Article of interest:
Unaided and Aided Performance with a Directional Open-Fit Hearing Aid
Valente, M., and Mispagel, K.M. (2008)
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.
With the continued popularity of directional microphone use in open-fit and receiver-in-canal (RIC) hearing aids, there has been increasing interest in evaluating their performance in noisy environments. A number of studies have investigated the performance of directional, open-fit BTEs in laboratory conditions. (Valente et al., 1995; Ricketts, 2000a; Ricketts, 2000b). Some have evaluated directional microphone performance in real-life or simulated real-life noise environments (Ching et al, 2009). In the current study, the authors compared performance in omnidirectional, directional and unaided conditions using RIC instruments in R-SpaceTM (Revitt et al, 2000) recorded restaurant noise. Their goal was to obtain more externally valid results by using real-life noise in a controlled, laboratory setting.
The R-SpaceTM method involved recordings of real restaurant noise from an 8-microphone, circular array. For the test conditions, these recordings were presented through an 8-speaker, circular array to simulate the conditions in the busy restaurant. One important factor that distinguishes this study from most others is that the subjects listened to speech stimuli in the presence of noise from all directions, including the front. At the time of this study only a few other studies had tested directional microphone performance in the presence of multiple noise sources, including frontal (Ricketts, 2000a; Ricketts, 2001; Bentler et al., 2004).
The authors recruited 26 adults with no prior hearing aid experience for the study. They were fitted with binaural receiver-in-canal (RIC) instruments. The instruments were programmed without noise reduction processing and with independent omnidirectional and directional settings. Subjects were counseled on use and care of the instruments, including proper use of omnidirectional and directional programs. They returned for follow-up adjustments one week after their fitting then used their instruments for four weeks before returning for testing. Subjects were given the opportunity to either purchase the hearing aids after the study at a 50% discount or receive a $200 payment for participation.
Hearing in Noise Test (HINT) (Nilsson et al., 1994) sentence reception thresholds were obtained to evaluate sentence perception in the uncorrelated R-Space noise. The Abbreviated Profile of Hearing Aid Benefit (APHAB) (Cox & Alexander, 1995) was also administered to evaluate perceived benefit from the instruments in the study. Four APHAB subscales were evaluated independently:
- Ease of communication (EC)
- Reverberation (RV)
- Background noise (BN)
- Aversiveness to loud sounds (AV)
The authors found that subjects’ performance in the directional condition was significantly better than both omnidirectional and unaided conditions. The omnidirectional condition was not significantly better than unaided; in fact results were slightly worse than those obtained in the unaided condition.
For the APHAB results, the authors found that on the EC, RV and BV subscales, aided scores were significantly better than unaided scores. Perhaps not surprisingly, the AV score, which evaluates “aversiveness to noise” was worse in the aided conditions. The aided results combined omnidirectional and directional conditions, so it is possible that aversion to noise in omnidirectional conditions was greater than the directional conditions. However, this was not specifically evaluated in the current study.
The authors pointed out that their directional benefit, which on average was 1.7dB, was lower than those found in other studies of open-fit or RIC hearing instruments (Ricketts, 2000b; Ricketts, 2001; Bentler, 2004; Pumford et al., 2000). However, they mention that most of those studies did not use frontal noise sources in their arrays. Frontal noise sources should have obvious detrimental effects on directional microphone performance, so it is likely that the speaker arrangement in the current study affected the measured directional improvement. At the time of this publication one other study had been conducted using the R-SpaceTM restaurant noise (Compton-Conley et al 2004). They found mean directional benefits of 3.6 to 5.8 dB, but their subjects had normal hearing and the hearing aids they used were not an open-fit design and were very different from the ones in the current study..
Clinicians can gain a number of important insights from Valente and Mispagel’s study. First and foremost, directional microphones are likely to provide significant benefits for users of RIC hearing aids. At the time of publication, the authors noted that directional improvement should be studied in order to warrant the extra expense of adding directional microphones to an open-fit hearing aid order. However, most of today’s open-fit and RIC instruments already come standard with directional microphones, many of which are automatically adjustable. So there is no need to justify the use of directional microphones on a cost basis, as they usually add nothing to the hearing aid purchase price.
This study provided more evidence for directional benefit in noise, but further work is needed to determine performance differences between directional and omnidirectional microphones in quiet conditions. Dispensing clinicians should always order instruments that have omnidirectional and directional modes, whether manually or automatically adjustable. This helps ensure that the instruments will perform optimally in most situations. Even instruments with automatically adjustable directional microphones often have push-buttons that allow us to give patients additional programs. For example, a manually accessible, directional program, perhaps with more aggressive noise reduction, offers the user another option for excessively noisy situations.
The current study obtained slightly reduced directional effects compared to other studies that tested subjects in speaker arrays without frontal noise sources. This underscores the importance of counseling patients about proper positioning when using directional settings. In general, patients should understand that they will be better off when they can put as much noise behind them as possible. But, it is also important to ensure that patients have reasonable expectations about directional microphones. They must understand that the directional microphone will help them focus on conversation in front of them, but will not completely remove competing noise behind them. Patients must also understand that omnidirectional settings are likely to offer no improvement in noise and might even be a detriment to speech perception in some noisy environments.
Subjects in Valente and Mispagel’s study were offered the opportunity to purchase their hearing instruments at a 50% discount after the study’s completion. Only 8 of the 26 subjects opted to do so. Of the remaining subjects, 3 reported that the perceived benefit was not enough to justify the purchase, whereas 15 subjects did not report any significant perceived benefit. This leads to another important point about patient counseling.
The subjects in this study, like most candidates for open-fit or RIC instruments, had normal low-frequency hearing. Therefore, they may have had less of a perceived need for hearing aids in the first place. It is important for audiologists to discuss realistic expectations and likely hearing aid benefits with patients in detail at the hearing aid selection appointment, before hearing aids are ordered. Patients who are unmotivated or do not perceive enough need for hearing assistance will ultimately be less likely to perceive significant benefit from their hearing aids. This is particularly true in everyday clinical situations, in which patients are not typically offered a 50% discount and will have to factor financial constraints into their decisions. For most open-fit or RIC candidates, their motivation and perceived handicap will be related to their lifestyle: their social activities, employment situation, hobbies, etc. Because a patient who has a less than satisfying experience with hearing aids may be reluctant to pursue them again in the future, it is critical for the clinician to help them establish realistic goals early on, before hearing aid options are discussed.
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Valente, M., & Mispagel, K.M. (2008). Unaided and aided performance with a directional open-fit hearing aid. International Journal of Audiology, 47, 329-336.