NYU Conference 10-27-12: Section 4: Audiology

Next Topic: Section 5: Clinical Trials

Topic Speaker

Joe Montano
New York Presbyterian, Weill Cornell Medical Center
Associate Professor in Clinical Audiology
Chief of Audiology and Speech Language Pathology

Topics

1. Understanding an Audiogram
2. Hearing Loss / Communication Loss
3. Amplification Options
4. Communication Strategies - Speechreading and ASL
5. Cued Speech
6. Amplification Options
7. Hearing Assistive Technology
8. Loop
9. FM System
10. Telephone Devices
11. Computer Technology
12. Signal Alerting Technology
13. Auditory Visual Training
14. Communication Groups
15. Conclusion
16. Questions

Audiology

Carole Mitchell: Now Joe Montano from New York Presbyterian.

Joe Montano: How is everyone? You still awake?

FROM THE AUDIENCE: Yes.

Joe Montano, NY Presbyterian: Good. I am the nonphysician on the panel here today. I'm an audiologist. Director of the hearing and speech center at Cornell. I'm going to talk a little bit about the communication options for people with hearing loss. I know as a nonphysician, when I look at MRI slides, all I see is ET, or some alien kind of thing. It never really makes a lot of sense to me. But there are things that I look at all the time.

1. Understanding an Audiogram

That's the audiogram. That graph that we have when we do your hearing test and we plot out what your hearing loss is all about. Dr. Brown mentioned this already. I'm only going to touch on it. But one of the things I want to touch on is this area -- is there a cursor here? The area down there that talks about SR percentage. Can you see that? 20 percent and 8 percent? That is not an uncommon number when we see that for people who have acoustic neuromas or NF2 schwannomas. We find the word recognition ability -- the ability to understand speech is significantly decreased. So even in an area where hearing -- if you look at those circles and those X's -- they represent a moderate level of hearing loss. People with this hearing loss can do very, very well with hearing aids. But even with hearing aids, when you have word recognition scores that are so decreased, what you hear is very distorted. And sometimes wearing a hearing aid can be difficult.

2. Hearing Loss / Communication Loss

What can you do about your hearing loss? I have a friend who is a psychologist. And he says it's not hearing loss; it's a communication loss. And I truly relate to that because even though there is a lack of hearing, the lack of hearing doesn't just affect the person with hearing loss; it affects the people around them as well. It affects the situations that they're in. And living with a hearing loss is not as simple as putting a hearing aid on, and everything is going to be fine. You all know this already. So everyone is different. And we can't assume that what works for one is going to work for someone else. Sometimes it's important that we talk about hearing loss, and we get a good understanding about who are the partners that you communicate with, what are the environments that you're in, what is the noise level of the places that you have to talk and listen in? Those are very, very important.

3. Amplification Options

The other thing is we need to look at the amplification options.There are many. Sometimes we limit them to hearing aids. But the hearing aid is only one of the many, many options. So I'm going to talk a little bit about that today. Certainly the surgical options are very, very important. But there might be a long period of time that you live with hearing loss before there's actual surgical intervention. That period of time is very, very important that we look at options.

4. Communication Strategies - Speechreading and ASL

And then there's rehabilitative strategies. Auditory and visual training. Many people know it as speechreading or lipreading or auditory training. The use of communication strategies. Those simple strategies that say look at me when you talk to me so I can read your lips. Or let's go to a quieter restaurant where I can hear a little bit better. Those little strategies go a long way. And finally, groups. I think groups are really important, especially in the beginning when people are trying to get used to living with hearing loss. Sam Trychin, he's the psychologist who said to me hearing loss is a communication loss, he finds there are 12 recurring issues for people with hearing loss. Sometimes there's depression, sometimes a feeling of isolation where they begin to avoid activities that they did at one time. I'm not going to go to that restaurant with you because it's too noisy. I'm just going to stay home tonight. So it affects so much more than just hearing because it affects their lifestyle. Sometimes people are angry. Exhaustion. It's very hard to lipread all the time. You must concentrate on everything. And so it's kind of exhausting. Sometimes there's anxiety and fear, negative self-images. And sometimes there's that loss of intimacy. The ability to just be quiet with someone, and have quiet conversations can even be impaired. Our communication options. We want to maximize whatever hearing you have. That's the first goal that I always look at. What's available to use, what can we do to help that? Certainly sign language is an option. But it's not an option for everyone. In fact, sign language is very difficult for a lot of people. Many times we identify these tumors early in adulthood, maybe in the 20s, and the 30s, and by that time people have been using speech and language, and to all of a sudden say I have to learn sign language is very difficult. Because once again, it's not just the person with hearing loss that has to learn sign language, but it's the people around them. So while it may open up a new avenue, a new group of people to communicate with, it may isolate you from other people who don't sign. It's a good strategy for some, but it's not a strategy for everyone.

5. Cued Speech

Cued speech, if you're familiar with cued speech, here in New York there's not a lot of places that offer cued speech. In fact, I don't know of any. It is geographically based. But cued speech is sort of a physical aid to lipreading. So it has a combination of using some signs, yet focusing on watching the lips. So it's a combination of both lipreading and signing.

6. Amplification Options

Surgical options. My colleagues here have done a beautiful job discussing the implants and the ABI's, the Bahas. I'm not going to go into those. That's already been done. But the amplification options are hearing aids, and what I think is probably even more important than the hearing aids are the hearing assistive technology systems which we use an acronym called HATS, which is kind of cute.

What is a hearing aid? Essentially a hearing aid is a device that brings sound to the ear, increasing the loudness, and trying to reduce the distortion as much as possible. That's what we do. That's what a hearing aid does. The new hearing aids -- we've got many, many different types of hearing aids. In the ear styles, behind the ear styles, body aids -- not too often anymore -- eye glass aids, and the cros hearing aid. The cros hearing aid is sort of a nonsurgical option for people with hearing loss on only one side. It takes the sound from the poor ear, transmits it through the air to a hearing aid on the better ear. And then amplifies it. These are what some of them look like. We've got the canal, the little canal ones -- they're fun now, all different colors. I have a lot of patients that come to me and say I want my hearing aid to be invisible. I say well, how about we make it purple? Because I'd like everybody to know that you wear a hearing aid so everybody can make the efforts necessary for you to hear? The manufacturers have done a good job in trying to make the hearing aids a little bit more pleasurable.

7. Hearing Assistive Technology

Let's talk about hearing assistive technology. This is something that we don't hear a lot of. But where you do hear it is when you get together with people who have hearing loss, and they talk amongst themselves. Because people with hearing loss realize that to use the assistive technology makes communication a little bit easier, and it really helps the hearing aid to work even better. The HATS are commonly known as assistive listening devices. We have systems that we call hard wire systems. We have infrared systems. We have FM systems. And we have telephone devices.

The major benefit -- I'm going to try to explain this to you, is that it's an improvement in what we call the signal to noise ratio. That ratio means how loud is the signal compared to the background noise? And all of these devices work the exact same way. What they do is they take the microphone and they put it right by the sound source. So if the microphone is by the sound source, the signal that you want to hear will be more audible, and will pick up less noise. When the microphone is on the hearing aid, the sound has to travel to that microphone and get amplified. Right? So the noise and the speech are all traveling to the microphone. But when the microphone is right by the speaker, then you pick up less noise and you get a better signal. So what makes these devices different is how they send that sound from the microphone to your hearing aid or to your ears. That's what makes them different.

When you use a hard wire system, it means exactly what it says. There's a wire that connects you directly to the speaker. If you look at that picture there, that's a device called a Williams Pockettalker. It's just one of the examples of a hard wire system. That microphone can come out of the box, connect with a wire, and you can hand it to the person you're talking to. So if you're sitting in a loud restaurant, the person across the table can have that microphone and it won't pick up the noise that the hearing aid alone would pick up. You could use it with ear phones, or you could use it with a loop. I'll get to that in a minute.

Some other people take that microphone and they put it by the speaker of the television, and they can hear the television better because the sound travels directly from the TV to your ears. Infrared does the same thing. Except there's no wire. This time the sound goes from the sound source over to your ears using infrared light waves, and your receiver which is that thing on the right that has the ear phones, that's what goes into your ears. That picks up the signal, and then there's a button on there for you to adjust your own volume. You may have seen these in the theater. They're very common in our theaters in New York. You also may have seen them in department stores. There's a company called TV Ears. TV Ears is an example of infrared systems. They are designed mostly to be worn without hearing aids that you put them into your ears directly. However, they can also be used with a loop, which is the second time I've mentioned the loop. I'll get to that pretty soon.

8. Loop

How many of you are familiar with loop systems? I think you're going to be hearing a lot more about them in the coming years. It's not new technology. In fact, it's fairly old technology. We've been using loops in the '50s and the '60s. In fact, the schools for children with hearing loss used to be looped. What it means is that on a hearing aid, you should have a Telephone Switch, or a T Switch on the hearing aid. Not all hearing aids have them. But they're very, very important. The initial idea was inside every telephone there's a little wire. And it translates the message on the phone into this magnetic wave, this induction wave. And when you have a T Switch in the hearing aid, it picks up that wave, amplifies it, and then converts it back to sound. So that's how you would hear over the telephone using that t switch.

But now they've taken that technology and we're beginning to loop public areas. So this room, if it had a loop, would have a wire going around the room. And if you had a hearing aid, all you had to do was put it into the t position, and everything that's being said would go directly into your hearing aid. So we've got a lot of museums now that are beginning to loop. The intrepid museum is looped. The information kiosk for Amtrak is looped. The MT A. Is beginning to loop. So you're going to see more and more places have this technology. So if you need to get a hearing aid, you might want to discuss this with your audiologist, and make sure that the hearing aid has the t switch, which is called the telephone switch. Otherwise the loop will not work.

The other thing is that hearing aid manufacturers are making hearing aids smaller and smaller. One of the ways they reduce the size is by eliminating the T switch. What they replace it with is bluetooth so they have bluetooth capability. That's great if you have a bluetooth system. But those you find on cell phones. But you're not finding bluetooth in public arenas. So you have to weigh what your needs are.

9. FM System

FM. These are the Cadillac of our communication systems. Again, the same principle. You take sound directly from the sound source, and you send it to the hearing aid. Or you send it to the Baha, or you send it to the Cochlear Implant. Whatever device you have. And that signal will increase the signal to noise ratio, reduce the noise, and enhance the speech signal. It's an external microphone that the person you're talking to will be wearing. Or you can move the microphone to the middle of a table and pick up people around the table. Or you can hand it to the speaker at a meeting like this, and have the speaker wear the FM System. So no matter where you sat in the auditorium, the signal would be right to you as though you were sitting right next to me. These are a little costly. But they're wonderful systems. This is now the system that they use with hearing impaired children in the classroom. But there are a lot of applications for adults.

10. Telephone Devices

Telephone devices. Very frustrating for people with hearing loss to be able to hear on the telephone. Especially when those speech recognition scores are very low because you lose the visual cues. Without the lipreading ability, it's very difficult for you to be able to hear what somebody says on the telephone. Some of the newest technology is something like this picture there which is called the CapTel. It's called captioned telephones. And captioned telephones work with the Internet. What you do is you make your phone call, and somebody on the other end of the invisible world of the Internet takes that sound when the person speaks to you and types it out so you can read it on the screen. And it all happens fairly instantaneously. So it's like your captioned television except it's live and it's happening on the phone. These are becoming very, very popular.

11. Computer Technology

The other thing that I always suggest to people with hearing loss is to use computer technology. Even things like face time on your apple iPads, or Skype where you get the visual cues while someone is speaking to you is very, very helpful.

12. Signal Alerting Technology

Signal alerting technology. These are the devices that signal the presence of a warning sound. There are many, many different options. You can have your smoke detector connected to a vibrator that's under your bed that shakes your mattress. You can have a device that flashes when the telephone rings, or the door bell rings. You can have a microphone in the baby's bedroom. You know we have all those baby monitors. So if you're a parent with hearing loss, it's very nerve racking to think you might not hear your baby cry at night. And the monitor may not be loud enough for you to hear. So they have bed shakers. So if the baby begins to cry, it uses vibration to shake the mattress or pillow to let you know the baby is crying or there's noise in the baby's bedroom.

13. Auditory Visual Training

Auditory visual training. Auditory training, speechreading, communication groups. Sometimes it's difficult to find where you're going to get lipreading training, or where you're going to get auditory training. There are some facilities here that offer them. We offer them at Cornell. They offer them at the Center For Hearing and Communication, formerly known as the League. But there are places where you can get that individual kind of therapy. A lot of people now are relying on the computers, and the interactive programs that are available for training.

One of the most popular programs is a program called LACE which stands for Listening and Auditory Communication Enhancement. This is an interactive communication program that you use with your computer. It works on areas like speech and background noise, trying to enhance your ability to understand speech and noise. It also talks about rapid speech, like our New York presenters, myself included who like to talk too fast. Hearing when there's one person talking. It looks at cognitive issues like auditory memory, and it looks at processing speed. It's a number of different exercises that you can practice using the computer.

Another program called Seeing and Hearing speech is a lipreading and auditory training program. So there are lots of different categories where you look at the person and you watch what they're saying. And you are corrected if you're wrong. And you get applauded if you're right. They look at a lot of different things. The difference between auditory and visual cues.

Understand that visual cues alone only represent about 50 percent of what is spoken. So it's the combination of audition hearing and vision that enhances communication the best. There are studies that show that even the smallest amount of auditory input helps lipreading ability. So for those who have significant hearing loss, the ability to hear with the hearing aid may not be terrific. But chances are it will help with your lipreading ability. The same thing with the Cochlear Implant and the Auditory Brain stem implant. Any introduction of sound usually results in an improvement in the ability to comprehend speech using lipreading. That's an example of one of the pages from seeing and hearing speech.

14. Communication Groups

Communication groups. We run groups at Cornell. I believe they have groups at the Center For Hearing and Communication. I'm not sure if they have communication groups at NYU. They might. But these are good opportunities for people to get together and discuss the issues that people have living with hearing loss.

15. Conclusion

Finally, regardless where you go, you need to explore the possibilities. That means speaking with your surgeons, speaking with your audiologists, speaking with other people with hearing loss. It's amazing what you can find. You want to try to overcome as many obstacles as possible. If that means using a hearing aid and an assistive listening device, then do it. It will enhance your ability to communicate. Use whatever technique works for you. And we're constantly making new improvements. The hearing aid manufacturers are changing their hearing aids almost on a daily basis. It's hard to keep up with the changes. So if it didn't work last year, maybe there's something that could work for you this year. So keep looking around, and feel free to contact me if you have any questions. I hope that I provided you with some information that's helpful. Thank you very much. (Applause).

16. Questions

Carole Mitchell: A question.

Joe Montano, NY Presbyterian : Actually I apologize but I'm not going to be able to stay so maybe we can take just a couple of questions. Yes, sir.

FROM THE AUDIENCE: I'm aware that in the medical field in the world, a better way to clarify what I'm saying is the hearing world. There's a bias towards deafness that I think limits, it ends up being toward sign language. I genuinely believe, even though I agree with some of the things you said about the discord and how you feel because the people we know are not going to know sign language. You're in situations where it doesn't feel that good. However, I think the sooner you learn sign language, if you have NF2, and you can take it as given that you're probably going to lose your hearing, learn it and see that it's really truly a beautiful language. It's a tool, same kind of tool you're talking about for truly improving communication and also improving your understanding. It's a different way of learning. It's not easy to learn but it's also beautiful to learn. It opens up a whole other way of your mind understanding the world.

So it frustrates me often. I see in the medical community, and I know you're not that way, but I see there's less in encouragement. Learning is wonderful. Learn whatever you can. Because if it was French or if it was Spanish or Chinese, whatever, I think learn a language. It's always wonderful to learn a language. There is not that same emphasis on sign language. More like if you have a problem hearing, you can't connect with all these things that are wrong with your hearing.

Joe Montano: I actually agree with everything that you said. I have no disagreement. I believe it's every person's option. And I believe that we have the duty to inform people and to let them know that this option exists. And ultimately the individual's decision has to be yeah, I want to learn this language, or I need other things as well. I absolutely do not disagree with you at all. I think it's a beautiful language. And I agree with you.

FROM THE AUDIENCE: Just one quick question. The FM Systems you spoke about, you mentioned with hearing aids or with Cochlear Implants. Do they also work with ABI?

Joe Montano, NY Presbyterian: I don't know if they have an external receiver for the AB I implant. I'm not sure.

Carole Mitchell: Can you answer that?

Dr. Sean McMenomey: I don't know.

Joe Montano, NY Presbyterian: I'm sorry.

Carole Mitchell: Last question.

FROM THE AUDIENCE: I was just going to say that my husband when he was using his ABI did plug it into the computer and other things.

Joe Montano, NY Presbyterian: If there's an external port to get into the ABI, then my guess is that they do have a receiver that will plug in. But I don't know that for sure. I would suspect that there is. But I don't want to say that for sure. Thank you very much.

FROM THE AUDIENCE: There's a comment here. The ABI, the small model doesn't have the have external port, but all the other models of the ABI, have a receiver to plug in your iPad, phone, television, computer and other exturnal systems.

Joe Montano, NY Presbyterian: If that's the case, then I would say most likely there is a FM compatible receiver.

Carole Mitchell: Thank you, Dr. Montano. (Applause).

Next Topic: Section 5: Clinical Trials