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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4507_Библиотеки_им_академика_М_И_Перельмана.pdf
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band with NBN or WT, and the uncomfortable frequencies should be identied and
reduced.
In addition to the loud (85dB SPL) input level control, the infant’s responses to
soft sounds (50dB SPL) should also be evaluated for each frequency band, and the
inadequate gain should be increased only at the “soft” and “moderate” input levels
at the appropriate frequencies. Hearing impaired infants and children should hear
relatively “soft” sounds such as “sh,” “s,” “th,” “f,” “k,” “ch,” “p,” “h,” and “g,”
especially in the high-frequency bands. The VRA/COR should be used to determine
if the baby can hear these sounds at soft and moderate input levels (50 and 65dB
SPL) and, if necessary, amplication should be increased (especially in the highfrequencies) (Fig.11.5).
In pediatric patients with severe and profound hearing loss, frequency-lowering
technologies should be considered if adequate auditory gain cannot be achieved at
high-frequencies. The effectiveness of frequency-lowering technologies can be easily evaluated by CAEP using high-frequency stimuli.
11.7.3.8 Hearing Aid Accessories andAssistive
Listening Technologies
Pediatric hearing aid manufacturers also develop accessories and assistive listening
devices that can be used with hearing aids. These accessories can be used to increase
both the visibility and functionality of the hearing aids. Hearing aid hooks designed
specically for infants provide a comfortable grip on the ear and an aesthetic appearance. The retention cord or clip is used to prevent the hearing aids from falling off
and getting lost. In addition, electrical or nonelectrical drying boxes and drying
capsules ensure the longevity of the hearing aids. In addition, an earmold cleaning
solution or hearing aid spray can be used to clean the earmolds, and then a puffer
can be used to dehumidify the earmold tubing. Finally, a battery tester can make it
easier for parents to change batteries (Fig.11.6a).
In addition to hearing aid accessories, assistive listening systems should be considered for the pediatric population. Until recently, FM systems were the most popular assistive listening devices for infants and children. However, it was a technology
that some parents could not afford due to its high price. On the other hand, its multiconnectivity and high SNR capabilities made it an essential accessory for schoolaged children. In recent years, the discontinuation of FM systems by the Oticon
brand has shown that hearing aid manufacturers are focusing on BT-based “remote
Fig. 11.5 Fitting bands for ne-tuning
a
b
11 Selection and Application Principles of Hearing Aids in Pediatric and Adult…
Fig. 11.6 (a) Hearing aid care kit for children, (b) Remote microphone
231
microphone” technologies (Fig.11.6b). Remote microphones can be easily connected to hearing aids with BT technology and provide direct sound transmission.
They are also less expensive, lighter, smaller, and more portable than FM systems.
They do not require an additional device to be attached to the hearing aid and can
achieve sufcient SNR values. This technology, which can be used in the aural
rehabilitation of infants/toddlers, can also support the academic life of children in
later stages. In addition to the SNR enhancement feature, the remote microphones
also function as a remote control. It also provides audio transmission from Android
phones and computers to hearing aids.
Finally, there are products that make life easier for parents and babies with hearing loss. These assistive listening devices, which consist of a receiver and a transmitter, can be used for a variety of purposes. Transmitters for baby monitors, re
alarms, doorbells, and telephones transmit information to stationary or wristmounted receivers that provide vibration/light alerts. For example, a mother with
profound hearing loss can place a transmitter in the baby’s room and wear the
receiver on her wrist to alert her to her baby’s crying when she is not using her hearing aid (e.g., sleeping). A vibrating receiver on the wrist alerts the mother when the
baby cries. In another example, a mother of a school-aged hearing-impaired child
can place a vibrating alarm clock under her pillow to help her wake up in the morning and avoid being late for school.
11.7.3.9 Informing Parents About theUse ofHearing Aids andHow
toApproach aHearing-Impaired Baby
Before returning home with their hearing-aid-equipped babies, parents should be
thoroughly informed about the use and care of hearing aids and how to interact
with their hearing-impaired babies. Since the brieng may include a lot of information at once, it is recommended that this process be recorded on video by the
mother or father. In addition, audiologists should use a checklist during the brieng
process to ensure that nothing is overlooked. This checklist may include the following topics;
• Attaching the earmold to the hook of the hearing aid, cleaning the earmold, and
when to replace the earmold.
• Checking the battery with a tester, inserting the battery into the hearing aid,
explaining the size and color of the battery.
• Turning the hearing aid on and off and placing it in the ear. (Practice with family).
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• Explaining the buttons, lights, and tampered/locked battery cover on the
hearing aid
• How to use accessories, such as a retaining cord or clip, that are used with the
hearing aid.
• Feedback and factors that can cause feedback.
• Placing the right and left ear markings on the hearing instrument and informing
the family.
• Protecting the hearing instruments from moisture and liquids by using drying
boxes and capsules
• Warranty period and coverage
• Failure and repair procedures for hearing aids
In addition to information about hearing aid use, the checklist should include
information about daily use:
• Wear the hearing aids when the baby wakes up in the morning and keep them in
the ear at all times except during sleep.
• If the baby/child takes the hearing aids off and throws them away, parents should
be patient, not show exaggerated reactions and put the hearing aids back in the
baby’s ear after 5–10minutes. This “waiting time” may increase over time, but
the baby should not be allowed to use the hearing aids as a means of blackmail.
• The positive effect of follow-up with regular checks on the baby’s hearing
quality.
• Referral to an ENT specialist for conditions such as otitis media or ear wax
removal. Adjustment of hearing aid gain to the patient’s new hearing thresholds
in cases of prolonged disease or otitis media that severely alter hearing thresh-
olds. Re-adjust the hearing aids according to the results of the post-treatment
evaluation.
• Inform all family members and friends about the baby/child’s hearing loss and
hearing aid use.
Parents should also be informed about the rehabilitation period after hearing aid
use. However, it should be remembered that this rehabilitation process is not limited
to a few hours a week at the rehabilitation center. Parents should continue this educational process anytime and anywhere.
• Do not use “baby talk” with your child. Speak with correct grammar and pronun-
ciation in as quiet an environment as possible.
• Keep the baby away from “one-way” communication devices such as televi-
sions, tablets, and smartphones. Instead, play games that reinforce “two-way”
communication skills with parents.
• It is important to make “eye contact” when communicating with the baby. The
contribution of eye contact to the emotional part of communication should be
explained to parents.
• The baby/child should be involved in daily tasks as much as possible. In addi-
tion, all completed tasks should be explained to the baby in a “repetitive” way.
For example, when you put the forks in the dishwasher, you can explain to the
baby: “Yes, now we are putting the fork in the machine. Oh, there is another fork.
In this example, the word “fork“ is repeated. However, the emphasis is on the
11 Selection and Application Principles of Hearing Aids in Pediatric and Adult…
233
phrases. Repeating a single word is not recommended for language acquisition.
In addition, using sounds such as “yes“ and “oh” can help keep the baby’s atten-
tion on the conversation.
• In crowded environments, people need to talk one-on-one with the baby/child.
Because “multi-talker” environments create “noise” rather than a verbal com-
munication link for the baby.
• “Real” names of objects seen in the house, garden, or street should be used.
Nicknames or “cute names” can negatively affect the language acquisi-
tion process
• The baby/child should be encouraged to vocalize, engage in two-way communi-
cation, and create an overall dialogue.
• Finally, parents should be informed about the importance of cooperation between
the family audiologist, the ENT specialist, and the rehabilitation center.
11.7.3.10 The Importance ofAuditory-Verbal Therapy
Language development cannot be achieved with hearing aids alone. They act as a
bridge between the ear and the brain. However, language development is related
to the quantity and quality of auditory input that passes through the bridge to the
brain. While audiologists and otolaryngologists are concerned with the healthy
functioning of this bridge, rehabilitation teachers and parents are concerned with
getting as much auditory input across the bridge as possible. Studies show that
auditory verbal therapy and cognitive auditory therapy make important contributions to the language development of hearing-impaired infants/children [64, 65].
In addition, auditory- verbal therapy improves the speech quality of infants/children [66].
In this process, families are expected to be very involved with their infants/
children with hearing loss. This is because the psychosocial and academic development of children and ultimately their quality of life depends on the involvement
of parents and the quality, quantity, and timing of care services [67, 68]. On the
other hand, raising a hearing-impaired child in a healthy condition is a very difcult and grueling task. Parents spend a lot of effort for their children to socialize
with their normal hearing peers, to have a healthy sociological/psychological
development, and to be successful in family and academic life. In this process,
parents are known to have difculties in explaining their children’s hearing problems to others, nding good babysitters and daycare programs for their children,
in nding transportation, and sometimes they need psychological, social, and
nancial support [69].
The psychological and social well-being of parents can be supported by hearing
aid clinics. They can do this by organizing educational and social events for parents.
Through these activities, families can see that they are not the only ones with a
hearing-impaired child and feel a stronger sense of solidarity. In addition, hearing
aid clinics can connect parents with social associations interested in infants and
children with hearing loss. Finally, providing parents with a list of institutions and
organizations that offer auditory rehabilitation through hearing aid clinics will facilitate their search.
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11.7.4 Conclusion toPediatric Hearing Aid Application
Hearing loss in children should be diagnosed and treated as early as possible because
its negative effects increase with age. The “snowball” should be stopped before it
rolls down the hill to the playground where children play “together” with joy. As
Helen Keller said, “Blindness separates people from things; deafness separates people from people.”
11.8 Adult Hearing Aid Application
11.8.1 Assessment ofHearing Aid Candidate
In order to properly apply for hearing aids, the candidate must undergo a medical,
audiological, physical, and psychological evaluation. In this process, the candidate’s
expectations are ltered through audiological, physical, and psychological reality
and then it is decided what type of hearing aid application will be made.
11.8.1.1 Medical Evaluation
To ensure a healthy hearing aid tting, the candidate should undergo a medical and
otological evaluation by an otolaryngologist. During the otological examination, the
ENT specialist should assess the outer/middle ear and Eustachian tube function, as
well as the candidate’s surgical history. Cleaning of the earwax in the ear canal is
also essential for hearing aid tting. After the medical/otological examination, the
otolaryngologist may plan medical or surgical treatment. In this case, the hearing
aid tting may be delayed until the candidate is medically t. After medical and
surgical treatment, the candidate should be referred to an audiologist for hearing aid
tting.
11.8.1.2 Audiological Evaluation
The success of the hearing aid application is directly proportional to the quality of
the audiological evaluation. Performing a complete audiological evaluation plays an
important role in determining factors such as hearing aid selection, earmold acoustic modication, and use of technological features. In general, an audiological evaluation evaluates the type and degree of hearing loss, hearing threshold conguration,
speech discrimination ability in quiet and noisy environments, tympanometry and
acoustic reex test results, presence of hyperacusis, misophonia, autophony, tinnitus, and Eustachian tube dysfunction.
11.8.1.3 Physical Evaluation
Anatomical evaluation of the candidate prior to hearing aid tting is essential for
hearing aid selection and tting. Anomalies of the auricle or ear canal, extremely
narrow ear canal, hand tremor, inadequate ne motor skills, excessive wax production in the ear canal, and deterioration of the ear canal structure after ear surgery are
physical factors that can directly affect hearing aid selection and application style.
11 Selection and Application Principles of Hearing Aids in Pediatric and Adult…
235
Deformities such as microtia, anotia, bat ear, lop ear, cup ear, and cryptotia can
both prevent the earmold from entering the ear canal and cause the BTE/RITE hearing aid to not t rmly in the ear. The degree of deformity may vary from person to
person. For this reason, the width and functionality of the ear canal are important
when tting an air-conduction hearing aid. For example, IIC/CIC models may be
recommended for candidates who have adequate ear canal width but whose pinna is
inappropriate for BTE/RITE hearing aids. In addition, “custom” earmolds can be
designed for candidates whose pinna is partially functional. 3D scanning and printing technology, which has become widely available in recent years, also facilitates
the creation of “special” earmolds or custom hearing aids. On the other hand, bone
conduction hearing aids or bone-anchored hearing system (BAHS) surgery may be
considered for candidates whose ear canal is extremely narrow or completely
blocked. In addition to ear anomalies, ear canal deterioration may occur after ear
surgery. These candidates should be carefully evaluated with ear impressions and
earmolds optimized for the structures of the ear canal. It should also be noted that
these candidates may not have a standard ear canal resonance and hearing aid gain
should be veried with REM. At this point, postoperative ear canal resonance
should be considered in the hearing aid tting.
There are also ear canals that appear perfectly normal when examined with an
otoscope, but excessive wax production in these canals interferes with the use of
RITE or custom hearing aids. The glands in the ear canals produce a moist secretion
called “cerumen” to prevent dust and dirt from entering the ear. Over time, dust and
dirt adhere to this secretion and dry out. Normally, this dried earwax is pulled out of
the ear canal and drained away over time. However, in some people, if this defense
system is overworked or the self-cleaning process is inadequate, the wax can build
up in the ear canal and cause it to become blocked. Accumulated earwax causes
blockages in RITE or custom hearing aids such as IIC, which have the receiver part
directly in the ear canal. The process of cleaning or replacing receiver lters
becomes quite difcult if the user has additional problems such as hand tremors or
poor vision. It is logical to suggest BTE models to candidates with excessive earwax
production because they are easy to clean and maintain.
In general, candidates with hand tremors due to various causes such as hyperthyroidism, epilepsy, or multiple sclerosis, and with poor vision or a disease that affects
their ne motor skills, are recommended to use a BTE hearing aid [70] It is important to provide the patient with binaural acoustic stimulation. Therefore, medical,
audiological, and physical conditions should rst be assessed in the hearing aid
application. These form the “reality” part of the hearing aid application. Then the
psychological–social expectations and “dreams” of the patient are evaluated. The
hearing aid application should be carried out by “inviting” the candidate to a reasonable and rational level of expectations.
11.8.1.4 Psychological Evaluation
In addition to the medical, audiological, and physical evaluation, it is recommended
that hearing aid candidates undergo a psychological evaluation. Feelings of inadequacy, helplessness, anxiety about the device is too big for the ear, fear of needing
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a device for life, and the stress of uncertainty following a hearing loss diagnosis can
affect the emotional state of hearing-impaired individuals. Aesthetic concerns and
social stigma can also inuence the decision to use hearing aids. It is very important
for candidates to be psychologically ready to use hearing aids during the application
process. Whether a candidate decides to continue using hearing aids depends largely
on whether he/she is psychologically ready. In addition, the candidate’s lifestyle,
social environment, business life, private life, age, and gender also affect the adaptation to the hearing aid tting process.
The loss of a major sense, such as sight or hearing, can lead to feelings of inadequacy. Especially for hearing losses that occur after middle age, such as presbycusis, the psychology of being “unable to be independent” and “dependent on a
device” should be well managed. In addition, candidates who are not adequately
informed following the diagnosis of hearing loss may experience stress due to
“uncertainty.” The implications of the hearing loss, how the hearing aid will be tted
and how the hearing aid will contribute to the individual’s life from that point on
may be of interest. Therefore, the candidate’s concerns and questions should be
listened to carefully throughout the hearing aid process and the candidate should be
informed in “understandable language.”
Occasionally, candidates may have unrealistic expectations of the hearing aid. In
such cases, the candidate’s expectations should be drawn to a reasonable point on
the “reality-dreams” bridge. For example, people with high aesthetic demands may
choose IIC hearing aids that cannot be seen by others. If the medical, audiological,
and physical condition of the candidate is appropriate for the use of IIC hearing
aids, the candidate’s aesthetic needs should not be ignored. However, it should be
explained to the candidate that IIC cannot be used if the ear canal is too narrow. The
candidate may be advised to use RITE to balance aesthetic needs with audiological
benets. Audiologists should not prioritize aesthetic needs over audiological
benets.
The hearing aid application process should be conducted in the light of scientic
knowledge and candidates should be educated with easily understandable scientic
arguments. This is the only way to protect candidates from the harmful effects of
“social pressure” and a “gossip culture.” Negative statements about hearing aids
cause candidates to come to the clinic with prejudices about hearing aids. For example, the statement that “hearing aids cause headaches” makes candidates uncomfortable. Another argument often heard from candidates is that “using hearing aids
makes the ear lazy and worse.” The replacement of the candidate’s “old normal”
perception with the “new normal” perception created by the hearing aid represents
a signicant shift in the individual’s perception of reality. The user who hears better
with a hearing aid is usually not satised with the hearing aid-free state.
Lifestyle and social environment also play a role in hearing aid selection and use.
The needs of a nonsocial person are different from those of a social person. A candidate who spends most of the day at home in front of the television may be satised
with hearing aids with a TV accessory, while a candidate who chats with friends
frequently may be satised with a premium hearing aid with a remote microphone
accessory. Therefore, a person’s lifestyle and hearing aid expectations should always
11 Selection and Application Principles of Hearing Aids in Pediatric and Adult…
237
be considered when applying for a hearing aid. In addition, a person’s family life is
also an important factor in hearing aid selection. For example, assistive home systems such as a doorbell or online assistive technologies such as IFTTT can improve
the quality of life for people who live alone. In addition to personal needs, the person’s business needs should also be considered. The communication needs of a
candidate who works alone in a warehouse all day are not the same as those of a
customer service representative who works in a store. While a basic hearing instrument and phone accessory may be recommended for the warehouse worker who
communicates frequently by phone, a premium hearing instrument model may be
recommended for the store associate who communicates extensively with customers throughout the day.
Personality, age, and gender also play a role in hearing aid preferences. Candidates
with extroverted personalities feel the need to communicate more than introverted
candidates. In addition, people who do not like to use accessories may not like a
hearing aid that is worn on the ear. While young candidates may be more concerned
with technological features, older patients may prefer the ease of use of hearing
aids. Finally, female candidates may be more likely than men to make full use of
hearing aids [71].
Audiologists should also keep in mind that candidates may have concerns that
are not easily explained. For example, there are many hearing aid users who hide
their hearing aid use from their family or colleagues. The concerns of these candidates should not be judged and should be handled with care. In addition to their
clinician identity, audiologists should also act as “counselors” and plan a hearing
aid application that is appropriate for the psychological/social prole of the
candidates.
11.8.2 Hearing Aid Application Process
Hearing aid tting can be described as “microphonic/electronic” support of the partially functioning “natural” auditory system. Therefore, certain stages of hearing aid
tting should be followed so that candidates can become accustomed to this new
“hybrid” stimulation and the “new” normal with the hearing aid.
11.8.2.1 Anamnesis
At this stage, the hearing-impaired individual meets the audiologist who will perform the hearing aid tting and can ask questions. The audiologist conducts the
audiological examination and completes the medical history/COSI (Client Oriented
Scale of Improvement) forms [72]. Audiology is the science of ensuring that the
individual’s verbal communication skills are maintained. Of obvious importance,
audiologists are expected to have strong communication skills. They should establish effective verbal–nonverbal communication with their patients and listen carefully. At this point, audiologists should also pay attention to the patient’s nonverbal
communication. Open-ended questions should be used to get candidates to explain
themselves and their expectations. A history form designed by the hearing care
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professional will support two-way communication between the candidate and the
audiologist and create a “patient-professional” relationship. The history form can be
used to inquire about hearing loss, tinnitus, hyperacusis, misophonia, autophonia,
vertigo, history of surgery and chronic diseases, and nally the patient’s expectations for the hearing aid. The COSI assessment can also be used to learn the candidate’s expectations. By using the COSI, candidates can become aware of their needs
and prioritize them. An anamnesis form used in hearing aid clinics may include the
following questions:
• When did the hearing loss begin?
• Is the hearing loss symmetrical? Which ear hears better?
• Do you have difculty in crowded places?
• Have you ever had ear surgery? When? Where? For what purpose?
• Have you ever been in a situation that could cause acoustic trauma, such as an
explosion?
• Have you ever taken any medications that may cause ototoxicity (e.g., chemo-
therapy drugs such as cisplatin)?
• Have you had radiation therapy?
• Does anyone in your family have a history of hearing loss?
• Do you feel any blockage in your ears?
• Do sounds that others consider normal often seem loud to you?
• Do you nd your voice loud?
• Do some sounds, such as the ticking of a clock, bother you?
• Do you have tinnitus?
• In which ear do you experience tinnitus?
• Does the tinnitus sound like a ringing bell or a motor/wind?
• Does the tinnitus happen all the time or from time to time?
• Does the tinnitus pulsate and sound like a heartbeat?
• Does the severity of the tinnitus change with the position of the head?
• What are your expectations for the hearing aid?
11.8.2.2 Informing Candidates andTheir Companions About
Hearing Loss andHearing Aids
Candidates should be educated about the nature of hearing loss and its devastating
effects before applying for hearing aids. Usually, audiologists and ENT specialists
working in hospitals may not have enough time to counsel patients and their companions about hearing loss. Therefore, hearing-impaired people should be fully
informed about the “dark face” of hearing loss and hearing aids in hearing aid clinics. In clinical practice, many of the problems that users complain about during the
hearing aid tting process are due to a lack of information prior to the hearing aid
tting. For example, because many candidates do not know the difference between
“hearing loss” and “discrimination loss,” they expect to be able to discriminate all
conversations after the hearing aid tting. In such cases, it should be clearly
explained to the patient that the hearing aid can support the individual’s unaided
auditory discrimination ability. The auditory system can be easily explained using a
half-full bottle of water: “Hearing loss can be dened as a hole in the bottom of this
11 Selection and Application Principles of Hearing Aids in Pediatric and Adult…
239
bottle. Thus, as the duration of the hearing loss increases, the water in the bulge (the
discrimination ability) decreases. The use of hearing aids ensures that the hole is
closed but cannot add extra water to the bottle.” In addition, the education of the
candidate’s signicant others is very important in this process. Companions can
assist audiologists in convincing the patient to seek treatment for hearing loss and to
use hearing aids.
Hearing-impaired individuals should rst be educated about the peripheral and
central auditory systems. A poster depicting both the peripheral and central auditory
systems can be used to educate candidates and their companions about the relationship between hearing and the brain, the negative effects of hearing loss, and the
positive effects of hearing aid use on the central auditory system. In addition, the
audiological, neurological, psychological, and social consequences of untreated
hearing loss should be mentioned. The key point here is that these explanations
should be made in plain language appropriate to the socio-cultural level of the
candidate.
Most hearing aid candidates may have little knowledge about hearing loss and
hearing aids prior to being diagnosed with hearing loss. Therefore, hearing aid segments, hearing aid models, and important technologies used in hearing aids should
be explained to candidates and their companions. Hearing aids are generally divided
into four segments based on price: basic, essential, advanced, and premium. Basic
is the least expensive model and has fewer technological features than premium
models. Hearing aid manufacturers usually introduce a new technology platform
every year. Although the same processor and processing power are used in all price
segments, segmentation is created by limiting the potential of the technologies used.
Although the potential distribution ratio may change depending on the brand’s sales
strategy, the segmentation of hearing aids is similar for all hearing aid manufacturers. Fortunately, features such as BT, remote tting, and tinnitus sound enhancement are offered at all price levels. Different models such as BTE, RITE, or IIC and
rechargeable options are available at all price points. After the information phase,
candidates should know why they should purchase a “premium” segment hearing
aid at a higher cost. Candidates should be told exactly what technologies are used to
compensate for what is wrong with their hearing instrument.
11.8.2.3 Determining theAppropriate Hearing Aid Model
andApplication Style
The hearing healthcare professional should ensure that the candidate’s audiological
data is current before deciding on the hearing aid model and application style. If the
audiological data are inconsistent with each other and with the patient’s medical
history, it is strongly recommended that the audiological evaluation be repeated at
the hearing center. This evaluation should include air-bone conduction thresholds,
interoctave frequency thresholds, Speech Reception Thresholds (SRT), Silence/
Noise Speech Discrimination Scores (SDS), LDL levels, tympanogram ndings and
acoustic reex test results. In addition to the standard evaluation, tinnitus mapping
can be performed in patients with tinnitus. In addition, a threshold equalizing noise
(TEN) test can be performed to assess the dead zone in cases of sharply decreasing