Article of interest:
The Effects of Receiver Placement on Probe Microphone, Performance and Subjective Measures with Open Canal Hearing Instruments
Alworth, L., Plyler, P., Bertges-Reber, M. & Johnstone, P. (2010)
This editorial discusses the clinical implications of an independent research study. The original work was not associated with Starkey Laboratories and does not reflect the opinions of the authors.
Open-fit behind-the-ear hearing instruments are favored by audiologists and patients alike, because of their small size and discreet appearance, as well as their ability to minimize occlusion. The performance of open-fit instruments with the Receiver-In-The-Aid (RITA) and Receiver-In-Canal (RIC) has been compared to unaided conditions and to traditional, custom-molded instruments. However, few studies have examined the effect of receiver location on performance by comparing RITA and RIC instruments to each other. In the current paper, Alworth and her associates were interested in the effect of receiver location on:
- maximum gain before feedback
- speech perception in quiet and noise
- subjective performance and listener preferences
Theoretically, RIC instruments should outperform RITA instruments for a number of reasons. Delivery of sound through the thin tube on a RITA instrument can cause peaks in the frequency response, resulting in upward spread of masking (Hoen & Fabry, 2007). Such masking effects are of particular concern for typical open-fit hearing aid users; individuals with high-frequency hearing loss. RIC instruments are also capable of a broader bandwidth than RITA aids (Kuk & Baekgaard, 2008) and may present lowered feedback risk because of the distance between the microphone and receiver (Ross & Cirmo, 1980), and increased maximum gain before feedback (Hoen & Fabry, 2007; Hallenbeck & Groth, 2008).
The authors recruited twenty-five subjects with mild to moderate, high frequency, sensorineural hearing loss participated in the study. Fifteen had no prior experience with open-canal hearing instruments, whereas 10 had some prior experience. Each subject was fitted bilaterally with RIC and RITA instruments with identical signal processing characteristics, programmed to match NAL-NAL1 targets. Directional microphones and digital noise reduction features were deactivated. Subjects used one instrument type (RIC or RITA) for six weeks before testing and then wore the other type for six weeks before being tested again. The instrument style was counterbalanced among the subjects.
Probe microphone measures were conducted to evaluate occlusion and maximum gain before feedback. Speech perception was evaluated with the Connected Speech Test -CST (Cox et al, 1987), the Hearing in Noise test -HINT (Nilsson, et al, 1994), the High Frequency Word List – HFWL (Pascoe, 1975) and the Acceptable Noise Level – ANL test (Nabelek et al, 2004). Subjective responses were evaluated with the Abbreviated Profile of Hearing Aid Benefit – APHAB (Cox & Alexander, 1995), overall listener preferences for quiet and noise, and satisfaction ratings for five criteria: sound quality, appearance, retention and comfort, speech clarity and ease of use and care.
Real-Ear Occluded Response measurements showed minimal occlusion for both types of instruments in this study. Although there was more occlusion overall for RIC instruments, the difference between RIC and RITA hearing instruments was not significant. Overall maximum gain before feedback did not differ between RIC and RITA instruments. However, when analyzed by frequency, the authors found significantly greater maximum gain in the 4000-6000Hz range for RIC hearing instruments.
On the four speech tests, there were no significant differences between RITA versus RIC instruments. Furthermore, there were no significant improvements for aided listening over unaided, except for experienced users with RIC instruments on the Connected Speech Test (CST). It appears that amplification did not significantly improve scores in quiet conditions, for either instrument type, because of ceiling effects. The high unaided speech scores indicated that the subjects in this study, because of their audiometric configurations, already had broad enough access to high frequency speech cues, even in the unaided conditions. Aided performance in noise was significantly poorer than unaided on the HINT test, but no other significant differences were found for aided versus unaided conditions. This finding was in agreement with previous studies that also found degraded HINT scores for aided versus unaided conditions (Klemp & Dhar, 2008; Valente & Mispagel, 2008).
APHAB responses indicated better aided performance for both instrument types than for unaided conditions on all APHAB categories except aversiveness, in which aided performance was worse than unaided. There were no significant differences between RIC and RITA instruments. However, satisfaction ratings were significantly higher for RIC hearing instruments. New users reported more satisfaction with the appearance of RIC instruments; experienced users indicated more satisfaction with appearance, retention, comfort and speech clarity. Overall listener preferences were similar, with 80% of experienced users and 74% of new users preferring RIC instruments over RITA instruments.
The findings of Alworth and colleages are useful information for clinicians and their open-fit hearing aid candidates. Because they provided significantly more high frequency gain before feedback than RITA instruments, RIC instruments may be more appropriate for patients with significant high-frequency hearing loss. Indeed, this result may suggest that RIC instruments should be the preferred recommendation for open-fit candidates. The results of this study also underscore the importance of using subjective measures with hearing aid patients. Objective speech discrimination testing did not yield significant performance differences between RIC and RITA instruments, but participants showed significant preference for RIC instruments.
Further information is needed to compare performance in noise with RIC and RITA instruments. In this study and others, some objective scores and subjective ratings were poorer for aided conditions than unaided conditions. It is important to note that in the current study, all noise and speech was presented at a 0° azimuth angle, with directional microphones disabled. In real-life environments, it is likely that users would have directional microphones and would participate in conversations with various noise sources surrounding them. Previous work has shown significant improvements with directionality in open-fit instruments (Valente & Mispagel, 2008; Klemp & Dhar, 2008). Future work comparing directional RIC and RITA instruments, in a variety of listening environments, would be helpful for clinical decision making.
Although the performance effects and preference ratings reported here support recommendation of RIC instruments clinicians should still consider other factors when discussing options with individual patients. For instance, small ear canals may preclude the use of RIC instruments because of retention, comfort or occlusion concerns. Patients with excessive cerumen may prefer RITA instruments because of easier maintenance and care, or those with cosmetic concerns may prefer the smaller size of RIC instruments. Every patient’s individual characteristics and concerns must be considered, but the potential benefits of RIC instruments warrant further examination and may indicate that this receiver configuration should be recommended over slim-tube fittings.
Alworth, L.N., Plyler, P.N., Rebert, M.N., & Johstone, P.M. (2010). The effects of receiver placement on probe microphone, performance, and subjective measrues with open canal hearing instruments. Journal of the American Academy of Audiology, 21, 249-266.
Cox, R.M., & Alexander, G.C. (1995). The Abbreviated Profile of Hearing Aid Benefit. Ear and Hearing, 16, 176-186.
Cox, R.M., Alexander, G.C. & Gilmore, C. (1987). Development of the Connected Speech Test (CST). Ear and Hearing, 8, 119-126.
Hallenbeck, S.A., & Groth, J. (2008). Thin-tube and receiver-in-canal devices: there is positive feedback on both! Hearing Journal, 61(1), 28-34.
Hoen, M. & Fabry, D. (2007). Hearing aids with external receivers: can they offer power and cosmetics? Hearing Journal, 60(1), 28-34.
Klemp, E.J. & Dhar, S. (2008). Speech perception in noise using directional microphones in open-canal hearing aids. Journal of the American Academy of Audiology, 19(7), 571-578.
Kuk, F. & Baekgaard, L. (2008). Hearing aid selection and BTEs: choosing among various “open ear” and “receiver in canal” options. Hearing Review, 15(3), 22-36.
Nabelek, A.K., Tampas, J.W. & Burchfield, S.B. (2004). Comparison of speech perception in background noise with acceptance of background noise in aided and unaided conditions. Journal of Speech and Hearing Research, 47, 1001-1011.
Nilsson, M., Soli, S. & Sullivan, J. (1994). Development of the Hearing in Noise Test for the measurement of speech reception threshold in quiet and in noise. Journal of the Acoustical Society of America, 95, 1085-1099.
Pascoe, D. (1975). Frequency responses of hearing aids and their effects on the speech perception of hearing impaired subjects. Annals of Otology, Rhinology and Laryngology suppl. 23, 84: #5, part 2.
Valente, M. & Mispagel, K. (2008). Unaided and aided performance with a directional open-fit hearing aid. International Journal of Audiology, 47, 329-336.