Starkey Research & Clinical Blog

Cochlear Dead Regions and High Frequency Gain: How to Fit the Hearing Aid

Cox, R.M., Johnson, J.A. & Alexander, G.C. (2012). Implications of high-frequency cochlear dead regions for fitting hearing aids to adults with mild to moderately severe hearing loss. Ear and Hearing, May 2012, e-published ahead of print.

This editorial discusses the clinical implications of an independent research study. This editorial does not represent the opinions of the original authors.

Cochlear dead regions (DRs) are defined as a total loss of inner hair cell function across a limited region of the basilar membrane (Moore, et al., 1999b). This does not result in an inability to perceive sound at a given frequency range, rather the sound is perceived via a spread of excitation to adjacent regions in the cochlea where the inner hair cells are still functioning. Because the response is spread out over a broader tonotopic region, patients with cochlear dead regions may perceive some high frequency pure tones as “clicks”, “buzzes” or “whooshes” rather than tones.

Dead regions can be present at moderate hearing thresholds (e.g. 60dBHL) and are more likely to be present as the degree of loss increases. Psychophysical tuning curves are the preferred method for identifying cochlear dead regions in the laboratory, complicated and time consuming. Moore and his colleagues developed the Threshold Equalizing Noise (TEN) Test as a clinical means of identifying dead regions (Moore et al., 2000; Moore et al., 2004). The TEN procedure looks for shifts in masked thresholds beyond what would typically be expected for a given hearing loss.  A threshold obtained with TEN masking noise that shifts at least 10dB indicates the likely presence of a cochlear dead region.

Historically, there has been a lack of consensus among clinical investigators as to whether or not high frequency gain is beneficial for hearing aid users who have cochlear dead regions. Some studies suggest that high frequency gain could have deleterious effects on speech perception and should be limited for individuals with cochlear dead regions (Moore, 2001b; Turner, 1999; Padilha et al., 2007). For example, Vickers et al. (2001) and Baer et al. (2002) studied the benefit of high frequency amplification in quiet and noise for individuals with and without DRs. Both studies reported that individuals with DRs were unable to benefit from high frequency amplification. While Gordo & Iorio (2007) found that hearing aid users with DRs performed worse with high-frequency amplification than they did without it.

In contrast, Cox and her colleagues (2011) found beneficial effects of high frequency audibility whether or not the participants had dead regions. Others have reported equivalent performance for participants with and without dead regions for quiet and low noise conditions; however, in high noise conditions the individuals without dead regions demonstrated further improvement when additional high frequency amplification was provided, whereas participants with dead regions did not (Mackersie et al., 2004). This article is summarized in more detail here:

The current study was undertaken to examine the subjective and objective effect of high frequency amplification on matched pairs of participants (with and without DRs) in a variety of conditions. Participants were fitted with hearing aids that had two programs: the first (NAL) was based on the NAL-NL1 formula and the second (LP) was identical to the NAL-NL1 program below 1000Hz, with amplification rolled off above 1000Hz.  The goals of the study were to compare performance with these two programs, for individuals with and without dead regions. The following measures were conducted:

1) Speech discrimination in quiet laboratory conditions

2) Speech discrimination in noisy laboratory conditions

3) Subjective performance in everyday situations

4) Subjective preference for everyday situations

Participants were recruited from a pool of individuals who had previously been identified as typical hearing aid patients (Cox et. al., 2011). Participants had bilateral flat or sloping sensorineural hearing loss with thresholds above 25dB below 1kHz and thresholds of 60 to 90dB HL for at least part of the frequency range of 1-3kHz.

The TEN test (Moore et al., 2004) was administered to determine the presence of DRs. To be eligible for the study, participants needed to have one or more DRs in the better ear at or above 1kHz and no DRs below 1kHz. Participants were then divided into to two groups: the experimental group with DRs and the control group without DRs.  Individuals in the experimental group showed a diverse range of DR distribution across frequency. Almost half of the participants had DRs between 1-2kHz, whereas the remainder had DRs only at or above 3kHz. A little more than half of the participants had one DR only, whereas the others had more than one DR.

Individuals in the experimental group were matched in pairs with individuals from the control group. In total, there were 18 participant pairs; each matched for age, degree of hearing loss and slope of hearing loss. There were 24 men and 12 women. No attempt was made to match pairs based on gender.

Participants were fitted monaurally with behind-the-ear hearing aids coupled to vented skeleton earmolds. The monaural fitting was chosen to avoid complications when participants switched between the NAL and LP programs. Data collection was completed before the widespread availability of wireless hearing aids, so the participants would have had to reliably switch both hearing aids individually to the proper program every time to avoid making occasional subjective judgments based on mismatched programs.

The hearing aids had two programs: a program based on the NAL-NL1 prescription (NAL) and a program with high-frequency roll-off (LP). Participants were able to switch the programs themselves but could not identify the programs as NAL or LP. Half of the participants had NAL in P1 and LP in P2, whereas the other half had LP in P1 and NAL in P2.  Verification measures were conducted to ensure that the two programs matched below 1kHz and to make sure the participants judged the programs to be equally loud.

After a two week acclimatization period, participants returned for speech recognition testing and field trial training. Speech and noise stimuli were presented in a sound field with the unaided ear was plugged during testing. Speech recognition in quiet was evaluated using the Computer Assisted Speech Perception Assessment (CASPA; Mackersie, et al., 2001).  The CASPA test includes lists of 10 consonant-vowel-consonant words spoken by a female. Five lists were presented for each of the NAL and LP programs. Stimuli were presented at 65dB SPL.

Speech recognition in noise was evaluated with the Bamford-Kowell-Bench Speech in Noise (BKB-SIN test,  Etymotic Research, 2005), which contains sentences spoken by a male talker, masked by 4-talker babble. The test contains lists of 10 sentences with 31 scoring words. In each list, the signal-to-noise ratio (SNR) decreases by 3dB with each sentence, so that within any list the SNR ranges from +21dB to -6dB. Sentences were presented at 73dB, a “loud but OK” level, as recommended for this test.

Following the speech recognition testing, participants were trained in the field trial procedures for subjective ratings. They were asked to evaluate their ability to understand speech in everyday situations with the NAL and LP programs and identify occasions during which they felt they could understand some but not all of the words they were hearing. Participants were given booklets with daily rating sheets and listening checklists to record daily hours of hearing aid use and track the variety of their daily listening experiences.

After a two week field trial, participants returned to the laboratory for a second session of CASPA and BKB-SIN testing. They submitted ratings sheets and listening checklists and were interviewed about their preferred hearing aid program for everyday listening. The interview consisted of questions that covered program preferences related to:  understanding speech in quiet, understanding speech in noise, hearing over long distances, the sound of their own voice, sound quality, loudness, localization, the least tiring program and the one that provided the most comfortable sound. Participants were asked to indicate their preferred program for each of these criteria, as well as their preferred program for overall everyday use. They were asked to provide three reasons for overall preference.

Speech recognition testing in quiet revealed no difference in overall performance between the two groups, but there was a significant difference based on the hearing aid program that was used. Listeners from both the experimental group and the control group performed better with the broadband NAL program, though the difference between the NAL and LP programs was larger for the control group than the experimental group. This indicates that the individuals without DRs were able to derive more benefit from the additional high frequency information in the NAL program than the individuals with DRs did.

Speech recognition testing in noise revealed a similar finding but in this case the improvement with the NAL program was only significant for the control group. Although the experimental group’s mean scores with the NAL program were higher than those with the LP program, the difference did not reach statistical significance.  Because the BKB-SIN test used variable SNR levels, performance-intensity functions were constructed with scores obtained using the NAL and LP programs. These functions revealed that at any given SNR, speech was more intelligible with the NAL program. However, there was more of a difference between the NAL and LP functions for the control group than the experimental group, consistent with a program by group statistical interaction.

Subjective ratings of speech understanding revealed no significant difference between the experimental and control groups, but there was a significant difference based on program.  Participants from the control and experimental groups rated their performance better with the NAL program.

Interviews concerning program preference revealed that 23 participants preferred the NAL program and 11 preferred the LP program. There was no association with the presence of DRs. When the reasons supporting the participants’ preferences were analyzed, the most frequently mentioned reason for NAL preference was greater speech clarity. The most common reason for LP preference was that the other program (NAL) was too loud.

This investigation by Dr. Cox and her colleagues indicates that high-frequency amplification was beneficial to participants with single or multiple DRs, especially for speech recognition in quiet. In noise, participants with DRs still performed better with the NAL program, though the improvement was not as marked as it was for those without DRs. In field trials, participants with DRs reported more improvement with the NAL program than the control group did, indicating that perceived benefits in everyday situations exceeded any predictions of the laboratory results. At no point in the study did high-frequency amplification reduce performance for individuals with or without DRs.

This finding is in contrast with previous reports (Vinay & Moore, 2007a; Gordo & Iorio, 2007). Cox and her colleagues note that most of the participants in their study had only one or two DRs as opposed to several contiguous DRs. They allow that their findings might not relate to the performance of participants with several contiguous DRs, but point out that among typical hearing aid candidates, it is unlikely for individuals to have more than one or two DRs. With this consideration, the authors suggest that, high frequency amplification should not be reduced, even in cases with identified dead regions.

This study from the University of Memphis provides a recommendation for use of prescribed settings and against reduction of high frequency gain for hearing aid users with one or two DRs.  They found beneficial effects of high frequency amplification in laboratory and everyday environments and noted no circumstances in which listeners demonstrated deleterious effects of high frequency amplification. These results may not pertain to individuals with several contiguous DRs but they are pertinent to the majority of typical hearing aid wearers. Their findings also support the use of subjective performance measures, as these provided additional information that was sometimes in contrast to the laboratory results. They point out that laboratory results do not always predict performance in everyday life and it can be extrapolated that clinical measures of efficacy should always be supported with subjective reports of effectiveness, like self-assessment of comfort and acceptance.


Baer,  T., Moore, B.C. & Kluk, K. (2002). Effects of low pass filtering on the intelligibility of speecdh in noise for people with and without dead regions at high frequencies. Journal of the Acoustical Society of America 112(3 pt. 1), 1133-1144.

Ching, T.Y., Dillon, H. & Byrne, D. (1998). Speech recognition of hearing-impaired listeners: predictions from audibility and the limited role of high-frequency amplification. Journal of the Acoustical Society of America 103, 1128-1140.

Cox, R. M., Alexander, G.C., & Johnson, J.A. (2011). Cochlear dead regions in typical hearing aid candidates: prevalence and implications for use of high-frequency speech cues. Ear and Hearing 32, 339-348.

Cox, R.M., Johnson, J.A. & Alexander, G.C. (2012). Implications of high-frequency cochlear dead regions for fitting hearing aids to adults with mild to moderately severe hearing loss. Ear and Hearing, May 2012, e-published ahead of print.

Etymotic Research (2005). BKB-SIN Speech in Noise Test, Version 1.03. Elk Grove Village, IL: Etymotic Research.

Moore, B.C., Glasberg, B. & Vickers, D.A. (1999b). Further evaluation of a model of loudness perception applied to cochlear hearing loss. Journal of the Acoustical Society of America 106, 898-907.

Moore, B.C., Huss, M. & Vickers, D.A. (2000). A test for the diagnosis of dead regions in the cochlea. British Journal of Audiology 34, 205-224.

Moore, B.C., Glasberg, B. R. & Stone, M.A. (2004). New version of the TEN test with calibrations in dB HL. Ear and Hearing 25, 478-487.

Gordo, A. & Iorio, M.C. (2007). Dead regions in the cochlea at high frequencies: Implications for the adaptation to hearing aids. Revista Brasileira de Otorrinolaringologia 73, 299-307.

Hogan, C.A. & Turner, C.W. (1998). High frequency audibility: benefits for hearing-impaired listeners. Journal of the Acoustical Society of America 104, 432-441.

Mackersie, C.L., Boothroyd, A. & Minniear, D. (2001). Evaluation of the Computer-Assisted-Speech Perception Assessment Test (CASPA).  Journal of the American Academy of Audiology 12, 390-396.

Mackersie, C.L., Crocker, T.L. & Davis, R.A. (2004). Limiting high-frequency hearing aid gain in listeners with and without suspected cochlear dead regions. Journal of the American Academy of Audiology 15, 498-507.

Moore, B.C. (2001a). Dead regions in the cochlear: Diagnosis, perceptual consequences and implications for the fitting of hearing aids. Trends in Amplification 5, 1-34.

Moore, B.C., (2001b). Dead regions in the cochlear: Implications for the choice of high-frequency amplification. In R.C. Seewald & J.S. Gravel (Eds). A Sound Foundation Through Early Amplification, p 153-166. Stafa, Switzerland: Phonak AG.

Padilha, C., Garcia, M.V., & Costa, M.J. (2007).  Diagnosing cochlear dead regions and its importance in the auditory rehabilitation process. Brazilian Journal of Otolaryngology 73, 556-561.

Turner, C.W. (1999). The limits of high-frequency amplification. Hearing Journal 52, 10-14.

Turner, C.W. & Cummings, K.J. (1999). Speech audibility for listeners with high-frequency hearing loss. American Journal of Audiology 8, 47-56.

Vickers, D.A., Moore, B.C. & Baer, T. (2001). Effects of low-pass filtering on the intelligibility of speech in quiet for people with and without dead regions at high frequencies. Journal of the Acoustical Society of America 110, 1164-1175.

Vinay, B.T. & Moore, B.C. (2007a). Prevalence of dead regions in subjects with sensorineural hearing loss. Ear and Hearing 28, 231-241.