Question
When I have an adult who presents with specific auditory/hearing loss complaints (i.e., difficulty understanding speech in background noise or other difficult situations in which they previously had no difficulty) and the audiogram is normal or really close to normal, I always do OAEs next. Often the high frequency OAEs are absent, which I interpret as "early cochlear changes" or "changes in outer hair cell function" which affect their auditory function, but are not sufficient to show up on the audiogram. There are no other symptoms in these cases no dizziness, tinnitus, etc. First, is this a correct interpretation of these test results? Second, what else besides monitoring their symptoms and having the patient return if the symptoms change or worsen should I recommend? I am not sure if it is necessary to recommend any further testing, or what that might be. I also counsel patients about "realistic expectations" for normal hearing. Many people are satisfied with this, but some are insistent that they don't "hear" well.
Answer
First, I applaud your efforts to be comprehensive and proactive in your objective assessment processes. At the same time, rather than focusing on repeat testing, predicting future hearing loss, focusing on "normal" results in the face of complaints, or moving quickly to counseling, I'd like to see you spend some more time gathering information about your patient's difficulties, and using that information to generate intervention options. First, the audiogram and OAEs provide some - but not all - of what we need to know about the auditory system. Therefore, I suggest you consider adding a different objective element to your assessment protocol when patients complain of speech-in-noise problems, or when you want to rule out the presence of speech-in-noise difficulties. For instance, you could include a speech-in-noise test such as the Quick SIN (Killion, Niquette, Gudmundsen, Revit, & Banerjee, 2004), or the Hearing in Noise Test (Soli, Vermiglio, & Cruz, 2000). Each of these recorded tests take about one minute to administer, and differ in talker and noise characteristics, and in how they are administered (Duncan & Aarts, 2006).
Second, "I can't understand when it's noisy" is the most common compliant of adults who are visiting an audiologist (Kochkin, 2002; 2005). Because hearing handicap (such as that which may be caused by speech-in-noise problems) cannot be predicted from the audiogram, adding a measurement of patient perception of hearing difficulty will help give you information you need to provide more meaningful intervention. You probably already have on hand copies of the Hearing Handicap Inventory for the Elderly (HHIE) or Hearing Handicap Inventory for Adults (HHIA) (either full or screening versions), or the Abbreviated Profile of Hearing Aid Benefit (APHAB). If not, the HHIE and HHIA can be downloaded from various websites found with a search engine. The APHAB can be downloaded from the University of Memphis' Hearing Aid Research Laboratory web page. If you are concerned about time, you could send the patient a self-assessment in the mail along with your other intake forms, rather than ask patients to complete the form during the clinic appointment.
While I appreciate your desire to have a complete understanding of what is audible to your patient, people don't see a hearing health care provider because they want to know their thresholds; they want help with real-life problems. Your patient told you what his or her problem is: difficulty hearing speech in noisy settings. By adding subjective and objective measures of speech understanding and hearing handicap to your assessment protocol, you will have more information on which to base an intervention plan. And isn't intervention really what your patient is asking for? Perhaps this patient has an unusually high internal response criterion and wants to hear everything at all times. Perhaps your patient has speech-in-noise skills that are seemingly out of line with the audiogram, but are not unexpected based on the patient's age. Either way, objective and subjective tests that tap into speech-in-noise skills and difficulties will give you information you can use to help your patient. Additionally, like objective measures of speech understanding, these self-assessments can be used as outcome measures to document the changes in patient performance and perception after intervention.
References:
Duncan, K.R., & Aarts, N.L. (2006). A comparison of the HINT and Quick SIN tests. Journal of Speech-Language Pathology & Audiology, 30(2), 86-94.
Killion, M.C., Niquette, P.A., Gudmundsen, G.I., Revit, L.J., & Banerjee, S. (2004). Development of a quick speech-in-noise test for measuring signal-to-noise ratio loss in normal-hearing and hearing-impaired listeners. Journal of the Acoustic Society of America, 116(4), 2395-2405.
Kochkin, S. (2002). MarkeTrak VI: 10-year customer satisfaction trends in the US hearing instrument market. The Hearing Review, 9(10). Retrieved June 29 2006, from www.hearingreview.com
Kochkin, S. (2005). MarkeTrak VII: Customer satisfaction with hearing instruments in the digital age. The Hearing Journal, 58(9), 30-37.
Soli, S.D., Vermiglio, A.J., & Cruz, R. (2000, March). Clinical applications of the Hearing In Noise Test (HINT). Paper presented at the meeting of the American Academy of Audiology, Chicago, IL.
Dr. Nancy L. Aarts has been an audiologist for 20 years. She is currently Associate Professor of Communication at the College of Wooster and the Director of the Freedlander Speech and Hearing Clinic. Dr. Aarts can be contacted at naarts@wooster.edu.