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Amplification II > 11 - Fine Tuning > Flashcards

11 - Fine Tuning Flashcards

1
Q

What is the first question we should ask ourselves about fine tuning?

A

Does the patient need hearing aid fine tuning or more counselling?

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2
Q

How do you decide if the HA needs fine tuning or the patient just needs more counselling?

A
  • It takes time to adapt to amplified sound and many new users don’t know what to expect from hearing aids
  • Will the complaint still be there at the fitting follow-up appointment?
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3
Q

What is the primary reason patients are seeking assistance?

A

Amplification of Soft or “Un-important Sounds” in the Environment

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4
Q

What happens when a person first gets HAs?

A
  • The brain needs to re-learn to ignore certain sounds in the environment (e.g., fan noise, footsteps, etc)
  • “You have to hear what you don’t want to hear to know what you don’t want to hear”
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5
Q

What are some basic questions to ask a patient at post-follow up?

A
  1. Improvement in hearing, example of situations that remain difficult; comments from significant others
  2. Clarity of sounds; own voice, voices of others, conversation
  3. Tolerance to loud sounds
  4. Hours of HA use; frequency of VC use, use of manual programs (can get this info from data logging)
  5. Hearing on phone
  6. Handling of hearing aids (insertion/removal, batteries…)
  7. Physical comfort
  8. Anything else that you noted in your journal/progress notes at the time of fitting
  9. Questions related to situations specified on COSI (communication-based markers)
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6
Q

What do patients commonly complain about regarding their voice?

A

“My voice doesn’t sound normal”

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7
Q

What do we do when patients complain that their voice doesn’t sound natural?

A

The key to alleviating own voice complaints is to understand what is driving them

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8
Q

When we hear our own voice through a microphone (or set of mic), why does it sound different from when we hear ourselves speak naturally?

A
  • There is less low end (part of what we hear from our own larynx is coming from the conductive pathway- there is lower end)
  • When you put a set of hearing aids on someone you disrupt that acoustic conductive component
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9
Q

What 3 questions should we ask ourselves when a patient says “my voice doesn’t sound normal”?

A

1) Has the patient forgotten what his/her own voice sounds like?
2) Has their voice changed with aging?
3) Are they adjusting to hearing their voice through hearing aids?

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10
Q

Is thinking our own voice sounds weird an actual occlusion problem or an issue with the acoustic/conductive balance?

A
  • We hear our own voice via the acoustic & conductive pathways; people listening to us hear only the acoustic component of our voice.
  • When we put a hearing aid in someone’s ear, we are changing this ratio of acoustic vs. conductive sound; thereby, changing the way the person’s voice sounds to themselves.
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11
Q

What is occlusion?

A
  • When we put in a hearing aid, the vibrations from the cartilaginous portion can no longer escape via the ear canal and this can raise the level reaching the tympanic membrane (highly variable) & is typically low frequency in nature
  • Additional boost of LFs
  • This results in ‘head in a barrel’ quality
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12
Q

What is one way to deal with the OE?

A

Sealing in the bony portion will eliminate this, but this is often uncomfortable for clients.

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13
Q

Define the OE? How much of an increase? What frequency is the greatest increase?

A
  • The increase the level of sounds in the low frequencies (greatest at 500 Hz and below) when the canal is occluded
  • This increase can be between 20-30 dB in an occluded canal vs. “open” canal
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14
Q

What does the OE result in?

A

Own voice sounds “loud”, “hollow”, “boomy”, chewing becomes aggravating

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15
Q

Why does the OE happen?

A
  • Low frequency sounds (vowels in particular) have high SPL level
  • Those high intensity sounds conduct through the mandible, and condyle to the cartilaginous portion of the ear, causing vibration in the ear canal itself
  • Without any physical obstruction on the ear canal (i.e. a hearing aid), those sounds would escape through the canal.
  • With a device in place, energy can be trapped, and redirected to the tympanic membrane, and transmit through the auditory system, perceived as a increase in low frequency sounds
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16
Q

When a patient complains that their voice sounds hollow and boomy, what are 3 questions we should ask ourselves?

A

1) Is it Occlusion Effect or something else?
2) Are other people’s voices “bad” too? If no, then suspect OE.
3) Is this complaint happening with the hearing aids in place and turned off? If yes, suspect OE.
– Measure ear canal SPL to patient’s voice (“ee”).
– Does SPL increase with HA in place and turned off? If yes, then OE.

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17
Q

____ vents reduce a lot of the OE

A

2 ml

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18
Q

The more severe the HL, the ____ venting we will have

A

Less

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19
Q

What are 4 possible solutions to stop the OE?

A
  1. Increase venting (so that sound pressure in canal can escape)
  2. Open-canal fitting (if audiometric configuration allows)
  3. Decrease LF gain (not additionally adding low frequency gain unnecessarily; can decrease LF gain because they aren’t important for speech)
  4. Increase LF gain for high level sounds so that amplified speech exceeds (masks) the SPL caused by OE.
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20
Q

____ give the least amount of occlusion

A

Open-canal fittings

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21
Q

What can too much or too little LF gain cause?

A

Too much - or perhaps surprisingly - too little gain in the low frequency region can lead wearers to complain that their own voice sounds “too loud”

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22
Q

Will a gain-related complaint be present when the hearing aid is turned off?

A

No (tells us it isn’t the OE)

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23
Q

What should you do if the patient is experiencing mild occlusion (40-45dB) and they are complaining about how they hear their voice?

A

If the result arises from mild occlusion (40-45dB) if they are hearing their own voice as described above, in which case it can be helpful to increase gain so that what they hear is dominated by the amplified path (mask the OE)

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24
Q

What do we have to counsel patients about when fitting them with HAs?

A

Need to counsel patients on the fact that it will take time for them to become adjust to their own voice (time varies and is dependent on how long the patient has went without hearing their own voice, how adaptive they are to change, and gain)

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25
Q

Patient’s voice provides an ____dB input

A

80-85

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26
Q

What is saturation response?

A
  • The saturation response is the maximum output that the hearing aid can produce. In a saturation response, a higher input does not translate to a higher output
  • Need to make sure there is enough MPO for for the HA to handle the loud input of the patients voice (80-85dB)
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27
Q

What question should we ask if a patient says, “My hearing aid sounds dull, muffled, unclear, etc.”?

A

Does this occur in noisy environments only (too much gain cut with digital noise reduction?) or all environments?

28
Q

What are 3 possible solutions when a patient says, “My hearing aid sounds dull, muffled, unclear, etc.”?

A

1) Reduce aggressiveness of noise reduction? Is it turning everything down in a noisy environment and making everything less clear for the patient?
2) Increase HF gain for additional clarity? Give them access to consonants to make things a bit clearer
3) Counsel on the use of DM: make sure they know to be close to the talker, back to the noise, within 10 feet, use communication strategies

29
Q

What 3 things should we ask ourselves when a patient says, “My hearing aid sounds tinny, sharp, hissy, metallic, etc.”?

A

1) Let us first consider the audiogram— was the patient “missing” high- frequency sounds due to a presbycusis slope that are now audible?
2) Check for unwanted HF peaks in REM
3) What type of environment is this most noticeable? Is it in noisy environments (DM roll off in noise? speech enhancement?) or all environments?

30
Q

Tinny or sharp sounds are often problematic in those with ____

A

Steeply sloping audiograms (haven’t had access to HF sounds in a long time)

31
Q

If a patient’s HAs sound tinny or sharp, what should you ask the patient and why?

A

Ask them if it’s clear? Because maybe they just aren’t used to hearing these sounds

32
Q

What should you consider when a patient complains of a sharp or tinny HA?

A

Should also consider adaptation/acclimization: instead of setting the HA to 100% of their prescription, can pull it back to maybe 70% (it won’t be as sharp to the patient), and it will gradually go up to 100%

33
Q

Explain the process of doing REMs if you use adaptation/acclimization with your patient?

A
  • if you do this, still do your REMs at 100% (you will know where your targets will be when you get there)
  • if you turn the HA off and turn it back on and they don’t notice a difference, you need to turn up the prescription more (they need to notice a difference)
  • if they don’t notice a difference, they won’t be adjusting to amplification
34
Q

What are 3 possible solutions when a patient says, “My hearing aid sounds tinny, sharp, hissy, metallic, etc.”?

A

1) Decrease HF gain?
2) Reduce speech enhancement?
3) Increase LF gain? Gives the perception of a more balanced environment

35
Q

What can it mean when a patient says, “I hear noise, static, etc. in the HA.”?

A
  • Internal HA noise
  • Does the person have good LF hearing?
  • Expansion in HA helps reduce gain of low-level noise in the environment
  • Is it the fan in the clinic room?
  • Is it hair against the mic?
  • Do you need to reduce the gain for soft sounds?
  • Is the hearing aid malfunctioning?
36
Q

How much sound does a hearing aid typically produce on its own?

A

Around 20 dB

37
Q

What are 6 questions we should ask ourselves when a patient says, “I can’t understand speech when there is noise around”?

A

1) Assuming that there a good fit to prescribed targets, we may need to counsel on realistic expectations of hearing aids?
2) What were the word recognition or QuickSIN scores pre-fitting?
3) Are some HA features making speech understanding worse? e.g., noise reduction or frequency lowering strategies too aggressive?
4) Are DMs programmed appropriately? Is patient manually switching to noise program if applicable? How are they using this feature?
5) Are accessories needed? (e.g., remote mic or FM systems)
6) Counselling on environment modification when possible (back to the nosie source)

38
Q

What should we ask ourselves when a patient says, “Things are too loud, I can hear my footsteps”? (2)

A
  • Reduce gain for soft sounds?
  • Does the brain need to re-learn to ignore some sounds (adaptation)?
39
Q

What should we ask ourselves when a patient says, “Things are too loud, The hockey game I went to, and the cheers from the crowd, were too loud” 4

A
  • Tolerance issue?
  • Reduce MPO?
  • Reduce gain for loud sounds?
  • Counselling instead (it should sound loud)?
40
Q

What should we ask ourselves when a patient says, “TEverything is just a little too loud”? 2

A
  • Decrease overall gain?
  • Adaptation?
41
Q

What are 3 questions to ask ourselves when a patient says, “It’s too loud when there’s noise around”?

A

1) Tolerance problem?
- Reduce MPO
2) Too loud but no discomfort?
- Should NR be made more aggressive?
- Should the gain for loud sounds be decreased?
3) Which frequencies?
- HF: paper rustling, clattering dishes, running water
- LF: traffic noise

42
Q

What questions should we ask ourselves when a patient says, “Things are too quiet when there’s noise around”? 2

A

1) How aggressive is the noise reduction (NR) system?
2) Is average speech still audible with the NR activated?
- Using a noise input, obtain REAR with NR off and with NR on. Is REAR still audible when NR is on?
- With NR on, compare REAR with speech vs noise input.

43
Q

What 5 questions should we ask ourselves when a patient says, “My noise program (or directional mic) doesn’t make any difference”?

A
  • Does the patient understand the technology?
  • Is the patient setting themselves up for success?
  • How is the patient “testing” the noise program or directional mic?
  • Is the directional mic working well?
  • Measure front-to-back ratio in 2-cc coupler.
44
Q

What can we look at when a patient says, “My hearing aid cuts in and out”? 3

A
  • Is the HA intermittent (needing repair or cleaning?)
  • Is the HA “pumping” at high level inputs?
    • What are the attack and release times?
    • What is the CR?
  • Is the noise reduction system too aggressive (too much change too rapidly)?
45
Q

What 6 questions should you ask yourself when a patient says, “I can’t hear on the phone”?

A

1) What phone system is being used?
2) How is the phone being placed on the ear or near the hearing aid?
3) How is the hearing aid coupled to the ear (open dome or closed dome or occluded earpiece)
4) What are the monaural word recognition scores?
5) Should the phone signal be coming to one or both ears?
6) Placement, equipment, and signal choices

46
Q

Where should the phone be placed when using HAs?

A
  • Placement near t-coil
  • Don’t bring the phone up to your ear, bring it to your HA (behind the ear)
47
Q

How can we improve a patient’s SNR when talking on the phone? 3 best to worst

A

Telecoil > wireless streaming > acoustic telephone

48
Q

What can you do to the microphones of a HA when a patient is on the phone?

A

Adjust the microphone functionality during phone conversations

49
Q

What should you look at with decision making when adjusting for patient complaints? 4

A
  • Which direction? (increase or decrease gain)
  • For which frequencies? (high, low, all)
  • For which levels? (soft, medium, loud, or all sounds)
  • What parameter do I change on the HA? (depends on the HA model)
50
Q

Try changing ____ parameter at a time

A

one

51
Q

Is a change to a hearing aid always good?

A
  • Remember that a change can potentially create a new problem (if you things are too loud and you turn down the gain, you affect audibility)
  • Should you leave the settings alone and counsel instead? or give the patient enough time to get used to new HAs? What issues should you “park”
52
Q

What should you adjust on the HA when a patient says “loud sounds are too loud”? 2

A

Reduce high level input or increase CR

53
Q

What should you adjust on the HA when a patient says “soft speech is not loud enough”?

A

Increase low-level input gain, or lower TK

54
Q

What should you adjust on the HA when a patient says “speech is not clear”?

A

Reduce CR

55
Q

What does adjusting gain for different input levels do?

A
  • Decreasing gain for loud sounds increases the CR.
  • Increasing gain for soft sounds increases the CR and/or lowers the TK.
56
Q

What does increasing the CR directly do?

A

Increases gain for soft sounds & reduces gain for loud sounds.

57
Q

What are software fitting assistants?

A
  • HA programming software have a “fitting assistant”
  • Using drop-down menu, select the problem that matches the patient’s issue.
  • The software will propose some HA modifications
  • Before applying the proposed solution… do you agree with what is being proposed?
58
Q

What will you do if… your patient attends weekly faith meetings during which there is often hand clapping. She complains that the clapping doesn’t sound loud like it should be. She also mentions that this did not occur with her previous hearing aids. 3

A

1) Is this problematic or just different (If it’s just different, tell her we will check in with her in about a month)?
2) Were her previous aids more linear (with no NR)?
3) Increase CR to reduce gain for loud sounds.

59
Q

What will you do if… your patient has noted a marked improvement hearing his partner and his daughter. However, he complains that paper rustling is too loud.

A

1) Decreasing the gain for HF sounds may create a new problem (wife and daughter’s voices).
2) Try increasing the TK to reduce the gain for soft HF sounds only
- How long as he been wearing the devices?
- Is the rustling of paper so bothersome it is decreasing his ability to communicate? Probably not

60
Q

What will you do if… your patient wears a hijab. She reports that she hears a static type of noise.

A
  • What is causing the noise?
    • Head scarf fabric rubbing against the microphone.
  • What are other potential issues with head scarf and HA use?
    • Feedback, muffled sound, moisture, access to program buttons & VC, battery replacement.
61
Q

What are 2 solutions to wearing HAs with a head scarf?

A

1) remote control or app to change program, etc.
2) can thinner fabric be used?

62
Q

What will you do if a patient says, “people who are not close by are too loud. For example, I went to a restaurant with my friend and I could hear the people at a couple of tables away from us just as loud as I could hear the person sitting next to me 3

A

1) Is gain for soft (distant) speech too high?
2) Is DM polar plot adapting to the wrong speaker?
3) How is the patient seating themselves in the environment? Where are the other noise sources?

63
Q

What is a way to help a patient adjust to amplification?

A
  • A word on adaptation and acclimatization (uses and verification)
  • Always verify to 100% target
64
Q

Remember that you might need to fine tune ____ instead of fine tuning the hearing aids

A

patient expectations

65
Q

Give the patient ____ to adjust before fine tuning; some problems may be gone at the post fitting follow-up

A

time

66
Q

Remember that fine tuning a problem can ____

A

create a new one

67
Q

____ is KEY. Set your patient up for success with realistic expectations

A

counselling

Amplification II (13 decks)

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