Audiology Speech Testing

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Audiology Speech Testing Reflex Testing

• CEP ACAud , 2008
• Joyce M Dalgleish
• BSpThyHons(Aud) FACAud MAudSA.CC

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Speech

• Is a secondary to hearing developmentally
• Humans are biologically programmed to learn
  speech and language
• It is an, ephemeral, supra-threshold signal
• It is highly redundant but highly dependent on
  prior learning and contextually based
• What is an awl? / What is a owl?

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Phoneme

• Smallest unit of sound that alters the meaning of
  a word
• /c/ /a/ /t/ a pet- has staff
• /c/ /a/ /p/ head apparel

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The Introduction of Speech Testing

• Suprathreshold speech-recognition testing, also
  referred to as speech discrimination testing, has
  been used for 50 years.
• Five main uses of word recognition tests include
  (Gelfand, 1997 Silman Silverman, 1997)
• To assess the degree of hearing handicap as it
  relates to communication ability.
• To determine the site of lesion.
• To determine the need for, and to monitor
  progress in aural rehabilitation.
• To compare hearing aid performance.
• To monitor patient performance over time.

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Speech Materials

• Wordlists
• PB Wordlists 50 items - whole word score
• AB Wordlists 10 items phoneme score
• Spondee Words down town SRT .SAT SSW
• Time Compressed Words Central Processing
• Sentence Material
• Go change your car colour is red site of
  lesion - SSI
• SPIN HP/LP context / high frequency
  audition

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Appropriate Selection

• Selection of materials must be appropriate to the
  task.
• Some speech material are not appropriate for
  evaluation of hearing aid performance.
• Word lists need to be culturally and age
  appropriate
• They must reflect know vocabulary and may
  need forms that avoid speech problems e.g. to
  use a pointing response to overcome articulation
  problems with children or CP clients.

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PB Wordlists

• Most of the speech research has been done on PB
  words 50 items in each list and the whole word
  is either wrong or right
• Has a gradual performance curve so that there is
  not such a strong ceiling effect.
• Takes a long time to do
• Half lists are popular but still take time if you
  perform a full discrimination function.

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PB Wordlist

• bat least oils or peck pert pinch pod race rack
  rave raw rut sage scab shed shin sketch slap sour
  starve strap test tick touch bee blonde budge
  bus bush cloak course court dodge dupe earn eel
  fin float frown hatch heed hiss hot how kite
  merge lush neat new

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Speech Function Curves
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AB Wordlists

• Boothroyd and Nittrouer (1988) developed twelve
  lists each consisting of ten phonetically
  balanced CVC words with similar structure to the
  isophonemic lists developed by Boothroyd (1968,
  1984).
• Boothroyds original lists were termed
  "isophonemic" because they each contained the
  same 30 phonemes in different meaningful word
  combinations.
• The term "phonetic balance" indicates that speech
  material has a phonemic composition equivalent to
  that of everyday speech. Though phonemic
  balance is a better term.
• For their CVC lists Boothroyd and Nittrouer
  (1988) selected words that appeared in the
  Thorndike-Lorge word count based on 4,500,000
  words appearing in American literature,
  magazines, etc (Lyregaard, 1987).
• .

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AB Lists 1 -15

• Each word is scored on phonemes.
• Three per word and the results are
• recorded as a percentage at
• presentation level.
• Routinely three lists is needed to
• indicate a speech function curve.

• List 1
• Rug
• Ship
• Fan
• Cheek
• Haze
• Dice
• Both
• Well
• Jot
• Move

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Curves for AB and PB Lists
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What Do You Do ?
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A Speech Function Assessmentminimum fuss

• Perform PTA . Instruct patient.
• Calculate predicted AB MAX (consider SPL or HL)
• ( OTEN or, 30dB above 1KHz threshold or 20dB
  above 3FAHL. (Use of MCL not appropriate here )
• Test at that level ABMax 100 or 95
• Next Increase by 10/20/30/40dB and retest
  looking for ABMax (if not achieved) or rollover.
  
• Rollover assessed at high intensity and must be
  greater than 20 decrease in score.
• Decrease from AB Max to establish SRT.
• Plot on Speech graph and observe the curve
  obtained.
• Masking in the non test ear should be standard.
  Consider using the best bone conduction threshold
  of the non test ear. For masking select a speech
  band noise.

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Assessment by the book

• Conduct full PTA with ULL bilaterally
• Calculate speech and masking levels
• Speech eHPL 19dB
• Masking MwDs-9-BBCnt
• Where eHPL average of best two AC thresholds of
  test ear for 250Hz 4KHZ
• Mw threshold for speech noise in test ear
• Ds speech dial setting
• BBCnt best BC threshold in non-test ear

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Continued

• Instructions You are going to hear someone
  speaking single words, at the beginning the words
  will be at a comfortable level but they will
  gradually become quieter and finally louder.
  Please listen carefully and repeat after each
  word what you think you have heard, even if it is
  only part of a word. Ignore and sounds that may
  be present in your other ear.

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Continued

• Play fist list and score the correct phonemes in
  each word.
• Reduce speech and masking by 10db and repeat
  lists until the total score is less than 10.
• Present at 20dB above initial settings and repeat
  until ULL is reached.
• Calculate optimal discrimination score (ODS),
  determine half peak level (HPL)dB
• Calculate half peak level elevation (HPLE )
  HPL-HPLn
• where HPLn normal HPL for that
  equipment
• (subjective calibration curve)
• Compare ODS and HPLE with PTA and investigate
  possibility of Rollover effect
• THE END except to do it again for the other ear

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Relationship of ST /SRT and SAT to PTA and
3FAHL

• SAT Speech Awareness Threshold .
• This is the level at which the person is aware
  that the signal is speech . They do not have to
  understand the words. This will usually be 10dB
  lower than the ST and the 3FAHL unless the loss
  is steeply sloping .
• ST /SRT Spondee Threshold / Speech Reception
  Threshold
• This is the lowest intensity at which a person
  can repeat two syllable words with 50 accuracy  
  
• What is the relation ship between the ST /SRT and
  the 3FAHL?
• The ST and 3FAHL are very similar
• TAKE HOME MESSAGE ST and SAT can be used as an
  internal test of the validity of the pure of the
  audiogram where you doubt the responses given.  

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What is a "good" score? How do you interpret a
word recognition score?

• Normal scores are near 100, if the stimulus is
  presented at 30 dB SL or above, at MCL or above. 
  
• Cochlear losses and significant hearing losses
  will not have a normal score, but we want to know
  how well they hear with amplification.  
• A score of 20 is poor and we will need to
  consider why it is poor. Is it the level of the
  hearing loss? Is it consistent with the history
  e g Active Menieres
• Is it too poor for the audiogram in which case we
  wonder if there is a retro-cochlear lesion.
• Is the score the same for air and bone
  conduction, if much better by bone is the
  patient eligible for BAHA?  

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Why is this testing conducted?

• Word recognition testing provides a relative
  indicator of the difficulty the person has, and
  alerts the audiologists to persons who have
  unusually poor (or unusually good check for
  malingering) scores. 
• Very poor scores are a sign of possible
  retrocochlear involvement, and further testing is
  needed. 
• Low scores when testing is conducted at a
  comfortable level indicate that the person may
  have limited benefit from hearing aids.

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Dymanic Range for Speech Testing what does it
mean ?

• If the spondee threshold is 10 dB HL, and the UCL
  for speech is 90 dB HL, what is the speech
  dynamic range? Answer 80dBHL - Fitting
  not too much of a worry with intelligibility vs
  UCL
• But what if its 30dBHL?
• that is t he threshold is 60 dB HL and the UCL
  is 90dBHL
• It is good to know this before you go into a
  fitting situation , although the aids may try and
  counter this the more the dynamic range is
  squashed the more likely that distortion will
  occur. Yes even in wonderful digital aids.

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If you suspect a client is having central
problems

• Use some of the central speech tests to show
  that there is central involvement (not just a
  poor fitting!).
• Try some time compressed speech
• 30 and 60 compression lists and check the
  client against norms.

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With Hearing Aid Assessment

• What are you using now?
• What are we trying to do?
• What else could we use?

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SPIN Testing

• Using the SPIN in conjunction with your hearing
  aid fittings/adjustments will give you useful
  information
• Check the difference with HP and LP Lists
• If the fitting is poor on LP consider
• doing more fine tuning Please!

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Using Speech with REAR
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Speech Testing Can be Your Friend!

• Thanks for listening.

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Reflex Testing

• Review of anatomy
• Equipment and testing
• Test profiles
• Interpretaion

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Reflexes happen simultaneously in both ears

• If a loud sound is presented to just one ear
  (monaural presentation), the reflex in normal
  hearers will occur bilaterally.  Since the
  reflex pathway has decussations (the neural
  pathways cross the head), the reflex can occur
  in both ears, even though the stimulus was just
  to one ear.

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Three parts need to be working Input ear
Hearing Stimulus / Crossover in Brainstem/
Output Stapedius muscle innervation
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What Muscles Contract in Reflexes

• Primarily, the stapedius muscle innervated by the
  facial nerve twig in the middle ear. 
• Most research says that the tensor tympani is not
  active in humans.
• Contraction of the stapedial muscle stiffens the
  middle ear system, and the added stiffness
  reduces the transmission of low-frequency
  sound.  

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When does it happen?

• When a loud sound occurs a stapedial
  musclereflex occurs.  Loud sounds are sounds
  about 70 dB HL and louder. 
• Some normal listeners will not have a reflex
  until the sound is as high as 95 or 100 dB HL.
• You can also have a reflex to non-auditory
  stimuli.  For example, a puff air to the eye will
  cause a stapedial reflex.  

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What is recruitment ?

• Recruitment is when a person with hearing loss
  still has normal perception of loud sounds.  This
  is an odd phenomenon - the person does not hear
  soft sounds but loud sounds are perceived
  relatively normally. We can theorize that the
  loss of the active mechanism of the inner ear is
  responsible for this phenomenon. 
• The outer hair cells are suppose to
  shrink/elongate to accentuate the movement of
  basilar membrane, which causes greater shearing
  of the inner hair cell cilia and thus aids in
  the perception of very soft sounds.  If the outer
  hair cells are dead, then the active mechanism
  cannot occur. When sound is loud enough, though,
  the movement of the basilar membrane directly
  stimulates the inner hair cell cilia. So, loud
  sounds are heard, and perceived as loud!  That is
  recruitment.
• So, a sound at 55 dB above threshold in a
  cochlear impaired person, the sound is perceived
  as loud and therefore
• triggers an acoustic reflex.

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Cochlear , Conductive and Retrocochelar, Who
has reflexes ?

• All cochlear losses will have reflexes depending
  upon the level of the hearing loss.
• Conductive losses do not have reflexes
• Retrocochoclear losses often have absent reflexes
  as the first sign of involvment, but they are not
  always absent in the presence of a small CPA
  tumor

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Probe Tip

• Manometer
• Probe tone
• Receiver
• Sound reflected

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What are the parts of the acoustic reflex
measurement system?

• The device, just like the tympanometery, has a
  sound generator to produce the 226 Hz probe
  tone.  It has a pressure pump, and a manometer to
  measure the pressure in the hermetically
  (air-tight) sealed ear canal. It has a measuring
  microphone that measures the intensity of the
  sound in the ear canal.
• Additionally, there is a sound generator to
  create the loud reflex eliciting sounds, and a
  way to control the intensity and frequency of the
  reflex eliciting sounds.
• The reflex eliciting sounds can be channeled to
  the probe, or can be sent to the earphone or the
  other ear. 

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Reflexes are measuredat the Point of Maximum
Compliance

• This is important if you have a leaking seal or
  the equipment has not stored the correct pressure
  for the performance of acoustic reflexes

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Reflexes are Tested at the Point of Maximum
Compliance.
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Distribution of Tympanogram in Different
Pathologies p26Jerger Jerger Maudlin Anthony 1973
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• Bilateral super-threshold activation.
• Depends on the integrity of
• The hearing in the stimulus ear
• The middle ear status of the probe ear
• The integrity of the central reflex arc

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Normal Reflex Pattern
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Right Stimulus Ear
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Left Probe Ear
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Left Stimulus Ear
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Possible Brainstem