Speech Perception/Speech Audiometry

ROUGH EDITED COPY

EHDI

SEGELL ROOM

"Speech Perception/Speech Audiometry:

BEYOND the Audiogram"

MARCH 9, 2015

3:20 P.M.

CAPTIONING PROVIDED BY:

ALTERNATIVE COMMUNICATION SERVICES, LLC

P.O. BOX 278

LOMBARD, IL 60148

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This is being provided in a roughdraft format. Communication Access Realtime Translation (CART) is provided in order to facilitate communication accessibility and may not be a totally verbatim record of the proceedings.

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>MODERATOR: Hi. I'm Pauline. I'm the moderator for this session. You are in "Speech Perception/Speech Audiometry: BEYOND the Audiogram." Before Dr.Goldberg speaks, if you could please just silence your phones, that would be greatly appreciated. Thank you.

> DONALD GOLDBERG: This is on the program, and it has no name. So I'm glad you came here, even without a name. Speech perception. I just did a brief talk about the audiogram, so I have a few faces that might be the same, but I'm assuming that you have audiograms under your belt and we'll talk a little bit more about actual speech measurements. Same slide from a previous talk, but how many of you are parents so I can get a feel for the room. How many of you are speech pathologists? Teachers of the deaf? Audiologists? So once again, you can leave if you want. You're more than welcome to stay.

AB cert AVTs. Good. I won't be called upon by the cert AVT police. Classroom teachers. And other folks.

Great. Welcome.

One of my basic premise, kind of hard loo it to see some of my blue here, but one of the my basic premises as we talk about audiology is, as you are aware, for a variety of reasons, more and more families are, in fact, electing a listening and spoken language outcome for their children, and that being said, it's very important to realize that without excellence in audiology, all of our efforts to do auditory teaching are compromised. How many of you are married to an audiologist? How many of you are dating your audiologist? Don't want to go any further than that, but I have sometimes tried my best to make more clinicians marry their audiologist, or at least have a very strong relationship, because unless you really are working in tandem with your audiologist, I would venture to say some of our care and some of our work is compromised.

So you don't have to marry your audiologist. But consider dating.

Anyway, moving on, just a basic early slide is, although a version of this has been with me for a lot of talks through the years, I now feel very comfortable with saying, even though it may be hard for some to completely process, children who are severe to profound are absolutely learning to listen and develop spoken language. It's becoming more and more common, and it is something that's been in place for many years, including being taught by someone who started in the 1940s with the very first wearable hearing aids. This auditory teaching did not happen in the last ten years, and did not happen just because of cochlear implants. It goes back to people like Helen and Doreen who had the very first patients wearing wearable hearing aids. One of the reasons why it is so exciting to be in the field, I'm not sure how many of you might be in training, but one of the things about being in this field is this is the coolest time in our lives to be working with children with hearing impairment. We have babies coming in to our practice. The idea that I've been working with some children as early as two months of age already wearing hearing aids is hard to fathom. It was not that long ago that the average age of identification of severe to profound hearing loss was two and a half to three years of age. And then, I thought they were so little and small. Imagine a student in training who's about to have to work with a threemonthold. They're so scared about they're going to break the threemonthold, nothing is funner than working with the younger and younger children. And clearly I know the word funner is not syntactically correct.

I also have the opportunity as many of you, I'm sure, also have, that many of the children we work with do not just have hearing loss. They have other disabilities, and although that may create some challenges for us, my clinical skills are enhanced when I'm working with a child with other disabilities. Those little fighters that sometimes weighed one pound or two pounds at birth are really quite remarkable, and their small gains are oftentimes the greatest joy you can have as a clinician. Even something as simple as having lip closure for a child who had difficulty doing something such as lip closure. So it's a very cool world and there is no question, cochlear implants have been a gamechanger. But I do not leave or have anyone I don't want anyone to leave the room with the idea that it's just the device. It is all about excellence in audiology testing and programming and the beauty of what parents can do when appropriately coached by skilled clinicians.

So the sky's the limit. That's really a mantra of very great importance to me as we move along to talk about audiology.

In the ideal world, your intervention program hopefully also has audiology facilities. That doesn't happen everywhere in the world, but that is ideal. And if not, we need better communication between people in the field when they have their children go to cochlear implant centers, audiology centers, and we also need audiologists and cochlear implant centers to give more information to the classroom teacher and to the clinicians and the family. Too often the parents are sort of the messenger, and oftentimes that's an unfair position for parents to be put in.

For children under three, I can't imagine ever doing testing with the without the presence of a pediatric assistant. And the pediatric assistant hopefully is wired with FM or a bone oscillator, but FM would be better, and there's wonderful communication between the audiologist in the booth and the clinician who's in the booth. And, in fact, the person in the booth has the harder job. And ideally, we have parents that are actively involved and understand audiology and hopefully we'll see in a slide in just a moment, we have great comprehensive testing. But the one area that many audiologists, I think, feel uncomfortable with is the classic pediatric speech audiometry doesn't always work for severe to profound kids or for younger and younger children. So if nothing else, you're going to hopefully get some resources of things to do beyond the audiogram.

So I'm not going to do a complete lesson of the anatomy, but you clearly know this is the beautiful ear. Ultimately, our air conduction and bone conduction testing, we'll talk about it being a problem in the outer or middle ear, or conductive hearing loss or a problem in the sense organ of hearing, the cochlea, or the auditory nerve for a sensorineural hearing loss, the problem being in or beyond on the way to the brain. And this, I think, is a classic slide where it shows if you were testing with an ear phone or an ear insert, you would be measuring the whole system, outer, middle, inner, and as soon as you go to the bone vibrator, you go right to the cochlea.

There are three types of bone conduction hearing and some are contributed by the outer and middle ear, but the primary information from bone conduction testing is for the sensorineural measurement and when you compare the two, if it takes a lot of energy to get through the whole system, and it's no problem with bone, it's a conductor problem, and if they're similarly poor, it's a sensorineural problem and sometimes there's even a gap, and they're poor scores for mixed hearing loss.

These are just the basic audiogram key, which I'm assuming you're familiar with, and moving on to just see the audiogram in just a moment. I do want to point out the pure tone average because that has to do with how we describe the severity of the hearing loss.

This is just a cheat sheet with some more symbols, and I point out no response, which means no response at the limits of the audiometer. There's only so much power the hearing audiometer can do that sometimes we get to the end and there's no response. It really means we just didn't get a response. It doesn't necessarily mean no hearing. And of course, beauty of masking thresholds, which people in audiology sometimes fear, but it actually is much more fun when you have to mask once in a while.

The degrees of hearing loss are fairly straightforward, but I would make the comment, rarely are they all in one degree of hearing loss. More often, it's a slope of involvement of different severity levels.

And then depending on the thresholds, we need to think about and keep up with what are the criteria for cochlear implants, because the criteria keeps changing. I'm just back from Australia, and I was at a center where there were six pediatric patients, completely normal hearing in one ear, deaf on the other side, and in Australia, they're now doing singlesided deafness with a cochlear implant even in the presence of completely normal hearing. So it's kind of a new world, and they do much earlier implantation in cochlear in Australia.

This is the classic Erber hierarchy, and I point out that a threshold just detection. It's not telling us about how they really hear the sound, so when you drop a block or raise your hand, you're doing detection. Discrimination is when you might gobaba, same, orbapa, different. Recognition is when they might point or pick up a toy in a field. Identification is when they're asked to repeat it back. Say the word "Please." Andnirvana would be comprehension, which is hopefully what we're all working for.

Then they get to speech science and acoustics, and you all know about vowels, you probably have heard ofdiphthongs. And then there's these consonants, and as a speech pathologist and an audiologist, nobody ever told me half this stuff when I was in school, but I'm going to tell you, and maybe you've never heard it before. Speech sounds by definition are not frequency specific. They're Broadband. But there is information we can learn from speech sounds. Vowels in general are low to mid frequency. So we have back vowels and mid vowels and front vowels and not surprisingly the front vowels turn out to be the ones hardest to actually hear.

If you were to do a analysis of all of the vowels, you could analyze on a computer the first band of energy above the vocal fold vibration and the second band of energy. You may have heard that in order to perceive a vowel sound, you must hear F1 and F2. If you're not able to hear both, you can't figure out the vowel. And I always remember, I think I'm hopefully it's the next slide, but I always remember seeing this picture from those of us who have been around for a while, that's from Ling and Ling, and it always looked nice, but when I volunteered at the BB center, I never could understand why did those kids have trouble with some of those Ling sounds? I've traveled all around, and lots of people are doing the Ling sounds throughout the world, but not everyone's understanding the acoustics, and it turns out the F1 and the F2 of oo, turns out to be fairly similar at the F1 level for ee. Ee becomes the hardest vowel to hear because to hear ee, you must have hearing in the high frequencies.

So going back a slide, I think I can do that, I don't care for anyone to ever memorize F1s and F2s. It's really the ratio, and my F1 is different than your F1, there's a male and female, and two males will have different F 1s and F2s, but the relationships are very similar, when you do the Ling sounds, it turns out that oo is the easiest sound to hear because of low frequency hearing, where most people have their best hearing. Ee is the hardest vowel to hear because the second format from around 2,000 hertz is where some kids do not have good hearing. So that little picture, which I have in my head becomes a very important feature, but it's more important to understand why we talk about F1s and F2s, and it has implications for speech production and speech training as well. So when you think about the SRT, the speech recognition threshold, so everyone in audiology and St.Petersburg pathology and education for the deaf learn that stuff. I sometimes take a joke and I pretend I have no teeth and I pretend I take out my teeth, and I can give the SRT without making a single consonant sound. You tell me which one I just said. Aain. Let's try it again. Good. Iean. So essentially, although you really should do all the sounds when you produce words doing SRT, it should not be rocket science for us to go vowels, low and mid frequency hearing, the SRT should be close to the frequency responses in the low frequencies. You learn things like it has to match the pure tone average, but much more importantly, where's the hearing at 500 hertz. So think vowels as low frequency and mid frequency and SRT makes great sense. And for those of you who are clinicians, play the whisper game in therapy because when you go to audiology, that should not be the first time a child is heard. I'm trying to establish criteria. Criteria is a 50% response. I need you to listen to the soft sound. Kids don't know what the heck you're talking about, but if they've practiced with toys, baseball, cowboy, airplane, ice cream, that they get the idea there's going to be a game in audiology where the audiologist gets softer and softer and softer, and guess. We do not yell when they make a mistake and pick the wrong toy. So definitely SRT low frequency information in general. So in SRT does not necessarily match the pure tone average. It really matches probably closer to 500 hertz. And then in classical audiology teaching, we also talk about the consonants and word recognition. We still have physicians at the Cleveland Clinic, where I work, where thedocs still call it word discrimination. We gotta stop the physicians from saying word discrim. It's not same different. It's recognition or identification. And although it's been referred to as a speech banana, I'd prefer to call it speech produce, because I think that looks like a pickle. There's zucchini, and there's squash, and some bananas, I guess, might look like that, but when I saw that banana, first of all, there's very little data to demonstrate the accuracy of these speech banana audiograms, but the message should be important that nasal sounds are low frequency and intense, and unvoiced consonants likephth, are hardest to hear because they're in the high frequencies and they don't have much dB to them. Which is the hardest what's the hardest sound to hear in the English language? Th. What's the most powerful vowel when you measure the intensity of vowels? Take a guess. Ah is good. Wrong. It's around an ah. The Au is the most powerful vowel so it just goes to show that you could look for patterns. I don't put Ling sounds on an audiogram, but oo andmm are easy. Ah is sort of this direction. Ee is the hardest vowel, and sh, S are going across the audiogram. So we can train monkeys to do the Ling sound test, but more importantly what are the errors? If I do oo and a kid says S, that's a bad mistake.

But if I do oo and the kid goesmm, most of my kids with implants actually do that. I don't care because oo andmm are very close acoustically, so don't become a monkey, but understand the mistake, and one time making a mistake on Ling sound doesn't mean they rush to the cochlear implant center to fix the ee electrode because there ain't no ee electrode, but there are electrodes that correspond the acoustics that make up the ee sound. So what I usually do is I make a note in my note, and then if I have a kid who consistently is having trouble with a particular Ling sound, I'll alert the cochlear implant team to maybe look at this child for programming.

And the first thing I usually see are slippage of vowel perception.

So in the word recognition world, I think kids just love this sound. [Raspberry sound] And I did that with my sixmonthold granddaughter and my other granddaughter went, papa, don't do that to baby Elizabeth. The twoyearold is tell me to stop doing that to the sixmonthold, but quite frankly, the sixmonthold really liked them, and she giggled. But what's better than having them in the booth and all of a sudden some kid goes [raspberry sound] coming through the speaker. So with really little kids it could be things like touch your nose or where's mommy, and they turn to their moms, who's holding the baby. So there's lots of levels. You should not leave audiology or be an audiology and put CNT on the audiogram because there's something you should be able to do to monitor the intensity of your voice and to see how the child is responding.