Book excerpt – James Jerger: A Life in Audiology

The following excerpt is from the autobiography, James Jerger: A Life in Audiology

American Academy of Audiology

The AAA is now in its 28th year. Younger members may not appreciate what it has meant to our profession. Before the Academy was launched in 1988 we were the step-children of the American Speech-Language-Hearing Association, commonly abbreviated as ASHA. We followed their code of ethics, accepted their certification programs, attended their conventions, and published in their journals. How this came about was essentially an accident of history. Most of the earliest audiologists were people originally trained in speech science and speech pathology. As such, ASHA was their natural home and they were comfortable within its ranks. Raymond Carhart’s doctoral dissertation, for example, concerned a model of the human larynx.  But as younger people became audiologists they did not share the common bond with speech science and speech pathology so typical of their mentors. As the field of audiology grew, some of the younger members began to ask whether we might not be better served by creating our own national professional organization. Expressing this view, however, met with stern disapproval. Our elders insisted that fragmentation must never happen, that we must always remain one profession because you could not separate hearing from speech and language; they were all part of the unique process we call “human communication.”  I always thought this argument specious. For example, you cannot separate the brain from the foot: they are both part of the whole body, but there are quite distinct medical specialties to treat their disorders. Certainly the more you know about language and speech the better, but that doesn’t mandate that you belong to their professional organization.

In any event, opponents of fragmentation failed to appreciate that ASHA itself began as the American Academy of Speech Correction (AASC) by fragmenting off from the National Association of Teachers of Speech (NATS) in 1925. NATS in turn was formed by splitting off from the National Council of Teachers of English (NCTE) in 1914.

In 1958 I was elected to ASHA’s executive board. At one of our meetings, I suggested that we consider setting up special interest groups that would lend some separate identity to various clearly distinguishable groups within the organization. There was much shoe shuffling, and some support from the aphasia people, but little general willingness to pursue the topic. A fellow board member, one of the revered elder statesman in audiology, came over to me as the meeting broke up, put his hand on my shoulder, and said, “Jim, it will never happen. They are afraid we will split off.”  Actually the idea of special interest groups within ASHA did eventually happen, but only after we had formed AAA.

Nothing much transpired for the next few decades, but matters came to a head at the 1987 ASHA convention in New Orleans. Rick Talbot had organized a session on “future trends in audiology.” There were five of us on the panel: Jay Hall, George Osborne, Charles Berlin, Lucille Beck and me. Each presented a thoughtful glimpse at what the future might hold in their particular area. I was the last speaker and my message was simple. I said, “I think it is time for audiologists to form their own professional organization” The response from the audience shocked me. There was a deafening roar of approval, which I truly had not expected. I think that everyone on that stage was also amazed.

Back in Houston I asked colleague Brad Stach what he thought of the idea. He was leery at first, but came around when I drew an analogy with an umbrella organization like the American Medical Association, under which each medical specialty had its own organization, its own publication and its own convention. In retrospect the analogy is not quite apt, but it convinced Brad to take up the cause. We put together a list of 35 audiologists that we considered leaders in their respective areas and sent each one a letter of invitation to come to Houston for a two-day meeting to discuss the possibility of forming a new organization “of, by, and for” audiologists. Only one invitee declined. The rest arrived, at his/her own expense, ready to consider the idea.

We met in the ballroom of a hotel just across Fannin street from the Methodist Hospital. The first morning was chaotic. It was difficult to believe that the group could ever agree on anything. By the end of the second day, however, there was general consensus that the effort at least ought to be attempted. In 2009 I wrote, in my book Audiology in the USA, the following:

 “The first year of the Academy’s existence, 1988, was an uncertain time. The founders were not at all sure that their efforts would succeed. They knew what they wanted to do, and where they wanted to go, but recognized, with some trepidation, the formidable forces arrayed against them. The primary concern was, of course, the ASHA.  It already counted, at that time, more than 8000 audiologists among its roughly 60,000 members, and was not disposed to view this defection in a collegial manner.”

If I were to rewrite that last sentence today, I would undoubtedly use more colorful language, so I had better not try. That passage does illustrate, however, what I perceived to be the most important reason to break away from ASHA. Speech pathologists outnumbered audiologists in the ratio of about 8:1. But, profession-wise, speech pathology is, and perhaps always will be, based on an educational model, whereas audiology is based on more of a medical model. At that time the bulk of speech pathologists worked as therapists in the public schools of America. They worked primarily with children. Most held only the bachelor’s degree.  Our profession, on the other hand, is more like a medical model. Most of us are engaged in clinical services, either in private practice, or in medical environments. At the time we started the Academy, most audiologists held the master’s degree, and there was already pressure to upgrade to the doctoral level, which we have since accomplished with the AuD degree (a move, incidentally, with which ASHA did not initially share our enthusiasm.) Many of us felt that we would never be able to achieve the much-desired doctoral level degree until we were free of dominance by ASHA.

HEARING AID FITTINGS TODAY vs YESTERDAY; IS IT BETTER?

Compression did not begin with digital hearing aids

By Theodore H. Venema, PhD
Author of Compression for Clinicians: A Compass for Hearing Aid Fittings, Third Edition

My career in this field began in 1987 as a new audiologist at The Canadian Hearing Society in Toronto. All hearing aids were analog and provided linear gain, although a few compression circuits floated around too. These used output limiting compression, with its high knee-point and high compression ratio. The knee-point was adjustable, which in turn adjusted the maximum power output (MPO). It was a way to limit the MPO without the use of “peak clipping,” which caused distortion.

Wide dynamic range compression (WDRC) entered the scene with a cannonball splash right around 1990. The action of the outer hair cells (OHCs) was now understood by clinicians as being distinct from that of the inner hair cells (IHCs). As we all know today, the OHCs enable the IHCs to sense soft incoming sounds below around 50 dB SPL. WDRC was thus seen as a rather “intellectual” type of compression, in that it electronically sought to imitate the role of the OHCs. With its low knee-point and a low compression ratio, the focus of WDRC is to elevate the “floor” of hearing sensitivity, rather than to limit the MPO or “ceiling” of loudness tolerance. It is no coincidence that otoacoustic emissions—also known to arise from the action of the OHCs—suddenly emerged as part of clinical practice.

Compression in today’s digital hearing aids hasn’t really changed all that much from then. We continue to use both output limiting compression and WDRC. The point here is that the analog hearing aids of that time (late 1980s, early 1990s) used either one type of compression or another. Clinicians had to know their compression types because their hearing selection for any client depended on this knowledge. Manufacturer fitting software did not yet exist. Today’s digital hearing aids are programmed exclusively by software. Once the audiogram is entered through Noah, the hearing aid signal processing is automatically programmed to provide whatever compression is deemed necessary. We’ve become “dumbed down,” because we no longer have to know how to apply the compression. The manufacturer fitting software takes care of all that!

The cables, the cables, the cables…

The emergence of the cables actually began in the very late 1980s, with the first “programmable” analog hearing aids. A cable from a computer (or more often a handheld programming device) was plugged into a socket on the faceplate of an ITE or on the backside of a BTE. Adjustments were made via this “digital screwdriver.” This seemed like a really “cool” alternative to manually adjusting hearing aid settings by trimmers, trim pots, potentiometers, whatever they were called. We simply turned these clockwise or counterclockwise, in order to raise or lower the MPO, gain, low-cut, high-cut, etc. I used to laugh that if the original settings were somehow lost, one could simply set all the trimmers halfway; that way, one could maximally be only half-wrong.

Back to the cables, it is truly amazing just how many different ones exist, even for the product lineup of any one manufacturer! This issue is not at all new, and I am not the  first to complain about that. I must admit to feeling a little odd though, when hanging a weird looking hook around the client’s neck with cables connected to the hearing aids positioned in the client’s ears. The next step is to sit in front of the computer, hoping and praying the manufacturer’s fitting software will read the hearing aids.

Manufacturer fitting software, fitting software, fitting software…

Fitting software emerged at the end of the analog era (mid 1990s) and flourished with the advent of digital hearing aids in 1997. Of course, with each manufacturer, the fitting software is completely different. Oh, there are some similar traits among them, but the look, the feel, the labels, and also the quirks and exceptions, are different for each manufacturer.

Digital technology and software certainly do add flexibility; they also however, invite their best friend, complexity. There are so many parameters involved with fitting now: noise reduction amounts and types, directional microphones and associated polar plots, feedback suppression adjustments, linking binaural hearing aids, and don’t forget about the battery indicator beeps! It gets better; we in separate programs, make combinations of the above-said parameters, in order to specifically address various different listening situations, such as quiet, conversations, and traffic.

Has anyone seen ANSI? Where did it Go? Sometime during the late 1990s, with the advent of digital hearing aids in 1997, ANSI slipped away. It happened in the middle of the night. Since the 1950s for hearing aids, ANSI was intended to be a measurement standard for hearing aid hardware, which consists of the microphone, amplifier, and receiver (aka speaker). Add a few capacitors, resistors, inductors (and trimmers to adjust their behaviors), and you still have nothing but analog hardware. Such was the consistency of analog hearing aids. ANSI ruled in the analog land of hardware, but now fitting software rules. Quaint concerns about OSPL90, Reference Test gain, Harmonic Distortion, and Equivalent Input Noise have almost faded from view. Today it’s all about software. Most clinicians today never bother with ANSI because they are just trying to figure out the fitting software.

The dongles and Bluetooth paraphernalia…

On a semi-annual basis, the goals and deadlines of their product management cycles dictate that manufacturers must pound out new and updated products. The cacophony of their escalating product releases has become deafening. What’s more, hearing aids now come with all kinds of dongles, Bluetooth remotes and gadgets to be used with other devices that work with the phone, television, etc. Of course, these have to be “paired” together to work with the hearing aids. Despite the best efforts of manufacturers to explain things, it does make me feel a bit like “Ted the Cable Guy.”

Clients commonly come back to the office with bags containing unused cords, boxes, television streaming devices, and dongles. It can be quite difficult to get elderly people to make sense of it all! Bottom line: Clinicians today are still constantly “putting out fires,” much like they always did in the past.

Epilogue

It’s obvious that hearing aids today are far better than the squealing, beige “banana-shaped” BTEs of yesterday. The disappointing thing, however, is that the rate of client satisfaction has not risen at the same rate as hearing aid development and complexity. The unwanted byproduct from complexity is confusion, felt by both clinicians and clients.

We have made amazing strides in technology, digital algorithms, and features. The downside is that it has all come at a cost, literally and figuratively, to clients and clinicians. With all the recent progress, I’m not sure clinicians feel that fittings are easier today than they used to be. I also do not believe the monetary cost of hearing aids compared to eyeglasses is at all well understood by clients. Is anyone really surprised at the recent emergence of (and governmental support for) an alternative, namely, those low-cost personal sound amplification products, also known as PSAPs?

Talking Hearing Aids with Brian Taylor and H. Gustav Mueller

Brian_TaylorGus_Mueller TaylorMueller_2e_FDHA2E

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!

 

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

AVT book - artwork -v8

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.

Plural Supports Student Research Forum Awards at AudiologyNOW!

Each year, five recipients present their research findings at AudiologyNOW! and receive a $500 award from the Foundation as sponsored by Plural. We congratulate this year’s very deserving award recipients.

SRF Group Photo

Messages from the award recipients:

“It was a great honor and privilege to be selected and given the opportunity to present my research project and represent the University of North Texas in the Student Research Forum. From applying to presenting, the experience was full of nervousness. However, the possibility of presenting the research that I devoted so much time to in the last 3 years on a national stage was something I could not pass up. I am so very appreciative to the Foundation and Plural Publishing for allowing five students the opportunity to gain experience in public speaking and share the work that is so meaningful to them. I enjoyed meeting the four other students involved, Dr. Samuel Atcherson from the University of Arkansas, and other representatives from audiology programs and the Academy.  It would not have been possible for me to be selected without the hard work and dedication of my mentor, Dr. Amyn Amlani. The experience could not have been more perfect and I am appreciative for the award.”

Kyle Harber | Au.D. Student | University of North Texas

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Auditory-Verbal Therapy- Hearing, Listening, Talking, Thinking

Warren_Estabrooks

 

 

By Warren Estabrooks, M.Ed., Dip. Ed. Deaf, LSLS Cert. AVT, co-author of Auditory-Verbal Therapy: For Young Children with Hearing Loss and Their Families, and the Practitioners Who Guide Them

 

 

Globally, there is a great shift towards listening and spoken language for children who are deaf and hard of hearing.

Amazing auditory options, state-of-the-art hearing aids, and a variety of implantable hearing devices and the pursuit of excellent (re)habilitation by highly qualified practitioners working in partnerships with families, will hopefully become the standard of international health care and educational intervention for children with hearing loss around the world.

It is the work of therapists, teachers, audiologists, surgeons, social workers, and allied practitioners in health care and education to guide, navigate, and coach parents on their search for the treasure chest of spoken communication—to help them help their children discover the valued jewels of hearing, listening, and spoken conversation.  Practitioners everywhere form alliances of hope and trust with parents, and together we polish these precious gems until they sparkle and dance with life.

Why would one ever consider compromising when so much is possible?

We hope that one day we will look back and see an abundance of evidence-based outcomes, all barriers to equitable service gone, and a global focus on literacy with a deep understanding of powerful auditory access to the brain provided by state-of-the-art hearing technologies.

Renaissance man and mentor of many of today’s auditory-verbal practitioners, Dr. Daniel Ling, wrote that “auditory-verbal therapy… developed as a result of the natural outcomes of advances in knowledge, skills and technology.  As such advances occurred, new treatment strategies were devised to maximize their applications”.

Auditory-Verbal Therapy is now widely accepted because more children are acquiring, or have already acquired, the abilities to use spoken language, to interact more freely with other members of society, to obtain higher levels of academic education, and to have a more extensive range of careers, a greater security of employment and fewer limitations on the personal and social aspects of their lives” (Estabrooks, 2006).

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AudiologyNOW! 2016 Author Signing Schedule

AudiologyNOW! attendees – Meet our authors and connect with experts in the field! Stop by the Plural booth (#301) for the following Meet the Author sessions: 


Thursday, April 14, 11:00 am – 12:00 pm
Meet Marc Fagelson, BA, MS, PhD 
Co-editor of Tinnitus: Clinical and Research Perspectives

Marc Fagelson   Tinnitus


Thursday, April 14, 3:00 – 3:30 pm
Meet Mark DeRuiter, MBA, PhD and Virginia Ramachandran, AuD, PhD
Authors of Basic Audiometry Learning Manual, Second Edition 

Mark DeRuiter   Virginia Ramachandran   Basic Audiometry Learning Manual, Second Edition


Friday, April 15, 11:00 – 11:30 am
Meet Ruth Bentler, PhD, H. Gustav Mueller, PhD, and Todd A. Ricketts, PhD
Authors of Modern Hearing Aids: Verification, Outcome Measures, and Follow-Up  

Ruth Bentler   H. Gustav Mueller   Todd A. Ricketts  Bentler_MHA.jpg

Congratulations to Ruth Bentler, 2016 recipient of the Jerger Award for Research in Audiology. 


Friday, April 15, 1:00 – 2:00 pm
Meet Anne Marie Tharpe, PhD
Co-editor of Comprehensive Handbook of Pediatric Audiology, Second Edition

Anne Marie Tharpe   Comprehensive Handbook of Pediatric Audiology

Congratulations to Anne Marie Tharpe, 2016 recipient of the Marion Downs Award for Excellence in Pediatric Audiology. 

2016 Awards and Honors

We are thrilled to announce the winners of the 2016 Plural Publishing Research Awards given in honor of the late Dr. Sadanand Singh, Plural’s founder. These two scholarships are awarded by the Council of Academic Programs in Communication Sciences and Disorders and the honorees and their faculty sponsors will be acknowledged at the annual CAPCSD meeting award banquet, in San Antonio, TX on March 31.

At the MS/AuD level, the award went to Chelsea Hull of the University of Nebraska-Lincoln. Working with advisor Dr. Sherri Jones, Chelsea is researching the impact of Sound Field Amplification (SFA) devices, specifically the REDCAT amplification system, on student academic outcomes and teacher perspectives of this amplification system on academic improvement.

CAPCSD Scholarship Chelsea Hull

Chelsea Hull                                                         Au.D. Student                                             University of Nebraska-Lincoln

At the PhD level, the award was given to Nancy Quick of the University of North Carolina. Under advisor Dr. Melody Harrison, the focus of Nancy’s research is on investigating the impact of underlying linguistic sources of knowledge on spelling among children with hearing aids, cochlear implants and normal hearing, utilizing a multilinguistic analytic approach.

CAPCSD Scholarship Nancy Quick

Nancy Quick, M.S. CCC-SLP               University of North Carolina at Chapel Hill PhD Candidate in Speech and Hearing Sciences, Class of 2017

Congratulations Chelsea and Nancy on your achievements!


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The Changing Indications for Cochlear Implantation

Theodore R. McRackan, MD Otology, Neurotology, and Skull Base Surgery

By Ted McRackan, MD, co-editor of Otology, Neurotology, and Skull Base Surgery: Clinical Reference Guide

Cochlear implantation is the gold standard for treatment of severe to profound sensorineural hearing loss. Cochlear implants (CIs) were approved by the Food and Drug Administration (FDA) in 1985 and have been suggested to be the most successful neural prosthesis created to date. Over 300,000 cochlear implants have been performed worldwide, with over 50,000 performed in the past year alone. Cochlear implantation involves a surgical procedure whereby an electrode array is placed in the cochlea of the inner ear, which is organized in a tonotopic fashion with decreasing characteristic frequency along its length. Modern CIs contain between 12 and 22 electrodes, which are spaced with the intention of each electrode stimulating a unique area of the spiral ganglia of the auditory nerve. Cochlear implants work by having an external microphone and an external processor convert an acoustic signal to an electrical signal. It is then sent to a speech processor, which is designed to enhance the signal and reduce noise before sending the information to the spiral ganglion through the CI electrode array.

Cochlear implantation is currently at an exciting time point due to the combination of improving technology and proven outcomes that has led to rapid expansion of its indications. The FDA approved the first single-channel CI electrode for adults in 1984, followed by the multichannel electrode in 1987. Cochlear implants were then approved in 1990 for children older than 2 years, in 1998 for children over 18 months, and ultimately in 2000 for children older than 12 months. There has been a recent push to implant children younger than 12 months due to evidence that children implanted at this age are more likely to catch up to normal-hearing peers at an earlier time point. Three major obstacles have hampered this movement. First, obtaining accurate hearing diagnostic testing in a timely manner can often be difficult in those less than 12 months. Second, there is a slight increased risk of surgical complications due to the low blood volume in this age group. Third, it can be extremely difficult to perform cochlear implant programming in this age group. Nonetheless, the clear benefits of early implantation likely outweigh these risks. Pediatricians, audiologists, and otolaryngologists are encouraged to identify infants with hearing loss as soon as possible for hearing rehabilitation. The earlier this is performed, the earlier children with profound hearing loss can be identified, and the earlier they can be implanted, leading to better CI outcomes.

Use of cochlear implantation in patients with residual hearing has been another area of rapid expansion. It was initially thought that all hearing would be lost with cochlear implantation and that if hearing was preserved, patients would not be able to process electrical and acoustic hearing. However, through the trials of the Cochlear Hybrid electrode and the MED-EL EAS electrode, it appears that both are possible. Through these and other trials, most patients had preserved residual hearing after cochlear implantation. Additionally, these patients showed improved hearing outcomes compared to patients without residual hearing. At the present time, it is not clear whether this preserved hearing is sustainable over time. This is an active area of investigation and will continue to be studied for years. Nevertheless, this technology has greatly expanded the indications for cochlear implantation beyond traditional candidacy.

As discussed above, it was previously thought that individuals would not be able to process combined electrical and acoustic hearing. However, cochlear implantation in patients with residual hearing proved this incorrect. This has led to the more widespread use of CIs in individuals with single-sided deafness. Current standard treatment for single-sided deafness includes devices that essentially ignore the deafened ear. However, with cochlear implantation, hearing can be restored to that ear. This was initially performed in patients with severe tinnitus in the deafened ear but is now being more commonly performed in the absence of tinnitus. Further work is certainly needed to develop a more comprehensive understanding of cochlear implantation in this population, but preliminary data show decreased head shadow effect and improvement in binaural summation, spatial release from masking, and potentially sound localization.

Beyond cochlear implantation, the use of auditory brainstem implants (ABIs) in children is another area of expansion. Although this has been performed in Europe for years, it is only more recently being performed in the non-neurofibromatosis type II population in the United States. Several centers have active clinical trials to perform ABIs in children unlikely to benefit from cochlear implantation due to either absent cochlear nerves or cochlear malformations. This is an unfortunate population as they have limited hearing rehabilitation options. Auditory brainstem implants provide an opportunity for hearing in this population, and the neurotology community is excited to hear the results of these trials.

We have come a long way since Bill House developed the first single-channel CI. As outcomes and technology continue to improve, the indications for cochlear implantation will grow. The audiology and otology communities are eager to see what the future holds for cochlear implantation.

About the Author
Dr. Theodore R. McRackan is an assistant professor of otolaryngology at the Medical University of South Carolina. He received his medical degree from the Medical University of South Carolina and completed his otolaryngology residency at Vanderbilt University. Dr. McRackan then completed his fellowship in neurotology-skull base surgery at the House Ear Clinic. His professional interests include neurotologic outcomes and quality of life research. Dr. McRackan and Derald E. Brackmann, MD co-edited Otology, Neurotology, and Skull Base Surgery, which serves as both a study resource for qualifying exams and a portable clinical reference guide. This text features a concise and approachable outline format, contributions by leaders in the field, and key topics such as anatomy and embryology, hearing loss, cochlear implantation, skull base tumors, vestibular disorders, and pediatric otology. View sample pages and place your order at www.PluralPublishing.com.

Tinnitus: In the Brain of the Beholder

Marc_Fagelson    Baguley_PTINN    David_Baguley

 

By: Marc Fagelson, BA, MS, PhD and David M. Baguley, BSc, MSc, MBA, PhD

Co-editors of Tinnitus: Clinical and Research Perspectives

Most audiologists and patients understand tinnitus to be the perception of a sound that is not connected in any way to an environmental event. For some patients, the sound produces minimal discomfort and is noticeable only a fraction of the time. Other patients are not so fortunate, and their tinnitus may persist and prove distracting when they are in the presence of other sounds or when they try to communicate. A relatively small proportion of patients with tinnitus, still probably more than 10 million people worldwide, have bothersome tinnitus that consistently reduces their quality of life and affects most routine activities. Such patients often respond to tinnitus as though its presence merits the attention and concern consistent with that demanded by a sound that is recognized as a threat. These patients illustrate some of the more confounding elements of tinnitus: it is a sound experience that may produce, or be associated with, powerful emotions and physiologic responses consistent with those demonstrated in fear-avoidance research.

A person’s experience with tinnitus may be complex and multi-faceted. Some patients link tinnitus to traumatic events, perhaps those that triggered the tinnitus onset. Other patients report psychological conditions such as anxiety and depression appear to exacerbate tinnitus and may be reinforced by tinnitus-related negative associations. Often, tinnitus severity is dictated not by the sound, but by the patient’s interpretation of and response to the sound. In this regard, the power of tinnitus to exert influence over a person’s life is in the eye, or ear, of the beholder.

Tinnitus interventions, then, may be viewed as proceeding along parallel tracks: abolishing or attenuating the sound may be the target of a treatment strategy, or the patient’s response to tinnitus may be the target of a management strategy. Both approaches are considered in detail, and with many examples, in Tinnitus: Clinical and Research Perspectives. Continue reading