input. We often advise our students to be mindful that if they are perfectionists, they should not allow this to morph into fear of failure. We remind them that it is okay to admit that they do not know something, and it is much better to do so than to seem falsely competent.

Members of Generation X, the cohort immediately preceding the Millennials, were shaped by many factors. Generation Xers learned independence, autonomy, and self-reliance early in life. They were the first to be described as “latch-key” kids, and they often took care of themselves and their siblings. They grew up in a time when divorce was commonplace, and therefore ended up in single-family or blended-family homes. As a result, they have been described as being more accepting of themselves and others, and embracing of diversity. Members of this generational cohort have been described as valuing flexibility and creativity, as well as encouraging of individualism.

According to Jean Scheid (2010), “Gen Xers aren’t afraid of technology and love new gadgets, even if it takes a little longer than a Millennial to understand how it all works. Their communication style is one brief and to the point, and e-mail is their preferred method.” Gen Xers desire feedback from supervisors and do not hesitate to offer feedback in return. On the other hand, if not kept in the loop, they may become upset and feel left out.

The “Boomers,” as they are often referred to as, make up approximately 29% of the U.S. population and 50% of the workforce. The oldest members of the Baby Boom generation are now mostly retired, and in less than 15 years, one in five Americans (the youngest members) will be over the age of 65. Those who were born at the end of this generational cohort (1960–1964), however, are still a large part of the workforce and may still embody some general characteristics used to describe this group: focused on hard work, ambitious, competitive, and believers in equality.

To summarize, it is important to always show respect by communicating clearly and demonstrating that you acknowledge what your communication partner feels is important, regardless of position or age difference. This does not mean that individuals across the generations cannot understand each other, or learn from each other; it simply means that we must take into consideration that we may have different ways of looking at the same issue. Being part of a diverse workplace may be challenging to some, yet it can provide an environment that fosters rich personal as well as professional growth.


Deal, J. (2015). Ten principles for working across generations [Podcast]. Center for Creative Leadership. Retrieved from http://insights.ccl.org/multimedia/podcast/10-principles-for-working-across-generations/

Schied, J. (2010). Types of communication styles: Bridging the communication gap. Bright Hub. Retrieved from http://www.brighthub.com/office/home/articles/76498.aspx

U.S. Census Bureau. (2012). Current Population Survey, 2012 Annual Social and Economic (ASEC) Supplement. Washington, DC: Author.


Perspective-Taking for Neurotypicals


By Stephanie D. Sanders, MA, CCC-SLP, author of The FILTER Approach: Social Communication Skills for Students with Autism Spectrum Disorders

While creating The FILTER Approach, I took exhaustive measures to help students with Autism Spectrum Disorders (ASD’s) identify, comprehend, and explain essential social skills, while putting them into practice.  As I implemented this curriculum, it began a personal perspective-taking opportunity for me.  I noticed weaknesses within my own communication skills in specific situations. A perfect example is my inability to Listen to my family with technology distractions in view (thank you, Pinterest).  Demonstrating social errors as a neurotypical Speech-Language Pathologist (SLP) could likely justify a new DSM-5 diagnosis of “social skills hypocrite.”

The truth is that most of us have room for improvement socially and in considering the perspectives of those with social impairments.  Perspective-taking tasks usually present a challenge to individuals with ASD, due to Theory of Mind.  I’ve frequently referenced the idiom “put yourself in my shoes” with students during these activities. However, SLP’s can also struggle with taking perspective when driven by accountability for pragmatic language goals printed on a report. I become frustrated when my student resists the educationally relevant IEP goals that will undoubtedly transform him or her into a social skills superhero.  An epiphany soon occurred with a hint of witty wordplay.  My mission: try taking a new perspective on perspective-taking.

I began investigating:

  • How do those with social impairments perceive conversation?

I asked students individually, “Why are conversations important?”  The same response was consistently given, “To find out information.”  This perspective came across as task-driven, lacking any element of enjoyment.  Some interrogation sessions I’ve witnessed appear to be information-seeking at its finest.  In other instances, my students feel obligated to be the source of information.  They lecture peers regarding topics of interest, rather than seeking to find out information.  We’ve discussed how obsessive interests and “conversation hog” habits will cause one to miss the Target, socially.  I’ve also taught this concept in the middle school gifted-student classroom during monthly F.I.L.T.E.R. lessons.  Luckily, the “conversation hog” reference hasn’t triggered any speeches about swine or guinea pig fixations!

Other questions on my mind:

  • How are common rules of social language perceived?
  • What are the most stressful things about social situations?

My little brother Zach was diagnosed with an ASD at the age of thirteen and was my primary inspiration for “The FILTER Approach.” As part of this perspective-taking endeavor, I knew it would be beneficial to get Zach’s viewpoint on social rules.  I asked him to speak freely, without concern of giving a wrong answer.

Me: What do you think the expression, “Put yourself in his/her shoes” means?

Zach: It means you should consider the other person’s feelings.

Me: Exactly.  I want to put myself in your shoes to find out what conversation is like for you, having an ASD.  I want to know your perspective about some social rules in conversation.

Zach: Okay.

Me:  What do I mean when I tell you to “use your filter” in conversation?

Zach: It’s what you should or should NOT say in conversation.  If you always say what you’re thinking, then you could look bad as an employee, lose respect, and look unconcerned about feelings.

Me: Great explanation!  Now I want your perspective on some social rules from my book.  How do you feel about making eye contact and looking for Facial clues?

Zach: A little uncomfortable.  A symptom of people with Autism is sometimes having a hard time with eye contact.  I don’t want to give too much and it’s hard for me to know.

Me: Very true.  We’ve talked about glancing, which works.  You’ve done a nice job of avoiding inappropriate topics in person.  However, you and many other people might post strong opinions on Facebook.  Why do you think that is?

Zach: On Facebook, it’s virtual and like your own little world, so it’s not as real.  It’s uncomfortable in person because you’re actually with them.

Me:  I see what you’re saying.  Do you think it’s hard to Listen during a conversation with someone and why or why not?

Zach: It can be a lot of work. Sometimes I run out of things to say or my mind is off-topic while I’m trying to listen.  The conversation gets stressful if it’s too long and boring.  Sometimes, I think about something totally unrelated, like a conversation with someone earlier.

Me:  Staying focused probably does feel like a lot of work. Why do you think we should try to “hit the Target” socially and what did we talk about for your target?

Zach: We should make goals to be successful. I need to close my conversations with “See you later” and ask about someone else’s interests.

Me: Excellent. Is it awkward for you to End conversations with people at places like church or work?

Zach: Yes, because I run out of things to say.  It’s also difficult to end things at work when my shift is over.  I want to tell my manager I’m ready to leave, but he’s usually busy.  If I just leave, I might look disrespectful like I’m trying to get out of my job.

Me:  Later, we’ll make a plan for leaving work.  Is it difficult for you to Repair conversation mistakes you’ve made and have you used some of the Repair tools we’ve talked about?

Zach: I’ve used some.  Apologizing can be hard and it’s hard to admit you’re wrong.  I’ve asked, “Should I stop now?” when the person was being quiet. I also messaged, “Did I say something wrong?” two times to someone on Facebook who quit talking to me.  He never responded, so I didn’t ask anymore.

Me: I’m so proud of you for trying to Repair social mistakes.  You made a good choice to quit asking when the person on Facebook never responded.  At least you tried.

Me: Overall, what are the most stressful things for you in social situations?

Zach:  It’s stressful because:

  • I don’t know what the other person is thinking.
  • I don’t know if I’ve said something wrong.
  • I don’t know what will happen to that friendship (in the future).
  • It’s tough to start new friendships as an adult.
  • Losing a childhood friendship is discouraging and can’t be replaced.
  • I’ve become shy as an adult.

Me:  Thanks for sharing, Zach.  Therapists need to consider what it’s like for someone with ASD to follow these rules.  It has really helped me to hear your perspective.

From Zach’s outlook, it must be draining to worry about confusing social cues and potential negative outcomes.  If someone repeatedly struggles to use verbal and nonverbal social behaviors in conversation, then it could become a losing battle.  Isn’t it easier to retreat into a virtual world where at least all of the nonverbal challenges are removed?  Many of our students/clients with ASD’s could perceive communication as a lot of effort with little worth.

The challenge is to find pragmatic goals that are realistic, beneficial, and meaningful for our students/clients.  The perspectives of these individuals are usually disregarded as wrong with an immediate need for change. If I truly listen to the individual’s perspective, I can not only set an example of showing interest, but also ensure my therapy approach remains individualized.  I can clearly and personally define the advantages of practicing good social habits now in order to make future social success a possibility. Taking the student’s perspective increases my chances of enlisting him or her in therapy, which will result in a more socially responsible individual. Early investment in the views of my students could allow the opportunity to become an influence in rewriting a lifelong story filled with social struggles and disappointments.

Book Review: Auditory Verbal Therapy: For Young Children with Hearing loss and Their Families, and the Practitioners Who Guide Them

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Reviewed by Estelle Roberts, Speech-Language Therapist, Jhb Cochlear Implant Programme, Johannesburg, South Africa

Advances in technology have increasingly cast a spotlight on the possibilities for children with hearing loss, however severe, to learn to listen and use spoken language as their preferred mode of communication.   Auditory Verbal Therapy (AVT) has gained prominence as the intervention of choice for these families and their practitioners.  Auditory Verbal Therapy: For Young Children with Hearing loss and Their Families, and the Practitioners Who Guide Them provides a current, comprehensive and evidence-based text with appeal for a broad spectrum of professionals. The editors’ global experience reflects in, and influences the text, as does the work of 29 contributors, all international experts in their fields.

This is a substantive book:  seventeen chapters spanning 600 pages.  While this might initially seem daunting, the text makes for absorbing reading.  Much of the information is presented to encourage a fresh look at familiar topics. Throughout the text, the latest thinking and research is applied to AVT. In Chapter 2, hearing and listening are naturally paired with thinking and its accompanying research.  In Chapter 8, extensive and relevant information covering auditory processing, speech, language, emergent literacy and play is linked to developmental scales to provide diagnostic guidelines for practitioners.  Chapter 9 explores emergent literacy and provides compelling data that highlights the importance of early and effective access to sound for infants with hearing loss.  Very topically, it includes a balanced perspective on digital literacy.  For students and practitioners seeking practical knowledge in skill development, there are a number of ‘How to…’ chapters that have the potential to be used as ‘templates’ for acquiring skills or refining professional practice.

Unlike most texts, where the emphasis is directed at a particular group of practitioners, this inclusive text speaks to a broader audience within the field.  The material presented in chapters 4 – 7, covering audiology, hearing aids, implantable hearing technologies and assistive and access technologies, balances the next chapters, which provide greater depth for Auditory Verbal practitioners in particular. This balance between depth and breadth creates a must-have reference for the broader professional community interacting with cochlear implants.

The final chapter presents the voices of families from twelve countries as they reflect on their journeys with their children with hearing loss. Their reports, told from this powerful perspective, bear touching and convincing testimony to the global reach of AVT.

The lay-out of the book contributes to an ease of understanding that would be appreciated by parents, students and others not wholly familiar with the field.  Generous spacing, bulleting and frequently highlighted sub-sections creates a navigable reading experience and serves as a useful reference for those who prefer to use the text as a ‘dip-in’ resource.

Given its broad appeal to professionals and families, its presentation of extensive current, researched information and practical application to AVT, as well as its easy navigability, this resource may well replace existing texts to become the favoured ‘go-to’ resource for practitioners, students, families and the broader CI community seeking exploration and guidance in the field of AVT.

Speech-Language Pathologists Climbing the Steps to Mastery


Speech-Language Pathologists Climbing the Steps to Mastery
By Lydia Kopel
Co-author of IEP Goal Writing for Speech-Language Pathologists: Utilizing State Standards

Facing the mountain
As a speech-language pathologist (SLP), you are forever tackling a huge mountain called language. There are peaks at the top that you are trying to help your students/clients reach. Do you ever find yourself working on a skill with a student/client who does not seem to be making progress? That peak didn’t seem so far away, but along the way, you encounter twists and turns, making it around one corner only to face an obstacle around the next bend. Frustrating, right? On the inside you’re screaming, “Why can’t he get this? How can I approach this in a different way? What am I doing wrong?”

You’ve set your goal(s) for this individual carefully choosing the target skill(s). But, did you think about prerequisite skills? Prerequisite skills are all the skills that lead up to the targeted skill; the building blocks. Every skill has several prerequisite skills; each prerequisite skill has prerequisite skills. With language learning there is a great deal of scaffolding – one skill builds upon another skill, builds upon another skill, and so on. Let’s look at an example related to the skill of the main idea.

To be able to identify the main idea when it is not stated in a text, one has to have success with many other language skills. These include being able to answer factual questions, determine important details from unimportant details, determine how the details go together in the sequence of events, and be able to draw inferences. Of course, each one of these skills has even more prerequisite skills! And it doesn’t end there!

Each target skill also has several steps to mastery. With the same example of the main idea, we probably shouldn’t expect that a 6th grade student will learn the prerequisite skills outlined above and be able to identify the main idea and supporting details from a grade level text in one year. It is more likely that additional scaffolding and instruction will be needed at various steps. The student may first need to identify a supporting detail when given a choice of three and given the main idea in a 5th grade text. Maybe then you can move them to identifying three details that support a given main idea in a 5th grade text. With further scaffolding, this student may move toward identifying the details in a 6th grade text when the main idea is unknown. Going through these prerequisite skills and steps to mastery can increase an individual’s success and decrease therapist and client frustration—making for a much smoother climb up that language mountain.

Peaks and valleys
We all encounter those individuals who have splinter skills.   They have some of the language skills in the developmental continuum but are missing others. There may be no specific order, no rhyme or reason, to what they can and cannot do. If we can tap into the skills that haven’t fully developed, we can help increase performance on the target skills that are lacking.

Let’s look at the semantic skill of compare/contrast. Perhaps you have a client who can label pictures of nouns and verbs. He can tell you the color, size, and shape of single pictured items. He may be able to use comparatives and superlatives. However, he can’t sort items by attribute, identify things that do not belong, or state category labels. His describing skills are limited because he breaks down when more than one item is pictured together in a scene and more than two descriptors are expected.  Would it be reasonable to expect this client to state how two or more items are the same or different? It seems like there may be numerous gaps in his semantic skills that would be imperative to the skill of compare/contrast.

Reaching the peak
As an SLP, do you have students/clients who are lacking some of the necessary prerequisite skills? Taking the time to figure out what prerequisite skills are needed can lead to success with the target skill(s).   Take a step back and work on the missing skills. Sometimes we need to go backward in order to move forward.

When setting goals, consider the amount of prerequisite skills needed and how fast you anticipate the student to progress. Is your anticipated target skill too high? Maybe you need to aim for a smaller peak. Maybe the goal needs to be one of the prerequisite skills. Take it one step at a time and you’ll soon find the individual standing at the peak.

Prerequisite skills, goal writing, and much more are discussed and outlined in the book IEP Goal Writing for Speech-Language Pathologists:  Utilizing State Standards. Check it out!

Please visit our blog Living the Speech Life and feel free to contact us at livingthespeechlife@gmail.com

Lydia Kopel and Elissa Kilduff

Living the Speech Life

Book Review: Auditory-Verbal Therapy reviewed by Helen M. Morrison, Ph.D., CCC/A, LSLS Cert. AVT

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Auditory-Verbal Therapy: For Young Children with Hearing Loss and Their Families, and the Practitioners Who Guide Them, by Warren Estabrooks, Karen MacIver-Lux and Ellen A. Rhoades, Plural Publishing, 2016.

Reviewed by Helen M. Morrison, Ph.D., CCC/A, LSLS Cert. AVT




Auditory-Verbal Therapy provides a thorough, 21st century resource for professionals, families, and students. Each chapter is organized in a way that technical information is accompanied by suggestions for practical application, making it a likely “go-to” reference that will be consulted frequently.

The history of Auditory-Verbal therapy (AVT) described in the first chapter is comprehensive and much needed in order to ensure that the story of the approach is not lost to current and future generations of professionals and families. The book is clear about the principles of AVT, what it is and is not, all while demonstrating how AV therapy has evolved to apply evidence-based practices that meet the needs of today’s diverse families and children.

A highlight of the book is a systematic review of literature concerning AVT that utilizes the most current techniques and standards for scientific rigor to describe the state of evidence supporting the approach. The chapters that address audiological procedures and hearing technology are current and provide a basis for deeper reading of the topics discussed. The book addresses each of the knowledge domains that Auditory-Verbal therapists apply in practice, including comprehensive developmental milestones, emergent literacy, inclusion and specific strategies for parent coaching.

An important section of this book provides a rationale and framework for planning and implementing AVT sessions, followed by a series of case studies and lesson plans written by experienced AV therapists that apply this framework. The children and families in these case studies and lessons represent a range of ages, diagnoses, additional disabilities, and cultural/economic situations. The lesson plans at first glance may not seem like conventional lesson plans. They illustrate how important teaching within the conversational context is in AVT, beginning with initial greetings and entering the therapy room or home. Following the child’s lead and exploiting teachable moments are highlighted.

Finally, families from across the global community tell their own stories, demonstrating the universality of the approach. The families not only hail from many different countries, but they are each unique in their cultural and economic situations, types of hearing loss and the ages at which their children entered AVT. Many of the children in these families have challenges in addition to hearing loss.

This book is a must-have for anyone who works with children with hearing loss and their families. The information has value for professionals and families across the communication options that families might choose. This book is essential for professionals working to attain Listening and Spoken Language Specialist certification. It will guide their learning during their certification period and serve as a foundational source for examination preparation.

Does Anybody Hear Me? Hearing as a Public Health Issue

This week’s post is an excerpt from the American Academy of Audiology Foundations’s An EAR to the Ground Report.  We will be distributing the full report at our booth at AudiologyNow! in April so please stop by to pick up a free copy. Enjoy!

Reprinted/republished with permission from the American Academy of Audiology.

Just over a decade ago, the World Health Organization (WHO) declared that, worldwide, noise-induced hear­ing impairment is the most prevalent irreversible occupational hazard. In the WHO’s 1999 “Guidelines for Community Noise,” it was estimated that over 120 million people worldwide had disabling hearing difficul­ties (Environmental Health Perspectives 113, no. 1 [January 2005]). The causes of the growing noise pollution problem include increased population growth, urban sprawl, lack of noise-reduction regulations, an increasing number of vehicles and air traffic, and human dependence on noise-producing electronics.

In Gordon Hempton’s One Square Inch of Silence, the author identifies silence as an endangered species. Indeed, he quotes Nobel Prize–winning bacteriologist Robert Koch to reinforce the potential future impact of noise pollution: “The day will come when man will have to fight noise as inexorably as cholera and the plague.” In his pursuit of silence, Hempton traverses the United States measuring the deci­bel levels of machines, cars, airplanes, rain, and even deer trekking through the woods. He visits state parks and federal buildings/department offices (the Federal Aviation Administration, for example). He informs, educates, and attempts to increase awareness of noise pollution and prevention. He perseveres, undaunted and optimistic in a time when, as he notes, noise is so prevalent, it’s taken for granted—so much so that noise is not among the 25 metrics that constitute the Environmental Performance Index rankings issued annu­ally by Yale University’s Center for Environmental Law and Policy. Those rankings include drinking water, indoor air pollution, industrial CO2 emissions, and pesticide regula­tion. The reason that noise pollution is excluded, according to the center’s director, is lack of consistent data collected methodologically among more than 150 countries.

Additionally, the National Institute for Occupational Safety and Health (NIOSH) estimates that over 30 million U.S. workers are exposed to hazardous sound levels on the job (“Work Related Hearing Loss,” NIOSH Publication No. 2001-103, www.cdc.gov/niosh/docs/2001-103/). While the Occupational Safety and Health Administration (OSHA) requires employers to provide hearing protection to workers who are overexposed to noise on the job, OSHA recognizes that the problem is difficult to monitor. In spite of requirements that include employer implementation of a continuing, effective hearing conservation program, the problem is not abating. Worse, noise pollution, both on and off the job, has a growing impact on quality of life.

Chew Faster, the Noise Is Killing Me—Purposeful Noise: Some workplace and environmental noise is purposeful. In April 2010, CNN aired a segment on how restaurants use loud music to help turn over tables and increase consumption. According to the segment, “In the mid-1980s, researchers at Fairfield University dem­onstrated that people increased their rate of chewing by almost a third when listening to faster, louder music, accelerating from 3.83 bites a minute to 4.4 bites a minute. A 2008 study in France further found that when music decibels are amped up, men not only consumed more drinks but consumed them in less time.”

Anti-noise activists describe the effect of “second­hand noise” as similar to that of secondhand smoke. In an article published in the July/August 2010 issue of Audiology Today, a study on the effects of utility-scale wind turbines shows that the production of low-frequency noise and vibration from these turbines can have nega­tive effects on people living and working near them. While the noise produced is not believed to cause hearing loss, it is known that the “emissions” do cause sleep disturbances. Coined “Wind- Turbine Syndrome,” other symptoms include headache, visceral vibratory vestibular disturbance, dizziness, tinnitus, ear pressure/pain, external auditory canal sensation, memory and concentration deficits, irritabil­ity, and fatigue. On October 6, 2010, the New York Times online business feed reported on efforts in a small Maine community to remove a new local wind farm. According to the article, “Lawsuits and complaints about turbine noise, vibrations and subsequent lost property value have cropped up in Illinois, Texas, Pennsylvania, Wisconsin and Massachusetts, among other states. In one case in DeKalb County, Ill., at least 38 families have sued to have 100 turbines removed from a wind farm there. A judge rejected a motion to dismiss the case in June.”

It’s Hear, It’s Everywhere: And the United States is not alone. Other countries are also plagued by increased noise pollution. According to the European Environment Agency, over 65 percent of the population is exposed to ambi­ent sound at levels above 55 dBA, while over 17 percent is exposed to levels above 65 dBA (Environmental Health Perspectives 113, no. 1 [January 2005]). This exposure can lead to hearing loss as well as other health and learning problems. It’s not just about hearing loss prevention and restoration—it’s a matter of systemic health and well-being.

Why do humans have such a big snoring/sleep apnea issue?

By Dr. Kenny Peter Pang, Ear Nose Throat / Sleep Specialist, Asia Sleep Centre, Paragon, Singapore author of Advanced Surgical Techniques in Snoring and Obstructive Sleep Apnea available in March 2013.

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Contrary to popular belief, the throat and the upper airway has major impact on one’s sleep pattern and quality. The patency and size of one’s upper airway can affect the sleep quality and affect one’s health and quality of life. Due to a narrowed and/or congested throat (airway), the resistance to breathing can be very high, making breathing during sleep very difficult and laboured. This is more pronounced during sleep, as one’s muscles are completely relaxed and flaccid (soft), resulting in collapse and closure of the throat; hence, no breathing during sleep. This is known as Obstructive Sleep Apnea (OSA).

In Singapore, the incidence of Obstructive Sleep Apnea is estimated to be about 15%.

The Evolution of the Airway.

            It is well accepted that for most mammals, the airway is the most important conduit for the passage of air into the lungs, for gaseous exchange and the intake of oxygen. From the four-legged crawling canines to the two-legged standing gorillas, the airway is structurally within the cranio-facial skeleton (solid hard box/skull) of the animal.

Based on Darwin’s theory of evolution, it is well known that as the four-legged animal evolved and stood up, many changes took place in the upper body, namely, his upper limbs (arms/hands) got shorter, the spine became stronger, firmer and upright, the brain evolved bigger and, most crucially, the facial shape also changed.


Darwin’s Theory of Evolution

The face shaped changed and became shorter from front to back, the face grew longer, the upper head expanded (as the brain grew bigger), and his neck development also increased, the neck gradually grew longer, with the airway conduit no longer being protected by the cranio-facial skeleton.

The evolutionary changes are evident when examining the cross sections of the canine model, to the gorilla model to the human model. The facial morphology has changed to shorten the cranio-facial section of the airway in the skull, enlarge the cranium (brain), increase neck length and with most of the airway unprotected in the neck.

The unprotected airway in the neck is no longer protected by the cranio-facial skeleton, it is surrounded by skin, muscles and soft tissues; the airway is hence, more vulnerable, prone to collapse, injury and trauma.

This therefore leads to a much higher incidence of snoring and obstructive sleep apnea in humans compared to animals.

The Airway


God gave us the nose to breathe through it, warm the air we breathe, and filter dust particles. The nose is pivotal in the breathing apparatus of the human. Any swelling/obstruction in the nose would result in turbulent airflow and difficulty breathing; resulting in more negative pressure required to inhale air into the lungs, this results in a more negative pressure in the throat (creating a vacuum effect), causing collapse of the throat muscles and structures. (see diagram)

Hence, the nose is pivotal in the management of obstructive sleep apnea, however, numerous studies/research have shown that OSA is a disorder of a multilevel system in the throat (including the palate, the tonsils and/or the tongue) that collapses during sleep. Therefore, treating the nose alone is inadequate in the treatment of OSA.


The throat in the airway comprises of the palate (soft tissue structure containing mainly muscles), the side walls of the throat (mainly muscles and fat), the left and right  tonsils (mainly lymphoid tissue), and the tongue (see diagram). The throat is a dynamic structure that “acts” as a soft air conduit, to channel air into the lungs from the external environment. Any enlarged or swollen structure/s in this air conduit would narrow the space and result in obstruction during breathing. In the same vein, any form of negative pressure or vacuum effect would “suck” the structures inward and result in airway obstruction. With turbulent airflow in this soft air conduit, vibration ensues resulting in snoring. Snoring implies an increased resistance to the inflow of air during breathing at the level of the upper airways.

Some patients may have adeno-tonsillar hypertrophy with a crowded upper airway with very little space for airflow, while obese patients frequently have a thick and fatty soft palate and side walls in the throat. It is the vibration of these soft tissues during sleep that results in snoring.


The average human spends about 6 to 8 hours per day sleeping. Hence, we spend about one third of the day sleeping, and therefore, one third of our life time sleeping, yet so many of us take sleep for granted.

For the average Singaporean that lives up to about 80 years old (current life expectancy), hence, we sleep for a total of 26 years of our life!

It is well accepted that dream sleep (25% of sleep) is the most important element in the sleep process, for well being, memory re-building, rejuvenation and mental alertness. Hence, dream sleep is vital to the human mind and body. Simplistically, dream sleep is a highly active brain in a “paralyzed” body. This is a perfection made by our divine maker, so as to prevent us from acting out our dreams (i.e. if one was dreaming that one was playing soccer, one does not actually kick and act it out in bed, endangering one’s bed partner). This however, works against the patient with an already narrowed airway (narrow throat or air conduit), as this already narrowed airway will lose its tone (complete relaxation) during dream sleep and collapse, leading to upper airway obstruction, cessation of breathing and lack of oxygen. Therefore, this leads to stress on the heart, brain and other organs in the body. This condition is called obstructive sleep apnea (OSA).

This very important dream sleep component of sleep, that is crucial for memory rebuilding, rejuvenation and well being, will not be able to take place if the body is deprived of the fundamental basic need for oxygen, due to stoppages of breathing, resulting from a blocked airway (usually multilevel). This results in interrupted sleep, sleep fragmentation and poor sleep quality.

During the day, the patient is excessively sleepy, has poor concentration, poor memory and becomes irritable/moody. Common patient complaints include early morning tiredness and morning headaches. Other symptoms include forgetfulness, depression, irritability and, less commonly, impotence.

During the night, patients may complain of frequent awakenings with a choking and gasping sensation, nocturia (frequent passing urine at night), or nightmares. Many bed partners have witnessed their partners choking and holding their breaths (apneas) during their sleep.

Long term health consequences include high blood pressure, heart disease, strokes and sudden death during sleep.

Captain (NS) Jimmy Ang, has Ankylosing Spondylitis, high blood pressure and severe obstructive sleep apnea. He had been snoring loudly, and feeling very tired during the day for the past few years. Every morning he would not feel refreshed despite sleeping adequate hours at night. His wife would observe him choking and gasping for breath during the night while he slept.

Mr. Ang says that his “wake up” call came a few months before the surgery as he fell asleep whilst driving in the afternoon and hit another vehicle in front.  He had nose, palate and tongue surgery after undergoing the home based wrist worn sleep test that showed he had severe obstructive sleep apnea, in August 2009. Mr. Ang reveals that “since the surgery, my life has changed for the better. My nose passages feel opened, breathing is very smooth and I don’t snore anymore. It has been over 3 years since the surgery, I am able to breathe without difficulty in my sleep and feel refreshed in the mornings. My blood pressure is also very well controlled now, after the surgery. I am so happy that I also sent my son for the same sinus surgery.”


Social media tips for authors

social media image

With social media sites proliferating at a lightning fast pace, it is no surprise that the latest most buzzed about marketing trend is the idea of “earned marketing.” This is the organic, viral, word-of-mouth recommendations that create internet sensations like adorable kitten videos with a million+ views. Even professional, scholarly books such as those published here at Plural benefit tremendously from social media marketing, which is why we put together guidelines for our authors who are interested in promoting their books via social networks but maybe aren’t sure how best to do it. Once a month we will feature a new tip for using social media to raise your social profile, generate good word-of-mouth, and help your book reach the “earned marketing” promised land!

January tip: You are an expert (and have the published book to prove it!) – let people know. If you are on LinkedIn, join as many professional groups as are relevant and join in the discussions. Ask and answer questions and generally engage with the other professionals in your community. Include your published books in your profile with links to the Plural Publishing website. Post updates so that your professional network knows what you are working on. The more actively you use LinkedIn, the more you improve your ranking on the site and establish yourself as a thought leader in your field.



Advancements in Balance Function Assessment

This article by Devin L. McCaslin, PhD appeared in the January edition of the Plural Community enewsletter. Enjoy!

Devin McCaslin

Advancements in Balance Function Assessment

In 1998, when the author entered clinical practice, there were only a few textbooks dedicated to the assessment of balance function. One of these texts entitled Manual of Electronystagmography (1976) was written by Hugh O. Barber, a neurologist, and Charles W. Stockwell, a psychologist. The authors covered topics from anatomy and physiology to how to write reports. Additionally, the text provided illustrative examples, all of which was accomplished in approximately 200 pages. As it stands today, the current role of the ENG in the contemporary balance function assessment is essentially the same as it was in the 1970s. However, research over the past few decades has improved both the technology with which balance function testing is performed and our understanding of the pathophysiology of dizziness. In many cases, this has altered the way balance tests are currently conducted (e.g., electronystagmography). While it is impossible to cover all of the new developments in this brief report, it is this author’s opinion that three significant changes in balance function testing have been in the areas of eye tracking technology, chronic subjective dizziness, and the assessment and treatment of benign paroxysmal positional vertigo (BPPV). Influential advances in these areas of balance assessment have enabled clinicians to be more specific in the manner in which patients are diagnosed and managed for balance impairments.

Chronic Subjective Dizziness
For those of us who see patients on a routine basis, the anxious dizzy patient is a common occurrence. In fact, McKenna, Hallam, and Hinchcliffe (1991) reported that approximately 64 percent of dizzy patients seen in an audiology clinic also had an associated anxiety disorder. These patients often complain not of vertigo, but of a constant dizziness or “rocking.” Until recently, many patients suffering from anxiety and dizziness were given the label “psychogenic dizziness.” However, psychogenic dizziness was often a diagnosis of exclusion that patients would leave the office with when diagnostic testing was normal (e.g., neuroimaging and vestibular testing). The last 10 years have seen a significant change in how patients with psychiatric issues and dizziness are approached. In order to begin the process of correctly identifying and treating these patients, Staab and Ruckenstein (2005) have replaced the term “psychogenic dizziness” with the term chronic subjective dizziness (CSD). CSD is defined using both the results of a neurotological examination and the presence of a specific set of physical symptoms. Using the criterion set forth by recent research, patients with this type of dizziness can now be helped by interventions directed at their underlying psychiatric impairments. For a clinician seeing dizzy patients, an understanding of CSD is essential in order to give the patient the best chance at receiving intervention that will remediate the symptoms and avoid incorrect medical or surgical treatments.

Eye Tracking Technology
Another significant change that has occurred over the last decade is the implementation of video infrared technology in lieu of electronystagmography (ENG) to measure eye movements. Referred to as videonystagmography (VNG), these systems now comprise the majority of most new eye recording systems sold in the United States (Michelle Petrak, Ph.D., personal communication). VNG utilizes pupil localization technology and the reflective properties of the corneal surface to calculate pupil position and angle of gaze. This move away from the ENG to the VNG recording method has occurred because of the distinct advantages that VNG offers when compared with ENG. These include the shorter set up time, the extremely low noise floor of the VNG recording system, and the ability to record video and archive each session. The ability to review a patient’s eye movements offline has also been instrumental in shaping how we learn as clinicians and how patients are counseled. For instance, it is not uncommon to watch archived video of a patient’s eye movements when we review a case with a student or discuss a patient with a colleague. In some instances the patient can gain a better understanding of their disorder by watching their own eye movements during the post-test counseling session.

Benign Paroxysmal Positional Vertigo
The development of video eye recording systems has also been invaluable in advancing our understanding of benign paroxysmal positioning vertigo (BPPV). BPPV is one of the most common forms of vertigo (Furman & Cass, 1999; Bhattacharyya et al., 2008). Barany (1907) is credited with providing the initial description of this type of dizziness that is characterized by intense, but brief, vertigo and nystagmus provoked by changes in the position of the head. BPPV is the term most commonly used to describe the disorder with this specific set of symptoms. It is now 105 years following Barany’s description and much has changed regarding how we assess and manage the patient. While we do not understand all of the causes of BPPV, there has been progress regarding how we treat the disorder. There are two key pieces of knowledge that a clinician must have in order to successfully assess and treat a patient with BPPV. First, the clinician must be capable of correctly diagnosing the variants of BPPV. This requires an understanding of the semicircular canal ocular reflexes and affords the examiner the ability to characterize the nystagmus and identify the location of the displaced particles. Second, the clinician must have an arsenal of different treatment maneuvers in order to be prepared to treat each of the variants of BPPV. Fortunately, there is now an abundance of research available on both issues.
In my book Electronystagmography/Videonystagmography  (McCaslin, 2012) I describe the basic principles of each of the aforementioned topics and supplement them with the most current research. The early sections of the text are focused on describing normal and impaired peripheral and central vestibular system function. The topics that follow are descriptions of how to conduct the various ENG/VNG subtests and how to interpret them. This text is intended to be a practical and portable resource for use in the clinic.

Barber, H. O., & Stockwell C. W. (1976). Manual of electronystagmography (1st ed.). St. Louis, MO: Mosby.
Bhattacharyya, N., Baugh, R. F., Orvidas, L., Barrs, D.,Bronston, L. J., Cass, S., . . . & Haidari, J. (2008). Clinical practice guideline: Benign paroxysmal positional vertigo. Otolaryngology — Head & Neck Surgery, 139(5 Suppl. 4), S47–S81.
Furman, J. M., & Cass, S. P. (1999). Benign paroxysmal positional vertigo. New England Journal of Medicine, 341, 1590–1596.
McKenna, L., Hallam, R. S., & Hinchcliffe, R. (1991). The prevalence of psychological disturbance in neurotology outpatients. Clinical Otolaryngology and Allied Sciences, 16, 452–456.
Staab, J. P., & Ruckenstein, M. J. (2005). Chronic dizziness and anxiety: Effect of course of illness on treatment outcome. Archives of Otolaryngology — Head & Neck Surgery, 131, 675–679.