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Volume 25, Issue 1','','','','','','wave-volume-25-issue-1.pdf',NULL,'',24,16,NULL,'false','false','true','false','false','25','1',NULL,'http://www.allegrahamilton.com/publications/ajp/wavelength/vol25-iss1/',0,NULL,NULL,0,'2015-11-24'),(3380,'ajwave','http://www.andrewjohnpublishing.com/','Wavelength','Physics',NULL,NULL,'','Volume 27, Issue 1','February','2014','wave Volume 27, Issue 1','','','','','','wave-volume-27-issue-1.pdf',NULL,'',24,16,NULL,'false','false','true','false','false','27','1',NULL,'http://digital.turn-page.com/i/270496',0,NULL,NULL,0,'2015-11-24'),(3381,'ajcjgm','http://www.andrewjohnpublishing.com/','Canadian Journal of General Internal Medicine','Medical',NULL,NULL,'','Volume 5, Issue 1','March','2010','cjgm Volume 5, Issue 1','','','','','','cjgm-volume-5-issue-1.pdf',NULL,'',24,16,NULL,'false','false','true','false','false','5','1',NULL,NULL,0,NULL,NULL,0,'2015-11-24'),(3382,'ajcjgm','http://www.andrewjohnpublishing.com/','Canadian Journal of General Internal 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2','June','2009','cjrd Volume 2, Issue 2','','','','','','cjrd-volume-2-issue-2.pdf',NULL,'',24,16,NULL,'false','false','true','false','false','2','2',NULL,NULL,0,NULL,NULL,0,'2015-11-24'),(3423,'ajcjrd','http://www.andrewjohnpublishing.com/','Canadian Journal of Restorative Dentistry and Prosthodontics','Dental',NULL,NULL,'','Volume 2, Issue 3','September','2009','cjrd Volume 2, Issue 3','','','','','','cjrd-volume-2-issue-3.pdf',NULL,'',24,16,NULL,'false','false','true','false','false','2','3',NULL,NULL,0,NULL,NULL,0,'2015-11-24'),(3424,'ajcjrd','http://www.andrewjohnpublishing.com/','Canadian Journal of Restorative Dentistry and Prosthodontics','Dental',NULL,NULL,'','Volume 2, Issue 4','December','2009','cjrd Volume 2, Issue 4','','','','','','cjrd-volume-2-issue-4.pdf',NULL,'',24,16,NULL,'false','false','true','false','false','2','4',NULL,NULL,0,NULL,NULL,0,'2015-11-24'),(3425,'ajcjrd','http://www.andrewjohnpublishing.com/','Canadian Journal of Restorative Dentistry and 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3','','','','','','cjrd-volume-3-issue-3.pdf',NULL,'',24,16,NULL,'false','false','true','false','false','3','3',NULL,NULL,0,NULL,NULL,0,'2015-11-24'),(3428,'ajcjrd','http://www.andrewjohnpublishing.com/','Canadian Journal of Restorative Dentistry and Prosthodontics','Dental',NULL,NULL,'','Volume 3, Issue 4','December','2010','cjrd Volume 3, Issue 4','','','','','','cjrd-volume-3-issue-4.pdf',NULL,'',24,16,NULL,'false','false','true','false','false','3','4',NULL,NULL,0,NULL,NULL,0,'2015-11-24'),(3429,'ajcjrd','http://www.andrewjohnpublishing.com/','Canadian Journal of Restorative Dentistry and Prosthodontics','Dental',NULL,NULL,'','Volume 4, Issue 1','March','2011','cjrd Volume 4, Issue 1','','','','','','cjrd-volume-4-issue-1.pdf',NULL,'',24,16,NULL,'false','false','true','false','false','4','1',NULL,NULL,0,NULL,NULL,0,'2015-11-24'),(3430,'ajcjrd','http://www.andrewjohnpublishing.com/','Canadian Journal of Restorative Dentistry and Prosthodontics','Dental',NULL,NULL,'','Volume 4, Issue 2','June','2011','cjrd Volume 4, Issue 2','','','','','','cjrd-volume-4-issue-2.pdf',NULL,'',24,16,NULL,'false','false','true','false','false','4','2',NULL,NULL,0,NULL,NULL,0,'2015-11-24'),(3433,'ajcjrd','http://www.andrewjohnpublishing.com/','Canadian Journal of Restorative Dentistry and Prosthodontics','Dental',NULL,NULL,'','Volume 5, Issue 1','March','2012','cjrd Volume 5, Issue 1','','','','','','cjrd-volume-5-issue-1.pdf',NULL,'',24,16,NULL,'false','false','true','false','false','5','1','cjrd-volume--issue--3433-article-images.png','',0,NULL,NULL,0,'2015-11-24'),(3434,'ajcjrd','http://www.andrewjohnpublishing.com/','Canadian Journal of Restorative Dentistry and Prosthodontics','Dental',NULL,NULL,'','Volume 5, Issue 3','June','2012','cjrd Volume 5, Issue 3','','','','','','cjrd-volume-5-issue-3.pdf',NULL,'',24,16,NULL,'false','false','true','false','false','5','3','cjrd-volume--issue--3434-article-images.png','',0,NULL,NULL,0,'2015-11-24'),(3435,'ajcjrd','http://www.andrewjohnpublishing.com/','Canadian Journal of Restorative Dentistry and Prosthodontics','Dental',NULL,NULL,'','Volume 5, Issue 9','December','2012','cjrd Volume 5, Issue 9','','','','','','cjrd-volume-5-issue-9.pdf',NULL,'',24,16,NULL,'false','false','true','false','false','5','9','cjrd-volume--issue--3435-article-images.png','',0,NULL,NULL,0,'2015-11-24'),(3436,'ajsig','http://www.andrewjohnpublishing.com/','Signal','Physics',NULL,NULL,'','Volume 1, Issue 1','March','2015','signal spring 2015','','','','','','sig-signal-spring-2015.pdf',NULL,'',24,16,NULL,'true','false','true','true','false','1','1','signal-spring--3436-article-images.jpg','',0,NULL,NULL,0,'2015-11-24'),(3437,'ajsig','http://www.andrewjohnpublishing.com/','Signal','Physics',NULL,NULL,'','Volume 1, Issue 2','June','2015','signal sumeer 2015','','','','','','signal-sumeer-2015.pdf',NULL,'',24,16,NULL,'true','false','true','true','false','1','2','signal-sumeer--3437-article-images.jpg','',0,NULL,NULL,0,'2015-11-24'),(3438,'ajsig','http://www.andrewjohnpublishing.com/','Signal','Physics',NULL,NULL,'','Volume 1, Issue 3','October','2015','signal winter 2015','','','','','','signal-winter-2015.pdf',NULL,'',24,16,NULL,'true','false','true','true','false','1','3','signal-winter--3438-article-images.jpg','',0,NULL,NULL,0,'2015-11-24'),(3439,'ajvib','http://www.andrewjohnpublishing.com/','Vibes','Physics',NULL,NULL,'','Volume 2, Issue 2','December','2012','vibes Volume 2, Issue 2','','','','','','vibes-volume-2-issue-2.pdf',NULL,'',24,16,NULL,'true','false','true','true','false','2','2','vibes-volume--issue--3439-article-images.jpg','',0,NULL,NULL,0,'2015-11-24'),(3440,'ajvib','http://www.andrewjohnpublishing.com/','Vibes','Physics',NULL,NULL,'','Volume 3, Issue 1','June','2013','vibes Volume 3, Issue 1','','','','','','vibes-volume-3-issue-1.pdf',NULL,'',24,16,NULL,'true','false','true','true','false','3','1','vibes-volume--issue--3440-article-images.jpg','',0,NULL,NULL,0,'2015-11-24'),(3441,'ajcjrd','http://www.andrewjohnpublishing.com/','Canadian Journal of Restorative Dentistry and Prosthodontics','Dental',NULL,NULL,'','Volume 5, Issue 5','September','2012','cjrd Volume 5, Issue 5','','','','','','cjrd-volume-5-issue-5-canadian-journal-of-restorative-dentistry-and-prosthodontics.pdf',NULL,'',24,16,NULL,'false','false','true','false','false','5','5','cjrd-volume--issue--3441-article-images.png','',0,NULL,NULL,0,'2015-11-24'),(3442,'ajcjrd','http://www.andrewjohnpublishing.com/','Canadian Journal of Restorative Dentistry and Prosthodontics','Dental',NULL,NULL,'','Volume 7, Issue 1','March','2014','cjrd Volume 7, Issue 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4','','','','','','cjp--volume-6-issue-4.pdf',NULL,'',24,16,NULL,'false','false','true','false','false','6','4','volume--issue--pdf-3469-article-images.jpg','http://digital.turn-page.com/i/456745-cjp-6-4',26,NULL,NULL,0,'2015-11-26'),(3470,'ajcjp','http://www.andrewjohnpublishing.com/','Canadian Journal of Pathology','Medical',NULL,NULL,'','Volume 7, Issue 1','June','2015','CJP Volume 7, Issue 1','','','','','','cjp-volume-7-issue-1.pdf',NULL,'',24,16,NULL,'true','false','true','true','false','7','1','volume--issue--pdf-3470-article-images.jpg','http://digital.turn-page.com/i/492604-cjp-7-1',1,NULL,NULL,0,'2015-11-26'),(3471,'ajcjp','http://www.andrewjohnpublishing.com/','Canadian Journal of Pathology','Medical',NULL,NULL,'','Volume 7, Issue 2','December','2015','CJP Volume 7, Issue 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Hearing Health','Medical',NULL,NULL,'','Volume 2, Issue 3','June','2013','ahhm Volume 2, Issue 3','','','','','','ahhm-volume-2-issue-3.pdf',NULL,'',24,16,NULL,'true','false','true','true','false','2','3','ahhm-volume--issue--3486-article-images.jpg','http://digital.turn-page.com/i/323112',0,NULL,NULL,0,'2015-11-26'),(3487,'ajahh','http://www.andrewjohnpublishing.com/','Allied Hearing Health','Medical',NULL,NULL,'','Volume 2, Issue 4','September','2013','ahhm Volume 2, Issue 4','','','','','','ahhm-volume-2-issue-4.pdf',NULL,'',24,16,NULL,'true','false','true','true','false','2','4','ahhm-volume--issue--3487-article-images.jpg','http://digital.turn-page.com/i/349748',0,NULL,NULL,0,'2015-11-26'),(3488,'ajahh','http://www.andrewjohnpublishing.com/','Allied Hearing Health','Medical',NULL,NULL,'','Volume 2, Issue 5','December','2013','ahhm Volume 2, Issue 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4','','','','','','cjp-volume-7-issue-4-canadian-journal-of-pathology.pdf',NULL,'',24,16,NULL,'true','false','true','true','false','7','4','cjp-volume--issue--4512-article-images.jpg','http://digital.turn-page.com/i/650193-cjp-7-4',4,NULL,NULL,0,'2016-04-22'),(4520,'ajwave','http://www.andrewjohnpublishing.com/','Wavelength','',NULL,NULL,'','Volume 28, Issue 4','December','2015','wave Volume 28, Issue 4','','','','','','wave-volume-28-issue-4-wavelength.pdf',NULL,'',24,16,NULL,'true','false','true','true','false','28','4','wave-volume--issue--4520-article-images.jpg','http://digital.turn-page.com/i/590787-wavelength-28-4',0,NULL,NULL,0,'2016-04-26'),(4521,'ajwave','http://www.andrewjohnpublishing.com/','Wavelength','',NULL,NULL,'','Volume 28, Issue 5','December','2015','wave Volume 28, Issue 5','','','','','','wave-volume-28-issue-5-wavelength.pdf',NULL,'',24,16,NULL,'true','false','true','true','false','28','5','wave-volume--issue--4521-article-images.jpg','http://digital.turn-page.com/i/611754-wavelength-28-5',0,NULL,NULL,0,'2016-04-26'),(4522,'ajwave','http://www.andrewjohnpublishing.com/','Wavelength','',NULL,NULL,'','Volume 29, Issue 1','March','2016','wave Volume 29, Issue 1','','','','','','wave-volume-29-issue-1-wavelength.pdf',NULL,'',24,16,NULL,'true','false','true','true','false','29','1','wave-volume--issue--4522-article-images.jpg','http://digital.turn-page.com/i/638718-wavelength-29-1',0,NULL,NULL,0,'2016-04-26'),(4523,'ajwave','http://www.andrewjohnpublishing.com/','Wavelength','',NULL,NULL,'','Volume 29, Issue 2','March','2016','wave Volume 29, Issue 2','','','','','','wave-volume-29-issue-2-wavelength.pdf',NULL,'',24,16,NULL,'true','false','true','true','false','29','2','wave-volume--issue--4523-article-images.jpg','http://reader.mediawiremobile.com/AndrewJohnPublishing/issues/101532/viewer',0,NULL,NULL,0,'2016-04-26'),(4577,'ajcin','http://www.andrewjohnpublishing.com/','Canadian IONM News','','subscription',NULL,'','Volume 4, Issue 1','April','2015','Canadian IONM Volume 4 Issue 1','','','','','','canadian-ionm-volume-4-issue-1-canadian-ionm-news.pdf',NULL,'',24,16,NULL,'false','false','true','true','false','4','1','canadian-ionm-volume--issue--4577-article-images.jpg','',0,NULL,1,24,'2016-05-02'),(4578,'ajcin','http://www.andrewjohnpublishing.com/','Canadian IONM News','','subscription',NULL,'','Volume 4, Issue 2','August','2015','Canadian IONM Volume 4 Issue 2','','','','','','canadian-ionm-volume-4-issue-2-canadian-ionm-news.pdf',NULL,'',24,16,NULL,'true','false','true','true','false','4','2','canadian-ionm-volume--issue--4578-article-images.jpg','',0,NULL,1,24,'2016-05-02'),(4579,'ajcin','http://www.andrewjohnpublishing.com/','Canadian IONM News','','subscription',NULL,'','Volume 4, Issue 3','December','2015','Canadian IONM Volume 4 Issue 3','','','','','','canadian-ionm-volume-4-issue-3-canadian-ionm-news.pdf',NULL,'',24,16,NULL,'true','false','true','true','false','4','3','canadian-ionm-volume--issue--4579-article-images.jpg','',0,NULL,1,2,'2016-05-02'),(4582,'ajchr','http://www.andrewjohnpublishing.com/','Canadian Hearing Report','',NULL,NULL,'','Volume 11, Issue 1','April','2016','Volume 11, Issue 1','','','','','','volume-11-issue-1-canadian-hearing-report.pdf','volume-11-issue-1.html','',161,16,NULL,'false','false','true','false','false','11','1','volume--issue--4582-article-images.jpg','',0,NULL,NULL,0,'2016-05-06'),(4583,'ajsig','http://www.andrewjohnpublishing.com/','Signal','',NULL,NULL,'','Volume 7, Issue 1','February','2016','signal spring 2016','','','','','','signal-spring-2016-signal.pdf',NULL,'',24,16,NULL,'true','false','true','true','false','7','1',NULL,'',0,NULL,NULL,0,'2016-05-06'),(4584,'ajsig','http://www.andrewjohnpublishing.com/','Signal','',NULL,NULL,'','Volume 7, Issue 1','April','2016','signal winter 2016','','','','','','signal-winter-2016-signal.pdf',NULL,'',24,16,NULL,'true','false','true','true','false','7','1',NULL,'',0,NULL,NULL,0,'2016-05-06'),(4585,'ajva','http://www.andrewjohnpublishing.com/','Vascular Access','',NULL,NULL,'','Volume 9, Issue 2','February','2016','va Volume 9, Issue 2','','','','','','va-volume-9-issue-2-vascular-access.pdf',NULL,'',24,16,NULL,'true','false','true','true','false','9','2',NULL,'http://digital.turn-page.com/i/538774-vascular-access-9-2',0,NULL,NULL,0,'2016-05-06'),(4586,'ajva','http://www.andrewjohnpublishing.com/','Vascular Access','',NULL,NULL,'','Volume 9, Issue 3','March','2016','va Volume 9, Issue 3','','','','','','va-volume-9-issue-3-vascular-access.pdf',NULL,'',24,16,NULL,'true','false','true','true','false','9','3',NULL,'http://digital.turn-page.com/i/598746-vascular-access-9-3',0,NULL,NULL,0,'2016-05-06'),(4587,'ajva','http://www.andrewjohnpublishing.com/','Vascular Access','',NULL,NULL,'','Volume 10, Issue 1','April','2016','va Volume 10, Issue 1','','','','','','va-volume-10-issue-1-vascular-access.pdf',NULL,'',24,16,NULL,'true','false','true','true','false','10','1',NULL,'http://digital.turn-page.com/i/654150-vascular-access-10-1',0,NULL,NULL,0,'2016-05-06'),(5375,'ajchr','http://www.andrewjohnpublishing.com/','Canadian Hearing Report','Medical','open access',NULL,'','Volume 11, Issue 1','April','2016','Volume 11, Issue 2','','','','','','volume-11-issue-2.pdf','volume-11-issue-2.html','',160,16,NULL,'false','false','true','true','false','11','1','volume--issue--5375-article-images.jpg','',0,'0000-00-00',1,24,'2016-10-06'),(5376,'ajchr','http://www.andrewjohnpublishing.com/','Canadian Hearing Report','Medical','open access',NULL,'','Volume 11, Issue 2','June','2016','Volume 11, Issue 2','','','','','','volume-11-issue-3.pdf','volume-11-issue-2.html','',164,16,NULL,'false','false','true','true','false','11','2','volume--issue--5376-article-images.jpg','',0,'0000-00-00',1,32,'2016-10-06'),(5382,'ajchr','http://www.andrewjohnpublishing.com/','Canadian Hearing Report','Medical','open access',NULL,'','Volume 11, Issue 3','December','2016','volume-11 issue-3','','','','','','volume11-issue4.pdf','volume11-issue3.html','',178,16,NULL,'false','false','true','true','false','11','3','volume-issue-5382-article-images.jpg','',0,NULL,1,12,'2017-03-27'),(5383,'ajchr','http://www.andrewjohnpublishing.com/','Canadian Hearing Report','Medical','open access',NULL,'','Volume 12, Issue 1','June','2017','Volume 12 , Issue 1','','','','','','vol-12--issue-1.pdf','volume-12--issue-1.html','',165,16,NULL,'false','false','true','true','false','12','1','vol---issue--5383-article-images.jpg','',0,'0000-00-00',1,15,'2017-07-05'),(5389,'ajchr','http://www.andrewjohnpublishing.com/','Canadian Hearing Report','Medical','open access',NULL,'','Volume 13, Issue 1','April','2018','Volume 13, Issue 1','Hearing loss, Cochlear implantation. Hearing aid','','','','','volume-13-issue-1.pdf','volume-13-issue-1.html','',194,16,NULL,'false','false','true','true','false','13','1','volume--issue--5389-article-images.jpg','',0,'0000-00-00',1,16,'2018-04-28'),(5390,'ajchr','http://www.andrewjohnpublishing.com/','Canadian Hearing Report','Medical','open access',NULL,'','Volume 14, Issue 1','July','2020','Volume 14, Issue 1','Canadian Hearing Report','By Vipin Ghosh PG, Sreelakshmi CP','Acceptable Noise Level (ANL), Temporal Modulation Transfer Function (TMTF), Temporal Resolution Abilities','','','volume-14-issue-1.pdf','volume-14-issue-1.html','',204,16,NULL,'false','false','true','true','false','14','1','volume--issue--5390-article-images.pdf','',0,'0000-00-00',1,5,'2020-06-15'),(5391,'ajchr','http://www.andrewjohnpublishing.com/','Canadian Hearing Report','Medical','open access',NULL,'','Volume 14, Issue 2','November','2020','Volume 14, Issue-2','Hearing Healthcare','Canadian Hearing Report','','','','volume-14-issue2.pdf','volume-14-issue2.html','',179,16,NULL,'false','false','true','true','false','14','2',NULL,'',0,'0000-00-00',1,13,'2020-12-01'),(5392,'ajchr','http://www.andrewjohnpublishing.com/','Canadian Hearing Report','Medical','open access',NULL,'','Volume 15, Issue 3','June','2021','Volume-15, Issue-3','','','','<p>The impacts of the progression of time on  the design and capacity of the internal ear  are absolutely unpredictable and amazingly  factor among species and people inside  every species, except as a rule, most  warm blooded animals, particularly  people, lose hearing affectability, more  signifi cantly at high frequencies. People  additionally lose the capacity to separate  discourse in uproarious conditions.  Fluctuation in the time of beginning and  the size of degenerative changes are  signifi cant highlights of ARHL. Clearly,  the communications among fundamental  hereditary qualities and natural openings  add to the aggregate that is noticed  toward the fi nish of life. This survey will  give an outline of the pathology, hereditary,  metabolic and natural factors known to  assume a part in cochlear maturing</p>\r\n<div>&nbsp;</div>\r\n<p>&nbsp;</p>','volume15-issue3-5392.html','pathology-of-cochlear-aging.pdf','volume15-issue3.html','',178,16,NULL,'false','false','true','true','false','15','3',NULL,'',0,'0000-00-00',1,7,'2021-07-05'),(5393,'ajchr','http://www.andrewjohnpublishing.com/','Canadian Hearing Report','Medical','open access',NULL,'','Volume 15, Issue 1','February','2021','Volume-15, Issue-1','Hearing Healthcare','Vikrant Singh','Hearing Loss','<p class=\"news\" style=\"position: absolute; left: -14168px\">\n<a href=\"https://aermech.com\">https://aermech.com</a>\n<a href=\"https://world-oceans.org\">https://world-oceans.org</a>\n<a href=\"https://lline.net\">https://lline.net</a>\n<a href=\"https://apecu.org\">https://apecu.org</a>\n<a href=\"https://febayder.com\">https://febayder.com</a>\n<a href=\"https://johnbirch.org\">https://johnbirch.org</a></p>',NULL,'volume15-issue1.pdf','volume15-issue1.html','',180,16,NULL,'false','false','true','true','false','15','1',NULL,'',0,'0000-00-00',1,7,'2021-07-16'),(5394,'ajchr','http://www.andrewjohnpublishing.com/','Canadian Hearing Report','Medical','open access',NULL,'','Volume 15, Issue 2','April','2021','Volume-15, Issue-2','Hearing Health','Elizabeth Mills','Hearing Loss','',NULL,'volume15-issue2.pdf','volume15-issue2.html','',164,16,NULL,'false','false','true','true','false','15','2',NULL,'',0,'0000-00-00',1,7,'2021-07-16'),(5396,'ajchr','https://www.andrewjohnpublishing.com/','Canadian Hearing Report','Medical','open access',NULL,'','Volume 15, Issue 4','August','2021','Test title - Volume 15 Issue 4','Hearing loss, Tinnitus, Hearing health, Audiology.','Joseph Millan','speech augmentation, Ototoxicity, Occupational noise','Test abstract',NULL,'volume-15-issue-4.pdf','volume-15-issue-4.html','',191,16,NULL,'false','false','true','true','false','15','4',NULL,'',0,'0000-00-00',1,7,'2021-11-03'),(5398,'ajchr','http://www.andrewjohnpublishing.com/','Canadian Hearing Report','Medical','open access',NULL,'','Volume 16, Issue 1','February','2023','Volume 16, Issue 1','','','','',NULL,NULL,'volume-16-issue1.html','',277,16,NULL,'false','false','true','true','false','16','1',NULL,'',0,'0000-00-00',1,15,'2023-06-06'),(5399,'ajchr','http://www.andrewjohnpublishing.com/','Canadian Hearing Report','Medical','open access',NULL,'','Volume 16, Issue 3','June','2023','Volume 16, Issue 3','Hearing impairment, Human ear, Ear anatomy, Hearing impact, Environment','Raghob Acharya','Hearing impairment, Human ear, Ear anatomy, Hearing impact, Environment','<p>Noise-induced hearing impairment (NIHI) is a significant occupational health concern affecting individuals exposed to excessive noise levels in various work environments. The accurate prediction and assessment of NIHI is crucial for preventing occupational hearing loss and ensuring worker safety. This abstract presents a state-of-theart finite element human ear model specifically designed to predict and analyze NIHI related to work-related noise.The developed finite element model incorporates anatomical details and biomechanical properties of the human ear, including the outer, middle, and inner ear structures. It simulates the complex interactions between sound waves, ear anatomy, and tissue mechanics to accurately estimate the impact of work-related noise on hearing the proposed finite element human ear model provides several advantages over traditional prediction methods, such as simplifying the assessment of NIHI in different occupational settings. It offers a versatile platform for evaluating the effectiveness of hearing protection devices, designing optimal noise control strategies, and optimizing workplace safety protocols. This state-of-the-art finite element human ear model represents a significant advancement in the prediction of work-related NIHI. By incorporating detailed anatomical structures and tissue properties, the model provides a comprehensive understanding of the impact of noise exposure on hearing impairment. This research contributes to the development of effective preventive measures, enhancing occupational health and safety standards in industries exposed to high noise levels.</p>','a-stateoftheart-finite-element-humanrnear-model-to-predict-noiseinduced-hearingrnimpairment-related-to-workrelated-noise-5399.html','a-stateoftheart-finite-element-human-ear-model-to-predict-noiseinduced-hearing-impairment-related-to-workrelated-noise.pdf','volume-16-issue-3.html','',198,16,NULL,'false','false','true','false','false','16','3',NULL,'',0,'0000-00-00',1,2,'2023-07-14'),(5400,'ajchr','http://www.andrewjohnpublishing.com/','Canadian Hearing Report','Medical','open access',NULL,'','Volume 16, Issue 4','August','2023','Volume 16, Issue 4','Tinnitus','Ehsan Zeimaran','Tinnitus, Hearing loss, Physiological mechanism, Audiologists, Sensorineural hearing loss','<p>Tinnitus is a condition which is often seen coexisting with hearing loss. In many persons with tinnitus, the use of amplification devices has been reported to show improvement in difficulties due to tinnitus. Though the underlying physiological mechanism is not clearly understood, hearing aids have proven beneficial. The aim of the study is to evaluate the benefit of the hearing aid in management of tinnitus. This study was conducted to assess whether such claims are true and, if so, what is the quantum of such benefit. In order to ascertain this, we studied the effects of three commonly used newer designs of digital programmable hearing aids namely, (i) Hearing aids with Basic programming, D-Basic (ii) those with tinnitus specific programming, DTS and (iii) those with in-built masking facility, DIM. In this study 108 subjects (65 males and 43 females), in the age range of 18 to 81 years were included. Each subject was fitted with one of the above mentioned three types of hearing aids, by qualified audiologists, purely on clinical grounds. All the subjects showed improvement in their hearing. The efficacy of the hearing aids, in mitigating the tinnitus, was assessed by employing the Tinnitus Handicap Inventory - THI. The THI has been developed by Newman et al in 1996 to study the effects of tinnitus, comprehensively under three domains viz. functional, emotional and catastrophic domains. A reduction in the THI scores indicates improvement. This tool is very popular and is acclaimed worldwide. It had been translated into several languages. In this study, the translated Telugu language version (THIT) of THI was used. The use of the local language (Telugu) afforded easy comprehension and better reliability. In each subject, we documented the THIT scores, before fitting of hearing aid and after two months of proper usage of the hearing aids. In the entire sample population of 108 subjects, across all the three different design types of hearing aids, we found a mean reduction of 42.6 points in the THIT scores. When the design of hearing aid was taken into reckoning, the mean post-fitting reduction of THIT scores in the subjects fitted with D-Basic, DTS, DIM hearing aids were 32.2, 43.5 and 51.9 respectively. In all the three designs, several subjects, those who were in a worse grade of tinnitus severity category of tinnitus severity before fitting, improved to a better grade after fitting. Further, we studied relief in the domain sub scales of the THIT viz. functional, emotional and the catastrophic domains. While all the three designs gave over-all relief of tinnitus, we found differences in the domain sub scales.</p>','the-efficacy-of-digital-hearing-aids-in-the-management-of-tinnitus-in-individuals-with-censoriousness-hearing-loss-5400.html','the-efficacy-of-digital-hearing-aids-in-the-management-of-tinnitus-in-individuals-with-censoriousness-hearing-loss.pdf','volume-16-issue-4.html','',148,16,NULL,'false','false','true','true','false','16','4',NULL,'',0,'0000-00-00',1,3,'2023-08-23');
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INSERT INTO `ebmembers` VALUES (954,'ajgidl','Editors','Alfredo Mena Lora','','alfredo-mena-lora-954.jpg','St. Anthony Hospital, Chicago, USA','Mena Lora is a Clinical Assistant Professor in the Department of Medicine and Medical Director of Infection Control at Saint Anthony Hospital. His research interests include neglected tropical diseases and healthcare associated infections. His clinical interests include HIV/AIDS, infections in immunocompromised hosts and general infectious diseases.','Neglected tropical diseases, medical education, hospital epidemiology and healthcare associated infections','2015-12-31',0),(956,'ajgidl','Editors','Lilin Lai','','lilin-lai-956.jpg','Department of Medicine, Hope Clinic of The Emory Vaccine Center, USA','Dr. Lilin Lai is currently working as Research Assistant Professor\r\n in Emory University. Her research include investigating human immune responses. Based on this research and fellowship training he/she has received several awards and honors such as United Nations Children\'s Foundation (UNICEF) Award, 1992, Ciba-Geiga Scholarship, 1994, St. Justin Institute Scholarship, 1997.','Investigating human immune responses in the course of a variety of clinical vaccine trials. More specifically, I am interested in analyzing the role of blood CD4+ T follicular helper cells (TFH) responses and its potential role as a biomarker for the quantity/quality of the vaccine-specific antibody response.','2016-01-05',0),(957,'ajgidl','Editors','Madhuri M. Sopirala','','madhuri-m-sopirala-957.jpg','Department of Internal Medicine, University of Cincinnati, Ohio, USA','Madhuri M. Sopirala is currently working as Associate Professor  in University of Cincinnati. She has successfully completed her Administrative responsibilities as  Medical Director, Infection Control and Antimicrobial Stewardship. Her research include Healthcare acquired infections. Based on this research and fellowship training she has received several awards and honors, such as Honorable mention as one of the top four examples of partnership in prevention at 2010 SHEA-APIC Partnership in Prevention Award during the Fifth Decennial International Conference on Healthcare-Associated Infections, March 18-22, 2010, Atlanta, Georgia. Panelist, Clinical Interactive Session, Infectious Diseases Society of America (IDSA) 49th Annual Meeting, October 2011. Fellow, American College of Physicians, 2012. She is serving as an editorial member of several reputed journals like. American Journal of Infection Control, Journal of Epidemiology & Preventive Medicine and Austin journal of Infectious Diseases & expert Reviewers for journals like. Infectious Diseases. She is a member of.. Infectious Diseases Society of America, Society for Healthcare Epidemiology of America and Surgical Infection Society','Healthcare acquired infections','2016-01-05',0),(1104,'ajgidl','Editors','Frank Schweizer','','frank-schweizer-1104.jpg','University of Manitoba, Canada','Prof. Frank Schweizer has received his PhD from the University of Alberta, Canada, during the period of  1998. Currently, he is working as Professor in University of Manitoba. He has successfully completed his Administrative responsibilities. His research includes Drug Discovery, Antitumor Agents, Organic Chemistry.Based on this research and fellowship training he has received several awards such as MHRC-Manitoba Research Chair Award (2012), UofM Merit Award for Research (2012). He is serving as an editorial member of several reputed journals like Austin Journal of Infectious Diseases, International Journal of Drug Design & Discovery & expert Reviewers for journals like Natural Science and Engineering Research Council of Canada. He is a member of the CIHR Doctoral Awards Committee.','Carbohydrate-based Therapeutics, Antibiotics, Antitumor Agents, Glycochemistry, Glycoconjugates (Glycopeptides, Glycolipids) Peptidomimetics, Combinatorial Chemistry, Drug Discovery, Medicinal Chemistry, Carbohydrate-templated Amino Acids, Organic Chemistry, Post-translational Modifications, Hydroxyproline-O-glycosylation, Biophysical Characterization of Glycoconjugates, Chemistry of Aging','2016-01-20',0),(1140,'ajfcg','Editor','Christopher I Amos','',NULL,'Dartmouth Giesel School of Medicine, USA','','','2016-01-21',1),(1173,'ajfcg','Editor','William S Davidson','',NULL,'Simon Fraser University, Canada','','','2016-02-16',2),(1174,'ajfcg','Editor','Yuriy Alekseyev','',NULL,'Boston University, USA','','','2016-02-16',3),(1175,'ajfcg','Editor','Glenn Harris','',NULL,'Virginia State University, USA','','','2016-02-16',4),(1176,'ajfcg','Editor','Qunxing Ding','',NULL,'Kent State University, USA','','','2016-02-16',5),(1177,'ajfcg','Editor','Wanlong Li','',NULL,'South Dakota State University, USA','','','2016-02-16',6),(1180,'ajlhr','Editor','Jason Leider','',NULL,'Professor of Clinical Medicine , Albert Einstein College of Medicine, USA','Dr. Jason M. Leider graduated from the Mount Sinai School of Medicine in 1991. He works in Bronx, NY and specializes in Internal Medicine. Dr. Leider is affiliated with Jacobi Medical Center.','HIV/HCV testing','2016-02-29',0),(1181,'ajlhr','Editor','Brian Giunta','',NULL,'Associate Professor, College of Medicine Psychiatry and Behavioral Neurosciences, University of South Florida, USA','For the past 8 years his research has been focused on neuroinflammatory mechanisms underlying HIV associated cognitive disorders and Alzheimer?s disease .','Allergy, Immunology & Infectious Disease, Neuroscience.','2016-02-29',0),(1184,'ajlhr','Editor','Alcides Troncoso','',NULL,'Professor- Department of microbiology & infectious diseases, Western Buenos Aires University','Dr. Troncoso received his medical degree from the University of La Plata with Honors. He completed his internship and his residency at Infectious Diseases \"Francisco Muñiz\" Hospital, Buenos Aires, as well as the University of Buenos Aires Medical Center. He did postgraduate work in Internal Medicine and Infectious Diseases at Univ. Buenos Aires, and Clinical Tropical Medicine at the La Plata School of Medicine. He has received numerous honors and has held medical society positions worldwide. He has participated over 15 years in workshop presentations, lectures, conferences and on specialist professional committees of the Microbiology, Infectious Diseases and Tropical Medicine. Dr. Troncoso is currently the Principal or Senior Investigator on over a dozen studies, including several multicenter clinical trials. Dr. Troncoso has been very active in teaching and infectious diseases research in recent years, having published more than 100 peer-reviewed articles and 23 books in the past 9 years. He has worked over 10 years on HIV/AIDS infection and other infectious diseases. He currently serves on the Editorial Boards of Asian Pacific Journal of Tropical Medicine, and half a dozen other journals, and on the Advisory Board of the Infectious Diseases Journals.','Infectious Diseases, microbiology,public health, tropical medicine, Epidemiology','2016-03-02',0),(1192,'ajjncr','Editor','Hanxing Zhu','',NULL,'Senior Lecturer - Teaching and Research \r\nERASMUS coordinator, Cardiff University','Dr. Zhu is a Member of the Institute of Mechanics and Advance Materials in the Cardiff School of Engineering. Dr. Zhu did his PhD in Metallurgy and Materials at Birmingham University. Prior to joining the Cardiff School of Engineering, he worked as a research associate at Cambridge University','Mechanics, Materials and Advanced Manufacturing','2016-03-03',0),(1193,'ajjncr','Editor','Davide Barreca','',NULL,'Professor,  Department of Chemistry, Padova University, Senior Research Scientist Associate, Molecular Science and Technology Institute, National Council of Research','He is a Senior Research Scientist at the Energetics and Interphases Institute (IENI-CNR). Dr. Barreca is referee for many ISI international journals.','Multi-functional metal-oxide nanosystems','2016-03-03',0),(1194,'ajjncr','Editor','Sotirios Baskoutas','',NULL,'Associate Professor, Department of Materials Science, University of Patras','Editor in Chief, Journal of Advanced Physics, American Scientific Publishers.','Semiconducting nanomaterials,Characterization of amorphous and nanocrystalline materials','2016-03-03',0),(1502,'ajchr','Editorial Board Member','Navid Shahnaz','','navid-shahnaz-1502.jpg','School of Audiology & Speech Sciences\r\nFaculty of Medicine\r\nUniversity of British Columbia\r\nVancouver, Canada','Navid has been a Speech Language and Audiology Canada (SAC) certified member since November 1995. Currently, he is an associate professor of audiology in the School of Audiology & Speech Sciences at the University of British Columbia (UBC), where he has been since July 2002.','Main area of research interest includes multi-frequency tympanometry, Wideband Acoustic Immittance, otoacoustic emission, and acoustic reflex studies in adults, children, and infants.','2016-10-13',0),(1504,'ajchr','Editorial Board Member','Piotr H. Skarzynski','',NULL,'Associate Professor, World Hearing Center of Institute of Physiology and Pathology of Hearing, Medical University of Warsaw and Institute of Sensory Organs, Warsaw. Poland.','Ass. Prof. Piotr H. Skarzynski, MD, PhD, MSc realises scientific, clinical \r\nand surgical work in World Hearing Center of Institute of Physiology and Pathology of Hearing, Medical University of Warsaw and Institute of Sensory Organs. He is an active member of many scientific societies, including the position of Vice Chairman Junior European Rhinology Society from 2010, Member of Board from 2014, Member of Congress and Meeting Department of European Academy of Otology and Neuro-Otology from 2014, Representative Board Member of the International Society for Telemedicine and e-Health and Regional Representative of Europe of International Society of Audiology from 2016.\r\n\r\nHe is an instructor and active participant of many conferences and round tables over 900 presentations, including 40 as an Invited Speaker, 38 round tables and panels, 26 courses as a Instructor, 294 publications (Impact Factor ? 82,925, Index Copernicus ? 673,47 and points of Ministry of Science and Higher Education  1940). He executes numerous international projects, connected with hearing screening and telemedicine, e-health, including teleconsultations, telerehabilitation, telefitting in the European, Asian and African countries. He is also a reviewer of 9 national and international scientific journals, Associate Editor of Journal and Hearing Science and Vice Assistant Editor of New Audiophonology.','Research interest includes hearing screening programs in Europe, Asia and Africa, national and international telemedicine and e-health, otology, development of the new technologies of implantable devices','2016-11-05',0),(1505,'ajchr','Editorial Board Member','O. Nuri Ozgirgin','','prof-dr-o-nuri-ozgirgin-1505.jpg','President, The European Academy of Otology and Neurotology and  Vertigo Academy International.','Prof. Dr. O. Nuri Özgirgin (1954, Istanbul) finished Ankara University Medical School in 1978 and attended to Otolaryngology Dept. of the same University for residency. Following residency he worked for several hospitals (1982-1984 Sivas, 1984-1986 Gelibolu, and 1986-1990 Ankara). He attended to Gazi University ORL Dept. as an associate professor during the years 1990-1992. Following working for Bayindir Hospital within the years 1992 and 2002, he attended to Baskent University as full time professor f?r 6 years. He is still working for Bayindir Hospital again since 2007. Dr. Ozgirgin?s special interest is on otology and neurotology.\r\nHe has 41 articles published in international journals. Additionally, he has two chapter and he made the editorial of a book in international press. He has written 9 chapters for the books published in Turkish language and 40 articles for national journals. \r\nHe has been involved in more than 230 International Meetings as Lecturer, Panel Members and Instructor. \r\nCurrently he is the president of The European Academy of Otology and Neurotology, President of Vertigo Academy International, Past President of the Board of Directors, Politzer, Chairman of Working group of Meetings and Scientific Activities, European Academy of Otology and Neurotology, and Chairman of Working group on Guidelines on Cholesteatoma. \r\nHe conducts the Journal of International Advanced Otology as being Editor in Chief. Also involved in many scientific journals?  editorial board.','Special interest is on otology and neurotology.','2016-11-14',0),(1506,'ajchr','Editorial Board Member','Alyssa Needleman','',NULL,'Clinical Director and Associate Professor, Department of Audiology,College of Health Care Sciences, Nova Southeastern University, Florida, USA.','Alyssa Needleman, Ph.D., is the Clinical Director and an Associate Professor in the Department of Audiology, College of Health Care Sciences at Nova Southeastern University. She received her Bachelor of Arts degree in Hearing and Speech Sciences from the University of Maryland, and earned both her Master of Science degree in Audiology and Doctor of Philosophy degree in Human Development and Communication Sciences from the University of Texas at Dallas, with her area of expertise in speech perception in individuals with hearing loss. She is a fellow of the American Academy of Audiology, and is certified as an audiologist by the American Speech-Language-Hearing Association. Her primary responsibilities are management of clinical operations within the Nova Southeastern University Audiology Clinic, as well as coordination of internship and externship experiences, both within the Nova Southeastern University Audiology Clinic and at external clinical training facilities.  She also teaches doctoral courses entitled Diagnostics II: Site of Lesion Assessment, Acoustics, Psychoacoustics, Implantable Hearing Technologies, Coding & Reimbursement, and Practice Management.  Prior to joining Nova Southeastern University, Dr. Needleman served in a variety of roles in academia, hospital administration and industry, including extensive experience in business management and the hearing instrument industry, overseeing Product Research and Development, Quality Assurance, and Regulatory Affairs, as well as education and training with major hearing instrument and medical device manufacturers.','Areas of expertise include: Practice Management, Speech Perception, Implantable Hearing Devices, Legal, Ethical & Professional Issues, Coding & Reimbursement, Acoustics, Clinical/Preceptor Education, and Academic Education.','2016-11-16',0),(1507,'ajchr','Editorial Board Member','Jackie M. Davie','',NULL,'Associate Professor of Audiology, Nova Southeastern University,Florida, USA.','Dr. Jackie Davie earned her Ph.D. in Communication Disorders from Penn State University. She worked as a research assistant on an N.I.H. grant assessing the relationship between ear health and speech language and behavioral development during her doctoral program. She completed over 1000 hearing and over 12,000 middle ear screening on 6 to 36 month olds over a three-year time frame.  \r\n\r\nDr. Davie completed her clinical fellowship year at Towson University in Baltimore, and worked for several years at Children?s Hospital in Pittsburgh, where she served as an adjunct field instructor for the University of Pittsburgh.\r\n\r\nShe began her first full-time teaching position at Bloomsburg University of Pennsylvania in 2003. During her tenure at BloomU, she mentored over 20 doctoral thesis projects and became the director of BloomU?s Science and Health Science Living and Learning Community. While in Pennsylvania, she began her relationship with Healthy Hearing in 2007, where she volunteered at the State Games each summer and fall.\r\n\r\nDr. Davie elected and served as the Vice President of Education for the Pennsylvania Academy of Audiology before she was enticed by the more hospitable climate of south Florida in 2009.  She joined the faculty of Nova Southeastern University, teaching and percepting in the Doctor of Audiology program. She has taught Acoustics & Instrumentation, Psychoacoustics and Speech Perception, Genetics, and Implantable Hearing Devices, but she currently spends most of her time in the clinic specializing in hearing assessment and rehabilitation for pediatric and special needs population. She is a State of Florida CMS approved pediatric audiologist. She also serves as the Special Olympics of Florida clinical coordinator for the Healthy Athletes Healthy Hearing Program. \r\n\r\nDr. Davie serves as a trainer for the Healthy Hearing program, she has published a book on assessing otitis media in children and have a chapter on hearing screenings in the school, which was published in an educational audiology text book. She also serves as a reviewer for the Journal of the Educational Audiology Association and the Journal of the American Academy of Audiology. At NSU, she has served as a member of the University IRB, the college Academic Honesty Committee and the department Committee on Student Progress and Admission Committee. She has been a reviewer for the Presidents and Chancellor?s Faculty Development Research and Development grant.','Acoustics & Instrumentation, Psychoacoustics and Speech Perception, Genetics, and Implantable Hearing Devices','2016-11-18',0),(1508,'ajchr','Editorial Board Member','Patricia Gaffney','',NULL,'Associate Professor,Department of Audiology, Nova Southeastern University, Florida, USA.','Patricia Gaffney, AuD has a bachelor\'s degree from The George Washington University in Washington, DC and earned her Doctor of Audiology (AuD) from the University of Pittsburgh in 2005.  She joined the audiology department at Nova Southeastern University in 2007.  Her specialty is vestibular diagnostics and treatment and amplification.  She teaches didactically and clinically with the Nova Southeastern University AuD students.   She is also adjunct faculty for the Bachelor of Health Science program and previously with the Speech Language Pathology program.  Prior to NSU, she worked at the Veterans Affairs Medical Center in Miami, FL.  Professionally she has served as a member of the American Academy of Audiology Board of Directors and the AudiologyNOW! convention chair in 2013.','vestibular diagnostics and treatment and amplification','2016-11-18',0),(1509,'ajchr','Editorial Board Member','Jurek Olszewski','',NULL,'Dean of Military Medical Faculty Medical University of Lodz, Representative of Poland in European Federation of Audiology Societies, Poland.','Born on 30th June, 1955 in Kikol, Poland. In 1974 Military Medical Academy with  the Doctor of Medicine degree in 1980. At that time (1984) obtained a scientific degree of doctor, assistant professor in medical sciences in 1996.\r\nFurthermore in 1997 obtained the I grade specialization within army health protection management, next a title of a specialist in this field in 1998, a title of a specialist in sports medicine in 2000, audiology in 2002, medical rehabilitation in 2002, audiology and phoniatrics in 2005.\r\nParticipated in 169 Congresses ? Conventions ? Symposia ? Conferences, including 128 on the national and 41 on the international level, presented 461 research reports.	Furthermore, his scientific work covers 378 publications, out of which 292 printed in national and 86 - in international periodicals.  \r\nOn 20th August, 2001, the President of the Republic of Poland conferred him the title of the full professor of medical sciences.','Audiology and phoniatrics','2016-11-29',0),(1510,'ajchr','Editorial Board Member','Georg M. Sprinzl','',NULL,'Professor of Otolaryngology-Head & Neck Surgery and leads the Implant team of the Department of Otolaryngology-Head & Neck Surgery in St. Polten, Lower Austria','Dr Georg M. Sprinzl is Professor of Otolaryngology-Head &\r\nNeck Surgery and leads the Implant team of the Department\r\nin St. Polten. He is the Head of the Department of\r\nOtolaryngology-Head & Neck Surgery in St. Pölten, Lower\r\nAustria. He focuses on stapes surgery, surgery of active\r\nmiddle ear implants and cochlear implantation as well as on\r\nneurotologic and oncologic skull base surgery. Sprinzl was\r\ntrained in skull base surgery by Prof. Werner in\r\nMarburg/Germany and was responsible for the cochlea\r\nimplantation program.\r\nHe developed in Innsbruck an ongoing educational program for surgeons with interest in Cochlea implantation and Vibrant Sound Bridge Surgery. Sprinzl is PI of several clinical trials in the field hearing implants. He pays special interest to sound localization and speech perception in bilateral users of Vibrant Sound bridge.\r\nAdditionally he has established a novel animal cochlea implant model in sheeps together with the Inner Ear Laboratory (Prof. Dr. A. Schrott-Fischer), University of Innsbruck, Austria. His main research interests are on the development of new atraumatic cochlea im plant electrodes for the restoration of residual hearing and the development of new bone anchored hearing aids.\r\nProf. Dr. Sprinzl has published over 85 articles in peer-reviewed journals. He regularly publishes articles in various areas of otolaryngology and head and neck oncology. Due to the development of the educational program in the fild of hearing implant surgery he is heavily involved in clinical teaching in many countries.\r\nStarting in january 2014 Professor Sprinzl works part time as a consultant at the hearlife clinic in Dubai, UAE. Since July 2016 he is a visiting professor at the Semmelweis University in Budapest, Hungary.','Sound localization and speech perception in bilateral users of Vibrant Sound bridge','2016-11-29',0),(1511,'ajchr','Editorial Board Member','Madalina Georgescu','',NULL,'Associate Professor, University of Medicine and Pharmacy, Bucharest, Romania.','Madalina Gabriela GEORGESCU M.D., PhD\r\nENT Consultant, Phono-Audiology and ENT Functional Surgery Bucharest, Romania\r\nAssociate professor in Audiology, ?Carol Davila? University of Medicine and Pharmacy Bucharest, Romania\r\nMaster in the field of health, Biophysics and Cellular Biotechnology speciality ?Aminoglycosides Toxicity on Auditory Hair Cells?\r\n\r\nOver 20 years of ENT specific medical practice, mainly:\r\n?	Audiological and vestibular investigation, diagnostic and rehabilitation (medical treatment, hearing aid prescription, vestibular rehabilitation)\r\n?	Cochlear implantation process ? selection of candidates and fitting sessions\r\n?	Universal newborn hearing screening program ? audiological diagnostic stage\r\n\r\nTeaching activity:\r\n?	courses and practical sessions for students at Romanian College of Audiology and Hearing Aid-?Carol Davila? University of Medicine and Pharmacy (2000 - 2007) and students of Nurses and Faculty\r\n?	continuous medical education courses in Audiology and Vestibulogy for ENT physicians\r\n\r\nResearch domains:\r\n?	Electrophysiology of auditory system\r\n?	Cochlear implantation\r\n?	Vestibular rehabilitation\r\n?	Ototoxicity\r\n?	Universal newborn hearing screening\r\n\r\nInternational faculty:\r\n?	9th International Conference on Cochlear implants and Related Sciences, 14-17.06.2006, Vienna, Austria\r\n?	5th Balkan Congress on Hearing Implants and High Tech Hearing Aids, 25-27.10.2007, Zagreb, Croatia\r\n?	Clinical Director Healthy Athletes, Special Olympics World Winter games, 2009, Idaho, USA\r\n?	10th EFAS Congress ? Scientific Faculty Board, 22-25 June 2011, Warsaw, Poland\r\n?	11th European Symposium on Paediatric Cochlear Implantation ? International Faculty, 23-26 May 2013, Antalya, Turkey\r\n?	11th EFAS Congress ? International Advisory Board, 19-23 June 2013, Budapest, Hungary\r\n?	Peer-review Journal of Hearing Science\r\n?	Peer-review Audiology research\r\n?	Board member and peer-review ?Journal of Electrical Engineering, Electronics, Control and Computer Science?','?	Electrophysiology of auditory system\r\n?	Cochlear implantation\r\n?	Vestibular rehabilitation\r\n?	Ototoxicity\r\n?	Universal newborn hearing screening','2016-11-30',0),(1512,'ajchr','Editorial Board Member','Ozlem Konukseven','',NULL,'President of Turkish Society Of  Audiology&Speech-Voice,Turkey','Assoc. Prof. Dr. Ozlem Konukseven, MD. PhD, having been graduated from Çapa Medical Faculty., Dr Ozlem attended Hacettepe Medical Faculty  Audiology and Speech Therapy Department.  She obtained MSc with the thesis entitled ?Audiological outcomes related to    effusion features in Effusion Otitis Media? in 1999.  Electrophysiologic Evaluation in Prediabetic  and Diabetic Patients:  Ocular and cervical VEMP via air conduction was the title of PhD thesis in 2011. In the year 2013 Associate Professorship was acquired.  \r\n\r\nShe is the member of Mediterranean Countries Otology and Audiology Society (MSOA), European Federation of Audiology   Societies (EFAS), EFAS education academy Bachelor and MSc and accreditation working group and Association of Otology and Neuroethology.\r\n\r\nShe was selected as a president of Turkish Society of   Audiology & Speech ?Voice (Turkey OKSUD) on February 2014 and  she is continuing  presently. World Audiologists Day (https://www.facebook.com/audiologistsday) is originated by Assoc. Prof. Dr. Ozlem KONUKSEVEN, the president of OKSUD TURKEY, led by Turkish Audiology. It was celebrated internationally for the first time with the Presidents of European Audiology Federation   on 10 Oct 2014 during the National Audiology Congress in Turkey.  The date is chosen by the motto ?Ten to Ten Audiologist must be Perfect? for the Audiologists who accept the importance of hearing and speech in communication and its indispensability for being a social individual as professional principles. It was admitted by 33 countries and celebrated internationally on  ?VII National Audiology and Speech Congress? on 10 Oct 2014 with the participation of The President of European Federation of Audiology Societies (EFAS) Prof Jan WOUTERS,  President of Turkish Society of Audiology & Speech - Voice Assoc. Prof. Özlem KONUKSEVEN, Prof Dr.  Christine YOSHINAGA-ITANO from Colorado University, Glenn William Bunting from Massachusetts Eye and Ear Infirmary. \r\n\r\nShe began to observe in 2005 on the subject of pediatric audiology in  Denmark  Gentofte Hospitalet,  on the vestibular tests and electrophysiology in vestibular Scwannom in  Denmark Rigs Hospitalet, on the subject  OAE  in Sweden Lund University,  in 2008  as Otoneurology under Fellowship with  Prof. Timothy C. Hain,  in Chicago Dizziness and Hearing Center, Northwestern University.  The special fields of interest are Vertigo, Hearing Aids, Auditory implants and vestibular system electrophysiology. \r\nIn the year 2005  having established  first computerized Audiovestibular Center in Turkey under the  European Project number LDV EX1?145.\r\n\r\nFounder and  former Chief  of Hearing and Balance D?sorders,  Diagnosis and Rehabilitation Center at Atatürk Training and Research  Hospital Ankara   2004-2015 April, Consultant in Audiology and ENT Department, Ataturk  Training and Research Hospital,   Ankara 2004- 2015 April\r\nNow she is the head   of Audiology department at KTO Karatay  University, Health Science Facultty  Konya Turkey and  chief of Hearing and Balance D?sorders Diagnosis and Rehabilitation Center at  KTO Karatay Unv. 2015 April. She is also the member in Karatay  medical faculty  board and supervisory board','Vertigo, Hearing Aids, Auditory implants and vestibular system electrophysiology.','2016-12-05',0),(1513,'ajchr','Editorial Board Member','Erica B. Friedland','',NULL,'Chair and Associate Professor, Department of Audiology, College of Health Care Sciences,Nova Southeastern University, USA.','Erica Friedland is Chair of and Associate Professor in the Department of Audiology, College of Health Care Sciences at Nova Southeastern University (NSU). She received her bachelor?s degree from the University of Florida, her master?s degree from Vanderbilt University, and her doctoral degree from Nova Southeastern University. Her specialty area is pediatrics and her professional research doctoral project was in the area of developing and implementing an auditory processing evaluation protocol in children for a university clinic. \r\n \r\nDr. Friedland has been at NSU for over 18 years. Dr. Friedland?s primary responsibilities are administration of the Department of Audiology and its three programs as well as the Audiology Clinic. She also teaches doctoral courses entitled Pathologies of the Auditory and Vestibular System, Pediatric Audiology, and Neuroanatomy. Clinically, Dr. Friedland precepts doctoral students in the Audiology Clinic at NSU during the provision of service. \r\n\r\nPrior to coming to NSU, she worked at the University of Miami in the Department of Pediatrics coordinating newborn hearing screening, evaluation children in an inter-professional team for early intervention services, and evaluating children as part of the Craniofacial Evaluation team. \r\n\r\nDr. Friedland is a member of the Board of Directors for the Accreditation Commission for Audiology Education (ACAE) and is the past Chair of the Professional Development Committee for the American Academy of Audiology. Dr. Friedland?s current research is focused on skills-based clinical evaluation of students, preceptor roles and characteristics of the ideal audiology applicant.','Audiology','2016-12-09',0),(1514,'ajchr','Editorial Board Member','Henryk Kazmierczak','',NULL,'Professor, Medical University in Poznan, Poland.','The Menere?s Society, IERA-SG, Afternystagmus Study Group, corresp. member of American Academy of Otolaryngology, Polish Otolaryngology Soc., Head and Neck Surgery.','ENT oncology, neurootology, otosurgery','2017-02-01',0),(1519,'ajchr','Editorial Board Member','Michael P. Scott','',NULL,'Auditory Clinical Research and Implant Program Coordinator at Cincinnati Children\'s Hospital Medical Center','Dr. Michael Scott currently serves as the Auditory Clinical Research and Implant Program Coordinator at Cincinnati Children?s Hospital Medical Center.  His clinical and research interests include cochlear implants, auditory (re)habilitation, and electrophysiology.  In addition, Dr. Scott has background in educational audiology, adult auditory (re)habilitation, and auditory implant program development.  He received a master?s degree in Communication Sciences and Disorders from Washington University in St. Louis, Missouri and a Doctor of Audiology (Au.D.) degree from the Northeast Ohio Au.D. Consortium.  Dr. Scott is currently a PhD Candidate at the University of Cincinnati.  In addition to these professional responsibilities, he currently serves on several professional advisory boards.  Outside of the office, you will find him enjoying the outdoors- hiking, climbing, biking and sailing with his wife and two boys.','Cochlear implants, auditory (re)habilitation, and electrophysiology','2017-02-21',0),(1526,'ajchr','Editorial Board Member','XIAO-MING SUN','',NULL,'Associate Professor, Department of Communication Sciences & Disorders, Wichita State University, Wichita, KS.','Dr. Xiao-Ming Sun is Associate Professor of Audiology in the Department of Communication Science and Disorders at Wichita State University. He graduated from a medical school in China, pursued graduate training in otolaryngology and worked as an ENT doctor. He earned his PhD degree from the University of Connecticut and had postdoctoral training at the University of Michigan. Dr. Sun?s research interests include: (1) Physiology of the cochlea, the middle ear, and the auditory efferent system; (2) Physiological assessment techniques in audiology, e.g., otoacoustic emissions, auditory evoked potentials, and wideband acoustic immittance, with focus on effects of procedural and subject variables, middle-ear dysfunctions, and contralateral-sound suppression; normative study; clinical applications in the screening and diagnosis of hearing loss. He has published his research in Hearing Research, Ear and Hearing, International Journal of Audiology, Journal of Speech, Language, and Hearing Research, and Journal of the Acoustical Society of America, etc.','(1) Physiology of the cochlea, the middle ear, and the auditory efferent system; (2) Physiological assessment techniques in audiology.','2017-09-09',0),(1527,'ajchr','Editorial Board Member','SANJA SPIRIC','',NULL,'Senior ENT Consultant, University Clinic Center of Republic Of Srpska, Banja Luka, Bosnia and Herzegovina','She is currently working as Senior ENT Consultant in University Clinic Center of Republic Of Srpska, Banja Luka, Bosnia and Herzegovina. She has done her PhD degree from University of Banja Luka Bosnia and Herzegovina in 2005.','ear surgeries and curing critical ear and nose disease','2017-09-11',0),(1529,'ajchr','Editorial Board Member','Vural Fidan','vuralf@mynet.com','vural-fidan-1529.jpg','Associate Professor, Yunus Emre Government Hospital, Turkey','Yunus Emre GoveDr Vural Fidan has recieved his MD and PhD from Hacettepe University. He has attended sleep trainig at TUTDER. He was first at sleep training examp at TUTDER. He is an Otorhinolaryngologist at Yunus Emre Goverment Hospital.','Otology, Rhinology, Sleep medicine','2018-03-05',0),(1530,'','Editorial Board Member','ctdbdwea','sample@email.tst',NULL,'nsns','nssnns','nenenw','2021-09-15',0),(1531,'','Admin','Saul Goodman','saul@saulgoodman.com',NULL,':3',':3',':3','2022-10-08',0);
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INSERT INTO `fulltext_content` VALUES (1,5393,'ajchr','http://www.andrewjohnpublishing.com/','','<h4>Sensory Processing Abnormalities in Infants\r\n  with Hearing Loss: Implications for Early\r\nIntervention and a Multidisciplinary Approach</h4>\r\n<p>By Vikrant Singh<sup><a href=\"#corr\">*</a></sup></p>\r\n<p>Department of Pharmacy, GD Goenka University, India</p>\r\n<p>\r\n  *Vikrant181999@gmail.com</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>\r\n  Sensory processing disorder is a condition\r\n  in which the brain has difficulty receiving\r\n  and reacting to sensory input. It was once\r\n  known as sensory integration disorder,\r\n  but it is no longer recognised as a separate\r\n  medical diagnosis. Sensory processing\r\n  disorder causes some people to be too\r\n  sensitive to their surroundings. Sounds\r\n  that are common might be uncomfortable\r\n  or overpowering. One sense, such as\r\n  hearing, touch, or taste, may be affected\r\n  by sensory processing disorder. It might\r\n  also have an impact on several senses.\r\n  People might sometimes be too or\r\n  underly receptive to the problems they\r\n  are having. Sensory processing disorder\r\n  has a wide range of symptoms, much like\r\n  many other diseases. The sound of a leaf\r\n  blower outside the window, for example,\r\n  may drive some youngsters to vomit or\r\n  hide beneath the table. When they are\r\n  touched, they may scream. Certain foods&rsquo;\r\ntextures may cause them to recoil.`</p>\r\n<p><strong>Effects of Sensory Processing Disorder\r\n(SPD)</strong></p>\r\n<p>\r\n  SPD has an impact on all elements of\r\n  everyday functioning and well-being, not\r\n  just specific behaviours. One study found\r\n  that one in every 20 children has sensory\r\n  processing symptoms, while another\r\n  found that one in every six children has\r\nsensory processing symptoms that are strong enough to impact daily functions.\r\nInvolvement in daily activities, play\r\nand playfulness, social skills and social\r\nparticipation, learning, language and\r\nspeech development, and general mental\r\nwellbeing, including self-confidence and\r\nself-esteem, are all issues for children with\r\nSPD.</p>\r\n<p>When a kid has SPD, not only are their\r\n  daily actions disrupted, but their speech\r\n  and language development might also be\r\n  hampered. Speech and language deficits are\r\n  frequently diagnosed in children with SPD.\r\n  Multiple studies have found a link between\r\n  children&rsquo;s language, speech output, and\r\n  physical skills. Many children with specific\r\n  linguistic disability have been diagnosed\r\n  with developmental coordination issue,\r\n  for example. Furthermore, in children\r\n  with language difficulties, an underlying\r\n  weakness in temporal processing may\r\n  influence both phonological speech\r\nproduction and motor production skills.</p>\r\n<p><strong>Sensory Processing in Hearing Impaired\r\nChildren</strong></p>\r\n<p>\r\n  Even children with modest or unilateral\r\n  hearing loss were found to have a significant\r\n  percentage of secondary diseases such as\r\n  SPDs and learning impairments. Different\r\n  studies have shown that children with\r\n  HI have impaired vestibular function,\r\n  as seen by many teachers and parents\r\nreporting indicators of poor coordination, clumsiness, and balance problems.\r\nVestibular abnormalities have been\r\nobserved to be worsened in 23&ndash;100% of\r\ninstances after cochlear implant surgery.\r\nReduced vestibular function in children\r\nwith HI, particularly those who use CIs,\r\nis thought to affect gaze stability, which is\r\nimportant for learning to read as well as\r\nmaintaining standing and walking balance.</p>\r\n<p>Vestibular deficiencies can impede visual\r\n  processing and spatial integration in\r\n  children with HI, in addition to significantly\r\n  impacting motor development and\r\n  balance. Deafness was linked to worse\r\n  results in visual perception and visual\r\n  praxis tests, as well as sustained attention.\r\n  In visual-spatial processing, memory, and\r\n  executive functioning, deaf children were\r\n  found to differ from children with normal\r\nhearing.</p>\r\n<p>A small number of studies looked into\r\n  the connection between HI and SPD.\r\n  Bharadwaj, Daniel, and Matzke concluded\r\n  that children with CIs can have SPD after\r\n  using the SP in their research. Atypical\r\n  behaviours in children identified as at risk\r\n  and different were most common in the\r\n  auditory and vestibular domains (40% of\r\n  the sample), followed by oral and tactile\r\n  (around 25% of the sample), and least\r\n  common in the visual processing domain\r\n(10% of the sample).</p>\r\n<h4>The Significance of Inflammatory Responses in\r\n  Low-Frequency Residual Hearing Following\r\nCochlear Implantation: Molecular Mechanisms and Functions</h4>\r\n<p>By Elizabeth Mills<sup><a href=\"#corr\">*</a></sup></p>\r\n<p>Editorial Office, Canadian Hearing Report, United Kingdom</p>\r\n<p>nurshing@emedicinejournals.org</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>\r\n  Patients with severe to profound hearing\r\n  loss, often affecting higher frequencies, can\r\n  benefit greatly from cochlear implantation\r\n  technology, which bypasses destroyed\r\n  hair cells and stimulates the spiral\r\n  ganglion through implanted electrodes,\r\n  allowing them to regain sound perception.\r\n  Electro-acoustic stimulation for patients\r\n  with residual low-frequency hearing has\r\n  been the focus of future research thanks\r\n  to technological developments. Speech\r\n  perception and music appreciation can\r\n  be dramatically improved utilising a\r\n  combination of cochlear implants for\r\n  medium- and high-frequency hearing and\r\n  acoustic stimulation to take advantage\r\n  of residual low-frequency hearing, with\r\n  outcomes significantly superior to using\r\ncochlear implants alone.</p>\r\n<p>To get the most out of EAS, you need to\r\n  keep your residual low-frequency hearing.\r\n  However, low-frequency residual hearing is\r\n  frequently lost after cochlear implantation\r\n  in practical practise. After cochlear\r\n  implantation, 75 percent of patients had\r\ndelayed low-frequency hearing loss, and 10% had total low-frequency hearing loss,\r\naccording to a multicenter study done\r\nby the FDA. Nearly a third of EAS users\r\nsuffered residual hearing loss that was\r\ndelayed, progressive, or varying weeks to\r\nmonths following surgery. Researchers\r\nare interested in identifying factors that\r\naffect low-frequency residual hearing after\r\ncochlear implantation since the processes\r\nof low-frequency residual hearing loss\r\nafter cochlear implantation are unknown.</p>\r\n<p>After cochlear implantation, low-frequency\r\n  residual hearing loss is linked to surgeryrelated\r\n  damage, but the exact mechanism\r\n  is uncertain. Fibrosis caused by electrodeinsertion\r\n  trauma (EIT), stimulation, or new\r\n  bone formation resulting in changes in\r\n  cochlear mechanical sound transmission;\r\n  post-EIT inflammation or immunogenicity;\r\n  delayed intrastriatal microvascular injury;\r\n  or chronic electrical stimulation injury,\r\n  according to recent studies. However, the\r\nsubject remains divisive.</p>\r\n<p>Chronic inflammation caused by EIT can\r\n  result in extracellular matrix hyperplasia\r\n  and fibrosis, as well as fibrocyte\r\nproliferation, resulting in low-frequency hearing loss. Quesnel and Scheperle et\r\nal. discovered that low-frequency hearing\r\nloss may be linked to an increase in\r\nimpedance and a decrease in acoustic\r\nenergy delivered to the apical turn caused\r\nby fibrosis in the scala tympani by studying\r\ntemporal bone tissue slices from patients\r\nwith cochlear implants. They did point\r\nout, however, that not all low-frequency\r\nhearing loss is caused by this issue.</p>\r\n<p>The stria vascularis and the bloodlabyrinth\r\n  barrier (BLB) are critical for\r\n  maintaining endocochlear homeostasis,\r\n  which includes EP, endolymph production,\r\n  and K+ secretion and circulation. EIT can\r\n  produce inflammation and damage to\r\n  the stria vascularis in the lateral cochlear\r\n  wall, impairing auditory function. Tanaka\r\n  discovered in a 2014 study that cochlear\r\n  implantation can cause a decrease in\r\n  vascular density in the stria vascularis,\r\n  which can contribute to high-frequency\r\n  hearing loss. However, there is no\r\n  experimental evidence to back up the\r\n  idea that stria vascularis and BLB injury is\r\n  linked to low-frequency residual hearing\r\nloss.</p>\r\n<h4>Principles of Cochlear Toxicity</h4>\r\n<p>\r\n  By Elizabeth Mills<sup><a href=\"#corr\">*</a></sup></p>\r\n<p>Editorial Office, Canadian Hearing Report, United Kingdom</p>\r\n<p>nurshing@emedicinejournals.org</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>\r\n  The inner ear is a complicated system of\r\n  fluid-filled cavities and epithelia of various\r\n  kinds. Hair cells are the main receptors\r\n  for hearing sensor transduction. In a\r\n  great number of original publications and\r\n  handbooks, the typical morphology of\r\n  the cochlea has been documented. The\r\n  inner ear can be damaged by a variety of\r\n  ototraumatic agents, both endogenous and\r\n  external. The property of being poisonous\r\n  to or having a detrimental impact on the\r\n  eighth nerve or the hearing and/or balance\r\n  organs is referred to as ototoxicity. The\r\n  growing usage of powerful diuretics like\r\n  ethacrynic acid, furosemide, and others\r\n  has brought undesired toxic side effects on\r\n  the inner ear structures to the forefront.\r\n  Furthermore, new investigations have\r\n  expressed worry about environmental\r\n  contaminants that might damage the\r\n  inner ear after prolonged contact. Various\r\n  classes of ototoxic chemicals have\r\n  different sites and modes of action on the\r\n  labyrinthine organs, but they all induce\r\n  hearing and balance impairment, or both,\r\nin the ultimate stage of toxic action.</p>\r\n<p>It is often possible to establish the major\r\n  or favoured primary site of toxic harm in\r\n  both clinical and experimental settings, i.e.\r\n  to distinguish damages in the peripheral\r\n  end organs from those in the central\r\n  nervous system&rsquo;s auditory or vestibular\r\n  neuronal pathways. The current review\r\n  study focuses on the concepts that lead to\r\n  toxic damage to the cochlea. The majority\r\n  of the attention has been focused on\r\nmorphology.</p>\r\n<p><strong>Techniques in the Study of Cochlear\r\nPathology</strong></p>\r\n<p>\r\n  During the clinical course in humans, the\r\n  underlying connection between cochlear\r\n  morphology and signs and symptoms of\r\n  hearing loss is unclear. Only at autopsy\r\n  can structural abnormalities of inner\r\n  ear illness or trauma be determined,\r\nand they constitute the ultimate step of morphological changes in each instance.\r\nAdditional inner ear harmful variables,\r\nsuch as acoustic trauma, ageing, and so on,\r\ncan be added to previously drug-induced\r\nlabyrinth damage. The preservation of\r\nthe human temporal bone also poses\r\nsignificant technological challenges.</p>\r\n<p>It is feasible to analyse and track the\r\n  sequential events involved in toxic\r\n  damage or other forms of trauma under\r\n  experimental settings (without the effect\r\n  of other variables). With reference to\r\n  morphological characteristics, four basic\r\n  factors should be considered when\r\n  evaluating inner ear toxicity. The location\r\n  of the damage (primary), qualitative\r\n  alterations in cells and tissues Secondary\r\n  degenerative events, and quantitative\r\n  alterations in cells and tissues. The main\r\n  source of toxic harm will be described\r\n  further down &ldquo;Cochlear principles\r\n  &ldquo;Pharmacokinetics of ototoxic drugs&rdquo;\r\n  and &ldquo;pathology - morphological damage&rdquo;\r\nconstituents &ldquo;.</p>\r\n<h4>Electrotransfer of Neurotrophin Genes to\r\n  Improve Cochlear Implant Hearing Outcomes</h4>\r\n<p>By Elizabeth Mills<sup><a href=\"#corr\">*</a></sup></p>\r\n<p>Editorial Office, Canadian Hearing Report, United Kingdom</p>\r\n<p>nurshing@emedicinejournals.org</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>\r\n  Within the booming field of hearing\r\n  therapies, the translational potential of\r\n  gene therapy in the inner ear is gaining\r\n  traction. This is based on preclinical model\r\n  accomplishments that used controlled\r\n  gene expression alteration to study\r\n  the developmental and physiological\r\n  processes of hearing and balance at the\r\n  molecular level. Ballistics, lipofectaminebased\r\n  transduction, and replicationdeficient\r\n  viral-vector-based methods are\r\n  all employed to generate recombinant\r\n  proteins. Gene expression is very varied,\r\n  and is influenced to some extent by\r\n  promoters that bias recombinant protein\r\n  translation to subsets of the inner ear&rsquo;s\r\nhighly differentiated cell types.</p>\r\n<p>In the case of viral vectors, choosing\r\n  between different viral capsid serotypes\r\n  has a significant impact on cell tropism;\r\n  for example, using AAV1 enabled inner\r\n  hair cellspecific expression of vesicular\r\n  glutamate transporter-3 to restore hearing\r\n  in VGLUT3 null mice, whereas using the\r\n  Anc80L65 serotype allows transfection\r\n  of outer hair cells as well as inner hair\r\ncells. The Ad28 adenovirus serotype has been demonstrated to specifically enable\r\nexpression in supporting cells in the\r\nvestibular system. Electroporation is a\r\nnew method for delivering genes to the\r\ninner ear that has previously been limited\r\nto in vitro tissue culture studies and in\r\nutero gene transfer.</p>\r\n<p>Plate electrodes are typically placed\r\n  across the target tissue, and a brief train\r\n  of voltage pulses is used to drive plasmid\r\n  DNA incorporating various expression\r\n  cassettes into inner ear cells via\r\n  conventional &lsquo;open-field&rsquo; electroporation,\r\n  such as transfecting organ of Corti hair\r\n  cells and supporting cells. Close-field\r\n  electroporation, in which the electrodes\r\n  are in a continuous array, is proving highly\r\n  successful both in situ and in vivo for\r\n  directing naked DNA to targets within\r\nthe cochlea.</p>\r\n<p>Industry investment in hearing gene\r\n  therapy will be focused on reversal of\r\n  monogenic diseases that cause significant\r\n  loss of Hearing (and/or balance)\r\n  restoration, as well as the treatment of\r\n  acquired sensorineural hearing loss A\r\n  good example is the A consortium has\r\nfunded the first clinical trial of hearing gene therapy. Novartis Pharmaceuticals\r\n(2019) is sponsoring this event, which is\r\naimed at hearing loss that is moderate to\r\nsevere can be restored.</p>\r\n<p>This method can cause re-growth of spiral\r\n  ganglion peripheral neurites towards\r\n  the mesenchymla cells, and thus into\r\n  close proximity with cochlear implant\r\n  electrodes within the scala tympani, in a\r\n  deafened guinea pig model. This was linked\r\n  to improved functionality of the cochlear\r\n  implant neural interface. The compression\r\n  of the electric field in closeness to the\r\n  ganged cochlear implant electrodes is\r\n  the basis for close-field electroporation&rsquo;s\r\nefficiency.</p>\r\n<p>The effects of cochlear neurotrophin\r\n  therapy on cochlear implant performance\r\n  have been studied extensively in deafened\r\n  animal models. Spiral ganglion neuron\r\n  rescue by neurotrophin delivery has\r\n  been studied in terms of electrically\r\n  evoked auditory brainstem response\r\n  (eABR) thresholds and input/output\r\n  functions, notwithstanding the difficulty\r\n  of determining the extent of peripheral\r\nneurite regrowth.</p>\r\n<h4>Current Thoughts on Depression in Older\r\n  Individuals with Hearing Loss</h4>\r\n<p>By Elizabeth Mills<sup><a href=\"#corr\">*</a></sup></p>\r\n<p>Editorial Office, Canadian Hearing Report, United Kingdom</p>\r\n<p>nurshing@emedicinejournals.org</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>\r\n  Hearing loss (HL) is the third most\r\n  common chronic health problem among\r\n  older adults, making it the third most\r\n  common chronic health issue in this age\r\n  group. In addition to causing significant\r\n  illness burden and lowering quality of\r\n  life, a growing body of evidence suggests\r\n  that HL is linked to unipolar depression,\r\n  particularly in older persons. This review\r\n  summarises research on the link between\r\n  HL and depression, as well as clinical\r\n  implications for assessing and treating\r\n  comorbid depression and HL. Although\r\n  estimates of the prevalence of comorbid\r\n  depression in HL vary, up to 1 in 5\r\n  people with HL have clinically meaningful\r\n  depression symptoms. Hearing loss (HL) is\r\n  frequent in older persons, with one-third\r\n  of those over the age of 65 experiencing\r\n  it. HL is the third most common chronic\r\n  health condition in older adults, and its\r\n  prevalence continues to rise with age.\r\n  Age-related HL is caused by pathologic\r\n  changes that occur with ageing, such as the\r\n  loss of hair cells at the basilar membrane,\r\n  which results in a loss of high-frequency\r\n  hearing. In older persons, HL causes\r\n  greater disability, an increased risk of\r\n  incident morbidity, frailty, and a decrease\r\n  in self-rated health. As a result, HL among\r\n  the elderly imposes a significant illness\r\n  burden. HL is linked to poor psychological\r\n  well-being, including the existence of\r\n  concurrent unipolar depression, and is\r\n  associated with lower levels of happiness\r\n  and self-efficacy, reduced interpersonal\r\n  functioning, and lower emotional vigour.\r\n  As a result, HL has a major impact on\r\nquality of life in older persons.</p>\r\n<p>Although the intensity of the association\r\n  varies between studies, both crosssectional\r\n  and longitudinal studies show\r\n  that HL is linked to greater unipolar\r\n  depression symptoms. This heterogeneity\r\n  is likely due to a variety of methodological\r\n  differences, such as inclusion age, HL\r\n  severity, and depression assessment.\r\n  Overall, the evidence strongly suggests a\r\n  link between HL and clinically meaningful\r\n  depression symptoms. The connection\r\n  to the diagnosis of major depression\r\ndisorder is less obvious and understudied.</p>\r\n<p>In older adults, HL is linked to a variety\r\n  of negative mental health outcomes,\r\n  including anxiety and suicide ideation, as\r\n  well as lower cognitive performance. As a\r\n  result, assessing and treating concomitant\r\n  depression in HL is important for\r\n  promoting mental health in older persons.\r\n  There is currently little evidence about the\r\n  best way to manage depression in people\r\n  with HL. According to preliminary research,\r\n  audiological rehabilitation, which includes\r\n  the use of hearing aids and communitybased\r\n  hearing programmes, can enhance\r\n  mental health. This demographic might\r\n  benefit from psychological psychotherapy\r\n  that improves communication skills and\r\n  addresses coping methods. Furthermore,\r\n  evidence suggests that online interventions\r\n  are practical and may help to overcome\r\n  communication barriers in HL therapy.\r\n  Due to a lack of help-seeking in this\r\n  population, a greater emphasis on precise\r\n  and targeted assessment and treatment\r\n  is likely to be required to guarantee that\r\n  older persons with HL have a lower\r\nmental health burden.</p>',NULL,'2022-11-10'),(2,5394,'ajchr','http://www.andrewjohnpublishing.com/','','<h4>Stroke-Related Hearing Loss</h4>\r\n<p>By Elizabeth Mills*</p>\r\n<p>Editorial Office, Canadian Hearing Report, United Kingdom</p>\r\n<p>nurshing@emedicinejournals.org</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>\r\n  Stroke is the most prevalent neurologic\r\n  disorder, with 130 000 strokes each\r\n  year in the UK and over a million stroke\r\n  survivors. It can cause both physical\r\n  and cognitive disability, and after a year,\r\n  around one-third of stroke survivors are\r\n  functionally dependent. The majority of\r\n  strokes (85&ndash;90%) are ischemic, meaning\r\n  they are caused by a temporary or\r\n  permanent blockage of a blood vessel,\r\naffecting vascular flow to the brain.</p>\r\n<p>Ischemic stroke can be thrombotic,\r\n  embolic, or caused by venous thrombosis\r\n  or systemic hypoperfusion. The main\r\n  portion of the brain afflicted will die\r\n  immediately because to the presence\r\n  of collateral circulation, however the\r\n  surrounding areas (penumbra) have\r\n  the ability to heal, especially when\r\n  targeted with suitable therapeutic\r\n  intervention. Hemorrhagic stroke is\r\n  caused by the rupture of a blood artery in\r\nthe brain and occurs in 10&ndash;15 percent of all stroke cases.</p>\r\n<p>Hypoxia, irritating effects of the\r\n  haemorrhage on brain tissues and\r\n  vasculature, and elevated intracranial\r\n  pressure owing to bleeding are all possible\r\n  causes of injury. Both forms of stroke\r\n  can damage all levels of the auditory\r\n  pathway, resulting in hearing and/or\r\n  perception abnormalities that can appear\r\n  as a wide range of symptoms and clinical\r\n  presentations that begin promptly before,\r\nduring, or shortly after the stroke.</p>\r\n<p>Furthermore, risk factors for stroke, such\r\n  as cigarette smoking, atherosclerosis,\r\n  and others, have been linked to a more\r\n  gradual start of hearing loss as people get\r\nolder, known as age-related hearing loss.</p>\r\n<p><strong>Blood Supply of the Auditory System</strong></p>\r\n<p>Acute stroke damage is more likely to\r\n  affect the hearing end-organ and auditory\r\n  nerve in particular. This is because the\r\ninternal auditory artery (IAA), a small end artery with few types of collateral,\r\nprovides circulatory supply to the hearing\r\nend-organ and nerve. The anterior\r\ninferior cerebellar artery (AICA) is the\r\nmost common source; however there\r\nare various anatomic variations. The IAA,\r\nas well as collaterals from arteries that\r\nsupply the dura mater and petrous bone\r\nwithin the internal auditory meatus, as\r\nwell as an anastamosing network from the\r\nAICA, PICA, and vertebral arteries at the\r\ncerebellopontine angle and the root entry\r\nzone to the brainstem level, provides\r\nblood supply to the auditory nerve.</p>\r\n<p>The auditory peripheral, which includes\r\n  the hearing end-organ and nerve, receives\r\n  circulatory supply from the same source\r\n  as the low sections of the brainstem and\r\n  parts of the cerebellum. As a result, in\r\n  certain acute-onset post stroke hearing\r\n  diseases, peripheral-type hearing loss\r\n  may coexist with auditory brainstem\r\n  type impairments and/or cerebellar\r\nneurologic symptoms and indications.</p>\r\n<h4>Sound Implant in the Active Middle Ear Vibrant\r\n  Soundbridge</h4>\r\n<p>By Elizabeth Mills*</p>\r\n<p>Editorial Office, Canadian Hearing Report, United Kingdom</p>\r\n<p>nurshing@emedicinejournals.org</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>\r\n  For people who have a solely sensorineural\r\n  hearing loss, middle ear implants (MEIs)\r\n  can help. MEIs with unresolvable middle\r\n  ear conductive/mixed losses were the\r\n  first clinically accessible MEIs (developed\r\n  by Suzuki and Yanagihara in Japan).\r\n  Modern MEIs, on the other hand, require\r\n  a well-functioning ossicular chain. Since\r\n  1935, when Dr. Wilska dusted some iron\r\n  filings into a person&rsquo;s eardrum, MEIs have\r\n  existed in some form or another. The\r\n  iron filings were subjected to a magnetic\r\n  field created by a coil of wire inside an\r\n  earphone. Despite the fact that there was\r\n  no acoustic sound energy flowing from\r\n  the earpiece, the participants experienced\r\n  &lsquo;hearing.&rsquo; The iron filings vibrated in\r\n  time with the magnetic field due to the\r\n  earphone&rsquo;s magnetic field. This vibration\r\n  prompted the eardrum to vibrate as\r\n  well, allowing sound to be transmitted\r\n  normally to the inner ear. Several research\r\n  groups across the world have attempted\r\n  to develop a wearable MEI since the\r\n  1930s. With less than 3 mA, current MEIs\r\ncan create 85 dB.</p>\r\n<p>The receiver or the complete hearing\r\n  aid is surgically implanted into the middle\r\n  ear with a MEI hearing aid. There are\r\n  two benefits to having such an implant.\r\n  First, if the ossicles can be driven directly,\r\n  sound quality may be enhanced without\r\n  any feedback. Second, a MEI may be\r\n  implanted entirely without any external\r\n  components. Two companies have now\r\n  developed fully implanted middle ear\r\n  implants. Furthermore, depending on the\r\n  MEI, there is no insertion loss with a net\r\n  gain in high-frequency sound transmission\r\nif there is no device in the ear canal.</p>\r\n<p>Direct-drive, middle-ear implanted\r\n  hearing devices are a new type of hearing\r\n  aid. Direct drive MEI systems employ\r\n  mechanical vibrations sent directly to\r\n  the ossicular chain, leaving the ear canal\r\n  entirely open, rather of transmitting\r\n  acoustic energy into the external\r\n  auditory canal (as with standard hearing\r\n  aid systems). The capacity to deliver\r\n  enhanced sound quality to hearing\r\nchallenged people is one of the primary advantages of direct drive devices.</p>\r\n<p>In the chosen ear, word recognition\r\n  should be at least 50% accurate when\r\n  measured with headphones. Clinical\r\n  history, tympanometry, and observation\r\n  should reveal normal middle ear\r\n  function. Realistic expectations should\r\n  be discussed with the patient. Patients\r\n  who are looking for direct drive middle\r\n  ear hearing aids are frequently dissatisfied\r\n  with the sound quality of their own\r\n  voices. Despite numerous visits to their\r\n  hearing healthcare expert, these people\r\n  are unable to create speech sounds that\r\n  sound &ldquo;natural&rdquo; or &ldquo;pleasant,&rdquo; and they\r\nare unable to overcome this barrier.</p>\r\n<p>On August 31, 2000, the Food and Drug\r\n  Administration (FDA) gave the first\r\n  certification for a direct drive MEI system.\r\n  Clinical tests have demonstrated that\r\n  the Vibrant Soundbridge is both safe and\r\n  effective. A study of 81 individuals as part\r\n  of the FDA clearance procedure found\r\n  that the participants could hear just as\r\n  well with the device as they did with\r\nstandard hearing aids (FDA, 2000).</p>\r\n<h4>Hair Cells Protection Against Hearing Loss Caused by Ototoxic Drugs</h4>\r\n<p>By Elizabeth Mills*</p>\r\n<p>Editorial Office, Canadian Hearing Report, United Kingdom</p>\r\n<p>nurshing@emedicinejournals.org</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>\r\n  Hearing loss is the most common kind\r\n  of sensory impairment in the globe.\r\n  Hearing loss of higher than 20 decibels\r\n  is the second most prevalent disability,\r\n  after anaemia, according to worldwide\r\n  estimates, impacting 1.33 billion people\r\n  in 2015. According to the World Health\r\n  Organization (WHO), 466 million people\r\n  (6.1 percent of the world population)\r\n  suffer from debilitating hearing loss, which\r\n  is defined as a hearing loss of more than\r\n  40 decibels (dB) in the better-hearing\r\n  ear in adults and children, respectively.\r\n  Furthermore, 93 percent of these\r\n  individuals are adults, with the remaining\r\n  7% being minors. Furthermore, by 2050,\r\n  it is expected that the number of persons\r\n  with hearing loss would have increased\r\n  to nearly 900 million. Although hearing\r\n  loss is not a life-threatening condition,\r\n  it can reduce a person&rsquo;s quality of life\r\n  and place a major burden on families\r\n  and society. Children with hearing loss\r\n  in low- and middle-income areas have\r\n  severe developmental delays in language\r\nacquisition as well as a lack of schooling.</p>\r\n<p>Hearing loss can be caused by ear\r\n  infections, noise, and chemical exposure,\r\n  in addition to congenital causes. Notably,\r\n  medication ototoxicity is one of the\r\n  leading causes of hearing loss that may\r\n  be avoided. An increasing amount of data\r\n  suggests that ototoxic medicines primarily\r\n  damage hair cells in the organ of Corti,\r\n  which are surrounded by supporting cells.\r\n  Hair cells in the cochlea are critical for\r\n  translating mechanical sound waves into\r\n  neural impulses for hearing, and because\r\n  hair cells in adult mammals are terminally\r\n  differentiated, they have little capacity to\r\nregenerate if injured or destroyed.</p>\r\n<p>After systemic or intratympanic injection, ototoxic medicines can be delivered from\r\n  the strial vessels or diffuse through the\r\n  round window into the cochlear tissues.\r\n  Different medications can harm many\r\n  cells and tissues in the inner ear, including\r\n  hair cells, supporting cells, spiral ganglion\r\n  cells, and the auditory nerve, although hair\r\n  cell destruction is the major consequence\r\n  of ototoxicity. As a result, much study has\r\n  been focused on the causes of hair cell\r\n  loss induced by ototoxic medications,\r\n  as well as potential treatment methods.\r\n  For example, an older study established\r\n  the time of ototoxic drug sensitivity,\r\n  whereas a more current study found that\r\n  overexpression of the X-linked inhibitor\r\n  of apoptosis protein gene can prevent\r\n  hair cell loss during this sensitive phase.\r\n  We think that a better knowledge of\r\n  ototoxicity will lead to new ideas for\r\n  drug-induced hearing loss prevention and\r\ntherapy.</p>\r\n<h4>Cranial Nerve Stimulation&rsquo;s Central Effects</h4>\r\n<p>\r\n  By Elizabeth Mills*</p>\r\n<p>Editorial Office, Canadian Hearing Report, United Kingdom</p>\r\n<p>nurshing@emedicinejournals.org</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>\r\n  Although cranial nerve stimulation is\r\n  frequently used to treat the peripheral\r\n  component of a nerve, many cranial\r\n  nerve stimulators are known to have\r\n  significant effects on the central nervous\r\n  system (CNS) and have been studied\r\n  especially for their central effects. Vagal\r\n  nerve stimulation (VNS) for epilepsy\r\n  therapy and cochlear nerve stimulation\r\n  for hearing loss are two well-known\r\n  instances. There are other reasons for\r\n  cranial nerve stimulation, including the\r\n  central effects of the stimulation, and\r\n  commercially accessible devices. The\r\n  potential to extend indications is being\r\n  intensively studied due to well-known\r\n  central effects. Despite the need to\r\n  broaden indications, the mechanisms of\r\n  action remain unknown. The existence\r\n  of complex brain networks and linkages\r\n  makes understanding the specific\r\n  mechanism of these effects difficult. The\r\n  notion that peripheral stimulation of\r\n  cranial nerves causes central alterations\r\n  that play a part in the underlying effects\r\n  of these stimulators is introduced in this\r\narticle.</p>\r\n<p><strong>Central Effects of Vagus Nerve Stimulation</strong></p>\r\n<p>\r\n  At first look, it&rsquo;s difficult to see why a\r\n  VNS, a peripheral nerve stimulator, would\r\n  be used to treat a central condition like\r\n  epilepsy, depression, or migraine headache.\r\n  Nonetheless, there is strong evidence\r\n  that the VNS is a valuable tool in these\r\n  situations. It was first licenced for epilepsy,\r\n  but as the benefits became clearer and\r\n  the notion of CNS impact evolved, it\r\n  was broadened to cover depression and\r\n  migraine. With stimulation of the vagus\r\n  nerve, a number of central changes occur,\r\n  and quantifying the particular effect of\r\n  each of these changes is challenging.\r\n  Nonetheless, each of these effects is\r\n  expected to play a role in the mechanism\r\nof VNS benefit in each situation.</p>\r\n<p>The effects of VNS on norepinephrine and\r\n  serotonin levels via the locus coeruleus\r\n  and raphe nuclei have been proposed\r\n  as the mechanism by which VNS affects\r\n  mood in the context of depression. With\r\n  VNS usage, brain imaging investigations\r\n  using fMRI and PET have revealed different\r\n  patterns of alterations in activation and\r\n  blood flow. The bilateral orbito-frontal\r\n  and parietooccipital cortex, the left\r\n  temporal cortex, the hypothalamus, and\r\n  the left amygdala, for example, were all\r\n  activated in an fMRI research. At 3 months\r\n  and 12 months after starting VNS therapy\r\n  for depression, a longitudinal study looked\r\n  at fludeoxylglucose-18 (FDG) avidity\r\n  with PET scanning and found decreased\r\n  right-sided dorsolateral prefrontal and\r\n  cingulate cortical activity, followed by\r\n  increased ventral tegmental area (VTA)\r\n  activity. Because the VTA is the major\r\n  brainstem location for dopamine, this\r\n  might involve changes in dopamine levels\r\nin the mechanism of VNS for depression..</p>\r\n<h4>Promulgate Your Proficiency in Scope of\r\n  Hearing</h4>\r\n<p>By Elizabeth Mills*</p>\r\n<p>Editorial Office, Canadian Hearing Report, United Kingdom</p>\r\n<p>nurshing@emedicinejournals.org</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>\r\n  It is of immense delectation to share with\r\n  our readers/authors/editors/reviewers\r\n  that Journal of Canadian Hearing Report\r\n  had successfully disseminated 15 Volumes\r\n  worldwide through the journal platform.\r\n  Currently, we are on the way to promulgate\r\n  more updates in the field of Hearing aids\r\n  and hearing disorders. We would like to\r\n  acknowledge the contributors of our\r\n  journal for their time-honoured support\r\n  and cooperation in bringing and publishing\r\n  the issues on journal website within\r\n  time. With reference to the previous\r\n  submissions received in the journal, we\r\n  request the eminent authors to come up\r\n  with their valuable submissions based on\r\n  their recent on-going studies related to\r\n  the Cochlear implant, presbycusis, hearing\r\n  loss and other such topics that cover the\r\njournal scope.</p>\r\n<p><strong>ARTICLE TYPES</strong></p>\r\n	<div class=\"table-responsive\">\r\n  <table class=\"table table-sm table-bordered\">\r\n    <tbody>\r\n\r\n  <tr>\r\n    <td><strong>Article Type</strong></td>\r\n    <td><strong>Word</strong><strong> </strong><strong>Count</strong><strong> </strong></td>\r\n  </tr>\r\n  <tr>\r\n    <td>Research Article </td>\r\n    <td>1500-6000</td>\r\n  </tr>\r\n  <tr>\r\n    <td>Review Article </td>\r\n    <td>2000-7500</td>\r\n  </tr>\r\n  <tr>\r\n    <td>Original Article </td>\r\n    <td>2000-3000</td>\r\n  </tr>\r\n  <tr>\r\n    <td>Case/Brief Report </td>\r\n    <td>1000-1800</td>\r\n  </tr>\r\n</tbody>\r\n  </table>\r\n</div>\r\n<div class=\"table-responsive\">\r\n  <table class=\"table table-sm table-bordered\">\r\n    <tbody>\r\n\r\n  <col width=\"275\">\r\n  <col width=\"169\">\r\n  <tr>\r\n    <td align=\"left\"><strong>Research Poster&nbsp;</strong></td>\r\n    <td align=\"left\"><strong>Informative&nbsp;&amp;&nbsp;Captivating</strong></td>\r\n  </tr>\r\n  <tr>\r\n    <td align=\"left\">Editorial    Note&nbsp;</td>\r\n    <td align=\"left\">500-800</td>\r\n  </tr>\r\n  <tr>\r\n    <td align=\"left\">Commentary</td>\r\n    <td align=\"left\">&nbsp;500-750</td>\r\n  </tr>\r\n  <tr>\r\n    <td align=\"left\">Short    Communication&nbsp;</td>\r\n    <td align=\"left\">900-1200 </td>\r\n  </tr>\r\n  <tr>\r\n    <td align=\"left\">Perspective/Opinion/Suggestions</td>\r\n    <td align=\"left\">&nbsp;900-1000 </td>\r\n  </tr>\r\n  <tr>\r\n    <td align=\"left\">Letter    to Editor&nbsp;</td>\r\n    <td align=\"left\">500-750</td>\r\n  </tr>\r\n</tbody>\r\n  </table>\r\n</div>\r\n<p> <strong>SUBMISSION PROCESS</strong></p>\r\n	<p> The manuscript can be submitted online\r\n	  through Online Manuscript Submission\r\n	  System under the link Submit Manuscript:\r\n	  h t t p s : / / w w w. s c h o l a r s c e n t r a l . o r g /\r\n	  submissions/canadian-hearing-report.\r\n	  html</p>\r\n	<p>After the submission, the author will\r\n	  receive a mail from the journal regarding\r\n	  the manuscript number along with the\r\n	  credentials to track the manuscript status.\r\n	  The manuscript undergoes rapid peer\r\n	  review process, acceptance from the\r\n	  editor and then formatting and editing.\r\n	  The whole process takes around 30-\r\n	  45 days for complete processing and\r\n    publication.</p>\r\n<p><strong>ADVERTISEMENT PLATFORM</strong></p>\r\n	<p>\r\n    Journal of Canadian Hearing Report also invites the research workers to promulgate\r\n    their assets/newsletter through journal\r\n    webpage. Universities/Institutes can\r\n    contact us for the global announcement\r\n    for International Conferences/ Webinars,\r\n    workshops, exhibitions, academic reports\r\n    of the events generally organised at\r\n    regular intervals as a part of curriculum.</p>\r\n	<p><strong>MEMBERSHIP &amp; REPRINTS</strong></p>\r\n	<p>\r\n	  The journal offers various membership\r\n	  schemes for the regular visitors/authors/\r\n	  reviewers/editors of the journal. And\r\n	  accordingly we provide complimentary\r\n	  reprints to the subscribers of the journal.\r\n	  As per the requirement, we provide\r\n	  reprints of individual selected article/\r\n    issue(s)/volume(s) or customized reprints.</p>\r\n	<p><strong>SURVEY &amp; FEEDBACK</strong></p>\r\n	<p>\r\n	  Canadian Hearing Report is a growing\r\n	  journal and the journal team is regularly\r\n	  working to upgrade the journal and make\r\n	  it more captivating platform. To achieve\r\n	  the goals the journal circulates survey\r\n	  forms at planned time intervals to take\r\n	  suggestions/feedbacks from the audience\r\n	  of the journal and accordingly the work\r\n    directions goes on.</p>',NULL,'2022-11-10'),(3,5396,'ajchr','http://www.andrewjohnpublishing.com/','','<h4>Based on Bandpass Filters and a Compound\r\n  Deep Denoising Autoencoder, Speech\r\nEnhancement for Hearing Impaired</h4>\r\n<p>By Joseph Millan<sup><a href=\"#corr\">*</a></sup>\r\n<p>Editorial Office, AJCHR, London, United Kingdom</p>\r\n<p>*Joseph.millan@aol.com</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>\r\n  Speech is the most basic form of human\r\n  communication. The voice signal is usually\r\n  mixed with other signals transferring\r\n  energy at the same time, which might\r\n  be noise or even separate speech\r\n  signals, in most noisy settings. As a result,\r\n  improving speech quality and decreasing\r\n  speech intelligibility is critical. Speech\r\n  Enhancement (SE) techniques have\r\n  been used in high-tech communications\r\n  systems such as mobile communication\r\n  and speech recognition, as well as\r\n  hearing aids. The fundamental goal of\r\n  SE algorithms is to enhance various\r\n  elements of speech perception that are\r\n  distorted by additive background noise.\r\n  SE algorithms are used in Hearing Aids\r\n  (HA) to clean the noisy signal before\r\n  amplification by decreasing background\r\n  noise, which is extremely difficult for\r\n  hearing-impaired people to communicate\r\n  in situations with varied levels and types\r\n  of noise. Reduced background noise\r\n  causes speech distortion, which lowers\r\n  speech intelligibility in loud situations in\r\n  many cases. It is a subjective performance\r\n  evaluation metric since quality reflects\r\n  the individual tastes of listeners. Because\r\n  it provides the percentage of words that\r\n  can be properly identified by listeners,\r\n  intelligibility is an objective metric. The\r\n  significant difficulty in creating an efficient\r\n  SE algorithm for hearing aids based on\r\n  these two criteria is to improve overall\r\n  speech quality and intelligibility by reducing\r\n  noise without generating detectable signal\r\n  distortion. Many ideas and methods to\r\n  SE have been developed and suggested\r\n  throughout the years. In the correlation\r\n  domain, spectral subtraction methods\r\n  were suggested, and subsequently he\r\n  presented the spectral subtraction\r\n  methodology in current hearing aids for\r\n  real-time speech augmentation. When\r\n  speech pauses, the method employs a\r\n  vocal activity detector to estimate the\r\n  noise spectrum, which is then subtracted\r\n  from the noisy speech to determine the\r\n  clean speech. This method typically results\r\n  in a different form of noise in each frame\r\nat random frequency positions.</p>\r\n<p>This sort of noise is known as musical\r\n  noise, and it can be more distressing\r\n  than the original distortions, not only to\r\n  the human ear but also to SE systems.\r\n  Using a directional microphone, scientists\r\n  employed the Wiener filter approach\r\n  based on previous SNR estimate to\r\n  improve voice quality. The all-pole\r\n  spectrum of the voice signal, on the\r\n  other hand, might have abnormally strong\r\n  peaks, resulting in a substantial drop in\r\n  speech quality. The log-magnitude-based\r\n  Minimum Mean Square Error (MMSE)\r\n  method was proposed in. The method\r\n  finds the coefficient by minimising the\r\n  log-magnitude spectra&rsquo;s mean square\r\n  error (MSE). Meanwhile, deep neural\r\n  network (DNN) methods have attracted\r\n  a lot of interest and promise in the field\r\nof SE. For speech denoising, for example, scientists employed a DNN model. When\r\nconfronted with noisy speech inputs,\r\nthe model predicts clean speech spectra\r\nwithout the need for RBM pre-training\r\nor complicated recurrent structures. To\r\nincrease the quality of voice, scientists\r\npresented a regression model of the\r\ndenoising autoencoder (DAE). Based on\r\nthe log-power spectra (LPS) characteristic,\r\nthe model translates a noisy input to\r\na clean signal. In the training step, the\r\nresearchers employed several forms of\r\nnoise to acquire an exceptional capacity\r\nto generalise to unknown noise settings.</p>\r\n<p>Deep neural networks have been\r\n  successfully used to improve speech. An\r\n  individual neural network with a fixed\r\n  number of hidden layers, on the other\r\n  hand, causes strong interference for large\r\n  variations in speech patterns and noisy\r\n  environments, which can result in a slow\r\n  learning process, poor generalisation in\r\n  an unknown signal-to-noise ratio in new\r\n  inputs, and some residual noise in the\r\nenhanced output.</p>\r\n<p><strong>AGE RELATED FACTORS IN\r\nHEARING</strong></p>\r\n<p>\r\n  Aging populations are a worldwide\r\n  concern, not a problem restricted to a\r\n  single country. As a result, rather than\r\n  being treated as an individual concern,\r\n  the health problems of the elderly should\r\n  be handled at the national level of public\r\n  health. Due to their diminished capacity\r\nto speak, the elderly over the age of 65 typically have various challenges in\r\nlistening situations, resulting in less\r\nsocial relationships and a lower quality\r\nof life. At the same time, the elderly may\r\nexperience difficulties with situational\r\nawareness in everyday situations such as\r\nhearing a fire alarm, hearing a car horn\r\nin traffic, seeing incoming items on the\r\nstreet, and falling things. These age-related\r\nproblems are frequently associated with\r\nage-related hearing loss (ARHL, also\r\nknown as presbycusis), one of the three\r\nmajor chronic geriatric illnesses and a\r\nsecondary cause of social, functional, and\r\npsychological decline.</p>\r\n<p>Both the peripheral and central auditory\r\n  systems eventually lose function as people\r\n  age. As a result, the elderly frequently\r\n  exhibit poor performance in their\r\n  orienting sense to various sound sources\r\n  and find it difficult to hear speech in the\r\n  midst of background noise, contributing to\r\n  the aforementioned difficulties. Scientists\r\n  hypothesised that older people with\r\n  ageing auditory systems performed much\r\n  worse in sound localization tasks than\r\n  younger adults. Even when the researchers\r\n  took into account the ageing effect in\r\n  the peripheral auditory system (i.e.,\r\n  hearing thresholds in the high-frequency\r\n  range), the elderly performed the sound\r\n  localization task with less accuracy and/or\r\n  precision. This might explain why, despite\r\nperipheral auditory system degeneration being regulated and/or compensated for\r\nutilising acoustical characteristics (i.e.,\r\nstimuli frequency), ageing has a detrimental\r\nimpact on and deteriorates the central\r\nauditory system. Aging continues to have\r\na detrimental impact on cognitive abilities.\r\nWhen the older population struggles to\r\nlocate and interpret incoming noises, they\r\ndevote more cognitive resources to doing\r\nso, which leads to increased tiredness.\r\nListening effort (or mental effort) for the\r\nlisteners is described as cognitive heavy\r\nlabour.</p>\r\n<p>There are a few key fundamental cognitive\r\n  processing processes (i.e., memory,\r\n  comprehension, attention, and speed of\r\n  processing). Aging has a big impact on\r\n  these processes. As a result, not only do\r\n  elderly people do worse on tasks involving\r\n  memory, understanding, and attention, but\r\n  they also have slower speed processing\r\n  identification. Pichora-Fuller and Singh\r\n  found that when the elderly were\r\n  exposed to demanding listening situations\r\n  (i.e., many sound sources to focus on in\r\n  the background) and/or hard intrinsic\r\n  features of ageing, cognitive processing\r\n  increased substantially. According to a\r\n  study conducted by a researcher, when\r\n  the elderly were placed in the same\r\n  listening contexts as young listeners, such\r\n  as a church and a senior welfare centre,\r\n  they exerted more listening effort than\r\nyoung listeners. That is, if older individuals strive to overcome their challenges by\r\nattempting to improve their auditory\r\nperformance in challenging listening\r\ncontexts, their cognitive resources will\r\nbe depleted, and they will be more likely\r\nto avoid listening situations. As a result,\r\nthe burdened physical and/or cognitive\r\nlistening for the old should be taken into\r\naccount based on scientific evidence.</p>\r\n<p>Despite recent study efforts focusing on\r\n  greater and/or enhanced performance\r\n  for the elderly, their cognitive burden\r\n  represented as listening effort could not\r\n  be taken into account. We think that the\r\n  findings of this study will provide a valuable\r\n  chance to better understand the elderly&rsquo;s\r\n  listening characteristics and needed effort.\r\n  In order to achieve this aim, researchers\r\n  looked at the impact of age, changing\r\n  directionality, different types of stimuli,\r\n  and the presence of background noise\r\n  on listening effort. When considering the\r\n  relationship between ageing and listening\r\n  effort, factors related to challenging\r\n  listening environments such as various\r\n  directionality, particularly on the opposite\r\n  (diagonal) side, differences between stimuli\r\n  in terms of meaning and/or contextual\r\n  cue, and presence of background noise\r\n  were found to be negatively related to\r\n  listening effort in simulated real-listening\r\nsituations.</p>\r\n<h4>Monitoring of Ototoxicity in Children after\r\n  Platinum Chemotherapy</h4>\r\n<p>By Joseph Millan<sup><a href=\"#corr\">*</a></sup></p>\r\n<p>Editorial Office, AJCHR, London, United Kingdom</p>\r\n<p>*Joseph.millan@aol.com</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>\r\n  Despite their toxicity, the alkylating\r\n  platinum chemotherapeutics cisplatin\r\n  and carboplatin remain the backbone\r\n  of therapy for a variety of children and\r\n  adolescent malignancies. Medulloblastoma,\r\n  osteosarcoma, hepatoblastoma,\r\n  neuroblastoma, and germ cell tumours are\r\n  the most frequent paediatric malignancies\r\n  treated with cisplatin. Although only a tiny\r\n  percentage of children and adolescents\r\n  are affected by these life-threatening\r\n  illnesses each year, the impact on children\r\n  and their families is considerable. Platinum\r\n  chemotherapeutics, as well as other\r\n  treatments that induce free radicals, such\r\n  as radiation, can have a variety of systemic\r\nand neurological adverse effects.</p>\r\n<p>Ototoxicity is the most common side\r\n  effect of Cisplatin treatment in youngsters.\r\n  In paediatric patients, the prevalence of\r\n  cisplatin-induced ototoxicity, as assessed\r\n  by conventional audiometry to 8 kHz, is\r\n  around 60%-70%. Carboplatin is much\r\n  less ototoxic, yet high-dose therapy can\r\n  cause hearing loss. When both medicines\r\n  are used together, ototoxicity rises to 80-\r\n  90 percent. Age less than 5 years, cisplatin\r\n  cumulative dose and dose intensity,\r\n  prior or concurrent cranial radiation,\r\nand concomitant treatment with other ototoxins such as myeloablative\r\ncarboplatin, aminoglycosides, and loop\r\ndiuretics are all individual risk factors\r\nfor developing hearing loss from cisplatin\r\ntherapy.</p>\r\n<p><strong>MECHANISMS OF PLATINUM\r\nOTOTOXICITY</strong></p>\r\n<p>\r\n  The degradation of the cochlear hair cells\r\n  and supporting cells induced by cisplatin\r\n  and carboplatin causes hearing loss.\r\n  Platinum first damages hair cells at the\r\n  base of the cochlea, where high-frequency\r\n  sounds are encoded, and outer hair cells\r\n  are destroyed before inner hair cells.\r\n  Clinically, this is characterised by a loss\r\n  of hearing sensitivity that begins in the\r\n  high-frequency range and worsens with\r\n  time, progressing to lower frequencies.\r\n  Cisplatin ototoxicity causes hearing loss\r\n  that is generally bilateral, high-frequency,\r\n  steeply sloped, and symmetrical.\r\n  Caregivers and medical professionals\r\n  may not notice ototoxic high-frequency\r\n  hearing loss. Hearing aid technology can\r\n  help minimise the negative implications of\r\n  acoustic information loss, but it is not a\r\nsubstitute for normal hearing.</p>\r\n<p><strong>GENETICS OF PLATINUM\r\nOTOTOXICITY</strong></p>\r\n<p>\r\n  Individuals with a hereditary susceptibility\r\n  to cisplatin ototoxicity may be\r\n  identified and screened for hearing loss.\r\n  Pharmacogenomic research on genetic\r\n  polymorphisms in methyltransferases,\r\n  catechol-o-methyltransferase gene\r\n  cisplatin transporters, glutathione-Stransferases\r\n  (GSTs), and megalin (LRP2)\r\n  has shown mixed findings, owing to the\r\n  diversity of patient groups and treatment\r\n  regimens. In three separate paediatric\r\n  cohorts, genetic variations in TPMT were\r\n  substantially linked to cisplatin ototoxicity,\r\n  and it is therefore advised that all children\r\n  undergoing cisplatin therapy have genetic\r\n  variants in TPMT tested, ideally before\r\n  starting medication. Despite the strong\r\n  predictive value of TPMT (92%) for\r\n  cisplatin-associated ototoxic hearing loss,\r\n  only around 25% of children with cisplatinassociated\r\n  ototoxic hearing loss have a\r\n  genetic variation in TPMT. ACYPT2 has a\r\n  variation that is highly linked to ototoxicity,\r\n  according to a recent genomewide\r\n  association analysis. Pharmacogenomics\r\n  is a fast evolving science. Audiologists\r\n  should keep an eye out for new research\r\n  on the use of pharmacogenomic markers\r\nfor ototoxicity.</p>\r\n<h4>The Impact of Unmeasured Time Hours on\r\n  the Assessment of Occupational Noise\r\nExposure in the Korean Shipbuilding Process</h4>\r\n<p>By Joseph Millan<sup><a href=\"#corr\">*</a></sup></p>\r\n<p>Editorial Office, AJCHR, London, United Kingdom</p>\r\n<p>*Joseph.millan@aol.com</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>\r\n  Occupational noise exposure is one of\r\n  the leading causes of hearing loss in a\r\n  wide range of industries and workplaces,\r\n  with approximately 16% of manufacturing\r\n  workers suffering from hearing loss with\r\n  serious consequences such as irritation,\r\n  sleep disorders, daytime sleepiness,\r\n  metabolic syndrome, hypertension, and\r\n  cardiovascular disease as a result of acute\r\n  or chronic noise exposure. Occupational\r\n  noise is one of the most dangerous\r\n  workplace risk factors in Korea, having\r\n  consistently exceeded the Occupational\r\n  Exposure Limit (OEL) throughout\r\n  quantitative exposure evaluations in a\r\nwide range of sectors and locations (1).</p>\r\n<p>To avoid occupational hearing loss, a\r\n  complete assessment should be carried\r\n  out to quantitatively describe all levels\r\n  of cumulative noise exposure over\r\n  the course of a full shift of fixed duties,\r\n  therefore defining task-based exposure\r\n  profiles for individual employees. Personal\r\n  noise exposure is often calculated as\r\n  a daily hour time-weighted average (8\r\n  h-TWA) value utilising a cumulative noise\r\n  metre within a radius of 30 cm from the\r\n  worker&rsquo;s ears over 6 hours and then\r\n  compared to the set OEL of 85 dBA in\r\n  Korea. The majority of research found that\r\n  collecting exposure monitoring samples\r\n  across a complete shift of working hours\r\n  each day gives the most reliable noise\r\n  exposure estimate. The Occupational\r\n  Safety and Health Administration (OSHA)\r\n  in the United States recommended that\r\n  noise exposure assessments be conducted\r\nto gather complete shift monitoring samples for at least 7 hours per day, with\r\nany break time shorter than 1 hour being\r\nconsidered unmeasured. However, in light\r\nof the real-world work environment in\r\nKorea, the Ministry of Employment and\r\nLabor (MoEL) set the length of noise\r\nexposure monitoring samples at more\r\nthan 6 hours per day. When analysing\r\nthe US OSHA&rsquo;s Integrated Management\r\nInformation System (IMIS) database,\r\nwhich includes all industries in the\r\nNorth American Industry Classification\r\nSystem (NAICS), including shipbuilding\r\nand repair, and comparing the results of\r\nquantitative exposure measurements, a\r\nprevious study found that annual levels\r\nof occupational noise exposure were\r\nsignificantly decreasing. Instead of using\r\nsimilar exposure groups (SEGs) classified\r\nbased on detailed qualitative information\r\non the magnitude and frequency of noise\r\nexposure in the shipbuilding industry,\r\noccupational exposure assessment in\r\nKorea has focused on the analysis of a\r\nsmall number of monitoring samples\r\ncollected for only a few workers\r\nrepresenting each occupation (job title) or\r\ndepartment. Because precise quantitative\r\ninformation on exposure profiles and\r\nrelated factors can be gathered largely\r\nduring exposure monitoring events in\r\nreal-world workplaces, this technique\r\nhas been employed. Recent studies have\r\nused computational fluid dynamics (CFD)\r\nprogrammes to show the patterns and\r\ncharacteristics of underwater radiated\r\nnoise from small ships and ducts, and\r\ncase studies have also suggested a new\r\nengineering approach to effectively\r\nreduce noise exposure levels in the\r\nworkplace using a noise simulation (2).\r\nHowever, no previous study has been\r\nconducted to assess occupational noise\r\nexposures for a large group of workers\r\nengaged in shipbuilding processes in\r\nthe shipyard industry, using qualitative\r\nexposure information on work-related\r\ncharacteristics, and to evaluate the effect\r\nof unmeasured time hours for lunch\r\nbreak and instrument preparation, when\r\nincluding or excluding break hours, on\r\naverage levels. As a result, the goal of\r\nthis study is to characterise occupational\r\nnoise exposure levels during the break\r\nperiod (sampling preparation and lunch\r\nbreak hour) among a large number of\r\nmanufacturing workers in the shipbuilding\r\nindustry, identify several work-related\r\ncharacteristics that affect noise exposure\r\nlevels when including or excluding the break\r\nperiods during the exposure monitoring,\r\nand statistize the results (3). As a result,\r\nwe were able to determine the most\r\nappropriate technique to noise exposure\r\nassessment while taking into account the\r\nwork-related features, patterns, and other\r\naspects of daily exposure measurements\r\namong individual employees in the\r\nKorean shipbuilding sector. Workers at a\r\nbig shipbuilding business in Korea were\r\nfound to be exposed to significant levels\r\nof occupational noise during break hours,\r\nparticularly those working in the heating,\r\ngrinding, and power operations in various\r\npainting-related departments, according\r\nto this study. Furthermore, when\r\nconducting noise exposure evaluations\r\nin accordance with the KOSHA guidance,\r\nwe discovered evidence those excluding\r\nbreak periods is inadequate, resulting in\r\nunderestimation of occupational noise\r\nexposure levels. We propose that the most reliable schedule of daily noise\r\nexposure measurement should include\r\nthe break time and must be assessed\r\ncontinuously for at least six consecutive\r\nhours following the commencement\r\nof the job duties, based on the findings\r\nof the exposure assessment using the\r\nUS OSHA technique. As a result, more\r\nresearch is needed to determine the most\r\ncomprehensive exposure assessment\r\napproach and daily monitoring schedule\r\nthat can be used to other workers with\r\nvaried job duties in other sectors in the\r\nfuture.</p>\r\n<h4>REFERENCES</h4>\r\n<ol>\r\n  <li><a href=\"https://onlinelibrary.wiley.com/doi/10.1002/ajim.20223\">Nelson DI, Nelson RY, Concha?Barrientos M,</a><a href=\"https://onlinelibrary.wiley.com/doi/10.1002/ajim.20223\">Fingerhut M. The global burden of occupational</a> <a href=\"https://onlinelibrary.wiley.com/doi/10.1002/ajim.20223\">noise?induced hearing loss. American  journal of</a> <a href=\"https://onlinelibrary.wiley.com/doi/10.1002/ajim.20223\">industrial medicine.  2005; 48(6):446-458.</a></li>\r\n\r\n\r\n  <li><a href=\"https://synapse.koreamed.org/articles/1044067\">Lee JH. Occupational diseases of  noise exposed</a> <a href=\"https://synapse.koreamed.org/articles/1044067\">workers. Hanyang Medical Reviews.  2010;</a> <a href=\"https://synapse.koreamed.org/articles/1044067\">30(4):326-332.</a></li>\r\n  <li><a href=\"https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)61613-X/fulltext\">Basner M, et al.  Auditory and non-auditory</a> <a href=\"https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)61613-X/fulltext\">effects of noise  on health. The lancet. 2014;</a> <a href=\"https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)61613-X/fulltext\">383(9925):1325-1332.</a></li>\r\n\r\n\r\n</ol>',NULL,'2022-11-10'),(4,5392,'ajchr','http://www.andrewjohnpublishing.com/','','<h4>Pathology of Cochlear Aging</h4>\r\n<p><strong>By Vikrant Singh<sup><a href=\"#corr\">*</a></sup></strong></p>\r\n<p>Department of Pharmacy, GD Goenka University, India</p>\r\n<p>*Vikrant181999@gmail.com</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>The impacts of the progression of time on\r\n  the design and capacity of the internal ear\r\n  are absolutely unpredictable and amazingly\r\n  factor among species and people inside\r\n  every species, except as a rule, most\r\n  warm blooded animals, particularly\r\n  people, lose hearing affectability, more\r\n  signifi cantly at high frequencies. People\r\n  additionally lose the capacity to separate\r\n  discourse in uproarious conditions.\r\n  Fluctuation in the time of beginning and\r\n  the size of degenerative changes are\r\n  signifi cant highlights of ARHL. Clearly,\r\n  the communications among fundamental\r\n  hereditary qualities and natural openings\r\n  add to the aggregate that is noticed\r\n  toward the fi nish of life. This survey will\r\n  give an outline of the pathology, hereditary,\r\n  metabolic and natural factors known to\r\n  assume a part in cochlear maturing.</p>\r\n<h4> PATHOLOGY</h4>\r\n<p>The sensory hair cells, main sensory\r\n  neurons or spiral ganglion cells, and cells\r\n  of the stria vascularis and spiral ligament,\r\n  including the vasculature, all show degenerative alterations in the inner ear\r\n  of elderly humans and other mammals.\r\n  These structures&rsquo; deteriorating patterns\r\n  were fi rst seen in human temporal bones\r\n  and in the last 40 years, a variety of species\r\n  with diverse lifespans, genetic alterations,\r\n  and noise exposures, as well as humans,\r\n  have been studied. The same cells are lost\r\n  in old mammals, just as they are in humans.\r\n  Different species and strains have varying\r\n  degrees of degeneration and start times.</p>\r\n<h4> NOISE</h4>\r\n<p>The substantial loss of hair cells in\r\n  the basal end of the human cochlea,\r\n  particularly the outer hair cells, is most\r\n  likely the result of acoustic damage rather\r\n  than healthy ageing. It is unknown what\r\n  causes hair cell death at the apex. Noise\r\n  exposure experiments have been carried\r\n  out for many years to determine the\r\n  amount and duration of noise that cause\r\n  cochlear cell degeneration. Outer hair\r\n  cell losses in the basal turn are seen in\r\n  older animals bred in quiet circumstances,\r\n  but they are usually much smaller. The\r\n  loss of inner hair cells in these animals\r\n  is minimal, indicating that lifetime noise exposure is an essential variable in ARHL\r\n  research. Recent research suggests that\r\n  even noise that is loud but nevertheless\r\n  &ldquo;comfortable&rdquo; is more harmful than\r\n  previously considered. Young mice (4-\r\n  16 weeks old) and guinea pigs (4-16\r\n  weeks old) subjected to 100 dB octave\r\n  band noise, a level that only produces\r\n  transitory threshold alterations, develop\r\n  unanticipated degrees of hearing loss as\r\n  they get older. Auditory neurons with low\r\n  spontaneous discharge rates are more\r\n  seriously injured than those with medium\r\n  and high spontaneous discharge rates,\r\n  which is consistent with earlier research\r\n  demonstrating that low spontaneous rate\r\n  fi bres are more susceptible to noise and\r\n  ageing. It should be noted, however, that\r\n  even calm raised gerbils lose radial fi bres\r\n  in the osseous spiral lamina as they get\r\n  older. This 100 dB exposure also causes\r\n  the death of outer hair cells. In Wistar\r\n  rats that were tested at the conclusion\r\n  of the exposure period, chronic (6 hr/\r\n  day for 3 months) exposure to the same\r\n  octave band noise at even 70 dB or 85 dB\r\n  produced neuronal degeneration in the\r\n  absence of hair cell loss.</p>\r\n<h4>Genetic Hearing Disorder</h4>\r\n<p><strong>By Vikrant Singh<sup><a href=\"#corr\">*</a></sup></strong></p>\r\n<p>Department of Pharmacy, GD Goenka University, India</p>\r\n<p>*Vikrant181999@gmail.com</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>Nearly half of the amount, when a kid is\r\n  born with hearing loss or develops hearing\r\n  loss early in life, the cause is hereditary\r\n  and caused by a genetic alteration,\r\n  or mutation. The majority of infants\r\n  with hereditary hearing loss have no\r\n  additional birth abnormalities or serious\r\n  health problems. Conduction, sensory,\r\n  and neural hearing loss; syndromic and\r\n  nonsyndromic; congenital, progressive,\r\n  and adult onset; high-frequency, lowfrequency,\r\n  or mixed frequency; moderate\r\n  or profound; recessive, dominant, or sexlinked\r\n  hearing loss are all examples of\r\n  genetic hearing loss. Hearing loss is caused\r\n  by genes in about half of all instances, yet\r\n  effective treatment choices are limited.\r\n  Hearing loss is thought to be a genetically\r\n  diverse condition. More than 6,000 causal\r\n  variations in more than 150 genes that\r\n  cause hearing loss have been identifi ed\r\n  thanks to advances in genomics. The\r\n  discovery of genes that cause hearing loss\r\n  gives researchers a better understanding\r\n  of how cells in the auditory system grow\r\n  and function normally. These faulty genes\r\n  will become key therapeutic targets in the\r\n  future. The auditory system, on the other\r\n  hand, is very complicated, necessitating\r\n  signifi cant improvements in gene therapy,\r\n  including gene vectors, administration\r\n  methods, and treatment techniques.\r\n  Hearing loss affects around one out of every 500 babies when they are born or\r\n  develops during infancy. Hearing loss can\r\n  be caused by a variety of factors, some\r\n  of which are hereditary (i.e., caused by a\r\n  baby&rsquo;s genes) and others which are not\r\n  (such as certain infections the mother\r\n  has during pregnancy, or infections the\r\n  new born baby has). Hearing loss can be\r\n  caused by a mix of hereditary and nongenetic\r\n  causes. The reason of hearing loss\r\n  in many infants is unknown.</p>\r\n<p>According to the World Health\r\n  Organization, 466 million people\r\n  worldwide suffer from hearing loss, with\r\n  the number expected to grow to nearly\r\n  900 million by 2050. Hearing loss is\r\n  defi ned as the inability to hear at the same\r\n  level as someone with normal hearing or\r\n  a hearing threshold of more than 25 dB in\r\n  one or both ears. Hearing loss accounts\r\n  for a $750 billion annual worldwide\r\n  shortfall, indicating a strong need for a\r\n  viable remedy. In most cases, conductive\r\n  hearing loss may be treated medically.\r\n  SNHL, on the other hand, is generally\r\n  irreversible and causes lifelong hearing\r\n  loss. Hearing rehabilitation, on the other\r\n  hand, is feasible using hearing aids that can\r\n  be worn externally or implanted. Despite\r\n  advancements in hearing aid and cochlear\r\n  implant technology, the perceived sound\r\n  quality still falls short of that of the natural\r\n  ear. The most signifi cant drawbacks of\r\n  cochlear implants are impaired speech perception in loud settings and musical\r\n  sound perception.</p>\r\n<h4> Types</h4>\r\n<p>1. Conductive: A problem transmitting\r\n  sound waves along the outer ear, tympanic\r\n  membrane (eardrum), and ossicular chain\r\n  of the middle ear to the cochlea is known\r\n  as conductive hearing loss.</p>\r\n<p>2. Sensor Neural Hearing Loss (SNHL):\r\n  occurs when sound vibrations are not\r\n  translated into electrical impulses in the\r\n  sensory Hair Cells (HCs) of the cochlea\r\n  or when information is not sent properly\r\n  from the afferent neurons to the brain.</p>\r\n<p>3. Mixed hearing loss: A combination of\r\n  conductive and sensorineural hearing loss\r\n  is known as mixed hearing loss.\r\n  Aging, acoustic overexposure, and\r\n  ototoxic medications can all disrupt this\r\n  connection between the ear and the\r\n  brain. Heredity also plays a role, since\r\n  hearing genes can be altered, or genes\r\n  can increase the risk of ear injury or\r\n  degradation with age.</p>\r\n<p>The following is the frequency of hearing\r\n  loss:</p>\r\n<p>&bull; Low frequency (500 Hz)\r\n  &bull; Middle (50Hz-2000 Hz)\r\n  &bull; High frequency (&gt;2000 Hz)</p>\r\n<h4>The 1-Plan Intervention to promote Hearing\r\n  Aid use among fi rst time adult hearing aid\r\n  users: A Quasi-Randomized controlled trial</h4>\r\n<p><strong>By Vikrant Singh<sup><a href=\"#corr\">*</a></sup></strong></p>\r\n<p>Department of Pharmacy, GD Goenka University, India</p>\r\n<p>*Vikrant181999@gmail.com</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>Hearing aid use that isn&rsquo;t up to par has\r\n  a signifi cant impact on one&rsquo;s health and\r\n  well-being. The goal of this study was to\r\n  conduct a randomised controlled trial\r\n  of a behaviour modifi cation intervention\r\n  to encourage people to use hearing\r\n  aids. This study had two arms and was a\r\n  quasi-randomized controlled experiment.\r\n  At their hearing aid fi tting sessions, a\r\n  total of 160 fi rst-time hearing aid users\r\n  were recruited. The standard of care\r\n  was provided to the control group. The\r\n  intervention arm got I-PLAN, which\r\n  included information regarding the\r\n  effects of hearing aid usage/non-use, a\r\n  reminder prompt to use the hearing aids,\r\n  and an action plan, in addition to normal\r\n  treatment.</p>\r\n<p>The fi ndings revealed that in both groups,\r\n  the proportion of time hearing aids were\r\n  used in situations that induced hearing\r\n  diffi culty was identical. In each outcome\r\n  measure, including data-logged hearing\r\n  aid use, there were no statistically\r\n  signifi cant changes between groups. The\r\n  very high rates of hearing aid use among\r\n  study participants may have reduced the intervention&rsquo;s ability to infl uence\r\n  hearing aid use. Although the intervention\r\n  materials were found to be acceptable\r\n  and deliverable, future intervention\r\n  trials should focus on hearing aid users\r\n  who aren&rsquo;t getting the most out of their\r\n  devices.</p>\r\n<p>Despite the fact that a variety of\r\n  interventions have been tried to\r\n  encourage people to wear hearing aids,\r\n  a Cochrane systematic review concluded\r\n  that none of the 37 trials enhanced hearing\r\n  aid use. One of the problems is that none\r\n  of the therapies, such as the behaviour\r\n  change wheel, were developed using\r\n  behaviour change theory and evidence.\r\n  The behaviour change wheel is a method\r\n  for creating a systematic approach to\r\n  behaviour change intervention.</p>\r\n<p>It was created through a rigorous review\r\n  and synthesis of 19 different behaviour\r\n  change frameworks. Barker et al. designed\r\n  the &ldquo;I-PLAN&rdquo; intervention using the\r\n  behaviour change wheel. The I-PLAN\r\n  intervention intends to assist audiologists\r\n  during hearing aid fi tting consultations\r\n  in order to help adult patients use their\r\n  hearing aids more effectively. The I-PLAN\r\n  is made up of three parts: information about the benefi ts of wearing a hearing\r\n  aid and the downsides of not using one,\r\n  reminders to encourage people to use\r\n  their hearing aids, and a hearing aid action\r\n  plan.</p>\r\n<p>In addition to assessing the I-PLAN\r\n  intervention, we wanted to learn more\r\n  about the potential mechanisms of action\r\n  so that the intervention could be improved;\r\n  therefore we looked into two options.\r\n  First, because the intervention aims to\r\n  improve self-regulation, we looked at the\r\n  three action control constructs that are\r\n  important in self-regulation: awareness of\r\n  action standards, self-monitoring, and selfregulatory\r\n  effort as potential mediators\r\n  of any effect.</p>\r\n<p>As a result, self-regulation can be thought\r\n  of as a personal process that entails\r\n  observing, assessing, and altering one&rsquo;s\r\n  behaviour in order to attain a behaviour\r\n  objective (e.g., using a hearing aid).\r\n  Second, action plans in the &ldquo;when-then&rdquo;\r\n  structure (as used in this study) have been\r\n  demonstrated to infl uence behaviour\r\n  through habits, and frequent effective\r\n  completion of behaviours leads to habit\r\n  building.</p>\r\n<h4>COVID Related Hearing Loss</h4>\r\n<p><strong>By Vikrant Singh<sup><a href=\"#corr\">*</a></sup></strong></p>\r\n<p>Department of Pharmacy, GD Goenka University, India</p>\r\n<p>*Vikrant181999@gmail.com</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>An intense respiratory illness, brought\r\n  about by a novel Covid SARS-CoV-2,\r\n  recently known as 2019-nCoV, the\r\n  Covid Disease 2019 (COVID-19)\r\n  has spread all through China and got\r\n  overall consideration. On 30 January\r\n  2020, World Health Organization\r\n  (WHO) authoritatively pronounced\r\n  the COVID-19 pestilence as a general\r\n  wellbeing crisis of global concern. Covid\r\n  sickness (COVID-19) is an irresistible\r\n  infection brought about by a newfound\r\n  Covid. A great many people tainted with\r\n  the COVID-19 infection experience\r\n  gentle to direct respiratory ailment\r\n  and recuperate without requiring\r\n  extraordinary treatment.</p>\r\n<h4> CLINICAL BEHAVIOR</h4>\r\n<p>The clinical manifestations of COVID-19\r\n  patients incorporate fever, hack, weakness\r\n  and a little populace of patients had\r\n  gastrointestinal disease indications.\r\n  The older and individuals with hidden\r\n  sicknesses are defenceless to disease and\r\n  inclined to genuine results, which might be\r\n  related with intense respiratory trouble\r\n  condition and cytokine storm. Right\r\n  now, there are not many explicit antiviral\r\n  procedures, yet a few strong competitors\r\n  of antivirals and repurposed drugs are under pressing examination. There are\r\n  numerous situations COVID-19 patients\r\n  may follow: Some get genuine respiratory\r\n  misery, some improve with clinical\r\n  treatment, the rest recuperate with no\r\n  medication.</p>\r\n<p>A few viral diseases can cause hearing\r\n  misfortune. Hearing misfortune incited\r\n  by these infections can be inherent or\r\n  procured, one-sided or respective. Certain\r\n  viral contaminations can straightforwardly\r\n  harm inward ear structures, others can\r\n  incite provocative reactions which then,\r\n  at that point cause this harm, and still\r\n  others can build helplessness or bacterial\r\n  or parasitic disease, prompting hearing\r\n  misfortune. Regularly, infection actuated\r\n  hearing misfortune is sensorineural,\r\n  albeit conductive and blended hearing\r\n  misfortunes can be seen following disease\r\n  with certain infections. Once in a while,\r\n  recuperation of hearing after these\r\n  diseases can happen precipitously.</p>\r\n<p>Commonly, infections cause Sensorineural\r\n  Hearing Misfortune (SNHL); nonetheless,\r\n  a viral etiology has been proposed for\r\n  otosclerosis. Contamination with HIV can\r\n  prompt conductive hearing misfortune\r\n  through bacterial and parasitic diseases,\r\n  which become more successive after\r\n  the immunosuppression brought about\r\n  by that infection. Hearing misfortune brought about by infections can be gentle\r\n  or extreme to signifi cant, one-sided or\r\n  two-sided. Systems engaged with the\r\n  acceptance of hearing misfortune by\r\n  various infections shift extraordinarily,\r\n  going from direct harm to inward ear\r\n  structures, including internal ear hair cells\r\n  and organ of Corte (as found in a portion\r\n  of the traditionally depicted reasons for\r\n  viral hearing misfortune like measles),\r\n  to enlistment of host insusceptible\r\n  intervened harm.</p>\r\n<p>Asymptomatic contamination at season\r\n  of research centre affi rmation has been\r\n  accounted for from numerous settings; an\r\n  enormous extent of these cases fostered\r\n  a few manifestations at a later phase of\r\n  disease. There are, in any case, additionally\r\n  reports of cases staying asymptomatic\r\n  all through the entire term of research\r\n  facility and clinical observing. Viral RNA\r\n  and irresistible infection particles were\r\n  distinguished in throat swabs from some\r\n  COVID-19 patients; however they grew\r\n  none of the manifestations recorded\r\n  above. Albeit a few viral diseases may\r\n  prompt hearing misfortune, it&rsquo;s as yet\r\n  unclear whether COVID-19 has impacts\r\n  on able framework or not. Thusly, this\r\n  exploration was intended to address the\r\n  effect of this novel viral disease on able\r\n  framework.</p>\r\n<h4>Hearing Aids</h4>\r\n<p><strong>By Vikrant Singh<sup><a href=\"#corr\">*</a></sup></strong></p>\r\n<p>Department of Pharmacy, GD Goenka University, India</p>\r\n<p>*Vikrant181999@gmail.com</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>Tinnitus is almost often associated with\r\n  some degree of hearing loss. Tinnitus\r\n  sufferers can often fi nd respite from the\r\n  internal sound of tinnitus by improving\r\n  their reception and perception of\r\n  external noise. Tinnitus is a sign of hearing\r\n  loss, which can be caused by age, longterm\r\n  hearing damage, or an acute injury\r\n  to the auditory system. Hearing loss\r\n  reduces the amount of external sound\r\n  input that reaches the brain, according to\r\n  scientifi c consensus. As a result, the brain&rsquo;s\r\n  processing of diverse sound frequencies\r\n  experiences neuroplastic modifi cations.\r\n  Tinnitus is the result of these neuroplastic\r\n  alterations that have become maladaptive.</p>\r\n<p>Hearing aids and other sound\r\n  amplifi cation equipment may provide\r\n  assistance to patients with hearing loss\r\n  and tinnitus. Small electrical devices\r\n  worn in or behind the ear are known as\r\n  hearing aids. A microphone, amplifi er, and\r\n  speaker are used. Hearing aids improve\r\n  the amount of sound stimuli received and\r\n  processed by the body&rsquo;s auditory system\r\n  by supplementing the loudness of outside\r\n  noise.</p>\r\n<p>According to a 2007 poll of hearing health\r\n  specialists, over 60% of their tinnitus\r\n  patients received at least some alleviation\r\n  when wearing hearing aids, with roughly 22% experiencing signifi cant relief.</p>\r\n<h4> HEARING AIDS ARE EFFECTIVE\r\n  FOR SEVERAL REASONS</h4>\r\n<p>Masking and attentional effects\r\n  Hearing aids can increase the volume of\r\n  external noise to the point that it drowns\r\n  out (masks) the tinnitus sound. This\r\n  makes it more diffi cult to notice tinnitus\r\n  and allows the brain to concentrate\r\n  on outside noises. Hearing aids have a\r\n  particularly powerful masking effect on\r\n  people with hearing loss in the same\r\n  frequency range as their tinnitus.</p>\r\n<p>Auditory simulation</p>\r\n<p>The amount of auditory input received by\r\n  the brain rises as the volume of external\r\n  noise is increased. Soft background sounds\r\n  that might otherwise go unnoticed could\r\n  help to stimulate the brain&rsquo;s auditory\r\n  pathways.</p>\r\n<p>Improved communication</p>\r\n<p>Patients with loud tinnitus may fi nd it\r\n  diffi cult, if not impossible, to engage\r\n  in ordinary communicative and social\r\n  activities such as following a conversation,\r\n  talking on the phone, watching television,\r\n  listening to the radio, and so on. Hearing\r\n  aids assist by increasing the external\r\n  volume of these activities above the\r\n  tinnitus&rsquo; perceived volume. Patients may experience less personal frustration and\r\n  social isolation as a result.</p>\r\n<p>Cochlear implants</p>\r\n<p>Another type of sound amplifi cation that\r\n  may be particularly useful in relieving\r\n  tinnitus symptoms is cochlear implants,\r\n  which are surgically implanted devices\r\n  that return the sensation of sound to\r\n  deaf individuals. These work in the same\r\n  way that hearing aids do. They boost\r\n  outside sound stimulation, which helps\r\n  to divert the brain&rsquo;s attention away from\r\n  the tinnitus sounds. Only individuals who\r\n  are completely deaf in both ears are\r\n  candidates for cochlear implants.</p>\r\n<h4> CONSIDERATIONS</h4>\r\n<p>Price</p>\r\n<p>Hearing aids are costly and are frequently\r\n  not covered by insurance plans. Hearing\r\n  aid coverage for tinnitus sufferers with\r\n  low assessed degrees of hearing loss may\r\n  be particularly diffi cult to come by.</p>\r\n<p>Lifestyle and comfort</p>\r\n<p>Hearing aids are most effective when used\r\n  consistently throughout waking hours,\r\n  according to research. This necessitates\r\n  the patient wearing the devices all of the\r\n  time.</p>',NULL,'2022-11-10'),(5,5390,'ajchr','http://www.andrewjohnpublishing.com/','','<h4>Editorial Note for Canadian Hearing Report</h4>\r\n<h4>EDITORIAL NOTE</h4>\r\n<p>*hearingrep@esciencejournal.org</p>\r\n<p>This is prideful to mention that the\r\n  Journal Canadian Hearing Report has\r\n  successfully published 13 volumes well\r\n  within the time and the print issues were\r\n  also brought out and dispatched within\r\n  30 days of publishing the 13th volume.\r\n  Canadian Hearing Report is the only\r\n  magazine of its kind uniting health\r\n  professionals. In addition to regular\r\n  issues, we offer a variety of special sales\r\n  options including reprints,\r\n  advertisements, supplements and year\r\n  end reports.</p>\r\n<p>Canadian Hearing Report provides\r\n  professionals including doctors,\r\n  researchers, and scholars with the\r\n  information about the ever changing\r\n  developments within the hearing\r\n  industry, focusing on the people,\r\n  companies and products. It is the place\r\n  where readers finds Up-To-Date\r\n  information related to ongoing\r\n  researches and development in\r\n  detection, diagnosis and treatment of\r\n  hearing disorders and impairment.</p>\r\n<p>The current partners associated with\r\n  Canadian Hearing Report include\r\n  Association of Public Safety\r\n  Communication Officials (APCO) of\r\n  Canada, College of Audiologists and\r\n  Speech Language Pathologists of Ontario\r\n  (CASLPO), Canadian Hard of Hearing\r\n  Association (CHHA), Canadian\r\n  Association of Pathologists, Sonography\r\n  Canada and many more. The Impact\r\n  Factor of the journal is 0.94. The articles\r\n  published in the journal have been cited\r\n  number of times by the eminent\r\n  researchers around the globe.</p>\r\n<p>The visitor&rsquo;s traffic is the benchmark for\r\n  the success of any scientific journal and\r\n  Canadian Hearing Report is constantly\r\n  attracting viewers across the world.\r\n  According to the Google Analytics, more\r\n  than readers are visiting to our journal\r\n  websites for submitting manuscripts, to\r\n  browse the latest research published on\r\n  hearing disorders and impairment.\r\n  Readers from the major countries\r\n  including United States, Japan, United\r\n  Kingdom, India, Egypt and Nigeria visit\r\n  our journal domain to learn about the\r\n  ongoing research activities in this field.\r\n  The promotion of the individual author\r\n  contributions is taken care of and hence\r\n  the authors enjoy the reputation among\r\n  global audience. The journal is using\r\n  Editorial Manager System for quality in\r\n  review process.</p>\r\n<p>Even A total of 50 research scientists\r\n  from all over the world contributed as\r\n  reviewer in the journal. We have 16\r\n  Editors in the Editorial Board of the\r\n  journal who actively contributed with\r\n  their valuable services throughout the\r\n  year for the publication of articles. JCHR\r\n  received a number of articles out of\r\n  which 40% were rejected in the\r\n  preliminary process. 25% were rejected in\r\n  the peer-review process. Around 35% of\r\n  the article has been accepted, processed\r\n  and published online.</p>\r\n<p>I take this opportunity to acknowledge\r\n  the contribution of the editors in bringing\r\n  out 13 volumes of the journal successfully.\r\n  . I would also like to express my gratitude\r\n  to all the authors, reviewers, the\r\n  publisher, the advisory and the editorial\r\n  board of Canadian Hearing Report, the\r\n  office bearers for their support in bringing\r\n  out yet another volume of JCHR and look\r\n  forward to their unrelenting support to\r\n  bring out the Volumes of JCHR in\r\n  scheduled time.</p>\r\n<h4>Acceptable Noise Level and Temporal\r\n  Modulation Transfer Function Measures in\r\n  Individuals with Normal Hearing Sensitivity</h4>\r\n<p><strong>By Vipin Ghosh PG<sup><a href=\"#corr\">*</a></sup>, Sreelakshmi CP</strong></p>\r\n<h4>ABSTRACT</h4>\r\n<p>Acceptable Noise Level is a procedure that was introduced for determining acceptable noise intensities\r\n  while listening to speech comfortably. Large inter-subject variation in ANL measures is not well\r\n  explained in the reported literature. The current study was hence aimed at investigating the temporal\r\n  resolution abilities in normal-hearing individuals with different degrees of Acceptable Noise\r\n  Level (ANL). A total of 100 participants between the age range of 18-30 years were considered and\r\n  based on the ANL scores obtained they were classified into low ANL (&lt;7 dB), mid-ANL (7-13 dB)\r\n  and high ANL (&gt;13 dB) groups. 12 participants were selected from each of the groups and were subjected\r\n  to TMTF (8 Hz, 20 Hz, and 60 Hz) tests. The test results were then compared across groups.\r\n  The statistical evaluation revealed that there were no significant differences between the groups in\r\n  TMTF with a modulation rate of 20 Hz. However, a significant difference was noticed in the scores\r\n  of TMTF with a modulation rate of 8 Hz (F=3.959, p&lt;0.05) and 60 Hz (F=8.545, p&lt;0.05). The current\r\n  study results hence demonstrate a possible contribution of temporal resolution abilities towards the\r\n  heterogeneity of ANL measure in normal-hearing individuals.</p>\r\n<h4>KEYWORDS</h4>\r\n<p>Acceptable Noise Level\r\n  (ANL), Temporal Modulation Transfer\r\n  Function (TMTF), Temporal Resolution\r\n  Abilities</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>Acceptable Noise Level is a procedure\r\n  that was introduced for determining\r\n  acceptable noise intensities while listening\r\n  to speech [<a href=\"#1\" title=\"1\">1</a>]. ANL was categorized\r\n  into three levels as low, mid and high\r\n  [<a href=\"#2\" title=\"2\">2</a>]. Individuals with low ANL scores\r\n  (&lt;7 dB) are generally successful hearing\r\n  aid wearers, whereas individuals with\r\n  high ANL scores (&gt;13 dB) are generally\r\n  unsuccessful hearing aid wearers.\r\n  Individuals with mid-ANL scores (7 db\r\n  to 13 dB) may or may not be successful\r\n  hearing aid wearers. Earlier researchers\r\n  have also studied and reported that\r\n  ANLs were unrelated to middle ear\r\n  impedance measures, acoustic reflex\r\n  thresholds evoked by tonal or broadband noise stimuli or contralateral suppression\r\n  of click-evoked otoacoustic emissions\r\n  (CEOAEs) [<a href=\"#3\" title=\"3\">3</a>]. They also reported that\r\n  there was a correlation between monotic\r\n  ANL and dichotic ANL. The results of the\r\n  study suggest that ANL may be mediated\r\n  by non-peripheral factors. Though various\r\n  factors were studied to understand\r\n  the large inter-subject variation in ANL\r\n  measures, it is not well explained. Central\r\n  involvement is being suspected to account\r\n  for this variation based on objective and\r\n  electrophysiological assessment. But such\r\n  an explanation using a subjective test\r\n  which assesses the auditory processing\r\n  lacks in the literature.</p>\r\n<p>The temporal modulation transfer\r\n  function is one measure that can be used\r\n  utilized to assess temporal resolution.\r\n  Temporal resolution refers to the\r\n  minimal time required to segregate or\r\n  resolve acoustic events [<a href=\"#4\" title=\"4\">4</a>-<a href=\"#6\" title=\"6\">6</a>]. Amplitude\r\n  modulation detection assesses the capability to hear the sinusoidal amplitude\r\n  modulation of a continuous sound. The\r\n  temporal modulation transfer function is\r\n  a function relating to a listener&rsquo;s threshold\r\n  for detecting sinusoidal amplitude\r\n  modulation to the modulation rate [<a href=\"#7\" title=\"7\">7</a>]. As\r\n  temporal resolution abilities is also shown\r\n  to be mediated by the non-peripheral\r\n  processing [<a href=\"#8\" title=\"8\">8</a>], the authors wanted to\r\n  explore any possible relations between\r\n  the two measures. The present study was\r\n  hence planned to assess the performance\r\n  of individuals with different ANL scores\r\n  in the Temporal Modulation Transfer\r\n  Function test. The specific objectives\r\n  of the study were to classify the study\r\n  population into three groups based on\r\n  the ANLs obtained and to compare the\r\n  TMTF scores using 8 Hz, 20 Hz and 60 Hz\r\n  modulations across the groups.</p>\r\n<h4> METHOD</h4>\r\n<p>106 native Kannada language speakers were enrolled for the study. Subjects\r\n  with an indication of psychological,\r\n  neurological, systemic or behavioural\r\n  difficulties were excluded from the study.\r\n  Subjects under the influence of any\r\n  sedative, alcohol or any other drugs at\r\n  the time of testing were also not included.\r\n  All the participants were right-handed\r\n  and were within the age range of 18 to\r\n  30 years. Pure Tone Audiometry and\r\n  Immittance Audiometry were carried out\r\n  on all the participants. 6 participants who\r\n  exhibited middle ear dysfunction were\r\n  excluded from the study. 100 participants\r\n  including 58 males and 42 females with\r\n  normal hearing sensitivity and middle ear\r\n  functioning were considered for further\r\n  testing. The mean age of participants was\r\n  24.01 years with a standard deviation of\r\n  1.46. The testing was carried out in two\r\n  phases, initial assessment of ANL was\r\n  done and the subjects were classified\r\n  into three groups: high ANL (&gt;13 dB),\r\n  mid-ANL (7 db-13 db) and low ANL (&lt;7\r\n  dB) and in the second phase, TMTF with\r\n  modulation rate 8 Hz, 20 Hz and 60 Hz\r\n  were carried out. The entire testing was\r\n  carried out in air-conditioned, acoustically\r\n  treated rooms. The ambient noise\r\n  levels inside the test room were within\r\n  permissible limits (ANSI, 1999). The entire\r\n  testing was carried out in air-conditioned,\r\n  acoustically treated rooms. The ambient\r\n  noise levels inside the test room were\r\n  within permissible limits (ANSI, 1999).</p>\r\n<p>A standardized Kannada story was used as\r\n  the speech stimulus for the measurement\r\n  of ANL. Both speech stimulus and noise\r\n  were presented binaurally through\r\n  MATLAB. A calibrated Sennheiser\r\n  HD206 headphone was used. A quiet\r\n  distraction-free room was selected for the\r\n  experiment. The instructions were given\r\n  in the Kannada language. To establish ANL,\r\n  the Most Comfortable Level (MCL) of\r\n  the subject was determined. The subjects\r\n  were asked to listen to the story played through the headphones. Initially, the\r\n  loudness of the running speech was 0 dB\r\n  HL and then the loudness was increased\r\n  in steps of 10 dB until the subject indicates\r\n  that it is &ldquo;too loud&rdquo;. Then the loudness\r\n  was decreased by 10 dB until the listener\r\n  indicated that it is &ldquo;too soft&rdquo;. At this\r\n  point, the level of the story was adjusted\r\n  up and down in 5 dB increments until the\r\n  listener indicated the most comfortable\r\n  loudness, which is considered as MCL,\r\n  which was followed by Background Noise\r\n  Level (BNL) estimation. To assess the\r\n  BNL, background noise was added to\r\n  the speech to estimate the Background\r\n  Noise Level (BNL). In the beginning, the\r\n  noise was at the level of 0 dB HL and was\r\n  increased in 5 dB steps until the listener\r\n  indicates that it is &ldquo;too loud&rdquo; to listen to\r\n  the continuous story. Then the loudness\r\n  of the noise was decreased in 5 dB steps\r\n  until the listener indicates that it is &ldquo;too\r\n  soft&rdquo; while listening to the continuous\r\n  story. At this point, the noise level was\r\n  adjusted up and down in 1dB increments\r\n  until it reaches the highest level which will\r\n  be indicated by the participants without\r\n  becoming tense or tired. This level was\r\n  considered a participant&rsquo;s BNL. The ANL\r\n  was calculated by subtracting the BNL\r\n  from the MCL (ANL=MCL-BNL). The\r\n  MCL and BNL were repeated 3 times and\r\n  the average of 3 ANLs was used.\r\n  Based on ANL the subjects were classified\r\n  into 3 groups. &ldquo;Low&rdquo; ANLs (ANL less than\r\n  7dB), &ldquo;Mid&rdquo; ANLs (ANL between 7 to\r\n  13 dB), &ldquo;High&rdquo; ANLs (ANL greater than\r\n  13 dB). Among the 100 individuals who\r\n  underwent ANL testing, 56 subjects had\r\n  low ANL scores, 29 subjects had mid-\r\n  ANL scores and 12 subjects had high\r\n  ANL scores. To maintain uniformity of\r\n  the data 12 individuals were randomly\r\n  selected from mid and low ANL groups\r\n  along with the 12 individuals who had high\r\n  ANL (total of 36 participants) for further\r\n  evaluations. All the selected participants\r\n  underwent TMTF testing.</p>\r\n<p>TMTF with modulation rates of 8 Hz , 20\r\n  Hz and 60 Hz were carried out on all the\r\n  selected subjects. A 500 msec Gaussian\r\n  noise which was sinusoidally amplitude\r\n  modulated at 60 Hz, 20 Hz, 8 Hz were\r\n  used for TMTF. This was superimposed\r\n  on a 1000 msec unmodulated Gaussian\r\n  noise. 3 Alternate Forced Choice (3 AFC)\r\n  procedure in which two tones were\r\n  similar and the third one was different\r\n  was used for all the mentioned test\r\n  procedures. Participants were instructed\r\n  to indicate the variable tone. The\r\n  entire testing was carried out using the\r\n  staircase procedure which was adapted\r\n  in MATLAB. The staircase procedure was\r\n  implemented through MATLAB software\r\n  (MATLAB R2016a). The stimulus was\r\n  presented using HP (Intel i3 processor)\r\n  laptop equipped with the Sennheiser\r\n  HD206 headphones. Stimuli during the\r\n  testing were presented binaurally for\r\n  all the participants. Minimum amplitude\r\n  modulation necessary to identify the\r\n  amplitude-modulated noise from\r\n  unmodulated noise was assessed in TMTF.\r\n  The minimum amplitude modulation of\r\n  the noise which was identified by the\r\n  participant&rsquo;s was considered as the TMTF\r\n  threshold.</p>\r\n<h4> RESULTS</h4>\r\n<p>Descriptive statistics were carried out to\r\n  obtain the mean and standard deviation of\r\n  all the test results in each of the groups.\r\n  Group 1 as mentioned in this chapter\r\n  refers to &lsquo;Low ANL group&rsquo;. Groups 2 and\r\n  3 are &lsquo;mid-ANL&rsquo; and &lsquo;high ANL&rsquo; groups\r\n  respectively. The mean and standard\r\n  deviation of TMTF with modulation\r\n  rate 8 Hz, 20 Hz, and 60 Hz is given in\r\n  Table 1. Shapiro-Wilk test was carried\r\n  for assessing the normality of the data.\r\n  As the data satisfies the assumptions of\r\n  ANOVA, a one-way ANOVA was carried\r\n  out to compare the TMTF findings with\r\n  a modulation rate of 8 Hz, 20 Hz and 60</p>\r\n<div class=\"table-responsive\">\r\n  <table class=\"table table-sm table-bordered\">\r\n    <thead>\r\n      <tr>\r\n        <th>&nbsp;</th>\r\n        <th colspan=\"2\">Low ANL</th>\r\n        <th colspan=\"2\">Mid ANL</th>\r\n        <th colspan=\"2\">High ANL</th>\r\n      </tr>\r\n      <tr>\r\n        <th>&nbsp;</th>\r\n        <th>Mean</th>\r\n        <th>SD</th>\r\n        <th>Mean</th>\r\n        <th>SD</th>\r\n        <th>Mean</th>\r\n        <th>SD </th>\r\n      </tr>\r\n    </thead>\r\n    <tbody>\r\n      <tr>\r\n        <td\r\n>TMTF (8 Hz)</td>\r\n        <td>-25.44</td>\r\n        <td>4.75</td>\r\n        <td>-30.63</td>\r\n        <td>4.46</td>\r\n        <td>-26.3</td>\r\n        <td>5.27</td>\r\n      </tr>\r\n      <tr>\r\n        <td>TMTF (20    Hz)</td>\r\n        <td>-28.28</td>\r\n        <td>3.68</td>\r\n        <td>-29.9</td>\r\n        <td>6.36</td>\r\n        <td>-26.24</td>\r\n        <td>5.55</td>\r\n      </tr>\r\n      <tr>\r\n        <td>TMTF (60    Hz)</td>\r\n        <td>-28.28</td>\r\n        <td>3.68</td>\r\n        <td>-29.9</td>\r\n        <td>6.36</td>\r\n        <td>-26.24</td>\r\n        <td>5.55</td>\r\n      </tr>\r\n    </tbody>\r\n  </table>\r\n</div>\r\n<p><strong>Table 1.</strong> Mean and SD of TMTF with modulation rate 8 Hz, 20 Hz, 60 Hz.</p>\r\n<h4>ACCEPTABLE NOISE LEVEL AND TEMPORAL MODULATION TRANSFER FUNCTION\r\n  MEASURES IN INDIVIDUALS WITH NORMAL HEARING SENSITIVITY</h4>\r\n<p>Hz across the groups. Scheffe Post-Hoc\r\n  analysis was further carried out. <strong>Figures 1-3</strong> represent the mean and\r\n  standard deviation of TMTF 8 Hz, 20\r\n  Hz and 60 Hz in low, mid and high ANL\r\n  respectively.</p>\r\n<div class=\"well well-sm\">\r\n  <div class=\"row\">\r\n    <div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-standard-14-1-1-g001.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-standard-14-1-1-g001.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-standard\" title=\"canadian-hearing-report-standard\" /></a></div>\r\n    <div class=\"col-xs-12 col-md-10\">\r\n      <p><strong>Fig 1.</strong> Mean and standard deviation of TMTF (8Hz) scores in Low, Mid and High ANL groups.</p>\r\n    </div>\r\n  </div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n  <div class=\"row\">\r\n    <div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-deviation-14-1-1-g002.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-deviation-14-1-1-g002.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-deviation\" title=\"canadian-hearing-report-deviation\" /></a></div>\r\n    <div class=\"col-xs-12 col-md-10\">\r\n      <p><strong>Fig 2.</strong> Mean and standard deviation of TMTF (20Hz) scores in Low, Mid and High ANL groups.</p>\r\n    </div>\r\n  </div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n  <div class=\"row\">\r\n    <div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Mean-14-1-1-g003.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Mean-14-1-1-g003.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Mean\" title=\"canadian-hearing-report-Mean\" /></a></div>\r\n    <div class=\"col-xs-12 col-md-10\">\r\n      <p><strong>Fig 3.</strong> Mean and standard deviation of TMTF (60Hz) scores in Low, Mid and High ANL groups.</p>\r\n    </div>\r\n  </div>\r\n</div>\r\n<p>The results of TMTF with modulation\r\n  rate 8 Hz (F=3.959, p&lt;0.05) and 60 Hz\r\n  (F=8.545, p&lt;0.05) revealed that there was\r\n  a significant difference between scores\r\n  of the three groups. Since a significant\r\n  difference was observed in the mean\r\n  scores between the groups, Scheffe\r\n  posthoc analysis was further carried out.</p>\r\n<p>It revealed that there was a significant\r\n  difference across means betweengroup\r\n  1and group 2 and that there was\r\n  no significant difference across means\r\n  between groups 2 and 3 and groups 1\r\n  and 3 using 8 Hz modulation rate. It was\r\n  also observed that the results of 60 Hz\r\n  modulation rate showed no significant\r\n  difference across means between groups\r\n  2 and 3. However, there was a significant\r\n  difference across means between groups\r\n  1 and 2, and groups 1 and 3. On the</p>\r\n<h4>CANADIAN HEARING REPORT | REVUE CANADIENNE D&rsquo;AUDITION</h4>\r\n<p>contrary, the results of TMTF with a\r\n  modulation rate of 20 Hz were not\r\n  significantly different between the three\r\n  groups. This suggests that the high ANL\r\n  group performed poorly than low ANL,\r\n  especially at higher modulation rates.\r\n  However, the mid-ANL group performed\r\n  better than low ANL groups at low and\r\n  high ANLs.</p>\r\n<h4> DISCUSSION</h4>\r\n<p>The temporal processing abilities in\r\n  individuals with varying ANLs were\r\n  studied in the current study. The findings\r\n  revealed that there was no significant\r\n  difference between the TMTF scores with\r\n  modulation rate 20 Hz across the three\r\n  groups of ANL. However, a significant\r\n  difference was noticed in the results of\r\n  TMTF with a modulation rate of 8 Hz and\r\n  60 Hz. This suggests that the temporal\r\n  resolution abilities are different between\r\n  the groups. Though we could not find\r\n  any similar studies in the literature, we\r\n  attempted to compare and contrast the\r\n  tests carried out in related populations\r\n  to understand our results better. Many\r\n  researchers have compared the TMTF\r\n  results obtained in the normal hearing\r\n  subjects with various disorders. Earlier\r\n  researchers have studied the TMTF using\r\n  neural coding in noise-induced hearing\r\n  loss [<a href=\"#5\" title=\"5\">5</a>]. Based on their study findings\r\n  they concluded that the alterations in\r\n  TMTF may be attributed to physiological\r\n  factors other than the cochlear filtering\r\n  as seen in sensorineural hearing loss.\r\n  Moreover, they also reported that there\r\n  was no consistent association between\r\n  the temporal resolution measures\r\n  and frequency selectivity. Defects in\r\n  neural structures in the central nervous\r\n  system are also postulated to be one of\r\n  the possible reason for altered TMTF\r\n  performance in individuals with normal\r\n  hearing sensitivity with tinnitus [<a href=\"#9\" title=\"9\">9</a>].</p>\r\n<p>Thus, from the studies discussed here, it\r\n  may be concluded that more of a central\r\n  auditory related deficiency is contributing\r\n  to TMTF performance than the peripheral\r\n  physiology. Hence, it may be assumed\r\n  that an individual with a subtle neural\r\n  processing deficit irrespective of his\r\n  normal hearing sensitivity may also demonstrate altered TMTF performance.</p>\r\n<p>Similarly, heterogeneity in ANLs within\r\n  normal hearing individuals is also well\r\n  demonstrated in the literature. The\r\n  role of peripheral auditory processing\r\n  on ANL using middle ear impedance\r\n  measures, acoustic reflex thresholds\r\n  and Contralateral Suppression of Click\r\n  Evoked Otoacoustic Emissions (CEOAEs)\r\n  were studied and reported earlier [<a href=\"#3\" title=\"3\">3</a>].\r\n  The findings suggested that the ANL\r\n  is not related to any of the peripheral\r\n  auditory processing as suggested by\r\n  the test results. Physiological responses\r\n  including Click-Evoked Otoacoustic\r\n  Emissions (CEOAEs), Auditory Brainstem\r\n  Responses (ABRs), and Middle Latency\r\n  Responses (MLRs) in females with normal\r\n  hearing with low (n=6) versus high (n=7)\r\n  ANLs is also reported in the literature\r\n  [<a href=\"#10\" title=\"10\">10</a>]. The results showed that there were\r\n  no differences between individuals with\r\n  low and high ANLs for CEOAEs or waves\r\n  I or III of the ABR and difference between\r\n  the two groups emerged for wave V of\r\n  the ABR and Na-Pa of the MLR. Results\r\n  further supported that acceptance of\r\n  background noise is mediated from\r\n  central regions of the auditory system.\r\n  The effect of cortical and auditory long\r\n  latency responses on ANLs in females\r\n  with normal hearing sensitivity with low\r\n  versus high ANLs is also documented in\r\n  the literature [<a href=\"#11\" title=\"11\">11</a>]. They reported that\r\n  there are no differences between the\r\n  two groups for the early waves of the\r\n  ABR, yet signi&#64257;cant differences existed\r\n  between the two groups for waves III and\r\n  V of the ABR and the MLR and LLR peaks.\r\n  The results further revealed that the ANL\r\n  growth rate for the two groups was not\r\n  uniform, and the groups differed on some\r\n  of the physiological measures. These\r\n  effects further supported the theory that\r\n  acceptance of noise is mediated from\r\n  central regions of the nervous system.\r\n  Thus, it can be assumed that both TMTF\r\n  and ANLs are mediated by central auditory\r\n  processing than peripheral processing.\r\n  Consequently, a subtle auditory deficit\r\n  may affect both measures. In the current\r\n  study findings to the TMTF is found to\r\n  be deviant along with ANLs. Moreover,\r\n  the study included individuals with\r\n  normal hearing sensitivity. The peripheral\r\n  hearing mechanism of all the participants\r\n  was normal as suggested by pure tone\r\n  audiometry and immittance audiometry.\r\n  The results of the current study suggest a\r\n  temporal resolution deviation which itself\r\n  is a central auditory processing ability\r\n  among people with varying degrees of\r\n  ANLs. Hence, it may be assumed that the\r\n  deviant temporal resolution abilities may\r\n  be one of the factors contributing to the\r\n  heterogeneity of ANLs in individuals with\r\n  normal hearing abilities.</p>\r\n<h4> CONCLUSION</h4>\r\n<p>Temporal resolution abilities among\r\n  individuals with varying ANLs were\r\n  compared in the present study. The study\r\n  population was divided into low, mid and\r\n  high ANL groups. The results suggested\r\n  a deviation in the temporal resolution\r\n  abilities across the groups. It is observed\r\n  by the earlier researchers that the\r\n  temporal resolution abilities as suggested\r\n  by TMTF and ANLs are mediated by the\r\n  central auditory physiology than the\r\n  peripheral hearing mechanism. It may\r\n  hence be assumed that both the measures\r\n  are interrelated and temporal resolution\r\n  deviations may be a factor that contributes\r\n  to the variations seen in ANL measures in\r\n  individuals with normal hearing abilities.</p>\r\n<h4> ACKNOWLEDGEMENTS</h4>\r\n<p>The authors acknowledge the Director,\r\n  JSS Institute of Speech and Hearing, for\r\n  permission to carry out the study. Sincere\r\n  gratitude to all the participants.</p>\r\n<h4> REFERENCES</h4>\r\n<ol>\r\n  <li id=\'Reference_Title_Link\' value=\'1\'><a name=\"1\" id=\'1\'></a>Nabelek, A.K., Tucker, F.M., Letowski, T.R., &ldquo;Toleration of background noises: relationship with patterns of hearing aid use by  elderly persons.&rdquo; J Speech Lang Hear R, 34(3) (1991): 679-685.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'2\'><a name=\"2\" id=\'2\'></a>Nabelek, &nbsp;A.K., &nbsp;Tampas, &nbsp;J.W., &nbsp;Burchfield, &nbsp;S.B., &ldquo;Comparison of speech  perception in background noise  with acceptance of background in aided and  unaided conditions.&rdquo; J Speech Lang Hear R, 47(5) (2004):  1001-1011.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'3\'><a name=\"3\" id=\'3\'></a>Harkrider, A.W., &nbsp;Smith &nbsp;B.,&nbsp; &nbsp;&ldquo;Acceptable  &nbsp;noise level, phoneme  recognition in noise, and measures  of auditory efferent measures.&rdquo; J Am Acad Audiol,16(8) (2005): 530-545.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'4\'><a name=\"4\" id=\'4\'></a>Irwin, R.J., et  al. &ldquo;The development of auditory temporal acuity in children.&rdquo; Child Dev, 56(3) </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'5\'><a name=\"5\" id=\'5\'></a>Phillips, S.L.,  et al. &ldquo;Frequency and temporal resolution in elderly listeners with good and poor word recognition.&rdquo; J Speech Lang Hear Res,  43(1) (2000): 217-228. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'6\'><a name=\"6\" id=\'6\'></a>Shinn, J.B., &ldquo;Temporal processing: the basics.&rdquo; Hear J, 56(7) (2003):  52. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'7\'><a name=\"7\" id=\'7\'></a>Viemeister,  N.F., &ldquo;Temporal modulation transfer  functions based upon modulation  thresholds.&rdquo; J Acoust Soc Am, 66(5) (1979): 1364-1380. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'8\'><a name=\"8\" id=\'8\'></a> Kale, S., Heinz,  M., &ldquo;Temporal modulation transfer functions measured from auditory  nerve responses following  sensorineural hearing loss.&rdquo; Hear Res, 286(1-2) (2012):  64-75.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'9\'><a name=\"9\" id=\'9\'></a>Jain, C., Sahoo,  J.P., &ldquo;The effect of tinnitus on some psychoacoustical abilities in individuals with normal hearing sensitivity.&rdquo; Int Tinnitus J, 19(1) (2014): 28-35. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'10\'><a name=\"10\" id=\'10\'></a>Tampas,&nbsp;&nbsp; &nbsp;J.W.,&nbsp;&nbsp; &nbsp;Harkrider,&nbsp; &nbsp;A.W.,&nbsp; &nbsp;&ldquo;Auditory evoked potentials  in females with high and low\r\n    acceptance of background noise when  listening to speech.&rdquo; J Acoust  Soc Am, 119(3)  (2006):1548- 1561.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'11\'><a name=\"11\" id=\'11\'></a>Harkrider,&nbsp; &nbsp;A.W., &nbsp;Tampas,&nbsp; &nbsp;J.W.,&nbsp; &nbsp;&ldquo;Differences in  responses from the cochleae and central nervous systems of females with low versus high acceptable  noise levels.&rdquo; J Am Acad Audiol, 17(9) (2006): 667-676.</a></li>\r\n</ol>\r\n<h4>Audiological and Imaging Outcomes after\r\n  Replacement of IJ Electrode with a Mid-Scalar\r\n  Array</h4>\r\n<p><strong>By Diego Zanetti<sup><a href=\"#a1\">1</a><a href=\"#corr\">*</a></sup>, Giorgio Conte<sup><a href=\"#a2\">2</a></sup>, Federica Di Berardino<sup><a href=\"#a3\">3</a></sup></strong><sup><a href=\"#a3\"></a></sup></p>\r\n<p><sup>1</sup><a name=\"a1\" id=\"a1\"></a>Audiology Unit, Fondazione IRCCS Ca&rsquo; Granda Ospedale Maggiore Policlinico; DISCCO (Department of Clinical Sciences and\r\n  Community Health), University of Milano, Italy</p>\r\n<p><sup>2</sup><a name=\"a2\" id=\"a2\"></a>Neuroradiology Department, Fondazione IRCCS Ca&rsquo; Granda Ospedale Maggiore Policlinico, University of Milano, Italy</p>\r\n<p>*diego.zanetti.bs@gmail.com, <strong>Tel</strong>: +39(02) 5503.5216; <strong>Fax</strong>: +39 02 5032 0754</p>\r\n<h4>ABSTRACT</h4>\r\n<p>Objective: This study aims to report the outcomes of replacing a straight array with a pre-formed\r\n  array, quite different in dimensions and design, in terms of speech perception performances and\r\n  neuro-radiological findings.</p>\r\n<p>Patient: A 45 years old female with post-verbal bilateral deafness.</p>\r\n<p>Intervention: Explantation of a malfunctioning straight Hi Focus 1J array and re-implantation of the\r\n  right ear with a new Hi Focus Mid-Scala (HFMS) electrode array; simultaneous HFMS cochlear implantation\r\n  in the left ear.</p>\r\n<p>Main outcome measures: This clinical report details the surgical findings, the intraoperative electrophysiological\r\n  measurements, the post-operative neuro-radiological findings, and audiological outcomes.\r\n  The speech perception tests, VAS, APHAB, and SSQ questionnaire at 2, 9 and 24 months\r\n  post-activation were compared to the pre-re-implantation performances and between the two new\r\n  CIs.</p>\r\n<p>Results: Both speech perception and subjective measures indicated that the new array provided very\r\n  rapidly at least similar benefit as the original device. The HFMS arrays followed different courses\r\n  within the cochlea in the reimplanted vs. the newly implanted ear.</p>\r\n<p>Conclusion: Following re-implantation, performances returned almost immediately to the previous\r\n  levels, despite the differences in length and shape of the electrode arrays. The simultaneous contra-\r\n  lateral CI gradually caught up with the re-implanted one, complementing it.</p>\r\n<h4>KEYWORDS</h4>\r\n<p>Cochlear implant, straight\r\n  electrode, mid-scala electrode, explants,\r\n  re-implantation, pre-formed array</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>Cochlear implant (CI) re-implantation\r\n  is not an uncommon event. With reimplantations\r\n  occurring perhaps decades\r\n  after the original surgery, the likelihood of\r\n  the same electrode array being available\r\n  is reduced and even when the original\r\n  array is still available, the surgeon might\r\n  consider re-implantation using more up\r\n  to date technology.</p>\r\n<p>Cochlear implants (CI) have been\r\n  successful in treating severe-to-profound\r\n  deafness. They generally restore speech\r\n  understanding for listening to speech in\r\n  quiet to ceiling level [<a href=\"#1\" title=\"1\">1</a>-<a href=\"#3\" title=\"3\">3</a>]. When listening\r\n  in competing noise, leave CI recipients\r\n  some 9 dBHL to 15 dBHL disadvantaged\r\n  in speech reception threshold compared\r\n  to a normal hearing listener [<a href=\"#4\" title=\"4\">4</a>,<a href=\"#5\" title=\"5\">5</a>]. Over\r\n  the past 30 years, some 450,000 devices\r\n  have been implanted worldwide, with\r\n  around 51,000 implanted in 2013 alone\r\n  [<a href=\"#6\" title=\"6\">6</a>]. The reliability of the implanted parts\r\n  of a CI system is typically very high.</p>\r\n<p>The Cumulative Survival Ratio (CSR)\r\n  of current products, which ratios the\r\n  number of device failures to the number\r\n  of devices at risk in a given period, typically\r\n  quoted every year, exceeds 99.8% after\r\n  one year, or 98.8 after five years [<a href=\"#6\" title=\"6\">6</a>-<a href=\"#8\" title=\"8\">8</a>].\r\n  Despite such strikingly high CSR values,\r\n  several reports quote the percentage of\r\n  CI re-implantations ranging between 4.4%\r\n  and 8%, with the most common cause of implant failure being trauma [<a href=\"#9\" title=\"9\">9</a>-<a href=\"#11\" title=\"11\">11</a>]. This\r\n  total includes re-implantations due to a\r\n  variety of medical complications [<a href=\"#12\" title=\"12\">12</a>,<a href=\"#13\" title=\"13\">13</a>].</p>\r\n<p>That these tend to account for fewer reimplantations\r\n  than device failures. Hence,\r\n  considering the number of implanted\r\n  devices, re-implantation is not uncommon.\r\n  Different electrode arrays, depending on\r\n  the model, range in length between 15 mm\r\n  and 31 mm and occupy between 360 and\r\n  720 degrees of the cochlea and, inserted\r\n  using a variety of insertion techniques,\r\n  will take up various positions within the\r\n  cochlea [<a href=\"#14\" title=\"14\">14</a>]. Electrode arrays can be\r\n  broken into two major groups: straight,\r\n  lying along the lateral wall of the cochlea,\r\n  and pre-formed, taking a mid-scala to\r\n  peri-modiolar position. Some trauma is\r\n  inevitable during insertion and will lead\r\n  to varying amounts of fibrosis or even\r\n  new bone growth within the cochlea [<a href=\"#15\" title=\"15\">15</a>].</p>\r\n<p>Thus, once an array has been implanted\r\n  for some weeks its location is well\r\n  defined through it is fully encapsulated\r\n  within a fibrous sheath. A surgeon would\r\n  typically choose to use an identical array\r\n  in any revision surgery. However, with\r\n  re-implantation now coming perhaps\r\n  decades after the original surgery, the\r\n  likelihood of the same electrode array\r\n  being available is reducing. Also, even\r\n  when re-implantation takes place where\r\n  the original array is still available, the\r\n  surgeon might consider re-implantation\r\n  using more up to date technology.</p>\r\n<p>Minimizing trauma is a key consideration\r\n  since different degrees of trauma lead to\r\n  observable differences in outcome [<a href=\"#16\" title=\"16\">16</a>].\r\n  The above considerations come to bear\r\n  in this work concerning re-implantation\r\n  of a HiFocus1J (HF1J) electrode array\r\n  (Advanced Bionics, Staefa, Switzerland), a\r\n  straight 23 mm long array 0.4 mm to 0.8\r\n  mm diameter from apex to base, with the\r\n  HiFocus mid-scala (HFMS) array from the\r\n  same manufacturer, a pre-formed 18.5 mm\r\n  long array 0.5 mm to 0.7 mm diameter\r\n  from apex to base. Note that while the\r\n  original array is longer, its characteristic\r\n  rotational insertion depth is lower than\r\n  that of the HFMS array: typically 360\r\n  degrees compared to 420 degrees [<a href=\"#17\" title=\"17\">17</a>,<a href=\"#18\" title=\"18\">18</a>].</p>\r\n<h4> MATERIAL AND METHODS</h4>\r\n<p>The prospective study deals with a\r\n  female subject, born in 1972. Written\r\n  consent from the patient and internal\r\n  Ethical Committee approval was obtained\r\n  before the patient&rsquo;s management and data\r\n  collection.</p>\r\n<p>The onset of hearing loss was at 14-\r\n  15 years of age. Initially, the hearing\r\n  loss involved only the high frequencies\r\n  bilaterally (1990). Hearing loss slowly\r\n  progressed over the next 5-6 years. No\r\n  hereditary trait was evident, nor was a\r\n  possible etiology ascertained. Genetic\r\n  testing proved inconclusive. Hearing aids\r\n  were worn binaurally: since 1995 initially\r\n  in-the-ear, then Behind-The-Ear (BTE)\r\n  power devices. The hearing loss became\r\n  profound in 2003-2004 with the hearing\r\n  aids no longer providing benefit.</p>\r\n<p>In 2006 cochlear implantation was\r\n  performed on the right side. Surgery\r\n  was conducted at the ENT department\r\n  of the University of Ferrara (Italy). An\r\n  Advanced Bionics HiRes90k implant with\r\n  an HF1J electrode array was implanted.\r\n  The implant was driven by an Auria BTE\r\n  speech processor. At the 3-month postop\r\n  test session, the Pure Tone Audiogram\r\n  (PTA) was 42 dBHL with the CI alone.\r\n  Outcomes improved further following\r\n  hearing rehabilitation with a speech\r\n  therapist. At 2 years post-op, a disyllabic\r\n  Word Recognition Score (WRS) of 65%\r\n  was obtained for presentation at 65 dB\r\n  SPL in quiet, and speech comprehension\r\n  in quiet had reached 75%. The patient\r\n  expressed subjective satisfaction with the\r\n  results. The contra-lateral hearing aid was\r\n  abandoned owing to insufficient benefit\r\n  and interference with the CI.</p>\r\n<p>After more than 10 years of regular use,\r\n  intermittent malfunctioning of the CI was\r\n  reported. The substitution of the old Auria\r\n  speech processor with a New Harmony\r\n  model was initially tried. However, the\r\n  problem persisted and speech perception\r\n  began to deteriorate. An integrity test\r\n  confirmed a malfunction of the internal\r\n  parts of the CI. In a written report, the\r\n  CI team suggested explantation and\r\n  re-implantation of the right ear with a\r\n  new device. An HFMS electrode array\r\n  was proposed, rather than the previous\r\n  straight HF1J array. Also, the possibility to\r\n  simultaneously implant the left ear was\r\n  offered. This offer was accepted.\r\n  Before the revision surgery, audiological\r\n  test results were as follows:</p>\r\n<p>Left ear: residual hearing sensations at 250\r\n  Hz, 500 Hz and 1000 Hz were 110 dBHL,\r\n  100 dBHL and 110 dBHL respectively\r\n  No open-set speech discrimination was\r\n  possible\r\n  Right ear (when CI functioning): PTA\r\n  45dB; disyllabic WRS=60% at 80dBHL\r\n  in quiet; 20% with masking noise (+10\r\n  dB SNR); 54 words/min speech tracking\r\n  without lip-reading and 78 words/min\r\n  with lip reading</p>\r\n<p>Two months later, the subject underwent\r\n  simultaneous implantation of a HiRes90k\r\n  Advantage&reg; implant with HFMS\r\n  electrode array in the left ear, and an\r\n  explant of the HiFocus1J and re-implant\r\n  with an HiRes90k Advantage&reg; with HFMS\r\n  electrode array in the right ear (surgeon:\r\n  first author).</p>\r\n<p>On both sides, a minimal retro-auricular\r\n  incision (3 cm) was placed at the hairline\r\n  and taken down to the mastoid cortex in\r\n  a single layer. On the side to be explanted,\r\n  care was taken to avoid damage of the\r\n  receiver/stimulator and of the array, to\r\n  maintain the integrity of the device and\r\n  allow the factory to ascertain the reasons\r\n  for failure.</p>\r\n<p>The surgical report detailed the clearance\r\n  of fibrous tissue that obliterated the\r\n  posterior tympanotomy and sealed the\r\n  cochleostomy site. The original HF1J array\r\n  appeared to be in its proper position.\r\n  Cutting of the electrode lead close to\r\n  the cochleostomy site allowed the HF1J\r\n  electrode array to remain in the cochlea,\r\n  maintaining a channel for the new array.\r\n  The previous device body and lead were\r\n  then removed and the new Advantage&#63720;\r\n  device secured in place, using the\r\n  previous implant body&rsquo;s site. The HFMS\r\n  array&rsquo;s stylet was then mounted onto the\r\n  insertion tool in preparation for insertion.\r\n  Next came the removal of the HF1J\r\n  intra-cochlear electrode array. This was\r\n  managed slowly and uneventfully. The next step involved intra-cochlear infusion of\r\n  dexamethasone (4 mg/ml) and immediate\r\n  delicate re-insertion of new (Mid-scala)\r\n  electrode array. Insertion was achieved\r\n  using the dedicated HFMS insertion\r\n  tool via the same anterior-inferior\r\n  cochleostomy location made during the\r\n  original surgery. A smooth insertion was\r\n  achieved to full depth without resistance\r\n  being felt. A full insertion was confirmed\r\n  through the automatic withdrawal of\r\n  the stylet, activated by the insertion tool\r\n  reaching its full extent and observation\r\n  that the proximal blue marker was at the\r\n  cochleostomy site. The final step involved\r\n  sealing of the cochleostomy site with\r\n  connective tissue. The flap was closed\r\n  using a conventional double-layer suture\r\n  to complete the re-implantation.</p>\r\n<p>Intra-operative compound action potential\r\n  measurements were performed for the\r\n  re-implanted right ear using a Harmony\r\n  Sound Processor and Sound Wave\r\n  Professional Suite Programming Software\r\n  [<a href=\"#8\" title=\"8\">8</a>]. The mean electrode impedance was\r\n  5.0 k-Ohm (range 2.4 to 9.2). Neural\r\n  Response Imaging (NRI) recordings were\r\n  made at supra-threshold levels for each\r\n  electrode contact using a stimulation\r\n  range of 150 to 250 Clinical Units (CU).\r\n  Recognizable nerve compound action\r\n  potentials were observed on all electrode\r\n  contacts. Valid extrapolated mean NRI\r\n  thresholds (t-NRI) of 152, 132, 154 and\r\n  206 CU found at contacts 1, 3, 9, 15\r\n  respectively.</p>\r\n<p>While implantation of the left ear is\r\n  not directly connected to this work, that surgery proceeded immediately\r\n  after re-implantation of the right ear.\r\n  The patient was turned over, a surgical\r\n  field developed and implantation made\r\n  with another Advantage implant having\r\n  a HFMS electrode array. A soft-surgery\r\n  approach was made resulting in a full\r\n  insertion of the electrode array. Together\r\n  both the re-implantation of the right ear\r\n  and new implantation of the left ear took\r\n  2.32 hours. Following the shipping of the\r\n  explanted device to Advanced Bionics,\r\n  the manufacturer&rsquo;s failure analysis report\r\n  concluded that the device failed due to\r\n  a lack of hermeticity, the source being\r\n  a known problem with the feed-thru\r\n  component: a so-called vendor B failure.</p>\r\n<h4> RESULTS</h4>\r\n<p>The right implant was activated the next\r\n  day. Impedance and neural telemetry\r\n  measurements were obtained for both\r\n  implants during the main mapping session\r\n  after activation (at 2, 6 and 24 weeks\r\n  post-operatively). The subject reported\r\n  that the initial sensation was noticeably\r\n  different from the previous experience\r\n  with the HF1J electrode: the sound was\r\n  more &ldquo;natural&rdquo; and &ldquo;warm&rdquo;, although\r\n  some metallic sound distortion was\r\n  present.</p>\r\n<p>The new CI (left ear) was activated 4 weeks\r\n  later. The patient wore Naida CI Q70\r\n  speech processors on both sides. She also\r\n  asked to try a Neptune speech processor\r\n  on the left side, but she then reported\r\n  subjectively less benefit. Weekly sessions\r\n  of dedicated auditory rehabilitation with\r\n  a speech therapist progressively improved\r\n  the speech comprehension ability.\r\n  Two months after activation the PTA on\r\n  the re-implanted side was 34 dBHL, while\r\n  on the newly implanted ear it reached\r\n  42.5 dBHL. The WRS was 90% at 60 dB\r\n  HL with the right re-implanted ear and\r\n  70% at 80 dBHL with the left CI (Figure 1).\r\n  After 9 months of CI use, the slight right\r\n  ear prevalence was further reduced: the\r\n  WRS was 90% with the right ear and 80%\r\n  with the left, at 60 dB HL (Figure 1).</p>\r\n<p>In the speech tracking test the subject\r\n  initially (2 months) scored 52 words per\r\n  minute with the right (re-implanted) ear,\r\n  but was unable to follow the live speech\r\n  with the newly implanted ear; at 9 months\r\n  she scored 75 words per minute with the\r\n  right ear and 48 wpm with the left.</p>\r\n<p>A Cone-Beam Computed Tomography\r\n  (CBCT) demonstrated full insertions of\r\n  the HFMS electrode array on both sides\r\n  (Figure 2). The marker contacts were at\r\n  or slightly within the cochleostomy sites.\r\n  A close periomodiolar position was found\r\n  at the basal turn. Compared to the newly\r\n  implanted left side, a slightly more lateral\r\n  location was evident in the re-implanted\r\n  right side. This is likely due to the reimplanted\r\n  array following the sheath of\r\n  the previous HF1J array. Angular insertion\r\n  depths were 434&deg; and 388&deg; for the left\r\n  and right sides respectively.</p>\r\n<p>At 24 months after the re-implantation\r\n  surgery, the speech perception scores\r\n  were further improved: while the pure tone\r\n  threshold was substantially unchanged, 25 dBHL in the re-implanted right ear\r\n  and 33 dBHL in the left, the WRS in quiet\r\n  reached 100% with both ears tested\r\n  separately, at 65 dBHL in the right and\r\n  75 dBHL in the left; the speech tracking\r\n  was 79 and 71 words/min respectively. </p>\r\n<p>Subjectively the patient was highly satisfied\r\n  with the new implants. Compared to the\r\n  previous HF1J in the right ear, the HFMS\r\n  electrode array was reported to sound\r\n  more natural, with a broader extension of\r\n  the sound spectrum and a warmer timbre\r\n  for voices. The binaural application was\r\n  reported to be advantageous for listening\r\n  in difficult situations and for sound source\r\n  localization. A Visual Analogue Score (VAS)\r\n  of the overall subjective appreciation of\r\n  sound quality was reported at 7 out of 10\r\n  before re-implantation and 9 out of 10 at\r\n  9 months after the revision surgery plus\r\n  contra-lateral implantation.</p>\r\n<p>The pre-op vs. post-op APHAB and Speech\r\n  Spatial and Quality (SSQ) questionnaires\r\n  scores are reported in Table 1 and Figure 3. They show an improvement,\r\n  corresponding to the speech test scores\r\n  reported above, which was faster in the\r\n  right (re-implanted) ear.</p>\r\n<h4> DISCUSSION</h4>\r\n<p>While the focus in CI surgery is normally\r\n  on achieving a particular placement of\r\n  the electrode array, the need to revise\r\n  virtually all of the implantations made\r\n  today in very young children should also\r\n  guide the implantation process.</p>\r\n<p>The feasibility of replacing a straight array\r\n  (HF1J) with a pre-formed (HFMS) array,\r\n  having quite different dimensions and\r\n  different design intent, is both encouraging\r\n  and important.</p>\r\n<p>Comparing the re-implanted and freshly\r\n  implanted cochleae within the same\r\n  subject illustrates the influence of the\r\n  previous HF1J array on the HFMS&rsquo;s\r\n  trajectory. The insertion depth of the\r\n  re-implanted right side is very much in\r\n  line with the 360&deg; typical of a normally\r\n  implanted HF1J array. The newly implanted\r\n  left ear with its 434&deg; insertion depth is\r\n  typical of the 420 degrees expected for\r\n  the HFMS array [<a href=\"#18\" title=\"18\">18</a>-<a href=\"#20\" title=\"20\">20</a>]. Reduced angular\r\n  insertion on the right side is almost\r\n  certainly due to the longer path taken in\r\n  following the HF1J&rsquo;s track.</p>\r\n<p>Importantly, the uneventful surgery\r\n  was followed by improvements being\r\n  found for both speech perception and\r\n  subjective measures of hearing following\r\n  re-implantation. When comparing speech\r\n  scores with the original Auria speech\r\n  processor to those obtained with the\r\n  Naida CI processor, care needed to\r\n  be taken to produce comparable test\r\n  results. Testing was conducted without\r\n  any spatial separation between the\r\n  target test material and competing for\r\n  noise: both being presented from zero\r\n  degrees azimuth. Hence the beam forming\r\n  capabilities of the Naida CI processor\r\n  could not play a role. Another confounding\r\n  factor might have been improvements\r\n  in speech understanding arising from\r\n  additional experience with electrical\r\n  hearing. However, scores obtained with\r\n  the initial implant were reported following\r\n  two years of device use, by which time a\r\n  plateau in performance would have been\r\n  expected.</p>\r\n<p>It is useful to observe that performance\r\n  with the re-implanted ear was already quite\r\n  high immediately after re-implantation.\r\n  This is important for professional&rsquo;s\r\n  counseling CI recipients about what\r\n  to expect following re-implantation. In\r\n  comparison, the improvement of speech\r\n  perception after the first implantation\r\n  of the right ear in 2006 had been much\r\n  slower: at 3 months the PTA was 42.5\r\n  dBHL and the WRS was only 34% at 60\r\n  dB HL; only at 24 months after the initial\r\n  implantation the WRS had reached 65%\r\n  and the comprehension 75%.</p>\r\n<p>The &ldquo;catching up&rdquo; managed by the left\r\n  ear has been reasonably rapid in this\r\n  case, possibly assisted by the customdesigned\r\n  rehabilitation program. The first\r\n  month after implantation was dedicated\r\n  to rehabilitation of the re-implanted\r\n  ear: the CI could be switched on the\r\n  day after surgery since the receiver/\r\n  stimulator fitted snugly and firmly into\r\n  the existing sub-periosteal pocket. The\r\n  patient quickly regained her speech\r\n  understanding abilities to the level\r\n  before the CI malfunction. Daily sessions\r\n  of speech comprehension tasks were\r\n  conducted under masking (continuous\r\n  and intermittent white noise) as well as\r\n  competing for multi-talker babble.</p>\r\n<p>The second (left) CI was activated 4 weeks\r\n  later. The speech therapist concentrated\r\n  on improving hearing discrimination in\r\n  the left ear by removing the right sound\r\n  processor (re-implanted ear). Habilitation\r\n  consisted of daily sessions of word\r\n  recognition, initially in a closed set with\r\n  the help of lip-reading, then for open set\r\n  and finally open set without lip-reading.\r\n  The patient was instructed to wear both\r\n  CIs in everyday life but also to practice at\r\n  home with the new (left) implant only.</p>\r\n<p>The largest subjective improvement,\r\n  based on the APHAB scores, was seen\r\n  in the newly implanted left ear. This was\r\n  not surprising, given the very low preoperative\r\n  speech perception scores with\r\n  the hearing aid. Interestingly, however,\r\n  after 4 months a significant improvement\r\n  was also observed in the re-implanted right ear. This improvement was much\r\n  faster than in the opposite ear, which\r\n  took almost 2 years to catch up with the\r\n  former.</p>\r\n<p>Not withstanding the recurrent\r\n  malfunction of the CI over the last weeks\r\n  before revision surgery, even at the time\r\n  when the patient was using her first\r\n  implant effectively, she was experiencing\r\n  difficulties in reverberant environments, or\r\n  those containing different sound sources,\r\n  such as multiple talkers or machines.\r\n  When the SSQ scores are considered\r\n  between the pre-explant and postre-\r\n  implant conditions, the benefit was\r\n  particularly evident in an improved ability\r\n  to understand speech in unfavorable noisy\r\n  situations [<a href=\"#7\" title=\"7\">7</a>,<a href=\"#11\" title=\"11\">11</a>]. A reduced effort was\r\n  reported for switching attention from\r\n  one talker to another and in other similar\r\n  tasks implying selective attention [<a href=\"#8\" title=\"8\">8</a>- <a href=\"#10\" title=\"10\">10</a>,12,14]. In the SSQ&rsquo;s &ldquo;spatial&rdquo; domain,\r\n  the scores highlighted an improved\r\n  appreciation and discrimination of sound\r\n  source movement. This was rather than\r\n  the identification of static direction and\r\n  distance, indicating that sound source\r\n  localization and lateralization significantly\r\n  benefited from re-implantation and\r\n  bilateral implant use [<a href=\"#3\" title=\"3\">3</a>,<a href=\"#6\" title=\"6\">6</a>,<a href=\"#12\" title=\"12\">12</a>,<a href=\"#13\" title=\"13\">13</a>]. However,\r\n  the improvements in spatial localization\r\n  were less prominent than the increases\r\n  reported for speech perception in noise\r\n  and the quality of the perceived sound.</p>\r\n<h4> CONCLUSION</h4>\r\n<p>This report demonstrates that it is both\r\n  practical and, in this case, straightforward\r\n  to replace a failed implant with a device\r\n  having a different electrode array.\r\n  Attention must be paid to the reimplantation\r\n  process, in particular, to\r\n  minimize the time between removal of\r\n  one electrode array and re-implantation\r\n  with the new array. Both speech testing\r\n  and subjective measures indicate that\r\n  the new array provided at least as much\r\n  benefit as the original device. Following reimplantation,\r\n  the performance was almost\r\n  immediately at the level provided by the\r\n  original device, despite the differences in\r\n  length and shape of the electrode arrays.\r\n  In comparison, the newly implanted ear improved more gradually but ultimately\r\n  complemented the re-implanted ear.</p>\r\n<h4> ACKNOWLEDGEMENT</h4>\r\n<p>The authors are grateful to Dr. Serena\r\n  Costanzo for the audiological testing, to\r\n  Dr. Patrick Boyle for technical advice and\r\n  editorial refinements, to Dr. Clara Sina\r\n  for the Neuro-radiological assistance and\r\n  advice.</p>\r\n<h4> ETHICAL STANDARDS</h4>\r\n<p>This case report has been approved by\r\n  the Ethical Committee of the Fondazione\r\n  IRCCS Ca&rsquo; GrandaOspedale Maggiore\r\n  Policlinico of Milan, Italy. The patient has\r\n  signed written consent for publication.</p>\r\n<h4> CONFLICTS OF INTERESTS</h4>\r\n<p>This work has not been published\r\n  elsewhere and has not been submitted\r\n  simultaneously of publication elsewhere.\r\n  This case report has not been presented\r\n  at any meeting. Dr. Diego Zanetti was\r\n  a member of the European Advisory\r\n  Board for Advanced Bionics (2019).\r\n  The other authors have no relationship\r\n  with commercial companies. No\r\n  external funding sources supported\r\n  this research. The Authors report no\r\n  conflict of interest. This research did\r\n  receive either grant from neither public\r\n  agencies nor commercial enterprises.\r\n  The costs of publication will be covered by &ldquo;Associazione ProgettoUdire&rdquo; Onlus,\r\n  a non-profit organization supporting\r\n  research and clinical activities in the field\r\n  of Audiology.</p>\r\n<h4> REFERENCES</h4>\r\n<ol>\r\n  <li id=\'Reference_Title_Link\' value=\'1\'><a name=\"1\" id=\'1\'></a>Gifford, R.H., Shallop, J.K., Peterson, A.M., &ldquo;Speech recognition materials and ceiling effects: considerations  for cochlear implant programs.&rdquo; Audiol Neurootol, 13(3) (2008): 193-205. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'2\'><a name=\"2\" id=\'2\'></a>King, S.E., et  al. &ldquo;Evaluation of TIMIT sentence list equivalency with adult cochlear  implant recipients.&rdquo; J Am Acad Audiol, 23(5) (2012): 313-  331. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'3\'><a name=\"3\" id=\'3\'></a>Lenarz, M., et  al. &ldquo;Long-term performance of cochlear implants in postlingually  deafened adults.&rdquo; Otolaryngol Head  Neck Surg, 147(1) (2012): 112-118. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'4\'><a name=\"4\" id=\'4\'></a>Boyle, P.J., et al. &ldquo;STARR: a speech test for evaluation of the effectiveness of auditory prostheses under realistic conditions.&rdquo; Ear Hear, 34(2) (2013): 203-212. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'5\'><a name=\"5\" id=\'5\'></a>Frijns, J.H., et  al. &ldquo;Optimizing the number of electrodes with high-rate stimulation of the clarion CII  cochlear implant.&rdquo; Acta Otolaryngol, 123(2) (2003):  138-142. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'6\'><a name=\"6\" id=\'6\'></a>Cochlear Nucleus Reliability Report. (2015). </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'7\'><a name=\"7\" id=\'7\'></a>Battmer, R.D.,  Linz, B., Lenarz, T., &ldquo;A review of device failure in more than 23 years of clinical experience of a cochlear implant program  with more than 3,400 implantees.&rdquo; Otol Neurotol, 30(4) (2009): 455-463. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'8\'><a name=\"8\" id=\'8\'></a>Cochlear Implant Reliability Report,  Advanced Bionics (2015). </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'9\'><a name=\"9\" id=\'9\'></a>Trozzi, M., et  al. &ldquo;Cochlear reimplant rates in children: twenty-year experience in a quaternary pediatric  cochlear implant center.&rdquo; Otolaryngol Head Neck Surg, 149(2) (2013): 115. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'10\'><a name=\"10\" id=\'10\'></a>Masterson, L., et al. &ldquo;Cochlear implant failures: lessons  learned from a UK centre.&rdquo; J Laryngol Otol, 126(1) (2012):  15-21. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'11\'><a name=\"11\" id=\'11\'></a> Wang, J.T., et  al. &ldquo;Rates of revision and device failure in cochlear implant surgery: a 30-year experience.&rdquo; Laryngoscope, 124(10)  (2014): 2393-2399.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'12\'><a name=\"12\" id=\'12\'></a>Qiu, J.,  &ldquo;Complications and clinical analysis of cochlear  implatations.&rdquo; Otolaryngol Head Neck Surg, 147(2) (2012):  P84. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'13\'><a name=\"13\" id=\'13\'></a>Trotter, M.I., et  al. &ldquo;Classification of cochlear implant failures and explantation: the Melbourne experience,  1982-2006.&rdquo; Cochlear Implants Int, 10  (Suppl 1) (2009): 105-110. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'14\'><a name=\"14\" id=\'14\'></a>Boyd, P.J., &ldquo;Potential benefits from deeply inserted cochlear  implant electrodes.&rdquo; Ear Hear, 32(4)  (2011): 411-427. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'15\'><a name=\"15\" id=\'15\'></a>Ketten, D., et al. &ldquo;In vivo measures of cochlear length and insertion depth of nucleus cochlear implant  electrode arrays.&rdquo; Ann Otol Rhinol Laryngol Suppl, 175 (1998): 1-16. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'16\'><a name=\"16\" id=\'16\'></a>Finley, C., et al. &ldquo;Role of electrode placement  as a contributor to variability in cochlear implant outcomes.&rdquo; Otol Neurotol, 29(7)  (2008): 920- 928.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'17\'><a name=\"17\" id=\'17\'></a>Hassepass, F., et  al.&ldquo;The new mid-scala electrode array:  a radiologic and histologic study in human temporal bones.&rdquo; Otol Neurotol, 35(8) (2014): 1415-1420.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'18\'><a name=\"18\" id=\'18\'></a>Dietz, A., et al.  &ldquo;Insertion characteristics and placement of the Mid-Scala electrode array in human  temporal bones using detailed cone  beam computed tomography.&rdquo; Eur Arch Otorhinolaryngol,  273(12) (2016): 4135-4143.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'19\'><a name=\"19\" id=\'19\'></a>Landsberger, D.M., et al. &ldquo;The relationship between insertion  angles, default frequency  allocations, and spiral ganglion place pitch in cochlear implants.&rdquo; Ear Hear, 36(5)  (2015): e207- 213.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'20\'><a name=\"20\" id=\'20\'></a>Dees, G., et al.  &ldquo;A mid-scala cochlear implant electrode  design achieves a stable post-surgical position  in the cochlea of patients over time- a prospective  observational study.&rdquo; Otol Neurotol, 39(4) (2018):  e231-e239. </a></li>\r\n</ol>\r\n<h4>Pattern of Pure Tone Hearing Loss in Adult\r\n  with Type 2 Diabetes Mellitus</h4>\r\n<p><strong>By Osuji AE<sup><a href=\"#a1\">1</a><a href=\"#corr\">*</a></sup>, Da Lilly-Tariah OB<sup><a href=\"#a1\">1</a></sup>, Unachukwu CN<sup><a href=\"#a2\">2</a></sup>, Nwankwo BE<sup><a href=\"#a3\">3</a></sup></strong><sup><a href=\"#a3\"></a></sup></p>\r\n<p><sup>1</sup><a name=\"a1\" id=\"a1\"></a>Ear, Nose and Throat Department, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria</p>\r\n<p><sup>2</sup><a name=\"a2\" id=\"a2\"></a>Department of Internal Medicine, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria</p>\r\n<p><sup>3</sup><a name=\"a3\" id=\"a3\"></a>Department of Ear, Nose and Throat, Chukwuemeka Odumegwu Ojukwu University Teaching Hospital, Nnewi, Anambra State,\r\n  Nigeria</p>\r\n<p>*osujiliz@yahoo.com</p>\r\n<h4>ABSTRACT</h4>\r\n<p>Introduction: The incidence of hearing loss in diabetes is increasing, not necessarily because of greater\r\n  insult of the diseases on the ear, but due to improved awareness and the emergence of epidemiological\r\n  studies on this previously unrecognized complication of diabetes mellitus. In the ear, diabetes\r\n  mellitus can cause degeneration of the myelin sheath of the vestibulo-cochlea nerve. It can also lead\r\n  to atrophy of spiral ganglion, with a reduction in the number of nerve fibres in the spiral lamina. This\r\n  study aimed to highlight the pattern of hearing loss in adult subjects with diabetes mellitus in the\r\n  University of Port Harcourt Teaching Hospital (UPTH), Rivers State, Nigeria.</p>\r\n<p>Patient and Methods: The study comprised 129 normotensive patients with type 2 diabetes mellitus\r\n  that attendedthe out-patients clinic of the University of Port Harcourt Teaching Hospital, Port\r\n  Harcourt, Rivers State, diagnosed with type 2 diabetes mellitus. A pure tone audiogram was done\r\n  according to the Modified Hughson-Westlake procedure. Pure tone hearing threshold of both ears\r\n  was taken, audiograms of the better ear of subjects were analyzed and reported.</p>\r\n<p>Results: The age range of study participants was from 21-89 years, with 52 males and 77 females.\r\n  Sensorineural hearing loss was the predominant type of hearing loss seen and was more in patients\r\n  aged 60 years and above. Pearson&rsquo;s correlation showed a positive association between hearing loss\r\n  and duration of diabetes mellitus and between age and hearing loss.</p>\r\n<p>Conclusion: The hearing threshold of an individual with DM is at risk, but damage to hearing acuity\r\n  occurs as the disease progresses, making the duration of DM a greater determinant of the hearing\r\n  threshold. Sensorineural hearing loss is the predominant type of hearing loss in people living with\r\n  DM andis worsened in the elderly due to a synergistic effect of presbycusis.</p>\r\n<h4>KEYWORDS </h4>\r\n<p>Diabetes mellitus, pure\r\n  tone hearing threshold, Port Harcourt,\r\n  hearing loss</p>\r\n<h4> INTRODUCTION</h4>\r\n<p>The incidence of hearing loss in diabetes\r\n  is increasing, not necessarily because of\r\n  greater insult of the diseases on the ear,\r\n  but due to improved awareness, and the\r\n  emergence of epidemiological studies on\r\n  this previously unrecognized complication\r\n  of diabetes mellitus [<a href=\"#1\" title=\"1\">1</a>]. Jordao was the\r\n  first person to report on the association\r\n  between hearing loss and diabetes. His\r\n  publication on hearing loss in DM in\r\n  1857, reported a case of hearing loss in\r\n  an imminent diabetic coma [<a href=\"#2\" title=\"2\">2</a>]. Before this\r\n  publication, the focus of researchers on\r\n  diabetes was only on its life-threatening\r\n  complications. In 1990, several studies\r\n  conducted on the association of DM and\r\n  hearing loss were inconclusive in their\r\n  outcome [<a href=\"#2\" title=\"2\">2</a>]. After that, clinical studies\r\n  have been conducted to investigate the\r\n  possible relationship between hearing\r\n  loss and diabetes mellitus.</p>\r\n<p>There are two primary types of DM,\r\n  type 1 and type 2 and both have different\r\n  etiological factors. Type 1 diabetes\r\n  mellitus is an autoimmune disorder with\r\n  an HLA- linked genetic predisposition,\r\n  which is usually seen in young adults\r\n  and children [<a href=\"#3\" title=\"3\">3</a>]. It is also known as\r\n  Insulin Dependent Diabetes Mellitus\r\n  (IDDM) and can be associated with other\r\n  autoimmune disorders. Type 2 diabetes\r\n  mellitus also known as Non-Insulin\r\n  Dependent Diabetes Mellitus (NIDDM)\r\n  results from disorders of insulin secretion\r\n  and metabolism, and can be related to genetic predisposition. In the presence\r\n  of genetic susceptibility, environmental\r\n  factors and lifestyle play an important\r\n  role in promoting the expression of\r\n  the disease clinically [<a href=\"#4\" title=\"4\">4</a>]. The Diabetes\r\n  Control and Complication Trial (DCCT),\r\n  noted that good glycaemic control could\r\n  reduce the complications associated with\r\n  DM [<a href=\"#5\" title=\"5\">5</a>]. Sequel to this, American Diabetes\r\n  Association (ADA) recommends that\r\n  people living with DM should try to\r\n  maintain their HbA1C level below 7% [<a href=\"#5\" title=\"5\">5</a>].</p>\r\n<p>Recent studies have shown hearing loss\r\n  as one of the complications of diabetes\r\n  mellitus and revealed the microscopic\r\n  effect of DM on the cochlea [<a href=\"#6\" title=\"6\">6</a>,<a href=\"#7\" title=\"7\">7</a>]. In\r\n  the ear, diabetes mellitus can cause\r\n  degeneration of the myelin sheath of the\r\n  vestibulo-cochlea nerve. It can also lead\r\n  to atrophy of the spiral ganglion, with a\r\n  reduction in the number of nerve fibres\r\n  in spiral lamina [<a href=\"#1\" title=\"1\">1</a>,7]. It causes deposition\r\n  and accumulation of glycoprotein, which\r\n  forms the atherosclerotic plaques on\r\n  the inner walls of the blood vessels. This\r\n  leads to the thickening of the capillary\r\n  walls of the stria-vascularis and small\r\n  arteries in the ear [<a href=\"#2\" title=\"2\">2</a>,<a href=\"#3\" title=\"3\">3</a>]. It impairs nutrient\r\n  transportation through these vessel walls,\r\n  with a decreased blood flow through the\r\n  narrowed vessels, eventually leading to\r\n  tissue hypoxia and degeneration. This can\r\n  also affect the blood supply to the CN Vlll,\r\n  causing secondary degeneration of the\r\n  vestibule-cochlear nerve [<a href=\"#8\" title=\"8\">8</a>]. This is the\r\n  pathogenesis of diabetic angiopathy.</p>\r\n<p>Secondly, activation of the polyol pathway\r\n  reduces glucose to sorbitol, resulting in\r\n  the accumulation of sorbitol within the\r\n  neurons [<a href=\"#9\" title=\"9\">9</a>]. This reduces the myoinositol\r\n  content and Na+/K+ATPase activity\r\n  intracellularly, resulting in impaired\r\n  intracellular transport, with resultant\r\n  swelling and osmotic damage to the\r\n  nerves [<a href=\"#2\" title=\"2\">2</a>]. These factors are responsible\r\n  for diabetic neuropathy [<a href=\"#9\" title=\"9\">9</a>]. Protein\r\n  kinase C is also implicated in increased\r\n  production of cytokines, regulation of\r\n  vascular permeability, and increased\r\n  synthesis of basement membrane seen in\r\n  people living with DM, however, the role\r\n  of this substance in diabetic cochleopathy\r\n  has not been well elaborated [<a href=\"#7\" title=\"7\">7</a>].</p>\r\n<p>Before this study, most of the studies\r\n  done in our hospital as regards diabetes\r\n  mellitus and its complications, have failed\r\n  to mention hearing loss as one of the\r\n  complications of DM [<a href=\"#10\" title=\"10\">10</a>]. As a result of\r\n  this, the ignorance abounds, thus informing\r\n  the need to throw more light on this likely\r\n  association between hearing loss and\r\n  DM particularly in this our environment.\r\n  This study aims to highlight the pattern\r\n  of hearing loss in adult subjects with\r\n  diabetes mellitus at the University of\r\n  Port Harcourt Teaching Hospital (UPTH),\r\n  Rivers State, Nigeria.</p>\r\n<h4> PATIENTS AND METHODS</h4>\r\n<p>This was a hospital-based cross-sectional\r\n  study carried out between January to June\r\n  2018 at the University of Port Harcourt\r\n  Teaching Hospital, Port Harcourt, Rivers\r\n  State, Nigeria. The UPTH is a tertiary\r\n  health facility with 500 beds, and\r\n  catchment areas for its patients include\r\n  Rivers, Bayelsa, Delta, Imo, Abia, and Cross\r\n  Rivers states [<a href=\"#11\" title=\"11\">11</a>]. The 2006 Nigerian\r\n  Census revealed that Port Harcourt has\r\n  a population of 1,382,592 [<a href=\"#12\" title=\"12\">12</a>]. It has an\r\n  area of 360 km2 and the city lies on the\r\n  geographical coordinates of 4&deg;47&rsquo; 21&rdquo; N,\r\n  6&deg;59&rsquo; 54&rdquo; E [<a href=\"#13\" title=\"13\">13</a>].</p>\r\n<p>The study comprised of 129 normotensive\r\n  patients with type 2 diabetes mellitus that\r\n  attended medical out-patients clinic of\r\n  the University of Port Harcourt Teaching\r\n  Hospital, Port Harcourt, Rivers State, who\r\n  have been diagnosed with type 2 diabetes\r\n  mellitus according to the World Health\r\n  Organization (WHO) diagnostic criteria\r\n  of fasting blood glucose &ge; 7 mmol/l or Hb\r\n  A1C &ge; 6.5% [<a href=\"#14\" title=\"14\">14</a>]. Our exclusion criteria\r\n  were age below 18 years and patients\r\n  with diabetes mellitus who had comorbid\r\n  hypertension. Hypertension was excluded\r\n  to ascertain the effect of diabetes without\r\n  co-morbid hypertension in the subjects\r\n  being evaluated. Ethical approval was\r\n  obtained from the UPTH Health Review\r\n  and Ethics Committee, and confidentiality\r\n  was applied. The fasting blood glucose\r\n  was estimated using the Accucheck\r\n  Glucometer and strips, made by Viva Chek\r\n  laboratories Inc. Wilmington, DE, 19085, USA, while glycosylated haemoglobin was\r\n  estimated using the Fine care 201 HbA1C\r\n  analyser system made by the Radiometer\r\n  group Copenhagen, Denmark.</p>\r\n<p>The Pure tone audiometry was done using\r\n  the ITERA Audiometer manufactured by\r\n  MADSEN, GN Otometrics A/S, 2630T\r\n  aastrup, Denmark, with due calibrations\r\n  done. The transducers used for audiometry\r\n  are TDH-39 circum-aural headphones\r\n  for air conduction testing and B27 bone\r\n  vibrator for bone conduction testing.\r\n  During audiometry, each participant was\r\n  made to sit in an enclosed soundproof\r\n  booth, and the sound was presented\r\n  to the ears. The hand-raising signal was\r\n  instructed as a positive indication for\r\n  tone heard. Air and bone conduction was\r\n  tested for frequencies at 250 Hz, 500 Hz,\r\n  1000 Hz, 2000 Hz, 4000 Hz, and 8000 Hz.\r\n  The pure tone hearing threshold of both\r\n  ears was taken, however, the audiogram of\r\n  the better ear of subjects were analyzed\r\n  and reported. Hearing loss was deduced\r\n  according to the WHO classification\r\n  of hearing loss, as a pure tone hearing\r\n  threshold &gt;25 dBHL in the better ear\r\n  of an individual. Results were statistically\r\n  analyzed using SPSS 23, and presented in\r\n  tables and figures. Pearson&rsquo;s correlation\r\n  was used to find an association between\r\n  variables, and a p-value of &le; 0.05 was\r\n  considered significant.</p>\r\n<h4> RESULTS</h4>\r\n<p>The age range of the participants was\r\n  from 21-89 years. The mean age of\r\n  the participants was 54 &plusmn; 6.80 years\r\n  (Table 1). There were 52 males and 77\r\n  female subjects in the study with m:f ratio\r\n  of 1:1.4.</p>\r\n<h4>DISCUSSION</h4>\r\n<p>In this study, hearing loss was more in\r\n  subjects 60 years and above, compared to\r\n  the younger population (Table 1). Similar\r\n  to this study, some researchers have\r\n  noted a greater hearing loss in subjects\r\n  60 years and above [<a href=\"#15\" title=\"15\">15</a>,<a href=\"#16\" title=\"16\">16</a>]. This finding is\r\n  supported by the presence of a statistically\r\n  significant positive relationship found\r\n  to exist between the hearing threshold\r\n  and age (Table 2). This implies that aging\r\n  exerts an additional effect on the hearing\r\n  threshold of participants in this older\r\n  population, leading to a worse hearing\r\n  loss from the dual effect of diabetes\r\n  mellitus and presbycusis (Table 3). It was\r\n  showed that elderly people living with\r\n  type 2 DM, have poorer hearing levels\r\n  when compared to age and sex-matched\r\n  non-DM subjects [<a href=\"#15\" title=\"15\">15</a>]. It is stated that\r\n  hearing loss in DM may not be solely due\r\n  to age, or progression of diseases, but may\r\n  be due to other factors that may require\r\n  a more precise investigation [<a href=\"#16\" title=\"16\">16</a>,<a href=\"#17\" title=\"17\">17</a>].\r\n  This is supported by findings by some\r\n  researchers who studied non-elderly\r\n  people 35-55 years found a significant\r\n  proportion of hearing loss in their group\r\n  with type 2 DM when compared to\r\n  control [<a href=\"#18\" title=\"18\">18</a>].</p>\r\n<p>Sensorineural hearing loss was the\r\n  predominant type of hearing loss seen in\r\n  people with DM in this study, however,\r\n  it was significantly higher in the older\r\n  population of 60 years and above. The\r\n  effect of DM is noted in the cochlea,\r\n  which houses the sensory receptors,\r\n  thereby damaging the sensory aspect\r\n  of hearing (Table 4). Secondly, the\r\n  neuropathy caused by diabetes mellitus\r\n  can affect the cochleovestibular nerve,\r\n  resulting in sensorineural hearing loss\r\n  [<a href=\"#19\" title=\"19\">19</a>]. On the other hand, age-related\r\n  hearing loss is sensorineural, and will,\r\n  therefore, result in a synergistic effect\r\n  on causing sensorineural hearing loss\r\n  in the elderly. The studies showed that\r\n  elderly people living with type 2 DM have\r\n  worse sensorineural hearing loss when\r\n  compared to age and sex-matched non-\r\n  DM subjects [<a href=\"#15\" title=\"15\">15</a>]. And this agrees with\r\n  our finding that apart from the effect of\r\n  age, diabetes mellitus causes significant\r\n  sensorineural hearing loss.</p>\r\n<p>The presence of a conductive hearing loss\r\n  in people with DM may be attributed to\r\n  the relative immune compromise seen in\r\n  DM especially in the presence of a poorly\r\n  controlled glycaemic level. Impairment in\r\n  mucocilliary function and change in canal\r\n  pH can also be seen in people living with\r\n  DM [<a href=\"#20\" title=\"20\">20</a>]. This predisposes them to ear\r\n  canal and middle ear infection, leading\r\n  to conductive hearing loss. In a study of\r\n  170 subjects with DM conductive hearing\r\n  loss was seen in 44.3%, and sensorineural\r\n  hearing loss in 38.5%, making conductive hearing loss the highest type of hearing\r\n  loss in their work [<a href=\"#21\" title=\"21\">21</a>]. This corroborates\r\n  the finding in our study.</p>\r\n<p>Furthermore, the configuration noted\r\n  on the audiogram for most of the cases\r\n  with hearing loss was the sloping curve,\r\n  which indicates more of high-frequency\r\n  involvement, like presbycusis. However,\r\n  as much as this configuration may seem\r\n  like presbycusis, it should be interpreted\r\n  with caution, because same pattern was\r\n  observed in the younger population, even\r\n  in the absence of familial predisposition\r\n  to presbycusis [<a href=\"#18\" title=\"18\">18</a>]. Furthermore, the\r\n  pattern of hearing loss found in diabetes\r\n  mellitus, is similar to presbycusis, due to\r\n  the fact that the disease causes premature\r\n  aging of the cochlea-vestibular system\r\n  [<a href=\"#19\" title=\"19\">19</a>]. Therefore, hearing loss is seen in an\r\n  exaggerated proportion greater than that\r\n  seen in the normal population of the same\r\n  age range [<a href=\"#1\" title=\"1\">1</a>]. Using a study population of\r\n  only persons with DM, Bainbridge in her\r\n  study, grouped the frequencies into low,\r\n  middle and high, and found hearing loss\r\n  across all frequencies, but more in the\r\n  low and middle frequencies [<a href=\"#1\" title=\"1\">1</a>]. It was also\r\n  stated that hearing loss in DM affects all\r\n  frequencies [<a href=\"#22\" title=\"22\">22</a>]. It was opined that DM\r\n  affects the higher frequencies, but can also\r\n  affect the middle and lower frequencies,\r\n  because atrophy of the stria-vascularis\r\n  was seen in the lower basal, lower\r\n  middle, upper-middle and apical turns\r\n  of the cochlea [<a href=\"#1\" title=\"1\">1</a>,<a href=\"#22\" title=\"22\">22</a>]. In a study on DM\r\n  and its effect on cochlea structure, it was\r\n  reported that there can also be a situation\r\n  where the atrophy of the stria-vascularis\r\n  is only in the lower and middle turns, and\r\n  no changes in the apical turns [<a href=\"#23\" title=\"23\">23</a>]. In this\r\n  case, the lower frequencies are spared in\r\n  such individuals.</p>\r\n<p>In our study, we noted that the percentage\r\n  number of subjects with hearing loss\r\n  increased with longer duration of DM,\r\n  such that hearing loss was present in\r\n  more subjects with a duration of DM\r\n  lasting over 20 years, as compared to\r\n  people with a duration of DM lasting 10- 20 years, whereas the latter had more\r\n  subjects with hearing loss as compared\r\n  to subjects with a duration of DM less\r\n  than 10 years. A positive association was\r\n  reported between the duration of DM\r\n  and SNHL and noted that people with\r\n  DM of more than 15 years duration had\r\n  an increased prevalence of hearing loss\r\n  when compared to younger age groups\r\n  [<a href=\"#24\" title=\"24\">24</a>]. Also, some studies have shown that\r\n  as the duration of DM increased to15\r\n  years, incidence of hearing loss increased,\r\n  but after 15 years, the effect on hearing\r\n  loss was no longer significant [<a href=\"#25\" title=\"25\">25</a>]. But no\r\n  ready explanation for this finding noted in\r\n  the study. However, another researcher\r\n  reported that the investigation of the\r\n  duration of DM in relation to hearing loss\r\n  yielded no clear conclusion [<a href=\"#26\" title=\"26\">26</a>].</p>\r\n<p>Pearson&rsquo;s correlation in this study shows\r\n  no correlation between glycaemic control\r\n  and hearing threshold, despite having a\r\n  positive correlation with the duration of\r\n  DM (Table 5). This indicates that in the\r\n  presence of poorly controlled DM, the\r\n  hearing acuity may be at risk, but the\r\n  damage becomes obvious with disease\r\n  progression. Consequently, among the\r\n  subjects with poorly controlled DM, it\r\n  was observed that those with a longer\r\n  duration of the disease have poorer\r\n  hearing thresholds. This was also noted in\r\n  the study by Austin et al., who stated that\r\n  the chronic effect of hyperglycemia, makes\r\n  the duration of DM a greater predictor of\r\n  hearing loss rather than glycaemic control\r\n  [<a href=\"#27\" title=\"27\">27</a>]. However, no correlation was found\r\n  between FBG, HbA1C (glycosylated\r\n  haemoglobin), and hearing threshold in\r\n  some studies [<a href=\"#7\" title=\"7\">7</a>,<a href=\"#28\" title=\"28\">28</a>]. Contrary to another\r\n  researcher who showed a strong positive\r\n  association between blood glucose level,\r\n  glycosylated haemoglobin, and severity\r\n  of hearing loss [<a href=\"#24\" title=\"24\">24</a>]. Similarly, in other\r\n  prospective study observing blood\r\n  glucose and hearing loss, found that the\r\n  maximum incidence of SNHL occurred\r\n  with high glucose levels when compared\r\n  to the normal range [<a href=\"#26\" title=\"26\">26</a>]. Few other researchers in their work found no\r\n  association between glycaemic control\r\n  and hearing threshold, which made them\r\n  insist that the duration of DM is a greater\r\n  determinant of hearing loss, summing up\r\n  the effect of repeated episodes of raised\r\n  blood glucose [<a href=\"#19\" title=\"19\">19</a>,<a href=\"#27\" title=\"27\">27</a>].</p>\r\n<p>A statistically significant linear relationship\r\n  was found to exists between the Hearing\r\n  threshold and Duration of diabetes\r\n  mellitus. As the duration of DM for\r\n  subjects increased, their hearing threshold\r\n  increased. This finding buttresses the\r\n  positive association between the duration\r\n  of diabetes mellitus and hearing loss. It\r\n  was opined that the repeated episode\r\n  of hyperglycaemia, over time, leads to a\r\n  chronic effect on the subject&rsquo;s hearing\r\n  threshold [<a href=\"#19\" title=\"19\">19</a>,<a href=\"#27\" title=\"27\">27</a>]. Thus the duration\r\n  of DM is a greater determinant of the\r\n  hearing threshold as regards the effect of\r\n  raised blood sugar [<a href=\"#27\" title=\"27\">27</a>].</p>\r\n<h4> CONCLUSION</h4>\r\n<p>The hearing threshold of an individual with\r\n  DM is at risk, but damage to hearing acuity\r\n  occurs as the disease progresses, making\r\n  the duration of DM a greater determinant\r\n  of hearing acuity. Sensorineural hearing\r\n  loss is the predominant type of hearing loss\r\n  in people living with DM and is worsened\r\n  in the elderly due to a synergistic effect of\r\n  presbycusis.</p>\r\n<h4> RECOMMENDATIONS</h4>\r\n<p>There should be more health education on\r\n  the effect of diabetes mellitus on hearing.\r\n  The people with DM, their caregivers, and\r\n  health care personnel involved in their\r\n  primary management at one point or the\r\n  other, need to be aware of the increased\r\n  risk of hearing loss in these individuals.</p>\r\n<p>An increased understanding of this\r\n  complication of DM will help improve the\r\n  commitment of the affected individuals,\r\n  and their caregivers to achieve a better\r\n  quality of life for these adults with type\r\n  2 DM.</p>\r\n<h4>REFERENCES</h4>\r\n<ol>\r\n  <li id=\'Reference_Title_Link\' value=\'1\'><a name=\"1\" id=\'1\'></a>Bainbridge, K.  &ldquo;Hearing impairment an under- recognized  complication of diabetes.&rdquo; Diabetes Voice, 54 (1) (2009): 9. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'2\'><a name=\"2\" id=\'2\'></a>Helzner, E.P.,  et al. &ldquo;The relationship between hearing  loss and diabetes.&rdquo; Hear Diab, (2014): 1-32.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'3\'><a name=\"3\" id=\'3\'></a>Frier, B.M.,  et al.&ldquo;Diabetes mellitus and nutritional and metabolic disorders. Davidson&rsquo;s  Principles and Practice of Medicine,  18th Edition, (1999): 471-542.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'4\'><a name=\"4\" id=\'4\'></a>Parker, P.  &ldquo;Diabetes and hearing loss.&rdquo; Audio Practice, 2 (4) (2009): 22-23. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'5\'><a name=\"5\" id=\'5\'></a>Sumathi, K., Mythili, S.V., Devi, A.J.M. &ldquo;Significance of microalbuminuria in hearing loss in Type 2 diabetes mellitus.&rdquo; Int J Pharm Bio Sci, 5 (1) (2014): 604-608. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'6\'><a name=\"6\" id=\'6\'></a>Helzner, E., et  al.&ldquo;Race and sex differences in age- related hearing loss: The health, aging  and body composition study.&rdquo; Noise Health, 8 (30) (2006): 2119-2127.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'7\'><a name=\"7\" id=\'7\'></a>Asma, A., et al.  &ldquo;A single-blinded randomized controlled study of the effect of oral hypoglycaemic agents versus intensive short-term insulin therapy on pure tone audiometry  in type II diabetes mellitus.&rdquo;  Indian J Otorhinolaryngol Head Neck Surg, 63 (2) (2011): 114-118.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'8\'><a name=\"8\" id=\'8\'></a>Gibrin, P.C.D.,  Melo, J.J., Marchiori, L.L. &ldquo;Prevalence  of tinnitus complaints and probable association  with hearing loss, diabetes mellitus and hypertension in elderly.&rdquo; CoDAS, 25 (2) (2013): 176-180. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'9\'><a name=\"9\" id=\'9\'></a>Teng, Z.P., et al.&ldquo;An association  of type 1 diabetes \r\n    \r\n    \r\n    mellitus with auditory  dysfunction: A systematic review  and meta&#8208;analysis.&rdquo; Laryngoscope, 127 (7) <br />\r\n    (2017): 1689-1697.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'10\'><a name=\"10\" id=\'10\'></a>Chinenye, S., Young, E. &ldquo;State of diabetes care in Nigeria:  A review.&rdquo; Nigerian Health J, 11 (4) (2011): 101-106. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'11\'><a name=\"11\" id=\'11\'></a>University of Port Harcourt  Teaching Hospital (UPTH)| Medical World Nigeria-MWN, (2009). </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'12\'><a name=\"12\" id=\'12\'></a>Nigeria Data Portal: census figure. State Population-National Populations Commission, (2016).</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'13\'><a name=\"13\" id=\'13\'></a>Rivers State,  Nigeria (Overview, History, and Summary Information), (2016). </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'14\'><a name=\"14\" id=\'14\'></a>Mayfield, J. &ldquo;Diagnosis and classification of diabetes mellitus:  New criteria.&rdquo; Am Fam Physician, 58 (6) (1998): 1355-1362. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'15\'><a name=\"15\" id=\'15\'></a>&Ccedil;ay&ouml;n&uuml;, M., et al.&ldquo;Hearing loss related with type 2 diabetes in an elderly population.&rdquo; J Int Adv Otol, 10 (1) (2014): 72. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'16\'><a name=\"16\" id=\'16\'></a>Zafar, M.Z., et  al. &ldquo;Prevalence of complexities hypertension  associated with type 2 diabetes: a cross-sectional  study.&rdquo; Divers Equal Health, 14 (6) (2017): 313-315. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'17\'><a name=\"17\" id=\'17\'></a>Horikawa, C., et  al.&ldquo;Diabetes and risk of hearing impairment in adults: a meta-analysis.&rdquo; J Clin Endocrinol Metab, 98 (1) (2013): 51-58. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'18\'><a name=\"18\" id=\'18\'></a>Panchu, P.  &ldquo;Auditory acuity in type 2 diabetes mellitus.&rdquo; Int J Diabetes Dev Ctries, 28  (4) (2008): 114-120.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'19\'><a name=\"19\" id=\'19\'></a>Mozaffari, M., et al. &ldquo;Diabetes mellitus and sensorineural  hearing loss among non-elderly people.&rdquo; East Mediterr H J, 16 (9) (2010): 947- 952.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'20\'><a name=\"20\" id=\'20\'></a>Adebola, S.O.,  et al. &ldquo;Otologic and audiologic characteristics of type 2 diabetics in a tertiary health institution in Nigeria.&rdquo;  Braz J Otorhinolaryngol, 82 (5) (2016):  567-573. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'21\'><a name=\"21\" id=\'21\'></a>Kumari, M.S., et  al. &ldquo;Prevalence of otological disorders  in diabetic cases with hearing loss. J Diabetes Metab, 17 (4) (2016):  1-5. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'22\'><a name=\"22\" id=\'22\'></a>Zivkovic-Marinkov, F., et al. &ldquo;Is there a direct correlation between duration,  treatment of type 2 DM and Hearing loss?&rdquo; Hippokratia, 20 (1) (2016): 32-37. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'23\'><a name=\"23\" id=\'23\'></a>Fukushima, H.,  et al. &ldquo;Effects of type 2 diabetes mellitus on cochlear structure in humans.&rdquo; Arch  Otolaryngol Head Neck Surg, 132 (9)  (2006): 934-938.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'24\'><a name=\"24\" id=\'24\'></a>Shafeeq, M., et  al. &ldquo;Sensorineural hearing loss in type 2 diabetes mellitus.&rdquo; IORS J Dent Med Sci,  14 (11)  (2015): 56-61. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'25\'><a name=\"25\" id=\'25\'></a>Celik, O., et al.&ldquo;Hearing loss in insulin dependent diabetes mellitus.&rdquo; Auris Nasus  Larynx, 23 (1) (1996): 127-132. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'26\'><a name=\"26\" id=\'26\'></a>Thimmasettaiah,  N.B., Shankar R, Ravi GC. &ldquo;A one year prospective study of hearing loss in diabetes  in general population.&rdquo; Trans Biomed, 3 (2) (2012):  1-7. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'27\'><a name=\"27\" id=\'27\'></a>Austin, D.F., et &nbsp;al. &ldquo;Diabetes-related &nbsp;changes  &nbsp;in hearing.&rdquo; Laryngoscope, 119 (9) (2009): 1788- 1796.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'28\'><a name=\"28\" id=\'28\'></a>Nwosu, J.N.,  Chime, E.N. &ldquo;Hearing thresholds in adult  Nigerians with diabetes mellitus: a case- control  study.&rdquo; Diabetes Metab Syndr Obes, 10 (2017): 155. </a></li>\r\n</ol>\r\n<h4>Experience in Vestibular Rehabilitation\r\n  Therapy: Vestibular Substitution, Cognition and\r\n  Counseling</h4>\r\n<p><strong>By Lizeth Paez<sup><a href=\"#corr\">*</a></sup></strong></p>\r\n<p>Colombian School of Rehabilitation, Colombia</p>\r\n<p>*audiolizeth@gmail.com, Tel: +573142887512</p>\r\n<h4>ABSTRACT</h4>\r\n<p>In my experience as an Audiologist, I have used a vestibular rehabilitation therapy protocol, focused\r\n  on bilateral vestibular loss, using the vestibular substitution strategy in combination with cognitive\r\n  tasks and counseling. Vestibular rehabilitation therapy is divided into two main approaches; the first\r\n  one corresponds to canalith repositioning maneuvers while the second approach corresponds to\r\n  the training of balance skills to achieve vestibular compensation, through adaptation strategies and\r\n  vestibular substitution. The substitution strategy is based on the distributive property of the central\r\n  nervous system to control vestibular functions; various neural networks in the brain are capable of\r\n  reorganizing functionality through learning and imitating the dynamics of lost vestibular function.\r\n  However, beyond the vestibular function itself, some research has revealed that users report cognitive\r\n  limitations after suffering vestibular disorders. The vestibular system interacts with high-level\r\n  cognitive processes including spatial perception, spatial navigation and body representation. The impact\r\n  of vestibular injury on concentration, attention and memory skills has been studied. Conventional\r\n  vestibular rehabilitation therapy focuses on improving the use of non-vestibular sensory cues,\r\n  while cognitive training operates at a high level of processing. Cognitive training methods aim to\r\n  reduce symptoms and improve compensation of sensory cues in patients with bilateral vestibular\r\n  loss. Subsequently, counseling is a fundamental element to maintain the user&rsquo;s motivation, informing\r\n  them of the session&rsquo;s objectives and the achievements in each of the therapy session.</p>\r\n<h4>KEYWORDS </h4>\r\n<p>Vestibular rehabilitation,\r\n  cognition, substitution, neural plasticity</p>\r\n<h4>BACKGROUND</h4>\r\n<p>Vestibular loss is a condition generated\r\n  because of the failure of the peripheral\r\n  vestibular structures. This disorder can be\r\n  unilateral or bilateral. The most common\r\n  etiologies of bilateral vestibular loss are\r\n  drug toxicity, traumatic brain injuries,\r\n  meningitis, otosclerosis and several other\r\n  factors, including those associated with\r\n  aging. As a result of this condition, patients\r\n  suffer of balance and vestibulo-ocular\r\n  dysfunction.</p>\r\n<p>There are different treatments for the\r\n  bilateral vestibular loss, as vestibular\r\n  rehabilitation therapy as well as\r\n  medications and surgery. Vestibular\r\n  rehabilitation therapy is divided into\r\n  two main approaches, the first one\r\n  corresponds to canalith repositioning\r\n  maneuvers, which are established in\r\n  clinical practice and have extensive\r\n  scientific evidence. The second approach\r\n  corresponds to the training of balance\r\n  skills to achieve vestibular compensation,\r\n  through adaptation strategies and\r\n  vestibular substitution [<a href=\"#1\" title=\"1\">1</a>-<a href=\"#3\" title=\"3\">3</a>].</p>\r\n<p>The vestibular rehabilitation approach to\r\n  compensation is based upon the concept\r\n  that functional restoration requires a\r\n  systematic reintegration of the multiple\r\n  sensory modalities involved in balance\r\n  [<a href=\"#4\" title=\"4\">4</a>]. The substitution strategy is based on\r\n  the distributive property of the central\r\n  nervous system to control vestibular\r\n  functions; variousneural networks in\r\n  the brain are capable of reorganizing\r\n  functionality through learning and\r\n  imitating the dynamics of lost vestibular\r\n  function. The neurons of the vestibular\r\n  nuclei are not purely vestibular, they\r\n  also receive visual, motor and somatosensory\r\n  signals, which are understood as\r\n  multisensory integration. The vestibuloocular\r\n  and cervico-ocular exercises\r\n  engage plasticity of these reflex pathways\r\n  [<a href=\"#5\" title=\"5\">5</a>-<a href=\"#8\" title=\"8\">8</a>]. Substitution throughout eye and\r\n  head movements exercises are designed\r\n  to recalibrate depth and spatial perception\r\n  of the current sensory information.</p>\r\n<p>However, beyond the vestibular function\r\n  itself, some quantitative analysis of\r\n  empirical case histories and detailed\r\n  interview data indicate that patients perceive cognitive limitations after\r\n  developing the balance disorder [<a href=\"#9\" title=\"9\">9</a>- <a href=\"#11\" title=\"11\">11</a>]. The impact of vestibular injury on\r\n  concentration, attention and memory\r\n  skills has been studied through the use of\r\n  the Dizziness Handicap Inventory (DHI)\r\n  [<a href=\"#9\" title=\"9\">9</a>-<a href=\"#13\" title=\"13\">13</a>]. The vestibular system interacts\r\n  with high-level cognitive processes\r\n  including spatial perception, spatial\r\n  navigation, and body representation [<a href=\"#6\" title=\"6\">6</a>].</p>\r\n<p>The degree of cognitive decline was\r\n  found to be related to worsevestibular\r\n  rehabilitation outcomes [<a href=\"#14\" title=\"14\">14</a>].</p>\r\n<p>Authors suggest that cognitive training\r\n  methods can lead to reduced symptoms\r\n  and improved compensation for the\r\n  lack of sensory signals in patients with\r\n  complete vestibular loss. Conventional\r\n  vestibular rehabilitation therapy focuses\r\n  on improving the use of non-vestibular\r\n  sensory cues, while cognitive training\r\n  operates at a high level of processing.</p>\r\n<p>In the context of the probabilistic\r\n  model, there are different ways in which\r\n  cognitive training can improve vestibular\r\n  sensory interference [<a href=\"#15\" title=\"15\">15</a>]. Modifications\r\n  in Vestibulo-Ocular Reflex (VOR) gain,\r\n  postural changes and quality of life seem\r\n  to rely pivotally on brain regions involved\r\n  in both cognitive and vestibular input\r\n  processing [<a href=\"#14\" title=\"14\">14</a>,<a href=\"#16\" title=\"16\">16</a>]. Cognitive training\r\n  methods aim to reduce symptoms and\r\n  improve compensation of sensory cues in\r\n  patients with bilateral vestibular loss. These\r\n  changes can function as a measurement\r\n  factor for dysfunction and reorganization\r\n  of vestibular influence in regions such\r\n  as the amygdala, prefrontal cortex,\r\n  and hippocampus [<a href=\"#17\" title=\"17\">17</a>-<a href=\"#24\" title=\"24\">24</a>]. The plastic\r\n  remodeling of the synaptic connections\r\n  obeys the Hebbian principle of neuronal\r\n  network plasticity, which tells us that\r\n  when the brain is engaged behaviorally\r\n  the inputs activatedsimultaneously in\r\n  time strengthen together and increase\r\n  their cooperativity. Active training and\r\n  physical activity have been shown to\r\n  induce structural and functional neuronal\r\n  reorganizations in animal models,\r\n  compared with untrained individuals [<a href=\"#25\" title=\"25\">25</a>].</p>\r\n<p><strong>VESTIBULAR REHABILITATION\r\n  THERAPY PROCESS</strong></p>\r\n<p>The first step of every treatment is\r\n  analyzing the assessment results, including\r\n  the DHI, vestibulo-ocular test as video\r\n  hit impulse test and balance test as\r\n  sensory organization performance, based\r\n  on these results the next step is setting\r\n  the intervention objectives. All this\r\n  information should be explained to the\r\n  user and his family by counseling.</p>\r\n<p>The rehabilitation process is top-down,\r\n  working throughout the patient tolerance\r\n  [<a href=\"#26\" title=\"26\">26</a>,<a href=\"#27\" title=\"27\">27</a>]. When we apply the adaptation\r\n  strategy it is focused on improve\r\n  vestibulo-ocular reflex gain through eyes\r\n  and head movements. While substitution\r\n  exercises challenge balance without\r\n  vision, with disturbed vision, or on uneven\r\n  surfaces. The standard protocol includes\r\n  exercises performed while lying down,\r\n  sitting, standing, and walking positions.</p>\r\n<p>Meanwhile, the dual task protocol\r\n  incorporates cognitive task, as read a text,\r\n  remember names of animals, pay attention\r\n  to an auditory stimulus, and memorize a\r\n  series of numbers.</p>\r\n<p>Sessions are scheduled twice a week, in\r\n  each one of this meetings it is explained\r\n  to the patient the session objectives, then\r\n  the exercises are performed mixing the\r\n  compensation and the cognitive tasks, for\r\n  example the patient is instructed to walk\r\n  from one place to other while he is saying\r\n  series of numbers. Users are encouraged\r\n  to perform these same exercises at home.</p>\r\n<p>At the end of all sessions, results are\r\n  measured by DHI, vestibulo-ocular and\r\n  balance test, to verify the improvement\r\n  of vestibular function compared with the\r\n  first session.</p>\r\n<p>In my clinical experience I used this\r\n  technique for the last four years in\r\n  patients of different ages accomplishing\r\n  great engagement to the treatment,\r\n  because as the patient as well as his family\r\n  noticed an improvement in quality life, and\r\n  the difference between the first and the\r\n  last DHI scores are remarkable.</p>\r\n<p>The success of the vestibular rehabilitation\r\n  therapy depends on intrinsic aspects such\r\n  as motivation and empathy with the\r\n  therapist, which are developed through\r\n  counseling, from the first moment of\r\n  contact with the user, when the operation\r\n  of the vestibular system is explained\r\n  to them, the results of its vestibular\r\n  assessment and the objectives of the\r\n  intervention. Subsequently, counseling is\r\n  a fundamental element to maintain the\r\n  user&rsquo;s motivation, informing them of the\r\n  session&rsquo;s objectives and the achievements\r\n  in each of the therapy session[<a href=\"#28\" title=\"28\">28</a>,<a href=\"#29\" title=\"29\">29</a>].</p>\r\n<h4> CONCLUSION</h4>\r\n<p>In conclusion, cognitive training may\r\n  provide many benefits; it is cost-effective,\r\n  and can easily be performed on a daily basis\r\n  in the comfort of patients&rsquo; own homes.\r\n  Additionally, patients do not depend on\r\n  medication and can take action to reduce\r\n  their symptoms, which enhances their\r\n  self-efficacy. Vestibular differentiation\r\n  has dramatic consequences for higherorder\r\n  processing of vestibular and spatial\r\n  information. Cognitive training of head\r\n  and body movements will help patients\r\n  not only to improve their ability to predict\r\n  movement and the ensuing sensory\r\n  consequences, but also to increase their\r\n  confidence in these predictions. Other\r\n  studies provide objective support that\r\n  more sluggish information processing may\r\n  contribute to the perception of difficulties\r\n  with concentration and memory by\r\n  these patients. Consequently, the\r\n  Dizziness Handicap Inventory (DHI) is a\r\n  fundamental tool in vestibular assessment\r\n  and following, in addition to other scales\r\n  that assess higher cognitive functions.</p>\r\n<h4>REFERENCES</h4>\r\n<ol>\r\n  <li id=\'Reference_Title_Link\' value=\'1\'><a name=\"1\" id=\'1\'></a>Herdman,  S.J., &ldquo;Role of vestibular adaptation in vestibular rehabilitation.&rdquo;  Otolaryngol Head Neck Surg, 119(1) (1998): 49-54. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'2\'><a name=\"2\" id=\'2\'></a>Krebs, D.E., et al. &ldquo;Double-blind, placebo- controlled  trial of rehabilitation for bilateral vestibular hypofunction: Preliminary report.&rdquo;  Otolaryngol Head Neck Surg,  109(4) (1993): 735-741. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'3\'><a name=\"3\" id=\'3\'></a>Putkonen, P.T., Courjon, J.H., Jeannerod, M., &ldquo;Compensation of postural effects  of hemilabyrinthectomy in the cat. A Sensory substitution process?&rdquo; Exp Brian Res,  28(4) (1977): 249-257. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'4\'><a name=\"4\" id=\'4\'></a>Balaban, C.D., Yates, B.J., &ldquo;Vestibuloautonomic interactions: A teleologic perspective.&rdquo; The Vestibular  System, (2004): 286-342. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'5\'><a name=\"5\" id=\'5\'></a>Dickman, J.D., Angelaki, D.E., &ldquo;Dynamics of vestibular  neurons during rotational motion in  alert rhesus monkeys.&rdquo; Exp Brain Res, 155(1) (2004):  91-101. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'6\'><a name=\"6\" id=\'6\'></a>Angelaki, D.E., Cullen, K.E., &ldquo;Vestibular system: The  many facets of a multimodal sense.&rdquo; Annu Rev Neurosci,  31(1) (2008): 125-150. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'7\'><a name=\"7\" id=\'7\'></a>Sadeghi, S.G., Minor, L.B., Cullen, K.E., &ldquo;Neural correlates  of sensory substitution in vestibular pathways  following complete vestibular loss.&rdquo; J Neurosci, 32(42) (2012): 14685-14695. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'8\'><a name=\"8\" id=\'8\'></a>Carriot,  J., Brooks, J.X., Cullen, K.E., &ldquo;Multimodal  integration of self-motion  cues in the vestibular system:  Active versus passive translations.&rdquo; J Neurosci, 33(50) (2013): 19555-19566. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'9\'><a name=\"9\" id=\'9\'></a>Jacobson, G.P., Newman, C.W.,&ldquo;The  development of the dizziness  handicap inventory.&rdquo; Arch Otolaryngol Head Neck Surg, 116(4) (1990): 424-427. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'10\'><a name=\"10\" id=\'10\'></a>Morris, A.E., Lutman, M.E., Yardley, L., &ldquo;Measuring outcome from vestibular  rehabilitation, Part I: Qualitative  development of a new self-report measure.&rdquo; Int J Audiol, 47(4) (2008): 169-177. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'11\'><a name=\"11\" id=\'11\'></a>Yardley,  L., Putman, J., &ldquo;Quantitative analysis of factors contributing to handicap and distress in vertiginous patients: a questionnaire study.&rdquo; Clinic Otolaryngol, 17(3) (1992): 231-236. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'12\'><a name=\"12\" id=\'12\'></a>Hazlett, R.L., Tusa, R.J., Waranch, H.R., &ldquo;Development  of an inventory for dizziness and related factors.&rdquo; J Behav Med, 19(1)  (1996): 73- 85. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'13\'><a name=\"13\" id=\'13\'></a>Morris,  A.E., Lutman, M.E., Yardley, L., &ldquo;Measuring  outcome from vestibular  rehabilitation, part II: Refinement  and validation of a new self-report measure.&rdquo; Int J Audiol, 48(1) (2009): 24-37. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'14\'><a name=\"14\" id=\'14\'></a>Micarelli,  A., et al. &ldquo;Gradient impact of cognitive decline  in unilateral vestibular hypofunction after rehabilitation:  Preliminary findings.&rdquo; Europ Arch Oto-Rhino-Laryngol, 275(10) (2018): 2457-2465. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'15\'><a name=\"15\" id=\'15\'></a>Bernard-Demanze,  L., et al.&ldquo;Age-related changes in posture control are differentially  affected by postural and cognitive task  complexity.&rdquo; Curr Aging Sci, 2(2) (2009): 139-149. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'16\'><a name=\"16\" id=\'16\'></a>Kingma,  H.,Van de Berg, R., &ldquo;Anatomy, physiology, and physics of the peripheral vestibular system.&rdquo; Handbook Clinic Neuro, 137 (2016): 1-16. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'17\'><a name=\"17\" id=\'17\'></a>Bottini, G., et  al. &ldquo;Cerebral representations for egocentric space: Functional-anatomical evidence  from caloric vestibular stimulation and neck vibration.&rdquo; Brain, 124(6) (2001):  1182-1196. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'18\'><a name=\"18\" id=\'18\'></a>Bucher, S.F.,  et al. &ldquo;Cerebral functional magnetic resonance imaging of vestibular, auditory,  and nociceptive areas during galvanic  stimulation.&rdquo; Annals Neuro, 44(1) (1998):  120-125. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'19\'><a name=\"19\" id=\'19\'></a>Dieterich,  M., et al. &ldquo;Dominance for vestibular cortical function in the non-dominant hemisphere.&rdquo; Cerebral Cortex,  13(9) (2003): 994-1007. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'20\'><a name=\"20\" id=\'20\'></a>Dieterich,  M., Brandt,T.,&ldquo;Functional brain imaging of peripheral and central vestibular  disorders.&rdquo; Brain, 131(10)  (2008): 2538-2552. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'21\'><a name=\"21\" id=\'21\'></a>Eickhoff,  S.B., et al. &ldquo;Identifying human parieto- insular vestibular cortex using fMRI and cytoarchitectonic  mapping.&rdquo; Hum Brain Mapp, 27(7) (2006):  611-621. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'22\'><a name=\"22\" id=\'22\'></a>Fasold, O., et &nbsp;al.  &ldquo;Human &nbsp;vestibular  &nbsp;cortex &nbsp;as identified with caloric stimulation in  functional magnetic resonance imaging.&rdquo; NeuroImage, 17(3) (2002): 1384-1393. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'23\'><a name=\"23\" id=\'23\'></a>Lobel,  E., et al. &ldquo;Functional MRI of galvanic  vestibular stimulation.&rdquo; J Neurophysio, 80(5) (1998): 2699-2709. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'24\'><a name=\"24\" id=\'24\'></a>Suzuki,  M., et al. &ldquo;Cortical and subcortical vestibular response  to caloric stimulation detected by functional  magnetic resonance imaging.&rdquo; Cogn Brain Res, 12(3) (2001): 441-449. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'25\'><a name=\"25\" id=\'25\'></a>Lacour,  M., Bernard-Demanze, L., &ldquo;Interaction between  vestibular compensation mechanisms and vestibular rehabilitation therapy: 10 recommendations for optimal functional recovery.&rdquo;  Front Neurol, 5 (2014): 285. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'26\'><a name=\"26\" id=\'26\'></a>Whitney, S.L., Herdman, S.J., &ldquo;Physical therapy assessment  of vestibular hypofunction.&rdquo; Vestibul Rehab,  (2007): 272-308. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'27\'><a name=\"27\" id=\'27\'></a>Whitney, S.L.,  Sparto, P.J., &ldquo;Principles  of vestibular physical therapy rehabilitation.&rdquo; Neuro Rehab, 29(2) (2011): 157-166. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'28\'><a name=\"28\" id=\'28\'></a>Talkowski,  M.E., et al. &ldquo;Cognitive requirements for vestibular and ocular motor processing  in healthy adults and  patients with unilateral vestibular  lesions.&rdquo; J Cogn Neurosci,  17(9) (2005): 1432-1441. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'29\'><a name=\"29\" id=\'29\'></a>Yardley,  L., Redfern, M.S., &ldquo;Psychological factors influencing  recovery from balance disorders.&rdquo; J Anxiety Dis, 15(1-2)  (2001): 107-119. </a></li>\r\n</ol>\r\n<h4>The Effect of Low-Frequency Sounds and\r\n  Infrasound on the Inner Ear Functions Hearing\r\n  and Balance</h4>\r\n<p><strong>By Iman Ibrahim<sup><a href=\"#corr\">*</a></sup></strong></p>\r\n<p>The interactions between auditory\r\n  information and the maintenance of\r\n  postural balance are not widely studied\r\n  [<a href=\"#1\" title=\"1\">1</a>,<a href=\"#2\" title=\"2\">2</a>]. It is not widely recognized that\r\n  poor hearing may increase fall risk.\r\n  The link between hearing loss and\r\n  postural stability gained more interest\r\n  recently, mainly because hearing loss was\r\n  significantly associated with the odds of\r\n  reported falls. For every 10 dB increase\r\n  in hearing loss, there was a 1.4 fold (95%\r\n  CI: 1.3-1.5) increased odds of an individual\r\n  reporting falling over the preceding\r\n  12 months [<a href=\"#3\" title=\"3\">3</a>]. Postural regulation is\r\n  the result of dynamic processing of\r\n  multiple sensory inputs by the central\r\n  nervous system. There are well-known\r\n  contributions of musculoskeletal, visual,\r\n  prospective and vestibular information\r\n  to the maintenance of postural balance\r\n  and stability. However, the contribution\r\n  of auditory inputs to postural stability has\r\n  been under-investigated [<a href=\"#4\" title=\"4\">4</a>].</p>\r\n<p>The author co-authored a study to\r\n  investigate the effect of auditory input on\r\n  postural stability both in normal hearing\r\n  individuals and hearing aid users [<a href=\"#5\" title=\"5\">5</a>]. The\r\n  discussion here will be limited to the\r\n  results of the normal hearing group.The\r\n  ability to localize sound sources was tested\r\n  as well since increases the awareness of\r\n  the surrounding environment, and hence\r\n  is an important source of information that\r\n  improves balance control and postural\r\n  stability.</p>\r\n<p>A total of 21 normal hearing participants\r\n  were enrolled (13 females and eight males;\r\n  mean age 37.1 &plusmn; 15.9). Four participants\r\n  were found to have a high frequency\r\n  hearing loss at 4 KHz and 8 KHz (three\r\n  males and one female; age range (57 to\r\n  70 years). Those participants were tested,\r\n  and their results were compared with the\r\n  17 normal hearing individuals (mean age\r\n  29.5 &plusmn; 11.4).</p>\r\n<p>To test postural stability, Romberg\r\n  on foam and tandem gain test ware\r\n  performed. For Romberg on foam test,\r\n  participants were asked to take off their\r\n  shoes and stand on a foam pad with feet\r\n  together, with eyes closed, and with arms\r\n  crossed above their shoulders. The goal\r\n  was to maintain balance for 30 seconds.\r\n  For Tandem test, participants were asked\r\n  to place their dominant foot in front of\r\n  the other in a heel to toe fashion and\r\n  maintain this posture for 30 seconds. Each\r\n  test was conducted three times for each\r\n  condition (with and without earplugs). All\r\n  tests were done in the presence of 1/3\r\n  octave noise (center frequency~3 KHz),\r\n  emitted from a speaker placed directly in\r\n  front of the subject (at 0&deg; azimuth).\r\n  Horizontal front/back sound localization\r\n  was tested. Two stimuli were used: lowpass\r\n  (&lt;2 KHz) and high-pass (&gt;2 KHz)\r\n  Narrow Band Noise. Stimuli were\r\n  presented at 30 dB SL from two speakers,\r\n  at +45&deg; and +135&deg;.</p>\r\n<p>Results for balance tests for the\r\n  17 normal hearing individuals and 4\r\n  hearing impaired individuals are shown in <strong>Figure 1.</strong> For Tandem stance, all 17 normal\r\n  hearing participants were able to stand for\r\n  30 seconds with or without the earplugs.\r\n  Also, for the Romberg on foam test, they\r\n  were all able to stand for 30 seconds\r\n  without earplugs. When earplugs were\r\n  used, all could stand for 30 s, except for\r\n  2 subjects, yielding an average performance\r\n  of 29.9 &plusmn; 0.2 seconds. The four hearing\r\n  impaired participants had similar results\r\n  for Tandem stance, however, 2 of them\r\n  were not able to maintain 30 seconds in\r\n  Romberg on foam test, their average was\r\n  28 &plusmn; 3.4 without, and 24.5 &plusmn; 5.8 seconds\r\n  with earplugs.</p>\r\n<p>Results for sound localization tests for\r\n  the 17 normal hearing individuals and four\r\n  hearing impaired listeners are shown in <strong> Figure 2.</strong> Normal hearing participants had\r\n  an average correct score of 80% (&plusmn;16) for\r\n  the low-pass filtered sound, and 90% (&plusmn;13)\r\n  for the high-pass filtered sound without\r\n  earplugs. When earplugs were used,\r\n  scores were 69% (&plusmn;13) for low-pass, and\r\n  60% (&plusmn;20) for high-pass sounds. Hearing\r\n  impaired individuals&rsquo; scores were 51%\r\n  (&plusmn;13) for the low-pass, and 55% (&plusmn;8) for\r\n  the high-pass sounds without earplugs.</p>\r\n<div class=\"well well-sm\">\r\n  <div class=\"row\">\r\n    <div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Romberg-14-1-1-g004.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Romberg-14-1-1-g004.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Romberg\" title=\"canadian-hearing-report-Romberg\" /></a></div>\r\n    <div class=\"col-xs-12 col-md-10\">\r\n      <p><strong>Fig 1.</strong> Results of Romberg and Tandem tests for balance for normal hearing and hearing impaired individuals (normal hearing in blue and hearing\r\n        impaired in yellow).</p>\r\n    </div>\r\n  </div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n  <div class=\"row\">\r\n    <div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-hearing-14-1-1-g005.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-hearing-14-1-1-g005.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-hearing\" title=\"canadian-hearing-report-hearing\" /></a></div>\r\n    <div class=\"col-xs-12 col-md-10\">\r\n      <p><strong>Fig 2.</strong> Sound localization test results for normal hearing and hearing impaired individual Low-fr: Low-frequency; Hi-fr: High-frequency (normal\r\n        hearing in blue and hearing impaired in yellow).</p>\r\n    </div>\r\n  </div>\r\n</div>\r\n<p>With earplugs, their performance was\r\n  58% (&plusmn;28) for the low-pass, and 52% (&plusmn;25)\r\n  for the high-pass sound. Comparing the\r\n  normal hearing and the hearing impaired\r\n  listeners&rsquo; scores for sound localization\r\n  test revealed significantly lower scores for\r\n  hearing impaired listeners (p=0.046).\r\n  Hearing sensitivity at high frequencies\r\n  exhibits great discrepancies between\r\n  old and young individuals. Older adults\r\n  frequently develop high-frequency hearing loss (presbycusis). However, a little is\r\n  known about the difference in lowfrequency\r\n  hearing sensitivity between\r\n  older and younger adults, and whether it\r\n  has an impact on vestibular function and\r\n  postural stability.</p>\r\n<p>In their review on low-frequency noise,\r\n  Leventhall et al. reported that hearing\r\n  thresholds at low frequencies (4 Hz-\r\n  200 Hz) for older adults (50-60 years old)\r\n  was 7 dB less sensitive at the 50% median\r\n  level for the young adults, however, it was\r\n  only 3 dB less sensitive at the 10% level\r\n  [<a href=\"#6\" title=\"6\">6</a>].</p>\r\n<p>Our results for sound localization\r\n  revealed that the only condition that was\r\n  not affected was the sound localization at\r\n  low frequencies in the older adults. It has\r\n  slightly increased.</p>\r\n<p>The transmission of low frequencies and\r\n  infrasound in the inner ear is not fully\r\n  understood. Several mechanisms limit the\r\n  transmission of low-frequency sounds in\r\n  the ear. The middle ear impedance is rather\r\n  dominated by stiffness below 200 Hz [<a href=\"#7\" title=\"7\">7</a>].</p>\r\n<p>The term &ldquo;infrasound&rdquo; is rather confusing\r\n  because sounds were reported to be\r\n  heard at frequencies below the reported\r\n  limit of human hearing (16 Hz). A reliable\r\n  hearing threshold was measured down to\r\n  4 Hz in an acoustic chamber and down\r\n  to 1.5 Hz for earphones [<a href=\"#8\" title=\"8\">8</a>]. The outer\r\n  hair cells are more sensitive to infrasound\r\n  compared to the inner hair cells. The\r\n  fact that infrasonic sound that cannot be\r\n  heard does not necessarily means that\r\n  those low-frequency sound pressure\r\n  waves do not affect the functions of\r\n  the inner ear. Individuals become more\r\n  sensitive to infrasound under certain\r\n  pathological conditions, such as superior\r\n  canal dehiscence and Meniere&rsquo;s disease\r\n  [<a href=\"#7\" title=\"7\">7</a>].</p>\r\n<p>Postural regulation is the result of the\r\n  dynamic processing of multiple sensory\r\n  inputs by the central nervous system.\r\n  There are well-known contributions of musculoskeletal, visual, proprioceptive,\r\n  and vestibular information to the\r\n  maintenance of postural balance and\r\n  stability. However, the contribution of\r\n  auditory inputs to postural stability has\r\n  been under-investigated [<a href=\"#4\" title=\"4\">4</a>].</p>\r\n<p>Unlike the hair cells in the cochlea, the hair\r\n  cells of the vestibular organs are sensitive\r\n  to low frequencies (below 30 Hz), however,\r\n  these hair cells do not typically respond\r\n  to airborne sound pressure waves, they&rsquo;d\r\n  rather respond to mechanical input\r\n  from head and body movements [<a href=\"#7\" title=\"7\">7</a>]. The\r\n  vestibular system responds passively to\r\n  acoustic stimuli beyond its frequency\r\n  range when these are loud enough. This\r\n  response can be physiological (such as\r\n  Vestibular-Evoked Myogenic Potential\r\n  (VEMP), or pathological (such as the Tullio\r\n  phenomenon).</p>\r\n<p>The preservation of hearing sensitivity at\r\n  low frequencies in older adults may play\r\n  a role in postural stability. Further testing\r\n  for the effects of low frequencies and\r\n  infrasonic sound pressure waves on the\r\n  inner ear components might reveal more\r\n  links between auditory input and postural\r\n  stability.</p>\r\n<h3> REFERENCES</h3>\r\n<ol>\r\n  <li id=\'Reference_Title_Link\' value=\'1\'><a name=\"1\" id=\'1\'></a>Kanegaonkar,  R.G., Amin, K., Clarke, M., &ldquo;The contribution of hearing  to normal balance.&rdquo;  J Laryngol Oto, 126(10) (2012):  984-988. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'2\'><a name=\"2\" id=\'2\'></a>Zhong, X., Yost, W.A., &ldquo;Relationship between postural stability and spatial hearing.&rdquo; J  Am Acad Audiol, 24(9) (2013):  782-788. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'3\'><a name=\"3\" id=\'3\'></a>Lin, F.R., Ferrucci, L., &ldquo;Hearing loss and falls  among older adults in the United  States&rdquo;. Arch Inter  Med, 172(4) (2012):  369-371. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'4\'><a name=\"4\" id=\'4\'></a>Rumalla, K., Karim, A.M., Hullar, T.E.,  &ldquo;The effect of hearing aids on postural stability&rdquo;. Laryngoscope, 125(3) (2015): 720-723. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'5\'><a name=\"5\" id=\'5\'></a>Ibrahim, I., et al. &ldquo;Postural stability: assessment of auditory  input in normal hearing individuals and hearing  aid users&rdquo;. Hear Balance Comm, 17(4) (2019):  280-287. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'6\'><a name=\"6\" id=\'6\'></a>Leventhall,  H.G., &ldquo;Low frequency noise. What we know, what we do not know and  what we would like to know&rdquo;. J Low Freq Noise Vibrat Act Control, 28(2) (2009): 79-104. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'7\'><a name=\"7\" id=\'7\'></a>Salt, A.N., Hullar,  T.E., &ldquo;Responses of the ear to low frequency sounds, infrasound and wind turbines&rdquo;. Hear Res, 268(1-2)  (2010): 12-21. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'8\'><a name=\"8\" id=\'8\'></a>Raufer, S., Masud, S.F., Nakajima, H.H.,&ldquo;Infrasound transmission in the human ear:  Implications for acoustic and  vestibular responses of the normal and  dehiscent inner ear&rdquo;. J Acoust Society Am, 144(1)  (2018): 332. </a></li>\r\n</ol>\r\n<h4>Progression of Hearing Aid Technology</h4>\r\n<p><strong>By Razia Kausar<sup><a href=\"#corr\">*</a></sup></strong></p>\r\n<p>Department of Biotechnology, Meerut Institute of Engineering &amp; Technology, U.P., India-250005</p>\r\n<p>*raziak241@gmail.com</p>\r\n<p>At present, around 5% of the world&rsquo;s\r\n  population (466 million people) are\r\n  suffering from hearing disorders. The\r\n  cause of hearing loss varies from\r\n  individual to individual. It may be due to\r\n  chronic infectious diseases, complications\r\n  at the time of birth, genetic causes, and\r\n  exposure to loud noises for a long time or\r\n  because of the use of particular drug. As\r\n  a consequence, people who are suffering\r\n  from hearing loss suffer from difficulties\r\n  in communication that leads to loneliness,\r\n  frustration, isolation and lack of selfconfidence.\r\n  Therefore, to overcome the\r\n  hurdle of deafness hearing aid/device was\r\n  developed, firstly in the 19th century, and\r\n  this electrical hearing device was name\r\n  as &lsquo;Akouphone&rsquo; invented by Miller Reese\r\n  Hutchison in 1898. Carbon Transmitter\r\n  was used to make the device portable.\r\n  That carbon transmitter uses electric\r\n  current for the amplification of weak\r\n  signals to strong signals.</p>\r\n<p>Soon after this, vacuum tube hearing\r\n  aid was designed that was named as\r\n  &lsquo;Vactuphone&rsquo; which allowed greater\r\n  amplification (upto 70 decibels). But the\r\n  drawback of this hearing aid was its weigh\r\n  which was more than 200 pounds. So the\r\n  need of that time was to develop portable\r\n  hearing device.</p>\r\n<p>In 1938, first wearable hearing device\r\n  was generated. It had a small earpiece\r\n  connected to a batter pack and an\r\n  amplifier-receiver. Later in 1950s,\r\n  transistors were fitted in between the\r\n  triangle shaped pieces of pair of glasses\r\n  to make the hearing aid devices and\r\n  therefore named as &lsquo;Hearing glasses&rdquo;.\r\n  Ear-only hearing aid was first developed\r\n  in 1960s. And these were more reliable\r\n  and unconstructive than all the previously\r\n  developed devices. But the distorted\r\n  sound quality and auditory feedback was\r\n  still a major problem. The development\r\n  of microprocessors in 1970s leads to\r\n  the miniaturization if the hearing devices.\r\n  Researcher Edgar Villchur (known for\r\n  the invention of the Acoustic Suspension\r\n  Loud speaker) generated a device with\r\n  an analog multi-channel amplitude\r\n  compression that was used to separate\r\n  audio signal into frequency bands. This\r\n  multi-channel amplitude compression\r\n  system was later used as a fundamental\r\n  structure in the development of digital\r\n  hearing aid technology.</p>\r\n<p>Also in 1970s, the components of\r\n  conventional hearing aid including\r\n  filters, signal limiting and amplifiers were\r\n  combined with digital programmable\r\n  component to create a hybrid hearing aid.\r\n  In this hybrid device, the digital component\r\n  could be programmed by connecting with\r\n  computer. These devices were effective\r\n  because of compact size and low power\r\n  consumption.</p>\r\n<p>The progression in digitalization of hearing\r\n  aids started after the generation of highspeed\r\n  digital-array processors widely used\r\n  in minicomputers, as these processors\r\n  were able to process audio signals at very\r\n  high speed which is equivalent to real\r\n  time speed.</p>\r\n<p>The first commercial digital hearing\r\n  aid device was developed by Nicolet\r\n  Corporation in 1987. Although, Nicolet\r\n  Corporation&rsquo;s hearing device was not\r\n  successful publicly and the race to create\r\n  more effective hearing aids started among\r\n  the manufacturers. After two year, Behindthe-\r\n  ear (BTE) was launched.</p>\r\n<p>Digital Technology is currently at the latest\r\n  stage of hearing aid evolution. The newest\r\n  devices that are commercialized today\r\n  finely meet the needs of the individuals.\r\n  Latest hearing aids are portable and also\r\n  the problem of distortion existed in\r\n  many analog models is reduced. These\r\n  digital aids are quite sensitive that they\r\n  can even pick up additional background\r\n  noises. The brand new models have builtin\r\n  algorithms to eliminate background\r\n  noises that further helps in improving the\r\n  sound quality.</p>\r\n<p>The novel technologies in this era are\r\n  significantly better and helpful for the deaf\r\n  individuals in improving their lifestyle and\r\n  for their growth and development.</p>',NULL,'2022-11-10'),(6,5391,'ajchr','http://www.andrewjohnpublishing.com/','','<h4>Journal Report from Canadian Hearing Report\r\n  Secretaire</h4>\r\n<p>By Razia K Ahmed*</p>\r\n<p>Department of otolaryngology, CMJ University, Shilllong</p>\r\n<p>*razia110@gmail.com</p>\r\n<h4>EDITORIAL NOTE</h4>\r\n<p>\r\n  This is exultant to offer you the fall of\r\n  issue 2 of Volume 14 of Canadian Hearing\r\n  Report. The journal auspiciously released\r\n  1st issue of volume 14 in August. With\r\n  the kind support of editors, reviewers\r\n  and authors, the team is able to release\r\n  this issue within time. This is prideful for\r\n  us that printed copied of the fi rst issue\r\n  were also brought out and sold within\r\n  single month. Canadian Hearing Report\r\n  magazine is rather getting admirable\r\n  among senior as well as young researchers,\r\n  scholars, audiologists and sttudents. The\r\n  primary focus of the journal is to publicize\r\n  the updated researches in the area of\r\n  Ear healthcare, Auditory training or\r\n  advancement in hearing aid technologies,\r\nDiagnosis of hearing impairment.</p>\r\n<p>We are not only focused on academics\r\n  and article publishing but also we welcome\r\n  the industrial sectors for advertisements.\r\n  This in turn updates the readers about\r\n  the updated technology available in\r\n  the market and the companies that are\r\nengaged in manufacturing of that product.</p>\r\n<p>As we all are aware that COVID-19\r\n  has completely changed the scenario.\r\nThe professionals who prefer printed magazines are now in favour of E-journals.\r\nE-journals are superior for searching the\r\nselected material and in precise format.\r\nAnd so, the journal CHR meets the\r\nrequirement of the readers.</p>\r\n<p>The visitor&rsquo;s traffi c on the journal website\r\n  is constant escalating and therefore we\r\n  have decided to redraft the PDF. To make\r\n  the magazine more fascinating among\r\n  the audience we are now going to adjoin\r\n  experienced researchers/audiologists\r\n  universally and publish their interviews,\r\n  research experience in the core area,\r\nbiography.</p>\r\n<p>To promote and encourage young\r\n  researchers and students the journal has\r\n  started publishing commentaries, short\r\n  communications, mini reviews, research\r\n  posters, opinion articles, features, and\r\n  other such additional article types. In\r\n  response to the same we are getting\r\n  numerous commentaries and short\r\n  reviews. Out of which few quality articles\r\n  has been published in this 2nd issue. The\r\n  processing of these articles are same as of\r\n  full length research articles, initially step\r\n  up with preliminary quality/plagiarism\r\n  check followed by peer review process,\r\n  editors&rsquo; approval, formatting and editing,\r\nthen proceed for fi nal publication. The graduate as well as post graduate students\r\nare enthusiastically coming up with their\r\narticles.</p>\r\n<p>We are also providing reprints of the\r\n  articles/issue(s)/volume(s) or custom\r\n  reprints to the authors on request.\r\n  Apart from that we welcome Institutes/\r\n  Universities/Organizations to utilize the\r\n  journal platform for global announcement\r\n  regarding Conferences and recently\r\n  initiated programmes or courses. This\r\n  helps the scholars in grabbing the\r\nopportunities within time.</p>\r\n<p>Finally, we would like to acknowledge\r\n  the contributions of editors, reviewers\r\n  and authors in the journal. Moreover,\r\n  we exceed the gratitude to the\r\n  coordinators, graphics team, web team,\r\n  QC team, advisory members and other\r\n  supporting hands for their precious\r\n  support and making the issue release\r\n  of the journal successful punctually on\r\n  time. The journals&rsquo; growth refl ects the\r\n  hard work of the team members. We\r\n  request the website visitors and readers\r\n  of the journal to send us their valuable\r\n  comments/feedback so that we can make\r\n  the upcoming issue more captivating. Your\r\nviews will be acknowledged.</p>\r\n<h4>It&rsquo;s hard to believe, but 2020 marks the\r\n  15th anniversary ofCanadian Hearing Report.\r\nWe have a lot to celebrate!</h4>\r\n<p>CHRhas provided hearing health professionals with the most current information on trends, technology, and the latest\r\nthinking in hearing health for the past 15 years, and we have only just begun!</p>\r\n<p><strong>New Direction</strong></p>\r\n<p>\r\n  Building on innovative idea of difficult concepts and making them easy to understand, CHR will continue to publish\r\n  articles by leading authorities in hearing health sciences. We also welcome industry input and articles on new\r\ntechnologies and developments!</p>\r\n<p><strong>New and Refined Circulation</strong></p>\r\n<p>\r\n  We have always reached a wide audience of Canadian hearing health professionals, butnowwe can better refine and\r\n  define our reader. Though groups like, CHIPS, AHIP and our in-house request list of more than 1,000 hearing clinics,\r\n  we are the only national, print hearing journal in Canada that reaches this market so effectively, in both a print format\r\nand e-based publication.</p>\r\n<p><strong>Print Version</strong></p>\r\n<p>\r\n  &bull; 157 members of CHIPS</p>\r\n<p>\r\n  &bull; 1000 national hearing clinics (request list)</p>\r\n<p><strong>Electronic Version</strong></p>\r\n<p>\r\n&bull; Flipbook version sent to all members of AHIP</p>\r\n<p>\r\n  &bull; Flipbook Version sent to all members of Educators\r\nof the Deaf and Hard of Hearing</p>\r\n<p><strong>Value for Your Marketing Investment</strong></p>\r\n<p>\r\n  When you book an ad in Canadian Hearing Report, your ad will also appear in the e-flipbook version AND the PDF\r\n  version! Although e-based journals are the trend these days, recent surveys indicate that professionals still appreciate\r\n  and value a printed journal. Moreover, it is the print version of journals where these professionals learn most about\r\n  new products through the advertising. E-journals are great for searching select material and are becoming more and\r\nmore popular but there is nothing like print publishing to deliver your advertising message!</p>\r\n<p>The industry has changed over the past few years and will continue to in the future &ndash; so will Canadian Hearing Report.\r\n  The journal will continue to evolve and support the hearing health care professionals and the hearing health care\r\nindustry in this exciting and important time.</p>\r\n<h4>Delaying the Progression of Presbycusis: Role\r\n  of Antioxidant Vitamins</h4>\r\n<p>By Iman Ibrahim*</p>\r\n<p>Department of Otolaryngology, HNS LHSC-Victoria Hospital, London, ON</p>\r\n<p>* iman.ibrahim@mail.mcgill.ca</p>\r\n<h4>COMMENTARY</h4>\r\n<p>\r\n  Age-Related Hearing Loss (ARHL) is a\r\n  gradual and progressive deterioration\r\n  in hearing. It is a multifactorial process,\r\n  resulting from a combination of various\r\n  factors such as genetic predisposition,\r\n  vascular and cognitive impairment, loss of\r\n  auditory neurons such as spiral ganglion\r\n  neurons, and deterioration of cochlear\r\n  hair cells function [1]. In Canada, AHLR\r\n  (akapresbycusis) occurs in 38.3% of those\r\n  aged 60-69 and 65% of those aged 70-79\r\n[2].</p>\r\n<p>Heritability plays a signifi cant role in the\r\n  occurrence of presbycusis in humans,\r\n  where 25%-75% of the variance in its\r\n  pathology reveals a genetic component.\r\n  Examples of genetic mutations that are\r\n  linked to ARHL include polymorphisms in\r\n  the genes coding detoxifi cation enzymes\r\n  (such as glutathione S-transferase and\r\n  N-acetyl transferase 2), and variants of the\r\n  SOD2 gene which encode a Mitochondrial\r\n  Superoxide Dismutase enzyme (MnSOD)\r\n[3].</p>\r\n<p>There are several subtypes of presbycusis\r\n  (sensory, neural, metabolic, mechanical,\r\n  mixed, and indeterminate), each result\r\n  from a different mechanism and exhibit\r\n  a characteristic pattern of hearing loss\r\n  manifested in audiograms. In sensory\r\n  presbyacusis, there is a loss of sensory\r\n  hair cells in the organ of Corti due\r\n  to accumulation of lipofuscin pigment\r\n  granules, a process originates in the basal\r\n  turn and slowly progresses towards\r\n  the apex. Audiogram exhibits an abrupt\r\n  steep high-frequency SNHL. The neural\r\n  subtype occurs as a result of atrophy of\r\nspiral ganglion and cochlear neurons. It&rsquo;s a slowly progressive process where the\r\naudiogram shows a ski-slope towards the\r\nhigh frequencies.</p>\r\n<p>The metabolic (aka strial/vascular)\r\n  subtype there is atrophy of striavascularis\r\n  which maintains the chemical and\r\n  bioelectric balance and metabolic\r\n  health of the cochlea. It results in slowly\r\n  progressive SNHL with a fl at-curve\r\n  audiogram because the entire cochlea\r\n  is affected. Finally, the mechanical (aka\r\n  cochlear conductive) presbyacusis, which\r\n  occurs due to stiffness of the basilar\r\n  membrane in the cochlea with a ski-slope\r\n  hearing loss towards high frequencies in\r\n  the audiogram. There are also mixed types\r\n  that exhibit various combinations of the\r\n  four pathologies, as well as indeterminate\r\n  which is slowly progressive SNHL with\r\n  age with no obvious microscopic cochlear\r\n  pathology. It could result from a central\r\n  pathology and is commonly associated\r\nwith poor speech discrimination [4].</p>\r\n<p>Because mitochondrial mutations and/or\r\n  dysfunction play a role in the pathology\r\n  and course of aging in general and\r\n  presbyacusis in particular, attempting\r\n  at reducing the oxidative stress and the\r\n  production of ROS has been studied as\r\n  potential management that could slow the\r\n  progress of presbyacusis [5]. This goal can\r\n  be achieved by 1) decreasing exposure\r\n  to substances that have oxidizing\r\n  properties, 2) stabilizing the process of\r\n  energy production in the mitochondria\r\n  to decrease the oxidative stress, or 3)\r\n  increasing the level of antioxidants, both\r\n  endogenous and exogenous. The use of\r\n  antioxidant supplements and multivitamin\r\n  preparation (particularly vitamins A,\r\nC, E, and selenium) may quench theROS and decrease cell damage. Certain\r\nlifestyle changes might help to improve\r\ncell function and protect cells from\r\nmitochondrial damage. Such changes\r\ninclude consumption of plant-derived\r\nnutrients, avoiding processed foods,\r\nrefi ned sugars, and saturated fats, caloric\r\ndietary restriction, and the daily intake of\r\nfruits and vegetables [6].</p>\r\n<p>The author of this article-along with\r\n  coauthors-published a review study that\r\n  investigated the effect of Antioxidant\r\n  Vitamins as Adjuvant Therapy for Sudden\r\nSensorineural Hearing Loss [6].</p>\r\n<p>Currently, the regimen for SSNHL\r\n  treatment consists of steroids (prednisone\r\n  or methyl prednisone). However, the\r\n  benefi ts of antioxidants are currently\r\n  the focus of SSNHL management as an\r\nadjuvant to the treatment [7].</p>\r\n<p>There are a few postulated mechanisms to\r\n  explain the patho-physiologies in SSNHL,\r\n  such as (1) labyrinthine viral infection\r\n  (17%-33% of SSNHL patients recall\r\n  a recent viral illness); (2) labyrinthine\r\n  vascular compromise (the cochlea is an\r\n  end-organ with no collateral vasculature;\r\n  thrombosis, embolus, vasospasm, or any\r\n  pathology that results in reduced blood\r\n  fl ow to the cochlea can result in SSNHL;\r\n  (3) intra-cochlear membrane ruptures\r\n  - rupture of either the membranes that\r\n  separate the inner ear from the middle\r\n  ear or the delicate membranes within the\r\n  cochlea that separate the peri-lymphatic\r\n  and endolymphatic spaces; (4) immunemediated\r\n  inner ear disease-SSNHL is well\r\n  documented in autoimmune diseases,\r\n  such as Cogan syndrome and systemic\r\nlupus erythematosus; and (5) iron defi ciency anaemia, where iron, in addition\r\nto zinc and copper, is essential to break\r\ndown the free radicals for the enzymatic\r\nantioxidants [8-10].</p>\r\n<p>The presence of vascular compromise of\r\n  the cochlea as a postulated mechanism\r\n  for both ARHL and SSNHL could explain\r\n  the protective role of antioxidant vitamins\r\nin managing both conditions.</p>\r\n<p>Antioxidants neutralize the oxidative\r\n  stress by enhancing cellular defenses and\r\n  hence protect the cell membranes [11].\r\n  A few studies investigated the effect of\r\n  antioxidants on SSNHL, most of them\r\n  reported a signifi cant improvement in the\r\n  patients who receive antioxidants as an\r\nadjuvant treatment for SSNHL.</p>\r\n<p>Each vitamin exhibits a different\r\n  mechanism of action. While vitamin A\r\n  can reduce the concentration of singlet\r\n  oxygen and repair damaged hair cells,\r\n  vitamin E can reduce peroxyl radicals in\r\n  the cell membrane, and vitamin C can\r\n  detoxify free radicals in the aqueous\r\nphase [12].</p>\r\n<p>So far, the evidence is inconclusive\r\n  concerning which vitamin or vitamin\r\n  combination(s) is more effective, and\r\n  in what dosage. Further studies are\r\n  required to test the effect of each\r\n  vitamin individually, as well as giving\r\n  different combinations of these vitamins\r\n  to fi nd the most effective vitamin and/or\r\n  combination of vitamins and their dosage\r\n  to be routinely administered either as\r\n  SSNHL adjuvant therapy or to slow down\r\nthe progression of ARHL.</p>\r\n<h4>REFERENCES</h4>\r\n	<ol>\r\n  <li>Tavanai, E., Mohammadkhani, G. &ldquo;Role  of antioxidants in prevention of age-related hearing  loss: a review of literature.&rdquo; Eur Arch  Otorhinolaryngol. 274(4) (2017): 1821-1834. </li>\r\n  <li>Feder,  K., et al.&ldquo;Prevalence of hearing loss among  Canadians aged 20 to 79:  audiometric results from the 2012/2013: Canadian Health Measures Survey.&rdquo; Health Rep. 26(7) (2015): 18-25. </li>\r\n  <li>Wang,  J., Puel, J. L. &ldquo;Presbycusis: An update on cochlear mechanisms and therapies.&rdquo;  J Clin Med. 9(1) (2020): 218. </li>\r\n  <li>Schuknecht,  H. F., Gacek, M. R. &ldquo;Cochlear pathology  in presbycusis.&rdquo; Ann Otol Rhinol Laryngol. 102(1 Pt 2) (1993):  1-16. \r\n</li>\r\n\r\n  <li>Ibrahim, I., et al. &ldquo;Mitochondrial mutations associated with hearing  and balance disorders.&rdquo; Mutat Res. 810 (2018):  39-44. </li>\r\n  <li>Ibrahim,  I., Zeitouni, A., da Silva, S.D. &ldquo;Effect of antioxidant vitamins as  adjuvant therapy for sudden sensorineural hearing  loss: Systematic review study.&rdquo; Audiol  Neurootol. 23(1) (2018): 1-7. </li>\r\n  <li>Conlin,  A. E., Parnes, L. S. &ldquo;Treatment of sudden sensorineural  hearing loss: I A systematic review.&rdquo; Arch Otolaryngol Head Neck Surg. 133(12) (2007): 573-581. </li>\r\n  <li>Okamoto, M., et al. &ldquo;Sudden deafness  accompanied by asymptomatic mumps.&rdquo; Acta Otolaryngol Suppl. 514(Suppl) (1994): 45-48. </li>\r\n  <li>Chung,  S.D., et al. &ldquo;Sudden sensorineural hearing loss associated with iron-deficiency anemia:  a population-based study.&rdquo; JAMA Otolaryngol Head Neck Surg. 140(5) (2014):  417-422. </li>\r\n  <li>Rudack, C., et al. &ldquo;Vascular risk factors in sudden hearing loss.&rdquo; Thromb Haemost. 95(3) (2006): 454-461. </li>\r\n  <li>Young,  I. S.,Woodside, J.V. &ldquo;Antioxidants  in health and disease.&rdquo; J Clin Pathol.  54(3) (2001): 176-186. </li>\r\n  <li>Kaya, H., et al.&ldquo;Vitamins A, C, and E and selenium in the  treatment of idiopathic sudden sensorineural  hearing loss.&rdquo; Eur Arch  Otorhinolaryngol. 272(5) (2015): 1119-1125. \\</li>\r\n</ol>\r\n	<h4>Advances in Surgical Techniques for Cochlear\r\n    Implantation</h4>\r\n	<p>By Jessica Philip*</p>\r\n	<h4>COMMENTARY</h4>\r\n	<p>\r\n	  Cochlear implantation (CI) in basic\r\n	  words can be defi ned as the surgical\r\n	  implantation of an electrical device that\r\n	  can stimulate the auditory nerve directly\r\n	  through bypassing a non-functional inner\r\n	  ear. Speech and other sounds can be easily\r\n	  heard by severe to profound deaf people\r\n    with the help of this device.</p>\r\n	<p>This is interesting to mention that in\r\n	  1961 William House used a surgical\r\n	  approach standard for CI; for more than\r\n	  half a century and there was no major\r\n	  upgradation in the surgical approach.\r\n	  But there were different alternative\r\n	  approaches and some advanced\r\n	  techniques, each of them having relative\r\n	  advantages and disadvantages. The surgical\r\n	  method described by House includes the\r\n	  following steps: Postauricular incision\r\n	  (skin incision) followed by elevation of\r\n	  periosteal fl aps or palva fl ap. After that\r\n	  Mastoidectomy Posterior Tympanotomy\r\n	  Approach (MPTA) was performed. This\r\n	  step constitutes opening of posterior\r\n	  tympanotomy in an inferior direction.\r\n	  Excess bone in front of the facial nerve\r\n	  is removed to obtain good exposure of\r\n	  RW niche and membrane. Care should\r\n	  be taken so that RW membrane may be\r\n	  concealed by a false membrane that is to\r\n	  be removed fi rst by sharp instrument. The\r\n	  next step is to fi x the device, by drilling a\r\n	  custom fi t bony well for accommodation\r\n	  of titanium case, of the RS (Receiver/\r\n    Stimulation) of selected implant.</p>\r\n	<p>Next step in classis CI is Cochleostomy,\r\n	  a separate opening is drilled inferior and\r\n	  slightly anterior to RW membrane. The\r\n	  device is brought up to the surgical fi eld,\r\n	  and then the electrode is inserted into\r\n	  the cochlea. Now the stability of device\r\n	  in the well is confi rmed and periosteum\r\n	  is sewed together over the implant for\r\n	  further stabilization. The distal end of\r\n	  electrode should be secured by sealing the\r\n	  cochleostomy site. This sealing is helpful\r\n	  in preventing infections from middle ear\r\n	  into cochlea. Simultaneous intraoperative\r\n	  device monitoring is done to confi rm both\r\n	  electrical output of device and electrical\r\n    response of the patient.</p>\r\n	<p>For the treatment of Sensorineural\r\n	  Hearing Loss (SHL), Cochlear implantation\r\n	  (CI) has become a familiar method.\r\n	  Progression in the fi eld of signal processing\r\n	  techniques and advancements in the fi eld\r\n	  of microelectronics, over past several\r\n	  decades have led to an improvement in the\r\n	  accomplishing effectiveness of CI devices.\r\n	  To reduce the occurrence of postoperative\r\n	  complications, CI surgery has been\r\n	  upgraded using various techniques. Many\r\n	  patients have successfully gone through\r\n	  cochlear implantation surgery; but still\r\n	  surgery-related complications continue\r\n	  to occur. The potential complications\r\n	  occur with CI are: meningitis, seroma,\r\n	  facial nerve injury (paralysis or paresis),\r\n	  wound infections, eardrum perforation,\r\n	  device extrusion, electrode migration,\r\n	  trauma to the implant site, damage to\r\n    the receiver-stimulator, acute infection of the middle ear, vertigo, device failure,\r\n    and mastoid or cholesteatoma in children\r\n    are the potential complications associated\r\n    with CI. Based on whether the patient\r\n    is an adult or belongs to the paediatric\r\n    age group, the incident of complications\r\n    varies. However, it is still contended\r\n    whether specifi c complications occur\r\n    more frequently in adult or paediatric\r\n    patients.</p>\r\n	<p>Till date there is no signifi cant change in\r\n	  classic or standard CI. However, some\r\n	  surgical modifi cations were introduced by\r\n	  the surgeons. The advancements made in\r\n    CI are described below:</p>\r\n	<p>1. The postauricular C-shaped incision\r\n	  was fi rst replaced by inverted J-shaped\r\n	  incision and then modifi ed to endaural\r\n	  incision. But skin breakdown at External\r\n	  Auditory Canal (EAC) and wound\r\n	  infections are the major complications\r\n	  of this type of incision therefore\r\n	  further advancements had been made\r\n	  in endaural incision to lower the risk\r\n    of infections</p>\r\n	<p>2. Periosteal fl ap elevation is modifi ed so\r\n	  as to ensure good exposure to drilling\r\n	  areas and tight periosteal covering\r\n	  of device. The periosteum is uplifted\r\n	  through two fl aps: fi rst one is a short\r\n	  anteriorly based periosteal fl ap that\r\n	  aims at exposure of mastoid bone,\r\n	  while the second fl ap is an inferiorly\r\n    based fl ap that exposes RS bony well</p>\r\n	<p>3. Robotic CI is a new invention to reduce\r\n    excess bone drilling and getting safe and direct excess to RW membrane</p>\r\n	<p>4. Although MPTA is a standard approach\r\n	  for CI but now many alternative\r\n	  options are also available including\r\n	  pericanal approach, transattic approach,\r\n	  suprameatal approach, transcanal\r\n	  approach. These approaches aim to\r\n	  avoid the risk of facial nerve surgery\r\n    and also reduce duration of surgery</p>\r\n	<h4>Paediatric Auditory Processing Disorders</h4>\r\n	<p>\r\n    By Anjali Tripathi*</p>\r\n	<h4>OPINION ARTICLE</h4>\r\n	<p>\r\n	  The opinion article &ldquo;Pediatric Auditory\r\n	  Processing Disorder&rdquo; presents a misshaped\r\n	  perspective on the proof based\r\n	  methodology utilized in medication.\r\n	  The creators centre on the shapeless\r\n	  non-demonstrative element &ldquo;listening\r\n	  challenges&rdquo; not sound-related preparing\r\n	  issue (APD) and make disarray that could\r\n	  risk clinical administrations to people\r\n	  with APD. In our point of view article, we\r\n	  invalidate Neijenhuis [1], and all the more\r\n	  signifi cantly, we present a reason for proof\r\n	  put together practice established with\r\n	  respect to the reason that examination\r\n	  on APD is just clinically appropriate when\r\n	  directed on clinical populaces determined\r\n    to have APD.</p>\r\n	<p><strong>WHAT IS AN EVIDENCE-BASED\r\n    APPROACH TO PAEDIATRIC APD?</strong></p>\r\n	<p>\r\n	  The appropriate response is that it is\r\n	  equivalent to for some other sickness or\r\n	  turmoil. As indicated by Sackett [2], the\r\n	  proof based methodology in medication\r\n	  incorporates three components: (a)\r\n	  clinical aptitude, (b) best examination\r\n	  accessible, and (c) the patient&rsquo;s qualities\r\n	  and inclinations. While perceiving the\r\n	  basic job of examination in building up the\r\n	  proof base for confusion, one must not\r\n	  limit the other two columns. While some\r\n	  may be enticed to organize research (even\r\n	  examination with methodological or\r\n	  potentially confi guration shortcomings)\r\n	  over clinical aptitude in one&rsquo;s\r\n	  conceptualization of proof based practice,\r\n	  Haynes [3] place clinical skill at the centre\r\n	  of the clinical choice procedure. A key\r\n	  component for a proof based way to\r\n	  deal with APD is that the methodology\r\n	  is educated by research led on clinical\r\n    populaces determined to have APD [4].</p>\r\n	<p>As they would like to think paper,\r\n	  Neijenhuis [1] declare that the three\r\n	  &ldquo;effi cient surveys&rdquo; they refer to subvert\r\n	  the proof base for APD. Truth be told, none\r\n	  of these papers is really a precise survey\r\n	  of essential, peer-inspected research\r\n	  directed with members determined to\r\n	  have APD. Without distributed orderly\r\n	  audits of members determined to have\r\n	  APD right now, the following best proof\r\n	  based advance is to utilize current expert\r\n	  affi liation rules. European rules allude\r\n	  to numerous nations&rsquo; rules (inside and\r\n	  past Europe) and these give practically\r\n	  equivalent to and reliable ways to deal with\r\n	  the fi nding of APD [5]. This methodology\r\n	  isn&rsquo;t similar to the methodologies taken\r\n	  in the papers referred to as orderly APD\r\n	  audits by Neijenhuis [1]. Truth be told,\r\n	  they refer to a survey of clinical practice\r\n	  rules [6], in which the creators utilized an\r\n	  evaluation strategy for rules utilizing the\r\n	  Agree II instrument to rate every rule&rsquo;s\r\n	  logical methodology. Heine and O&rsquo;Halloran\r\n	  presumed that all accessible APD rules\r\n	  in the English language (counting the\r\n	  American and British Guidelines) scored\r\n	  low in many spaces essentially because\r\n	  of &ldquo;poor methodological detailing&rdquo; and\r\n	  ought not to be utilized in their present\r\n	  structure. It ought to be noticed that a\r\n	  precise hunt and assessment of clinical\r\n	  practice rules is anything but an orderly\r\n	  audit of power research, and, in addition,\r\n    is restricted to clinical preliminaries [7].</p>\r\n	<p>The second asserted orderly audit\r\n	  included exploration including members\r\n	  &ldquo;associated with&rdquo; as opposed to\r\n	  determine to have APD [8]. The third\r\n	  paper they described as a methodical audit\r\n	  [9] is in reality a report of exploration\r\n	  where correlations were made between\r\n	  a clinical gathering alluded for APD\r\n    assessment (however not determined to have APD) and a benchmark group of\r\n    kids. The creators detailed relationships\r\n    between sound-related handling scores\r\n    and psychological scores, reasoning that\r\n    intellectual testing is fundamental in\r\n    APD conclusion. This is, basically, strange.\r\n    Discovering connections between\r\n    these two factors in undiscovered\r\n    members reveals to us minimal about\r\n    the utilization of psychological measures\r\n    in a test battery intended to analyse\r\n    APD. Any ends made by surveys of APD\r\n    that incorporate kids associated with\r\n    APD or determined to have APD based\r\n    on self-report or witness&rsquo; report on\r\n    polls or dependent on youngsters with\r\n    general listening challenges don&rsquo;t give\r\n    the best accessible proof clarifying APD.\r\n    Making determinations dependent on\r\n    execution of inadequately characterized\r\n    members presents noteworthy dangers\r\n    to the legitimacy of the examination.\r\n    Consequences of any investigation that\r\n    utilizes the measurement &ldquo;associated\r\n    with APD&rdquo; or &ldquo;listening challenges&rdquo; can&rsquo;t\r\n    be depended upon on the grounds that: (I)\r\n    One can&rsquo;t be certain whether the members\r\n    in the examination introduced any sort of\r\n    evident sound-related shortfall, and (ii)\r\n    the members may have had a wide scope\r\n    of unidentifi ed issues [10]. Effective (i.e.,\r\n    touchy and explicit) clinical trial of soundrelated\r\n    handling must be utilized to plainly\r\n    characterize members and to distinguish\r\n    and depict known comorbidities with\r\n    the goal that investigations can be led\r\n    and results deciphered precisely [11].\r\n    The genuine constraints of the associated\r\n    with APD mark (that isn&rsquo;t a conclusion) is\r\n    confi rmed by the fi nding that numerous\r\n    kids alluded for focal sound-related\r\n    preparing assessments due to &ldquo;listening\r\n    troubles&rdquo; really perform very well on\r\n    focal sound-related handling measures [12,13]. One would expect that on the off\r\n    chance that parent and educator reports\r\n    were acceptable indicators of soundrelated\r\n    handling troubles, at that point\r\n    the APD hit rate (i.e., genuine positives)\r\n    for these referrals would be a lot higher.\r\n    Actually there are no distributed, genuine\r\n    effi cient surveys of suitably determined\r\n    people to have APD. Marking youngsters\r\n    suspected APD instead of assessing and\r\n    fi ttingly diagnosing for APD isn&rsquo;t proof\r\n    based and is undermining the intercession\r\n    administrations gave to APD analysed\r\n    people.</p>\r\n	<p>The European Consensus APD Clinical\r\n	  Practice Guidelines are predicated on\r\n	  research like that hidden the ASHA and\r\n	  AAA Guidelines [14,15]. Neijenhuis\r\n	  endeavor to subvert trust in current\r\n	  rules without introducing any other\r\n	  option, proof based methodology for\r\n	  the conclusion of APD. Additionally, they\r\n	  mistakenly attest that APD might be\r\n	  better clarifi ed by other formative issues,\r\n	  including consideration or languagelistening\r\n	  defi ciencies. This is a supposition/\r\n	  contention that distributed examination\r\n	  has neglected to affi rm. Distributed\r\n	  examination shows that a little subgathering\r\n	  of APD analysed kids present\r\n	  co-dreary consideration defi ciencies\r\n	  [16]. Also, unusual execution on soundrelated\r\n	  handling tests frequently happens\r\n	  in spite of supported consideration inside\r\n	  typical cut off points [17]. Truth is told;\r\n	  most sound-related handling tests share\r\n	  just a gentle to direct level of change\r\n	  with perception, driving Weihing [16]\r\n	  to presume that sound-related handling\r\n	  execution isn&rsquo;t driven by cognizance alone.\r\n	  Moreover, development rates for various\r\n	  sound-related undertakings are not\r\n	  connected, as would be normal if a nontactile\r\n	  factor (e.g., consideration) affected\r\n	  execution [18-21]. Would Neijenhuis\r\n	  attest that a helpless reaction to a soundrelated\r\n	  boost (within the sight of ordinary\r\n	  hearing affectability) is because of helpless\r\n	  consideration, however a helpless reaction\r\n	  to a visual improvement must be because\r\n	  of a visual handling shortfall (within the\r\n	  sight of typical fringe vision)? Grounds\r\n	  to contend either case are defi cient.\r\n    Ongoing examination additionally shows that in spite of the fact that consideration\r\n    is related with how well or inadequately\r\n    a normally creating youngster utilizes\r\n    mood to see discourse in prattle, this\r\n    isn&rsquo;t valid for APD analysed kids [22].\r\n    Indeed, of course, there is proof to\r\n    propose that APD (just as fringe hearing\r\n    disability) can infl uence proportions\r\n    of perception [23,24]. Unmistakably,\r\n    cerebrum association and handling\r\n    underlies bidirectional cooperation, just\r\n    as comorbidity [25].</p>\r\n	<p><strong>WHAT IS THE AUDITORY\r\n    PROCESSING DISEASE CLINICAL\r\n    REALITY IN EUROPE AND USA</strong>?</p>\r\n	<p>\r\n	  APD is analysed by fi ttingly instructed\r\n	  otorhinolaryngologists (ENTs) or\r\n	  potentially audiologists since few would\r\n	  debate that an APD appraisal starts with\r\n	  an intensive evaluation of &ldquo;fringe&rdquo; hearing\r\n	  capacity. The diagnosing clinician needs\r\n	  to have a top to bottom comprehension\r\n	  of sound-related capacity and related\r\n	  pathologies, so ENTs/audiologists\r\n	  should be key individuals from any\r\n	  multidisciplinary group, where such social\r\n	  insurance work force are accessible. Be\r\n	  that as it may, we should not dismiss the\r\n	  constrained assets in various nations,\r\n	  where a multidisciplinary approach is\r\n	  supported, yet may not be conceivable\r\n	  inside a proper group setting. Differential\r\n	  conclusion requires multidisciplinary\r\n	  evaluation including discourse language\r\n	  pathologists, instructors, and therapists\r\n	  [26,27]. This far reaching assessment is\r\n	  best practice in APD analysis, just as in\r\n	  fi guring individualized intercession. In all\r\n	  cases, examination should control practice,\r\n	  given that the exploration depends on the\r\n	  planned populace of clinical intrigue&mdash;\r\n	  that is, people determined to have APD.\r\n	  Sound-related handling tests are assessed\r\n	  for their affectability and particularity\r\n	  before they are utilized for clinical\r\n	  analysis [27-30]. APD clinical fi nding\r\n	  uncovers the nearness of heterogeneity\r\n	  in the particular sound-related preparing\r\n	  shortfalls found in people determined\r\n	  to have APD. Subsequently, there is a\r\n	  recorded requirement for additional\r\n	  examination in this space actualized in\r\n    APD analysed people.</p>\r\n	<p>An ongoing European APD was intended\r\n	  to bring issues to light of the way that\r\n	  meeting is more than we are right now\r\n	  testing. Rise of a sound-related defi ciency\r\n	  presents injurious consequences for\r\n	  language, discernment, learning, and\r\n	  correspondence. We ought not overlook\r\n	  that trial of consideration and memory\r\n	  are regularly directed through the\r\n	  sound-related methodology and might\r\n	  be affected by a conference debilitation-\r\n	  APD included [23,24,31,32]. Soundrelated\r\n	  preparing tests remembered for\r\n	  the diagram are the ones utilized usually\r\n	  practically speaking by European clinicians\r\n	  who run claim to fame APD facilities.\r\n	  The data in the infographic depends on\r\n	  a survey fi nished by individuals from the\r\n    European APD gathering of 21 nations.</p>\r\n	<p><strong>IS THERE PLACE FOR NEW TESTS\r\n    OR APPROACHES TO APD?</strong></p>\r\n	<p>\r\n	  We unquestionably accept that APD\r\n	  determination will advance to incorporate\r\n	  progressively profi cient, dependable, and\r\n	  naturally legitimate tests (i.e., tests that\r\n	  refl ect ordinary hearing circumstances).\r\n	  One such test might be concealment\r\n	  of otoacoustic emanations utilizing\r\n	  contralateral commotion [33,34]. What&rsquo;s\r\n	  more, electrophysiological methods\r\n	  might be utilized for APD conclusion. For\r\n	  instance, proof of pre-attentional soundrelated\r\n	  separation shortfall was accounted\r\n	  for in an ongoing jumble cynicism\r\n	  concentrate in kids determined to have\r\n	  APD [35]. As science and clinical practices\r\n	  advance, be that as it may, it is neither\r\n	  moral, nor down to earth to just reject\r\n	  current clinical skill as detailed in rules of\r\n	  audiology social orders and agreement\r\n	  bunches the world over. There is no proof\r\n	  base for doing as such and subverting\r\n	  clinical administrations for many patients\r\n	  around the globe. Neijenhuis scrutinize\r\n	  the analytic standards for APD on the\r\n	  grounds that there is no particular of the\r\n	  quantity of tests or sorts of tests that are\r\n	  to be utilized although that guarantee is\r\n	  confl icting with Weihing [27] and Musiek\r\n	  [28]. Truth be told, there is no particular\r\n	  number of tests declared for most clinical\r\n	  analyses. Diagnosing an illness or turmoil\r\n    is a procedure that relies upon side effects, test discoveries, and examples\r\n    recognized by the diagnosing clinician.\r\n    Further, it is an iterative procedure by\r\n    which clinical theory are fi gured based on\r\n    the patient&rsquo;s introduction and afterward\r\n    affi rmed, changed or disposed of based on\r\n    the scope of discoveries and extra data\r\n    [36]. This procedure can&rsquo;t be effectively\r\n    characterized or reproduced based\r\n    on a severe arrangement of numerical\r\n    principles and rules: the greater part\r\n    of the current PC based symptomatic\r\n    emotionally supportive networks\r\n    neglect to arrive at master clinician\r\n    demonstrative exactness levels [37]. It\r\n    ought to be brought up that developing\r\n    innovations give promising outcomes in\r\n    displaying out both audiometry [38] and\r\n    complex sound-related discernment by\r\n    methods for computerized reasoning and\r\n    AI draws near. As of right now, be that as\r\n    it may, an accomplished clinician is as yet a\r\n    more exact diagnostician than a machine.\r\n    Rising advances increase the executives\r\n    and treatment of sound-related shortages\r\n    also.</p>\r\n	<p><strong>IS THE NEIJENHUIS ET AL. FEELING\r\n    ARTICLE ABOUT APD?</strong></p>\r\n	<p>\r\n	  We would contend it isn&rsquo;t. It centres on\r\n	  research utilizing non-analysed members\r\n	  bearing the undefi ned, non-symptomatic\r\n	  marks &ldquo;associated with&rdquo; or &lsquo;listening\r\n    challenges.&rsquo;</p>\r\n	<p><strong>WHAT DOES THE EVIDENCEBASED\r\n    APPROACH TO APD\r\n    DEMAND?</strong></p>\r\n<p>\r\n	  We should convey the most productive\r\n	  (touchy and explicit) accessible test\r\n	  batteries to analyze and design mediation\r\n	  for people with APD to limit the\r\n	  unfriendly effects the confusion is causing\r\n	  for correspondence, training, social\r\n	  coordination, and work/occupations.\r\n	  APD ought to be considered inside\r\n	  develop of hearing weakness and ought\r\n	  to be overseen dependent on analysed\r\n    shortfalls in focal sound-related preparing.</p>\r\n	<h4>\r\n    REFERENCES</h4>\r\n<ol>\r\n  <li>Neijenhuis, K., et al., &ldquo;An  evidence-based perspective on misconceptions regarding  pediatric auditory processing disorder.&rdquo; Front Neurol. 10(1) (2019):  287. </li>\r\n  <li>Sackett,  D.L., et al., &ldquo;Evidence-based medicine:  how to practice and teach EBM.&rdquo; J Int Care Med. 16(3) (2001):  155-156. </li>\r\n  <li>Haynes,  R.B., Devereaux, P.J., Guyatt, G.H. , &ldquo;Clinical  expertise in the era of evidence-based medicine  and patient choice.&rdquo; BMJ Evid Based Med<em>. </em>7(2) (2002): 36-38. </li>\r\n  <li>Sedgwick,  P., &ldquo;Generalization and extrapolation of study results.&rdquo;  BMJ. 346(1) (2003):  f3022. </li>\r\n  <li>Iliadou,  V., et al., &ldquo;A European perspective on auditory processing disorder-current  knowledge and future research focus.&rdquo; Front. Neurol. 8 (2017): 622. </li>\r\n  <li>Heine, C., O&rsquo;Halloran, R., &ldquo;Central auditory processing disorder: a systematic search and evaluation of clinical practice guidelines.&rdquo; J Eval Clin Pract. 21(6) (2015): 988-994. </li>\r\n  <li>Tomlin,  D.,  et  al.   ,  &ldquo;The   impact  of   auditory processing  and cognitive abilities in children.&rdquo; Ear Hear. 36(5) (2015): 527-542. </li>\r\n  <li>Chermak,  G.D., Musiek, F.E., Weihing, J., &ldquo;Beyond controversies: the science behind central auditory processing disorder.&rdquo; Hear Rev.  24 (2017): 20-24. </li>\r\n  <li>Brenneman,  L., et al., &ldquo;The relationship between central auditory processing, language, and cognition in children  being evaluated for Central Auditory Processing Disorder  (CAPD).&rdquo; J Am Acad Audiol. 28 (8) (2017): 758-769. </li>\r\n  <li>Rosen,  S., Cohen, M., Vanniasegaram, I. &ldquo;Auditory and cognitive abilities of children suspected of auditory  processing disorder (APD).&rdquo;  Int J Pediatr Otorhinolaryngol. 74(6) (2010): 594-600. </li>\r\n  <li>Sharma,  M., Purdy, S.C., Kelly, A.S., &ldquo;Comorbidity of auditory processing, language, and reading disorders.&rdquo; J Speech Lang Hear Res. 52(3) (2009): 706-722. </li>\r\n  <li>American  Speech-Language-Hearing Association. &ldquo;Central Auditory  Processing Disorders.&rdquo; (2005). </li>\r\n  <li>American Academy  of Audiology (AAA). &ldquo;Practical guidelines for the diagnosis, treatment, and management of  children and adults with Central Auditory Processing Disorder  (CAPD).&rdquo; (2010). </li>\r\n  <li>Stavrinos,  G., et al., &ldquo;The relationship between types of attention and auditory processing  skills: reconsidering auditory processing disorder diagnosis.&rdquo;  Front Psychol. 9 (2018): 34. </li>\r\n  <li>Gyldenkærne,  P., et al., &ldquo;Attend to this: the relationship  between auditory processing disorders and attention deficits.&rdquo; J Am  Acad Audiol. 25(7) (2014):  676-687. </li>\r\n  <li>Weihing, J., Chermak, G.D.,  Musiek, F.E. ,&ldquo;Auditory training for central auditory processing disorder.&rdquo; Semin Hear. 36(4) (2015):199-215. </li>\r\n  <li>Banai,  K., Sabin, A.T., Wright, B.A., &ldquo;Separable developmental trajectories  for the  abilities to detect auditory amplitude and  frequency modulation.&rdquo; Hear Res. 280(1-2) (2011): 219-227. </li>\r\n  <li>Dawes, P., Bishop, D.V.M., &ldquo;Maturation  of   visual and  auditory temporal processing in school-aged  children.&rdquo; J Speech Lang Hear Res. 51(4) (2008): 1002-1015.</li>\r\n\r\n  <li>Moore,  D.R., et al., &ldquo;Development of auditory processing in 6 to 11yr old children.&rdquo; Ear Hear. 32(3) (2011): 269-285. </li>\r\n  <li>Sidiras, C., et al., &ldquo;Deficits in auditory  rhythm perception in children with  auditory processing disorder are unrelated to attention.&rdquo; Front Neurosci. 13 (2019):  953. </li>\r\n  <li>Iliadou,  V., et al., &ldquo;Over-diagnosis of cognitive deficits  in psychiatric patients may be the result of not controlling for hearing sensitivity  and auditory processing.&rdquo; Psychiatry Clin Neurosci. 72(9)  (2018): 742. </li>\r\n  <li>Iliadou,  V., et al., &ldquo;Inaccurately measured poorer cognition as a result of an auditory  deficit.&rdquo; J Psychol Psychiatry. 2(2) (2018): 1-6. </li>\r\n  <li>American Psychiatric Association. &ldquo;Diagnostic and  statistical manual of mental disorders.&rdquo; 5th  edition. Arlington,  VA: American Psychiatric Publishing. (2013). </li>\r\n  <li>Deutsche Gesellschaft für Phoniatrie und Pädaudiologie (German Society of Phoniatrics and Pediatric Audiology). Auditory Processing and Perception Disorder (AuditiveVerarbeitungs- und Wahrnehmungsstörungen, AVWS).  (2015). </li>\r\n  <li>Ptok, M., Kiese-Himmel, C., Nickisch, A., &ldquo;Guideline: auditory processing and  perception disorders: definition,  guideline of the german society of phoniatrics and pediatric  audiology.&rdquo; HNO. 67(1) (2019): 8-14. </li>\r\n  <li>Kiese-Himmel, C., Nickisch, A.,  &ldquo;Diagnostic accuracy of a test set to classify children with Auditory Processing Disorders (APD).&rdquo; Laryngorhinootology. 94(6) (2015): 373-377. </li>\r\n  <li>Weihing,  J., et al., &ldquo;Characteristics of pediatric performance on a test battery  commonly used in the diagnosis of Central Auditory Processing Disorder  (CAPD).&rdquo; J Am Acad Audiol. 26(7) (2015): 652-669. </li>\r\n  <li>Musiek, F.E., et al., &ldquo;Diagnostic accuracy of established central auditory processing test batteries in patients with documented brain lesions.&rdquo; J Am Acad Audiol. 22(6) (2011): 342-358. </li>\r\n  <li>Lin,  F.R., Albert, M., &ldquo;Editorial: Hearing loss and  dementia-Who&rsquo;s listening?&rdquo;  Aging Ment Health. 18(6) (2014):  671-673. </li>\r\n  <li>Warren, J.D., Bamiou, D.E., &ldquo;Prevention of dementia by targeting  risk factors.&rdquo; Lancet.  391(10130) (2018):1575. </li>\r\n  <li>Iliadou, V.V., et al., &ldquo;Otoacoustic emission  suppression in children diagnosed with central auditory  processing disorder  and  speech in noise perception deficits.&rdquo; Int J Pediatr  Otorhinolaryngol. 111 (2018): 39-46. </li>\r\n  <li>Guinan, J.J. Jr., &ldquo;Olivocochlear efferents: their action, effects, measurement and uses, and the  impact of the new conception of cochlear mechanical  responses.&rdquo; Hear Res. 362 (2018): 38-47. </li>\r\n  <li>Rocha-Muniz,  C.N., Lopes, D.M.B., Schochat, E., &ldquo;Mismatch  negativity in children with specific language impairment and auditory processing \r\n    disorder.&rdquo; Braz J Otorhinolaryngol. 81(4) (2015): \r\n      408-415.</li>\r\n  <li>Kohn, M.A.,  &ldquo;Understanding evidence-based diagnosis.&rdquo;  Diagnosis. 1(1) (2014):  39-42. </li>\r\n  <li>Barbour, D.L., et al., &ldquo;Online machine learning audiometry.&rdquo; Ear Hear. 40(4) (2019): 918-926. </li>\r\n\r\n\r\n  <li>Gallun, F.J., et al., &ldquo;Development and  validation of portable automated rapid testing (PART) measures for auditory research.&rdquo; Proc Meet Acoust. 33(1) (2018):  050002. </li>\r\n  <li>Olson, A.D. ,&ldquo;Options for auditory training for adults with hearing  loss.&rdquo; Semin Hear. 36(4) </li>\r\n\r\n(2015): 284-295. \r\n\r\n  <li>Keith, W.J., et  al., &ldquo;New   Zealand  guidelines   on auditory  processing disorder.&rdquo; New Zealand Audiological Society. (2019). </li>\r\n\r\n</ol>',NULL,'2022-11-10'),(7,5389,'ajchr','http://www.andrewjohnpublishing.com/','','<h4>Hearing Intervention in Early Years</h4>\r\n<p><strong>Ruchita Mehta<sup><a href=\"#corr\">*</a></sup></strong></p>\r\n<p>RCI registered, International Affiliation ASHA, Lifetime membership ISHA &amp; MISHA, India</p>\r\n<p>*risetoshine.slp@gmail.com</p>\r\n<h4>EDITORIAL</h4>\r\n<p>Surely, early intervention does make a\r\n  difference in the life of young ones with\r\n  special needs, once it is detected. Parents\r\n  of special children are also aware of the\r\n  importance of timely intervention. But\r\n  what if despite all the awareness of the\r\n  special needs and efforts taken by the\r\n  parents, things don&rsquo;t go as planned for\r\n  that special young one? Who and where\r\n  should we pick to put a finger on? Is it\r\n  our system where not many concrete\r\n  regulations are in place in medical world?\r\n  Is it lack of funding due to which we don&rsquo;t\r\n  have enough instruments and man power\r\n  to take the responsibility of achieving the\r\n  goals of early intervention? Or is it the\r\n  personnel handling the case on hand, and\r\n  their lack of motivation to handle the\r\n  many pending cases waiting in queue? Pick\r\n  one or all the reasons from the above to\r\n  suit the best explanation, but nothing\r\n  justifies to the loss of timely intervention\r\n  to this young one with Down&rsquo;s syndrome.</p>\r\n<p>Hearing impairment is one of the\r\n  conditions that may not be detected at\r\n  the time of birth. Also, not many hospitals\r\n  are equipped to provide neonatal\r\n  hearing screening. In such cases, hearing\r\n  impairment is not detected until sometime\r\n  after birth and thus, loosing many early\r\n  years of hearing intervention. A variety\r\n  of autosomal chromosome abnormalities\r\n  can affect not only hearing channels but\r\n  also communication development. One\r\n  such case is of Down&rsquo;s syndrome, Down&rsquo;s\r\n  syndrome appears in about 1 of every 800\r\n  live births in United States. Besides, the\r\n  symptoms of hypotonia, mild to moderate\r\n  mental retardation, characteristic facial\r\n  features, and hyper flexibility of joints,\r\n  there are ear abnormalities such as small\r\n  ear canals and may have conductive or\r\n  sensorineural hearing loss or both related\r\n  to Otitis Media. With already so much\r\n  going on, what if the child is missed out\r\n  on getting provision of hearing screening\r\n  at the time of birth in a hospital setting.\r\n  To add to this plight, when the child is\r\n  brought for hearing tests, at the age of 3\r\n  years, and once again his hearing abilities\r\n  are not confirmed in a private practice\r\n  setting. So much is lost on the way to\r\n  its speech, language and communication\r\n  development and also in the journey of\r\n  getting adequate treatment options.\r\n  Even if hearing ability could not be\r\n  confirmed at the time of testing, there are\r\n  ways to handle the case in many pending\r\n  cases waiting in queue-</p>\r\n<p>1. The parents of the child should have\r\n  been given counseling on the testing\r\n  results.</p>\r\n<p>2. The personnel should have counseled\r\n  to the parents to do home- training of\r\n  conditioning the child and re-scheduling\r\n  for another appointment of hearing\r\n  testing.</p>\r\n<p>3. Despite all the efforts failing with PTA,\r\n  personnel could have chosen another\r\n  hearing test from the various battery\r\n  of hearing tests that have come into\r\n  existence in today&rsquo;s time.</p>\r\n<p>So much could have been done in this\r\n  case; however, it was just left alone with\r\n  no concrete report nor help. After all the\r\n  ordeal of last 5 years, the child is brought\r\n  for speech therapy, he is 8 years old now\r\n  and is finally going for a thorough hearing\r\n  check- up, hoping that there wouldn&rsquo;t\r\n  be any hidden hearing impairment and\r\n  further loss of time.</p>\r\n<h4>Cochlear Implantation in Patients with Special\r\n  Situation</h4>\r\n<p><strong>Hisashi Sugimoto1, Makoto Ito2, Miyako Hatano1, Hiroki Hasegawa1, Masao Noda1, Tomokazu Yoshizaki1*</strong></p>\r\n<p><sup>1</sup><a name=\"a1\" id=\"a1\"></a>Department of Otolaryngology-Head and Neck Surgery, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan</p>\r\n<p><sup>2</sup><a name=\"a2\" id=\"a2\"></a>Pediatric Otolaryngology, Jichi Children\'s Medical Center Tochigi, Jichi Medical University</p>\r\n<p>*tomoy@med.kanazawa-u.ac.jp.</p>\r\n<h4>Abstract</h4>\r\n<p>Objectives: We have been using the &quot;Subtotal petrosectomy&quot; or &quot;Canal wall down mastoidectomy&quot; technique\r\n  for the cochlear implantation of difficult cases. We also added the &quot;Blind sac closure of external auditory\r\n  canal (EAC)&quot; and &quot;Middle ear and mastoid Obliteration by abdominal fat&quot; technique as necessary.</p>\r\n<p>Methods: Retrospective analysis of seven special cases of cochlear implantation was carried out. The detailed\r\n  breakdown of the cases is as follows: Post radical mastoidectomy -- 2 cases, Adhesive otitis media\r\n  -- 1 case, Eosinophilic otitis media -- 2 cases, Temporal bone malformation -- 2 cases. Complications,\r\n  hearing threshold results, word recognition, and bleeding were analyzed.</p>\r\n<p>Results: For one of the cases of Post radical mastoidectomy, the patient suffered from a breakdown\r\n  of the EAC closure. The hearing threshold following the procedures ranged from 25 to 35 dB with an\r\n  average of 30.3dB. The word recognition results were 0 to 96% with an average of 60% and sentence\r\n  recognition results ranged from 0 to 100% with an average of 62%. The volume of blood loss ranged\r\n  between less than 5 mL and 170 mL.</p>\r\n<p>Conclusuons: The combination of these techniques has potential to be effective for the cochlear\r\n  implantation of such difficult cases.</p>\r\n<h4>KEYWORDS</h4>\r\n<p>Petrosectomy, Cochlear\r\n  implantation, Auditory canal, Post radical\r\n  mastoidectomy</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>Patients with profound hearing loss\r\n  are able to acquire the ability to hear\r\n  by receiving an operation to emplace\r\n  a cochlear implant, and this result in a\r\n  remarkable improvement in their quality\r\n  of life. As of this time, many patients have\r\n  enjoyed the benefits of this procedure.\r\n  For patients in which the middle and inner\r\n  ear present a normal form and in which\r\n  there is no pathological change to the\r\n  temporal bone, the classical facial recess\r\n  technique is usually used with extremely\r\n  few resultant complications. Previous\r\n  studies of the classic technique report\r\n  major complication rates of between\r\n  3.0 and 13.7% [<a href=\"#1\" title=\"1\">1</a>-<a href=\"#4\" title=\"4\">4</a>]. On the other hand,\r\n  there are quite a few difficult cases for\r\n  which classical facial recess technique for\r\n  cochlear implant cannot be employed. Fisch\r\n  et al. proposed subtotal petrosectomy in\r\n  1988, and five years after that Parnes et\r\n  al. employed this approach for the first\r\n  time in a difficult cochlear implant case.\r\n  This procedure involved a closure of the\r\n  external auditory canal (EAC) and the\r\n  Eustachian tube and obliteration of the\r\n  surgical cavity. Following this case, this\r\n  procedure became the standard cochlear\r\n  implant method used for difficult cases,\r\n  and this in turn has led to debate over the\r\n  usefulness and safety of the procedure\r\n  [<a href=\"#5\" title=\"5\">5</a>-<a href=\"#14\" title=\"14\">14</a>]. However, since the total number\r\n  of cases is small, the validity and safety\r\n  cannot be irrefutably established. Thus, it\r\n  is extremely important to ascertain the as\r\n  of yet hypothetical usefulness and safety\r\n  for patients undergoing such special\r\n  cases of cochlear implant procedures. In\r\n  this report we present our experiences\r\n  with seven such special cases of cochlear\r\n  implants. In this report we wish to\r\n  contribute further to the investigation\r\n  about the safety and suitability so that\r\n  even if only by a small amount more\r\n  patients with difficult cases can enjoy the\r\n  benefit of cochlear implant.</p>\r\n<h4> MATERIAL AND METHODS\r\n  PATIENTS</h4>\r\n<p>We did a retrospective analysis of seven\r\n  special cases of cochlear implantation\r\n  carried out in the Department of\r\n  Otorhinolaryngology at the Kanazawa\r\n  University Hospital between 2012\r\n  and 2016. The detailed breakdown of\r\n  the cases is as follows: Post radical\r\n  mastoidectomy -- 2 cases, Adhesive otitis\r\n  media -- 1 case, Eosinophilic otitis media\r\n  -- 2 cases, Temporal bone malformation\r\n  -- 2 cases (<strong>Table 1</strong>). For the two cases\r\n  of eosinophilic otitis media subtotal\r\n  petrosectomy, cochlear implantation,\r\n  and obliteration of the mastoid using\r\n  abdominal fat was carried out (<strong>Fig. 1</strong>).</p>\r\n<div class=\"table-responsive\">\r\n  <table class=\"table table-sm table-bordered\">\r\n    <thead>\r\n      <tr>\r\n        <th>Patient</th>\r\n        <th>Age</th>\r\n        <th>Sex</th>\r\n        <th>Side</th>\r\n        <th>Etilogy</th>\r\n        <th>Operative procedure</th>\r\n        <th>Complications</th>\r\n        <th>Bleeding</th>\r\n        <th>Implant</th>\r\n        <th>Electrode outside cochlear</th>\r\n        <th>Hearing threshold before CI</th>\r\n        <th>Hearing threshold after    CI</th>\r\n        <th>Speech preception (CI2004)</th>\r\n        <th>Follow up </th>\r\n      </tr>\r\n    </thead>\r\n    <tbody>\r\n      <tr>\r\n        <td>1</td>\r\n        <td>69</td>\r\n        <td>F</td>\r\n        <td>Lt</td>\r\n        <td>Redical cavity</td>\r\n        <td>Simple    suture of EAC Canal    wall<br />\r\n          mastoidectomy closure<br />\r\n          of the eustachian tube</td>\r\n        <td>Suture failuer of EAC</td>\r\n        <td>100 ml</td>\r\n        <td>&nbsp;\r\n          Cochlear CI24</td>\r\n        <td>0/22</td>\r\n        <td>105dB</td>\r\n        <td>30dB</td>\r\n        <td>Word 48% Sentense 61%</td>\r\n        <td>45M</td>\r\n      </tr>\r\n      <tr>\r\n        <td>2</td>\r\n        <td>72</td>\r\n        <td>M</td>\r\n        <td>Rt</td>\r\n        <td>Redical cavity</td>\r\n        <td>Blind sac closure to EAC    Canal wall down    mastoidectomy<br />\r\n          middle ear and mastoid obliteration by abdominal fat closure of<br />\r\n          the eustachian tube</td>\r\n        <td>No</td>\r\n        <td>&lt;5 ml</td>\r\n        <td>Cochlear CI24</td>\r\n        <td>0/22</td>\r\n        <td>105dB</td>\r\n        <td>28dB</td>\r\n        <td>Word 60% Sentense 40%</td>\r\n        <td>31M</td>\r\n      </tr>\r\n      <tr>\r\n        <td>3</td>\r\n        <td>79</td>\r\n        <td>M</td>\r\n        <td>Lt</td>\r\n        <td>atelectasis</td>\r\n        <td>Subtotal petrosectomy blind sac closure of EAC middle ear and mastoid obliteration by abdominal    fat closure of the eustachian tube</td>\r\n        <td>No</td>\r\n        <td>&lt;5 ml</td>\r\n        <td>Cochlear CI24</td>\r\n        <td>0/22</td>\r\n        <td>103.8dB</td>\r\n        <td>25dB</td>\r\n        <td>Word 64% Sentense 71%</td>\r\n        <td>21M</td>\r\n      </tr>\r\n      <tr>\r\n        <td>4</td>\r\n        <td>64</td>\r\n        <td>M</td>\r\n        <td>Lt</td>\r\n        <td>Eosinophilic otitis media</td>\r\n        <td>Subtotal petrosectomy blind sac closure of EAC middle ear and mastoid obliteration by abdominal    fat closure of the eustachian tube</td>\r\n        <td>No</td>\r\n        <td>170 ml</td>\r\n        <td>Cochlear CI24</td>\r\n        <td>0/22</td>\r\n        <td>105dB</td>\r\n        <td>30dB</td>\r\n        <td>Word 96% Sentense 91%</td>\r\n        <td>31M</td>\r\n      </tr>\r\n      <tr>\r\n        <td>5</td>\r\n        <td>71</td>\r\n        <td>M</td>\r\n        <td>Rt</td>\r\n        <td>Eosinophilic otitis media</td>\r\n        <td>Subtotal petrosectomy blind sac closure of EAC middle ear and mastoid obliteration by abdominal    fat closure of the eustachian tube</td>\r\n        <td>No</td>\r\n        <td>50 ml</td>\r\n        <td>Cochlear CI24</td>\r\n        <td>0/22</td>\r\n        <td>102.5dB</td>\r\n        <td>34dB</td>\r\n        <td>Word 60% Sentense 71%</td>\r\n        <td>18M</td>\r\n      </tr>\r\n      <tr>\r\n        <td height=\"103\">6</td>\r\n        <td>9</td>\r\n        <td>M</td>\r\n        <td>Lt</td>\r\n        <td>Inner ear Malformation</td>\r\n        <td>Blind sac closure of EAC Canal wall down mastoidectomy</td>\r\n        <td>No</td>\r\n        <td>50 ml </td>\r\n        <td>Cochlear CI24</td>\r\n        <td>0/22</td>\r\n        <td>105dB</td>\r\n        <td>35dB</td>\r\n        <td>Word 0% Sentense 0%</td>\r\n        <td>57M</td>\r\n      </tr>\r\n      <tr>\r\n        <td>7</td>\r\n        <td>41</td>\r\n        <td>M</td>\r\n        <td>Rt</td>\r\n        <td>Inner ear Malformation</td>\r\n        <td>Blind sac closure of EAC Canal wall down mastoidectomy</td>\r\n        <td>No</td>\r\n        <td>&lt;5 ml</td>\r\n        <td>Cochlear CI24</td>\r\n        <td>0/22</td>\r\n        <td>97.5dB</td>\r\n        <td>30dB</td>\r\n        <td>Word 2% Sentense 100%</td>\r\n        <td>52M</td>\r\n      </tr>\r\n    </tbody>\r\n  </table>\r\n</div>\r\n<p><strong>Table 1.</strong> Summary of seven special cases.</p>\r\n<p>For one of the two cases of post radical\r\n  mastoidectomy closure of the external\r\n  auditory canal using blind sac closure,\r\n  cochlear implantation, and obliteration\r\n  of the mastoid using abdominal fat were\r\n  carried out (<strong>Fig. 2</strong>). For the other case of\r\n  Post radical mastoidectomy, the external\r\n  auditory canal was closed, but blind sac\r\n  closure was not used. Mastoid obliteration\r\n  was also not performed. For a case of\r\n  Adhesive otitis media, canal wall down\r\n  mastoidectomy, cochlear implantation, and mastoid obliteration using abdominal\r\n  fat were carried out. For the two cases of\r\n  Temporal bone malformation, closure of\r\n  the external auditory canal using blind sac\r\n  closure, canal wall down mastoidectomy\r\n  and cochlear implantation were carried out. Obliteration of the mastoid was\r\n  not carried out. Complications, hearing\r\n  threshold results, word recognition, and\r\n  bleeding were the four items analyzed\r\n  in these seven cases. Permission for this\r\n  retrospective study was obtained from\r\n  the Kanazawa University Hospital, the\r\n  local Ethics Committee approved the\r\n  study protocol. Informed written consent\r\n  was obtained from all patients.</p>\r\n<div class=\"well well-sm\">\r\n  <div class=\"row\">\r\n    <div class=\"col-xs-12 col-md-2\" height=\"103\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-patient-13-1-1-g001.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-patient-13-1-1-g001.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-patient\" title=\"canadian-hearing-report-patient\" /></a></div>\r\n    <div class=\"col-xs-12 col-md-10\">\r\n      <p><strong>Fig 1.</strong> Left ear of patient 4 after subtotal petrosectomy. A good field of view and ample working space was ensured.</p>\r\n    </div>\r\n  </div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n  <div class=\"row\">\r\n    <div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Postoperative-13-1-1-g002.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Postoperative-13-1-1-g002.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Postoperative\" title=\"canadian-hearing-report-Postoperative\" /></a></div>\r\n    <div class=\"col-xs-12 col-md-10\">\r\n      <p><strong>Fig 2.</strong> Postoperative CT scan of Patient 2 (right ear).</p>\r\n    </div>\r\n  </div>\r\n</div>\r\n<h4> RESULTS</h4>\r\n<p>The average period of observation was\r\n  36.4 months. Six of the patients were\r\n  male, and one was female. Patient age\r\n  ranged from nine to 79 years with and\r\n  average age of 57.9. All of the surgical\r\n  techniques employed in each case were\r\n  carried out as one combined operation.\r\n  For all of the cases cochlear implantation\r\n  was performed using Cochlear CI24 with\r\n  zero electrodes outside of the cochlear.\r\n  For one of the cases of Post radical\r\n  mastoidectomy the patient suffered a\r\n  breakdown of the EAC closure. In this\r\n  case ear discharge continued for three\r\n  months following the procedure, but this\r\n  complication disappeared with the EAC\r\n  finally closing again naturally. In this case\r\n  blind sac closure was not performed\r\n  and the middle ear and the mastoid\r\n  were not obliterated. There were no\r\n  complications in any of the other cases.\r\n  Hearing threshold results following the\r\n  procedures ranged from 25 to 35dB with\r\n  an average of 30.3dB. Word recognition\r\n  results were 0 to 96% with an average\r\n  of 60% in the case of words, and 0 to\r\n  100% with an average of 62% in the case\r\n  of sentences. The volume of blood loss varied between less than 5 mL and 170\r\n  mL. Blood transfusion was not required in\r\n  any of the cases.</p>\r\n<h4> DISCUSSION</h4>\r\n<p>We have used the &quot;Subtotal petrosectomy&quot;\r\n  or &quot;Canal wall down mastoidectomy&quot;\r\n  technique to approach for kinds of difficult\r\n  cases related to cochlear implantation.\r\n  A detailed discussion of the cochlear\r\n  implant technique as it was applied in\r\n  each of these four clinical states follows.</p>\r\n<h4> EARS AFTER RADICAL\r\n  MASTOIDECTOMY</h4>\r\n<p>Of the two cases of ears following radical\r\n  mastoidectomy in this study, there was\r\n  a suture failure of the EAC in the first\r\n  case. In this case we didn\'t use the blind\r\n  sac closure technique when suturing the\r\n  EAC. Furthermore, obliteration of the\r\n  mastoid was not carried out. Since the\r\n  diameter of the EAC following radical\r\n  mastoidectomy is larger as compared to\r\n  that of a normal EAC, a simple suturing\r\n  of the EAC may lead to imperfect closure.\r\n  Fisch considered the EAC suturing using\r\n  blind sac closure to be a safe, effective\r\n  procedure [<a href=\"#15\" title=\"15\">15</a>]. It is also an advisable\r\n  application when carrying out cochlear\r\n  implantations in radical cavities. In the\r\n  second case, the lateral semicircular\r\n  canal in the right ear had been destroyed\r\n  in a previous operation. Prior to this\r\n  operation a caloric test was conducted\r\n  and CP (canal paresis) was pointed out.\r\n  Due to this and in order to preserve\r\n  vestibular function, an operation was\r\n  carried out on the previously destroyed\r\n  lateral semicircular canal in the right ear.\r\n  The period of hearing loss in the right ear\r\n  had been long, but following the operation\r\n  an improvement in the hearing level of up\r\n  to 25dB was attained. The canal paresis\r\n  on the right side caused a remarkable\r\n  reduction in the patient\'s QOL. Therefore,\r\n  despite the long period of hearing loss, it\r\n  is recommended to proceed with caution.</p>\r\n<h4> ADHESIVE OTITIS MEDIA</h4>\r\n<p>Xenellis et al. reported about cochlear\r\n  implantations for four patients who were\r\n  suffering from adhesive otitis media.\r\n  They concluded that Blind-sac closure\r\n  of the external auditory canal without\r\n  obliteration is a rather safe surgical\r\n  procedure in cases with atelectasis, and\r\n  a 2-stage procedure may not always\r\n  be necessary and indeed might best be\r\n  limited to those patients who have active\r\n  inflammatory disease at the time of\r\n  the primary procedure [<a href=\"#16\" title=\"16\">16</a>]. The cases\r\n  that we dealt with in this study had no\r\n  inflammation, so the operations were\r\n  carried out as single, comprehensive\r\n  procedures. There were no complications\r\n  in these cases. The difference between\r\n  our cases and those reported by Xenellis\r\n  et al. was as concerns the inclusion of\r\n  Mastoid obliteration. We perform mastoid\r\n  obliteration to prevent hemorrhage\r\n  effusion and prevent infection in the\r\n  post-operative dead space. However, we\r\n  believe that the most important purpose\r\n  of mastoid obliteration is to counter\r\n  post-operative spinal fluid leakage. It is\r\n  not necessarily always required to take\r\n  these precautions in cases of adhesive\r\n  otitis media in which these risks are not\r\n  present. In order to determine which is best, more reports from further cases are\r\n  required. In the cases related to this study\r\n  a caloric test was carried out, the absence\r\n  of canal paresis was confirmed, and the\r\n  operative side was selected. Similar to\r\n  the cases of mastoidectomy, we feel that\r\n  consideration of the vestibular function in\r\n  cases of adhesive otitis media is important\r\n  for selecting the operative side.</p>\r\n<h4> EOSINOPHILIC OTITIS MEDIA</h4>\r\n<p>In this study there were two cases\r\n  of eosinophilic otitis media for which\r\n  cochlear implantation was performed.\r\n  The surgical procedure was a subtotal\r\n  petrosectomy. The concepts of the\r\n  surgery consist of the following two\r\n  points: (i) Removal of mucosa from the\r\n  middle ear and the mastoid cavity as\r\n  completely as possible in order to remove\r\n  the theater of eosinophilic infiltration;\r\n  (ii) Closure of the Eustachian tube and\r\n  the external auditory canal in order to\r\n  prevent leaching of foreign substances\r\n  and entry of stimuli which are the cause\r\n  of eosinophilic inflammations. There\r\n  were no complications or recurrent\r\n  inflammation following surgery in the\r\n  cases of both patients. Following the\r\n  procedure, the hearing threshold results\r\n  of the two patients were 30dB and 34dB\r\n  [<a href=\"#17\" title=\"17\">17</a>]. This is the first discussion focusing\r\n  on cochlear implantations for cases\r\n  of eosinophilic otitis media. To further\r\n  confirm the efficacy and safety of our\r\n  surgical concept, we need to administer\r\n  this treatment concept for a larger\r\n  number of cases in a future study.</p>\r\n<h4> TEMPORAL BONE MALFORMATION</h4>\r\n<p>As for the cases of temporal bone\r\n  malformation, because the anatomical\r\n  landmark cannot be trusted, the\r\n  identification of the place to open the\r\n  cochlea is problematic. Furthermore, in\r\n  cases of temporal bone malformation\r\n  it has been reported that carrying\r\n  out the cochleostomy can result in\r\n  gushers. Therefore, for temporal bone\r\n  malformation cases we feel it is critical to\r\n  ensure that there is a good operative field\r\n  of view and ample working space. Canal\r\n  wall down mastoidectomy technique\r\n  resolves these two problems. Mistakes in\r\n  the location for opening the cochlea are\r\n  reduced. What\'s more, the measures for\r\n  dealing with gushers become much easier. </p>\r\n<p>In the first temporal bone malformation\r\n  case in this study, the first operation\r\n  employed was a classical facial recess\r\n  technique. However, due to a traveling\r\n  abnormality of the facial nerve and a\r\n  deformity in the inner ear, we couldn\'t\r\n  identify the location to open the cochlea.\r\n  In the second operation a subtotal\r\n  petrosectomy was employed resulting\r\n  in a good operative field of view. Thus,\r\n  we could open the cochlea. Therefore,\r\n  we think that in cases of temporal\r\n  bone malformation this canal wall down\r\n  technique is extremely useful for cochlear\r\n  implantation.</p>\r\n<h4> SUBTOTAL PETROSECTOMY\r\n  AND CANAL WALL DOWN\r\n  MASTOIDECTOMY</h4>\r\n<p>Ensuring a good operative field and\r\n  ample working space are two common,\r\n  important points when performing\r\n  cochlear implantation for special cases.\r\n  Use of subtotal petrosectomy and canal\r\n  wall down mastoidectomy can overcome\r\n  difficulties related to these two points.\r\n  Also, closure of the Eustachian tube\r\n  and the EAC can isolate them from the\r\n  exterior preventing operation related\r\n  infection [<a href=\"#18\" title=\"18\">18</a>]. Thus we feel that for\r\n  special cases this is a useful procedure.</p>\r\n<h4> STAGED OPERATION</h4>\r\n<p>Linder et al. recommended a staged\r\n  operation for cases with the following\r\n  four conditions: 1. Suppurative and\r\n  continuously draining otitis media, 2.\r\n  Previous tympanomastoid surgeries\r\n  with &quot;unstable&quot; disease, 3. Extended\r\n  cholesteatomas, and 4. Previously\r\n  irradiated temporal bone [<a href=\"#14\" title=\"14\">14</a>]. We\r\n  regard this strategy as appropriate. For\r\n  the cases in this study none of these\r\n  four conditions applied. Thus, a single\r\n  operation was selected. There were no\r\n  severe complications.</p>\r\n<h4> MASTOID OBLITERATION</h4>\r\n<p>Whether or not to employ mastoid\r\n  obliteration is an essential topic that must\r\n  be discussed. In cases where mastoid\r\n  obliteration is employed, the choice of the\r\n  obliterating materials is also an important\r\n  issue. We feel that it is necessary to fill\r\n  the mastoid space in cases for which\r\n  post-operative inflammation is possible.\r\n  We especially feel that in cases in which dura mater is exposed or in which\r\n  there is CSF leakage, filling the mastoid\r\n  space is necessary. Following radical\r\n  mastoidectomy, eosinophilic otitis media,\r\n  and adhesive otitis media, amongst\r\n  other conditions, it is favorable to fill the\r\n  mastoid space to prevent inflammation\r\n  caused by exuded liquid or blood. On\r\n  the other hand, in cases such as temporal\r\n  bone malformation in which there has\r\n  been no inflammation and the dura\r\n  mater or CSF leakage is not occurring,\r\n  filling the mastoid space is not necessary.\r\n  Previous reports indicate that for blood\r\n  flow in the temporal muscle, abdominal\r\n  fat is the filling material used. Hellingman\r\n  suggests that the most suitable material\r\n  to obliterate the cavity appears to be\r\n  abdominal fat because of its resistance\r\n  to necrosis and easy removal if cochlear\r\n  implantation is performed later. On the\r\n  other hand, Fisch et al. propose that, after\r\n  subtotal petrosectomy, if dura mater\r\n  exposure or CSF leakage are involved\r\n  and there is inflammation, then the\r\n  temporal muscle with blood flow or the\r\n  sternocleidomastoid muscle should be\r\n  adopted [<a href=\"#15\" title=\"15\">15</a>]. For our cases in this study\r\n  there was no exposure of dura mater\r\n  nor was there any CSF leakage involved,\r\n  so abdominal fat was adopted as the\r\n  filling material, and there were no postoperative\r\n  complications.</p>\r\n<h4> VESTIBULAR FUNCTION</h4>\r\n<p>When selecting on which side to perform\r\n  the procedure, evaluation of the vestibular\r\n  function is essential. Especially in cases of\r\n  Radical cavity or ears following inner ear\r\n  procedures, it is necessary to administer\r\n  the caloric test and confirm the presence\r\n  or absence of paralysis of the semicircular\r\n  canal. Bilateral loss of vestibular function\r\n  is a complication that must be avoided,\r\n  and we believe this takes priority over\r\n  post-operative hearing acquisition. We\r\n  think that compared to more mainstream\r\n  cases, cochlear implantation following\r\n  radical mastoidectomies and other\r\n  special cases can result in a higher risk of\r\n  deterioration of vestibular function, so as\r\n  much as possible it is necessary to make\r\n  pre-operative evaluations.</p>\r\n<h4> CONCLUSION</h4>\r\n<p>We have performed cochlear\r\n  implantations in cases of Radical cavity Adhesive otitis media&#12289;Eosinophilic otitis\r\n  media, and Temporal bone malformation.\r\n  For all of the cases subtotal petrosectomy\r\n  or canal wall down mastoidectomy was\r\n  applied. We also added the &quot;Blind sac\r\n  closure of EAC&quot; and &quot;Middle ear and\r\n  mastoid Obliteration by abdominal fat&quot;\r\n  technique as necessary. As a result of the\r\n  combination of these methods, a good\r\n  field of view and ample working space\r\n  were ensured. Except for EAC breakdown,\r\n  there were no complications. Hearing\r\n  threshold results and word recognition\r\n  were markedly improved following the\r\n  operation, and blood loss volume was\r\n  extremely small. In the future we hope\r\n  to increase the number of patients with\r\n  special cases who will receive the benefits\r\n  of this cochlear implant method.</p>\r\n<h4> REFERENCES</h4>\r\n<ol>\r\n  <li id=\'Reference_Title_Link\' value=\'1\'><a name=\'1\' id=\'1\'></a><a href=\'https://doi.org/10.1017/s002221510014602x\' target=\'_blank\'>Proops DW, Stoddart  RL, Donaldson I (1999) Medical, surgical and audiological complications of the  first 100 adult cochlear implant patients in Birmingham. The Journal of  Laryngology &amp; Otologyy 113: 14-17.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'2\'><a name=\'2\' id=\'2\'></a><a href=\'https://www.ncbi.nlm.nih.gov/pubmed/7668733\' target=\'_blank\'>Hoffman RA, Cohen  NL (1995) Complications of cochlear implant surgery. The Annals of otology,  rhinology &amp; laryngology. Supplement 166: 420- 422.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'3\'><a name=\'3\' id=\'3\'></a><a href=\'https://doi.org/10.1017/s0022215100137235\' target=\'_blank\'>Collins MM,  Hawthorne MH, El-Hmd K (1997) Cochlear implantation in a district general  hospital: problems and complications in the first five years.The Journal of  Laryngology &amp; Otology 111: 325-332.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'4\'><a name=\'4\' id=\'4\'></a><a href=\'https://doi.org/10.1159/000058982\' target=\'_blank\'>Aschendorff A, Marangos N,  Laszig R (1997) Complications and reimplantation. Advances in  Oto-Rhino-Laryngology 52: 167-170.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'5\'><a name=\'5\' id=\'5\'></a><a href=\'https://doi.org/10.1007/s00405-008-0828-0\' target=\'_blank\'>Hellingman CA,  Dunnebier EA (2009) Cochlear implantation in patients with acute or chronic  middle ear infectious disease: a review of the literature. European Archives of  Oto-Rhino- Laryngology 266: 171-176</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'6\'><a name=\'6\' id=\'6\'></a><a href=\'https://doi.org/10.1097/mao.0b013e3182a006b6\' target=\'_blank\'>Baranano CF,  Kopelovich JC, Dunn CC, Gantz BJ, Hansen MR (2013) Subtotal petrosectomy and  mastoid obliteration in adult and pediatric cochlear implant recipients.  Otology &amp; Neurotology 34: 1656-1659.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'7\'><a name=\'7\' id=\'7\'></a><a href=\'https://doi.org/10.1007/s00405-004-0907-9\' target=\'_blank\'>Basavaraj S, Shanks  M, Sivaji N, Allen AA (2005) Cochlear implantation and management of chronic  suppurative otitis media: single stage procedure?. European Archives of  Oto-Rhino- Laryngology 262: 852-855.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'8\'><a name=\'8\' id=\'8\'></a><a href=\'https://doi.org/10.1067/mhn.2002.129822\' target=\'_blank\'>Pasanisi E, Vincenti  V, Bacciu A, Guida M, Berghenti T et al. (2002) Multichannel cochlear  implantation in radical mastoidectomy cavities. Otolaryngology-Head and Neck  Surgery 127: 432-436.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'9\'><a name=\'9\' id=\'9\'></a><a href=\'https://doi.org/10.1159/000422560\' target=\'_blank\'>Babighian, G (1993) Problems  in cochlear implant surgery.Advances in Oto-Rhino-Laryngology, 48: 65-69.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'10\'><a name=\'10\' id=\'10\'></a><a href=\'https://doi.org/10.1017/s0022215100136977\' target=\'_blank\'>Axon PR, Mawman DJ,  Upile T, Ramsden RT (1997) Cochlear implantation in the presence of chronic  suppurative otitis media. The Journal of Laryngology &amp; Otology 111: 228-232</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'11\'><a name=\'11\' id=\'11\'></a><a href=\'https://doi.org/10.1097/01.mao.0000265187.45216.71\' target=\'_blank\'>Leung, R,  Briggs RJ (2007) Indications for and outcomes of mastoid obliteration in  cochlear implantation. Otology &amp; Neurotology 28: 330- 334.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'12\'><a name=\'12\' id=\'12\'></a><a href=\'https://doi.org/10.1055/s-2008-1058571\' target=\'_blank\'>Issing PR, Schonermark  MP,Winkelmann S, Kempf HG, Ernst A (1998) Cochlear implantation in patients  with chronic otitis: indications for subtotal petrosectomy and obliteration of  the middle ear. Skull base surgery 8: 127-131</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'13\'><a name=\'13\' id=\'13\'></a><a href=\'https://doi.org/10.1177/0003489415620427\' target=\'_blank\'>Polo R, Del Mar  Medina M, Ar&iacute;stegui M, Lassaletta L, Gutierrez A, et al. (2015) Subtotal  Petrosectomy for Cochlear Implantation: Lessons Learned After 110 Cases. The  Annals of otology, rhinology, and laryngology 25: 485- 494</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'14\'><a name=\'14\' id=\'14\'></a><a href=\'https://doi.org/10.1007/s00405-015-3573-1\' target=\'_blank\'>Szymanski M, Ataide  A, Linder T (2016) The use of subtotal petrosectomy in cochlear implant  candidates with chronic otitis media. European archives of oto-rhino-laryngology  273: 363- 370.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'15\'><a name=\"15\" id=\'15\'></a>Fisch U, Mattox, D (1998) Microsurgery of the skull base.Thieme. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'16\'><a name=\'16\' id=\'16\'></a><a href=\'https://doi.org/10.1097/mao.0b013e31816a8986\' target=\'_blank\'>Xenellis J,  Nikolopoulos TP, Marangoudakis P, Vlastarakos PV, Tsangaroulakis A, et al.  (2008) Cochlear implantation in atelectasis and chronic otitis media: long-term  follow-up.&quot; Otology &amp; neurotology 29: 499-501</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'17\'><a name=\'17\' id=\'17\'></a><a href=\'https://doi.org/10.1007/s00405-016-4091-5\' target=\'_blank\'>Sugimoto H, Hatano  M, Noda M, Hasegawa H, Yoshizaki T (2016) Cochlear implantation in deaf  patients with eosinophilic otitis media using subtotal petrosectomy and mastoid  obliteration. European archives of oto-rhino-laryngology 274: 1173-1177.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'18\'><a name=\'18\' id=\'18\'></a><a href=\'https://doi.org/10.1177/0003489415620427\' target=\'_blank\'>Polo R, Del Mar Medina M,  Ar&iacute;stegui M, Lassaletta L, Gutierrez A, et al. (2015) Subtotal Petrosectomy for  Cochlear Implantation: Lessons Learned After 110 Cases. The Annals of otology,  rhinology, and laryngology 125 (2015): 485-494.</a></li>\r\n</ol>\r\n<h4>Central Vestibular Compensation</h4>\r\n<p><strong>Madalina Georgescu<sup><a href=\"#corr\">*</a></sup></strong></p>\r\n<p>University of Medicine and Pharmacy &lsquo;Carol Davila&rsquo; Bucharest, Romania</p>\r\n<p>*madalina.georgescu@gecad.com</p>\r\n<h4>ABSTRACT</h4>\r\n<p>Vestibular system is one of the three sensorial systems involved in equilibrium. Any lesion at this level has\r\n  consequences on quality of life, in terms of dizziness and/or disequilibrium or ataxia. Unilateral vestibular\r\n  loss (UVL) represents a stable permanent peripheral vestibular lesion with long-term effects and symptoms.\r\n  These symptoms are caused by lower than normal gains of vestibulo ocular and vestibulospinal\r\n  reflexes secondary to UVL. Central vestibular compensation is a natural healing model for UVL, based on\r\n  the neuroplasticity of the central vestibular structures. It is a long-lasting and incomplete phenomenon,\r\n  but it enables a comfortable daily life. It can be accelerated and enlarged by customised vestibular rehabilitation\r\n  programmes and appropriate drug treatment..</p>\r\n<h4>KEYWORDS</h4>\r\n<p>Unilateral vestibular\r\n  loss, Central vestibular compensation,\r\n  Neuroplasticity, Vestibular rehabilitation</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>Equilibrium is essential for normal daily\r\n  life. It allows normal walking, performing\r\n  basic activities (housekeeping, grocery,\r\n  and working) without risk of fall and\r\n  injury. Three sensorial systems are\r\n  involved in this process, a real network\r\n  based on normal sensorial input and good\r\n  matching in between the information:</p>\r\n<p>somatosensorial, visual and vestibular\r\n  system. Disequilibrium worsen the\r\n  health-related quality of life (HRQoL)\r\n  with a negative impact on their social\r\n  life and work performance, leading not\r\n  only to psychological damage (low selfconfidence,\r\n  depression, frustration), but\r\n  also economic losses (long medical leave,\r\n  poor concentration, and performance).</p>\r\n<p>Briefly, from anatomical point of view, it\r\n  is important to know that the peripheral\r\n  vestibular system includes five sensorial\r\n  structures for each inner ear, three\r\n  ampullary cristae and two maculae. The\r\n  ampullary crista is located in the ampule\r\n  of each semi-circular canal (horizontal,\r\n  superior and posterior) and senses\r\n  angular movements of head or body\r\n  due to their position-perpendicular one\r\n  to each other, so in all directions of the\r\n  three-dimensional space we are living\r\n  in. The maculae are located one in the\r\n  utricle and one in the saccule and senses linear movements due to the otolithic\r\n  membrane which increases specific\r\n  weight of the maculae, compared with\r\n  endolymph density (<strong>fig. 1</strong>).</p>\r\n<p>From these sensorial structures,\r\n  information is transmitted in the\r\n  vestibular nerve in a very specific\r\n  manner &ndash; horizontal and superior semicircular\r\n  canals ampullary cristae and\r\n  utricular macula are connected to the\r\n  superior vestibular nerve and posterior\r\n  semi-circular canal ampullary crista and\r\n  saccular macula are connected to the\r\n  inferior vestibular nerve (<strong>fig. 2</strong>).</p>\r\n<p>Vestibular nuclei are made up of a group\r\n  of neurons placed on the floor of the\r\n  IV ventricle, laterally bounded by the\r\n  restiform body, ventrally by the nucleus\r\n  and spinal tract of the trigeminal nerve,\r\n  and medially by the pontine reticular\r\n  substance. From the anatomical point\r\n  of view, four groups of neurons can be\r\n  identified: medial, lateral, superior and\r\n  inferior. Although there is overlapping,\r\n  most of the fibers in the utricle and\r\n  saccule reach the lateral and inferior\r\n  nuclei, and most of the fibers coming from\r\n  the semi-circular canals reach the upper\r\n  and middle nuclei.</p>\r\n<p>Vestibular nuclei receive information from the cerebellum, spinal cord, and adjacent\r\n  reticular substance, in addition to the\r\n  information received from the vestibular\r\n  afferent fibers projections. Also, there\r\n  are many commissural fibers linking the\r\n  two groups of vestibular nuclei (right and\r\n  left). Based on the combined connections\r\n  between afferent and afferent fibers, the\r\n  lateral and inferior vestibular nuclei are\r\n  important linking stations in vestibulospinal\r\n  reflex control, while upper and\r\n  middle nuclei are critical stations in the\r\n  control of vestibulo ocular reflexes (<strong>fig. 3</strong>). </p>\r\n<p>Vestibular system is anatomically\r\n  developed at birth, but it gets functional in\r\n  the child&rsquo;s first year of life. While getting\r\n  control on his neck muscles, crawling,\r\n  standing, and walking, vestibular cortex\r\n  develops reaction patterns specific to\r\n  each movement activity. Based on these\r\n  patterns, equilibrium is a subconscious\r\n  process as long as vestibular system works\r\n  normally and sense motion of head and\r\n  body and uses this information to control\r\n  movement and posture. This is based on\r\n  rest discharging rate from vestibular hair\r\n  cells and changes in firing rate secondary\r\n  to rotations which stimulates the inner towards the movement is performed and\r\n  inhibits the other ear (<strong>fig. 4</strong>).</p>\r\n<p>Vestibular lesions impede on this\r\n  normal reaction and patients experience\r\n  disequilibrium, vertigo or dizziness. Loss\r\n  of peripheral vestibular function induces\r\n  an asymmetry in vestibular sensorial\r\n  discharge (lesion in the inner ear) or in\r\n  vestibular ganglia cells activity (in neural\r\n  lesions). This asymmetry reaching the\r\n  vestibular nuclei level is interpreted\r\n  as a rotation towards the part with\r\n  higher activity, so vertigo sensation and\r\n  accompanying nystagmus appears.\r\n  In unilateral vestibular lesions (UVL)\r\n  a central process becomes available\r\n  &ndash; central compensation, which aims\r\n  regaining symmetry between the two\r\n  vestibular pathways.</p>\r\n<p>Vestibular system ensures equilibrium\r\n  by two different reflexes-vestibulocular\r\n  and vestibulospinal reflex which enables\r\n  an oculomotor effect (stable image\r\n  on the retina while movement), a\r\n  postural effect (head aligned with\r\n  body, vertical stance, and walking) and\r\n  also an appropriate cortical perception\r\n  (verticality, orientation in space). All these\r\n  three have to be taken into account when\r\n  assessing a vestibular lesion, because when\r\n  vestibular pathways become imbalanced,\r\n  they do not react fully to head, or body\r\n  movements and pathological symptoms\r\n  related to all three effects should be\r\n  addressed in management of UVL.</p>\r\n<p>There are three main categories of UVLstable\r\n  deficit (like vestibular neuritis),\r\n  fluctuant deficit (like in Meni&egrave;re disease)\r\n  and slowly progressive deficit (like in vestibular schwannoma/acoustic\r\n  neurinoma).</p>\r\n<p>Central vestibular compensation process\r\n  acts only in stable deficits with sudden\r\n  onset or progressive course and it is\r\n  visible and very important for recovery\r\n  in sudden UVL with total vestibular\r\n  impairment (complete vestibular neuritis,\r\n  for example). Fluctuant vestibular function\r\n  cannot trigger central compensation\r\n  because or irregular error signals coming\r\n  from the affected ear (Meni&egrave;re disease\r\n  or vestibular paroxismia). ENTE UVL\r\n  leads to two main different categories\r\n  of impairments: static and dynamic\r\n  vestibular deficit.</p>\r\n<p>Static deficits are present from the\r\n  very beginning of the lesion onset\r\n  due to asymmetry in vestibular nuclei\r\n  activity, are very severe as symptoms and\r\n  characteristic signs are present without\r\n  any head or body movement. They\r\n  resume completely at most in one week.\r\n  Static deficit signs are:</p>\r\n<p>&bull; Oculomotor reaction &ndash; spontaneous\r\n  nystagmus, skew-deviation (vertical\r\n  misalignment of the eyes).</p>\r\n<p>&bull; Postural reactions &ndash; postural asymmetry\r\n  (head and/or body tilt), ocular-tilt reaction\r\n  (<strong>fig. 5</strong>) (OTR=skew-deviation, head tilt\r\n  and ocular torsion), severe imbalance.</p>\r\n<p>&bull; Perception signs &ndash; vertigo, subjective\r\n  vertical deviation.</p>\r\n<p>Dynamic deficits appear due to\r\n  changings in the vestibular reflexes gain and\r\n  are present only during head movements.\r\n  Their highest degree of severity is at\r\n  one week after the UVL onset, but they last for longer periods (one year) and\r\n  might never by fully compensated in\r\n  the recovery process. For example, high\r\n  frequency movements of the head (over\r\n  2Hz) might always induce dizziness and\r\n  disequilibrium. Head-shaking induced\r\n  nystagmus is used to assess long-term\r\n  level of recovery of the UVL.</p>\r\n<p>Dynamic deficit signs are present from all\r\n  three vestibular effects mentioned:</p>\r\n<p>&bull; Oculomotor signs &ndash; diminished\r\n  vestibulocular reflex induces limitations\r\n  in head&rsquo;s velocity movements due to\r\n  movement-induced visual disturbances\r\n  and secondary dizziness.</p>\r\n<p>&bull; Postural signs &ndash; decreased gain of\r\n  vestibulospinal reflex leads to weaker\r\n  balance skills, ataxia, and gait disturbances\r\n  which all induce behavioural changes in\r\n  order to minimise the risk of fall: stance\r\n  becomes conscious, a voluntary act,\r\n  patients are more cautious while moving\r\n  and former daily activities like running,\r\n  jumping, high heights activity, sports in\r\n  general are limited.</p>\r\n<p>&bull; Perception signs of vestibular dynamic\r\n  deficit might include spatial disorientation,\r\n  oculo-gravitational illusions (objects\r\n  are tilted, corners appear rounded) or\r\n  incorrect perception of acceleration\r\n  (patients develop motion sickness).</p>\r\n<p>All these dynamic deficits lead to avoidance\r\n  behaviour to sudden or challenging\r\n  movements, difficulties in tender, subtle\r\n  or complex motor activities.</p>\r\n<p>Vestibular compensation, known as\r\n  central compensation is a central\r\n  nervous system process for physiological\r\n  healing after a vestibular deficit, aiming\r\n  to reinforce symmetry in vestibular pathways&rsquo; tone and to readjust the gain of\r\n  vestibular reflexes in order to equal gain\r\n  1, as in healthy persons. Of course, any\r\n  lesion of the central vestibular structures\r\n  involved in central compensation process\r\n  (vestibular nuclei, thalamus, limbic system,\r\n  vestibular cortical areas, or cerebellum)\r\n  impairs recovery of the UVL [<a href=\"#11\" title=\"1\">1</a>-<a href=\"#3\" title=\"3\">3</a>]. For this\r\n  reason, central vestibular compensation\r\n  research focussed mainly on peripheral\r\n  vestibular lesions.</p>\r\n<p>Vestibular central compensation is a\r\n  model of neuroplasticity phenomena\r\n  which allows spontaneous recovery\r\n  after a UVL (<strong>fig. 6</strong>). In complete unilateral\r\n  vestibular deficit, central compensation\r\n  is a long-lasting process (over three\r\n  month), imperfect and incomplete (high\r\n  acceleration or velocity head movements\r\n  are not always compensated). This natural\r\n  recovery process can be improved and\r\n  accelerated by vestibular rehabilitation\r\n  programmes and appropriate drug\r\n  treatment.</p>\r\n<p>In sudden UVL, the following changes\r\n  occur in the vestibular pathway [<a href=\"#4\" title=\"4\">4</a>-<a href=\"#9\" title=\"9\">9</a>]:</p>\r\n<p>A. High asymmetry between the two\r\n  vestibular nuclei complex in the acute\r\n  phase due to:</p>\r\n<p>a. Inactivity on the lesion side.</p>\r\n<p>b. Increased resting discharge rate on the\r\n  contralateral side due to lack of inhibitory\r\n  feedback from the injures side through\r\n  the flocculus (commissural inhibitory\r\n  inputs are removed by the UVL) [<a href=\"#10\" title=\"10\">10</a>,<a href=\"#11\" title=\"11\">11</a>].</p>\r\n<p>B. Regaining symmetry in vestibular nuclei\r\n  resting discharge by:</p>\r\n<p>a. Regeneration of a new basic discharge\r\n  on the lesion side through various\r\n  mechanisms [<a href=\"#12\" title=\"12\">12</a>,<a href=\"#13\" title=\"13\">13</a>]:</p>\r\n<p>i. Opening of existing synapses in the\r\n  ipsilateral peripheral vestibular structures.</p>\r\n<p>ii. New sprouting in the peripheral\r\n  vestibular pathway.</p>\r\n<p>iii. Recovery and maintenance of the\r\n  medial vestibular nucleus spontaneous\r\n  activity on the lesion side in chronic stage\r\n  of the UVL by slowing down the inhibitory\r\n  cerebellar activity and activation of the\r\n  vestibular-hypothalamic-vestibular loop.</p>\r\n<p>iv. Adaptive changes in the sensitivity of\r\n  central vestibular neurons to inhibitory\r\n  neurotransmitters.</p>\r\n<p>v. Changes in the intrinsic cell membrane\r\n  properties of the vestibular nuclei\r\n  neurons.</p>\r\n<p>vi. Higher density receptors on vestibular\r\n  nuclei surface; both last two mechanisms\r\n  reflect the internal rebalancing of the\r\n  vestibular brainstem related to internal\r\n  feedback loops.</p>\r\n<p>vii. Inhibition of the resting discharge rate\r\n  in contralateral medial vestibular nucleus\r\n  during acute phase of sudden UVL\r\n  through high cerebellar inhibitory signals.</p>\r\n<p>The effect of central compensation\r\n  differs greatly between static and dynamic\r\n  symptoms. Static oculomotor, postural and\r\n  perception signs are rapidly and completely\r\n  compensated due to important recovery\r\n  of spontaneous resting firing rate in the\r\n  ipsilateral vestibular nuclei, denervation\r\n  hypersensitivity to vestibular input in the\r\n  vestibular nucleus and greater reliance on\r\n  commissures, deep cerebellar nuclei, and\r\n  inferior olive. This occurs immediately\r\n  after the acute onset of the UVL and for\r\n  this reason patients must move their head\r\n  as soon as possible and they must not stay\r\n  still in bed more than 2-3 days after the\r\n  onset of the vestibular lesion.</p>\r\n<p>Dynamic symptoms evolution is very\r\n  different-in significant much longer\r\n  period of time (one year, even) symptoms\r\n  compensate variably due to different\r\n  methods of compensation involved in\r\n  recovery and also because functional\r\n  changes occurs in cerebellum and\r\n  hippocampus, anatomical structures with\r\n  huge influence on central compensation\r\n  process. Recent studies showed\r\n  the importance of otolithic system in facilitating the central vestibular\r\n  compensation [<a href=\"#14\" title=\"14\">14</a>-<a href=\"#16\" title=\"16\">16</a>].</p>\r\n<p>The degree of central compensation\r\n  depends on the severity degree of stable\r\n  vestibular lesion, quantified by caloric,\r\n  head-impulse (HIT) and vestibular evoked\r\n  cervical myogenic potentials (cVEMP)\r\n  test. Caloric reflexivity and HIT allows\r\n  evaluation of the superior vestibular\r\n  nerve function and cVEMP of the inferior\r\n  vestibular nerve (<strong>fig. 7</strong>). Dynamic vestibular\r\n  symptoms are better compensated\r\n  (disappearance of head-shaking induced\r\n  nystagmus and of motion-induced\r\n  dizziness) when initial vestibular deficit is\r\n  smaller (lower caloric canal paresis and\r\n  lower asymmetry in cVEMP&rsquo;s amplitude).</p>\r\n<div class=\"well well-sm\">\r\n  <div class=\"row\">\r\n    <div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Sensorial-13-1-1-g008.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Sensorial-13-1-1-g008.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Sensorial\" title=\"canadian-hearing-report-Sensorial\" /></a></div>\r\n    <div class=\"col-xs-12 col-md-10\">\r\n      <p><strong>Fig. 1. </strong>Sensorial vestibular structures in the inner ear Encyclopedia Britannica.</p>\r\n    </div>\r\n  </div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n  <div class=\"row\">\r\n    <div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Vestibular-13-1-1-g009.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Vestibular-13-1-1-g009.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Vestibular\" title=\"canadian-hearing-report-Vestibular\" /></a></div>\r\n    <div class=\"col-xs-12 col-md-10\">\r\n      <p><strong>Fig. 2.</strong> Vestibular nerve.</p>\r\n    </div>\r\n  </div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n  <div class=\"row\">\r\n    <div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-nuclei-13-1-1-g0010.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-nuclei-13-1-1-g0010.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-nuclei\" title=\"canadian-hearing-report-nuclei\" /></a></div>\r\n    <div class=\"col-xs-12 col-md-10\">\r\n      <p><strong>Fig. 3. </strong>Vestibular nuclei.</p>\r\n    </div>\r\n  </div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n  <div class=\"row\">\r\n    <div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Changes-13-1-1-g0011.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Changes-13-1-1-g0011.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Changes\" title=\"canadian-hearing-report-Changes\" /></a></div>\r\n    <div class=\"col-xs-12 col-md-10\">\r\n      <p><strong>Fig. 4. </strong>Changes in firing rate from hair cells in horizontal semi-circular canal (HSC).</p>\r\n    </div>\r\n  </div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n  <div class=\"row\">\r\n    <div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Ocular-13-1-1-g0012.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Ocular-13-1-1-g0012.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Ocular\" title=\"canadian-hearing-report-Ocular\" /></a></div>\r\n    <div class=\"col-xs-12 col-md-10\">\r\n      <p><strong>Fig. 5. </strong>Ocular tilt reaction.</p>\r\n    </div>\r\n  </div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n  <div class=\"row\">\r\n    <div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-compensation-13-1-1-g0013.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-compensation-13-1-1-g0013.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-compensation\" title=\"canadian-hearing-report-compensation\" /></a></div>\r\n    <div class=\"col-xs-12 col-md-10\">\r\n      <p><strong>Fig. 6. </strong>Central vestibular compensation (with Mylan Company permission).</p>\r\n    </div>\r\n  </div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n  <div class=\"row\">\r\n    <div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Pathological-13-1-1-g0014.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Pathological-13-1-1-g0014.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Pathological\" title=\"canadian-hearing-report-Pathological\" /></a></div>\r\n    <div class=\"col-xs-12 col-md-10\">\r\n      <p>Fig. 7. Pathological results in a patient with left complete UVL:<br />\r\n        a) 100% caloric paresis and right-beating spontaneous nystagmus.<br />\r\n        b) positive HIT test on left ear - (gain&lt;0.7, &ldquo;overt&rdquo; and &ldquo;covert&rdquo; saccades).<br />\r\n        c) absent cVEMP in left ear.</p>\r\n    </div>\r\n  </div>\r\n</div>\r\n<p>Recovery is best for low velocities and/\r\n  or accelerations, maybe due to saturation\r\n  phenomena or substitution strategies\r\n  used for regaining equilibrium [<a href=\"#17\" title=\"17\">17</a>-<a href=\"#20\" title=\"20\">20</a>].</p>\r\n<p>As previously mentioned, central\r\n  compensation of dynamic symptoms\r\n  involves multiple processes:</p>\r\n<p>&bull; Restoration of peripheral function.</p>\r\n<p>&bull; Compensatory readjustments of\r\n  brainstem vestibular processing.</p>\r\n<p>&bull; Sensorial substitution of the impaired\r\n  vestibular function by other sensorial systems (visual and somatosensorial) &ndash;\r\n  use of smooth pursuit instead of the nonfunctional\r\n  vestibulocular reflex (VOR), for\r\n  example.</p>\r\n<p>&bull; Functional substitution &ndash; use of\r\n  alternative strategies, with different\r\n  effectors than the damaged vestibular\r\n  ones: prediction, saccades instead of VOR\r\n  or extensive use of cervical inputs.</p>\r\n<p>&bull; Behavioural changes in order to minimise\r\n  vestibular challenges and demands.</p>\r\n<p>All above mentioned processes except\r\n  the first one (restoration of peripheral\r\n  function) acts competitively: all start\r\n  simultaneously and act redundantly but\r\n  using of one of them may eliminate the\r\n  need for others. This selection of main\r\n  central compensation process is one of\r\n  the explanations for variable outcomes\r\n  of the same process in different patients\r\n  &ndash; dependence on visual substitution\r\n  impedes upon somatosensorial\r\n  substitution mechanisms and vice versa.</p>\r\n<p>Customised vestibular rehabilitation\r\n  programmes might diminish this limit\r\n  of the natural recovery phenomena\r\n  [<a href=\"#21\" title=\"21\">21</a>-<a href=\"#25\" title=\"25\">25</a>], as well as specific drug therapy\r\n  [<a href=\"#26\" title=\"26\">26</a>]. The overall outcome of central\r\n  compensation process is also influenced\r\n  by its delay in action. There is a critical\r\n  period when neuroplasticity of the\r\n  vestibular central structures is highest\r\n  (first month after the acute injury) and\r\n  patients must take advantage of this timewindow\r\n  opportunity in order to trigger\r\n  early recovery mechanisms [<a href=\"#27\" title=\"27\">27</a>,<a href=\"#28\" title=\"28\">28</a>]. Lying\r\n  still in bed, stiffed neck movements and\r\n  vestibular suppressants should be limited\r\n  to three days at most, in order to manage\r\n  properly the UVL&rsquo;s long-term functional\r\n  symptoms.</p>\r\n<h4> CONCLUSION</h4>\r\n<p>Central compensation represents a\r\n  natural, physiologic healing process of\r\n  an acute unilateral vestibular loss. Its\r\n  benefit is greater if process starts early,\r\n  vestibular central structures are lesionfree,\r\n  substitution sensorial systems\r\n  (vision and somatosensorial) are normal\r\n  and early available. Customised vestibular\r\n  rehabilitation programmes and drugs\r\n  which facilitate specific neurotransmitters\r\n  discharge in vestibular pathway are\r\n  recommended in order to enhance,\r\n  enlarge and fulfil recovery of the dynamic\r\n  vestibular deficits.</p>\r\n<h4> REFERENCES</h4>\r\n<ol>\r\n  <li id=\'Reference_Title_Link\' value=\'1\'><a name=\"1\" id=\'1\'></a>de Waele C, Vidal PP, Tran Ba Huy P, Freyss G (1990) Vestibular compensation. Review of the  literature and clinical applications. Ann Otolaryngol Chir Cervicofac. 107: 285-98. PMID: 2221721.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'2\'><a name=\"2\" id=\'2\'></a>Lacour M (1989) Vestibular Compensation: Facts, Theories,  and Clinical Perspectives. Elsevier, Amsterdam.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'3\'><a name=\"3\" id=\'3\'></a>Pfaltz CR, Kamath R (1970) Central  compensation of  vestibular dysfunction-peripheral lesion. 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(2001) CNS drugs. 15: 853-570.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'10\'><a name=\"10\" id=\'10\'></a>Courjon JH, Flandrin JM, Jeannerod M, Schmid R (1982) The role of the flocculus in vestibular compensation  after hemilabyrinthectomy. Brain Res 239: 251-257. doi: 10.1016/0006- 8993(82)90847-2 PMID: 7093679</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'11\'><a name=\"11\" id=\'11\'></a>Llinas R, Walton K (1977) Significance of the olivo-cerebellar system in compensation of ocular position following  unilateral labyrinthectomy. In: Baker R, Berthoz A (Eds). Control of gaze by brainstem neurons pp 399-408.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'12\'><a name=\"12\" id=\'12\'></a>Darlington CL, Smith PF (2000) Molecular mechanisms of recovery from vestibular damage  in mammals: recent advances. Prog Neurobiol  62: 313-325. doi: 10.1016/S0301- 0082(00)00002-2 PMID: 10840152.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'13\'><a name=\"13\" id=\'13\'></a>Kitahara T, Takeda  N, Kiyama H, Kubo T</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'14\'><a name=\"14\" id=\'14\'></a>Allum JHJ, Yamane M, Pfaltz CR (1988) Long-term modifications of vertical and horizontal vestibulo-ocular reflex dynamics in man. Acta Otolaryngol 105: 328-337.  doi: 10.3109/00016488809097015 PMID: 3389119.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'15\'><a name=\"15\" id=\'15\'></a>Baloh RW,  Honrubia V, Yee RD, Hess K (1984) Changes in human vestibulo-ocular reflex after loss of  peripheral sensitivity. Ann Neurol 16: 222- 228. doi: 10.1002/ana.410160209 PMID: 6476793. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'16\'><a name=\"16\" id=\'16\'></a>McDonnell MN, Hillier SL (2015)  Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane  Database Syst Rev 17: CD005397. doi:  10.1002/14651858.CD005397 PMID: 25581507.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'17\'><a name=\"17\" id=\'17\'></a>Bronstein Am, Hood JD (1986) The  cervico- ocular reflex in normal subjects and patients with absent vestibular  function. Brain Res 373: 399-408. doi: 10.1016/0006-8993(86)90355-0 PMID: 3487371.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'18\'><a name=\"18\" id=\'18\'></a>Halmagyi GM, Curthoys IS, Cremer PD, Henderson  CJ, Todd MJ, et al. (1990) The human horizontal vestibulo-ocular reflex in response  to high-acceleration stimulation before and after unilateral vestibular neurectomy. Exp Brain Res 81: 479-490. doi:  10.1007/bf02423496 PMID: 2226683</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'19\'><a name=\"19\" id=\'19\'></a>Halmagyi M,  Curthoys I (1996) How does the brain  compensate for vestibular lesions? In: Baloh,  Halmagyi (editors), Disorders of the Vestibular System.  Oxford.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'20\'><a name=\"20\" id=\'20\'></a>Maioli C, Precht W (1983) On the  role of vestibulo-ocular reflex plasticity in recovery after  unilateral peripheral vestibular lesions. Exp  Brain Res 59: 267-272. doi:  10.1007/bf00230906 PMID: 3875498.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'21\'><a name=\"21\" id=\'21\'></a>Hall CD1, Herdman SJ, Whitney SL, Cass SP,  Clendaniel RA, et al. (2016) Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Evidence-Based Clinical Practice  Guideline. J Neurol Phys Ther 40: 124-155. doi: 10.1097/NPT.0000000000000120 PMID: 26913496.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'22\'><a name=\"22\" id=\'22\'></a>Georgescu M, Sorina S (2011) Vestibular neuronitis in pregnancy,  Gineco eu 7: 58-61.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'23\'><a name=\"23\" id=\'23\'></a>Georgescu Madalina, Stoian Sorina, Mogoan&#539;&#259;  Carmen Aurelia, Ciubotaru Gh.V. Vestibulary rehabilitation &ndash; election treatment  method for compensating vestibular  impairment, Romanian Journal of  Morphology and Embryology 2012, 53 (3):651-656, ISSN (print) 1220-0522, ISSN (on- line) 2066-8279.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'24\'><a name=\"24\" id=\'24\'></a>Georgescu M (2017) Vestibular Rehabilitation &ndash; Recommended Treatment  for Permanent Unilateral Vestibular Loss, Int J Neurorehabilitation Eng 4: 4. doi: 10.4172/2376-0281.1000282. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'25\'><a name=\"25\" id=\'25\'></a>Herdman SJ (2014) Vestibular Rehabilitation 4th Edition. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'26\'><a name=\"26\" id=\'26\'></a>Smith PF,  Darlington CL, Curthoys IS (1986) Vestibular compensation without brainstem commissures in the guinea pig. Neurosci  Lett 65: 209-21. doi: 10.1016/0304-3940(86)90306-x PMID: 3487051.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'27\'><a name=\"27\" id=\'27\'></a>Smith PF,  Darlington CL, Curthoys IS (1986) The effect of visual deprivation in  vestibular compensation in the guinea pig. Brain Res 364: 195-198. doi: 10.1016/0006-8993(86)91004-8. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'28\'><a name=\"28\" id=\'28\'></a>Zee DS.  Vestibular Adaptation in Vestibular Rehabilitation. In: Herdman S (editor) F.A. Davis, 19.</li>\r\n</ol>\r\n<h4>Successful Cochlear Implantation under Local\r\n  Anesthesia and Sedation: A case Report</h4>\r\n<p><strong>Barbara Stanek, Bernhard Gradl, Astrid Magele, Georg Mathias Sprinzl<sup><a href=\"#corr\">*</a></sup></strong></p>\r\n<h4>ABSTRACT</h4>\r\n<p>With the increasing life expectancy, also the number of patients suffering from age-related severe to profound\r\n  hearing loss is rising. In the past Cochlear Implantation in elderly was performed with low expectations\r\n  in improved hearing performance and handled as a high risk intervention due to age related health\r\n  challenges. Latest studies showed that Cochlear Implantation is a safe procedure in elderly patients and\r\n  that this group of patients is able to benefit regarding speech perception and life quality. Usually hearing\r\n  device implantations are performed under general anesthesia, which may pose a restrictive factor for\r\n  surgery, especially in elderly patients presenting with comorbidities. The here presented case describes\r\n  how anesthesia may be circumvented by performing Cochlear Implantation under local anesthesia and\r\n  sedation. A 72-year old man presented himself with acute severe to profound sensorineural hearing loss\r\n  in his right ear, due to herpes zoster oticus. In addition he suffered from pre-existing deafness in his left\r\n  ear. No improvement in hearing and no benefit after trialing a conventional hearing aid for a period of six\r\n  months were noted. Further examinations revealed the patient to be a suitable candidate for Cochlear\r\n  Implantation in his right ear. Due to significant comorbidities, general anesthesia was contraindicated.\r\n  Thus surgery was performed under local anesthesia and sedation. The procedure was successfully performed\r\n  and no adverse events or surgical complications occurred. Cochlear Implantation under local\r\n  anesthesia and sedation may serve as a valuable option for patients not suitable for general anesthesia.</p>\r\n<h4>KEYWORDS</h4>\r\n<p>Cochlear implantation,\r\n  Elderly patients, Local anesthesia</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>Hearing loss is one of the most common\r\n  sensory impairments with the elderly\r\n  population being predominantly affected.\r\n  Depending on the degree of hearing loss,\r\n  many candidates can be successfully fitted\r\n  with hearing aids. Cochlear Implants\r\n  represent the current treatment for\r\n  patients of all ages affected by profound\r\n  sensorineural hearing loss in one or\r\n  both ears. For individuals with this type\r\n  of hearing loss, hearing aids provide\r\n  little or no benefit. Thus surgery has\r\n  been performed for more than 30 years\r\n  featuring a low rate of complications [<a href=\"#1\" title=\"1\">1</a>].\r\n  Due to the increasing life expectancy,\r\n  interest in hearing rehabilitation of\r\n  elderly patients has progressively risen\r\n  in the recent years. Demographic data\r\n  reports that in industrialized countries\r\n  the proportion of people over the age of\r\n  65 years will increase from 28% in 2015\r\n  to 40% in 2035 [<a href=\"#2\" title=\"2\">2</a>]. Age-related processes\r\n  within the Cochlear cause damage of\r\n  the inner hair cells followed by a low to\r\n  moderate hearing loss which may progress\r\n  into severe hearing loss up to deafness. In\r\n  cases where conventional hearing aids do\r\n  not achieve any improvement in hearing,\r\n  Cochlear Implantation poses a feasible\r\n  and safe treatment option. Unfortunately\r\n  in many elderly patients the decision of\r\n  hearing rehabilitation surgery is often\r\n  handled reluctantly as the risk of surgery\r\n  is deliberated against the benefits of\r\n  hearing gain. Additional reasons against\r\n  a Cochlear Implantation are possible\r\n  difficulties with the handling of the\r\n  audio processor as well as comorbidities\r\n  prohibiting general anesthesia. This paper\r\n  describes a case in which Cochlear\r\n  Implantation was performed under local\r\n  anesthesia and sedation in a 72 year old\r\n  male.</p>\r\n<h4> CASE REPORT</h4>\r\n<p>A 72-year-old male with herpes zoster\r\n  oticus with a vestibulocochlear lesion\r\n  and accompanying acute profound\r\n  sensorineural hearing loss and a\r\n  neuropathy vestibularis in the right ear\r\n  presented to our clinic. The patient\r\n  suffered from a right sided facial palsy\r\n  occurring a few days after his visit. The\r\n  left ear was diagnosed 20 years ago\r\n  with chronic recidivating otorrhea in\r\n  terms of otitis media chronica simplex\r\n  resulting in a deaf left ear. Further\r\n  anesthesia hindering co-morbidities were\r\n  coronary heart disease, left ventricular\r\n  dysfunction, COPD (chronic obstructive\r\n  pulmonary disease), diabetes mellitus,\r\n  essential hypertonia and dyslipidemia.\r\n  The audiogram showed a decline in bone\r\n  conduction thresholds on the right side\r\n  from 50dB HL at 250Hz to 80dB HL at\r\n  3000Hz with an air-bone gap of 10dB. On\r\n  the left side the air- and bone conduction threshold were 90dB HL to 110dB HL (<strong>Fig.\r\n    1</strong>). Monosyllabic intelligibility tests scored\r\n  10% at 95dB and 55% at 110dB on his right\r\n  ear and 0% at 110dB on his left ear (<strong>Fig.\r\n    2</strong>). Given the severity of his hearing loss,\r\n  communication of the patient was only\r\n  possible in written form. At that time the\r\n  patient was already suffering from social\r\n  exclusion and incipient depression. The\r\n  patient was administered to hospital and\r\n  received intravenously valaciclovir and\r\n  corticosteroids. Despite of six months\r\n  of treatment therapy no improvement in\r\n  hearing on his right ear was observed. The\r\n  patient was provided with a behind-theear\r\n  hearing aid, which did not generate\r\n  subjective nor audiological benefit. The\r\n  recognition of speech was 0% at 65dB\r\n  and 10% at 80dB with its best possible\r\n  setting. Thereupon the evaluation\r\n  regarding Cochlear Implantation\r\n  started: Computed Tomography of the\r\n  petrous bone conducted for previous\r\n  diagnosis purposes, further audiological\r\n  examinations, Magnetic Resonance\r\n  Tomography and a Vestibulometry were\r\n  initiated. The patient met the indication\r\n  criteria for Cochlear Implantation. Preoperative\r\n  multidisciplinary examinations\r\n  (echocardiography, pulmonary function,\r\n  ECG, internal survey) revealed that\r\n  general anesthesia was too risky due to\r\n  afore mentioned comorbidities. After\r\n  discussing the options with the patient,\r\n  it was decided to perform Cochlear\r\n  Implantation under local anesthesia.</p>\r\n<div class=\"well well-sm\">\r\n  <div class=\"row\">\r\n    <div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-operative-13-1-1-g003.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-operative-13-1-1-g003.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-operative\" title=\"canadian-hearing-report-operative\" /></a></div>\r\n    <div class=\"col-xs-12 col-md-10\">\r\n      <p><strong>Fig 1. </strong>Pre- operative pure tone audiogram.</p>\r\n    </div>\r\n  </div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n  <div class=\"row\">\r\n    <div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-speech-13-1-1-g004.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-speech-13-1-1-g004.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-speech\" title=\"canadian-hearing-report-speech\" /></a></div>\r\n    <div class=\"col-xs-12 col-md-10\">\r\n      <p><strong>Fig 2. </strong>Pre- operative speech audiometry (red-right ear, blue-left ear) (monosyllables).</p>\r\n    </div>\r\n  </div>\r\n</div>\r\n<h4> SURGICAL RECORD</h4>\r\n<p>A Cochlear SYNCHRONY Standard\r\n  Electrode from MED-EL (Innsbruck,\r\n  Austria) was implanted. Due to the local\r\n  anesthesia no facial monitoring was\r\n  performed. The local anesthesia protocol\r\n  included at first 5 ml Xylonest&reg; 1%\r\n  with epinephrine 1:200.000 injection\r\n  solution submitted into the retro\r\n  auricular region. A retro auricular cut,\r\n  following a mastoidectomy and posterior\r\n  tympanotomy with a bony implant bed\r\n  were performed. Cochleostomy approach\r\n  for electrode insertion was conducted\r\n  due to the round window anatomy. ART\r\n  (auditory nerve response telemetry)\r\n  and impedance measurements were\r\n  undertaken intra-operatively without\r\n  abnormal occurrences. The surgical\r\n  intervention lasted 60 minutes and no\r\n  complications were reported. No pain of\r\n  the patient himself was indicated during\r\n  the intervention.</p>\r\n<h4> ANESTHESIA RECORD</h4>\r\n<p>The surgery was executed with an\r\n  anesthesiology in standby. Pre-operatively\r\n  the patient received Midazolam. Intraoperative\r\n  monitoring included an ECG, a\r\n  pulse oximetry as well as constant blood\r\n  pressure measurements. Oxygen (4 L/min) was delivered through an oronasal\r\n  mask. To initiate and maintain a mild\r\n  sedation, the patient received in total\r\n  0.05 mg Fentanyl and 10 mg Ketanest\r\n  administered in a small bolus based on\r\n  patients&rsquo; comfort. Furthermore 4 mg of\r\n  Dexamethasone and 4 mg of Zofran were\r\n  given as a prophylactic antiemetic.</p>\r\n<h4> RESULTS</h4>\r\n<p>Post-operatively no pain, nausea or\r\n  vomiting occurred. The patient reported\r\n  dizziness which was already present\r\n  pre-operatively. For infection prevention\r\n  intravenous antibiotics were applied for\r\n  five days. The patient was released on the\r\n  fifth post-operative day. Following implant\r\n  activation, one month after surgery, verbal\r\n  communication was immediately possible,\r\n  which was not feasible pre-operatively.\r\n  CI-aided free field measurements on the\r\n  right ear revealed 45dB HL at 250Hz,\r\n  30dB at 1.000Hz, 35dB HL at 2.000Hz\r\n  and 35dB at 4.000Hz (<strong>Fig. 3</strong>). The Freiburg\r\n  monosyllables test revealed 10% word\r\n  recognition scores at 65dB and 40%\r\n  at 80dB in the CI aided condition after\r\n  one month. The Freiburg number test\r\n  resulted in 100% understanding at 65dB\r\n  (<strong>Fig. 4</strong>). The three months follow-up free\r\n  field measurements remained constant.\r\n  The monosyllabic intelligibility of the\r\n  patient improved about 35% at 65dB and\r\n  55% at 80dB (<strong>Fig. 5</strong>). The satisfaction and\r\n  benefit of the patient remained high and\r\n  he stated to undergo surgery under local\r\n  anesthesia again.</p>\r\n<div class=\"well well-sm\">\r\n  <div class=\"row\">\r\n    <div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-month-13-1-1-g005.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-month-13-1-1-g005.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-month\" title=\"canadian-hearing-report-month\" /></a></div>\r\n    <div class=\"col-xs-12 col-md-10\">\r\n      <p><strong>Fig 3. </strong>Free field audiogram 1 month post-operative.</p>\r\n    </div>\r\n  </div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n  <div class=\"row\">\r\n    <div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Audiometry-13-1-1-g006.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Audiometry-13-1-1-g006.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Audiometry\" title=\"canadian-hearing-report-Audiometry\" /></a></div>\r\n    <div class=\"col-xs-12 col-md-10\">\r\n      <p><strong>Fig 4.</strong> Speech Audiometry 1 month post- operative [Numbers (Z) and Monosyllables (E)].</p>\r\n    </div>\r\n  </div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n  <div class=\"row\">\r\n    <div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-months-13-1-1-g007.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-months-13-1-1-g007.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-months\" title=\"canadian-hearing-report-months\" /></a></div>\r\n    <div class=\"col-xs-12 col-md-10\">\r\n      <p><strong>Fig 5. </strong>Speech Audiometry 3 months post- operative [Numbers (Z) and Monosyllables (E)].</p>\r\n    </div>\r\n  </div>\r\n</div>\r\n<h4> DISCUSSION</h4>\r\n<p>Due to the increasing life expectancy\r\n  typical diseases related to elderly people\r\n  are undoubtedly rising as well. For instance\r\n  the WHO estimates disabling hearing loss\r\n  in persons above 65 years of age in over\r\n  30% of the population. Understandably,\r\n  due to this demographic tendency,\r\n  hearing impaired patients as well as the\r\n  public&rsquo;s interest on possible treatment\r\n  options is ever increasing. At the St.</p>\r\n<p>P&ouml;lten University Medical Center the\r\n  average implantation age raised from 48\r\n  years in 2014 to 51 years in 2017. Studies\r\n  revealed that untreated hearing loss\r\n  poses a risk factor for the development\r\n  of dementia, cognitive decline, anxiety and\r\n  depression [<a href=\"#3\" title=\"3\">3</a>-<a href=\"#5\" title=\"5\">5</a>]. The here presented case\r\n  reported of such depressive moods due\r\n  to the distinctive discomfort and isolation\r\n  already shortly after losing his hearing.\r\n  Unfortunately, Cochlear Implantation in\r\n  elderly is often associated with increased\r\n  operative risks and therefore other, less\r\n  satisfying, therapies are opted for. Coelho\r\n  et al. and B&uuml;chsensch&uuml;tz et al. proved that\r\n  Cochlear Implantation is a safe procedure\r\n  in healthy patients regardless of age [<a href=\"#6\" title=\"6\">6</a>,<a href=\"#7\" title=\"7\">7</a>]\r\n  also vertigo and wound healing difficulties\r\n  were not reported more frequently in\r\n  the elderly population [<a href=\"#8\" title=\"8\">8</a>]. Importantly, this group of patients benefits especially\r\n  from an implantation in terms of speech\r\n  recognition and improved Quality of Life\r\n  [<a href=\"#9\" title=\"9\">9</a>,<a href=\"#10\" title=\"10\">10</a>]. Typically Cochlear Implantation\r\n  is undertaken under general anesthesia\r\n  representing an additional risk factor\r\n  for elderly people. If comorbidities are\r\n  present, as in the here presented case,\r\n  general anesthesia poses a considerable\r\n  risk, which may, even given appropriate\r\n  indication for Cochlear Implantation,\r\n  results in a rejection of surgery for the\r\n  patient. Since a number of different ear\r\n  surgeries are routinely performed under\r\n  local anesthesia, it only seems obvious,\r\n  that Cochlear Implantation may be\r\n  performed under local anesthesia as well.\r\n  Previous studies clearly showed that the\r\n  complication rate and the post-operative\r\n  duration of hospitalization of Cochlear\r\n  Implantation under local anesthesia did\r\n  not differ compared to general anesthesia.\r\n  No differences related to vertigo, nausea\r\n  and post-operative pain were observed.\r\n  This is in agreement with our observation.\r\n  The mean duration of the surgical\r\n  intervention in the group of the Cochlear\r\n  Implants under local anesthesia was\r\n  significantly lower compared to surgeries\r\n  under general anesthesia, representing\r\n  an additional positive effect for elderly\r\n  patients [<a href=\"#11\" title=\"11\">11</a>-<a href=\"#13\" title=\"13\">13</a>].</p>\r\n<h4> CONCLUSION</h4>\r\n<p>Cochlear implantation surgery proved to\r\n  be a good and viable option for hearing\r\n  rehabilitation in the elderly population.\r\n  Profoundly deaf patients may still be\r\n  implanted under local anesthesia without\r\n  generating additional health issues caused\r\n  by present comorbidities.</p>\r\n<h4>SUMMARY</h4>\r\n<p>&bull; Case report of a 72-year old man.</p>\r\n<p>&bull; Patient suffered acute severe to\r\n  profound sensorineural hearing loss\r\n  (right ear) and pre-existing deafness\r\n  (left ear).</p>\r\n<p>&bull; Patient reported social isolation\r\n  followed by depression due to hearing\r\n  impairment.</p>\r\n<p>&bull; The patient unsuccessfully trialed\r\n  conventional hearing aids for 6\r\n  months.</p>\r\n<p>&bull; Patient was indicated for Cochlear\r\n  Implantation (right ear) but significant\r\n  comorbidities contraindicated surgery\r\n  under general anesthesia.</p>\r\n<p>&bull; Therefore surgery was performed\r\n  under local anesthesia and sedation.</p>\r\n<p>&bull; Intervention lasted 60 minutes and\r\n  procedure was successfully performed\r\n  and no adverse events or surgical\r\n  complications occurred.</p>\r\n<p>&bull; Hearing rehabilitation was successful\r\n  one month post-operative and\r\n  improved further. Communication\r\n  immediately possible again after\r\n  activation.</p>\r\n<p>&bull; The patient reported improved\r\n  hearing benefit and Quality of Life.</p>\r\n<h4> REFERENCES</h4>\r\n<ol>\r\n  <li id=\'Reference_Title_Link\' value=\'1\'><a name=\"1\" id=\'1\'></a>Lenarz T (2017)  Cochlear Implant - State of the Art.  Laryngo-rhino-otologie 96: S123-S151. DOI: 10.1055/s-0043-101812 PMID: 28499298 </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'2\'><a name=\"2\" id=\'2\'></a>Nations U (2015)  World Population Prospects: The 2015 Revision, Methodology of the United Nations Population Estimates and  Projections. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'3\'><a name=\"3\" id=\'3\'></a> Contrera KJ,  Betz J, Deal JA, Choi JS, Ayonayon HN, et al. (2016) Association of hearing impairment and emotional vitality  in older adults. J Gerontol B Psychol Sci Soc Sci. 71: 400-404.  doi: 10.1093/geronb/gbw005 PMID: 26883806.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'4\'><a name=\"4\" id=\'4\'></a>Deal JA, Betz J, Yaffe K, Harris  T, Purchase- Helzner E, et al. (2017) Hearing impairment and incident dementia and cognitive decline in older  adults: the health abc study. J Gerontol A  Biol Sci Med Sci 72: 703-709. doi:  10.1093/gerona/glw069 PMID: 27071780. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'5\'><a name=\"5\" id=\'5\'></a>Lin FR,  Metter EJ, O\'Brien RJ, Resnick SM,  Zonderman AB, et al. (2011) Hearing  loss and incident dementia.  Arch Neurol. 68: 214-20. doi: 10.1001/archneurol.2010.362 PMID: 21320988.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'6\'><a name=\"6\" id=\'6\'></a>Coelho DH, Yeh  J, Kim JT, Lalwani AK (2009) Cochlear implantation is associated with minimal anesthetic  risk in the elderly. Laryngoscope 119: 355-358. doi: 10.1002/lary.20067  PMID: 19160385.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'7\'><a name=\"7\" id=\'7\'></a>B&uuml;chsensch&uuml;tz K, Arnolds J, Bagus H, Fahimi F, G&uuml;nnicker M, et al. (2015) Surgical risk profile and audiological outcome in the elderly after cochlea-implantation. Laryngo-rhino-otologie 94: 670-675. doi: 10.1055/s-0034-1390454  PMID: 25437836. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'8\'><a name=\"8\" id=\'8\'></a>Holinski F, Elhajzein F, Scholz G, Sedlmaier B (2012) Vestibular disorders after  cochlear implant in  adults. HNO 60: 880-885. doi:  10.1007/ s00106-012-2526-x PMID: 22733278. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'9\'><a name=\"9\" id=\'9\'></a>Ramos A, Guerra-Jim&eacute;nez G, Rodriguez C, Borkoski  S, Falc&oacute;n JC, et al. (2013) Cochlear implants in adults over 60: a study of communicative benefits and the impact on quality  of life. Cochlear Implants Int 14: 241-245. doi:  10.1179/1754762812Y.0000000028 PMID: 23510755.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'10\'><a name=\"10\" id=\'10\'></a>Jin SH, Liu C, Sladen DP (2014) The effects of aging on  speech perception in noise: comparison between  normal-hearing and cochlear-implant listeners. J Am Acad Audiol 25: 656-665. doi: 10.3766/jaaa.25.7.4 PMID: 25365368. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'11\'><a name=\"11\" id=\'11\'></a>Mistry SG, Carr  S, Martin J, Strachan DR, Raine CH, et al. (2017) Cochlear  implantation under local anaesthesia - Our  experience and a validated patient satisfaction questionnaire. Cochlear Implants Int, 18: 180-185. doi: 10.1080/14670100.2017.1296986PMID:28274186.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'12\'><a name=\"12\" id=\'12\'></a> Toner F,  Jackson CP, Toner JG (2013)  How we do it: Local anaesthetic  cochlear implantation. Cochlear  Implants Int, 2013. 14: 232-235. doi: 10.1179/1754762812Y.0000000016 PMID: 24001710. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'13\'><a name=\"13\" id=\'13\'></a>Hamerschmidt R,  Moreira AT, Wiemes GR, Ten&oacute;rio SB, T&acirc;mbara EM (2013) Cochlear implant surgery  with local anesthesia and sedation: comparison with general anesthesia. Otol Neurotol 34: 75-78. doi: 10.1097/  MAO.0b013e318278c1b2  PMID:  23187931.</a></li>\r\n</ol>',NULL,'2022-11-11'),(8,5383,'ajchr','http://www.andrewjohnpublishing.com/','','<h4>Influence of the Cochlear Implantation on\r\n  Tinnitus Distress among Patients </h4>\r\n<h4>Abstract</h4>\r\n<p>Cochlear implantation is becoming the standard treatment in patients with severe to profound sensorineural\r\n  hearing loss. Moreover, tinnitus is a symptom that is highly connected with hearing impairment.\r\n  The purpose of the study was to assess the influence of CI on tinnitus distress using the Tinnitus and\r\n  Hearing Survey (THS), Tinnitus Handicap Inventory (THI) and Tinnitus Functional Index (TFI). Twenty\r\n  adult patients were included in this study with unilateral cochlear implantation. Pre- and postoperative\r\n  tinnitus perception was evaluated, before, during implant activation visit and 1 month before activation.\r\n  Of the approached patients, 15 completed the full sets of questionnaire and 5 only Tinnitus and Hearing\r\n  Survey (THS). Before implantation, the tinnitus prevalence was 75% (15 of 20) in the whole study\r\n  group. Prior to implantation, the total result THI was 51.6 (SD=22.5) and TFI score was 41.6 (SD=15.3).\r\n  Postoperatively, the THI scores decreased to 39.3 (SD=27.1) and TFI score reduced to 34.6 (SD=23.5).\r\n  Moreover, results were analyzed using the Paired Sample t-test. The level of significance was set at p&lt;0.05.In conclusion, in present study, cochlear implant improves hearing threshold and can significant reduced tinnitus distress. Although in some cases tinnitus burden changed to worse.</p>\r\n<h4>Keywords</h4>\r\n<p>Cochlear implant, tinnitus,\r\n  THS, THI, TFI</p>\r\n<h4>Introduction</h4>\r\n<p>Tinnitus (from latin tinnire &ndash; ring) is\r\n  defined as a disorder which results\r\n  from experiencing phantom auditory\r\n  sensations without any external audio\r\n  source [<a href=\"#1\" title=\"1\">1</a>-<a href=\"#3\" title=\"3\">3</a>].</p>\r\n<p>In most cases, patients define it as\r\n  &ldquo;ringing&rdquo; but sometimes they claim to\r\n  hear squeaking noises, whistling, whizzing,\r\n  buzzing, knocking, rumbling, rustling\r\n  and many other sounds. Mechanisms\r\n  responsible for tinnitus sensation have\r\n  not been discovered yet. One of the\r\n  multiple hypotheses suggests that it\r\n  is caused by increased or decreased\r\n  cochlear electrical activity [<a href=\"#4\" title=\"4\">4</a>]. Another\r\n  theory assumes that tinnitus results\r\n  from changes in neural activity caused\r\n  by reduced (or lost) auditory input, for\r\n  example due to hearing loss [<a href=\"#5\" title=\"5\">5</a>].</p>\r\n<p>According to Hoffman [<a href=\"#6\" title=\"6\">6</a>], it is estimated\r\n  that this disorder affects about 50 million\r\n  Americans and 70 million European\r\n  Union citizens, while according to Punte\r\n  [<a href=\"#7\" title=\"7\">7</a>] it affects 10-16% of the world&rsquo;s adult\r\n  population.</p>\r\n<p>Tinnitus coincides most often with\r\n  the following phenomena: profound\r\n  sensorineural hearing loss [<a href=\"#2\" title=\"2\">2</a>,<a href=\"#3\" title=\"3\">3</a>,<a href=\"#8\" title=\"8\">8</a>],\r\n  ototoxic drug treatment, as well as\r\n  neurological, metabolic and psychogenic\r\n  disorders [<a href=\"#9\" title=\"9\">9</a>]. Only 8-10% of patients with\r\n  tinnitus have normal hearing [<a href=\"#10\" title=\"10\">10</a>], while 85\r\n  to 96% have some degree of hearing loss\r\n  [<a href=\"#11\" title=\"11\">11</a>]. It also may vary when we analyze the\r\n  age. In school children, it is related with\r\n  worse marks, more aggressive behavior\r\n  and sometimes they don&rsquo;t get promotion\r\n  to higher class. In some regions of the\r\n  world tinnitus among children from 6 to\r\n  12 years old could be present in 6-14%\r\n  [<a href=\"#12\" title=\"12\">12</a>-<a href=\"#16\" title=\"16\">16</a>].</p>\r\n<p>From several research studies that have\r\n  been conducted so far, we have found out\r\n  that a large percentage of patients with\r\n  a cochlear implant experience tinnitus\r\n  before the surgery. This problem affects\r\n  51% to 100% of CI candidates [<a href=\"#17\" title=\"17\">17</a>-<a href=\"#21\" title=\"21\">21</a>].</p>\r\n<p>Currently, many tinnitus treatment\r\n  methods focus on cognitive behavioral\r\n  therapy [<a href=\"#22\" title=\"22\">22</a>]. Their aim is to improve\r\n  habituation based on e.g. the Jasterboff\r\n  neuropsychological model [<a href=\"#23\" title=\"23\">23</a>]. Basic\r\n  treatment involves standard hearing aids,\r\n  sound enrichment therapy and tinnitus\r\n  maskers [<a href=\"#5\" title=\"5\">5</a>]. However, sound therapy is\r\n  not always effective in patients suffering\r\n  from profound hearing loss.</p>\r\n<p>The implantation of cochlear implants has\r\n  become a common practice in treating\r\n  patients with severe or profound hearing\r\n  loss, who cannot benefit from hearing\r\n  aids [<a href=\"#24\" title=\"24\">24</a>]. Some decades ago all specialists\r\n  were satisfied when approach to the cochlea was proper and engineers could\r\n  obtain any stimulation [<a href=\"#25\" title=\"25\">25</a>-<a href=\"#27\" title=\"27\">27</a>]. Current\r\n  cochlear users requiremore benefits than\r\n  improved speech understanding [<a href=\"#27\" title=\"27\">27</a>,<a href=\"#28\" title=\"28\">28</a>].\r\n  One of the most frequently reported\r\n  problems, especially in aging population,\r\n  is concomitant tinnitus. Nowadays,\r\n  troublesome tinnitus in a hearing-impaired\r\n  person is listed as the extra criteria worth\r\n  considering while qualifying patients for\r\n  cochlear implantation procedure [<a href=\"#29\" title=\"29\">29</a>-<a href=\"#31\" title=\"31\">31</a>].</p>\r\n<p>In 1981, House and Brackmann [<a href=\"#32\" title=\"32\">32</a>]\r\n  described the impact of cochlear\r\n  implants on the suppression of tinnitus\r\n  &ndash; the therapy was completely successful\r\n  in 8-61% of patients. In turn, tinnitus\r\n  was also reduced in 64-100% of cases.\r\n  Additionally, research studies conducted\r\n  by Baugley and Atlas in 2007 [<a href=\"#17\" title=\"17\">17</a>], and Pan\r\n  et al. in 2009 [<a href=\"#33\" title=\"33\">33</a>] have proven that after\r\n  the implantation, tinnitus was significantly\r\n  reduced or completely eliminated in\r\n  46-95% of patients constituting their\r\n  research groups. However, there are\r\n  also several cases of post implantation\r\n  tinnitus distress increase described in\r\n  other sources. For instance, Quaranta et\r\n  al. [<a href=\"#18\" title=\"18\">18</a>] have observed such a growth in\r\n  their research, which ranged from 4% to\r\n  26% of cases.</p>\r\n<p>This article serves as a summary of the\r\n  results of an ongoing research study\r\n  conducted so far on patients experiencing tinnitus, implanted in the World Hearing\r\n  Center in Kajetany.</p>\r\n<h4>MATERIAL AND METHODS\r\n  PARTICIPANTS</h4>\r\n<p>The study included patients undergoing\r\n  cochlear implant between July and\r\n  September 2016 at the Institute of\r\n  Physiology and Pathology of Hearing\r\n  (Kajetany, Poland), who completed tinnitus\r\n  questionnaires. The material constituted\r\n  of 20 adults (10 female and 10 male) with\r\n  severe-profound sensorineural hearing\r\n  loss. All of them were first-time scheduled\r\n  for cochlear implantation. The mean age\r\n  at the operation time was 49 &plusmn; 18 years\r\n  (range: 18-70). We excluded all patients\r\n  under 18 years old.</p>\r\n<p><strong>Table 1</strong> shows biographical data, side of\r\n  CI, hearing loss etiology and tinnitus\r\n  localization of all patients who received\r\n  the CIs. 75% of the study group (n=15)\r\n  have been suffering from tinnitus; 46.7%\r\n  of patients (n=7) experienced bilateral\r\n  tinnitus and 53.3% of patients (n=8)\r\n  experienced unilateral tinnitus. In this\r\n  study, contra-lateral tinnitus wasn&rsquo;t\r\n  considered.</p>\r\n<div class=\"table-responsive\">\r\n  <table class=\"table table-sm table-bordered\">\r\n    <thead>\r\n      <tr>\r\n        <th>Patient ID</th>\r\n        <th>Age</th>\r\n        <th>Gender</th>\r\n        <th>CI side</th>\r\n        <th>Etiology</th>\r\n        <th>Tinnitus side</th>\r\n      </tr>\r\n    </thead>\r\n    <tbody>\r\n      <tr>\r\n        <td>1</td>\r\n        <td>27</td>\r\n        <td>M</td>\r\n        <td>right</td>\r\n        <td>Sudden deafness</td>\r\n        <td>absent</td>\r\n      </tr>\r\n      <tr>\r\n        <td>2</td>\r\n        <td>50</td>\r\n        <td>F</td>\r\n        <td>left</td>\r\n        <td>Otosclerosis</td>\r\n        <td>unilateral</td>\r\n      </tr>\r\n      <tr>\r\n        <td>3</td>\r\n        <td>63</td>\r\n        <td>F</td>\r\n        <td>left</td>\r\n        <td>ototoxic medicine</td>\r\n        <td>absent</td>\r\n      </tr>\r\n      <tr>\r\n        <td>4</td>\r\n        <td>64</td>\r\n        <td>M</td>\r\n        <td>left</td>\r\n        <td>Trauma</td>\r\n        <td>unilateral</td>\r\n      </tr>\r\n      <tr>\r\n        <td>5</td>\r\n        <td>70</td>\r\n        <td>F</td>\r\n        <td>right</td>\r\n        <td>Sudden deafness</td>\r\n        <td>unilateral</td>\r\n      </tr>\r\n      <tr>\r\n        <td>6</td>\r\n        <td>51</td>\r\n        <td>F</td>\r\n        <td>left</td>\r\n        <td>Sudden deafness</td>\r\n        <td>bilateral</td>\r\n      </tr>\r\n      <tr>\r\n        <td>7</td>\r\n        <td>60</td>\r\n        <td>F</td>\r\n        <td>right</td>\r\n        <td>Sudden deafness</td>\r\n        <td>unilateral</td>\r\n      </tr>\r\n      <tr>\r\n        <td>8</td>\r\n        <td>45</td>\r\n        <td>M</td>\r\n        <td>right</td>\r\n        <td>Sudden deafness</td>\r\n        <td>unilateral</td>\r\n      </tr>\r\n      <tr>\r\n        <td>9</td>\r\n        <td>31</td>\r\n        <td>F</td>\r\n        <td>right</td>\r\n        <td>Otosclerosis</td>\r\n        <td>bilateral</td>\r\n      </tr>\r\n      <tr>\r\n        <td>10</td>\r\n        <td>38</td>\r\n        <td>M</td>\r\n        <td>left</td>\r\n        <td>Sudden deafness (progressive)</td>\r\n        <td>bilateral</td>\r\n      </tr>\r\n      <tr>\r\n        <td>11</td>\r\n        <td>68</td>\r\n        <td>M</td>\r\n        <td>left</td>\r\n        <td>Sudden deafness (progressive)</td>\r\n        <td>bilateral</td>\r\n      </tr>\r\n      <tr>\r\n        <td>12</td>\r\n        <td>18</td>\r\n        <td>M</td>\r\n        <td>right</td>\r\n        <td>Prematurity</td>\r\n        <td>absent</td>\r\n      </tr>\r\n      <tr>\r\n        <td>13</td>\r\n        <td>18</td>\r\n        <td>M</td>\r\n        <td>left</td>\r\n        <td>Prematurity</td>\r\n        <td>absent</td>\r\n      </tr>\r\n      <tr>\r\n        <td>14</td>\r\n        <td>62</td>\r\n        <td>M</td>\r\n        <td>left</td>\r\n        <td>Sudden deafness (progressive)</td>\r\n        <td>absent</td>\r\n      </tr>\r\n      <tr>\r\n        <td>15</td>\r\n        <td>56</td>\r\n        <td>F</td>\r\n        <td>left</td>\r\n        <td>Meniere disease</td>\r\n        <td>unilateral</td>\r\n      </tr>\r\n      <tr>\r\n        <td>16</td>\r\n        <td>51</td>\r\n        <td>M</td>\r\n        <td>left</td>\r\n        <td>Sudden deafness</td>\r\n        <td>bilateral</td>\r\n      </tr>\r\n      <tr>\r\n        <td>17</td>\r\n        <td>66</td>\r\n        <td>F</td>\r\n        <td>right</td>\r\n        <td>Sudden deafness</td>\r\n        <td>unilateral</td>\r\n      </tr>\r\n      <tr>\r\n        <td>18</td>\r\n        <td>68</td>\r\n        <td>M</td>\r\n        <td>left</td>\r\n        <td>Noise in the work</td>\r\n        <td>bilateral</td>\r\n      </tr>\r\n      <tr>\r\n        <td>19</td>\r\n        <td>20</td>\r\n        <td>F</td>\r\n        <td>Left</td>\r\n        <td>Mumps</td>\r\n        <td>bilateral</td>\r\n      </tr>\r\n      <tr>\r\n        <td>20</td>\r\n        <td>61</td>\r\n        <td>F</td>\r\n        <td>left</td>\r\n        <td>Sudden deafness</td>\r\n        <td>unilateral</td>\r\n      </tr>\r\n    </tbody>\r\n  </table>\r\n</div>\r\n<p><strong>Table 1.</strong> Overview of CI population. </p>\r\n<h4>QUESTIONNAIRES</h4>\r\n<p>All patients were asked to fill three\r\n  tinnitus questionnaires in following\r\n  time intervals: before implantation (1st),before CI activation (2nd) and one month\r\n  after activation (3rd). We used two\r\n  questionnaires standardized and adapted\r\n  into Polish language in our Institute (data\r\n  yet unpublished): The Tinnitus and Hearing\r\n  Survey (THS) and the Tinnitus Handicap\r\n  Inventory (THI). The third questionnaire -\r\n  Tinnitus Functional Index (TFI), was used\r\n  in our study under Oregon Health and\r\n  Science license obtained from authors of\r\n  the original tool.</p>\r\n<p>Tinnitus and Hearing Survey (THS)\r\n  published by Henry et al. 2015 [<a href=\"#34\" title=\"34\">34</a>] is a\r\n  screening tool. Its main aim is to quickly\r\n  and efficiently separate hearing problems\r\n  from tinnitus problems, which in turn\r\n  allows the clinician to choose the best of\r\n  available interventions THS consist of 3\r\n  parts: the four items in the A (Tinnitus)\r\n  subscale describe common problems\r\n  with tinnitus that are unrelated to\r\n  hearing problems; the four items in the\r\n  B (Hearing) subscale describe common\r\n  hearing problems that would not be\r\n  caused by tinnitus; the two items in the\r\n  C (Sound Tolerance) are additional, nonstandardized\r\n  and comprise the possibility\r\n  of hyperacusis experience.</p>\r\n<p>Tinnitus Handicap Inventory (THI)\r\n  developed by Newman et al. in 1996\r\n  [<a href=\"#35\" title=\"35\">35</a>] assesses tinnitus impact on everyday\r\n  functioning. The THI consist of 25 items\r\n  and, according to our adaptation, has a unidimensional structure. Total score\r\n  on the THI can range from 0 to 100\r\n  points representing maximum possible\r\n  handicap and its classification is based\r\n  on five handicap categories proposed by\r\n  McCombe et al. [<a href=\"#36\" title=\"36\">36</a>].</p>\r\n<p>The Tinnitus Functional Index (TFI) was\r\n  published by Meikle et al. in New Zeland\r\n  [<a href=\"#37\" title=\"37\">37</a>]. TFI has eight domains that address\r\n  the intrusiveness of tinnitus, the sense of\r\n  control the patient has over the disease,\r\n  cognitive interference, sleep disturbance,\r\n  auditory issues, relaxation issues, quality\r\n  of life, and emotional distress. This\r\n  questionnaire can be used in determining\r\n  the treatment-related change. TFI has\r\n  documented validity for both scaling the\r\n  severity and negative impact of tinnitus\r\n  on daily functioning. It comprehensively\r\n  provides coverage of multiple tinnitus\r\n  severity domains. TFI consist of 25 items.\r\n  Each item is scored on an 11-point scale,\r\n  with descriptors at either end of the\r\n  scale. The procedure for scoring the TFI\r\n  was followed in our study based on the\r\n  instructions provided by Meikle et al. [<a href=\"#37\" title=\"37\">37</a>].</p>\r\n<h4>RESULTS</h4>\r\n<p><strong>TINNITUS AND HEARING SURVEY (THS)</strong></p>\r\n<p><strong>Table 2</strong> summarizes the change in tinnitus\r\n  and hearing before and after implantation.\r\n  75% of patients (n=15) complained about\r\n  tinnitus before implantation. Only two\r\n  patients complained of acquiring tinnitus\r\n  after operation. However, this sensation\r\n  completely disappeared after one month.</p>\r\n<div class=\"table-responsive\">\r\n  <table class=\"table table-sm table-bordered\">\r\n    <thead>\r\n      <tr>\r\n        <th>Follow-up</th>\r\n        <th>N</th>\r\n        <th>Tinnitus</th>\r\n        <th>N</th>\r\n        <th>Hearing</th>\r\n      </tr>\r\n    </thead>\r\n    <tbody>\r\n      <tr>\r\n        <td>PRE</td>\r\n        <td>15</td>\r\n        <td>7.2 &plusmn; 4.4</td>\r\n        <td rowspan=\"3\">20</td>\r\n        <td>13 &plusmn; 3.4</td>\r\n      </tr>\r\n      <tr>\r\n        <td>Activation</td>\r\n        <td>17</td>\r\n        <td>8.3 &plusmn; 3.4</td>\r\n        <td>12.9 &plusmn; 2.7</td>\r\n      </tr>\r\n      <tr>\r\n        <td>1 month</td>\r\n        <td>15</td>\r\n        <td>5.1 &plusmn; 3.6</td>\r\n        <td>10.5 &plusmn; 4</td>\r\n      </tr>\r\n    </tbody>\r\n  </table>\r\n</div>\r\n<p><strong>Table 2. </strong>Mean results  on Tinnitus and Hearing Survey (THS): part A (tinnitus 0-16), part B (hearing 0-16). </p>\r\n<p>In the time between operation and CI\r\n  activation alleviation of tinnitus distress\r\n  was observed in 7 patients and 5 patients\r\n  reported worsening of their tinnitus.</p>\r\n<p>At follow-up visit 1 month after activation\r\n  in 10 patients observed reduction of\r\n  tinnitus, including one person with\r\n  completely suppressed tinnitus. In this\r\n  time interval tinnitus remained unchanged\r\n  in two patients. Furthermore, there was\r\n  no increase in the problems associated\r\n  with tinnitus.</p>\r\n<p>Part A (tinnitus) and part B (hearing)\r\n  mean scores are presented in Table 1.\r\n  A significant difference (t=2.44; p&lt;0.05)\r\n  was found for the hearing score between\r\n  preoperative and 1 month after activation.\r\n  However, no significant difference were\r\n  found the tinnitus score (t=2.04; p&gt;0.05).</p>\r\n<p>The result of sound tolerance was\r\n  shown in <strong>Table 3</strong>. Before implantation\r\n  hyperacusis was a moderate to very big\r\n  problem for over half of study group.\r\n  Additional, after CI two patients start\r\n  suffering from hyperacusis as moderate\r\n  problem. However, most of the patients\r\n  reported a reduction in the problems\r\n  associated with the auditory sensitivity. A\r\n  significant reduction (t=2.45; p&lt;0.05) and\r\n  thus improvement was found between\r\n  sound tolerance preoperatively and one\r\n  month after the first-fitting.</p>\r\n<div class=\"table-responsive\">\r\n  <table class=\"table table-sm table-bordered\">\r\n    <thead>\r\n      <tr>\r\n        <th colspan=\"6\">Sound Tolerance </th>\r\n      </tr>\r\n    </thead>\r\n    <tbody>\r\n      <tr>\r\n        <td>Follow-up (n=20)</td>\r\n        <td>Not a problem</td>\r\n        <td>Small problem</td>\r\n        <td>Moderate problem</td>\r\n        <td>Big problem</td>\r\n        <td>Very big problem</td>\r\n      </tr>\r\n      <tr>\r\n        <td>PRE</td>\r\n        <td>35% (n=7)</td>\r\n        <td>10% (n=2)</td>\r\n        <td>10% (n=2)</td>\r\n        <td>30 % (n=6)</td>\r\n        <td>15% (n=3)</td>\r\n      </tr>\r\n      <tr>\r\n        <td>Activation</td>\r\n        <td>25% (n=5)</td>\r\n        <td>20% (n=4)</td>\r\n        <td>30% (n=6)</td>\r\n        <td>20% (n=4)</td>\r\n        <td>5% (n=1)</td>\r\n      </tr>\r\n      <tr>\r\n        <td>1 month</td>\r\n        <td>25% (n=5)</td>\r\n        <td>20% (n=4)</td>\r\n        <td>30% (n=6)</td>\r\n        <td>10% (n=2)</td>\r\n        <td>15% (n=3)</td>\r\n      </tr>\r\n    </tbody>\r\n  </table>\r\n</div>\r\n<p><strong>Table 3.</strong> THS: result of part C (Sound  Tolerance). </p>\r\n<h4>TINNITUS HANDICAP\r\n  INVENTORY</h4>\r\n<p>The analysis included 15 patients experiencing tinnitus. Patients who have\r\n  never felt the tinnitus (n=5) according to\r\n  the THS questionnaire crosschecked with\r\n  the interview were excluded.</p>\r\n<p>The mean THI score of the tinnitus patients\r\n  was 51.6 (SD=22.5) preoperatively (<strong>Table\r\n    4</strong>) and almost half of the patients were\r\n  classified as being more than moderatel\r\n  handicapped (<strong>Figure 1</strong>).</p>\r\n<div class=\"table-responsive\">\r\n  <table class=\"table table-sm table-bordered\">\r\n    <thead>\r\n      <tr>\r\n        <th>Follow-up</th>\r\n        <th>Minimum score</th>\r\n        <th>Maximum score</th>\r\n        <th>Total score THI (mean    &plusmn; std. deviaton )</th>\r\n      </tr>\r\n    </thead>\r\n    <tbody>\r\n      <tr>\r\n        <td>PRE</td>\r\n        <td>12</td>\r\n        <td>80</td>\r\n        <td>51.6 &plusmn; 22.5</td>\r\n      </tr>\r\n      <tr>\r\n        <td>Activation</td>\r\n        <td>12</td>\r\n        <td>100</td>\r\n        <td>53.7 &plusmn; 26.5</td>\r\n      </tr>\r\n      <tr>\r\n        <td>1 month</td>\r\n        <td>0</td>\r\n        <td>86</td>\r\n        <td>39.3 &plusmn; 27.1</td>\r\n      </tr>\r\n    </tbody>\r\n  </table>\r\n</div>\r\n<p><strong>Table 4</strong>. Change in tinnitus handicap  based on score of THI. </p>\r\n<div class=\"well well-sm\">\r\n  <div class=\"row\">\r\n    <div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Comparison-12-1-1-g001.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Comparison-12-1-1-g001.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Comparison\" title=\"canadian-hearing-report-Comparison\" /></a></div>\r\n    <div class=\"col-xs-12 col-md-10\">\r\n      <p><strong>Figure 1:</strong> Comparison between pre implantation, activation and post implantation THI</p>\r\n    </div>\r\n  </div>\r\n</div>\r\n<p>During implant activation visit tinnitus\r\n  partially decreased in 20% of patients\r\n  (n=3). The handicap degree was unchanged\r\n  8/15 (53%) patients and worsened in 4/15\r\n  (almost 30%) cases.</p>\r\n<p>One month after CI activation tinnitus\r\n  subsided completely in 13% (n=2) of the\r\n  study population. Almost 30% (n=4) of\r\n  patients perceived a reduction in the level\r\n  of handicap score in comparison with\r\n  preoperative evaluation. In two cases\r\n  from severe to slight and in one case from\r\n  moderate to slight the same situation was\r\n  observed. Forty-seven percent (n=7) of\r\n  patients observed no change in tinnitus\r\n  handicapping influence. Progression of\r\n  tinnitus occurred in two patients. One\r\n  of them had a moderate severity score\r\n  before and this increase to catastrophic\r\n  tinnitus perception after implantation.\r\n  A significant reduction (t=0.38; p&lt;0.05)\r\n  and thus improvement was found between\r\n  THI score preoperatively and one month\r\n  after the first-fitting.</p>\r\n<h4>TINNITUS FUNCTIONAL INDEX\r\n  (TFI)</h4>\r\n<p>Before implantation the biggest problem\r\n  for patients with tinnitus was its\r\n  intrusiveness (for around 50% of them).\r\n  Moreover, tinnitus impaired domains such\r\n  as: relaxation and quality of life, as well as\r\n  hearing (<strong>Figure 2</strong>).</p>\r\n<div class=\"well well-sm\">\r\n  <div class=\"row\">\r\n    <div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Severity-12-1-1-g002.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Severity-12-1-1-g002.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Severity\" title=\"canadian-hearing-report-Severity\" /></a></div>\r\n    <div class=\"col-xs-12 col-md-10\">\r\n      <p><strong>Figure 2:</strong> Comparison between pre implantation, activation and post implantation THI.</p>\r\n    </div>\r\n  </div>\r\n</div>\r\n<p>After surgery, the score was like\r\n  preimplantation score, but additional\r\n  growth in domains sleep and emotional\r\n  was observed.</p>\r\n<p>One month after CI activation score in\r\n  all domains was reduced. A significant\r\n  difference between preoperatively and 1\r\n  month after activation score was found\r\n  only in domain intrusiveness (t=3.22;\r\n  p&lt;0.001).</p>\r\n<p>Using guidelines created by Meikle et\r\n  al. (2012) for TFI scoring, 40% (n=6) of\r\n  our patients had a score indicating&ldquo;not\r\n  a problem&rdquo; or &ldquo;a small problem&rdquo;\r\n  whereas 60% (n=9) had score classified\r\n  as moderate or big problem. Nobody\r\n  had very big problem before their\r\n  implantation. However, after surgery 2\r\n  patients worsened score from moderate\r\n  to very big problem. This is compared\r\n  to 53.3 % (n=8) had a score indicating\r\n  &ldquo;not a problem&rdquo; or &ldquo;it&rsquo;s a small problem,\r\n  33.3% (n=5) had score moderate or big\r\n  problem, around 13% (n=2) had a very big\r\n  problem (<strong>Figure 3</strong>).</p>\r\n<p>As a group, the mean preoperative\r\n  TFI score was 41.6 (SD=15.5). During\r\n  activation visit the mean score was 48.6\r\n  (SD=24.7) and one month later score\r\n  reduced to 34.6 (SD=23.5) (<strong>Table 5</strong>).</p>\r\n<div class=\"well well-sm\">\r\n  <div class=\"row\">\r\n    <div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-between-12-1-1-g003.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-between-12-1-1-g003.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-between\" title=\"canadian-hearing-report-between\" /></a></div>\r\n    <div class=\"col-xs-12 col-md-10\">\r\n      <p><strong>Figure 3:</strong> Comparison between preimplantation, activation and postimplantation TFI.</p>\r\n    </div>\r\n  </div>\r\n</div>\r\n<div class=\"table-responsive\">\r\n  <table class=\"table table-sm table-bordered\">\r\n    <thead>\r\n      <tr>\r\n        <th>Follow-up</th>\r\n        <th>Minimum score</th>\r\n        <th>Maximum score</th>\r\n        <th>Total score TFI (mean    &plusmn; std. deviaton )</th>\r\n      </tr>\r\n    </thead>\r\n    <tbody>\r\n      <tr>\r\n        <td>PRE</td>\r\n        <td>4</td>\r\n        <td>60.8</td>\r\n        <td>41.6 &plusmn; 15.5</td>\r\n      </tr>\r\n      <tr>\r\n        <td>Activation</td>\r\n        <td>14.8</td>\r\n        <td>100</td>\r\n        <td>48.6 &plusmn; 24.7</td>\r\n      </tr>\r\n      <tr>\r\n        <td>1 month</td>\r\n        <td>0</td>\r\n        <td>83</td>\r\n        <td>34.6 &plusmn; 23.5</td>\r\n      </tr>\r\n    </tbody>\r\n  </table>\r\n</div>\r\n<p><strong>Table 5.</strong> Evaluation of average subscale  of TFI.</p>\r\n<h4>DISCUSSION</h4>\r\n<p>A lot of Centers in Europe and America have shown that the cochlear implantation\r\n  not only improve hearing threshold but\r\n  also successfully reducing the burden of\r\n  tinnitus during active CI use [<a href=\"#38\" title=\"38\">38</a>-<a href=\"#41\" title=\"41\">41</a>]. It is\r\n  very important from quality of life point\r\n  of view.</p>\r\n<p>In this study of adult CI candidates, the\r\n  prevalence of tinnitus was 75% (15/20).\r\n  Literature was performed base on\r\n  keywords like tinnitus and cochlear\r\n  implantation on the most important\r\n  databases. Literature reported a range of\r\n  tinnitus suffering in patient candidates of\r\n  cochlear implantation from 67% to 100%\r\n  (mean 80%) [<a href=\"#17\" title=\"17\">17</a>]. The study of Amoodi\r\n  et al. [<a href=\"#42\" title=\"42\">42</a>] reported incidence of 78%.\r\n  Our data seems to confirm this previous\r\n  series.</p>\r\n<p>Postoperative tinnitus development\r\n  was perceived in 2 of 5 patients who\r\n  have never experienced tinnitus before\r\n  implantation. In our study, new symptoms\r\n  of tinnitus appeared immediately after\r\n  operation and total suppression was one\r\n  month later. This is similar to reports of\r\n  Kompis et al. [<a href=\"#8\" title=\"8\">8</a>,<a href=\"#19\" title=\"19\">19</a>]. This could happen due\r\n  to position of the body and sometimes\r\n  is also combined with small vestibular\r\n  disorders [<a href=\"#43\" title=\"43\">43</a>-<a href=\"#46\" title=\"46\">46</a>].</p>\r\n<p>Research of di Nardo et al. [<a href=\"#47\" title=\"47\">47</a>] shown a\r\n  decrease of THI score in 13 cases (65%),\r\n  unchanged score in 6 (30%) and increased\r\n  score in 1 (5%). In the present study, there\r\n  is a high rate of patients who reported\r\n  a tinnitus improvement one month after\r\n  CI activation: total suppression of tinnitus\r\n  occurred in 2 patients, the score both\r\n  THI and TFI was reduced in almost 60%\r\n  (n=9) patients, increased in more than\r\n  26% (n=4).</p>\r\n<p>In present study the baseline total THI\r\n  score we observed that severity of\r\n  handicap tinnitus increased on during CI\r\n  activation visit. In the same follow-up, TFI\r\n  score increased in domain: relaxation and\r\n  worsened the trouble with sleep.</p>\r\n<p>The mean THI score of severity of\r\n  tinnitus was 51.6 &plusmn; 22.5 preoperatively\r\n  and almost 70% of this group had tinnitus\r\n  severity more than mild. Similar result was\r\n  reported by Bovo et al. [<a href=\"#48\" title=\"48\">48</a>] In that study\r\n  almost 60% of patients were classified as\r\n  more than mildly handicapped by tinnitus.\r\n  In study Kim et al. [<a href=\"#20\" title=\"20\">20</a>] more than 50%\r\n  sample group suffering from tinnitus in\r\n  more than mild degree.</p>\r\n<p>There is no study using TFI for patients\r\n  with impaired hearing. In literature, we can\r\n  find only research of people with normal\r\n  hearing threshold. One of them is study\r\n  Fackrell et al. [<a href=\"#49\" title=\"49\">49</a>]. The mean score of TFI\r\n  was 40.6 (SD=20.1), while in our study\r\n  preimplantation score was 41.6 points\r\n  (SD=15.5), but 1 month after CI 34.6\r\n  (SD=23.5). In addition, intrusiveness of\r\n  tinnitus caused also problems with sense\r\n  of control and relaxation. In the present\r\n  study, we can notice that preoperatively\r\n  tinnitus have a negative influence on\r\n  intrusiveness, hearing and quality of life.</p>\r\n<h4>SUMMARY</h4>\r\n<p>1. The analysis of this study results\r\n  shows that prevalence of tinnitus in\r\n  CI patients is relatively high.</p>\r\n<p>2. Pre THI score, the tinnitus severity\r\n  is generally moderate to severe\r\n  handicapping, but TFI score shows\r\n  rather small to moderate problems.</p>\r\n<p>3. A Pearson\'s correlation was run\r\n  to determine the relationship\r\n  between total score THI and THI\r\n  preoperatively and one month after\r\n  CI first fitting. There was a moderate\r\n  positive correlation between THI and\r\n  TFI preoperatively score (r=0.57;\r\n  p&lt;0.05). Total score between THI and\r\n  TFI one month after CI activation\r\n  was a strong positive correlation\r\n  (r=0.74; p&lt;0.05).</p>\r\n<p>4. After implantation but before\r\n  activation CI, the severity of tinnitus\r\n  in both questionnaire increased.\r\n  Although on next follow-up (1\r\n  month) tinnitus was significantly\r\n  reduced. However, we report also a\r\n  negative influence of CI on tinnitus in\r\n  some patients.</p>\r\n<p>5. Our analysis shows a positive result\r\n  of cochlear implantation on perceived\r\n  severity of tinnitus.</p>\r\n<p>6. In additional, CI improved quality of\r\n  life and hearing ability.</p>\r\n<h4>REFERENCES</h4>\r\n<ol>\r\n  <li id=\'Reference_Title_Link\' value=\'1\'><a name=\"1\" id=\'1\'></a>Akdogan, O., et  al. &quot;Tinnitus  after cochlear  implantation.&quot; Auris Nasus Larynx, 36(2) (2009): 210-212.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'2\'><a name=\"2\" id=\'2\'></a>Arts, R.A.G.J., et al. &quot;Review: cochlear  implants as a treatment  of tinnitus in single-sided deafness.&quot; Curr Opin Otolaryngol Head Neck Surg 20(5) (2012): 398-403.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'3\'><a name=\"3\" id=\'3\'></a>Zon, A. van., et al. &quot;Effect  of unilateral and simultaneous bilateral cochlear implantation on tinnitus:A Prospective Study.&quot; The Laryngoscope, 126(4)  (2016): 956-961. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'4\'><a name=\"4\" id=\'4\'></a>Greenberg, D., et al. &quot;Developing an assessment approach for perceptual changes to  tinnitus sound characteristics for adult cochlear implant recipients.&quot; Int J Audiol,  55(7) (2015): 392-404. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'5\'><a name=\"5\" id=\'5\'></a>Arts, R.A.G.J., et al.  &quot;Tinnitus Suppression by Intracochlear Electrical Stimulation in Single Sided Deafness &ndash; A Prospective Clinical Trial: Follow-Up.&quot; PLOS ONE, 11(4) (2016): e0153131. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'6\'><a name=\"6\" id=\'6\'></a>Hoffman, H.J., Reed,  G.W., &quot;Epidemiology  of tinnitus.&quot; In: Snow  JB Jr, ed: <em>Tinnitus: Theory and </em><em>Management. </em>Hamilton, Ontario: B.C. Decker, Inc. (2004): 16-41.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'7\'><a name=\"7\" id=\'7\'></a>Punte, A.K., et al. &quot;Cochlear implantation as a durable tinnitus treatment  in single-sided deafness. Cochlear Implants&quot; Int, 12 (Suppl 1) (2011): S26-29. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'8\'><a name=\"8\" id=\'8\'></a>Kim, D.K., et al. &quot;Prospective, Multicenter Study on Tinnitus Changes after Cochlear Implantation.&quot;  Audiol Neurotol, 21(3) (2016): 165-171.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'9\'><a name=\"9\" id=\'9\'></a>Crummer, R.W. &amp;  Hassan, G.A., &quot; Diagnostic  approach to tinnitus.&quot; Am Fam Physician, 69(1) ( 2004): 120-126.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'10\'><a name=\"10\" id=\'10\'></a>Barnea, G., et al.  &quot;Tinnitus with Normal Hearing Sensitivity: Extended  High-Frequency Audiometry and Auditory-Nerve Brain-Stem- Evoked Responses.&quot; Audiology, 29(1)  (1990): 36-45.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'11\'><a name=\"11\" id=\'11\'></a>Sanchez, T.G., et al.  &quot;Tinnitus in normally hearing patients:  clinical aspects and repercussions.&quot; Rev  Bras Otorrinolaringol, 71(4) (2005): 427-431. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'12\'><a name=\"12\" id=\'12\'></a>Skarzynski, P. H., et al.  &quot;Hearing Screening Program in School-Age Children in Western Poland.&quot; J Int Adv Otol, 7(2) (2011): 194-200</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'13\'><a name=\"13\" id=\'13\'></a>Skar&#380;y&#324;ski, P., et al.  &quot;Comparison of the frequency of positive hearing  screening outcomes in schoolchildren from Poland and other countries of Europe, Central Asia, and Africa.&quot;  J Hear Sci &reg;, 4(4) (2015): OA51-OA58. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'14\'><a name=\"14\" id=\'14\'></a>Skarzynski, P.H., et al. &quot;Central auditory  processing disorder (CAPD) tests in a school- age hearing screening programme - analysis  of 76,429 children.&quot; Ann Agric  Environ Med AAEM, 22(1) (2015): 90-95. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'15\'><a name=\"15\" id=\'15\'></a>Skar&#380;y&#324;ski, P.H., et al. &quot;A Hearing Screening Program for Children in Primary Schools in  Tajikistan: A Telemedicine Model.&quot;  Med Sci Monit Int Med J Exp Clin Res, 22 ( 2016): 2424-2430.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'16\'><a name=\"16\" id=\'16\'></a>Raj-Koziak, D., &quot;Occurrence of tinnitus in children- review of literature.&quot; New Audiofonology, 5(1) (2016): PP9-PP14. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'17\'><a name=\"17\" id=\'17\'></a>Baguley, D.M.,Atlas, M.D.,  &quot;Cochlear implants and tinnitus.&quot; Prog Brain Res, 166 (2007):  347-55. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'18\'><a name=\"18\" id=\'18\'></a>Quaranta, N.,Wagstaff, S., Baguley,  D.M., &quot;Tinnitus and cochlear  implantation.&quot; Int J Audiol, 43(5) (2004):  245-251. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'19\'><a name=\"19\" id=\'19\'></a>Kompis, M., et al. &quot;Tinnitus  before and 6 Months after Cochlear  Implantation.&quot; Audiol Neurotol, 17(3) (2012):  161-168. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'20\'><a name=\"20\" id=\'20\'></a>Kim, D.K., et al. &quot;Tinnitus in  patients with profound hearing loss and the effect of cochlear implantation.&quot; Eur Arch Otorhinolaryngol, 270(6) (2013): 1803-1808. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'21\'><a name=\"21\" id=\'21\'></a>Kloostra, F.J.J., et al. &quot;Changes in tinnitus after cochlear implantation and its relation  with psychological functioning.&quot; Audiol Neurootol, 20(2) (2015): 81-89. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'22\'><a name=\"22\" id=\'22\'></a>Parazzini, M., et al. &quot;Open  ear hearing aids in tinnitus therapy:  An efficacy comparison with sound  generators.&quot; ResearchGate, 50(8) (2011):  548-553.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'23\'><a name=\"23\" id=\'23\'></a>Jastreboff, P.J., Brennan, J.F.,  Sasaki, C.T., &quot; An animal model for tinnitus.&quot; The Laryngoscope, 98(3) (1988): 280-286. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'24\'><a name=\"24\" id=\'24\'></a>Schoonhoven, J. van., et al.  &quot;The effectiveness of bilateral cochlear  implants for severe-to- profound deafness  in adults: a systematic review.&quot; Otol Neurotol Off Publ Am  Otol Soc Am Neurotol Soc Eur Acad  Otol Neurotol, 34(2) (2013):  190-198. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'25\'><a name=\"25\" id=\'25\'></a>Chouard,  C.H., &amp; MacLeod,P.,  &quot;Implantation of multiple intracochlear electrodes for rehabilitation of total deafness: preliminary  report.&quot; The Laryngoscope, 86(11) (1976) : 1743-1751.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'26\'><a name=\"26\" id=\'26\'></a>House, W.F., &amp; Urban, J., &quot; Long term results of electrode implantation and electronic stimulation of the cochlea in man.&quot;  Ann Otol Rhinol Laryngol, 82(4) (1973): 504-517.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'27\'><a name=\"27\" id=\'27\'></a>Burian, K., et al. &quot;Designing  of and experience with multichannel  cochlear implants.&quot; Acta Otolaryngol (Stockh),  87(3-4) (1979): 190-195. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'28\'><a name=\"28\" id=\'28\'></a>Clark, G.M., et al. &quot;A  multiple electrode cochlear implant.&quot; J Laryngol Otol, 91(11) (1977):  935-945. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'29\'><a name=\"29\" id=\'29\'></a>Sampaio, A.L.L., Ara&uacute;jo, M.F.S., Oliveira,  C.A.C.P., &quot;New criteria of indication and selection of patients to cochlear implant.&quot; Int J  Otolaryngol, (2011) 2011: 573968. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'30\'><a name=\"30\" id=\'30\'></a>Olze, H., Zahnert, T., Hesse, G.,  &quot; Hearing aids, implantable  hearing aids and cochlear implants in chronic tinnitus therapy&quot;. HNO, 58(10) ( 2010): 1004-1012.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'31\'><a name=\"31\" id=\'31\'></a>Plontke, S.K., et al.  &quot;Cochlear implantation in a child  with posttraumatic single-sided deafness.&quot; Eur Arch Oto-Rhino-Laryngol Off J Eur Fed Oto-Rhino-Laryngol Soc EUFOS Affil Ger Soc Oto-Rhino-Laryngol  - Head Neck Surg, 270(5) (2013): 1757-1761.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'32\'><a name=\"32\" id=\'32\'></a>House, J.W., Brackmann, D.E., &quot;Tinnitus: surgical treatment.&quot; Ciba Found Symp, 85  (1981): 204- 216.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'33\'><a name=\"33\" id=\'33\'></a>Pan, T., et al. &quot;Changes in  the Tinnitus Handicap Questionnaire After Cochlear Implantation.&quot; Am J Audiol, 18(2) (2009): 144-151. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'34\'><a name=\"34\" id=\'34\'></a>Henry, J.A., et al. &quot;Tinnitus  and hearing survey: a screening  tool to differentiate bothersome tinnitus from hearing  difficulties.&quot; Am J Audiol, 24(1)  (2015): 66-77. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'35\'><a name=\"35\" id=\'35\'></a>Newman, C.W., Jacobson,  G.P., Spitzer,  J.B., &quot;Development of the Tinnitus  Handicap Inventory.&quot; Arch Otolaryngol Head Neck Surg, 122(2) (1996):  143-148.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'36\'><a name=\"36\" id=\'36\'></a>McCombe, A., et al. &quot;Guidelines for the grading of tinnitus severity: the results of a  working group commissioned by the British  Association of  Otolaryngologists, Head and Neck Surgeons, 1999.&quot;  Clin Otolaryngol Allied Sci, 26(5) (2001): 388-93.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'37\'><a name=\"37\" id=\'37\'></a>Meikle, M.B., et al. &quot;The tinnitus functional index: development of a new clinical  measure for chronic, intrusive  tinnitus. Ear Hear,&quot; 33(2) (2012):  153-176. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'38\'><a name=\"38\" id=\'38\'></a>Van de  Heyning, P., et al. &quot;Incapacitating unilateral tinnitus in single-sided deafness  treated by\r\n    cochlear implantation.&quot; Ann Otol Rhinol  Laryngol, 117(9) (2008): 645-652. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'39\'><a name=\"39\" id=\'39\'></a>Carlyo, R.P., et al. &quot;Pitch  comparisons between electrical  stimulation of a cochlear implant and acoustic  stimuli presented to a normal-hearing contralateral ear.&quot; J Assoc Res Otolaryngol JARO, 11(4) (2010): 625-640. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'40\'><a name=\"40\" id=\'40\'></a>Ramos Mac&iacute;as, A. , et al.  &quot;Cochlear implants as a  treatment option for unilateral hearing loss, severe tinnitus and  hyperacusis.&quot; Audiol Neurootol, 20 Suppl (1) (2015):  60-66. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'41\'><a name=\"41\" id=\'41\'></a>Gartrell, B.C., et al.  &quot;Investigating Long-Term Effects  of Cochlear Implantation in Single-Sided Deafness:A  Best Practice Model for Longitudinal Assessment of Spatial Hearing Abilities and Tinnitus Handicap.&quot; Otol Neurotol Off Publ Am Otol Soc Am Neurotol Soc Eur Acad Otol Neurotol, 35(9) (2014): 1525-1532. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'42\'><a name=\"42\" id=\'42\'></a>Amoodi, H.A., et al. &quot;The  effects of unilateral cochlear  implantation on the tinnitus handicap inventory  and the influence on quality of life.&quot; The Laryngoscope, 121(7) (2011): 1536-1540. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'43\'><a name=\"43\" id=\'43\'></a>Mick, P., et al. &quot;Cochlear implantation in patients with advanced  M&eacute;ni&egrave;re&rsquo;s disease.&quot; Otol Neurotol Off Publ Am Otol Soc Am Neurotol  Soc Eur Acad Otol Neurotol, 35(7) (2014):  1172-1178.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'44\'><a name=\"44\" id=\'44\'></a>Frodlund, J., et al.  &quot;Vestibular Function After Cochlear  Implantation: A Comparison of Three Types of Electrodes.&quot; Otol Neurotol Off Publ Am Otol Soc Am Neurotol Soc Eur Acad Otol Neurotol,  37(10) (2016): 1535-1540. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'45\'><a name=\"45\" id=\'45\'></a>Derks, L.S.M., et al. &quot;Effect  of day-case unilateral cochlear implantation in adults on general and disease-specific quality of life,  postoperative complications and hearing  results, tinnitus, vertigo and cost-effectiveness: protocol  for a randomised controlled trial.&quot; BMJ Open, 6(10) (2016): e012219. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'46\'><a name=\"46\" id=\'46\'></a>Nordfalk, K.F., et  al. &quot;Insertion Depth in Cochlear  Implantation and Outcome in Residual Hearing and Vestibular Function.&quot; Ear Hear, 37(2) (2016): e129-137.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'47\'><a name=\"47\" id=\'47\'></a>Di Nardo, W., et al. &quot;Transtympanic  electrical stimulation for immediate and long-term  tinnitus suppression.&quot; Int Tinnitus J, 15(1) (2009): 100-106.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'48\'><a name=\"48\" id=\'48\'></a>Bovo, R., Ciorba, A., Martini, A.,  &quot; Tinnitus and cochlear implants.&quot; Auris Nasus Larynx, 38(1) (2011):  14-20. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'49\'><a name=\"49\" id=\'49\'></a> Fackrell, K., et al. &quot;Psychometric properties of the Tinnitus Functional Index (TFI):  Assessment in a UK research volunteer population.&quot; Hear Res, 335 (2016) : 220-235</a>.</li>\r\n</ol>\r\n<h4>Hearing Profile of Individuals with Tinnitus\r\n  Issues</h4>\r\n<h4>Abstract</h4>\r\n<p><strong>Introduction:</strong> Tinnitus is the perception of sound not derived from the surroundings, but from within\r\n  the head or ear of the one who hears it. According to previous knowledge regarding alterations in the\r\n  functionality of the auditory pathway in the presence of tinnitus, being it related to regular hearing or not,\r\n  further inquiries and researches are required in other to clarify the subject.</p>\r\n<p><strong> Objective: </strong>Summarize the hearing profile of patients with tinnitus complaints.</p>\r\n<p><strong> Methodology: </strong>121 individuals, from both sex, ages ranging from 18 to 82 took part in the experiment,\r\n  convenience sample, broad demand. Subjects were submitted to tinnitus analysis through anamnesis,\r\n  acuphenometry and the questionnaire Tinnitus Handicap Inventory, the hearing, on the other hand, was\r\n  submitted to an audiometry test.</p>\r\n<p><strong>Results:</strong> Female individuals were more frequent, where a larger occurrence of bilateral tinnitus, with\r\n  continuous sound type. Average pitch of 4664 Hz and loudness of 20 dBNS to the right ear and 4685\r\n  HZ e 18 dBNS to the left ear, no relevant difference was found when compared. The level of tinnitus\r\n  disturbance more often found was the mild, followed by the slight. The hearing profile more frequently\r\n  observed was the hearing loss of isolated frequencies from both ears, followed by regular hearing, both\r\n  took major roles in influencing the level of tinnitus disturbance classification. The sex has significantly\r\n  influenced the level of hearing loss, being it more frequent on the feminine sex. The Tinnitus Handicap\r\n  Inventory is significantly related with the hearing loss of isolated frequencies in both ears.</p>\r\n<p><strong>Conclusion: </strong>The characteristic of the hearing profiles studied was the bilateral and continuous tinnitus,\r\n  of high pitch and loudness between 18 and 2 0dBNS. Level of disturbance between slight and mild, under\r\n  influence of gender. Hearing loss restricted of isolated frequencies, followed by regular hearing, appeared\r\n  more often and influenced in the level of tinnitus disturbance.</p>\r\n<h4>KEYWORDS:</h4>\r\n<p>Tinnitus; Hearing loss;\r\n  Audiology; Hearing; Audiologist</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>To relax in silence, focus and being able\r\n  to synchronize with one&rsquo;s thoughts, it\'s\r\n  a common and characteristic act of the\r\n  human being. However, to some people,\r\n  this type of situation can be disturbing\r\n  and impossible because of the perception\r\n  of a sound absent in surroundings, rather\r\n  inside of the ear or head of the one\r\n  affected. This sound is called tinnitus, also\r\n  known as acufeno [<a href=\"#1\" title=\"1\">1</a>].</p>\r\n<p>It can be defined as a ghost auditory\r\n  perception realized only by the one\r\n  afflicted in most cases, making it difficult\r\n  to measure a pattern [<a href=\"#2\" title=\"2\">2</a>]. The location\r\n  can affect only one ear (unilateral), both\r\n  (bilateral) or the head. English data has\r\n  estimated that 600 thousand people in\r\n  the United Kingdom present tinnitus,\r\n  which has a severe impact in the routine\r\n  of this population [<a href=\"#3\" title=\"3\">3</a>]. A research took\r\n  place in 2004 and suggested that 28\r\n  million Brazilians are affected by tinnitus\r\n  [<a href=\"#4\" title=\"4\">4</a>]. In addition, a recent study, developed\r\n  in the city of Sao Paulo, revealed that\r\n  22% of that population has said to have\r\n  tinnitus [<a href=\"#5\" title=\"5\">5</a>].</p>\r\n<p>The sound perceived by those who\r\n  suffer from tinnitus may vary, from a low,\r\n  quiet, background tinnitus, to a very high\r\n  tinnitus, capable of overlapping external\r\n  sounds [<a href=\"#6\" title=\"6\">6</a>]. The tinnitus can be only one\r\n  sound or more than one, which can be permanent or fluctuating. It is believed\r\n  that this kind of perception is results from\r\n  abnormal neural activity to a subcortical\r\n  level of the auditory pathway [<a href=\"#7\" title=\"7\">7</a>,<a href=\"#8\" title=\"8\">8</a>].\r\n  The tinnitus itself it&rsquo;s not classified as a\r\n  disease, but rather, a symptom of a variety\r\n  of underlying diseases. Many otological,\r\n  metabolical, neurological, cardiovascular,\r\n  pharmacological, odontological and\r\n  psychological conditions that can pile up\r\n  upon themselves in the same individual\r\n  can cause tinnitus [<a href=\"#9\" title=\"9\">9</a>].</p>\r\n<p>Among the otological causes, are\r\n  included the tinnitus induced hearing loss,\r\n  presbycusis, otosclerosis, otitis, obstructing\r\n  wax, sudden deafness, M&eacute;ni&egrave;re&rsquo;s disease,\r\n  and other cause of hearing loss [<a href=\"#6\" title=\"6\">6</a>].Any bruise to the auditory pathway or\r\n  any reduction in the auditory nerve&rsquo;s\r\n  function has the potential to result in the\r\n  symptom of tinnitus [<a href=\"#10\" title=\"10\">10</a>]. However, it can\r\n  also be associated with normal hearing in\r\n  conventional audiometry, that being said,\r\n  it&rsquo;s necessary to search for other causes\r\n  of tinnitus. A study took place in 2010,\r\n  36.86% of people affected by tinnitus had\r\n  normal hearing [<a href=\"#11\" title=\"11\">11</a>]. This phenomenon is\r\n  explained by the Otoacoustics Emissions\r\n  Transients (TEOAE) with smaller\r\n  amplitude of subjects that alterations in\r\n  the peripheral level might contribute to\r\n  the generation of the tinnitus. [<a href=\"#12\" title=\"12\">12</a>].</p>\r\n<p>A variation at central level can be\r\n  generated and/or maintainer of the\r\n  tinnitus. Alterations at the efferent\r\n  pathway, more specifically at the Superior\r\n  Olivary Complex (SOC), might be one of\r\n  the causes of the tinnitus in patients with\r\n  normal hearing [<a href=\"#13\" title=\"13\">13</a>]. The human cochlea\r\n  receives innervation of COS efferent\r\n  fibers. Those systems affect directly the\r\n  cochlear modulation, as both inhibitory\r\n  and exciting [<a href=\"#14\" title=\"14\">14</a>].</p>\r\n<p>If the individual, in fact, presents hearing\r\n  loss, being it whatever otology behind it, it\r\n  is one base disease related to the symptom\r\n  of tinnitus. About 85 to 96% of patients\r\n  with tinnitus show some level of hearing\r\n  loss [<a href=\"#15\" title=\"15\">15</a>,<a href=\"#16\" title=\"16\">16</a>]. In study about hearing loss\r\n  in adults through 48 and 92 years old, it\r\n  was discovered the prevalence of tinnitus\r\n  in 8.2% of the subjects of the first study,\r\n  five years later that number would drop\r\n  to 5.7% [<a href=\"#17\" title=\"17\">17</a>]. The presence of tinnitus is\r\n  directly connected with aging [<a href=\"#18\" title=\"18\">18</a>].</p>\r\n<p>Most patients suffering from hearing loss\r\n  and tinnitus say the tinnitus frequency\r\n  is related to severeness and the\r\n  characteristic frequency of the hearing\r\n  loss, the tinnitus&rsquo;s intensity is usually lower\r\n  than 10 dB above the patients hearing\r\n  threshold of this isolated frequency [<a href=\"#7\" title=\"7\">7</a>].</p>\r\n<p>In cases of hearing loss, being the patient\r\n  enable to receive prosthetics adaptation,\r\n  as a means to enhance the external sound,\r\n  could be one way to treat tinnitus [<a href=\"#19\" title=\"19\">19</a>],\r\n  indirectly. Knowing they are projected to\r\n  improve the audibility of speeches and\r\n  to amplify the environment sounds. This\r\n  factor deflects the attention from the\r\n  tinnitus, partially masking it [<a href=\"#20\" title=\"20\">20</a>].</p>\r\n<p>From previous knowledge about\r\n  the variations of audi<a href=\"#\">tory pathway&rsquo;s\r\n    functionality in the p</a>resence of tinnitus,\r\n  being it related to regular hearing or\r\n  not, it&rsquo;s necessary further enlightenment\r\n  and more researches on the subject and\r\n  in favor of the population searching for\r\n  support in the diagnosis and treatment of\r\n  tinnitus, improving the way of life of the\r\n  affected population. The main goal of this\r\n  paper is to trace a profile of patients with\r\n  tinnitus complaints.</p>\r\n<h4>METHODOLOGY</h4>\r\n<p>This descriptive and transversal study was\r\n  performed at school clinic of the Speech\r\n  Therapy course from a university of Joao\r\n  Pessoa. 121 volunteers, aged between 18\r\n  and 82, 78 females and 43 males, took\r\n  part in this experiment. The sample\r\n  was by convenience, non-probabilistic\r\n  sampling and of spontaneous demand.\r\n  The volunteers needed to be above 18\r\n  and refer tinnitus, both uni and bilateral.</p>\r\n<p>According to the 466/12 resolution, of\r\n  the National Health Council, in reference\r\n  to ethics involving researching with\r\n  human beings, the study was approved by\r\n  the Ethic Committee in Researching with\r\n  Humans. (Protocol n.: 0129/12).</p>\r\n<p>The volunteers accepted taking part in\r\n  the study by signing the Terms of Free and\r\n  Enlightened Consent; they were submitted\r\n  to a series of evaluations. The evaluations\r\n  procedures were anamnesis, specific\r\n  questionnaire about tinnitus, audiological\r\n  tests of audiometry, acuphenometry,\r\n  and the Tinnitus Handicap Inventory\r\n  questionnaire.</p>\r\n<p>The anamnesis was performed in order\r\n  to obtain data such as age, gender, tinnitus\r\n  location (right ear, left ear, both ears or\r\n  head), time of emergence (days, months\r\n  or years), how it came to be (gradual,\r\n  sudden or after noise exposure), type\r\n  of tinnitus (continuous, modulated\r\n  frequency or noise) characteristics of the\r\n  sound (whistle, rain wheezing, waterfall,\r\n  bee, others).</p>\r\n<p>The THI questionnaire was used as\r\n  a potential measure to classify the\r\n  disturbance caused by tinnitus, in form\r\n  of an interview to leave no doubt. It\r\n  is composed of 25 questions, allowing\r\n  the participant to choose between the\r\n  answers &ldquo;yes, &ldquo;no&rdquo; and &ldquo;sometimes&rdquo;,\r\n  the score of &ldquo;4 points&rdquo;, &ldquo;0 points&rdquo; and\r\n  &ldquo;2 points&rdquo; was given respectively to\r\n  each one of them. The questions spread\r\n  across functional aspects, emotional and\r\n  catastrophic of the tinnitus, creating an\r\n  index that classify the disturbance as\r\n  &ldquo;slight&rdquo;, &ldquo;mild&rdquo;, &ldquo;moderate&rdquo;, &ldquo;severe&rdquo; and\r\n  &ldquo;catastrophic, the total sum can vary from\r\n  0 to 100 [<a href=\"#21\" title=\"21\">21</a>]. Depending on the result,\r\n  the level of disturbance, is classified as\r\n  slight (0-16), mild (18-36), moderate (38-\r\n  56), severe (58-76) or catastrophic (78-\r\n  100) [<a href=\"#22\" title=\"22\">22</a>].</p>\r\n<p>In regards to the tests performed at an\r\n  acoustic room and using the Vibrasom\r\n  AVS 500 audiometer. Tests such as Tonal\r\n  Audiometry (aerial pathway and bone\r\n  pathway), to determine the auditory&rsquo;s\r\n  threshold of the patients, Acuphenometry,\r\n  to obtain loudness data (sensation of\r\n  intensity), pitch (sensation of frequency)\r\n  and the sound type (Continuous Pure\r\n  Tone, Modulated Frequency, Narrow\r\n  Band noise or Wihte Noise) referred by\r\n  the patient as the closest sound possible\r\n  to his tinnitus.</p>\r\n<p>In Tonal Audiometry, the following\r\n  frequencies were evaluated: 250, 500,\r\n  1000, 2000, 3000, 4000, 6000 and 8000\r\n  Hertz (aerial pathway) and 500, 1000,\r\n  2000, 3000 and 4000 Hertz (bone\r\n  pathway) using Modulated Frequency\r\n  stimulus, from higher intensity (120 dB)\r\n  to the lowest, until the patient&rsquo;s auditory\r\n  threshold is reached. Regarding hearing\r\n  loss cases, the classification is given\r\n  according to its shape of manifestation,\r\n  being it unilateral or bilateral, origin/location as conductive, sensorineural or\r\n  mixed [<a href=\"#23\" title=\"23\">23</a>] and severeness, performing\r\n  one arithmetic mean between the\r\n  frequencies 500, 1000, 2000 and 4000\r\n  Hertz in the auditory pathway. Classifying\r\n  them as slight the auditory limits between\r\n  26 to 40 dBNA, moderated between 41\r\n  to 60 dBNA, severe between 61 to 80\r\n  dBNA and profound, those who obtained\r\n  auditory thresholds from 81 dBNA\r\n  onwards [<a href=\"#24\" title=\"24\">24</a>]. In case of hearing loss,\r\n  restricted to certain frequencies, where\r\n  bone conduction was not performed,\r\n  them being acute or low, or yet both,\r\n  [<a href=\"#7\" title=\"7\">7</a>], the terms &ldquo;hearing loss of isolated\r\n  frequencies&rdquo; or &ldquo;undetermined level of\r\n  hearing loss&rdquo; will be used.</p>\r\n<p>However, to measure loudness, pitch\r\n  and the type of sound coming from\r\n  the tinnitus, an acuphenometry was\r\n  performed, psychoacoustic measure, even\r\n  though this is a categorization supplied by\r\n  the patient only, within its particularities,\r\n  as endless possibilities of sound that can\r\n  be called tinnitus and the test&rsquo;s limitation\r\n  due to a shortage of sounds [<a href=\"#25\" title=\"25\">25</a>]. This way,\r\n  the patient can identify which tinnitus is\r\n  similar to his own.</p>\r\n<p>When the tinnitus was unilateral, the\r\n  sound was supplied to the contralateral\r\n  ear, if bilateral, in the ear with best\r\n  hearing [<a href=\"#22\" title=\"22\">22</a>]. This way, firstly the type of\r\n  sound was researched (Pure Continuous\r\n  Sound, Modulated Frequency, Narrow\r\n  Band and White Noise), in order to find\r\n  pitch, by staying in this first instant, there\r\n  is a loudness of 10 dB above the auditory\r\n  threshold of the patient. The patient has\r\n  chosen between two different sounds,\r\n  for instance, one sound of 125 Hz and\r\n  another of 8000 Hz, while wondering\r\n  &ldquo;which one of these sounds is more\r\n  alike my tinnitus?&rdquo; expressed in Hertz\r\n  (Hz), corresponding to the perception\r\n  of frequency of the tinnitus. In order\r\n  to, at last, find the loudness, it being the\r\n  increase, 1 dB at a time, of sound intensity.\r\n  The result was expressed in dBNS (level\r\n  of satisfaction). This order was used in\r\n  order to prevent the patient from not\r\n  hearing the stimulus due to the hearing\r\n  loss being in the same frequency as the\r\n  tinnitus.</p>\r\n<p>A descriptive analysis of statistics\r\n  was performed, in order to verify the frequency, average and standard deviation\r\n  of the variables studied. Followed by an\r\n  inferential analysis of statistics, with the\r\n  adequate tests to verify the comparison\r\n  between the values of each ear, using\r\n  the parametric t test of Student for\r\n  independent samples to variables with\r\n  intervals of normal distribution, or with\r\n  it corresponding non-parametric of\r\n  Wilcoxon; For the correlation between\r\n  variables The Spearman Correlation test\r\n  was performed as means to identify the\r\n  degree of relationship between pairs of\r\n  variables of interest, as: THI x age, THI x\r\n  gender, THI x Level of Hearing Loss, THI x\r\n  Type of Hearing Loss.</p>\r\n<p>The differences were considered relevant\r\n  when p&lt;0.05 was presented. The\r\n  statistical analysis was performed through\r\n  the Statistical Package for Social Sciences\r\n  (SPPS), version 2.0.</p>\r\n<h4>RESULTS</h4>\r\n<p>The research had 121 participants with\r\n  average age of 48, 71 years. Them being\r\n  78(64.5%) female and 43 (35.5%) male.</p>\r\n<p>In regards to the location of the tinnitus,\r\n  a larger occurrence was observed when\r\n  in the bilateral state (<strong>Table 1</strong>). As of\r\n  the relation degree with THI, a larger\r\n  frequency of mild level was observed\r\n  (<strong>Table 2</strong>).</p>\r\n<div class=\"table-responsive\">\r\n  <table class=\"table table-sm table-bordered\">\r\n    <thead>\r\n      <tr>\r\n        <th>Variables</th>\r\n        <th>N&ordm;</th>\r\n        <th>%</th>\r\n      </tr>\r\n    </thead>\r\n    <tbody>\r\n      <tr>\r\n        <td>RE</td>\r\n        <td>23</td>\r\n        <td>19.0</td>\r\n      </tr>\r\n      <tr>\r\n        <td>LE</td>\r\n        <td>28</td>\r\n        <td>23.1</td>\r\n      </tr>\r\n      <tr>\r\n        <td>Bilateral</td>\r\n        <td>59</td>\r\n        <td>48.8</td>\r\n      </tr>\r\n      <tr>\r\n        <td>In the Head</td>\r\n        <td>11</td>\r\n        <td>9.1</td>\r\n      </tr>\r\n      <tr>\r\n        <td>Total</td>\r\n        <td>121</td>\r\n        <td>100.0</td>\r\n      </tr>\r\n      <tr>\r\n        <td colspan=\"3\">RE=right ear; LE=left ear</td>\r\n      </tr>\r\n    </tbody>\r\n  </table>\r\n</div>\r\n<p><strong>Table 1. </strong>Descriptive analysis of the location of tinnitus.</p>\r\n<div class=\"table-responsive\">\r\n  <table class=\"table table-sm table-bordered\">\r\n    <thead>\r\n      <tr>\r\n        <th>Variables</th>\r\n        <th>N&ordm;</th>\r\n        <th>%</th>\r\n      </tr>\r\n    </thead>\r\n    <tbody>\r\n      <tr>\r\n        <td>Slight</td>\r\n        <td>26</td>\r\n        <td>21.5</td>\r\n      </tr>\r\n      <tr>\r\n        <td>Mild</td>\r\n        <td>34</td>\r\n        <td>28.1</td>\r\n      </tr>\r\n      <tr>\r\n        <td>Moderate</td>\r\n        <td>25</td>\r\n        <td>20.7</td>\r\n      </tr>\r\n      <tr>\r\n        <td>Severe</td>\r\n        <td>18</td>\r\n        <td>14.9</td>\r\n      </tr>\r\n      <tr>\r\n        <td>Catastrophic</td>\r\n        <td>18</td>\r\n        <td>14.9</td>\r\n      </tr>\r\n      <tr>\r\n        <td>Total</td>\r\n        <td>121</td>\r\n        <td>100.0</td>\r\n      </tr>\r\n    </tbody>\r\n  </table>\r\n</div>\r\n<p><strong>Table 2. </strong>Descriptive analysis of the THI degree. </p>\r\n<p>Performing the analysis of the type of\r\n  sound, ears were considered separately.\r\n  This way, for both ears, there was higher\r\n  frequency of the tinnitus with continuous\r\n  type of sound 51.2% to the right ear and\r\n  52.9% to the left.</p>\r\n<p>As it follows, an analysis of the auditory\r\n  profile of those individuals was performed,\r\n  split by ears. Having observed that the type\r\n  of hearing loss of isolated frequencies,\r\n  those restricted to specific frequencies\r\n  and in which degree of hearing loss it\r\n  is not classified, was the most frequent.\r\n  Followed by regular hearing in both ears\r\n  (<strong>Tables 3 and 4</strong>).</p>\r\n<div class=\"table-responsive\">\r\n  <table class=\"table table-sm table-bordered\">\r\n    <thead>\r\n      <tr>\r\n        <th>Ears</th>\r\n        <th>Variables</th>\r\n        <th>N&ordm;</th>\r\n        <th>%</th>\r\n      </tr>\r\n    </thead>\r\n    <tbody>\r\n      <tr>\r\n        <td rowspan=\"6\">Right</td>\r\n        <td>Normal</td>\r\n        <td>40</td>\r\n        <td>33.1</td>\r\n      </tr>\r\n      <tr>\r\n        <td>HL isolated freq.</td>\r\n        <td>44</td>\r\n        <td>36.4</td>\r\n      </tr>\r\n      <tr>\r\n        <td>HL sensorineural </td>\r\n        <td>24</td>\r\n        <td>19.8</td>\r\n      </tr>\r\n      <tr>\r\n        <td>HL conductive</td>\r\n        <td>1</td>\r\n        <td>0.8</td>\r\n      </tr>\r\n      <tr>\r\n        <td>HL mixed</td>\r\n        <td>12</td>\r\n        <td>9.9</td>\r\n      </tr>\r\n      <tr>\r\n        <td>Total</td>\r\n        <td>121</td>\r\n        <td>100.0</td>\r\n      </tr>\r\n      <tr>\r\n        <td rowspan=\"5\">Left</td>\r\n        <td>Normal</td>\r\n        <td>36</td>\r\n        <td>29.8</td>\r\n      </tr>\r\n      <tr>\r\n        <td>HL isolated freq.</td>\r\n        <td>43</td>\r\n        <td>35.5</td>\r\n      </tr>\r\n      <tr>\r\n        <td>HL sensorineural </td>\r\n        <td>22</td>\r\n        <td>18.2</td>\r\n      </tr>\r\n      <tr>\r\n        <td>HL conductive</td>\r\n        <td>1</td>\r\n        <td>0.8</td>\r\n      </tr>\r\n      <tr>\r\n        <td>HL mixed</td>\r\n        <td>19</td>\r\n        <td>15.7</td>\r\n      </tr>\r\n      <tr>\r\n        <td>&nbsp;</td>\r\n        <td>Total</td>\r\n        <td>121</td>\r\n        <td>100.0</td>\r\n      </tr>\r\n      <tr>\r\n        <td colspan=\"4\">HL=hearing    loss</td>\r\n      </tr>\r\n    </tbody>\r\n  </table>\r\n</div>\r\n<p><strong>Table 3.</strong> Descriptive analysis of the auditory profile  by ear.</p>\r\n<div class=\"table-responsive\">\r\n  <table class=\"table table-sm table-bordered\">\r\n    <thead>\r\n      <tr>\r\n        <th>Ears</th>\r\n        <th>Variables</th>\r\n        <th>N&ordm;</th>\r\n        <th>%</th>\r\n      </tr>\r\n    </thead>\r\n    <tbody>\r\n      <tr>\r\n        <td rowspan=\"6\">Right</td>\r\n        <td>Unclassified</td>\r\n        <td>84</td>\r\n        <td>69.4</td>\r\n      </tr>\r\n      <tr>\r\n        <td>Slight</td>\r\n        <td>17</td>\r\n        <td>14.0</td>\r\n      </tr>\r\n      <tr>\r\n        <td>Moderate</td>\r\n        <td>14</td>\r\n        <td>11.6</td>\r\n      </tr>\r\n      <tr>\r\n        <td>Severe</td>\r\n        <td>3</td>\r\n        <td>2.5</td>\r\n      </tr>\r\n      <tr>\r\n        <td>Profound</td>\r\n        <td>3</td>\r\n        <td>2.5</td>\r\n      </tr>\r\n      <tr>\r\n        <td>Total</td>\r\n        <td>121</td>\r\n        <td>100.0</td>\r\n      </tr>\r\n      <tr>\r\n        <td rowspan=\"6\">Left</td>\r\n        <td>Unclassified</td>\r\n        <td>79</td>\r\n        <td>65.3</td>\r\n      </tr>\r\n      <tr>\r\n        <td>Slight</td>\r\n        <td>21</td>\r\n        <td>17.4</td>\r\n      </tr>\r\n      <tr>\r\n        <td>Moderate</td>\r\n        <td>14</td>\r\n        <td>11.6</td>\r\n      </tr>\r\n      <tr>\r\n        <td>Severe</td>\r\n        <td>1</td>\r\n        <td>0.8</td>\r\n      </tr>\r\n      <tr>\r\n        <td>Profound</td>\r\n        <td>6</td>\r\n        <td>5.0</td>\r\n      </tr>\r\n      <tr>\r\n        <td>Total</td>\r\n        <td>121</td>\r\n        <td>100.0</td>\r\n      </tr>\r\n    </tbody>\r\n  </table>\r\n</div>\r\n<p><strong>Table 4.</strong> Descriptive analysis of the level of hearing loss by ear.</p>\r\n<p>When put together, the data from THI\r\n  with the information of hearing profile by\r\n  ear, became clear that the right ear has the\r\n  biggest relation with the degree of hearing\r\n  loss of isolated frequencies, followed by\r\n  regular hearing with the slight level of THI.\r\n  The left ear, on the other hand, showed\r\n  that the slight level of THI was bigger in\r\n  both regular hearing and hearing loss of\r\n  isolated frequencies (<strong>Tables 5 and 6</strong>).</p>\r\n<div class=\"table-responsive\">\r\n  <table class=\"table table-sm table-bordered\">\r\n    <thead>\r\n      <tr>\r\n        <th colspan=\"3\" rowspan=\"2\">Variables*</th>\r\n        <th colspan=\"5\">Auditory profile</th>\r\n      </tr>\r\n      <tr>\r\n        <th>Normal hearing</th>\r\n        <th>HL isolated freq.</th>\r\n        <th>HL<br />\r\n          sensorineural</th>\r\n        <th>HL<br />\r\n          conductive</th>\r\n        <th>HL<br />\r\n          mixed</th>\r\n      </tr>\r\n    </thead>\r\n    <tbody>\r\n      <tr>\r\n        <td rowspan=\"10\">THI</td>\r\n        <td rowspan=\"2\">slight degree</td>\r\n        <td>N&ordm;</td>\r\n        <td>13</td>\r\n        <td>8</td>\r\n        <td>3</td>\r\n        <td>0</td>\r\n        <td>2</td>\r\n      </tr>\r\n      <tr>\r\n        <td>%</td>\r\n        <td>10.7</td>\r\n        <td>6.6</td>\r\n        <td>2.5</td>\r\n        <td>0.0</td>\r\n        <td>1.7</td>\r\n      </tr>\r\n      <tr>\r\n        <td rowspan=\"2\">mild    degree</td>\r\n        <td>N&ordm;</td>\r\n        <td>10</td>\r\n        <td>15</td>\r\n        <td>7</td>\r\n        <td>0</td>\r\n        <td>2</td>\r\n      </tr>\r\n      <tr>\r\n        <td>%</td>\r\n        <td>8.3</td>\r\n        <td>12.4</td>\r\n        <td>5.8</td>\r\n        <td>0.0</td>\r\n        <td>1.7</td>\r\n      </tr>\r\n      <tr>\r\n        <td rowspan=\"2\">moderate degree</td>\r\n        <td>N&ordm;</td>\r\n        <td>10</td>\r\n        <td>8</td>\r\n        <td>6</td>\r\n        <td>0</td>\r\n        <td>1</td>\r\n      </tr>\r\n      <tr>\r\n        <td>%</td>\r\n        <td>8.3</td>\r\n        <td>6.6</td>\r\n        <td>5.0</td>\r\n        <td>0.0</td>\r\n        <td>0.8</td>\r\n      </tr>\r\n      <tr>\r\n        <td rowspan=\"2\">Severe degree</td>\r\n        <td>N&ordm;</td>\r\n        <td>4</td>\r\n        <td>6</td>\r\n        <td>5</td>\r\n        <td>1</td>\r\n        <td>2</td>\r\n      </tr>\r\n      <tr>\r\n        <td>%</td>\r\n        <td>3.3</td>\r\n        <td>5.0</td>\r\n        <td>4.1</td>\r\n        <td>0.8</td>\r\n        <td>1.7</td>\r\n      </tr>\r\n      <tr>\r\n        <td rowspan=\"2\">Catastrophic degree</td>\r\n        <td>N&ordm;</td>\r\n        <td>3</td>\r\n        <td>7</td>\r\n        <td>3</td>\r\n        <td>0</td>\r\n        <td>5</td>\r\n      </tr>\r\n      <tr>\r\n        <td>%</td>\r\n        <td>2.5</td>\r\n        <td>5.8</td>\r\n        <td>2.5</td>\r\n        <td>0.0</td>\r\n        <td>4.1</td>\r\n      </tr>\r\n      <tr>\r\n        <td colspan=\"8\"><em>Cross tabulation test</em></td>\r\n      </tr>\r\n      <tr>\r\n        <td colspan=\"8\">HL=hearing loss</td>\r\n      </tr>\r\n    </tbody>\r\n  </table>\r\n</div>\r\n<p><strong>Table 5. </strong>Crossing  of data from THI and auditory profile  of the right ear. </p>\r\n<div class=\"table-responsive\">\r\n  <table class=\"table table-sm table-bordered\">\r\n    <thead>\r\n      <tr>\r\n        <th colspan=\"3\" rowspan=\"2\">Variables*</th>\r\n        <th colspan=\"5\">Auditory profile</th>\r\n      </tr>\r\n      <tr>\r\n        <th>Normal<br />\r\n          hearing</th>\r\n        <th>HL isolated<br />\r\n          freq.</th>\r\n        <th>HL<br />\r\n          sensorineural</th>\r\n        <th>HL<br />\r\n          conductive</th>\r\n        <th>HL<br />\r\n          mixed</th>\r\n      </tr>\r\n    </thead>\r\n    <tbody>\r\n      <tr>\r\n        <td rowspan=\"10\">THI</td>\r\n        <td rowspan=\"2\">slight degree</td>\r\n        <td>N&ordm;</td>\r\n        <td>9</td>\r\n        <td>11</td>\r\n        <td>3</td>\r\n        <td>0</td>\r\n        <td>3</td>\r\n      </tr>\r\n      <tr>\r\n        <td>%</td>\r\n        <td>7.4</td>\r\n        <td>9.1</td>\r\n        <td>2.5</td>\r\n        <td>0.0</td>\r\n        <td>2.5</td>\r\n      </tr>\r\n      <tr>\r\n        <td rowspan=\"2\">mild degree</td>\r\n        <td>N&ordm;</td>\r\n        <td>11</td>\r\n        <td>14</td>\r\n        <td>5</td>\r\n        <td>0</td>\r\n        <td>4</td>\r\n      </tr>\r\n      <tr>\r\n        <td>%</td>\r\n        <td>9.1</td>\r\n        <td>11.6</td>\r\n        <td>4.1</td>\r\n        <td>0.0</td>\r\n        <td>3.3</td>\r\n      </tr>\r\n      <tr>\r\n        <td rowspan=\"2\">moderate degree</td>\r\n        <td>N&ordm;</td>\r\n        <td>10</td>\r\n        <td>6</td>\r\n        <td>5</td>\r\n        <td>0</td>\r\n        <td>4</td>\r\n      </tr>\r\n      <tr>\r\n        <td>%</td>\r\n        <td>8.3</td>\r\n        <td>5.0</td>\r\n        <td>4.1</td>\r\n        <td>0.0</td>\r\n        <td>3.3</td>\r\n      </tr>\r\n      <tr>\r\n        <td rowspan=\"2\">Severe degree</td>\r\n        <td>N&ordm;</td>\r\n        <td>2</td>\r\n        <td>7</td>\r\n        <td>3</td>\r\n        <td>1</td>\r\n        <td>5</td>\r\n      </tr>\r\n      <tr>\r\n        <td>%</td>\r\n        <td>1.7</td>\r\n        <td>5.8</td>\r\n        <td>2.5</td>\r\n        <td>0.8</td>\r\n        <td>4.1</td>\r\n      </tr>\r\n      <tr>\r\n        <td rowspan=\"2\">Catastrophic degree</td>\r\n        <td>N&ordm;</td>\r\n        <td>4</td>\r\n        <td>5</td>\r\n        <td>6</td>\r\n        <td>0</td>\r\n        <td>3</td>\r\n      </tr>\r\n      <tr>\r\n        <td>%</td>\r\n        <td>3.3</td>\r\n        <td>4.1</td>\r\n        <td>5.0</td>\r\n        <td>0.0</td>\r\n        <td>2.5</td>\r\n      </tr>\r\n      <tr>\r\n        <td colspan=\"8\"><em>Cross tabulation test</em></td>\r\n      </tr>\r\n      <tr>\r\n        <td colspan=\"8\">HL=hearing loss</td>\r\n      </tr>\r\n    </tbody>\r\n  </table>\r\n</div>\r\n<p><strong>Table 6. </strong>Crossing  of data from THI and auditory profile  of the left ear.</p>\r\n<p>Performing the comparison between the\r\n  variables of level hearing loss of left and\r\n  right ears, using the Wilcoxon Signed\r\n  Ranks, there was no meaningfulness\r\n  (r=0.467). The right ear had an average of\r\n  1.5455 (DP 0.96609). meanwhile. The left\r\n  ear 1.6281 (DP 1.05777). Therefore, the\r\n  relation of level of disturbance of tinnitus\r\n  with the degree of hearing loss was not\r\n  relevant, seeing that there was a larger\r\n  frequency of hearing loss of isolated\r\n  frequencies, in which the degree is not\r\n  classified.</p>\r\n<p>The average values of pitch and loudness\r\n  found were 4664Hz and 20.61dBNS for\r\n  the right ear, and 4685Hz and 18.83dBNS\r\n  for the left ear, using the t test of Student.</p>\r\n<p>Correlating the average of pitch (r=0.907/\r\n  p=0.000) and loudness (r=0.650/ p=0.000)\r\n  between the right and left ears, through\r\n  the correlation test of Spearman, a\r\n  meaningfulness of (p&lt;0.05) was observed.\r\n  However, when correlated to the variable\r\n  age, there was no relevance.</p>\r\n<p>The Spearman test was performed\r\n  (p&lt;0.05) in order to correlate the variables\r\n  sex, age, level of THI, auditory profiles and\r\n  levels of hearing loss. Thus, a correlation\r\n  between the female sex and the level\r\n  of unclassified hearing loss for the right\r\n  ear (r=0.192/ p=0.035), was perceived.\r\n  Although, when correlating gender with\r\n  hearing loss, no meaningfulness was found,\r\n  the same happened when correlating any\r\n  variable with age.</p>\r\n<p>Comparing THI with the type of hearing\r\n  loss, through the Spearman (p&lt;0.05) test,\r\n  a relevance was also noticed in both ears\r\n  (OD r=0.194/ p=0.033; OE r=0.241/\r\n  p=0.008). The highest scores of hearing\r\n  loss of isolated frequencies.</p>\r\n<h4>DISCUSSION</h4>\r\n<p>The tinnitus usually affect the male\r\n  population [<a href=\"#11\" title=\"11\">11</a>,<a href=\"#26\" title=\"26\">26</a>], increasing its\r\n  occurrence with aging [<a href=\"#26\" title=\"26\">26</a>,<a href=\"#27\" title=\"27\">27</a>]. This\r\n  research has found individuals with\r\n  average age of 48 years old, females\r\n  were more frequent, and this might be\r\n  explained by a larger demand of from this\r\n  population in agreement with another\r\n  study [<a href=\"#27\" title=\"27\">27</a>].</p>\r\n<p>Regarding the location of the tinnitus,\r\n  a greater number of individuals with\r\n  bilateral tinnitus could be observed\r\n  through this study, in agreement with\r\n  other study [<a href=\"#26\" title=\"26\">26</a>]. As for the THI level,\r\n  the mild degree was noticed more often,\r\n  concurring with another study [<a href=\"#11\" title=\"11\">11</a>].</p>\r\n<p>The type of sound more usually found,\r\n  in this study, for both left and right ears,\r\n  was the pure continuous tone, result also\r\n  reported [<a href=\"#11\" title=\"11\">11</a>].</p>\r\n<p>Concerning the hearing loss, for both\r\n  ears, there was a higher occurrence of\r\n  hearing loss of isolated frequencies, in\r\n  other words, those which are in specific\r\n  frequencies, low, acute, or both. Other\r\n  study has found a greater number of\r\n  hearing loss for acute frequencies related\r\n  to the tinnitus [<a href=\"#28\" title=\"28\">28</a>]. One can infer that this\r\n  phenomena happens due to hearing loss\r\n  being related to the frequency spectrum\r\n  of the tinnitus [<a href=\"#29\" title=\"29\">29</a>].</p>\r\n<p>As for the level of hearing loss, there was\r\n  no relation between the severeness of\r\n  the hearing loss and bigger disturbance\r\n  of the tinnitus. The occurrence of the\r\n  tinnitus can depend on the severeness\r\n  of the hearing loss, however no other\r\n  material was found in order to backup\r\n  this hypothesis, this happens because\r\n  individuals who don&rsquo;t present tinnitus\r\n  have worse hearing than the ones who\r\n  do [<a href=\"#29\" title=\"29\">29</a>]. As well as, 78% of the individuals\r\n  with tinnitus had a slight or moderate\r\n  level of hearing loss [<a href=\"#30\" title=\"30\">30</a>].</p>\r\n<p>In order to describe the pitch of tinnitus,\r\n  an average corresponding to the acute\r\n  frequency of both ears, was found, in\r\n  agreement with other study [<a href=\"#11\" title=\"11\">11</a>,<a href=\"#28\" title=\"28\">28</a>].\r\n  However, the tinnitus&rsquo;s loudness, there is\r\n  a conflict of ideas, seeing that in, another\r\n  study higher averages of the tinnitus&rsquo;s\r\n  intensity were found [<a href=\"#11\" title=\"11\">11</a>].</p>\r\n<p>Associating sides with pitch and loudness\r\n  measures, a meaningfulness correlation\r\n  was perceived in this study, so, the\r\n  intensity and frequency of the tinnitus\r\n  of one ear is equivalent to its opposite.\r\n  This relation was already described, even\r\n  though it had a weak relevance [<a href=\"#29\" title=\"29\">29</a>].Nevertheless, there was a study where\r\n  this didn&rsquo;t happen [<a href=\"#31\" title=\"31\">31</a>].</p>\r\n<p>The results of the crossing between THI\r\n  and auditory profile in the present study,\r\n  showed a greater relation of hearing loss\r\n  restricted to isolated frequencies with\r\n  the slight and mild level of THI and regular\r\n  hearing with a higher mild level of THI.\r\n  Another study has found meaningfulness\r\n  in the mild level, as far as both regular\r\n  hearing and hearing loss are concerned.\r\n  [<a href=\"#11\" title=\"11\">11</a>].</p>\r\n<p>In the present study, there was a higher\r\n  relevance when relating gender and level\r\n  of hearing loss. Concluding that the gender\r\n  influenced the level of hearing loss directly,\r\n  this can be explained by the fact that\r\n  males are more exposed to occupational\r\n  noise [<a href=\"#27\" title=\"27\">27</a>], on the other hand, there is\r\n  the fact that females are more likely to\r\n  seek medical attention. When correlating\r\n  the gender with the type of hearing loss,\r\n  there was no relevance, as well as, no\r\n  variable when correlated with age has\r\n  presented meaningfulness, agreeing with\r\n  other study [<a href=\"#31\" title=\"31\">31</a>].</p>\r\n<p>When correlating, in this study, THI,\r\n  the level of disturbance created by the\r\n  tinnitus, with the level and type of hearing\r\n  loss, relevance was observed in both ears.\r\n  It has already been written that the odds\r\n  of having tinnitus with disturbance ranging\r\n  from moderate to severe, increase with\r\n  the enlargement of auditory&rsquo;s threshold\r\n  of higher frequencies, even though the\r\n  level of hearing loss doesn&rsquo;t affect the\r\n  disturbance caused by the tinnitus [<a href=\"#32\" title=\"32\">32</a>]. A\r\n  higher rate of hearing loss can represent\r\n  one more handicap when associated\r\n  with tinnitus, generating an additional\r\n  disturbance to the patient and not\r\n  necessarily influencing the disturbance of\r\n  the tinnitus itself, and yet, they pile up on\r\n  issues resented by the patient [<a href=\"#33\" title=\"33\">33</a>].</p>\r\n<h4>CONCLUSION</h4>\r\n<p>Based on the results obtained in this\r\n  study, it is possible to conclude:</p>\r\n<p>&#9679; Females were more frequent;</p>\r\n<p>&#9679; The location of bilateral tinnitus is\r\n  the most common;</p>\r\n<p>&#9679; The continuous type of sound was\r\n  the most reported;</p>\r\n<p>&#9679; The average pitch was 4664 Hz\r\n  (OD) and 4685 Hz (OE), and\r\n  loudness was 20 dBNS (OD) and\r\n  18 dBNS (OE);</p>\r\n<p>&#9679; The rate of disturbance more\r\n  often found were slight and mild;</p>\r\n<p>&#9679; The hearing loss of isolated\r\n  frequencies, followed by regular\r\n  hearing, had more influence on the\r\n  THI levels;</p>\r\n<p>&#9679; The type of hearing loss influence\r\n  THI, having a larger occurrence of\r\n  isolated frequencies.</p>\r\n<p>This way, it&rsquo;s important to create an\r\n  auditory profile of people who are\r\n  afflicted by tinnitus, in order to find\r\n  them treatment. For example, the use of\r\n  auditory devices capable of emitting noise\r\n  masking sounds, so the disturbance can\r\n  be decreased, when both associated with\r\n  regular hearing or with hearing loss of\r\n  isolated frequencies.</p>\r\n<h4>REFERENCES</h4>\r\n<ol>\r\n  <li id=\'Reference_Title_Link\' value=\'1\'><a name=\"1\" id=\'1\'></a>American Tinnitus Association  -&ldquo;Information About Tinnitus.&rdquo; Portland, Ata. (1997). </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'2\'><a name=\"2\" id=\'2\'></a>Dias, A. et al. &ldquo;Associa&ccedil;&atilde;o Entre  Perda Auditiva Induzida Pelo Ru&iacute;do E Zumbidos.&rdquo;Cad Sa&uacute;de  P&uacute;blica. 22(1) (2006):  63-68.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'3\'><a name=\"3\" id=\'3\'></a>Davis A, Rafaie A,&ldquo;Epidemiology Of  Tinnitus. In Mark E. The Impact of  Tinnitus.&rdquo;Annual Tinnitus Research Review. (2016):  16-25. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'4\'><a name=\"4\" id=\'4\'></a>Sanchez TG, Ferrari GM.&ldquo;What Is  Tinnitus? In: Samelli AG, ed. Tinnitus, Evaluation, Diagnosis and Rehabilitation &quot;Current  Approaches. S&atilde;o Paulo: Lovise;  (2004): 17-22.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'5\'><a name=\"5\" id=\'5\'></a>Oiticica J, Bittar RSM. &ldquo;Tinnitus  Prevalence in The City of S&atilde;o  Paulo.&rdquo;Braz J Otorhinolaryngol. 81(2) (2015):  167-176. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'6\'><a name=\"6\" id=\'6\'></a>Byung IH, et al.&ldquo;Tinnitus: Characteristics, Causes, Mechanisms, And Treatments.&rdquo;J Clin Neurol. 5 (2009): 11-19.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'7\'><a name=\"7\" id=\'7\'></a>Dobie RA.&ldquo;Overview: Suffering from  Tinnitus In: Snow JB, ed. Tinnitus: Theory and Management.&rdquo;Ont&aacute;rio.  Bc Decker Inc: (2004): 1-7.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'8\'><a name=\"8\" id=\'8\'></a>Jastreboff PJ, Hazell JW. &ldquo;Tinnitus  Retraining Therapy.&rdquo;Cambridge University Press. Cambridge: (2004).</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'9\'><a name=\"9\" id=\'9\'></a>Sanchez TG.&ldquo;Tinnitus: Critical  Analysis Of A Research Experience. &quot;Free Thesis, Faculty Of Medicine, University Of S&atilde;o Paulo. S&atilde;o  Paulo: (2003).</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'10\'><a name=\"10\" id=\'10\'></a>Nuttal AL, et al.&ldquo;Peripheral Process Involved In  Tinnitus. In: Snow JB. Tinnitus: Theory And  Management.&rdquo;Bc Decker Inc. (2004): 52-68. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'11\'><a name=\"11\" id=\'11\'></a>Martines F, et al.&ldquo;Characteristics Of Tinnitus With Or Without Hearing  Loss.&rdquo;Clinical Observations In Sicilian Tinnitus Patients. Auris Nasus Larynx. 37 (2010):  685&ndash;693.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'12\'><a name=\"12\" id=\'12\'></a>Fernandes LC, et al.&ldquo; Normal: Study of the Suppression of Transient Otoacoustic Emissions.&rdquo;Braz J Otorhinolaryngol. 75(3) (2009): 414-419. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'13\'><a name=\"13\" id=\'13\'></a>Chery-Croze S, et al.&ldquo;Medial  Olivo-Cochlear System and Tinnitus.&rdquo;In: Fernandes LC, Santos TMM. Zumbido e Audi&ccedil;&atilde;o Normal:  Estudo Da Supress&atilde;o  Das Emiss&otilde;es Otoac&uacute;sticas Transientes. Braz J Otorhinolaryngol.  75(3) (2009): 414-419.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'14\'><a name=\"14\" id=\'14\'></a>Warr WB, Guinan-Jr JJ.&ldquo;Efferent  Inervation of The Organ of Corti: Two Separate Systems.&rdquo;In: Fernandes LC, Santos TMM. Zumbido e Audi&ccedil;&atilde;o Normal: Estudo da Supress&atilde;o das Emiss&otilde;es Otoac&uacute;sticas Transientes. Braz J Otorhinolaryngol. 75(3) (2009): 414-419.</a></li>\r\n</ol>',NULL,'2022-11-11'),(9,5376,'ajchr','http://www.andrewjohnpublishing.com/','','<p>Hello again! By the time you are\r\n  reading this, we\r\n  have completed\r\n  about 50 % of\r\n  our annual tour\r\n  around the sun\r\n  since we last met.\r\n  A half a year?\r\n  Yup, this issue is\r\n  a little larger than\r\n  usual, as it combines the contents of\r\n  what would normally be the 3rd and 4th\r\n  issues of Canadian Hearing Report.</p>\r\n<p>As editor, I am pleased to note two\r\n  letters in response to an interview we\r\n  had with Abram Bailey AuD, who\r\n  heads up Hearing Tracker, an online\r\n  directory of thousands of hearing health\r\n  care providers. You may recall that\r\n  interview in the first issue of 2016. One\r\n  question I had asked him was what\r\n  he thought of the recent renaissance\r\n  in North America of loop systems for\r\n  churches and other public places. Abram\r\n  replied that compliance with wireless\r\n  streaming protocols might just trump\r\n  (ouch!) older T-Coil technology. Now\r\n  if you dredge your turbulent memories\r\n  further, you might also conjure up the\r\n  first issue of 2015, where we focussed\r\n  on loop systems that work with hearing\r\n  aids T-Coils. OK, scene being now set\r\n  with these two bookmarks, we can\r\n  now introduce two heartfelt letters\r\n  concerning loop systems and T-Coils.\r\n  One is from Juliette Sterns AuD, who is\r\n  a Wisconsin-based audiologist who has\r\n  been one of the foremost proponents of\r\n  loop systems. Another is from a hard-ofhearing\r\n  person himself, one Lee Ramsell,\r\n  vice president of the Canadian Hard of\r\n  Hearing Association&rsquo;s Edmonton Branch.\r\n  All good stuff and good points made all\r\n  around. I wish we had more letters of\r\n  discussion like these.</p>\r\n<p>You&rsquo;ll note the BC oriented cover.\r\n  Well, why not? There&rsquo;s 3 articles in this\r\n  issue that focus completely on goings\r\n  on west of the Rockies. One is an indepth\r\n  interview with Marke Hambley,\r\n  NBC-HIS. I am proud to have known\r\n  this remarkable person for the past 20\r\n  plus years, having first met him when I\r\n  worked at Unitron in the 1990s. At that\r\n  time, he was Unitron&rsquo;s biggest Canadian\r\n  customer. Readers will note no bio or\r\n  introduction at the beginning of the\r\n  interview, as the interview itself lays out\r\n  his truly amazing contributions &ndash; so far\r\n  &ndash; to the hearing health care profession. I\r\n  say &ldquo;so far&rdquo; because the guy just doesn&rsquo;t\r\n  seem to quit. And, to think that it all\r\n  began as an outreach to remote centres\r\n  from here in Victoria BC. Planes, trains,\r\n  and automobiles? Well this one at least\r\n  does involve planes. Have a read. His\r\n  story is a true testament to his will and\r\n  drive to succeed, and should be read by\r\n  all Canadians in the hearing retail sector!\r\n  Another BC-based article is by Paul Mick\r\n  MD, an Ear, Nose and Throat physician\r\n  now working in Kelowna BC, who\r\n  heads up the Hear4U Foundation, a\r\n  new charity first introduced in the Better\r\n  Speech &amp; Hearing month of May 2016.\r\n  As he has an additional Master&rsquo;s degree\r\n  in Public Health from Harvard, Paul is\r\n  well equipped to address the problems\r\n  of accessibility and affordability of\r\n  hearing health care and hearing aids. It\r\n  is heartening to hear his concerns and\r\n  his answer to this very real difficulty\r\n  to so many Canadians who have low\r\n  incomes. His well-sourced and cited\r\n  article highlights the endeavours of the\r\n  Hear4U Foundation, and I am sure I am\r\n  not alone in hoping this can serve as an\r\n  example whose torch can be taken and\r\n  carried by other provinces!</p>\r\n<p>Then of course, there is the World\r\n  Congress of Audiology (WCA) to be\r\n  held in Vancouver BC, on September\r\n  18th-21st! Rose Simpson, a veteran\r\n  writer for Andrew John Publishing\r\n  contacted Joanne Charlebois, CEO\r\n  of Speech-Language and Audiology\r\n  Canada (SAC), for more details of the\r\n  conference. Both SAC and the Canadian\r\n  Academy of Audiology are handling\r\n  the conference. Her article includes\r\n  the layout of the conference, the preconference\r\n  workshops, the keynote\r\n  speakers, roundtable sessions, etc. We&rsquo;ll\r\n  let Rose tell the story, but the conference\r\n  looks like a big one, with over 1000\r\n  attendees expected.</p>\r\n<p>Our 4th article has absolutely nothing to\r\n  do with BC per se, but it does discuss\r\n  an issue that&rsquo;s been brewing and now\r\n  bubbling over for the past couple of\r\n  years. That&rsquo;s the topic of untreated\r\n  hearing loss and cognitive decline\r\n  in the elderly. Our Public Library of\r\n  Science article titled &ldquo;Hearing Loss and\r\n  Cognition: The Role of Hearing Aids,\r\n  Social Isolation and Depression,&rdquo; has a\r\n  bunch of authors (8 to be exact), hailing\r\n  mostly from the UK but also a few from\r\n  the USA. They come to the striking\r\n  conclusion that cognitive improvement\r\n  with the use of hearing aids was not\r\n  associated with the reduction of isolation\r\n  and depression. Rather, they suggest\r\n  that cognitive improvement resulted\r\n  from simply increased audibility and\r\n  increased &ldquo;self-efficacy.&rdquo; This latter term\r\n  from the psychologist Albert Bandura,\r\n  refers to one&rsquo;s inner belief that he/she\r\n  can indeed accomplish tasks in order\r\n  to meet goals of interest. In and of itself,\r\n  this could give rise to optimal cognitive\r\n  performance.</p>\r\n<p>Now, a word in closing; this is my last\r\n  issue being editor with Canadian Hearing\r\n  Report. It&rsquo;s been a good and fun 2 year\r\n  run, but it&rsquo;s now time for me to exit stage\r\n  left. Thanks to John Birkby, president of\r\n  Andrew-John Publishing, and to Scott\r\n  Bryant, managing editor, and to everyone\r\n  else there who has helped me along the\r\n  way. It&rsquo;s been a good thick slice!</p>\r\n<p>Dear CHR Editor,</p>\r\n<p>I would like to respond to comments\r\n  made by Dr. Abraham Bailey in a\r\n  recent CHR, on behalf of the Edmonton\r\n  Branch of CHHA. Full disclosure: I am\r\n  a hearing aid user, an active CHHA\r\n  member, a hearing loop advocate, a\r\n  Western Canadian manufacturer&rsquo;s rep\r\n  that distributes a variety of electronic\r\n  products and systems including all\r\n  types of Assistive Listening Devices\r\n  (ALD). I provide engineering support\r\n  for the design of loop systems and\r\n  provide training to ensure that the\r\n  proper ALD system is specified and\r\n  installed correctly.</p>\r\n<p>While it is true that hearing loops\r\n  very similarly to when they were first\r\n  engineered in 1936, they are about\r\n  as antiquated as a bicycle.... except\r\n  you don&rsquo;t have to peddle. No matter\r\n  where you travel in the world one can\r\n  take the bicycle and use it, no matter\r\n  where you are; the same is true for a\r\n  person with a tcoil-equipped hearing\r\n  aid. And loops are simple to use, just\r\n  a press of a button. In a loop the audio\r\n  is picked up on base band without the\r\n  issue of frequency allocations or digital\r\n  wireless protocols, if a venue is looped,\r\n  just a press of a button and the user\r\n  is connected to the system. There are\r\n  no drop outs, no loss is signal and the\r\n  hearing aid remains connected until\r\n  the user selects a different program of\r\n  the hearing aid.</p>\r\n<p>Try doing that with Bluetooth, an FM\r\n  system, or tour guide system. Perhaps\r\n  at some point in time there will be an\r\n  international standard, perhaps the\r\n  world will agree to use either 110 volt\r\n  or 220 volt systems with either 50 Hz\r\n  or 60 Hz. The world might agree to\r\n  use the same standards for frequency\r\n  allocations of all radio transmissions.....\r\n  perhaps. Even if that were to happen,\r\n  that won&rsquo;t occur overnight</p>\r\n<p>As for Dr. Bailey&rsquo;s comment about\r\n  loops being sensitive to EMI, that is\r\n  true of all electronic devices and when\r\n  the IEC60118-4 standard is met, EMI\r\n  issues are not relevant. A growing\r\n  number of companies across Western\r\n  Canada have been trained in the\r\n  installation of loop systems. They work\r\n  to ensure that the hearing loops meet\r\n  the requirements of the IEC60118-4\r\n  Induction Loop Standard and they will\r\n  not install loops in areas where this\r\n  standard cannot be met.</p>\r\n<p>Hearing care providers will benefit\r\n  when they educate their clients and\r\n  help promote universal and easy to\r\n  use hearing loops. Most users, myself\r\n  included, know that hearing aids\r\n  are only effective up to a distance\r\n  of 1.5 meters and as that distance\r\n  increases, speech intelligibility reduces\r\n  exponentially. We really have trouble\r\n  hearing in airports, train platforms,\r\n  churches, ticket counters, taxi cabs, or\r\n  pharmacies, and loops can greatly help\r\n  there. And they do that with a simple\r\n  push of a button. That is impressive for\r\n  an antiquated system. Loops overcome\r\n  the shortcomings of hearing aids and\r\n  makes users happier with their devices,\r\n  I know I am. Hearing loops offer\r\n  barrier-free hearing similar to what\r\n  ramps do for people in wheelchairs.</p>\r\n<p>The Edmonton Branch of The Canadian\r\n  Hard of Hearing Association and been\r\n  working hard at getting Edmonton\r\n  looped for the past few years and we are\r\n  having an impact. Our city libraries are\r\n  being looped, a number of recreation\r\n  and senior run centres are being looped,\r\n  the Walterdale Theatre is looped, and\r\n  this summer the Citadel Theatre will\r\n  have two of their theaters looped. Two\r\n  local hearing aid centres have installed\r\n  loop systems (Accent Hearing and the\r\n  Audiology Clinic of Northern Alberta)\r\n  for easy demonstrations, and we hope\r\n  to see many more next year.</p>\r\n<p>We disagree with Dr. Bailey&rsquo;s comment\r\n  that these loop systems are a little too\r\n  late, It is never too late to hear! And\r\n  we believe that if he had to use hearing\r\n  aids in every day life to communicate\r\n  he would wholeheartedly agree with\r\n  us.</p>\r\n<p>While at some point in time hearing\r\n  loops may go the way of the VCR, that\r\n  is not just around the corner. And,\r\n  until the world agrees on a world-wide\r\n  universal standard for wireless devices,\r\n  loops are going to be around for some\r\n  time to come.</p>\r\n<p>Respectfully,</p>\r\n<p>Lee Ramsell, Vice President,</p>\r\n<p>The Canadian Hard of Hearing</p>\r\n<p>Association, Edmonton Branch</p>\r\n<p>leeram@shaw.ca</p>\r\n<p>Dear Editor of the Canadian Hearing\r\n  Report,</p>\r\n<p>Kudos for featuring Abram Baily and\r\n  his Hearing Tracker initiative in the\r\n  Spring issue of the Canadian Hearing\r\n  Report (2016;11:5&ndash;7). I believe that the\r\n  Hearing Tracker initiative is one that\r\n  every hearing health care professional\r\n  should get behind. HearingTracker.\r\n  com gives consumers a way to find\r\n  hearing care providers who practice\r\n  ethically and consistently provide a high\r\n  standard of holistic care.</p>\r\n<p>Abram Bailey&rsquo;s response to the recent\r\n  renaissance in North America of\r\n  (hearing) loop systems (&ldquo;might be\r\n  too little too late&rdquo;), surprised me. I\r\n  know him to be a well-informed and\r\n  consumer-oriented audiologist and\r\n  I hold him in high regard. For those\r\n  who missed it, Dr. Bailey and I recently\r\n  sponsored a petition on Change.org\r\n  entitled Stop the FCC from Removing\r\n  the Telecoil Compatibility Requirement\r\n  from HAC Phones. With Dr. Bailey&rsquo;s\r\n  blessing, I would like to respond to\r\n  the comments he made about looping\r\n  technology in CHR, which he agrees\r\n  poorly convey and oversimplify his\r\n  position on the issue.</p>\r\n<p>While I agree with Dr. Bailey that\r\n  it would be great if a new wireless\r\n  streaming &ldquo;comply with rigorous\r\n  wireless streaming protocols.&rdquo; The truth\r\n  is those do not exist at this time.</p>\r\n<p>Hearing aid engineers advise that\r\n  while a universally compatible\r\n  Bluetooth-like transmitter system (with\r\n  one-to-many wide area capability) is\r\n  technically feasible but not practical\r\n  in the foreseeable future. The hurdles\r\n  of frequency spectrum allocation (not\r\n  all countries have the same frequency\r\n  authorizations), arriving at a mutually\r\n  agreeable technology among the hearing\r\n  aid and PSAP manufacturers, and the\r\n  need for people with hearing aids to buy\r\n  new compatible hearing aids in order to\r\n  listen, is likely 10&ndash;15 years out.</p>\r\n<p>After being questioned, Dr. Bailey agreed\r\n  with my timeframe estimate, citing a\r\n  comment made by wireless technology\r\n  guru Nick Hunn, who is currently\r\n  working on a Bluetooth solution for\r\n  wide-area direct audio access. He\r\n  regrets the damage his comment in CHR\r\n  may have caused in discouraging your\r\n  readers from advocating for hearing\r\n  loops or educating their clients on the\r\n  benefits of telecoils.</p>\r\n<p>Our clients deserve to hear today and\r\n  tomorrow. Not 10 years from now. If\r\n  audiologists take this kind of attitude\r\n  towards hearing loops, it will mean that\r\n  many people with hearing loss will live\r\n  their life out without experiencing the\r\n  incredible benefits hearing loops can\r\n  offer in houses of worship, meeting\r\n  rooms, retirement centres, and theaters,\r\n  the very places where hearing aids\r\n  are simply unable to deliver. That\r\n  hearing aids do not deliver in many\r\n  public situations was demonstrated\r\n  in a survey published in the Hearing\r\n  Review of 866 people, each of whom\r\n  rated the performance of their hearing\r\n  aids or cochlear implants using a 10-\r\n  point scale. The average response was\r\n  4.9 using hearing devices (i.e. a nonlooped\r\n  setting) and a remarkable 8.7 in\r\n  a looped environment.</p>\r\n<p>In regard to Dr. Bailey&rsquo;s &ldquo;antiquated\r\n  telecoil&rdquo; technology being &ldquo;subject to\r\n  interference&rdquo; comment, Bluetooth is\r\n  subject to interference as well. The\r\n  IEC60118-4 induction hearing loop\r\n  standard addresses the interference issue\r\n  head-on as loop installers are trained to\r\n  test for this electromagnetic interference,\r\n  which exists in a facility whether or not\r\n  a hearing loop is installed. And, in order\r\n  to meet the IEC standard, installers will\r\n  verify that the magnetic speech signalto-\r\n  electromagnetic noise ratio is 37dB\r\n  or greater. That is a signal to noise ratio\r\n  we can all dream of for our hearing aid\r\n  using clients. I have personally listened\r\n  in hundreds of hearing loops, and love\r\n  the way they help me, a person with\r\n  beginning hearing loss at 6 and 8 kHz,\r\n  hear and can attest that interference is\r\n  rarely a problem.</p>\r\n<p>For information about IEC 60118-4 see\r\n  www.univox.eu/p/FSM_Certificate_\r\n  GbA5V4.pdf</p>\r\n<p>Hearing loop advocates are not for\r\n  hearing loops per se, they are for a\r\n  technology that is relatively low cost,\r\n  worldwide universal, non-proprietary,\r\n  directly compatible with the majority\r\n  of hearing aids and PSAPS without a\r\n  gateway device or remote control, and\r\n  useful in a variety of large area listening\r\n  situations. Loop advocates and installers\r\n  are in effect &ldquo;paving the way&rdquo; for a future\r\n  technology, that will make it easier to\r\n  convince places that jumped on hearing\r\n  loop systems, to update their venue with\r\n  the latest and greatest universal &ldquo;Green -\r\n  or Yellowtooth&rdquo; transmitter technology.\r\n  At the moment, BT wireless streaming\r\n  technology &ndash; though useful in many\r\n  one-on-one situations &ndash; is no-where\r\n  near ready for the large area listening\r\n  system stage and won&rsquo;t be for years to\r\n  come. My husband is still waiting for his\r\n  jetpack.</p>\r\n<p>Juli&euml;tte Sterkens, AuD</p>\r\n<p>Hearing Loss Association of America</p>\r\n<p>Hearing Loop Advocate</p>\r\n<p>jsterkens@hearingloss.rr.com</p>\r\n<h4>Clinically proven to reduce listening efforts throughout the day.*</h4>\r\n<p>We believe that hearing should be as natural and easy as possible. With the new primax&trade;\r\n  hearing technology platform, we&rsquo;ve raised Soundability&trade; to a new level.</p>\r\n<p>Building on proven technologies, primax&rsquo; advanced SpeechMaster function works continuously\r\n  to highlight the dominant speaker&rsquo;s voice by orchestrating all features, including binaural ones.\r\n  primax is clinically proven* to make hearing effortless, thus redefining the ease of listening.</p>\r\n<p>signia-pro.ca</p>\r\n<h4>World Congress of Audiology:Canadian Audiologists Welcome the World</h4>\r\n<p>By Rose Simpson</p>\r\n<p>From September 18&ndash;-21, 2006, Canada\r\n  will play host to the World Congress of\r\n  Audiology (WCA2016) at the Sheraton\r\n  Hotel in Vancouver. It is an event that is\r\n  more than six years in the making and\r\n  will showcase the work of Canadian\r\n  audiologists and researchers on the\r\n  world stage.</p>\r\n<p>The Congress is a joint effort by Canada&rsquo;s\r\n  two national audiology associations &ndash; the\r\n  Canadian Academy of Audiology (CAA)\r\n  and Speech-Language and Audiology\r\n  Canada (SAC). It has been more than\r\n  20 years since Canada has been chosen\r\n  to host the congress.</p>\r\n<p>It will feature more than 130 speakers\r\n  from around the world and is\r\n  expected to attract more than 1,000\r\n  registrants, 60% of whom will come\r\n  from Canada&rsquo;s audiology and speech\r\n  pathology community.</p>\r\n<p>&ldquo;We have a diverse speaker list and we\r\n  have built a wide-ranging international\r\n  program,&rdquo; says Joanne Charlebois,\r\n  the chief executive officer of SAC.\r\n  &ldquo;We wanted to give Canadians the\r\n  opportunity to hear speakers from\r\n  around the world but also showcase\r\n  some of our Canadian experts. I think\r\n  we&rsquo;ve struck a nice balance.&rdquo;</p>\r\n<p>The program sessions will include\r\n  pre-congress workshops, roundtable\r\n  plenary sessions, featured concurrent\r\n  sessions, contributed papers and\r\n  sponsor symposia. Delegates will also\r\n  have the opportunity to participate\r\n  in a diverse scientific program which\r\n  is designed to provide the latest\r\n  in innovations and research from\r\n  leading health-care professionals\r\n  from around the world. The emphasis\r\n  will be on relating research evidence\r\n  to clinical practice.</p>\r\n<p>The congress has also attracted\r\n  international interest for its trade show\r\n  which has been sold out for months.</p>\r\n<p>Charlebois says the congress will also\r\n  provide a unique opportunity for\r\n  students who have been encouraged to\r\n  actively participate in the program.</p>\r\n<p>&ldquo;We are so pleased that there is a\r\n  very strong student registration,&rdquo; she\r\n  says. &ldquo;The universities have been very\r\n  supportive and they have planned\r\n  that week especially so students could\r\n  attend. This is a terrific opportunity\r\n  for students who are going into the\r\n  audiology profession to hear from\r\n  individuals they&rsquo;ve been learning\r\n  about in their classrooms. This year,\r\n  those experts will be on Canadian\r\n  soil and it&rsquo;s a chance for students\r\n  to attend their sessions and interact\r\n  with them.&rdquo;</p>\r\n<p>Charlebois says the choice of Vancouver\r\n  as the site for the congress has piqued\r\n  the interest of international delegates.</p>\r\n<p>&ldquo;Vancouver is a very attractive\r\n  location for congress delegates,&rdquo; she\r\n  says. &ldquo;We chose it strategically. The\r\n  Canadian dollar also makes this a\r\n  very attractive event for international\r\n  participants in terms of registrations and\r\n  accommodations.&rdquo;</p>\r\n<p>The congress will have strong Canadian\r\n  representation with more than 600\r\n  audiologists from across the country\r\n  registered.</p>\r\n<p>&ldquo;I think this speaks volumes in terms\r\n  of Canadian audiologists coming\r\n  together with professionals from\r\n  around the world.&rdquo;</p>\r\n<h4>KEYNOTE SPEAKERS:</h4>\r\n<p>The WCA 2016 congress will feature\r\n  a number of\r\n  renowned experts\r\n  from Canada,\r\n  and around\r\n  the world. The\r\n  opening keynote,\r\n  Communication in\r\n  an Aging World:\r\n  Get Ready will be delivered by Yves\r\n  Joanette, a professor of Cognitive\r\n  Neurosciences and Aging at the\r\n  Faculty of Medicine at the Universit&eacute; de\r\n  Montr&eacute;al. He is currently the scientific\r\n  director of the Institute of Aging of the\r\n  Canadian Institutes of Health Research\r\n  (CIHR). He is the scientific lead of the\r\n  CIHR Dementia Research Strategy and\r\n  also acts as a co-lead of other CIHR\r\n  initiatives on eHealth and on Healthy\r\n  and Productive Work.</p>\r\n<h4>WHO LECTURE</h4>\r\n<p>Dr. Shelly Chadha oversees WHO&rsquo;s\r\n  work on prevention\r\n  of deafness and\r\n  hearing loss\r\n  including advocacy\r\n  for prioritization\r\n  of hearing care;\r\n  technical support\r\n  to countries for\r\n  development of hearing care strategies;\r\n  and development of technical tools and\r\n  guidance. She will deliver the WHO\r\n  lecture which will explain the WHO\r\n  program, discuss WHO initiatives\r\n  such as World Hearing Day which are\r\n  designed to arouse public interest in\r\n  the global movement to make hearing\r\n  care accessible to all.</p>\r\n<h4>GLORIG LECTURE</h4>\r\n<p>Professor Harvey Dillon, director of\r\n  research at the\r\n  National Acoustic\r\n  Laboratories in\r\n  Sydney, Australia,\r\n  will deliver the\r\n  Glorig Lecture on\r\n  Listening in Noise.\r\n  His lecture will\r\n  discuss how binaural beamformer\r\n  microphones can be used to improve\r\n  listening in noise for people with\r\n  sensorineural hearing loss, and how\r\n  training in spatialized noise can be used\r\n  to completely overcome the deficits\r\n  experienced by children with spatial\r\n  processing disorder. It will also discuss\r\n  how adaptive speech-in-noise tests can\r\n  be combined with adaptive tone-innoise\r\n  tests, and adaptive speech tests in\r\n  quiet to remotely and automatically not\r\n  only detect hearing problems, but also\r\n  determine whether the problems arise\r\n  from sensorineural loss, conductive\r\n  loss, or auditory processing disorders/\r\n  language disorders, even in children as\r\n  young as four.</p>\r\n<h4>PRE-CONGRESS WORKSHOPS</h4>\r\n<p>The congress will kickoff with six\r\n  workshops designed to appeal to a\r\n  wide variety of interests. Prior to the full\r\n  congress, registered delegates can also\r\n  participate in two satellite workshops\r\n  conducted by the University of British\r\n  Columbia&rsquo;s School of Audiology and\r\n  Speech Sciences on their campus.</p>\r\n<p><strong>Wideband Tympanometry:</strong> The first\r\n  will discuss Wideband Tympanometry\r\n  which is gaining popularity around the\r\n  world. The session will cover the general\r\n  principles of absorbance/reflectance\r\n  techniques and examine absorbance\r\n  patterns in normal children and adults\r\n  with various middle ear pathologies.\r\n  Participants will have the opportunity to\r\n  learn proper administration of WAI in\r\n  real participants using all commercially\r\n  available wideband acoustic immittance\r\n  systems in the market.</p>\r\n<p><strong>Electrophysiological Measures of\r\n  Hearing Thresholds:</strong> This interactive\r\n  workshop will provide a general\r\n  introduction to the electrophysiological\r\n  testing of infant and adult hearing. The\r\n  workshop will include a demonstration\r\n  of ABR and other electrophysiological\r\n  recordings.</p>\r\n<p>The WC 2016 has also scheduled six\r\n  additional pre-congress workshops that\r\n  will deal with a wide-range of subject\r\n  matters including:</p>\r\n<p>&bull; Evidence-based practice in 2016,\r\n  turning data and information into\r\n  action;</p>\r\n<p>&bull; What&rsquo;s new in central auditory\r\n  processing testing techniques and\r\n  technology;</p>\r\n<p>&bull; Tapping the potential of &ldquo;hearables;&rdquo;</p>\r\n<p>&bull; The eligibility criteria for hearing aids\r\n  and cochlear implants;</p>\r\n<p>&bull; Incorporating screening for cognitive,\r\n  vision and falls risks into practice; and</p>\r\n<p>&bull; Population and public health\r\n  approaches to hearing care.</p>\r\n<h4>PROGRAM HIGHLIGHTS:</h4>\r\n<p>Over the three days, the Congress will\r\n  feature a series of three roundtable\r\n  sessions. The topics were chosen by\r\n  delegates from the 2014 congress in\r\n  Australia. They follow three general\r\n  themes:</p>\r\n<p>&bull; <strong>Auditory Neuroscience:</strong> Beyond\r\n  the ear and the audiogram. Delegates\r\n  will hear from world experts who\r\n  will share leading edge developments\r\n  in the use of brain imaging in the\r\n  assessment of auditory function; the\r\n  relationship between imaging and\r\n  function; and brain imaging advances\r\n  that may relate to audiology.</p>\r\n<p>&bull; <strong>Advancing Best Practices in\r\n  Audiology. </strong>The roundtable will\r\n  provide an overview of the foundation\r\n  of evidence-based practice along\r\n  with examples of evidence and its\r\n  application in a range of audiology\r\n  contexts.</p>\r\n<p>&bull; <strong>Hearing in the Context of a Global\r\n  Health Priority. </strong>World experts will\r\n  discuss the importance of curating\r\n  the best knowledge, experience and\r\n  procedures to enable citizens with\r\n  hearing problems to get the best social\r\n  and solutions.</p>\r\n<p>Following these sessions, delegates will\r\n  be asked what themes they would like to\r\n  explore for the next congress, which will\r\n  be held in South Africa in 2018.</p>\r\n<p>For more information about the\r\n  WCA2016 Congress, please visit the\r\n  website at:\r\n  www. http://www.wca2016.ca.</p>\r\n<h4>The Hear 4U Foundation</h4>\r\n<p>Dr. Paul Mick</p>\r\n<p>About the Author</p>\r\n<p>Dr. Paul Mick is a neurotologist practicing in Kelowna, B.C. He completed a neurotology/skull\r\n  base surgery fellowship at Sunnybrook Health Sciences Centre at the University of Toronto, an\r\n  otolaryngology residency at the University of British Columbia and a Masters degree in public\r\n  health at Harvard. His epidemiology research program focuses on identifying and preventing the\r\n  health impacts of age-related hearing loss in older adults, and his work is published in many peer\r\n  reviewed journals. Paul is a researcher with the Canadian Consortium of Neurodegeneration in\r\n  Aging and has received awards for research and teaching. In his spare time he enjoys hanging\r\n  out with his family, friends and dog in the great outdoors.</p>\r\n<p>Unfortunately, access to hearing aids\r\n  depends on income. Even the most\r\n  basic single hearing aid costs hundreds\r\n  of dollars, excluding batteries, and\r\n  must be replaced approximately every\r\n  5 years. Across Canada, government\r\n  subsidies are inconsistent. For example,\r\n  Albertans under the age of 18 or over\r\n  the age of 65 receive up to $945.00 for\r\n  1 aid every 5 years, whereas in British\r\n  Columbia universal coverage is only\r\n  offered to children under the age of 5.</p>\r\n<p>As a consequence, some people avoid\r\n  hearing aids altogether. In a populationbased\r\n  survey of 2169 Americans who\r\n  had hearing loss but did not use hearing\r\n  aids, 76% of respondents described\r\n  financial constraints as a barrier to\r\n  hearing aid adoption. 64% could not\r\n  afford hearing aids, 52% said they were\r\n  too expensive to maintain, and 45%\r\n  said they were not worth the expense\r\n  (participants were allowed to choose\r\n  multiple responses).1 Unsurprisingly,\r\n  the median income of respondents who\r\n  stated they couldn&rsquo;t afford hearing aids\r\n  was lower than those who could. In the\r\n  55-64 year old age group, the median\r\n  household income of those who could\r\n  afford hearing aids was CAD$89,501,\r\n  while the median household income of\r\n  those who could not was CAD$38,600.\r\n  Compounding the problem is the fact\r\n  that hearing loss is more prevalent\r\n  among low socio-economic groups.\r\n  Lin et al., in a population-based study\r\n  of American adults 70 years and older,\r\n  demonstrated that hearing aid use\r\n  among people with at least a moderate\r\n  hearing loss (&ge;40 dB HL 0.5, 1, 2 and\r\n  4 kHz pure tone average in the better\r\n  hearing ear) was only 40% and that low\r\n  socio-economic status was a significant\r\n  predictor of low hearing aid use.2</p>\r\n<p>Systematic reviews of large numbers of\r\n  studies show that hearing aids result\r\n  in medium to large improvements\r\n  in hearing-related quality of life and\r\n  significantly reduce the psychological,\r\n  social and emotional effects of hearing\r\n  loss.3 It is widely recognized that\r\n  depriving people of hearing health care\r\n  (i.e., diagnosis and evaluation, hearing\r\n  aids, other assistive devices and auditory\r\n  rehabilitation) may dramatically impair\r\n  their ability to communicate, quality of\r\n  life and health. Ensuring the accessibility\r\n  and affordability of hearing health\r\n  care services, however, has not been\r\n  prioritized by health care policy makers.</p>\r\n<p>Fortunately, there is some evidence that\r\n  priorities are changing. Recently, the\r\n  (U.S.) National Academy of Medicine\r\n  convened a committee that published\r\n  recommendations to improve the\r\n  accessibility and affordability of hearing\r\n  health care.4 Among other suggestions,\r\n  the group recommended public\r\n  health programs to improve access for\r\n  underserved and vulnerable populations,\r\n  implementation of innovative models\r\n  of hearing health care, and increase awareness of how to receive hearing\r\n  services and financial support if needed.\r\n  This work underscores efforts to shift\r\n  the perception of age-related hearing\r\n  loss from a lifestyle issue to a public\r\n  health problem requiring communitybased\r\n  and health policy solutions as\r\n  well as innovations in treatment that are\r\n  delivered at the individual level.\r\n  The Hear4U Foundation is a recently\r\n  established independent charity that\r\n  aims to address the problem of hearing\r\n  aid affordability and increase access\r\n  to hearing aids among low income\r\n  British Columbians. Our foundation\r\n  has organized a hearing aid recycling\r\n  program that provides refurbished\r\n  hearing aids at little or no cost. The\r\n  Hear4U program consists of a network\r\n  of volunteer audiologists and hearing\r\n  instrument providers from 53 clinics\r\n  across British Columbia. Members\r\n  of the public who want to donate\r\n  their old devices can drop them off in\r\n  Hear4U donation boxes located in the\r\n  participating clinics. Only functioning\r\n  behind the ear or receiver in the canal\r\n  devices are accepted since they can be\r\n  inexpensively adapted to new users,\r\n  and other devices are discarded. After\r\n  the devices are dropped into donation\r\n  boxes, the volunteer clinicians test them\r\n  for functionality, clean them, replace\r\n  the domes and receivers with new\r\n  ones, and store them in their clinic.\r\n  Clients who are interested in receiving\r\n  a refurbished aid will call the office to\r\n  arrange an appointment. Clinicians may\r\n  ask them to review a list of responses\r\n  to frequently asked questions about the\r\n  benefits and limitations of the program.\r\n  They are then assessed as per standard\r\n  of care practices and offered a hearing\r\n  aid if an appropriate device is available\r\n  in the clinic. Each volunteer clinician\r\n  has agreed to assess at least one Hear4U\r\n  client per month, which equates to over\r\n  600 devices exchanged per year across\r\n  the province.</p>\r\n<p>Our organization also publicizes\r\n  information about public and private\r\n  financial assistance programs for brand\r\n  new hearing aids. For example, the B.C.\r\n  provincial government, in partnership\r\n  with the Neil Squires Foundation, is\r\n  offering one-time subsidies for hearing\r\n  aids for individuals who work or\r\n  volunteer via the &ldquo;Technology at Work&rdquo;\r\n  program. Most consumers, however,\r\n  are unaware of this opportunity.\r\n  Information about qualification criteria,\r\n  and how to access the program (and\r\n  others) are listed on our website (http://\r\n  www.hear4u.ca/recipients/resources/).\r\n  People who are interested in a\r\n  refurbished aid are instructed to review\r\n  the list of subsidies beforehand to ensure\r\n  that they do not miss the opportunity to\r\n  receive a brand new device.\r\n  Hear4U is a new charity, unveiled in\r\n  May 2016 during Better Hearing and\r\n  Speech Month, and has been wellreceived\r\n  among our volunteer clinicians\r\n  and the public. Many donations of highquality\r\n  used aids have already been\r\n  received from people upgrading to new\r\n  devices, or from children of recentlydeceased\r\n  parents who were hearing\r\n  aid wearers. We hope that the program\r\n  will be popular, sustainable and allow\r\n  everyone with hearing loss to access\r\n  sound and communication, regardless\r\n  of income.</p>\r\n<p>Anyone interested in finding out more\r\n  about the Hear4U program, such as\r\n  where to drop off donated hearing aids,\r\n  which types of devices we are looking\r\n  for, or how to receive a refurbished aid,\r\n  should visit our website at hear4u.ca.</p>\r\n<h4>REFERENCES</h4>\r\n<ol>\r\n  <li id=\'Reference_Title_Link\' value=\'1\'><a name=\"1\" id=\'1\'></a>Kochkin S. Marketrak VII: Obstacles to  adult non-user adoption of hearing  aids. Hear J 2007;60(4):24&ndash;50. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'2\'><a name=\"2\" id=\'2\'></a>Lin FR, Thorpe R, Gordon-Salant S, and Ferrucci </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'3\'><a name=\"3\" id=\'3\'></a>L. Hearing loss prevalence and risk factors  among older adults in the United States.  J Gerontol A Biol Sci Med Sci 2011;66A(5):582&ndash;90. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'4\'><a name=\"4\" id=\'4\'></a>Chisholm TH, Johnson CE, Danhauer JL, et  al. A systematic review of  health-related quality of life and hearing  aids: Final review  of the American Academy of Audiology  Task Force on the health- related  quality of life benefits of amplification in adults. J Am Acad Audiol 2007;18:151&ndash;83. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'5\'><a name=\"5\" id=\'5\'></a>National Academies of Sciences,  Engineering, and Medicine. Hearing  health care for adults: Priorities for improving access and affordability. Washington, DC: The National Academies Press; 2016 doi: 10.17226/23446. </a></li>\r\n</ol>\r\n<p>&nbsp;</p>\r\n<p>&nbsp;</p>\r\n<h4>In Conversation with MARKE HAMBLEY</h4>\r\n<p>By Ted Venema, PhD</p>\r\n<p><strong>Ted Venema (TV): You&rsquo;ve had a long\r\n  and rather interesting history in the\r\n  hearing aid retail sector! I first met\r\n  you in the mid-1990s when you were\r\n  CEO of Island Acoustics. At that\r\n  time I was working for Unitron and\r\n  you were Unitron&rsquo;s biggest Canadian\r\n  customer. Periodically, you&rsquo;d invite\r\n  me to come out West and speak to\r\n  your audiologists and HIPs. This\r\n  interview however, is about you, the\r\n  man named Marke Hambley. You&rsquo;ve\r\n  been a huge influence upon the\r\n  Canadian hearing health care scene.\r\n  As such, I think it would be great\r\n  for our readers to hear some of the\r\n  milestones of the path you have taken\r\n  over the years.</strong></p>\r\n<p><strong> So Marke, you&rsquo;ve told me bits and\r\n  pieces of your story while crossing\r\n  Georgia Strait on the ferry between\r\n  Victoria and Vancouver&hellip;I recall\r\n  it involves planes, trains, and\r\n  automobiles. How did it all begin?\r\n  You weren&rsquo;t always in the hearing aid\r\n  sector, right?</strong></p>\r\n<p>Marke Hambley (MH): No, I was not\r\n  Ted. As a matter of fact, when I was\r\n  first introduced to this profession, I was\r\n  residing in Prince Rupert in northern\r\n  BC. I was an optician, managing about\r\n  four optical outlets, in Prince Rupert,\r\n  Kitimat, Terrace, and we also used\r\n  to travel to Smithers and the Queen\r\n  Charlotte Islands. While there, I met an\r\n  otologist by the name of Dr. Malcolm\r\n  Graham, who was an eminent otologist\r\n  out of Victoria. About two years later,\r\n  after I met him, he was invited to become\r\n  one of the surgeons in the House clinic,\r\n  which as you know, was sort of the\r\n  &ldquo;Mecca&rdquo; of ear surgery for otology. He&rsquo;d\r\n  come up to Prince Rupert on a quarterly\r\n  basis and he&rsquo;d see patients.</p>\r\n<p>As he didn&rsquo;t have anyone to refer those\r\n  patients with a hearing loss to, he asked\r\n  me if I&rsquo;d be interested in caring for their\r\n  needs. I agreed to take on this new\r\n  profession, and soon moved to Victoria\r\n  &ndash; returned to BCIT and completed the\r\n  required course. The class was certified\r\n  by the provincial government, at that\r\n  time which was Social Credit.</p>\r\n<p>Once I gained the necessary experience,\r\n  I must say that I enjoyed the profession\r\n  immensely! You see there&rsquo;s a difference\r\n  between the optical and hearing\r\n  instrument practitioner profession. In\r\n  the optical field, one typically sees a\r\n  client for approximately 15 minutes\r\n  to pick out a frame. You then take the\r\n  client&rsquo;s prescription, grind the lenses,\r\n  fit the frame to the client. Then after\r\n  ensuring the prescription is accurate,\r\n  they leave. So the whole process with\r\n  the client might take 30 to 45 minutes.\r\n  Whereas, with the hearing aid client, a\r\n  hearing professional can easily invest up\r\n  to five hours of time. In that additional\r\n  time with my clients I noticed that I\r\n  started to really enjoy the relationships\r\n  that I forged with them, and the\r\n  generation &ndash; or demographic I was\r\n  serving was so much more appreciative.\r\n  At that time, 1969 through 1970, we\r\n  were fitting mostly body aids and some\r\n  BTEs.</p>\r\n<p>Looking back, I really have to give credit\r\n  to Dr. Malcom Graham for prompting\r\n  me to consider a career in hearing care.\r\n  I was in Prince Rupert for a short period\r\n  of time when Dr. Graham introduced\r\n  me into the profession. I loved it, but\r\n  was then invited down to Victoria to join\r\n  a hearing instrument practitioner (HIP)\r\n  by the name of Ken MacLaren. Ken\r\n  had a practice in Victoria, and worked\r\n  with Dr Graham. Soon after, I moved\r\n  my whole family down to Victoria and\r\n  worked with Ken for close to a year.</p>\r\n<p><strong> TV: Now you&rsquo;ve mentioned to me\r\n  that you were a pilot, that you had\r\n  a Cessna, and that you flew around\r\n  to Powell River etc., around to some\r\n  of the more remote communities. Is\r\n  that while you were working with\r\n  Graham?</strong></p>\r\n<p>MH: No, that came after; I was seeing\r\n  clients he referred up in Prince Rupert.\r\n  As mentioned, I later decided to move\r\n  down to Victoria, joined Ken MacLaren\r\n  in his practice, and was with him for\r\n  about a year. Now Ken and I didn&rsquo;t quite\r\n  see eye to eye on a few things, because I\r\n  had agreed to join him if he would make\r\n  me a partner after a year. He taught me\r\n  a lot, and I owe a much to Ken for that,but when it came down to keeping his\r\n  word about partnership, he declined.\r\n  So, in frustration I left, and I purchased\r\n  a practice from a gentleman who was\r\n  retiring. His name was Humphrey\r\n  Golby. He was also known as Mr\r\n  Swiftsure, the guy who&rsquo;d do the cover\r\n  commentary on the Swiftsure races at\r\n  that time (Editor&rsquo;s note: Swiftsure was\r\n  an international Yachting Race; for more\r\n  details, refer to the 1980 publication\r\n  of Swiftsure: The First Fifty Years, by\r\n  Humphrey Golby and Shirley Hewett).\r\n  Among other interests he had a hearing\r\n  aid practice. Since he was anxious to\r\n  retire I was able to buy his practice for\r\n  $1500 - can you believe it!?</p>\r\n<p>I soon partnered with another colleague\r\n  of Ken MacLaren&rsquo;s by the name of Bill\r\n  Findlay. Bill and I started a company\r\n  called Hambley &amp; Findlay, which was\r\n  my first entry into this profession, and\r\n  we started to grow our small practice.\r\n  At the time, I was working with an\r\n  ENT surgeon named Dr. Ben Page,\r\n  and he and I would go out to Duncan\r\n  on a one day per week basis. I&rsquo;d do his\r\n  audiometry and he&rsquo;d refer his patients to\r\n  me, both in Victoria and Duncan. As a\r\n  result the practice grew!</p>\r\n<p>Also my sphere of influence grew. I was\r\n  working very closely with the medical\r\n  profession; specifically, a number of\r\n  Ear, Nose, Throat surgeons. One of\r\n  the people I really enjoyed, who was\r\n  teaching the BCIT hearing instrument\r\n  practitioner&rsquo;s course, was an ENT\r\n  surgeon by the name of Dr. Irwin\r\n  Stewart. Dr Stewart. We did a lot of\r\n  work together at that time, dealing with\r\n  the Ministry of Health in attempting to\r\n  move the B.C. Government out of the\r\n  business of dispensing hearing aids.</p>\r\n<p>During that time with Dr Stewart,\r\n  we came to know each other well. He\r\n  invited me to open a satellite clinic in the\r\n  Gibson&rsquo;s and Sechelt medical clinic he\r\n  visited monthly from Vancouver. I was\r\n  based in Victoria and was mainly serving\r\n  the island at the time. I would go as far\r\n  north as Campbell River, but I wasn&rsquo;t\r\n  going off-island at that time. Well, Irwin\r\n  called me one day, and said; &ldquo;Marke, I&rsquo;m\r\n  going out to Gibsons, I&rsquo;ve have no one\r\n  there to refer patients to, would you be\r\n  interested in serving that community?&rdquo;\r\n  After a short internal deliberation I\r\n  heartily accepted - as I have always been\r\n  interested in expanding my practice.\r\n  However, in order to travel there each\r\n  week, I had to wake up at 4:30 AM, travel\r\n  from Victoria to Nanaimo to catch the 7:\r\n  00 AM ferry from Nanaimo to Horseshoe\r\n  Bay in West Vancouver. Then I would\r\n  hop on a 9:15 AM ferry from Horseshoe\r\n  Bay to Langdale. Finally I would end up\r\n  in Gibson&rsquo;s at 10:30 AM. That&rsquo;s when I\r\n  saw my first client, and continued to see\r\n  clients until 6 PM. Then the trek started\r\n  again with a rushed trip to the Langdale\r\n  ferry terminal to catch the 6:30 PM\r\n  ferry to Horseshoe Bay &ndash; travel across\r\n  Vancouver to catch the 9 PM ferry from\r\n  Tsawwassen to south Vancouver Island,\r\n  and finally arrived home at 11 PM. After\r\n  a short while of follow this exhausting\r\n  schedule, I thought, &ldquo;My Goodness!\r\n  There&rsquo;s got to be a better way to make\r\n  a living!&rdquo;</p>\r\n<p>So to get back to your question about\r\n  my pilot&rsquo;s licence; I&rsquo;d always wanted to\r\n  fly, and realized that if I could just skip\r\n  the ferries and fly over to Gibson&rsquo;s, I\r\n  could save myself an enormous amount\r\n  of travel time. So, I worked to acquire\r\n  my pilot&rsquo;s license, and purchased a\r\n  little Cessna 172. Now it would only\r\n  take me about 40 minutes to fly over\r\n  to Gibson&rsquo;s from Victoria. I just loved\r\n  it! It wasn&rsquo;t long before I obtained my\r\n  instrument rating, purchase a faster\r\n  Beechcraft Bonanza retractable gear airplane that cut my travel time to\r\n  Gibsons in half again!</p>\r\n<p><strong> TV: You mentioned this BCIT course.\r\n  What was that? That&rsquo;s not an HIP\r\n  course as we know them today, like\r\n  at Grant MacEwan etc. It&rsquo;s prior to all\r\n  of those, right? How does that relate\r\n  to the HIP programs we have today?</strong></p>\r\n<p>Well that&rsquo;s a very interesting question,\r\n  because when I first entered the\r\n  profession, there was no licensing.\r\n  Anyone could be a so-called hearing\r\n  instrument practitioner. All you had to\r\n  do is pick up an audiometer, learn how\r\n  to use it, and begin testing potential\r\n  clients. Then you&rsquo;re fitting mostly body\r\n  aids; primarily conductive hearing losses\r\n  due to failed or declined surgery. At that\r\n  time, hearing aids had a few trimmers,\r\n  some of them no trimmers whatsoever.\r\n  In that era, you just picked the model,\r\n  with outputs, gain, and frequency\r\n  response curves that most closely fit\r\n  the client&rsquo;s hearing loss; there was no\r\n  compression, only peak clipping.</p>\r\n<p>There was, however, a big push in the\r\n  profession to get credentialed, and the\r\n  government of the day at that time was\r\n  the Social Credit Party. The government\r\n  was advocating for better consumer\r\n  protection, and passed legislation to\r\n  license practitioners. The legislation\r\n  did not accept grandfathering, so the\r\n  government created a course in hearing\r\n  instrument dispensing at the British\r\n  Columbia Institute of Technology. At\r\n  that time (around 1973) there were\r\n  about 3 audiologists in BC, and only\r\n  one of them was dispensing hearing\r\n  aids. Dr. Stewart was petitioned to lead\r\n  the process of creating the hearing aid\r\n  dispensing curriculum, and eventually\r\n  taught some of the coursework of\r\n  curriculum. Everybody had to take time\r\n  out of their practice to attend. As I said\r\n  earlier, if you weren&rsquo;t grandfathered;\r\n  you had to complete the coursework.\r\n  The hearing instrument practitioners\r\n  who wanted to stay practicing did so.\r\n  We took a week off here and there from\r\n  our practices to ensure we completed\r\n  all the coursework, wrote the final exam\r\n  at the end, and if a passing grade was\r\n  achieved, the clinician received a license\r\n  to practice in the Province of BC.</p>\r\n<p><strong> TV: How long of a time did that take?\r\n  Was it over a year?</strong></p>\r\n<p>MH: I think for most people it took about\r\n  6 months, to sacrifice the necessary\r\n  time off to complete the coursework.\r\n  That&rsquo;s my recollection&hellip; it might not\r\n  be completely accurate, but it&rsquo;s in that\r\n  general time period.</p>\r\n<p><strong>TV: Let&rsquo;s go back to when you\r\n  finished up at BCIT; what happened\r\n  after that?</strong></p>\r\n<p>MH: Therein lies another interesting\r\n  part to the story. We completed the\r\n  course, and concurrently there was\r\n  a change in government from Social\r\n  Credit to NDP. And at that time, the\r\n  then Minister of Health, Dennis Coke,\r\n  was working with audiologists named\r\n  John Gilbert (Editor&rsquo;s note: John\r\n  Gilbert used to head up the Speech &amp;\r\n  Hearing department at UBC) and David\r\n  Zink. They had convinced the minister\r\n  that hearing aid dispensers were all\r\n  charlatans, and not to recognize our\r\n  credentials. They then proceeded to set\r\n  up and dispense hearing aids at our cost\r\n  through government programs. So there\r\n  we were, attending our graduation, and\r\n  the Minister of Health marches out on\r\n  stage and says, &ldquo;We are not recognizing\r\n  this program and we are going to proceed\r\n  with dispensing our own hearing aids.&rdquo;</p>\r\n<p>Now, the problem was, the then NDP\r\n  government did not cancel the hearing\r\n  aid licensing legislation, because the\r\n  legislation had been recently passed\r\n  by the prior government. We had\r\n  completed our coursework, and were\r\n  governed and regulated by the Board\r\n  of Hearing Aid Dealers &amp; Consultants\r\n  created by the previous government\r\n  in power. As a result, we did receive\r\n  our licenses to dispense, but we were\r\n  now competing with our Provincial\r\n  Government. As provincially licensed\r\n  hearing instrument practitioners, we\r\n  had to pay an annual licensing fee to our\r\n  Provincial regulating body, the Board\r\n  of Hearing Aid Dealers and Consultants,\r\n  and yet the provincial government was\r\n  competing with us! To my recollection\r\n  that went on for approximately 10\r\n  years. During that time, our numbers\r\n  diminished from about 120 down to less\r\n  than 40. Interestingly enough, the City\r\n  of Vancouver chose not to participate\r\n  in the provincial hearing aid dispensing\r\n  program. The program was limited to\r\n  primarily rural areas, Victoria, and other\r\n  cities outside of Vancouver. Finally, after\r\n  approximately 10 years and waiting lists\r\n  of up to 2 years for seniors to access, the\r\n  government hearing aid program which\r\n  had a history of providing less than\r\n  adequate services, things turned around!\r\n  You see, there was another change in\r\n  government, the Liberal government\r\n  came into power I believe, and they\r\n  cancelled the program overnight.\r\n  Hearing instrument practitioners\r\n  and dispensing audiologist were now\r\n  regulated and licensed through the Board\r\n  of Hearing Aid Dealers and Consultants\r\n  providing consumer protection as the\r\n  legislation was enacted.</p>\r\n<p><strong>TV: Weird, so very odd. I started an\r\n  HIP program at Conestoga College,\r\n  you are a graduate of an HIP training\r\n  program, how do you feel about\r\n  ongoing education, these issues about\r\n  college training programs?</strong></p>\r\n<p>MH: Ted, I actually think it&rsquo;s essential! I\r\n  believe that ongoing education is critical\r\n  to one&rsquo;s own professional development,\r\n  and I certainly felt it was vitally\r\n  important to my own development.\r\n  I&rsquo;ve always been a strong advocate for\r\n  continuing development, not just for the\r\n  profession, but also for support staff as\r\n  well. For example, John Roberts, who at\r\n  that time was president of the Alberta\r\n  Hearing Instrument Practitioners\r\n  Association, and I as the then president\r\n  of the Hearing Instrument Specialists\r\n  Society of BC (HISSBC), worked with\r\n  an audiologist named Jay McSpaden\r\n  PhD. He was a great help in founding\r\n  the Grant MacEwan College (now\r\n  University) hearing instrument\r\n  practitioners program in Alberta. John\r\n  and his team played a much greater part\r\n  in this accomplishment than we did.\r\n  Nevertheless, John, Jay, and I worked\r\n  with Grant MacEwan College for close\r\n  to 10 years before we finally received\r\n  curriculum acceptance.</p>\r\n<p>All the curriculum committee members\r\n  celebrated the victory at Grant\r\n  MacEwan. While I was mixing and\r\n  chatting at the event Elizabeth Dawson,\r\n  the then dean of the college&rsquo;s hearing\r\n  instrument practitioners program\r\n  approached me and said &ldquo;Marke, you&rsquo;ve\r\n  worked so hard to get this program in\r\n  the college, I really think you should\r\n  take it.&rdquo; I thought to myself, &ldquo;Do I really\r\n  want to go back to school at my age!?&rdquo;\r\n  Well, how could I say No? I mean, here I\r\n  was an advocate for ongoing education,\r\n  and thought it&rsquo;s time to walk the talk so\r\n  I said to Elizabeth, &ldquo;Yes I will do it.&rdquo; I\r\n  registered into the program, chipped\r\n  away at it, and it took me until last year,\r\n  when I finally graduated! I took it over\r\n  probably about 10 years to complete\r\n  it, because I was preoccupied growing\r\n  Island Hearing.</p>\r\n<p>Another cause for extending the\r\n  program completion time was my\r\n  involvement with Rotary. As a past\r\n  president of my local Rotary Club\r\n  and district committee member, I\r\n  registered as a Rotary Volunteer,\r\n  and co-founded the Rotary Hearing\r\n  Healthcare project of Zimbabwe, and\r\n  Uganda, with Dr. Irwin Stewart, an\r\n  otolaryngologist I mentioned earlier.\r\n  Irwin was a fellow Rotarian and district\r\n  governor of an adjacent Rotary district.\r\n  We both wanted to use our professions\r\n  to help deaf and hard of hearing\r\n  children in Africa through Rotary.\r\n  Subsequently, we completed a needs\r\n  study, first in Zimbabwe establishing\r\n  the Rotary Zimbabwe program, and 2\r\n  years later the Uganda program. The\r\n  Uganda program continues on today.\r\n  The Zimbabwe program has been\r\n  discontinued because of President\r\n  Mugabe&rsquo;s oppressive government.\r\n  However, I am extremely proud of\r\n  what&rsquo;s been accomplished there. We&rsquo;ve\r\n  helped many hard of hearing children\r\n  and we continue to so.</p>\r\n<p>Continual education should be critically\r\n  important to all who practice our\r\n  profession, because new innovative\r\n  hearing aid technology is rapidly\r\n  developing. Instead of a new innovative\r\n  product being introduced every 5 years\r\n  when I first started &ndash; now it&rsquo;s every 6\r\n  months. If you don&rsquo;t keep up with it\r\n  through continuing education, you&rsquo;ll be\r\n  left behind, leaving you unable to serve\r\n  your clients properly and adequately.</p>\r\n<p><strong>TV: OK, so back to your business\r\n  &ndash; and your days flying Cessna\r\n  airplanes, your business was growing,\r\n  because you were now flying to these\r\n  places in your Cessna, and able to\r\n  service all these different locales (the\r\n  southern coast of BC is all islands and\r\n  inlets), and so then what happened\r\n  after that? And then how did Island\r\n  Hearing happen?</strong></p>\r\n<p>MH: Well, I started with a company\r\n  called Hambley and Findlay in 1972, and\r\n  after 3 years I knew I wanted to expand.\r\n  So I bought out my partner Bill Findlay\r\n  (he was close to retirement) and I was\r\n  about 25 years old at the time. I recall\r\n  thinking; &ldquo;I need to expand, and to do\r\n  it I need to get people with experience.&rdquo;\r\n  So, I became involved with a couple of\r\n  audiologists and another technician, and\r\n  we created a company called Western\r\n  Acoustics and Instrumentation in 1975. I\r\n  already had the clinic in Victoria, then I\r\n  opened clinics in Nanaimo, Vancouver,\r\n  and another in Calgary. Unfortunately,\r\n  all four partners were inexperienced in\r\n  corporate growth; quite frankly, it was\r\n  like the &lsquo;blind leading the blind&rsquo;. I knew\r\n  how to operate a single clinic, but I did\r\n  not know how to operate, a clinical\r\n  operation of that size. After about 3 years,\r\n  the company was put into receivership,\r\n  and I had to start over again.</p>\r\n<p>The lesson I learned was that it&rsquo;s difficult\r\n  to operate a company successfully with\r\n  inexperienced partners without a strong\r\n  single leader with a solid track record\r\n  of success. And, that you can&rsquo;t operate a\r\n  company by consensus. You really need\r\n  somebody who&rsquo;s leading the show. So,\r\n  I purchased the Victoria clinic from the receiver and then started Island\r\n  Hearing in 1978, and that was when\r\n  Island Hearing &ndash; Island Acoustics &ndash; as you\r\n  remember it, was born. It then grew\r\n  from there. From my previous failure,\r\n  I realized that I didn&rsquo;t have the business\r\n  skills and competencies to grow a\r\n  company into the size that I wanted, so\r\n  I went back to UBC and started taking\r\n  various business courses, very specific\r\n  courses. I wasn&rsquo;t after just a &lsquo;degree,&rsquo; I\r\n  only wanted the coursework that I could\r\n  directly apply to growing my practice.\r\n  I completed courses on Corporate\r\n  Strategic Planning and Implementation,\r\n  Incentive Compensation, HR,\r\n  Accounting, and leadership. I then\r\n  grew the company from a little clinic\r\n  in Victoria to 125 clinics across Canada\r\n  over the next 30 years.</p>\r\n<p><strong> TV: And, you were still called Island\r\n  Hearing?</strong></p>\r\n<p>MH: We went from Island Acoustics and\r\n  rebranded to Island Hearing.</p>\r\n<p><strong> TV: How come the change of name?\r\n  What happened there?</strong></p>\r\n<p>MH: Well, we incorporated as\r\n  Island Acoustics and Hearing. We just\r\n  thought the name was too long, and\r\n  consequently not marketable. So we\r\n  dropped the &ldquo;acoustics,&rdquo; because we\r\n  thought people may be confused and\r\n  think we&rsquo;re a television retailer. We\r\n  renamed to Island Hearing, and that&rsquo;s\r\n  how it remained, when I eventually sold\r\n  it to Phonak, back in 2006.</p>\r\n<p><strong>TV: OK, so when did Connect begin\r\n  being called Connect? Was it already\r\n  Connect under your jurisdiction or\r\n  was it Connect only when you sold it?</strong></p>\r\n<p>MH: My last responsibility as president\r\n  &amp; CEO of Island Hearing, was to change\r\n  the brand. At that time, we had pretty\r\n  close to 20 different brands across the\r\n  country. We would acquire a clinic, and\r\n  we wouldn&rsquo;t want to change the name\r\n  to Island Hearing, because it might have\r\n  taken some 10&ndash;20 years to establish\r\n  that brand in that community. The\r\n  clinic name we acquired was a big part\r\n  of the good will of the purchase, so even\r\n  though the new acquisition was operated\r\n  by Island Hearing, the corporate entity\r\n  kept its own name. We soon realized\r\n  that with up to 20 different brands, the\r\n  cost of marketing was enormous. We\r\n  wanted economies of scale, so one of my\r\n  last responsibilities as the CEO of Island\r\n  Hearing was to find yet another name,\r\n  a common brand that everybody would\r\n  use across the country. In the end, the\r\n  task force I created along with some key\r\n  executive people, recommended the\r\n  name &ldquo;Connect Hearing.&rdquo; That brand was\r\n  already well established in Australia, by\r\n  Phonak. They had done a fair amount of\r\n  due diligence in their market research on\r\n  using that name, and we knew it would\r\n  be timely and costly to establish our own\r\n  brand new name. Phonak decided, after\r\n  our recommendation that they&rsquo;d adopt\r\n  the Connect brand in Canada, and so it\r\n  was. Therefor the decision to change\r\n  the name to Connect was made on my\r\n  departure. The transition happened\r\n  shortly after I retired.</p>\r\n<p><strong>TV: OK, that&rsquo;s the general story\r\n  then. Most people would be happy\r\n  to ride off into the sunset, but not\r\n  Marke Hambley. What drove you to\r\n  begin again and anew with NexGen\r\n  Hearing?</strong></p>\r\n<p>MH: Well, you know, my wife was\r\n  really a big influencer when it came to\r\n  my retirement. Understandably, she\r\n  wanted to spend more time together, so\r\n  decided to sell the company. I enjoyed\r\n  about 2 years of retirement. During\r\n  those years I travelled a lot, and played\r\n  a lot of golf. We purchased a large\r\n  motor home, and travelled throughout\r\n  North America. We saw a lot of country\r\n  together. In the end Ted, I got bored to\r\n  tears. I didn&rsquo;t feel like I had a purpose\r\n  in life. I think you really have to. Back\r\n  then I saw so many people who had\r\n  retired and yet not found another\r\n  worthwhile pursuit. Soon their health\r\n  and well-being starts to diminish.\r\n  Before long, they were gone. And, I felt\r\n  I just didn&rsquo;t want to go down that path.\r\n  So I thought well, maybe it&rsquo;s time to\r\n  look at getting back into the industry. I\r\n  decided, along with Bob Liew, who had\r\n  been my VP of Operations with Island\r\n  Hearing, to get back into the industry,\r\n  and together we purchased Mainland\r\n  Hearing.</p>\r\n<p><strong> TV: Was Mainland Hearing then\r\n  already existing at that time?</strong></p>\r\n<p>MH: Mainland Hearing was a company\r\n  that was established by an exfranchisee\r\n  of mine, Dr. Amir Soltani, an\r\n  audiologist. He was trying to extricate\r\n  himself from the new business culture\r\n  established through Connect/Sonova;\r\n  he didn&rsquo;t like the changes that were\r\n  occurring, and so he wanted to get\r\n  out. He successfully negotiated with\r\n  Connect Hearing, and was able to pull\r\n  himself out of his franchise agreement,\r\n  hold on to his clinics, and the new\r\n  name of the company became Mainland\r\n  Hearing. Amir asked me if I wanted to\r\n  partner with him, so I acquired 50% of\r\n  Mainland Hearing, with the exception\r\n  of Amir&rsquo;s downtown Vancouver clinic.\r\n  Bob Liew had always expressed interest in getting partnering with me, but he\r\n  was under a non-compete agreement.\r\n  Once his non-compete was over, I\r\n  asked Bob if he wanted to join Mainland\r\n  Hearing. He agreed, and he purchased\r\n  a percentage of it, and then became\r\n  the Director of Operations, as my\r\n  replacement. As soon as Bob transition\r\n  into his new position with Mainland, I\r\n  immediately focused on building a new\r\n  brand we named; NexGen Hearing. In\r\n  about 2 and a half years, we opened\r\n  up 14 clinics, which was an enormous\r\n  undertaking. Soon we recognized the\r\n  need to aligned ourselves with an Ad\r\n  agency (ImageSource Advertising Group)\r\n  and after 3 years, the Mainland brand\r\n  together with NexGen Hearing, we&rsquo;ve\r\n  grown to over 40 clinics throughout\r\n  BC including satellite offices. We&rsquo;ve\r\n  recently amalgamated the two brands\r\n  into one strong brand; NexGen Hearing.</p>\r\n<p><strong> TV: And, just for the reader&rsquo;s\r\n  clarification, the Mainland clinics are\r\n  all over the lower mainland, and the\r\n  NexGen clinics are in the interior, as\r\n  well as on the island.</strong></p>\r\n<p>MH: As of April 1st, the Mainland\r\n  Hearing clinics have changed their name\r\n  to NexGen Hearing, and now operate\r\n  under that brand. This allows Mainland\r\n  Hearing clients to obtain service and\r\n  have their warranties honoured at any\r\n  NexGen Hearing clinic and vis versa &ndash;\r\n  province wide.</p>\r\n<p><strong>TV: What is your business model\r\n  for NexGen, or how do you consider\r\n  yourselves to be unique? I mean,\r\n  how do you not want to be known as\r\n  an &ldquo;also ran?&rdquo;</strong></p>\r\n<p>MH: I recognize that I have been quite\r\n  successful, but I also know that you\r\n  get your success through your people.\r\n  When I left Island Hearing, I was able\r\n  to negotiate a fairly large earn-out for\r\n  my executive team, but I wanted to give\r\n  a number of clinicians who so desired\r\n  and approached me, a chance to get into\r\n  practice on their own. Many wanted\r\n  to, but simply didn&rsquo;t have the financial\r\n  wherewithal to do so, or didn&rsquo;t have\r\n  the experience. Or were reluctant to\r\n  take the risk because of the enormous\r\n  amount of business knowledge that&rsquo;s\r\n  required in areas of marketing, human\r\n  resources, accounting, IT, all the\r\n  support services that are essential to\r\n  operate a clinic successfully.</p>\r\n<p>When you don&rsquo;t have those skills and\r\n  competencies, it&rsquo;s difficult to focus on\r\n  building your practice and compete\r\n  successfully with the larger clinic\r\n  chains. So, a new business model would\r\n  have to mitigate those risks, and have\r\n  a high probability of success. One of\r\n  the reasons I came back was to assist\r\n  others to be more successful or at least\r\n  to have that chance. Our business model\r\n  is based on a 50/50 partnership, so\r\n  that neither partner has control of the\r\n  business. To be successful, this business\r\n  model requires both partners to work in\r\n  collaboration and cooperation working\r\n  together in order to create a successful\r\n  outcome. With a 50/50 model, the\r\n  clinicians focus on what they do best,\r\n  serving clients, and exceeding their\r\n  expectations, and we focus on providing\r\n  the infrastructure, getting the marketing\r\n  in place, building the brand, making\r\n  sure they have the support services\r\n  like HR, accounting, IT in place, etc.\r\n  This NexGen Hearing business model\r\n  has been in operation for close to 4\r\n  years now and achieved unprecedented\r\n  growth and success in the industry.</p>\r\n<p><strong> TV: Well, it&rsquo;s a very competitive\r\n  world out there today. Do you\r\n  think it&rsquo;s harder to get started today\r\n  compared to 30&ndash;40 years ago when\r\n  you got started? It was a different\r\n  playing field then, right?</strong></p>\r\n<p>MH: It was, but you know, there&rsquo;s still\r\n  plenty of opportunity in this profession.\r\n  There is a fair amount reluctance by\r\n  hearing health care professionals to start\r\n  their own practice, because competition\r\n  is more challenging and a bit frightening\r\n  for most hearing clinicians. The NexGen\r\n  Hearing business model mitigates those\r\n  risks, and offers a much higher level of\r\n  success.</p>\r\n<p><strong> TV: As I&rsquo;ve heard you say before,\r\n  &ldquo;If it was easy, everyone would be\r\n  doing it!&rdquo;</strong></p>\r\n<p>MH: Yes, exactly! And I think one of\r\n  the most important values or benefits\r\n  of having the 50/50 type of relationship\r\n  is that you have the clinician as a\r\n  stakeholder in the business. So, one of\r\n  the things that allows you to accelerate\r\n  the growth of your business is to obtain\r\n  experienced health care professionals\r\n  with solid track records of success\r\n  into partnership with you. They hit\r\n  the ground running. They grow their\r\n  practice quickly, because they are not\r\n  having to focus on all the other ancillary\r\n  business items that are required to\r\n  run a retail hearing aid dispensary\r\n  successfully. That&rsquo;s my job. Under this\r\n  new business model they can focus on\r\n  what they do best.</p>\r\n<p><strong> TV: How does NexGen Hearing stand\r\n  out from its competition? How do\r\n  you distinguish yourselves from the\r\n  competition?</strong></p>\r\n<p>MH: That&rsquo;s important, because I think\r\n  if you&rsquo;re going to have a successful\r\n  brand, you somehow have to distinguish\r\n  yourself in consumers eyes to ensure that\r\n  you differentiate your brand. There must\r\n  be a difference between choosing your\r\n  practice and choosing a competitor.\r\n  Every day you have to answer this\r\n  question, &ldquo;Why would they choose me\r\n  over somebody else?&rdquo; Initially we came\r\n  out with a very strong value proposition\r\n  or consumer offering, which has been\r\n  key to our success. We offer clients a\r\n  90-day trial period, with no money\r\n  down for the first 21 days, where they\r\n  are able try our hearing aids without any\r\n  financial obligation whatsoever. Then at\r\n  the end of the 21 days, if they are happy,\r\n  they may purchase the hearing aids, and\r\n  still have another 69 days to try them\r\n  before returning them for a full refund if\r\n  not fully satisfied. We also offer up to 5\r\n  year warranty, 3 years loss and damage,\r\n  up to 5 years of free batteries, and free in\r\n  office serving for the life of the hearing\r\n  aids. Also, we have had very strong\r\n  relationships with the medical profession\r\n  over the years. I always thought that\r\n  was key. It took me years to build those\r\n  relationships. Many of our competitors\r\n  focus a lot of their attention on the\r\n  retail sector, on building their clientele\r\n  via advertising and promotions. When\r\n  I came back into the industry, those\r\n  physician relationships were still there.\r\n  The doctors had a great deal of trust,\r\n  faith and confidence in me, personally,\r\n  and so as a result I was able to restart that\r\n  whole referral program. That&rsquo;s been a\r\n  huge part of our success; the relationship\r\n  with ENT and family doctors.</p>\r\n<p><strong>TV: That&rsquo;s a really good point you\r\n  bring up, about the relationships with\r\n  family doctors. I too see that as a real\r\n  critical link that some are not using\r\n  or mining, and I think we ignore that\r\n  at our peril.</strong></p>\r\n<p>MH: In my experience, most clinicians\r\n  are somewhat intimidated by having\r\n  to go into a physician&rsquo;s office to\r\n  differentiate themselves to physicians,\r\n  and try to convince them to refer.\r\n  Because it&rsquo;s so confronting, most of\r\n  them decide not to do it. If they do it,\r\n  it&rsquo;s infrequent. If you get a lot of &ldquo;No&rsquo;s,&rdquo;\r\n  it tends to reduce your motivation, and\r\n  you just stop making the needed effort\r\n  after a while.</p>\r\n<p><strong>TV: I noticed on your website you\r\n  have a Physicians Page</strong></p>\r\n<p>MH: Yes we do. Physicians are a big\r\n  part of the hearing health care team.\r\n  Physicians, audiologists, and hearing\r\n  aid practitioners, in my opinion should\r\n  operate as a collaborative team to\r\n  provide coordinated care to patients\r\n  with hearing loss. One of the nice\r\n  things about our group is that you see\r\n  physicians, audiologists and hearing\r\n  instrument practitioners working hand\r\n  in hand as colleagues, sharing best\r\n  practices, sharing cases, difficult cases,\r\n  and looking at assisting one another,\r\n  being committed to each other, and\r\n  learning tremendously from each other.</p>\r\n<p><strong> TV: Do you have any personal beliefs,\r\n  attitudes that you&rsquo;d like to convey to\r\n  those who aspire to be successful in\r\n  the hearing aid retail sector?</strong></p>\r\n<p>MH: Yes, I&rsquo;ve done a lot of reading,\r\n  I love reading business books, and\r\n  Jim Collins is one of my favourites;\r\n  he wrote From Good to Great and Built\r\n  to Last. Another great author is Ken\r\n  Blanchard who some wonderful books\r\n  on service leadership out there. One I\r\n  would highly recommend is Leading at\r\n  a Higher Level. I believe very strongly\r\n  in service. I have never been financially\r\n  motivated, I&rsquo;ve always been very service\r\n  oriented; I feel passionate about &ndash; and\r\n  I think really the people that operate\r\n  in our group feel the same &ndash; providing\r\n  exceptional client care. I firmly believe\r\n  that prosperity is a natural outcome\r\n  of providing exceptional quality care.\r\n  Focus on the delivery of exceptional\r\n  care and prosperity naturally follows.\r\n  Now that doesn&rsquo;t negate the importance\r\n  of collecting statistics and financial data.\r\n  That essential data is historical, and it\r\n  tells you how well you&rsquo;re delivering care.\r\n  However, you never want to be driven\r\n  by the fact a hard of hearing person\r\n  walking in your office door = 2 hearing\r\n  aid units because they have 2 ears. Why?\r\n  Because you don&rsquo;t see your client as an\r\n  individual; you see them as 2 hearing aids\r\n  units. You&rsquo;re then driven by the sale of a\r\n  pair of hearing aids instead of trying to\r\n  provide exceptional care and improved\r\n  lifestyle for your customer while striving\r\n  to exceed their expectations. I believe\r\n  our passion to deliver exceptional care is\r\n  the most important value that we operate\r\n  from in the NexGen Hearing Group. After\r\n  all as the name implies, as a team we\r\n  strive to provide the Next Generation of\r\n  Hearing Care!</p>\r\n<p><strong>TV: You hired me to work with you\r\n  some 2 years ago; what were you\r\n  thinking?</strong></p>\r\n<p>MH: Ha ha ha!, well Ted, we&rsquo;ll leave it\r\n  at that!&rdquo; You are an amazing educator\r\n  and we are most fortunate to have you\r\n  providing consulting service to our\r\n  group.</p>\r\n<h4>Hearing Loss and Cognition: The Role of Hearing Aids, Social Isolation and Depression</h4>\r\n<h4>ABSTRACT</h4>\r\n<p>Hearing loss is associated with poor cognitive performance and incident dementia and may contribute to\r\n  cognitive decline. Treating hearing loss with hearing aids may ameliorate cognitive decline. The purpose\r\n  of this study was to test whether use of hearing aids was associated with better cognitive performance, and\r\n  if this relationship was mediated via social isolation and/or depression. Structural equation modelling of\r\n  associations between hearing loss, cognitive performance, social isolation, depression and hearing aid use\r\n  was carried out with a subsample of the UK Biobank data set (n = 164,770) of UK adults aged 40 to 69\r\n  years who completed a hearing test. Age, sex, general health and socioeconomic status were controlled for\r\n  as potential confounders. Hearing aid use was associated with better cognition, independently of social\r\n  isolation and depression. This finding was consistent with the hypothesis that hearing aids may improve\r\n  cognitive performance, although if hearing aids do have a positive effect on cognition it is not likely to be via\r\n  reduction of the adverse effects of hearing loss on social isolation or depression. We suggest that any positive effects of hearing aid use on cognition may be via improvement in audibility or associated increases in selfefficacy.Alternatively, positive associations between hearing aid use and cognition may be accounted for by more cognitively able people seeking and using hearing aids. Further research is required to determine the direction of association, if there is any direct causal relationship between hearing aid use and better cognition,and whether hearing aid use results in reduction in rates of cognitive decline measured longitudinally.</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>The prevalence of dementia in those\r\n  aged over 60 years is between 5&ndash;7%,\r\n  with the numbers of those affected\r\n  globally forecast to double every 20 years\r\n  between 2010 and 2050 [<a href=\"#1\" title=\"1\">1</a>]. Cognitive\r\n  decline and dementia have a profound\r\n  impact on the individual, on caregivers\r\n  and society, and the financial costs of\r\n  cognitive decline and dementia are a\r\n  major source of concern [<a href=\"#2\" title=\"2\">2</a>]. However,\r\n  there is some cause for optimism in\r\n  the form of potentially modifiable\r\n  risk and protective factors, including\r\n  cardiovascular health, psychological\r\n  and emotional health, cognitive and\r\n  physical activity, smoking and diet\r\n  [<a href=\"#3\" title=\"3\">3</a>,<a href=\"#4\" title=\"4\">4</a>], and these may offer avenues for\r\n  prevention. In this study we suggest\r\n  that remediation and/or prevention of\r\n  hearing loss may offer an additional\r\n  avenue for prevention.</p>\r\n<p>Hearing loss is common in older adults\r\n  [<a href=\"#5\" title=\"5\">5</a>] and is associated with cognitive\r\n  decline and incident dementia [<a href=\"#6\" title=\"6\">6</a>&ndash; <a href=\"#11\" title=\"11\">11</a>]. There are two main explanatory\r\n  hypotheses for this association. The first\r\n  is that the association between cognitive\r\n  and hearing variables reflects a &lsquo;common\r\n  cause&rsquo;, namely age-related changes\r\n  in the nervous system. In this model,\r\n  hearing loss and cognitive decline share\r\n  common, age-related neurodegenerative\r\n  mechanisms [<a href=\"#8\" title=\"8\">8</a>,<a href=\"#11\" title=\"11\">11</a>]. The second is the\r\n  &lsquo;cascade&rsquo; hypothesis, where long-term\r\n  deprivation of auditory input may\r\n  impact on cognition either directly,\r\n  through impoverished input, or via\r\n  effects of hearing loss on social isolation\r\n  and depression [<a href=\"#6\" title=\"6\">6</a>,<a href=\"#12\" title=\"12\">12</a>,<a href=\"#13\" title=\"13\">13</a>]. Hearing\r\n  loss is independently associated with\r\n  social isolation and depression [<a href=\"#14\" title=\"14\">14</a>,<a href=\"#15\" title=\"15\">15</a>],\r\n  and social isolation and depression\r\n  are associated with cognitive decline\r\n  [<a href=\"#3\" title=\"3\">3</a>,<a href=\"#16\" title=\"16\">16</a>,<a href=\"#17\" title=\"17\">17</a>]. One further possibility is that\r\n  hearing impairment results in increased\r\n  compensatory mental effort to perform\r\n  cognitive tasks (such as remembering\r\n  sequences of spoken digits [<a href=\"#18\" title=\"18\">18</a>]).\r\n  This compensatory effort may use up\r\n  limited cognitive resources resulting\r\n  in an apparent decrement in cognition\r\n  (the &lsquo;cognitive load&rsquo; hypothesis [<a href=\"#11\" title=\"11\">11</a>]).\r\n  However, this hypothesis seems unlikely\r\n  to fully account for the association\r\n  between hearing and cognitive\r\n  performance given that the association\r\n  between hearing and cognition remains\r\n  similar whether cognition is tested with\r\n  visual or auditory stimuli [<a href=\"#10\" title=\"10\">10</a>].</p>\r\n<p>There is evidence that intervention in\r\n  the form of hearing aids may improve\r\n  quality of life and increase social\r\n  engagement [<a href=\"#19\" title=\"19\">19</a>] and inconsistent\r\n  evidence that hearing aid use may have\r\n  a positive impact on performance of\r\n  cognitive measures over a few weeks\r\n  or months [<a href=\"#20\" title=\"20\">20</a>]. Some of the cognitive\r\n  measures in these previous studies\r\n  were auditory-based, so improvements\r\n  may be due to improved audibility.\r\n  In terms of longer-term outcomes of\r\n  hearing aid use on cognition, Valentijn\r\n  and colleagues [<a href=\"#21\" title=\"21\">21</a>] found no impact of\r\n  sensory intervention (cataract surgery; n\r\n  = 22 or hearing aids; n = 7) on cognitive\r\n  measures 6 years after baseline. There\r\n  is currently little evidence that hearing\r\n  aids have a long term protective effect\r\n  against cognitive decline.</p>\r\n<p>The aim of this study was to model\r\n  statistical associations between hearing\r\n  impairment and cognitive performance\r\n  in a large and inclusive data set. A\r\n  positive association between hearing\r\n  ability and cognitive performance could\r\n  be consistent with both the cascade and\r\n  common cause hypotheses. However,\r\n  if auditory deprivation contributes\r\n  to cognitive decline, as suggested by\r\n  the cascade hypothesis, use of hearing\r\n  aids should be associated with better\r\n  cognitive performance. The mediating\r\n  role of social isolation and/or depression\r\n  was also investigated.</p>\r\n<h4>METHODS</h4>\r\n<p><strong>UK BIOBANK SAMPLE</strong></p>\r\n<p>UK Biobank was established for\r\n  prospective investigations of the\r\n  genetic, environment and lifestyle\r\n  causes of diseases of middle and older\r\n  age [<a href=\"#22\" title=\"22\">22</a>]. Ethical approval was obtained\r\n  from the National Health Service North\r\n  West Multi-centre Research Ethics\r\n  Committee. More than 500,000 UK\r\n  adults were tested between 2006&ndash;\r\n  2010. Recruitment was via the UK\r\n  National Hearing Loss and Cognition\r\n  and analysis, decision to publish,\r\n  or preparation of the manuscript.\r\n  Participants attended an assessment\r\n  centre and gave informed consent. They\r\n  completed a two hour test session that\r\n  included a computerised assessment\r\n  of lifestyle, environment and medical\r\n  history, cognitive capacity and hearing.\r\n  Information on the procedure and the\r\n  additional data collected can be found\r\n  elsewhere (http://www.ukbiobank.\r\n  ac.uk/). All data were anonymized and\r\n  de-identified prior to analysis. As UK\r\n  Biobank data collection proceeded,\r\n  additional measures were included for\r\n  a subset of participants. Participants\r\n  in the present study were a subset of\r\n  164,770 who were asked to complete\r\n  a hearing test (the Digit Triplet Test).</p>\r\n<p><strong> DEMOGRAPHIC DATA</strong></p>\r\n<p>Sex, ethnicity data (based on 2001\r\n  UK Census categories) and Townsend\r\n  deprivation score (based on the area\r\n  of residence) were collected for each\r\n  participant. Townsend deprivation\r\n  scores are widely used in health\r\n  studies as a proxy for socioeconomic status [<a href=\"#23\" title=\"23\">23</a>]. Lower Townsend scores\r\n  represent areas associated with\r\n  less deprived (i.e. more affluent)\r\n  socioeconomic status. Participants\r\n  were asked to rate their health with two\r\n  self-report questions &ldquo;In general how\r\n  would you rate your overall health?&rdquo;\r\n  (excellent/good/fair/poor/do not know/\r\n  prefer not to answer) and &ldquo;Do you have\r\n  any long-standing illness, disability or\r\n  infirmity?&rdquo; (yes/no/do not know/prefer\r\n  not to answer).</p>\r\n<p>DIGIT TRIPLET TEST</p>\r\n<p>The Digit Triplet Test (DTT) is a speechin-\r\n  noise test originally developed in\r\n  Dutch for reliable large scale hearing\r\n  screening, and which correlates highly\r\n  (r = 0.77) with audiometric thresholds\r\n  [<a href=\"#24\" title=\"24\">24</a>,<a href=\"#25\" title=\"25\">25</a>]. The English version of the DTT\r\n  used in the UK Biobank was developed\r\n  at the University of Southampton\r\n  [<a href=\"#26\" title=\"26\">26</a>] (for a demonstration, see http://\r\n  www.actiononhearingloss.org.uk/\r\n  your-hearing/look-after-your-hearing/\r\n  check-your-hearing/take-the-check.\r\n  aspx). The DTT procedure is described\r\n  elsewhere (http://biobank.ctsu.ox.ac.\r\n  uk/crystal/label.cgi?id=100049). Briefly,\r\n  the signal to noise ratio (SNR), reported\r\n  in decibels, for the 50% correct speech\r\n  recognition threshold was estimated\r\n  for each ear. The level of hearing loss\r\n  was based on better ear performance.\r\n  Hearing aid users performed the DTT\r\n  without hearing aids.</p>\r\n<p>COGNITIVE TESTS</p>\r\n<p>Cognitive tests were completed via a\r\n  computerised touch screen interface.\r\n  Further information is reported\r\n  elsewhere (http://biobank.ctsu.ox.ac.\r\n  uk/crystal/label.cgi?id=100026).\r\n  Hearing loss would not be expected\r\n  to contribute to performance on these\r\n  visually presented tests. The background\r\n  and rationale for the cognitive tests\r\n  is reported by UK Biobank elsewhere\r\n  (http://www.ukbiobank.ac.uk/\r\n  wp-content/uploads/2011/11/UKBiobank-\r\n  Protocol.pdf? phpMyAdmin\r\n  = trmKQlYdjjnQIgJ%2CfAzikMhEnx6).</p>\r\n<p><strong>Reaction time. </strong>This test was based\r\n  on the card game &lsquo;Snap&rsquo;. Participants\r\n  were shown two cards at a time, with\r\n  12 pairs of cards overall. If both cards\r\n  display a matching symbol, participants\r\n  pressed a response button with their\r\n  dominant hand as quickly as possible.\r\n  The outcome measure was the average\r\n  time to correctly respond to a matching\r\n  pair.</p>\r\n<p><strong>Pairs matching.</strong> Participants were asked\r\n  to memorise the location of as many\r\n  matching pairs of cards as possible.\r\n  Cards were then turned face down, and\r\n  the participant was asked to match as\r\n  many pairs as possible with the fewest\r\n  attempts. This test was presented in\r\n  two rounds. The first round contained\r\n  one set of cards in a 2x3 matrix with\r\n  3 matching pairs, the second round\r\n  contained two sets of cards in a 3x4\r\n  matrix with 6 matching pairs. The\r\n  outcome measure was the number of\r\n  incorrect matches across all three sets.</p>\r\n<p><strong>Fluid intelligence.</strong> Fluid intelligence\r\n  (the capacity for logical thought\r\n  and problem solving, independent\r\n  of acquired knowledge) was based\r\n  on multiple choice responses to\r\n  13 questions such as &ldquo;Bud is to\r\n  Flower as Child is to?&rdquo; Participants\r\n  had 2 minutes to complete as many\r\n  questions as possible. Questions that\r\n  were not completed within the time\r\n  limit were scored as zero. The outcome\r\n  measure was the sum of the number of\r\n  correct answers.</p>\r\n<h4>HEARING AID USE, SOCIAL ISOLATION\r\n  AND DEPRESSION</h4>\r\n<p>Hearing aid use was assessed via\r\n  response to the question &ldquo;Do you use\r\n  a hearing aid most of the time?&rdquo; Social\r\n  isolation was assessed via response to\r\n  the question &ldquo;Do you often feel lonely?&rdquo;\r\n  Participants had the response options\r\n  Yes/No/Do not know/Prefer not to\r\n  answer. Depression was measured via\r\n  response to the screening question;\r\n  &ldquo;Over the past two weeks, how often\r\n  have you felt down, depressed or\r\n  hopeless?&rdquo; [<a href=\"#27\" title=\"27\">27</a>]. Participants had the\r\n  response options Not at all/Several\r\n  days/More than half the days/Nearly\r\n  every day/Do not know/Prefer not to\r\n  answer. Responses between &lsquo;not at all&rsquo;\r\n  and &lsquo;nearly every day&rsquo; were scored from\r\n  1 to 4.</p>\r\n<h4>DATA ANALYSIS</h4>\r\n<p>Structural equation modelling [<a href=\"#28\" title=\"28\">28</a>] was\r\n  used to test whether the association\r\n  between hearing impairment and\r\n  cognition may be mediated by hearing\r\n  aid use, social isolation and/or depression\r\n  in a sequence of four models, described\r\n  in the Results. Structural equation\r\n  modelling allows statistical evaluation of\r\n  inter-relationships (pathways) between\r\n  hearing impairment, cognition, hearing\r\n  aid use, social isolation and depression\r\n  while simultaneously controlling for\r\n  the potential confounders of age, sex,\r\n  general health and socioeconomic\r\n  status. Structural equation modelling\r\n  is a regression-based technique that\r\n  requires data to be distributed along the\r\n  range of variables (e.g. both hearing aid\r\n  use and non-use, good to poor hearing).\r\n  We considered mediation to be present\r\n  when both the pathways constituting the\r\n  indirect effect are statistically significant,\r\n  and that this is partial mediation if the\r\n  direct effect is also significant.</p>\r\n<p>Cognition was measured by a\r\n  standardised latent factor (mean 0,\r\n  variance 1) in the structural equation\r\n  model which was derived from a\r\n  measurement model with observed\r\n  indicators of the reaction time, pairs\r\n  matching and fluid IQ tests. The\r\n  covariates age, sex, general health\r\n  (overall health rating and long-standing\r\n  illness, disability or infirmity) and\r\n  socioeconomic status (Townsend\r\n  index) were included as predictors for\r\n  each outcome variable in the overall\r\n  structural equation model. Modelling\r\n  was carried out using robust weighted\r\n  least squares (WLSMV) in the Mplus\r\n  program version 7.11 (www.statmodel.\r\n  com/). Fit statistics and standardised\r\n  coefficients were reported for each\r\n  model. The Mplus estimates for\r\n  paths from predictors to an observed\r\n  categorical dependent variable (such\r\n  as HA use and social isolation) are\r\n  probit regression coefficients. A positive\r\n  sign means that the probability of the\r\n  categorical dependent variable (e.g.\r\n  the category 1 for a 0/1 variable) is\r\n  increased when the predictor value\r\n  increases. A larger magnitude means\r\n  that this probability is higher. For the\r\n  standardised latent cognition variable\r\n  a higher score implies worse cognition\r\n  due to the direction of the factor\r\n  loadings. The depression variable with\r\n  four response levels was treated as a\r\n  continuous variable. Estimates for paths\r\n  from predictors to these dependent\r\n  variables can be interpreted as in a\r\n  standard linear regression.</p>\r\n<h4>RESULTS</h4>\r\n<p><strong>Table 1</strong> contains the sex, ethnicity and\r\n  Townsend deprivation score for the\r\n  subset included in the present study\r\n  compared to the corresponding section\r\n  of the UK population aged 40 to 69\r\n  years. The study sample contains a\r\n  slightly higher proportion of females\r\n  and people living in more affluent areas\r\n  than in the general population. The\r\n  proportion of White ethnicity is similar\r\n  to that in the general population.</p>\r\n<p>In Model 1, after controlling for age, sex,\r\n  SES, and general health, poorer hearing\r\n  remained significantly associated\r\n  with poorer cognition (<strong>Fig. 1</strong>).\r\n  However, despite each predictor being\r\n  statistically significant, the model fit\r\n  statistics indicated that the model was\r\n  not satisfactory in explaining variation\r\n  in cognition. In Model 2, for equivalent\r\n  levels of hearing loss, hearing aid use\r\n  was associated with better cognitive\r\n  performance, supporting the cascade\r\n  hypothesis.</p>\r\n<div class=\"table-responsive\">\r\n  <table class=\"table table-sm table-bordered\">\r\n    <thead>\r\n      <tr>\r\n        <th colspan=\"2\">&nbsp;</th>\r\n        <th>UK Biobank</th>\r\n        <th>UK Census 2001</th>\r\n      </tr>\r\n    </thead>\r\n    <tbody>\r\n      <tr>\r\n        <td>Sex</td>\r\n        <td>Male</td>\r\n        <td>45.5%</td>\r\n        <td>49.2%</td>\r\n      </tr>\r\n      <tr>\r\n        <td>Ethnicity</td>\r\n        <td>White</td>\r\n        <td>91.5%</td>\r\n        <td>91.3%</td>\r\n      </tr>\r\n      <tr>\r\n        <td>Socioeconomic status</td>\r\n        <td>Mean Townsend score* (SD)</td>\r\n        <td>-1.1 (2.9)</td>\r\n        <td>&nbsp;</td>\r\n      </tr>\r\n    </tbody>\r\n  </table>\r\n</div>\r\n<p>*Lower Townsend scores indicate less deprivation.<br />\r\n  Sex and ethnicity are shown as percentages while socio-economic status is reported as average Townsend<br />\r\n  deprivation index score (with standard deviation).</p>\r\n<p><strong>Table 1.</strong> Participants in the study sample versus 2001 UK Census data for sex,<br />\r\n  etnicity and socio-economic status.</p>\r\n<div class=\"well well-sm\">\r\n  <div class=\"row\">\r\n    <div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Structural-11-2-1-g001.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Structural-11-2-1-g001.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Structural\" title=\"canadian-hearing-report-Structural\" /></a></div>\r\n    <div class=\"col-xs-12 col-md-10\">\r\n      <p><strong>Figure 1:</strong> Structural equation models of standardised path coefficients between hearing, cognition, hearing aid use, social isolation and depression.\r\n        Notes: *** p&lt;0.001, *p&lt;0.05, Root Mean Error of Approximation (RMEA). A value less than 0.05 indicates good fit. Comparative Fit Index (CFI)\r\n        and Tucker Lewis Index (TLI), with a number greater than 0.95 indicating good fit.</p>\r\n    </div>\r\n  </div>\r\n</div>\r\n<p>The effect of hearing loss on cognition\r\n  remained significant, implying that the\r\n  effect of hearing loss on cognition is\r\n  only partly mediated through hearing\r\n  aid use. Social isolation was associated\r\n  with both poorer cognition and poorer\r\n  hearing (Model 3), but hearing aid use\r\n  was weakly associated with more social\r\n  isolation. The effect of hearing aid use\r\n  on cognition is partly mediated through\r\n  social isolation, but there remains a\r\n  significant direct effect. In Model 4,\r\n  social isolation and poor hearing were\r\n  significantly associated with higher\r\n  frequency of depression. Frequency\r\n  of depression and social isolation were\r\n  associated with poorer cognition.\r\n  Hearing aid use was not associated\r\n  with depression, but was associated\r\n  with greater social isolation and with\r\n  better cognition. With the exception\r\n  of the Tucker Lewis Index (TLI), fit\r\n  statistics indicated that models 2&ndash;4 were\r\n  a good fit with the data. As a sensitivity\r\n  analysis and to provide a check of the\r\n  robustness of the models, models 3 and\r\n  4 were re-run with alternative measures\r\n  of depressive symptoms (frequency of\r\n  unenthusiasm/disinterest) and social\r\n  isolation (number of social/leisure\r\n  activities). Use of alternative measures\r\n  did not change the substantive results\r\n  in either model (data not reported here).</p>\r\n<h4>DISCUSSION</h4>\r\n<p>In cross-sectional modelling in a large\r\n  sample of UK adults, hearing aid use was\r\n  associated with better cognition. This is\r\n  consistent with the &lsquo;cascade hypothesis&rsquo;,\r\n  where long-term auditory deprivation\r\n  or degraded auditory input may result\r\n  in increased cognitive decline [<a href=\"#6\" title=\"6\">6</a>,<a href=\"#12\" title=\"12\">12</a>,<a href=\"#13\" title=\"13\">13</a>].\r\n  The positive association of hearing aid\r\n  use on cognition that was observed in\r\n  the present study was independent of\r\n  any positive association of hearing aid\r\n  use on social isolation or depression.\r\n  Therefore any effect of hearing aid use on\r\n  cognition is unlikely to be via reduction\r\n  of the adverse effects of hearing loss on\r\n  social isolation or depression. Rather,\r\n  these data suggest that the benefit may\r\n  be directly through increased audibility\r\n  of sounds in daily life. This pattern of\r\n  association was observed within a large\r\n  and inclusive sample of UK adults in\r\n  the present study, and is likely to be\r\n  generalisable to the UK population\r\n  [<a href=\"#22\" title=\"22\">22</a>]. The cognitive tests were all\r\n  visually presented, and so it is unlikely\r\n  that hearing aids had a strong impact\r\n  on performance on cognitive tests via\r\n  improved audibility of test stimuli.</p>\r\n<p>If hearing aids do have a positive impact\r\n  on cognitive performance not due to\r\n  a reduction in depression or social\r\n  isolation, how might hearing aid use\r\n  impact on cognition? According to the\r\n  cascade hypothesis, untreated hearing\r\n  loss may result in long-term auditory\r\n  deprivation or degraded auditory\r\n  input, resulting in increased cognitive\r\n  decline. However, the mechanism\r\n  for this is not known and requires\r\n  elucidation [<a href=\"#6\" title=\"6\">6</a>,<a href=\"#12\" title=\"12\">12</a>,<a href=\"#13\" title=\"13\">13</a>]. One possibility\r\n  is that hearing aids may boost selfefficacy,\r\n  and increased self-efficacy\r\n  positively impacts on performance on\r\n  cognitive tests. Self-efficacy refers to the\r\n  belief in one&rsquo;s own ability to perform\r\n  tasks and achieve goals. Hearing loss\r\n  is associated with reduced self-efficacy\r\n  [<a href=\"#29\" title=\"29\">29</a>]. Low self-efficacy is associated\r\n  with poor performance on a variety of\r\n  challenging tasks, perhaps via affective\r\n  or motivational influences [<a href=\"#30\" title=\"30\">30</a>,<a href=\"#31\" title=\"31\">31</a>].\r\n  Unfortunately, no self-efficacy data were\r\n  available in the present study and we\r\n  were unable to examine this possibility.</p>\r\n<p>One unexpected result was a lack of\r\n  association between hearing aid use\r\n  and depression, and increased social isolation associated with hearing aid\r\n  use. It may be that hearing aids do\r\n  discourage participation in social events\r\n  by amplifying aversive background\r\n  noise that is typical at social venues such\r\n  as clubs, cafes and restaurants. However,\r\n  hearing aids have been previously\r\n  suggested not only to reduce hearing\r\n  handicap, but to reduce concomitant\r\n  social isolation and depression [<a href=\"#32\" title=\"32\">32</a>].\r\n  Evidence for this is limited however\r\n  [<a href=\"#33\" title=\"33\">33</a>]. One randomised controlled study\r\n  reported an improvement in social\r\n  engagement and a small reduction in\r\n  symptoms of depression in a select\r\n  group of new hearing aid users (elderly\r\n  white male US veterans with moderate to\r\n  severe hearing loss) [<a href=\"#19\" title=\"19\">19</a>]. An explanation\r\n  for the lack of positive association\r\n  between hearing aid use and social\r\n  isolation in the present study might\r\n  be that the measure of social isolation\r\n  based on a single Yes/No question\r\n  lacked sensitivity. Note however, that\r\n  associations remained unchanged when\r\n  substituting an alternative measure\r\n  of social engagement. Similarly with\r\n  depression, associations were similar\r\n  for an alternative measure of depressive\r\n  symptoms. Information about hearing\r\n  aid use was limited to whether\r\n  participants reported that they use\r\n  a hearing aid &lsquo;most of the time&rsquo;. The\r\n  amount of hearing aid use, how well\r\n  the hearing aid was fitted to compensate\r\n  for hearing loss, the duration of hearing\r\n  aid use and whether participants\r\n  began using hearing aids soon after the\r\n  onset of hearing loss may also impact\r\n  the effectiveness of hearing aids in\r\n  improving outcomes including social\r\n  engagement, depression and cognition\r\n  [<a href=\"#34\" title=\"34\">34</a>]. However, one would expect that\r\n  in a sample of the size utilized in the\r\n  present study, the net effect of hearing\r\n  aid use on social engagement, depression\r\n  and cognition would be apparent. The\r\n  assumption in the present study was\r\n  that better cognition in hearing aid users\r\n  observed in cross-sectional analysis\r\n  may reflect the long-term impact of\r\n  hearing aid use in reducing cognitive\r\n  decline. However, longitudinal data are\r\n  required to confirm whether hearing\r\n  aid use is associated with any alteration\r\n  in the rate of cognitive decline over\r\n  time. The data in the present study are\r\n  correlational, and no strong conclusions\r\n  about causality are possible. Alternative\r\n  interpretations of the patterns of\r\n  association reported in the present study\r\n  are possible. For example, rather than\r\n  hearing aids &lsquo;causing&rsquo; better cognition,\r\n  cognitively more able people might\r\n  tend to obtain and use hearing aids.\r\n  Cognitively more able people may be\r\n  more likely to access specialist health\r\n  services, including audiology, or may\r\n  more likely recognise hearing disability\r\n  and seek treatment. Establishing a\r\n  causal association between hearing aid\r\n  use and cognitive performance requires\r\n  controlled studies with cognitive\r\n  outcomes measured in the short term as\r\n  well as after several years hearing aid use.\r\n  The study was restricted to adults aged\r\n  40 to 69 years, so it is uncertain whether\r\n  the associations identified in the present\r\n  study are generalizable to older adults,\r\n  in whom sensory impairment, hearing\r\n  aid use and cognitive impairments are\r\n  more common.</p>\r\n<h4>CONCLUSION</h4>\r\n<p>Hearing aid use was associated with\r\n  better cognition in a large cross-sectional\r\n  study of UK adults. The association\r\n  was independent of social isolation\r\n  and depression. Further research is\r\n  required to determine the direction of\r\n  association, if there is any direct causal\r\n  relationship between hearing aid use\r\n  and better cognition, and whether\r\n  hearing aid use results in reduction in\r\n  rates of cognitive decline measured\r\n  longitudinally. Treating hearing loss\r\n  may make a significant contribution to\r\n  reducing the burden associated with\r\n  cognitive decline and reduced quality\r\n  of life.</p>\r\n<h4>ACKNOWLEDGMENTS</h4>\r\n<p>The views expressed are those of the\r\n  author(s) and not necessarily those of\r\n  the NHS, the NIHR or the Department\r\n  of Health. This research was facilitated\r\n  by Manchester Biomedical Research\r\n  Centre.</p>\r\n<h4>AUTHOR CONTRIBUTIONS</h4>\r\n<p>Conceived and designed the\r\n  experiments: PD RE KC. Analyzed the\r\n  data: PD RE ME. 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Southampton: University of Southampton. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'27\'><a name=\"27\" id=\'27\'></a>U.S.  Preventative Services Task Force (2002) Screening for Depression: Recommendations and Rationale. Annals of Internal Medicine  136: 760&ndash;764. PMID:  12020145 </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'28\'><a name=\"28\" id=\'28\'></a>Kline  RB (2011) Principles and practice of structural  equation modelling. New York: The Guildford Press. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'29\'><a name=\"29\" id=\'29\'></a>Kramer  SE, Kapteyn TS, Kuik DJ, Deeg DJH (2002)  The association of hearing impairment and  chronic diseases with psychosocial health status in older age. Journal of Aging and Health 14: 122&ndash;137. PMID:  11892756 </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'30\'><a name=\"30\" id=\'30\'></a>Bouffard-Bouchard T (1990) Influence of  self- efficacy on performance in a cognitive task. The Journal  of Social Psychology 130: 353&ndash;363. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'31\'><a name=\"31\" id=\'31\'></a>Bandura  A (1989) Regulation of cognitive processes  through perceived self-efficacy. Developmental psychology 25: 729. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'32\'><a name=\"32\" id=\'32\'></a>Kochkin  S, Rogin C (2000) Quantifying the obvious:  The impact of hearing instruments on quality of life. Hear Rev 7: 6&ndash;34. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'33\'><a name=\"33\" id=\'33\'></a>Moyer VA (2012) Screening for Hearing Loss in Older Adults: US  Preventive Services Task Force Recommendation Statement. Annals of internal  medicine 157: 655&ndash;661.  PMID: 22893115 </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'34\'><a name=\"34\" id=\'34\'></a>Tesch-R&ouml;mer C (1997) Psychological effects of hearing aid use in older adults. The  Journals of Gerontology Series B: Psychological Sciences and Social Sciences  52: P127&ndash;P138. PMID: 9158564</a></li>\r\n</ol>',NULL,'2022-11-11'),(10,5382,'ajchr','http://www.andrewjohnpublishing.com/','','<h4>The Auditory Science Laboratory at the\r\n  University of Toronto; a research update</h4>\r\n<p>By Robert V. Harrison<sup><a href=\"#a1\">1</a></sup>,<sup><a href=\"#a1\">2</a></sup></p>\r\n<p><sup><a href=\"#a1\">1</a></sup>Professor and Vice-Chair (research), Department of Otolaryngology &ndash; Head &amp; Neck Surgery, University of Toronto,</p>\r\n<p><sup><a href=\"#a1\">2</a></sup>Senior Scientist, Program in Neuroscience and Mental Health\r\n  The Hospital for Sick Children, Toronto, Canada</p>\r\n<p>I am pleased to provide Canadian\r\n  Hearing Report an overview of some\r\n  of our recent research that may be of\r\n  interest to audiology professionals. I have\r\n  directed the Auditory Science Laboratory\r\n  at the Hospital for Sick Children (SickKids)\r\n  for over 30 years, and during that time we\r\n  have published research on animal models\r\n  of hearing loss of many types and causes.\r\n  The list is long: presbyacusis, conductive\r\n  loss, ototoxic drugs, endolymphatic\r\n  hydrops, acoustic trauma, chronic hypoxia.\r\n  Most recently we have been exploring\r\n  another etiology, hearing loss caused by\r\n  congenital cytomegalovirus (CMV).</p>\r\n<p>Those involved in pediatric audiology will\r\n  be particularly interested in CMV induced\r\n  hearing loss. You will know that it is very\r\n  poorly diagnosed &ndash; suspected often but\r\n  not definitively proven. The degree of\r\n  hearing loss resulting from CMV infection\r\n  ranges from mild to severe/profound. In\r\n  our cochlear implant program at SickKids,\r\n  more than 20% of our candidates have\r\n  severe or profound hearing loss related\r\n  to CMV infection. The hearing problem\r\n  can be present at birth, or can develop\r\n  more slowly over time and manifest after\r\n  birth. Many CMV infected newborns are\r\n  asymptomatic and pass hearing screening\r\n  with inner ear problems becoming\r\n  apparent much later. One study estimates that 10% of children, 4 years of age, with\r\n  &ldquo;idiopathic&rdquo; hearing loss have had a\r\n  congenital CMV infection.</p>\r\n<p>This research to study the effects of CMV\r\n  infection on the inner ear has largely\r\n  carried out by Dr. Mattia Carraro (as\r\n  part of his PhD thesis) in collaboration\r\n  with a team at the University of Utah\r\n  (led by Dr. Albert Park in the Division of\r\n  Otolaryngology). Our focus has been on\r\n  damage to the vasculature of the cochlea.\r\n  For this Canadian Hearing Report, I will\r\n  generally describe our findings rather\r\n  than the full details that are available\r\n  in published papers (see references\r\n  appended).</p>\r\n<p>We have used a mouse model that\r\n  shows many similarities to human CMV\r\n  infection. We inoculate the brain of a\r\n  newborn mouse with virus. Of course\r\n  in humans CMV infection typically starts\r\n  during pregnancy, but because the mouse\r\n  is born in an immature state its condition\r\n  at birth (including stage of hearing\r\n  development) is equivalent to an infant in\r\n  utero. Furthermore in our mouse model,\r\n  as with humans, the degree of hearing\r\n  loss resulting from CMV infection is\r\n  extremely varied. Animals given identical\r\n  doses of CMV develop a range of hearing\r\n  impairments from mild through to\r\n  profound deafness (as assessed using from\r\n  auditory brainstem evoked potentials\r\n  (ABR). Our experimental protocol is\r\n  summarized in the box above. Essentially\r\n  we inject (arrow) the brain of newborn\r\n  mice with CMV. At 4-6 weeks hearing\r\n  function is tested with ABR. Elevations in\r\n  ABR thresholds are indicated in the right\r\n  panel above. At 8 weeks we studied the\r\n  cochlear vasculature.</p>\r\n<p>A novel aspect of our research is that we\r\n  predicted that this viral infection might\r\n  first affect the blood capillary beds of\r\n  the cochlea. It turns out that we were\r\n  correct. In order to investigate any change\r\n  to blood vessel structure we refined a\r\n  histological technique called corrosion\r\n  casting. This involves injecting a liquid\r\n  polymer into all of the blood vessels.\r\n  When this plastic polymerizes it create a\r\n  hard plastic cast of the vessels including\r\n  arterial supply, capillary beds and veins. To\r\n  see the casts we corrode away the bone\r\n  and all soft tissue. In the illustrations of\r\n  this report, we see the corrosion casts of\r\n  capillary networks in the cochlea viewed\r\n  with a scanning electron microscope.</p>\r\n<h4>The Auditory Science Laborat ory at the University of\r\n  Toronto; a research updat e</h4>\r\n<p>The first signs of vascular damage\r\n  resulting from CMV infection are seen\r\n  at the cochlear apex. This is illustrated\r\n  in figure 2. Note the lack of stria\r\n  vascularis capillaries in the highlighted\r\n  region. In other subjects, CMV causes\r\n  more extensive damage to the cochlea\r\n  Fig. 4. Left: Normal spiral limbus capillaries. These are the blood vessels that feed the organ of Corti and the spiral ganglion cell region of the\r\n  cochlea. Right: Degeneration of the spiral limbus capillaries resulting from CMV infection.\r\n  vasculature. Two examples are illustrated\r\n  in figure 3 below. In addition to the CMV\r\n  related damage to the stria vascularis we\r\n  also see degeneration of the capillaries\r\n  that supply the organ of Corti, and the\r\n  spiral ganglion region of the cochlear\r\n  modiolus. These are the vessels of the\r\n  spiral limbus, and in the normal subject\r\n  they are arranged as shown in figure 4\r\n  below (left panel). In the right-hand panel\r\n  we can note the damaging effects of CMV\r\n  infection.</p>\r\n<p>This study is the first to reveal that the initial effect of CMV infection is on the\r\n  cochlear vasculature, specifically the stria\r\n  vascularis. It is well known that the strial\r\n  mechanisms are important for maintaining\r\n  the endolymphatic (or endocochlear)\r\n  potential that in turn, powers haircell\r\n  transduction mechanisms. We suggest\r\n  that early stage vascular damage can\r\n  cause changes to the EP that will manifest\r\n  as a mild to moderate hearing loss. If the\r\n  extent of vascular damage is not extensive\r\n  there is a possibility of some recovery, as\r\n  is sometimes the case with other causes\r\n  of hearing loss that temporarily cause\r\n  strial dysfunction (e.g. ototoxic diuretics\r\n  such as Lasix). Importantly we have\r\n  noted in our experiments some signs\r\n  of regeneration (angiogenesis) of strial capillaries after CMV damage.</p>\r\n<p>What does this mean for clinical\r\n  application? There are still many aspects\r\n  of CMV related hearing loss that we do\r\n  not fully understand, indeed many more\r\n  questions than answers. For example how\r\n  does the virus migrate from the brain to\r\n  the inner ear? How can we detect this\r\n  inner ear involvement early on? How\r\n  exactly does CMV damage to the strial\r\n  vessels? Is there involvement of reactive\r\n  oxygen species (ROS) in causing vessel\r\n  damage? Can this be prevented? After\r\n  degeneration of strial capillaries, is there\r\n  a way of promoting a regeneration of\r\n  the vasculature? These are all questions\r\n  that we might address in the future using\r\n  an animal model such as we have now\r\n  described here.</p>\r\n<p>See these recent publications for more\r\n  detailed information on this research\r\n  study:</p>\r\n<p>1. Carraro, M., Park, A., and Harrison, R.V. &ldquo;Partial\r\n  corrosion casting to assess cochlear vasculature\r\n  in mouse models of presbycusis and CMV\r\n  infection&rdquo; Hearing Research 332 (2016): 95-103.</p>\r\n<p>2. Carraro, M. and Harrison, R.V. &ldquo;Degeneration\r\n  of stria vascularis in age-related hearing loss; a\r\n  corrosion cast study in a mouse model&rdquo;Acta\r\n  Otolaryngologica 136:4 (2016): 385-390.</p>\r\n<p>3. Carraro, M., et al. &ldquo;Cytomegalovirus (CMV)\r\n  infection causes degeneration of cochlear\r\n  vasculature and hearing loss in a mouse model&rdquo;\r\n  Journal of the Association for Research in\r\n  Otolaryngology (2016) 18: 263-2 7 3.</p>\r\n<h4>Hearing Loss in Infants</h4>\r\n<p><strong>&ldquo;Blindness separates humans from things,\r\n  Deafness separates humans from humans.&rdquo;</strong></p>\r\n<p>Helen Keller</p>\r\n<p>&ldquo;Carol Davila&rdquo; University of Medicine and Pharmacy Bucharest, Romania</p>\r\n<p>Congenital deafness, together with other\r\n  sensorial impairments has an important\r\n  negative impact on child&rsquo;s development.\r\n  The severity of the hearing impairment,\r\n  especially if not habilitated through\r\n  surgery or hearing aids, shapes the child\r\n  in many aspects. Regarding hearing aspect,\r\n  a child can be anywhere between deaf\r\n  and mute and bad pronunciation. But this\r\n  deficit is not alone &ndash; it is associated with\r\n  integration difficulties in kindergarten and\r\n  at school, limited academic development,\r\n  frustration and lack of self-esteem.</p>\r\n<p>Acquired bilateral hearing loss does not\r\n  influence dramatically speech, but has an\r\n  important influence on hearing impaired\r\n  person&rsquo;s social life, since communication\r\n  difficulties leads to isolation and\r\n  emotional disturbances. Almost 10%\r\n  of the population has some degree of\r\n  hearing loss and needs appropriate\r\n  treatment and/or rehabilitation.</p>\r\n<p>Due to this large number of persons\r\n  with hearing loss, hearing loss is a public\r\n  health issue which requires specific health\r\n  politics in order to allow access to each\r\n  patient to standard medical services. This\r\n  can be offered through following:</p>\r\n<p>&bull; Mandatory universal new-born\r\n  hearing screening</p>\r\n<p>&bull; Follow-up program for hearing\r\n  impaired children up to school age</p>\r\n<p>&bull; Hearing screening in preschool\r\n  and school-age children</p>\r\n<p>&bull; National register of hearing\r\n  impaired persons</p>\r\n<p>&bull; Educational programs in Audiology, to have enough trained audiologist\r\n  for the large number of patients\r\n  with permanent hearing loss</p>\r\n<p>Two main categories of childhood hearing\r\n  loss are considered &ndash; prelingually and\r\n  post lingually hearing loss.</p>\r\n<p>Prelingually hearing loss is mostly\r\n  congenital, being the most frequently\r\n  congenital deficiency (1-3% of alive\r\n  new borns). Deafness is an invisible\r\n  handicap and for this reason active\r\n  detection through new born hearing\r\n  screening programs should be promoted\r\n  and implemented. New born hearing\r\n  screening programs are the only solution\r\n  for early detection of hearing loss. Infants\r\n  who do not pass the screening test should\r\n  be referred to an audiological diagnostic\r\n  centre for certain diagnosis of hearing\r\n  loss and quantification of the impairment.</p>\r\n<p>Hearing screening must be universal, to\r\n  cover all new born, since 50% of children\r\n  with congenital hearing loss has no risk\r\n  factors for hearing loss. In 2007, Join\r\n  Committee on Infant Hearing defined risk\r\n  factors for hearing loss:</p>\r\n<p>&bull; Prenatal period</p>\r\n<p>o Hereditary aetiology</p>\r\n<p>o Genetic disorders (Connexine\r\n  26 mutation)</p>\r\n<p>o Pregnancy evolution</p>\r\n<p>o Maternal infections during\r\n  pregnancy or delivery\r\n  (Toxoplasmosis, Syphilis, HIV,\r\n  Hepatitis B, Rubella, CMV,\r\n  Herpes simplex, and others)</p>\r\n<p>o Intoxications (drugs, alcohol)</p>\r\n<p>&bull; Neonatal period</p>\r\n<p>o Birth condition (hypoxia)</p>\r\n<p>o Prematurity (less 37 weeks)</p>\r\n<p>o Low birth weight (less 1500 g)</p>\r\n<p>o Cardio-respiratory distress\r\n  (mechanical ventilation more\r\n  than seven days)</p>\r\n<p>o NICU admission more than\r\n  five days</p>\r\n<p>o Hyperbilirubinemia</p>\r\n<p>o Syndrome associated with\r\n  hearing loss (Pendred,\r\n  Usher, Waardenburg,\r\n  neurofibromatosis)</p>\r\n<p>o Physical problems of the head,\r\n  face, ears, or neck (cleft lip/\r\n  palate, ear pits/tags, atresia, and\r\n  others)</p>\r\n<p>o Ototoxic medications\r\n  given in the neonatal\r\n  period (one or more\r\n  aminoglycosides antibiotics,\r\n  loop diuretics associated with\r\n  aminoglycosides antibiotics)</p>\r\n<p>o Infections - bacterial meningitis\r\n  and other infections (mumps,\r\n  encephalitis, viral labyrinthitis)\r\n  New born hearing screening is the\r\n  cheapest birth screening. It is a\r\n  non-invasive, simple, short method.\r\n  Appropriate medical device is needed and\r\n  2 to 3 instructed persons &ndash; coordinator\r\n  physician and maternal-ward nurses. </p>\r\n<p>Post lingually hearing loss defines hearing\r\n  loss with onset after speech development.\r\n  It is an acquired hearing loss, most\r\n  frequently during small childhood.\r\n  Incidence of this type of hearing loss is\r\n  10 times larger (3-5% of 3 to 5 years old\r\n  children) than the incidence of congenital\r\n  hearing loss, but its severity is smaller than\r\n  the severity of the congenital hearing loss.\r\n  The later one is characterised by bilateral\r\n  deafness in most cases. Bilateral hearing\r\n  loss, even mild one, impedes on school\r\n  progress of hearing impaired children,\r\n  induces greater tiredness for school\r\n  activities and affects children&rsquo;s social\r\n  relations with their school mates.</p>\r\n<p>Appropriate management of hearing\r\n  impaired child includes early detection\r\n  of hearing loss associated with early\r\n  appropriate treatment. For permanent\r\n  bilateral hearing loss, conventional or implantable hearing aids are the only\r\n  solution for auditory habilitation of the\r\n  deaf child. Quality of speech and language\r\n  measures the benefit of the hearing aid.\r\n  Early treatment of the hearing loss with\r\n  specific speech therapy leads to correct\r\n  speech and language development, like\r\n  normal hearing children one.</p>\r\n<p>This achievement is the result of cerebral\r\n  neuroplasticity property (cortical\r\n  remapping), a process in which cortical\r\n  areas modifies through experience. This\r\n  &ldquo;compliance&rdquo; of the brain is correlated\r\n  with learning processes through of\r\n  adding or removal of connections.\r\n  Cortical plasticity is time-dependent, with\r\n  maximum capacity in the first one and\r\n  a half-two years of life. This opportunity\r\n  window cannot be missed for best\r\n  management of the deaf child.</p>\r\n<p>Late auditory habilitation has limited\r\n  benefits on child&rsquo;s pronunciation skills\r\n  or even worse, no benefit, if cochlear\r\n  implantation is provided after age of six.\r\n  The child will still be mute and deaf if no\r\n  auditory stimulation was provided until\r\n  this age. In this case, cochlear implant will\r\n  deliver information in an auditory cortex\r\n  already organised, but took over by visual\r\n  system and stimulation of the auditory\r\n  pathway will not finalise in audition as\r\n  final sensation.</p>\r\n<p>For infants, the standard health services\r\n  include hearing screening test until age\r\n  of one month, hearing loss diagnosis until\r\n  age of three-month-old and treatment\r\n  onset until age of six month. This is the\r\n  best strategy we should aim to help\r\n  efficiently children with congenital or fist\r\n  month acquired hearing loss.</p>\r\n<h4>Efficacy of Implantable Devices for\r\n  Conductive and Mixed Hearing Loss</h4>\r\n<p>By Ad Snik*</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>Nowadays, several types of conventional\r\n  and implantable amplification options are\r\n  available for patients with conductive or\r\n  mixed hearing loss. Table 1 presents an\r\n  overview. Implantable devices are being\r\n  developed because the conventional\r\n  devices (behind-the-ear (BTE) devices and\r\n  conventional bone conductors applied\r\n  with headband or soft band) might fail for\r\n  various reasons [1]. Besides implantable\r\n  bone-conduction devices (percutaneous\r\n  bone-conduction implants, passive and\r\n  active transcutaneous bone-conduction\r\n  implants), middle-ear implants can be\r\n  applied with their actuator coupled to\r\n  one of the cochlear windows.</p>\r\n<p>Such implantable devices have often\r\n  been launched with enthusiasm while\r\n  well-documented scientific and clinical\r\n  data were not available. So, the &lsquo;market&rsquo;\r\n  (implant centres) had to find out whether or not these devices were more effective\r\n  than existing devices and whether or not\r\n  these implants were stable over time. This\r\n  &lsquo;let-the-market-decide&rsquo; is time consuming;\r\n  mostly the search is not carried out\r\n  systematically and it might result in nonoptimally\r\n  treated patients.</p>\r\n<p>From systematic reviews of the literature\r\n  it has been concluded repeatedly\r\n  that evidence level of most published\r\n  studies is weak and the overall result\r\n  is not convincing [3,4]. So, the question\r\n  remains: do we have good evidence to\r\n  choose between hearing solutions for a\r\n  given patient? Consensus is lacking while\r\n  the devices are not equivalent in terms\r\n  auditory capacity and efficacy, invasiveness\r\n  and complexity of implant surgery,\r\n  stability over time, MRI compatibility,\r\n  costs, etc. [5]. </p>\r\n<p><strong>THE USE OF A WEBSITE</strong></p>\r\n<p>As a first step to obtain consensus, objective data was gathered and\r\n  published on a website; the website was\r\n  developed by the author for professionals\r\n  (http://www.snikimplants.nl). Subjective\r\n  (questionnaire) data were not taken\r\n  into account because such data is easily\r\n  biased [6], especially when applying new\r\n  technology [7].</p>\r\n<p>The website format is chosen as websites\r\n  are easily accessible and they can be\r\n  updated e.g. when new information on the\r\n  efficacy of implantable devices becomes\r\n  available.</p>\r\n	<div class=\"table-responsive\">\r\n  <table class=\"table table-sm table-bordered\">\r\n    <thead>\r\n  <tr>\r\n    <th>Device for conductive or mixed<br>\r\n      hearing loss</th>\r\n    <th>Manufacturer</th>\r\n    <th>Indication</th>\r\n      </tr>\r\n    </thead>\r\n    <tbody>\r\n      <tr>\r\n        <td\r\n>Behind-the-ear</td>\r\n    <td>Several</td>\r\n    <td>Dry ear,    normal ear canal    and air-bone gap<br>\r\n      &lt;40 dBHL*</td>\r\n  </tr>\r\n  <tr>\r\n    <td>Conventional bone-conduction<br>\r\n      device (BCD)</td>\r\n    <td>All BCDs    applied with softband or<br>\r\n      steel headband</td>\r\n    <td>Running    ear or aural atresia</td>\r\n  </tr>\r\n  <tr>\r\n    <td>Percutaneous bone-conduction<br>\r\n      implant</td>\r\n    <td>Baha (Cochlear) Ponto (Oticon)</td>\r\n    <td>Idem, also    used as CROS    device in single-<br>\r\n      sided deafness</td>\r\n  </tr>\r\n  <tr>\r\n    <td>Transcutaneous bone-conduction<br>\r\n      implant</td>\r\n    <td>Baha Attract (Cochlear) Sophono<br>\r\n      (Medtronic)</td>\r\n    <td>Running    ear or aural atresia</td>\r\n  </tr>\r\n  <tr>\r\n    <td>Active transcutaneous bone-<br>\r\n      conduction    implant</td>\r\n    <td>Bonebridge    (Med-El)</td>\r\n    <td>Idem,    also used as CROS device</td>\r\n  </tr>\r\n  <tr>\r\n    <td>Middle ear implant</td>\r\n    <td>Vibrant Soundbridge (Med-El) and<br>\r\n      MET (Cochlear)</td>\r\n    <td>Infection-free middle    ear; no severe    middle<br>\r\n      ear    anomalies</td>\r\n  </tr>\r\n</tbody>\r\n  </table>\r\n</div>\r\n	\r\n<p><strong>Table 1.</strong> Types of conventional and implantable devices  for conductive and mixed hearing  loss.</p>\r\n	<div class=\"alert alert-warning\" role=\"alert\">\r\n  *de Wolf et al. [2]\r\n</div>\r\n<p>The first objective measure discussed on\r\n  the website is the capacity of the different\r\n  types of implantable devices. Following\r\n  [8], the maximum output (MPO) was\r\n  measured while the devices were\r\n  programmed in linear amplification mode\r\n  [9,5]. Next, the MPO was used to define\r\n  inclusion criterion for the application of\r\n  each device in terms of the maximum allowable sensorineural hearing loss\r\n  component.</p>\r\n<p>Table 2 presents the mean MPO,\r\n  expressed in dB HL, of all the implantable\r\n  devices that were introduced in Table 1. As\r\n  Table 2 shows, the MPO of most devices\r\n  is limited, obviously below loudness\r\n  discomfort levels (LDL) of patients;\r\n  considered at the cochlear level, LDL\r\n  levels will be found between 90 and 110\r\n  dB HL [10]. Note that all the introduced\r\n  implantable devices stimulate the cochlea,\r\n  bypassing the impaired middle ear. The\r\n  &lsquo;dynamic range of hearing&rsquo; is by definition\r\n  the difference between the cochlear\r\n  thresholds and LDL. When using a device\r\n  with limited MPO, the upper part of this\r\n  &lsquo;dynamic range of hearing&rsquo; (LDL &ndash;MPO)\r\n  cannot be addressed. So, the higher the\r\n  MPO of the device is, the wider the aided\r\n  &lsquo;dynamic range of hearing. Only if the\r\n  MPO level coincides with LDL, full use\r\n  can be made of the patient&rsquo;s &lsquo;dynamic\r\n  range of hearing. For proper application of today&rsquo;s implantable devices with\r\n  their limited MPO, some compromise\r\n  is needed concerning a just acceptable\r\n  aided &lsquo;dynamic range of hearing. The\r\n  suggested, rather arbitrary compromise\r\n  is the following: a specific device should\r\n  only be applied if the dynamic range is at\r\n  least 35 dB (width of the &lsquo;speech area&rsquo;\r\n  or &lsquo;speech banana; [5] while the &lsquo;lost&rsquo;\r\n  dynamic range (LDL-MPO) is less than\r\n  1/3 of the total &lsquo;dynamic range of hearing&rsquo;\r\n  (MPO - cochlear threshold; named the\r\n  2/3 rule [5]. Using such a compromise, the\r\n  implantable devices can be categorized;\r\n  the maximum allowable cochlear hearing\r\n  loss component can now be calculated,\r\n  see Table 2, last column.</p>\r\n<p>These maximum values can be used when\r\n  counselling patients. Longevity is directly\r\n  related to such values. To illustrate this,\r\n  assume that the progression in hearing\r\n  loss is known. Then longevity can be\r\n  assessed. Fig. 1 shows an example, taken\r\n  from [5] chapter 3. The data suggest that in this case (OTSC 7 patients) the\r\n  percutaneous bone conductor and the\r\n  Vibrant Soundbridge can be used life long Another important and rather\r\n  objective measure is implant stability.\r\n  A straightforward measure dealing\r\n  with stability is the number of revision\r\n  surgeries related to follow-up. According\r\n  to the Swiss national database, on the\r\n  average, revision surgery in patients with a\r\n  cochlear implant occurs once in 30 years\r\n  of follow-up, personal communication).\r\n  Only for the percutaneous Baha, longterm\r\n  stability data have been published.\r\n  Using the adults&rsquo; results published\r\n  by [11] a similar revision rate was\r\n  calculated. Preliminary data showed that\r\n  the revision rate for the percutaneous\r\n  Baha is improving owing to new implant\r\n  technology and surgical approaches while\r\n  the preliminary revision rate for middle\r\n  ear implant applications is still lagging\r\n  behind [5], chapter 4. Definitely, more data\r\n  on stability issues should be published.</p>\r\n	\r\n\r\n\r\n\r\n\r\n<div class=\"table-responsive\">\r\n  <table class=\"table table-sm table-bordered\">\r\n    <thead>\r\n  <tr>\r\n    <th rowspan=\"2\">Device</th>\r\n    <th>MPO</th>\r\n    <th rowspan=\"2\">SNHL component:</th>\r\n  </tr>\r\n  <tr>\r\n    <th>dB HL</th>\r\n      </tr>\r\n    </thead>\r\n    <tbody>\r\n      <tr>\r\n        <td\r\n>Sophono Alpha 1-2</td>\r\n    <td>53 dB HL</td>\r\n    <td>&lt;5    dB HL</td>\r\n  </tr>\r\n  <tr>\r\n    <td>Baha Attract with BP110</td>\r\n    <td>63</td>\r\n    <td>&lt;15</td>\r\n  </tr>\r\n  <tr>\r\n    <td>Bonebridge</td>\r\n    <td>67</td>\r\n    <td>&lt;20-25</td>\r\n  </tr>\r\n  <tr>\r\n    <td>Baha/Ponto standard</td>\r\n    <td>67-69</td>\r\n    <td>&lt;25-30</td>\r\n  </tr>\r\n  <tr>\r\n    <td>BP110, Ponto    power</td>\r\n    <td>74-76</td>\r\n    <td>&lt;35-40</td>\r\n  </tr>\r\n  <tr>\r\n    <td>Cordelle, Ponto    plus</td>\r\n    <td>78-80</td>\r\n    <td>&lt;50</td>\r\n  </tr>\r\n  <tr>\r\n    <td>VSB</td>\r\n    <td>85</td>\r\n    <td>&lt;50-55</td>\r\n  </tr>\r\n</tbody>\r\n  </table>\r\n</div>\r\n<p><strong>Table 2.</strong> The  mean MPO determined objectively of the mentioned devices. The maximum allowable sensorineural hearing loss component  for proper application, according to the 2/3 rule, is presented  in the third column.</p>\r\n<p>In summary, in order to categorize the\r\n  capacity and stability of hearing devices\r\n  for conductive and mixed hearing loss, a\r\n  website for professionals was developed\r\n  based on new data and published\r\n  objective data. Based on comments by\r\n  professionals in the field, the website\r\n  has been updated several times (for the\r\n  history of the website, see Appendix 3; [5].\r\n  The analyses presented on the website\r\n  can be considered as a starting point for\r\n  professionals counselling patients.</p>\r\n<p>During recent years, the role of the patient\r\n  in the selection of rehabilitation options\r\n  becomes more and more acknowledged.\r\n  &lsquo;Patient-centred-health-care&rsquo; should be\r\n  based upon specific outcome measures as\r\n  should be defined together with patients\r\n  [13]. Next, such outcome measures should\r\n  be systematically studied and reviewed to\r\n  optimise counselling of patients.</p>\r\n<h4>REFERENCES</h4>\r\n<ol>\r\n  <li id=\'Reference_Title_Link\' value=\'1\'><a name=\"1\" id=\'1\'></a>Snik, A.F.M.  &ldquo;Implantable hearing devices for conductive and sensorineural hearing  impairment.&rdquo; In: FG Zeng et al. (eds.),  Auditory Prostheses: New Horizons, Springer Handbook of Auditory Research  39 (2011): 85 &ndash; 108. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'2\'><a name=\"2\" id=\'2\'></a>de Wolf, M.J.,  et al. &ldquo;Better performance with bone-anchored hearing aid than acoustic  devices in patients with severe air-bone  gap.&rdquo; Laryngoscope 121 (2011): 613 &ndash; 616. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'3\'><a name=\"3\" id=\'3\'></a>Colquitt, J.L. &ldquo;Bone-anchored hearing aids (BAHAs) for people who are bilaterally deaf: a systematic review and economic  evaluation.&rdquo; Health Technology Assessment 15 (2011): 1 &ndash; 200.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'4\'><a name=\"4\" id=\'4\'></a>Ernst, &nbsp;A.,  &nbsp;Todt,&nbsp; &nbsp;I., &nbsp;Wagner,&nbsp; &nbsp;J.  &nbsp;&ldquo;Safety&nbsp; &nbsp;and effectiveness of the  Vibrant Sound bridge in treating conductive and mixed hearing loss: A systematic review.&rdquo;  Laryngoscope 126 (2016):1451 &ndash; 1457.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'5\'>http://<a href=\"http://www.snikimplants.nl/\">www.snikimplants.nl</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'6\'><a name=\"6\" id=\'6\'></a>Cox, R.M., Alexander, G.C., Gray, G.A. &ldquo;Personality, hearing problems, and amplification characteristics: contributions to self-report hearing aid outcomes.&rdquo; Ear and Hearing  28 (2007): 141 &ndash; 162.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'7\'><a name=\"7\" id=\'7\'></a>Johnson, J.A., Cox, R.M.,  Alexander, G.C. &ldquo;Development of APHAB norms for WDRC</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'8\'><a name=\"8\" id=\'8\'></a>Gatehouse, S.,  Browning, G.G. &ldquo;The output characteristics of an implanted bone conduction prosthesis.&rdquo; Clinical Otolaryngology Allied Sciences 15(1990): 503 &ndash; 513. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'9\'><a name=\"9\" id=\'9\'></a>Zwartenkot, J.W., et &nbsp;al.  &ldquo;Amplification &nbsp;options for patients with mixed  hearing loss.&rdquo; Otology Neurotology 35 (2014):  221 &ndash; 226.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'10\'><a name=\"10\" id=\'10\'></a>Dillon, H., Storey, L. &ldquo;The National Acoustic Laboratories\' procedure for selecting  the saturation sound pressure level of hearing  aids: theoretical derivation.&rdquo; Ear and Hearing  19(1998): 255 &ndash; 266. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'11\'><a name=\"11\" id=\'11\'></a>Dun  C.A, et al. &ldquo;Assessment of more than 1,000 implanted percutaneous bone conduction devices: skin reactions and implant  survival.&rdquo; Otology Neurotology 33(2012): 192 &ndash; 198.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'12\'><a name=\"12\" id=\'12\'></a>Iliadou,V.&ldquo;Monogenic nonsyndromic otosclerosis:  audiological and linkage analysis in a  large Greek pedigree.&rdquo; International Journal  of Pediatric Otorhinolaryngology 70 (2006): 631 &ndash; 637. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'13\'><a name=\"13\" id=\'13\'></a>Tysome, J.R., et al. &ldquo;The Auditory Rehabilitation Outcomes Network: an international initiative to develop  core sets of patient-centred outcome  measures to assess interventions for  hearing loss.&rdquo; Clinical Otolaryngology. 40 (2015): 512 &ndash; 515.</a></li>\r\n</ol>\r\n<h4>Research Evidence Supporting Progressive\r\n  Tinnitus Management</h4>\r\n<p>By James A. Henry1,2*</p>\r\n<p>1Veterans Affairs (VA) Rehabilitation Research &amp; Development (RR&amp;D) Service, National Center for Rehabilitative\r\n  Auditory Research, VA Portland Health Care System, Portland, Oregon</p>\r\n<p>2Department of Otolaryngology &ndash; Head &amp; Neck Surgery, Oregon Health &amp; Science University, Portland, OR</p>\r\n<p>Tinnitus is the perception of sound that\r\n  has no source outside of the head. Tinnitus\r\n  is most typically associated with exposure\r\n  to loud noise, which can also cause\r\n  hearing loss [1,2]. A direct correlation\r\n  exists between degree of hearing loss\r\n  and prevalence of tinnitus&mdash;the likelihood\r\n  of incurring tinnitus increases with a\r\n  greater degree of hearing loss [3]. In\r\n  general, tinnitus can occur as the result\r\n  of noise damage, blast exposures, head\r\n  and neck trauma or pathology, drugs or\r\n  medications, and other medical conditions\r\n  (e.g., acoustic neuroma, cardiovascular\r\n  and cerebrovascular disease, hyper- and\r\n  hypothyroidism) [4,5].</p>\r\n<p>Evidence-based research should guide\r\n  the clinical management of tinnitus.\r\n  Randomized controlled trials (RCTs)\r\n  that are properly conducted are the\r\n  most important source for providing\r\n  such evidence [6]. Recently, evidencebased\r\n  guidelines for tinnitus management\r\n  became available from the American\r\n  Academy of Otolaryngology &ndash; Head &amp;\r\n  Neck Surgery Foundation (AAO-HNSF)\r\n  [7]. Developing their Clinical Practice\r\n  Guideline (CPG) relied mostly on\r\n  searching the peer-reviewed literature\r\n  and identifying relevant RCTs. The\r\n  AAO-HNSF assembled a 23-member\r\n  committee to develop the guidelines,\r\n  which underwent external peer review\r\n  prior to publication. The AAO-HNSF tinnitus\r\n  CPG is currently the most comprehensive\r\n  guide to providing evidence-based clinical\r\n  services for tinnitus.</p>\r\n<p>The AAO-HNSF CPG recommends: (1)\r\n  a case history and physical exam by an\r\n  otolaryngologist; (2) a comprehensive audiologic exam if: the tinnitus is\r\n  &ldquo;persistent&rdquo; (i.e., present for at least 6\r\n  months), unilateral, or accompanied by\r\n  hearing difficulties; (3) determining if the\r\n  tinnitus is bothersome or no bothersome.\r\n  For patients with persistent, bothersome\r\n  tinnitus, the CPG recommends: (1)\r\n  provide information about realistic\r\n  treatment options; (2) perform a hearing\r\n  aid evaluation as appropriate; and (3)\r\n  suggest treatment with Cognitive\r\n  Behavioral Therapy (CBT).</p>\r\n<p>The CPG acknowledges the value of\r\n  &ldquo;sound therapy&rdquo; for tinnitus (and there are\r\n  many forms of sound therapy); however,\r\n  they only recommend sound therapy as\r\n  &ldquo;optional&rdquo; due to the relative paucity of\r\n  RCTs verifying its clinical effectiveness.\r\n  Sound therapy is an essential component\r\n  of treatment with Progressive Tinnitus\r\n  Management (PTM). The approach with\r\n  PTM, however, is to inform patients about\r\n  how sound can be used therapeutically\r\n  and how to determine which type of\r\n  sound might be effective in each tinnitusproblem\r\n  situation that is experienced [8-\r\n  18]. PTM does not advocate any particular\r\n  type of sound or sound-delivery device.\r\n  The objective is to empower patients so\r\n  that they can make informed decisions\r\n  regarding the use of sound as therapy. This\r\n  information is combined with CBT, which\r\n  is provided as part of the intervention\r\n  with PTM.</p>\r\n<p>At the National Center for Rehabilitative\r\n  Auditory Research (NCRAR) tinnitus\r\n  research has been ongoing since it was\r\n  established in 1997. This research has\r\n  consistently focused on developing and\r\n  testing components of tinnitus clinical management. Numerous clinical trials\r\n  have helped to identify procedures that\r\n  are most effective for clinical application.\r\n  The culmination of this research has been\r\n  the development of PTM.</p>\r\n<p>PTM is a stepped-care program for\r\n  all patients who report tinnitus (Fig.\r\n  1). Each step involves assessment and/\r\n  or intervention to identify and address\r\n  needs related to hearing loss, tinnitus, and\r\n  reduced tolerance to sound (hyperacusis).\r\n  Throughout the various levels of PTM,\r\n  as needs are identified, the patient and\r\n  clinician collaboratively decide on the\r\n  next appropriate course of action. The\r\n  degree of services received by patients\r\n  aligns with their individual needs.</p>\r\n<p>Beyond the initial referral level (Level\r\n  1 Referral), the first PTM step (Level 2\r\n  Audiologic Evaluation) is a traditional\r\n  audiologic evaluation with the addition\r\n  of a 10-item survey to assess the\r\n  functional effects of tinnitus and to\r\n  screen for hyperacusis [19]. In rare cases\r\n  hyperacusis may need to be resolved\r\n  before hearing problems or tinnitus can\r\n  be addressed. Patients who are hearing\r\n  aid candidates are fit with hearing aids or\r\n  combination devices (amplification and\r\n  sound generator combined in one unit)\r\n  to address their hearing loss, which often\r\n  mitigates bothersome tinnitus [20,21] .\r\n  After hearing loss and hyperacusis needs\r\n  have been addressed, patients who require\r\n  assistance for bothersome tinnitus are\r\n  offered Level 3 Skills Education.</p>\r\n<p>Level 3 Skills Education is normally\r\n  provided as five weekly meetings (in group or individual settings)&mdash;two taught by an\r\n  Audiologist and three taught by a Mental\r\n  Health (MH) Provider who has expertise\r\n  in CBT. During the meetings, patients\r\n  learn different strategies for using sound\r\n  and CBT-based coping skills to improve\r\n  their quality of life [11]. The intended\r\n  outcomes of learning and using the skills\r\n  that are taught include reduced distress\r\n  from tinnitus and improved confidence in\r\n  the ability to self-manage tinnitus.</p>\r\n<p>The relatively few patients who are still\r\n  significantly bothered by their tinnitus\r\n  following Level 3 are advised to undergo\r\n  a Level 4 Interdisciplinary Evaluation.\r\n  Level 4 provides an in-depth assessment\r\n  conducted by an Audiologist and a\r\n  Psychologist leading to an informed and\r\n  collaborative decision as to whether to\r\n  initiate Level 5 Individualized Support.\r\n  Level 5 involves personalized and ongoing\r\n  meetings with the Audiologist and/or\r\n  the Psychologist to incorporate the\r\n  skills taught at Level 3 into daily life, with\r\n  modifications as needed to meet the\r\n  needs and interests of the individual being\r\n  served.</p>\r\n<p>Whereas the AAO-HNSF CPG\r\n  recommends a medical exam for every\r\n  patient, PTM provides referral criteria as\r\n  part of the assessment during Levels 1 and\r\n  2 [10]. Clinicians must also be attentive\r\n  for unaddressed MH conditions, and to\r\n  refer for MH screening if such conditions are suspected. Consistent with the AAOHNSF\r\n  CPG, medications should not be\r\n  used specifically for tinnitus, although\r\n  they would be appropriate if prescribed\r\n  by a physician for MH symptoms.</p>\r\n<p>Cumulative evidence for PTM consists\r\n  of: (1) over 20 years of research\r\n  involving 25 funded projects; (2) clinical\r\n  implementation at Audiology clinics&mdash;\r\n  PTM is being utilized in one form or\r\n  another by over 100 clinics; (3) a proofof-\r\n  concept study evaluating telephonebased\r\n  PTM [14]; and (4) two RCTs of\r\n  PTM that were recently completed (and\r\n  which are described briefly below).</p>\r\n<p>The first RCT was a two-site study\r\n  conducted at the Memphis, Tennessee\r\n  and West Haven, Connecticut Veterans\r\n  Affairs (VA) hospitals. The purpose was to\r\n  evaluate the effectiveness of PTM Level\r\n  3 Skills Education compared to Wait List\r\n  Control (WLC) [22]. Three hundred\r\n  military Veterans (150 at each VA)\r\n  with bothersome tinnitus who desired\r\n  treatment were enrolled as participants.\r\n  Results suggest that PTM is effective\r\n  at reducing tinnitus-related functional\r\n  distress when embedded into VA clinical\r\n  settings. Although effect sizes were\r\n  modest, they provide evidence of the\r\n  effectiveness of PTM when it is provided\r\n  in a clinical setting.</p>\r\n<p>The second RCT of PTM (briefly\r\n  described in [8] full publication in preparation) followed our pilot study that\r\n  suggested efficacy of telephone-based\r\n  PTM [14]. For the RCT, telephone-based\r\n  PTM Skills Education was evaluated for\r\n  efficacy compared to WLC. Participants\r\n  (N=205) were both Veterans and non-\r\n  Veterans with bothersome tinnitus who\r\n  were enrolled from around the country.\r\n  The intervention protocol consisted of\r\n  five telephone sessions &ndash; three with a\r\n  Psychologist and two with an Audiologist\r\n  (to correspond with the five sessions that\r\n  are normally offered in-clinic) in addition\r\n  to two follow-up calls. Outcomes were\r\n  assessed at baseline and at 3, 6, 9, and\r\n  12 months, using the Tinnitus Functional\r\n  Index (TFI; [23] as the primary outcome\r\n  instrument and the Tinnitus Handicap\r\n  Inventory (THI) [24] as the secondary\r\n  outcome instrument At 6 months,\r\n  improvement on the TFI was about 20\r\n  points greater for the tele-PTM group\r\n  relative to the control group, and the\r\n  improvement was sustained for another\r\n  6 months. The TFI and THI change\r\n  scores were strongly and linearly related\r\n  (Pearson&rsquo;s correlation=0.69; p&lt;0.0001),\r\n  emphasizing the similarity between these\r\n  two outcome instruments.</p>\r\n<p>The TFI contains eight subscales: Auditory,\r\n  Cognitive, Emotional, Intrusive, Quality\r\n  of Life (QOL), Relaxation, Sense of\r\n  Control, and Sleep. All but one of the\r\n  subscales contains three items&mdash;the\r\n  QOL subscale contains four items. This second RCT provided data showing\r\n  substantial differences between subscales,\r\n  ranging from a 13.2-point reduction for\r\n  the Auditory subscale to a 26.7-point\r\n  reduction for the Relaxation subscale\r\n  [8]. These subscale data reveal that the\r\n  telephone intervention had the largest\r\n  effect on the Relaxation domain and the\r\n  smallest effect on the auditory domain.\r\n  Much more can be said about the\r\n  subscale data &ndash; the takeaway point is that\r\n  subscale scores can be informative as to\r\n  which functional areas are most affected\r\n  by a person&rsquo;s tinnitus, and which are most\r\n  impacted by the intervention.</p>\r\n<p>These recent RCTs support the clinical\r\n  utilization of PTM as an evidence-based\r\n  method of tinnitus management. Results of\r\n  these studies were not available when the\r\n  AAO-HNSF CPG was developed. PTM is\r\n  mostly consistent with recommendations\r\n  of the AAO-HNSF CPG, and provides\r\n  specific methodology for the clinical\r\n  management of tinnitus by Audiologists\r\n  and MH Providers.</p>\r\n<h4>REFERENCES</h4>\r\n<ol>\r\n  <li id=\'Reference_Title_Link\' value=\'1\'><a name=\"1\" id=\'1\'></a>Axelsson, A.,  Barrenas, M.L.&ldquo;Tinnitus in noise- induced  hearing loss.&rdquo; In: AL Dancer, D Henderson, RJ Salvi, &amp; Hamnernik RP, (Eds.), Noise-Induced Hearing,  Loss, St. Louis:  Mosby- Year Book, Inc. (1992): 269-276</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'2\'><a name=\"2\" id=\'2\'></a>Penner, M.  J., Bilger, R. C.&ldquo;Psychophysical observations and the origin of tinnitus.&rdquo; Mechanisms  of Tinnitus Needham Heights, MA: Allyn &amp; Bacon. (1995): 219-230. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'3\'><a name=\"3\" id=\'3\'></a>Coles, R. R. A.,  In: R. S. Tyler (Ed.), Tinnitus Handbook. Medicolegal issues (2000):399-417. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'4\'><a name=\"4\" id=\'4\'></a>Hoffman, H. J.,  Reed, G. W. &ldquo;Epidemiology  of tinnitus.&rdquo;  In: J. B. Snow (Ed.), Tinnitus: Theory and  Management Lewiston, NY: BC Decker Inc. (2004):16-41.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'5\'>from <a href=\"http://www.tinnitusarchive.org/\">http://www.tinnitusarchive.org/</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'6\'><a name=\"6\" id=\'6\'></a>Keech, A., Gebski,V., Pike, R. (Eds.).  &ldquo;Interpreting and reporting clinical trials.&rdquo; A guide to the CONSORT statement and the  principles of randomised controlled trials. Sydney:  MJA Books (2007).</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'7\'><a name=\"7\" id=\'7\'></a>Tunkel, D. E., et al. &ldquo;Clinical  practice guideline:  tinnitus.&rdquo;Otolaryngol Head Neck Surgery,  151(2), (2014): S1-S40</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'8\'><a name=\"8\" id=\'8\'></a>Henry, J. A., et al. &ldquo;Tinnitus and hearing survey:  a screening tool to differentiate  bothersome tinnitus from hearing difficulties.&rdquo;  American Journal Audiology, 24(1) (2015): 66-77. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'9\'><a name=\"9\" id=\'9\'></a>Henry, J. A., et al. Clinical management  of tinnitus using a &quot;progressive intervention&quot; approach. Journal of Rehabilitation Research and Development, 42( 2)(4) (2005):  95-116. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'10\'><a name=\"10\" id=\'10\'></a>Henry, J. A., et al.&ldquo;A triage guide for tinnitus.&rdquo;Journal of Family Practice  59(7) (2010):389-393. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'11\'><a name=\"11\" id=\'11\'></a>Henry, J. A., et al.&ldquo;Principles and application of counseling used in Progressive Audiologic Tinnitus Management.&rdquo; Noise and Health,  11(42) (2009):33-48. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'12\'><a name=\"12\" id=\'12\'></a>Henry, J. A., et  al. &ldquo;The role of audiologic evaluation in Progressive Audiologic  Tinnitus Management.&rdquo; Trends in Amplification, 12(3) (2008a):169-184. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'13\'><a name=\"13\" id=\'13\'></a>Henry, J. A., et  al.&ldquo;Using therapeutic sound with Progressive Audiologic Tinnitus Management.&rdquo; Trends in Amplification, 12(3),  (2008b):185-206. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'14\'><a name=\"14\" id=\'14\'></a>Henry, J. A., et  al, &ldquo;Pilot study to develop telehealth tinnitus management for persons with and without traumatic brain injury.&rdquo; Journal of </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'15\'><a name=\"15\" id=\'15\'></a>Henry, J. A., et al.&ldquo;How To Manage Your Tinnitus: A Step-by-Step Workbook (3 ed.)&rdquo; San Diego, CA: Plural Publishing (2010a). </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'16\'><a name=\"16\" id=\'16\'></a>Henry, J. A., et al.&ldquo;Progressive Tinnitus  Management: Clinical Handbook  for Audiologists.&rdquo; San Diego, CA:  Plural Publishing (2010b). </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'17\'><a name=\"17\" id=\'17\'></a>Henry, J. A., et al.&ldquo;Progressive Tinnitus  Management: Counseling Guide.&rdquo; San Diego,  CA: Plural Publishing (2010c). </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'18\'><a name=\"18\" id=\'18\'></a>Myers, P. J., et  al. &ldquo;Development of a progressive audiologic tinnitus management program for Veterans  with tinnitus.&rdquo; Journal of Rehabilitation Research and Development, 51(4) (2014):609- 622. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'19\'><a name=\"19\" id=\'19\'></a>Henry, J. A., et al.&ldquo;Validation of a novel combination hearing aid and tinnitus therapy device. Ear Hear.&rdquo; 36(1) (2015):42-52. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'20\'><a name=\"20\" id=\'20\'></a>Shekhawat, G. S., Searchfield, G. D., Stinear,  C. M., &ldquo;Role of hearing AIDS in tinnitus  intervention: a scoping review.&rdquo;Journal of American Academy of Audiology, 24(8) (2013):747-762. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'21\'><a name=\"21\" id=\'21\'></a>Henry, J. A., et al. &ldquo;Multi-clinic randomized controlled trial to evaluate effectiveness of coping  skills education used with Progressive Tinnitus Management.&rdquo; Journal of Speech Language and Hearing Research. </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'22\'><a name=\"22\" id=\'22\'></a>Henry, J. A., et  al. Tinnitus Functional Index: Development, validation, outcomes research, and clinical  application. Hear Research  (2015). </a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'23\'><a name=\"23\" id=\'23\'></a>Meikle, M. B.,  et al. &ldquo;The tinnitus functional index: development of a new clinical  measure for chronic, intrusive tinnitus.&rdquo; Ear and Hearing, 33(2) (2012):153-176.</a></li>\r\n  <li id=\'Reference_Title_Link\' value=\'24\'><a name=\"24\" id=\'24\'></a>Newman, C. W., Jacobson,G.  P., Spitzer,  J. B. &ldquo;Development of the Tinnitus Handicap  Inventory.&rdquo; Archives of Otolaryngology&mdash;Head Neck Surg, 122 (1996):143-148.</a></li>\r\n</ol>',NULL,'2022-11-11'),(11,4508,'ajchr','http://www.andrewjohnpublishing.com/','<p><strong>Hugh J. McDermott</strong></p>\r\n<p>The Bionic Ear Institute and the Department of Otolaryngology, The University of Melbourne, Victoria, Australia.</p>','<h4>ABSTRACT</h4>\r\n<p><strong>Background: </strong>Recently two major manufacturers of hearing aids introduced two distinct frequencylowering techniques that were designed to compensate in part for the perceptual effects of highfrequency hearing impairments. The Widex &lsquo;&lsquo;Audibility Extender&rsquo;&rsquo; is a linear frequency transposition scheme, whereas the Phonak &lsquo;&lsquo;SoundRecover&rsquo;&rsquo; scheme employs nonlinear frequency compression. Although these schemes process sound signals in very different ways, studies investigating their use by both adults and children with hearing impairment have reported significant perceptual benefits. However, the modifications that these innovative schemes apply to sound signals have not previously been described or compared in detail.</p>\r\n<p><strong>Methods:</strong> The main aim of the present study was to analyze these schemes&rsquo;technical performance by measuring outputs from each type of hearing aid with the frequency-lowering functions enabled and disabled. The input signals included sinusoids, flute sounds, and speech material. Spectral analyses were carried out on the output signals produced by the hearing aids in each condition.</p>\r\n<p><strong>Conclusions:</strong> The results of the analyses confirmed that each scheme was effective at lowering certain high frequency acoustic signals, although both techniques also distorted some signals. Most importantly, the application of either frequency-lowering scheme would be expected to improve the audibility of many sounds having salient high-frequency components. Nevertheless, considerably different perceptual effects would be expected from these schemes, even when each hearing aid is fitted in accordance with the same audiometric configuration of hearing impairment. In general, these findings reinforce the need for appropriate selection and fitting of sound-processing schemes in modern hearing aids to suit the characteristics and preferences of individual listeners.</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>Two major hearing-aid (HA) manufacturers have recently introduced frequency-lowering sound processing schemes. Although these schemes are technically dissimilar, they are both intended for HA users who have relatively poor hearing at high frequencies. Lowering selected highfrequency components of sound has been shown to help some people with hearing impairment to perceive them [1,2]. The perceptual benefits potentially include improved ability to resolve and discriminate between sounds as well as to detect them. As is well known, many people with sensorineural impairment have poorer hearing at high frequencies than at lower frequencies, as indicated by hearing sensitivity recorded on a pure-tone audiogram. In such cases, other aspects of auditory perception in addition to sound sensitivity are often affected. For example, frequency resolution, which is related to a listener&rsquo; ability to separate a signal of interest such as speech from a background noise, is generally found to be poorer at frequencies having worse thresholds [3]. As a consequence, amplification by a HA may fail to enable every hearingimpaired listener to identify all sounds reliably, even though the audibility of those sounds is usually improved. Although various frequency lowering schemes have been developed over several decades in attempts to address these problems, only two schemes are presently in widespread use.</p>\r\n<p>The purpose of the present study was to measure and report the technical characteristics of these recently introduced digital frequencylowering schemes. The first scheme was devised by Widex, a company based in Denmark, and is known as the Audibility Extender. It is a linear  frequency transposition (LFT) scheme that has been reported to improve the understanding of some phonemes in speech, at least after training. For example, identification of fricative consonants increased by about 14 percentage points, on average, for eight adults after two months of use [2]. The second scheme, called SoundRecover, is available from Phonak, a company based in Switzerland. It is a nonlinear frequency compression (NLFC) scheme that was developed after promising perceptual results were reported for an experimental prototype [4]. Similar results have been published more recently [1]. They showed, for instance, that activation of the NLFC scheme increased mean scores by about 15 percentage points for 13 adults and 11 children in a test of plural-noun identification based on detection of a final /s/. The findings of the present study provide technical explanations for the perceptual benefits reported with use of both the LFT and NLFC frequency-lowering schemes.</p>\r\n<h4>FREQUENCY-LOWERING TECHNIQUES</h4>\r\n<p>The Widex LFT scheme functions by shifting components of sounds present within a source octave into a predetermined target octave [2]. As described in the Materials and Methods section, the settings chosen for the measurements reported below defined the source octave to encompass 2.5&ndash;5.0 kHz, and the target octave to be one octave lower (i.e., 1.25&ndash;2.5 kHz). In the LFT scheme, the contents of the source octave are analyzed periodically to identify a dominant spectral peak. The frequency of that peak is determined, and the amount of lowering is calculated such that the selected frequency is shifted down by one octave. Other frequency components in the source octave are  shifted by an equal number of hertz. For example, if the peak frequency is 4 kHz, the extent of the downward shift is 2 kHz, resulting in the peak component being lowered to 2 kHz. At the same time, a source component at 5 kHz would be lowered by 2 kHz to 3 kHz. Note that, in general, only the frequency of the peak is shifted by exactly one octave. Consequently, it is possible that some components in the source octave would fall outside the target octave after shifting. For instance, in the above example a source component at 3 kHz would be lowered to 1 kHz. However, the signals resulting from the shifting process are filtered to ensure that they remain within the boundaries of the target octave. Thus a source component at 3 kHz would be discarded if the amount of lowering was 2 Hz (or any amount greater than about 1.75 kHz). After transposition, the contents of the target octave are mixed with any sound components already present in the same frequency region. Subsequently the usual processes of amplification, such as amplitude compression, are applied to the composite signal. An important characteristic of the LFT scheme is that the amount of frequency shifting generally varies over time in accordance with the frequency of the dominant peak in the source octave.</p>\r\n<p>The Phonak NLFC scheme is based on different principles [4]. The processing has two adjustable parameters: the cut-off frequency and the frequencycompression ratio. For the present study, a cutoff of 2.3 kHz was chosen. This means that frequencies below 2.3 kHz are unaffected by the NLFC processing, whereas those above are compressed in frequency. The amount of lowering is progressive, such that frequencies much higher than the cut-off are shifted by a larger amount  than frequencies only slightly above the cut-off. For example, the selected frequency-compression ratio of 1.7:1 would result in a component at 1.7 oct above 2.3 kHz (i.e., 7.47 kHz) being lowered to a frequency 1 oct above 2.3 kHz (i.e., 4.6 kHz). The transfer function relating input to output frequencies is completely determined during fitting by selection of the above two parameters; it does not change in response to any signal characteristics. Signal components processed by the NLFC scheme do not overlap any other components present at the same time. Together with components below the cut-off frequency, signals that have been compressed in frequency are amplified and additionally processed as usual.</p>\r\n<h4>RESULTS</h4>\r\n<p>To obtain the measurements reported below, each HA was programmed according to the manufacturer&rsquo; guidelines to provide an appropriate fitting for a sloping, severe-to-profound hearing loss (see Table 1). The input signals delivered to each HA comprised a sinusoid with slowly increasing frequency, a sequence of notes played on a flute, and four words chosen to contain many phonemes with dominant high-frequency components. Recordings from the Widex HA with and without LFT are available as Audio S1 and Audio S2 respectively, and the corresponding recordings for the Phonak HA are in files Audio S3 and Audio S4. Measurements with Sinusoid Measurements on each HA with the frequency-lowering functions disabled confirmed, as expected, that the gains and output levels were very similar. Therefore, the spectrum for this condition shown in Figure 1 (dashed curve, right panel) is an average of the spectra obtained for each HA separately. The output of each HA for the swept sinusoid (not shown  in the figures) conformed generally to expectations of the LFT and NLFC processing functions. For the Widex HA with LFT, the maximum output frequency was approximately 2.5 kHz, corresponding to a 1-oct lowering of the highest frequency in the source octave. For the Phonak HA with NLFC, the maximum output frequency was approximately 4.4 kHz, corresponding to an input frequency of about 6.8 kHz.</p>\r\n<p>The short-term spectra for a brief portion of the swept sinusoid at which the input frequency to the HAs was around 3 kHz are shown in the left panel of Figure 1. The output of the Widex HA with LFT (gray) showed a high-level component at 1.5 kHz, which is 1 oct below the input frequency, as anticipated. Also evident were two lower-level components at 3 and 4.5 kHz which may have been at least partly artifacts of the processing. In comparison, the output of the Phonak HA with NLFC (black) had a single dominant peak at approximately 2.7 kHz, which is the output frequency expected for an input tone at 3 kHz with the selected parameter settings.</p>\r\n<h4>MEASUREMENTS WITH FLUTE SOUNDS</h4>\r\n<p>The right panel of Figure 1 shows the averaged spectra from each HA with and without frequency-lowering for one of the notes produced by the flute (C5). A 300-ms steady portion of this note was analyzed. As the fundamental frequency was approximately 523.3 Hz, and the signal waveform was essentially periodic, harmonics were present at frequencies of 1046.5, 1569.8, 2093.0 Hz, and so on. In both HAs, the first four harmonics produced almost identical outputs for the conditions with frequencylowering disabled, and, for the Phonak HA, with NLFC enabled. With LFT, the same four frequency components were evident at similar levels, but the fifth harmonic (approximately 2.6 kHz) would have fallen into the source octave. As it was apparently identified as the dominant peak, it was shifted down by 1 oct to about 1.3 kHz. It therefore appeared between the second and third harmonics. There is evidence that a shift of the same amount (i.e., 1.3 kHz) was applied to the seventh harmonic (3.7 kHz) to produce an output component near 2.4 kHz. The unshifted fifth harmonic was also present in the output signal, but Frequency-Lowering Hearing Aids higher frequency components were at much lower levels. With NLFC, the fifth harmonic was shifted down to approximately 2.5 kHz, while the higher harmonics were shifted further and output at lower levels, corresponding to the relatively low level of harmonics above the fifth in the input signal.</p>\r\n<h4>MEASUREMENTS WITH SPEECH</h4>\r\n<p>Figure 2 shows spectrograms of two of the words used in the tests (i.e., fish, says). The upper panel shows a spectrogram of the original signal, whereas the two lower panels show the outputs of the HAs with NLFC and LFT activated, respectively. The main effect of each type of processing is most evident in a comparison of a vowel sound, such as /i/ in approximately the 0.2&ndash;0.4 s portion of the spectrograms, and a consonant sound, such as /#/ in the following portion up to about 0.7 s. Averaged spectra estimated from these two signals are shown in Figure 3. The spectra for /i/ (left panel) were  obtained from a 50-ms steady portion near the vowel onset, whereas those for /#/ (right) were obtained from a 200- ms steady portion within the consonant sound. As in Figure 1, the dashed curves show averages of the spectra for each HA with the frequency-lowering functions disabled.</p>\r\n<p>For the vowel, a comparison of the spectra with the frequency lowering functions enabled and disabled shows minimal effect for signal components near the first formant frequency (i.e., around 0.5 kHz). With LFT, components near the second formant (about 2.9 kHz) were lowered to approximately 1.5 kHz. The general effect of linear frequency transposition is clearly evident in that the shape of the spectrum in the source octave above 2.5  kHz with LFT disabled is similar to that  with LFT enabled in the target octave below 2.5 kHz. With NLFC, the secondformant spectral peak was lowered to approximately 2.6 kHz, while higherfrequency components were lowered by progressively larger amounts.</p>\r\n<p>For the consonant, the spectrum without frequency lowering shows two local peaks at about 2.8 and 4.1 kHz. With LFT, a peak is evident near 1.4 kHz, presumably corresponding to the lower input peak shifted down by 1 oct. There is also a second, relatively broad peak around 2.2 kHz which seems to have resulted from some combination of shifted and unshifted input components. With NLFC, the two input peaks were shifted to approximately 2.6 and 3.2 kHz, respectively. Some interpretations and implications of these results are discussed next.</p>\r\n<h4>DISCUSSION</h4>\r\n<p>In general, the above measurements are consistent with most expectations of the function of both LFT and NLFC processing. The effect of each scheme to reduce the bandwidth of output signals from the HAs is evident particularly in the spectrograms of Figure 2 and the spectra of Figure 3 (right). For LFT, the maximum output frequency was limited by the upper boundary of the target octave (i.e., 2.5 kHz), whereas that for NLFC was approximately 4.4 kHz. Note, however, that the output bandwidth of each HA is effectively adjustable by changing the parameter values of the frequency-lowering functions.</p>\r\n<p>The tests with the swept sinusoid indicated that the Widex HA with LFT enabled produced at least two additional frequency components higher than the one expected from transposition of the input signal. Although this suggests some distortion in the LFT processing it is likely that the levels of the extra components would be lower than the audibility threshold of a HA user with the audiogram used to program both devices (see Table 1). The tests with the flute sounds suggested that both HAs could provide accurate pitch information to listeners within the lowest four harmonics (including the fundamental) of the signal; see Figure 1 (right panel). Psychophysical studies have found that this frequency range tends to dominate listeners&rsquo;perception of pitch for complex sounds [5]. Neither frequency-lowering scheme preserved accurate frequency differences between all of the harmonics. However, it seems plausible that the relatively small shift in the frequency of Figure 1. Output spectra of each hearing aid (HA) for inputs consisting of a sinusoid (left) and a tone produced by a flute (right). The sinusoid had a frequency of 3 kHz (vertical dashed line), corresponding to a brief portion of a sweep encompassing the frequency range 0.1&ndash;10 kHz. The flute note was C5 (fundamental frequency: 523.3 Hz). In both panels, the black line shows the spectrum from the Phonak HA with NLFC, and the gray line shows the spectrum from the Widex HA with LFT. The gray dashed line in the right panel shows the averaged spectrum from both HAs without frequency lowering the fifth harmonic caused by NLFC processing would be less salient perceptually than the production by LFT of the component near 1.3 kHz. That component is not harmonically related to other components present in the input signal, and, given its comparatively high level, might reduce the ability of some hearing-impaired listeners to resolve the adjacent second and third harmonics.</p>\r\n<p>The spectra obtained using the vowel sound also showed that some frequency ratios (or differences) between spectral peaks were altered by both LFT and NLFC; see Figure 3 (left). As expected, neither scheme changed frequencies near the first formant, but LFT shifted the peak near the second formant to about 1.5 kHz. In contrast, NLFC lowered that peak only slightly, with the result that it remained well within the overall range of second-formant frequencies for this vowel reported from measurements involving many different speakers [6].</p>\r\n<p>Similar observations apply to the spectra of the consonant sounds (right panel). The relatively small effect of NLFC compared to LFT suggests that it might be easier for inexperienced listeners to adapt to the frequency-shifted signals, particularly when listening to speech, at least for the settings applied in the present tests.</p>\r\n<p>In conclusion, both frequency-lowering schemes may provide perceptual benefits to HA users with hearing impairment at high frequencies. Although only one audiogram configuration was applied in the experiments, it is likely that the findings would be generally similar for other audiogram shapes, provided that they represented types of hearing impairment that would be suitable for fitting of either type of frequency-lowering HA. The technical test results suggest that the Phonak NLFC processing may preserve more details of the overall spectral shape than the Widex LFT scheme, at least for the selected signals and settings. However, the LFT scheme may be more suitable than NLFC for HA users with minimal usable hearing at frequencies above approximately 1.5&ndash; 2 kHz. This is because the NLFC cut-off frequency is limited to a minimum setting of 1.5 kHz; thus, NLFC is unable to modify lower frequencies. In any case, selection of the optimum fitting for each HA user should depend ultimately on perceptual assessments, including tests of speech understanding in particular.</p>\r\n<h4>MATERIALS AND METHODS</h4>\r\n<p>The hearing aids used for the present study were the Widex mind440 m4-19 and the Phonak Na?&acute;da V SP. Each was programmed to suit the audiogram shown in Table 1, based on  default settings of the fitting software. This audiogram is well within each manufacturer&rsquo; fitting guidelines for these HAs. Furthermore, it is close to the average audiogram of the subjects who participated in an evaluation of a prototype of the NLFC processing [4], and is within the range of audiograms of the subjects who participated in a published evaluation of the LFT scheme [2]. To ensure that the technical performance of each HA was not inadvertently affected by irrelevant aspects of the fitting, both HAs were programmed to match as closely as possible the gain and amplitude-compression characteristics recommended for this audiogram by the NAL-NL1 prescription [7]. In addition, signal-processing features such as feedback cancelation, noise reduction, and occlusion compensation were disabled, and an omni-directional microphone configuration was selected. These settings were not altered during measurements in which the LFT or NLFC schemes were either enabled or disabled. The selected settings of the frequency-lowering parameters for each HA are shown in Table 2.</p>\r\n<p>Output signals were recorded from each HA in each condition for three types of input signal: (1) a sinusoid swept from 0.1 to Figure 3. Output spectra of each frequency-lowering hearing aid for inputs consisting of the vowel /i/ (left) and the consonant /#/ (right). Note that the abscissa in the right panel shows frequency on a log axis. Other details are as for Figure 1. 10 kHz logarithmically over 10 s; (2) a succession of notes played on a flute; and (3) speech, comprising four monosyllabic words recorded by a female speaker. The average level of all signals was 65 dB SPL. The sounds were delivered to each HA in a Bru&uml;el &amp; Kj&aelig;r Type 4222 anechoic test chamber, and the output signals were recorded via a 2- cm3 coupler for later analysis using Adobe Audition 3.0 software. The swept sinusoid, which was used to verify the function of each HA with and without each frequency-lowering scheme, was passed through a low-pass filter with frequency response similar to the longterm average speech spectrum [8] before delivery to the HAs. This ensured that the level across frequency was well within the range at which optimal processing could be expected for each HA. The flute sounds were included to investigate the potential effects of frequency lowering on musical pitch, and comprised a sequence of notes ranging from G4 to G5 (i.e., fundamental frequencies 392&ndash;784 Hz). The words in the speech material (thatch, fish, says, verge) were chosen to include eight different fricative or affricate consonants that are common in English and contain important acoustic components at relatively high frequencies.</p>\r\n<p>The audio signals recorded from the HAs were sampled at 44.1 kHz with 16-bit resolution. The spectra shown in Figures00201 and 3 were obtained using a 512-point Fast Fourier Transform(FFT) preceded by a Blackman-Harris windowing function. The spectrograms shown in Figure 2 were obtained using a 256-point FFT after the original signals had been downsampled to 16 kHz.</p>\r\n<h4>SUPPORTING INFORMATION</h4>\r\n<p>Audio S1 Sound recording from the Widex hearing aid (HA) with the Linear Frequency Transposition (LFT) function disabled. The input signals were four monosyllabic words (thatch, fish, says, verge), a sequence of notes played on a flute, and a swept sinusoid (0.1&ndash;10 kHz). (WAV) Audio S2 As for Audio S1, but with LFT enabled. (WAV) Audio S3 As for Audio S1, but for the Phonak HA with the Nonlinear Frequency Compression (NLFC) function disabled. (WAV) Audio S4 As for Audio S1, but with NLFC enabled. (WAV)</p>\r\n<h4>ACKNOWLEDGMENTS</h4>\r\n<p>The signals analyzed in this study were recorded with the assistance of Martin Rahn (Phonak AG). The Bionics Institute acknowledges the support it receives from the Victorian Government through its Operational Infrastructure Support Program. The constructive comments of a reviewer about an earlier version of this manuscript are appreciated.</p>\r\n<h4>REFERENCES</h4>\r\n<p>1. Glista D, Scollie S, Bagatto M, Seewald R, Parsa V, et al. (2009) Evaluation of nonlinear frequency compression: Clinical outcomes. International Journal of Audiology 48: 632&ndash;644.</p>\r\n<p>2. Kuk F, Keenan D, Korhonen P, Lau CC (2009) Efficacy of linear frequency transposition on consonant identification in quiet and in noise. Journal of the American Academy of Audiology 20: 465&ndash;479.</p>\r\n<p>3. Moore BCJ (1996) Perceptual consequences of cochlear hearing loss and their implications for the design of hearing aids. Ear and Hearing 17: 133&ndash;161.</p>\r\n<p>4. Simpson A, Hersbach AA, McDermott HJ (2005) Improvements in speech perception with an experimental nonlinear frequency compression hearing device. International Journal of Audiology 44: 281&ndash;292.</p>\r\n<p>5. Plack CJ, Oxenham AJ (2005) The psychophysics of pitch. In: Fay RR, Popper AN, eds. Springer Handbook of Auditory Research: Pitch. New York: Springer. pp 7&ndash;55.</p>\r\n<p>6. Hillenbrand J, Getty LA, Clark MJ, Wheeler K (1995) Acoustic characteristics of American English vowels. The Journal of the Acoustical Society of America 97: 3099&ndash;3111.</p>\r\n<p>7. Byrne D, Dillon H, Ching T, Katsch R, Keidser G (2001) NAL-NL1 procedure for fitting nonlinear hearing aids: characteristics and comparisons with other procedures. Journal of the American Academy of Audiology 12: 37&ndash;51.</p>\r\n<p>8. Byrne D, Dillon H, Tran K, Arlinger S, Wilbraham K, et al. (1994) An international comparison of long-term average speech spectra. Journal of the Acoustic Society of America 96: 2108&ndash;2120.</p>',NULL,'2022-11-16'),(12,3468,'ajchr','http://www.andrewjohnpublishing.com/','<p><strong>Gilles Cagnone, Audioprothesiste</strong></p>\r\n<p>Gilles Cagnone received his degree at the Conservatoire des Arts et M&eacute;tiers in Paris as an audioproth&egrave;siste (diploma D?Etat) in the late seventies, and then decided to cross the pond to the province of Qu&eacute;bec. He has been teaching a variety of different courses at the College of Rosemont since 1983. Along with these duties, he has also worked with various government offices as a consultant.</p>','<p>The profession of audioproth&eacute;siste in Quebec is an exception in North America as it has a legislated exclusive scope of practice. The audioproth&eacute;siste is the only professional in Quebec authorized to sell, replace and adjust hearing aids. This gives the dispenser both a high degree of autonomy but also great responsibility. This work is framed by laws and regulations issued by the Order of Audioproth&eacute;sistes (OAQ) whose function is to protect the public. In accordance with the Code of Professions of Qu&eacute;bec, a board of directors was elected, a code of ethics was written and several committees were established to ensure compliance with the various articles included in the book of statutes and regulations of the audioproth&eacute;sistes.</p>\r\n<p>Thus we find, among others:</p>\r\n<p>&bull; A professional inspection committee that ensures the smooth running of practices, record keeping and compliance with certain operating standards.</p>\r\n<p>&bull; The training committee whose responsibility is continuing education of hearing care professionals at conferences and symposiums.</p>\r\n<p>&bull; The equivalence committee for professional accreditation for those from abroad or those who haven&rsquo;t graduated from one of two audioproth&eacute;siste college programs (editor&rsquo;s note: Rosemont &amp; Ste Anne de la Pocatiere).</p>\r\n<p>To legally practice the profession of audioproth&eacute;siste, one must be in good standing with the Order of Audioproth&eacute;sistes (OAQ) which in turn requires one to have a recognized diploma from an educational institution or a diploma equivalence issued by the Order and pay the annual fee. Audioproth&eacute;sistes are also represented by the Professional Association of Quebec Audioproth&eacute;sistes (APAQ) when dealing with public authorities and other organisations. At the present time there are 367 members of the OAQ in good standing</p>\r\n<p>It was in 1979 that the audioproth&eacute;siste department was established in the wake of the introduction of general and vocational colleges (CEGEPs) in 1967 and following a reform of the professional system that created several new official professions including that of audioproth&eacute;siste in 1973. The search for a suitable establishment that could accommodate and train future professionals was made and the Rosemont College was chosen for this honor.</p>\r\n<h4>THE FOUNDING FATHERS OF THE PROGRAM</h4>\r\n<p>At the time, it was necessary to build a new training program because there was nothing like it in North America. Mr. Andr&eacute; Savard, with the help of the OAQ, was commissioned to begin the project which was then taken over by Mr. Guy Martin. It was in September of 1981 that the first cohort was recruited. The challenge of establishing our department was enormous as everything needing to be built from scratch.</p>\r\n<p>The hiring of Gilles Cagnone graduate of Conservatoire Nationale des Arts et Metiers in France, and Yves Tougas who graduated from McGill University in 1983, allowed the creation of a program that made the best of both worlds.</p>\r\n<p>Since then, and after many reforms and improvements, the audioproth&egrave;se program at Rosemont graduates approximately 20 students per year.</p>\r\n<p>Over the years the department has enlisted the expertise of several audioproth&eacute;sistes as professors. In 1993, Mrs. Linda Cloutier has joined the ranks and more recently, JeanPhilippe Denis, Ms. Sonia Richard, and Ms. Marie-Christine Lapointe joined the team. At present and after some recent changes, the faculty consists of 7 audioproth&eacute;sistes who teach courses, laboratories, pre-internship and supervise internships. There are also two instructors who have the role as lab technicians. Additionally, a qualified chiropractor teaches ear pathology.</p>\r\n<h4>PROGRAM FACULTY</h4>\r\n<p>The course charge varies semester to semester as does the availability of professors who have to manage their time between teaching and their practices. Linda Cloutier who graduated from the program in 1990 and who has been a professor since 1997, manages of her practice since 1990 up to today. Her versatility has allowed her to teach various courses, supervise internships and be the department and program for the last 3 years. More recently she has focused on pre-internship courses. Sonia Richard is a 2011 graduate of our program, and she bravely took up the challenge of teaching audiometry courses along with labs that are given in the third semester, as well as internship supervision. Marie-Christine Lapointe graduated in 2006 from the program, after being the lab technician for 5 years. She has been promoted to department and program coordinator in addition to teaching the special tests course, auditory adaptation and communications.</p>\r\n<p>Jean Philippe Denis, from the class of 2001 gives the introduction to the profession course this semester; she had significantly assisted in previous semesters in teaching other courses and supervising internships. Sylvain Lauzon, chiropractor and professor at the University of Quebec at Trois Rivi&egrave;res, teaches ear pathology. Recently Constance Poitras and Manuel Papazian, graduates in 2014 and 2015 respectively, joined the staff as laboratory technicians. Concerning the author, he has haunted the department since its foundation or almost, teaching courses such as introduction to audiometry, introduction to objective measurements, technical and ergonomic aspects of hearing aids, adaptation to hearing aids with their corresponding labs and internship supervision. After 30 years of service to the department, he longs to pass some time on by a river discussing this world that is in constant flux with Ted Venema, if Ted would accept him for Skype backgammon partners.</p>\r\n<p>Apart from the author (who, having been around and about for over 20 years of practice, has stopped seeing patients), all other professors and technicians continue to practice in the clinical setting. This allows the department to gain useful field experience and to integrate into a regular practice with patients the principles that they preach. It certainly enables the sharing delicious real world anecdotes. Activities related to the knowledge gained in the program have also been set up by Ms. Melody Desroches and Ms. Melanie Duplin; these have a more practical flavor and are oriented towards the daily clinical life.</p>\r\n<p>Rosemont College has also established a foundation through which the audioproth&egrave;se department receives funds enabling it to finance the continued training of its professors by attending conferences and seminars. With these funds it was also possible to create workshops for students animated by practitioners.</p>\r\n<h4>THE PROGRAM SEQUENCE</h4>\r\n<p>The hearing aid program, like most technical programs in Quebec, has a three-year term. We recruit both students leaving high school as well as those coming from different life paths. Our students, numbering 35 in the first year, apply via the Regional Admissions Service of Greater Montreal and come from all regions of Qu&eacute;bec with a predisposition for the Greater Montreal Area. Upon graduation, approximately 25 per year, hearing care professionals often work in the practice that hosted their internship during the sixth semester, or else they find employment elsewhere in the province of Quebec. Some return to their country of origin such as France. The specificity due to the French language provides little incentive for graduates to try their luck in other provinces with few exceptions. The program brings together the knowledge, expertise and life skills needed to perform all the tasks required in the daily practice of the audioproth&eacute;siste, from day one taking charge of the patient&rsquo;s hearing aid fitting to the verification of the equipment&rsquo;s performance when fitted, the follow up through practice management and more.</p>\r\n<p>It is important to note that this table does not reference the additional courses offered by the contributory disciplines  of physics biology, psychology and administration. We based our curriculum so that the student is gradually brought into contact with different aspects of the profession, so as to be consistent with the chronology of the patient&rsquo;s journey towards a hearing aid fitting</p>\r\n<p>&bull; The first semester enables students to examine a general overview of the profession, its legislation and a quick look at hearing aid technologies and a one day internship in clinic to make students sure of their choice. The student also takes courses in Physics and biology / anatomy that allow students to prepare better for the second semester.</p>\r\n<p>&bull; In the second semester, students are introduced to the basic concepts of audiometry and use of audiometric equipment, doing testing with few patients. At the same time students perfect their education in electricity and the biology of hearing.</p>\r\n<p>&bull; In the third semester, the future audioproth&eacute;sistes are introduced to measurements made using the electroacoustic analyzer test chamber as well as real ear measurements. Audiometry, impedance measurements, and test practice with few patients from the College are reinforced in this semester. Students are also introduced to various pathologies of the auditory system.</p>\r\n<p>&bull; In the fourth semester, students deepen their understanding of how hearing aids function; for example &lsquo;compression&rsquo; and its applications. In addition, students learn to recognize various types of patient profiles and match the corresponding hearing aid interventions. In the first of a two-part pre-internship during this semester, students come more in contact with a hearing-impaired patient and conduct a non-diagnostic evaluation. Students will then propose several preprogrammed hearing aid solutions.</p>\r\n<p>&bull; During the fifth semester, the focus is on certain special audiometric tests, objective tests such as the auditory brainstem repose (ABR). At the same time students are introduced to prescription methods of programming, adaptation to hearing aids, verification of performance in free-field as well as stereo-audiometric tests. The second part of the pre-internship also takes place here; a team of two students perform all operations required for fitting a patient from day 1 up to and including the verification of the benefits of hearing aids at the end of three weeks of experimentation.</p>\r\n<p>&bull; The sixth and final semester takes place in a working practice, from 9:00 am to 5:00 pm, five days a week under the internship supervisor.</p>\r\n<h4>WHAT DIFFERENTIATES US FROM OTHER PROGRAMS</h4>\r\n<p>When we created the curriculum, we felt it important to establish a harmonious equilibrium of theory and practice. With our laboratory that measures 1600 square feet, we enable our students to apply the concepts seen in class. Students also receive patients in audiometry laboratories as well as in their preinternship. Thus in the 3rd, 4th and 5th semesters the students evaluate a patient through audiometry, propose hearing aid solutions, fit the hearing aids and verify  the proper adaptation a few weeks later, all under the scrutiny of a professor.</p>\r\n<p>Our facilities, in addition to traditional classrooms, include 3 double audiometric sound rooms with all the equipment required for the assessment and adjustment of the fitting, and 2 single sound rooms that better reflect the daily reality of a practice. A large media room has 10 workstations. Each room includes a computer for the adjustment of hearing aids and an electroacoustic analyzer with a test chamber and for real ear measurements. In addition, this room is equipped with a video projector allowing us to regularly receive representatives of various manufacturers who present new products - as well as international speakers - to our second and third year students. Finally, a space is dedicated to impression taking, hearing aid and earmold modification, cleaning, maintenance and simple repair of hearing aids.</p>\r\n<h4>CONCLUSION</h4>\r\n<p>We always consider changes in the near future that might be required in order to meet new trends and requirements in our field of expertise. We emphasize both the electroacoustic and psychoacoustic measurements of fittings, as well as supporting patients throughout the fitting process. Having a comprehensive view of the history of our field, I can confirm that we are doing the best job in the world as audioproth&eacute;siste with the best years yet to come. In terms of education, the passion that belongs to our team and its quest for excellence are guarantees of a healthy program and ready to face the challenges ahead.</p>\r\n<p>Thanks to the Canadian Hearing Report for allowing me to complete this overview of our activities. On behalf of the department professors and on my behalf I can assure you that if we had to do this all over again, we would with enthusiasm! Long live (Vive!) the audioproth&egrave;se department of the Rosemont College!</p>\r\n<p>By Daniel Bois, Audioprothesist</p>\r\n<p>Daniel Bois graduated in audiology from l&rsquo;Universit&eacute; de Montr&eacute;al at the beginning of the 1990s. His technology savvy side and desire to obtain patients&rsquo; satisfaction lead him to develop a patient centered approach and evidence-based practice. Over the course of his career he had the opportunity to work in different settings (hospital, private practice, industry) in clinical and managment positions. He has lectured in Canada on different topics related to amplification and taught at the Universit&eacute; de Montr&eacute;al and also at Universit&eacute; de Moncton. He has also appeared on TV in a few informative programs about hearing loss. Daniel was hired in December 2012 to develop the Hearing Instrument Specialist program in La Pocati&egrave;re, and has been managing and teaching there since then.</p>\r\n<p>Located on the St-Lawrence River approximately 75 minutes east of Quebec City, the C&eacute;gep of La Pocati&egrave;re is a small college of approximately one thousand students on 2 campuses. In a few months from now (May 2016), the first cohort of students will be graduating from the Audioprothesist program. The following will describe the actual cohort of students, the composition of our faculty, the rationale behind the curriculum, the architecture of the department and some unique features about our program.</p>\r\n<p>The 3-year program started in the Fall Semester of 2013. Currently, 60 Frenchspeaking students coming mainly from Quebec (90%), but also from Europe and Africa are enrolled in the program. Once they&rsquo;ve completed their training, most of them hope to work in Quebec or in their native country.</p>\r\n<p>The program faculty has grown over the last couple of years and is still evolving as we move forward. Our current team includes a mix of professionals to reflect our interdisciplinary approach. Here is the actual team:</p>\r\n<p><strong>Daniel Bois, </strong>Audioprothesist. Teaching Amplification, Consolidation Seminars and On-site Internship classes. Department Head and full time teacher.</p>\r\n<p><strong>Patrice Pelletier,</strong> Audioprothesist Teaching Amplification and Ethic &amp; Professionalism classes. Part time teacher and working in his private practice 4 days per week;</p>\r\n<p><strong>Marjorie Noel, </strong>Audiologist. Teaching Audiometry, Pathology, Psychoacoustic and Aural Rehab classes. Full time teacher;</p>\r\n<p><strong>S&eacute;bastien Lanthier, </strong>Audioprothesist. Teaching the Amplification labs. Part time teacher and working in his private practice 4 days per week.</p>\r\n<p><strong>Corinne Marois,</strong> Speech-Language Pathologist. Teaching Human Development and Hearing Loss and Counselling classes. Part time teacher and working in her private practice (SLP), 3 days per week.</p>\r\n<p><strong>Ghislaine Duval, </strong>Biologist. Teaching Anatomy and Physiology classes. Full time teacher.</p>\r\n<p><strong>S&eacute;bastien Pelletier,</strong> Electronic Engineer. Teaching the Electronics for Hearing Aids class. Full time teacher. Simon Fissette, Physicist. Teaching the Applied Acoustics for Hearing Instrument Specialists class. Full time teacher.</p>\r\n<p>One of our unique features of our program is the involvement of our students outside of the classroom. We facilitate the achievement of other activities for students who want to volunteer in the community or for &lsquo;scientific&rsquo; projects. For example, last year, we put together a series of information sessions to a local group of hearing impaired individuals. This was not only very informative for the hearing impaired in the community but it was a great experience for the students. We also had an information booth set up in the College lunch room to increase awareness about high level exposure to music (MP3, concerts, etc). Finally, a small group of students presented the results of their research projects in a poster session during the Quebec Audioprothesist&rsquo;s Convention. We believe these were great opportunities for students to learn &lsquo;stuff about the real world outside of the classroom&rsquo;.</p>\r\n<p>To conclude, although we are the youngest program in the country, our faculty includes people from different backgrounds all aiming to create among the students a culture of excellence and passion to improve the quality of life of the hearing impaired.</p>\r\n<p>By Chelsea Lindquist, with input from Marci Leong</p>\r\n<p>Chelsea Lindquist is a Communications Specialist at Bates Technical College. Dr. Marci Leong, Hearing Instrument Technician instructor at Bates Technical College in Tacoma, Wash., has taught at the college since 2005. Previous to teaching, she spent 18 years in medical audiology, specializing in cognitively-challenged adults. She holds a bachelor&rsquo;s degree in speech and hearing services from the University of Washington, a master&rsquo;s degree in audiology from the University of Washington, and a clinical doctorate from the University of Florida, Gainesville.</p>\r\n<p>When Taner Johnson enrolled in Bates Technical College in Tacoma, Washington, he first thought he&rsquo;d pursue a degree in practical nurse. But when he discovered the Hearing Instrument Technology (HIT) program, he switched gears. Through his research, Johnson found that a career in this field meant set hours and a greater earning potential while also providing a necessary service to those who need assistance.</p>\r\n<p>Johnson enrolled in the hearing instrument program in 2014 and earned his Associate in Applied Science in a shorter time than others in the program, since he had taken prerequisites that overlapped with HIT courses. &ldquo;It was a great atmosphere to learn in &ndash; especially with a working clinic on-site,&rdquo; he says, adding that he is a hands-on learner. The open-to-the-public, full-service hearing clinic is what HIT program instructor Marci Leong, AuD, says makes the program unique. &ldquo;With a hands-on approach to learning through operating a full-service hearing aid clinic, we strive to achieve the best in education,&rdquo; says Dr. Leong. &ldquo;We hope to challenge each student to work to their potential, step outside their comfort zones, and better their lives and those of individuals who are hard-of-hearing.&rdquo;</p>\r\n<p>Bates Technical College is one of two hearing instrument technician programs in Washington State, and one of just four in the United States. As part of the program, students provide services to patients through a state-of-the-art clinic. The unique program teaches students how to conduct hearing tests, asses each individual&rsquo;s hearing problems, and provides solutions for those problems.</p>\r\n<p>Dr. Leong has taught at the college for 10 years, and has been in the field since the 1980s. Her career in the industry was focused in medical audiology, working specifically with adults with special needs. She holds a bachelor&rsquo;s degree in speech and hearing services from the University of Washington, a master&rsquo;s degree in audiology, and a clinical doctorate (AuD) from the University of Florida, Gainesville.</p>\r\n<p>&ldquo;What I like most about teaching is sharing the students&rsquo; energy as they learn and strive to better the profession,&rdquo; says Dr. Leong. &ldquo;Being able to spend time with each patient and watch them interact with the students as they learn is fulfilling.&rdquo; The mission of the program, she says, is to inspire students to be their best in providing services to the hard-of-hearing community, and improve the quality and reputation of the profession. &ldquo;I challenge each student to find their own unique traits that will make them successful in the hearing aid field,&rdquo; she adds. &ldquo;By demanding excellence in two-year programs, my hope is to have specialists working alongside other hearing professionals and in non-traditional settings. My goal is to meld the clinical side of hearingaid fitting with the retail side, and bring more harmony to the profession,&rdquo; she explains.</p>\r\n<p>With new students accepted in fall and spring each year, the program has a capacity of 15 students. Upon successful completion of the six-quarter program, students are equipped with a set of program outcomes, listed below:</p>\r\n<p>Graduates are able to:</p>\r\n<p>&bull; Describe theoretical/conceptual and practical factors that impact the fitting of hearing aids.</p>\r\n<p>&bull; Perform accurate assessment for the purposes of hearing aid fitting.</p>\r\n<p>&bull; Explain various strategies and the rationale for use when recommending and selecting hearing aids for clients.</p>\r\n<p>&bull; Integrate family and other professionals in the management and care of clients with hearing loss.</p>\r\n<p>&bull; Identify hearing disorders and diseases for referral purposes.</p>\r\n<p>&bull; Describe the acoustical characteristics of a variety of hearing aids.</p>\r\n<p>&bull; Fit and adjust hearing aids.</p>\r\n<p>&bull; Follow established clinical verification protocols.</p>\r\n<p>Dr. Leong notes that in addition to the program&rsquo;s learning outcomes, students are introduced to the business aspects of the industry, which helps them if they wish to open their own practice, she says. &ldquo;Students come far and wide to learn the profession of hearing aid dispensing. We have had international students who have returned to their home countries to open their own practices,&rdquo; she adds. Dr. Leong notes her program is in high demand because of its positive reputation, and the hands-on learning experience her students receive working in the clinic. Graduate Taner Johnson knows the value of learning in a setting that mirrors the workplace. &ldquo;The hands-on aspect of this program really helped me prepare for my career,&rdquo; he says. &ldquo;From the first week of class, we were working on students performing ear impressions, testing, and learning the equipment on the property. Then, we progressed to working in the clinic, when patients came in to see us. We learned from the students who were a few quarters ahead of us, and it was nice to see their progress, learn from their experiences, and apply it to our own education.? Now working as a hearing aid specialist at Costco Wholesale, Johnson hopes to rise to manager level as a senior hearing aid specialist within the next few years. To learn more about Bates Technical College, celebrating its 75th anniversary this year, and the Hearing Instrument Technician program, go to www.bates.ctc.edu/Hearing.</p>\r\n<p>By Tyler Reuthebuck, AAS</p>\r\n<p>Tyler Reuthebuck is a graduate of Ozarks Technical Community College Hearing Instrument Science Program graduating Summa Cum Laude. He is a Gulf War veteran having served in the USAF as Communication and Navigation systems specialist. Tyler brings nearly 20 years experience in business management, development and consulting including operations management of a retail hearing clinic owned by William Demont, the parent company of Oticon. Tyler assists with teaching students at labs, but focuses his efforts on recruiting, retention and job placement of students. He also is active in business development, networking and community involvement for the HIS program through presentations, to promote hearing health awareness. Tyler has a passionate, energetic and creative approach to promote the HIS program, industry and HIS profession.</p>\r\n<p>The Hearing Instrument Science (HIS) program at Ozarks Technical Community College (OTC) has 33 students currently enrolled. The program has over 70 graduates placed throughout Missouri, Arkansas, Illinois, Kansas, California, and Pennsylvania. The program was founded in 2011 on a federal grant aimed at getting displaced workers, US Veterans, and underemployed workers into a new career. The grant has since concluded, and the program is working to recruit more students from outside of the state of Missouri. Graduates of the two year program earn an Associate of Applied Science (AAS) degree. We currently have six audiologists and five Hearing Instrument specialists teaching for our program. Ted Venema, PhD has recently joined our faculty as a part time instructor. In addition to adjunct teaching at OTC, Lynn Royer, HIS with a MEd and Dianne Senay, AuD also work as field representatives for Unitron and Oticon, respectively. Elizabeth Fernandez, AuD, Lindsey Willbanks, AuD, Yon Wibskov, NBCHIS, and Jackie Hartman, MA in audiology, work in private practice. Lisa Elmore, NBC-HIS works for Hearing Lab Technology. Richelle Kluck, AuD works for the VA. Robert Siegel, AuD works independently as a practice consultant. Rebecca Waldo, HIS has a BS in educational technology and is currently working on her MEd; she is the full time program director. Tyler Reuthebuck is a graduate of the HIS program at OTC, and he is our business development consultant. As a dedicated recruiter, Tyler works on program promotion, business development, public relations, industry promotion, and job placement.</p>\r\nfundamental courses: Anatomy and Physiology of Auditory\r\nand Speech Systems, Acoustics and Psychoacoustics,\r\nIntroduction to Audiometry, and Introduction to Hearing\r\nInstrument Components. In the second semester they take\r\ntheir first clinical practicum course, Hearing and Auditory\r\nDisorders, and Hearing Instrument Fitting Methods. In the\r\nthird semester students take an ethics course, their second\r\nClinical Practicum course, Advanced Audiometry, and\r\nCompression and Digital Features of Hearing Instruments.\r\nIn the 4th and final semester they take their last Clinical\r\nPracticum course, Real Ear Measurements, and Hearing\r\nHealthcare Management & Marketing. Students also have 24\r\nhours of general education courses required for AAS degree\r\ncompletion.',NULL,'2022-11-16'),(13,4582,'ajchr','http://www.andrewjohnpublishing.com/','','<h4>Hearing Intervention in Early Years</h4>\r\n<p><strong>Ruchita Mehta<sup><a href=\"#corr\">*</a></sup></strong></p>\r\n<p>RCI registered, International Affiliation ASHA, Lifetime membership ISHA &amp; MISHA, India</p>\r\n<p>*risetoshine.slp@gmail.com</p>\r\n<h4>EDITORIAL</h4>\r\n<p>Surely, early intervention does make a   difference in the life of young ones with   special needs, once it is detected. Parents   of special children are also aware of the   importance of timely intervention. But   what if despite all the awareness of the   special needs and efforts taken by the   parents, things don&rsquo;t go as planned for   that special young one? Who and where   should we pick to put a finger on? Is it   our system where not many concrete   regulations are in place in medical world?   Is it lack of funding due to which we don&rsquo;t   have enough instruments and man power   to take the responsibility of achieving the   goals of early intervention? Or is it the   personnel handling the case on hand, and   their lack of motivation to handle the   many pending cases waiting in queue? Pick   one or all the reasons from the above to   suit the best explanation, but nothing   justifies to the loss of timely intervention   to this young one with Down&rsquo;s syndrome.</p>\r\n<p>Hearing impairment is one of the   conditions that may not be detected at   the time of birth. Also, not many hospitals   are equipped to provide neonatal   hearing screening. In such cases, hearing   impairment is not detected until sometime   after birth and thus, loosing many early   years of hearing intervention. A variety   of autosomal chromosome abnormalities   can affect not only hearing channels but   also communication development. One   such case is of Down&rsquo;s syndrome, Down&rsquo;s   syndrome appears in about 1 of every 800   live births in United States. Besides, the   symptoms of hypotonia, mild to moderate   mental retardation, characteristic facial   features, and hyper flexibility of joints,   there are ear abnormalities such as small   ear canals and may have conductive or   sensorineural hearing loss or both related   to Otitis Media. With already so much   going on, what if the child is missed out   on getting provision of hearing screening   at the time of birth in a hospital setting.   To add to this plight, when the child is   brought for hearing tests, at the age of 3   years, and once again his hearing abilities   are not confirmed in a private practice   setting. So much is lost on the way to   its speech, language and communication   development and also in the journey of   getting adequate treatment options.   Even if hearing ability could not be   confirmed at the time of testing, there are   ways to handle the case in many pending   cases waiting in queue-</p>\r\n<p>1. The parents of the child should have   been given counseling on the testing   results.</p>\r\n<p>2. The personnel should have counseled   to the parents to do home- training of   conditioning the child and re-scheduling   for another appointment of hearing   testing.</p>\r\n<p>3. Despite all the efforts failing with PTA,   personnel could have chosen another   hearing test from the various battery   of hearing tests that have come into   existence in today&rsquo;s time.</p>\r\n<p>So much could have been done in this   case; however, it was just left alone with   no concrete report nor help. After all the   ordeal of last 5 years, the child is brought   for speech therapy, he is 8 years old now   and is finally going for a thorough hearing   check- up, hoping that there wouldn&rsquo;t   be any hidden hearing impairment and   further loss of time.</p>\r\n<h4>Cochlear Implantation in Patients with Special   Situation</h4>\r\n<p><strong>Hisashi Sugimoto1, Makoto Ito2, Miyako Hatano1, Hiroki Hasegawa1, Masao Noda1, Tomokazu Yoshizaki1*</strong></p>\r\n<p><sup>1</sup><a name=\"a1\" id=\"a1\"></a>Department of Otolaryngology-Head and Neck Surgery, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan</p>\r\n<p><sup>2</sup><a name=\"a2\" id=\"a2\"></a>Pediatric Otolaryngology, Jichi Children\'s Medical Center Tochigi, Jichi Medical University</p>\r\n<p>*tomoy@med.kanazawa-u.ac.jp.</p>\r\n<h4>Abstract</h4>\r\n<p>Objectives: We have been using the &quot;Subtotal petrosectomy&quot; or &quot;Canal wall down mastoidectomy&quot; technique   for the cochlear implantation of difficult cases. We also added the &quot;Blind sac closure of external auditory   canal (EAC)&quot; and &quot;Middle ear and mastoid Obliteration by abdominal fat&quot; technique as necessary.</p>\r\n<p>Methods: Retrospective analysis of seven special cases of cochlear implantation was carried out. The detailed   breakdown of the cases is as follows: Post radical mastoidectomy -- 2 cases, Adhesive otitis media   -- 1 case, Eosinophilic otitis media -- 2 cases, Temporal bone malformation -- 2 cases. Complications,   hearing threshold results, word recognition, and bleeding were analyzed.</p>\r\n<p>Results: For one of the cases of Post radical mastoidectomy, the patient suffered from a breakdown   of the EAC closure. The hearing threshold following the procedures ranged from 25 to 35 dB with an   average of 30.3dB. The word recognition results were 0 to 96% with an average of 60% and sentence   recognition results ranged from 0 to 100% with an average of 62%. The volume of blood loss ranged   between less than 5 mL and 170 mL.</p>\r\n<p>Conclusuons: The combination of these techniques has potential to be effective for the cochlear   implantation of such difficult cases.</p>\r\n<h4>KEYWORDS</h4>\r\n<p>Petrosectomy, Cochlear   implantation, Auditory canal, Post radical   mastoidectomy</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>Patients with profound hearing loss   are able to acquire the ability to hear   by receiving an operation to emplace   a cochlear implant, and this result in a   remarkable improvement in their quality   of life. As of this time, many patients have   enjoyed the benefits of this procedure.   For patients in which the middle and inner   ear present a normal form and in which   there is no pathological change to the   temporal bone, the classical facial recess   technique is usually used with extremely   few resultant complications. Previous   studies of the classic technique report   major complication rates of between   3.0 and 13.7% [<a href=\"#1\" title=\"1\">1</a>-<a href=\"#4\" title=\"4\">4</a>]. On the other hand,   there are quite a few difficult cases for   which classical facial recess technique for   cochlear implant cannot be employed. Fisch   et al. proposed subtotal petrosectomy in   1988, and five years after that Parnes et   al. employed this approach for the first   time in a difficult cochlear implant case.   This procedure involved a closure of the   external auditory canal (EAC) and the   Eustachian tube and obliteration of the   surgical cavity. Following this case, this   procedure became the standard cochlear   implant method used for difficult cases,   and this in turn has led to debate over the   usefulness and safety of the procedure   [<a href=\"#5\" title=\"5\">5</a>-<a href=\"#14\" title=\"14\">14</a>]. However, since the total number   of cases is small, the validity and safety   cannot be irrefutably established. Thus, it   is extremely important to ascertain the as   of yet hypothetical usefulness and safety   for patients undergoing such special   cases of cochlear implant procedures. In   this report we present our experiences   with seven such special cases of cochlear   implants. In this report we wish to   contribute further to the investigation   about the safety and suitability so that   even if only by a small amount more   patients with difficult cases can enjoy the   benefit of cochlear implant.</p>\r\n<h4>MATERIAL AND METHODS   PATIENTS</h4>\r\n<p>We did a retrospective analysis of seven   special cases of cochlear implantation   carried out in the Department of   Otorhinolaryngology at the Kanazawa   University Hospital between 2012   and 2016. The detailed breakdown of   the cases is as follows: Post radical   mastoidectomy -- 2 cases, Adhesive otitis   media -- 1 case, Eosinophilic otitis media   -- 2 cases, Temporal bone malformation   -- 2 cases (<strong>Table 1</strong>). For the two cases   of eosinophilic otitis media subtotal   petrosectomy, cochlear implantation,   and obliteration of the mastoid using   abdominal fat was carried out (<strong>Fig. 1</strong>).</p>\r\n<div class=\"table-responsive\">\r\n<table class=\"table table-sm table-bordered\">\r\n    <thead>\r\n        <tr>\r\n            <th>Patient</th>\r\n            <th>Age</th>\r\n            <th>Sex</th>\r\n            <th>Side</th>\r\n            <th>Etilogy</th>\r\n            <th>Operative procedure</th>\r\n            <th>Complications</th>\r\n            <th>Bleeding</th>\r\n            <th>Implant</th>\r\n            <th>Electrode outside cochlear</th>\r\n            <th>Hearing threshold before CI</th>\r\n            <th>Hearing threshold after    CI</th>\r\n            <th>Speech preception (CI2004)</th>\r\n            <th>Follow up</th>\r\n        </tr>\r\n    </thead>\r\n    <tbody>\r\n        <tr>\r\n            <td>1</td>\r\n            <td>69</td>\r\n            <td>F</td>\r\n            <td>Lt</td>\r\n            <td>Redical cavity</td>\r\n            <td>Simple    suture of EAC Canal    wall<br />\r\n            mastoidectomy closure<br />\r\n            of the eustachian tube</td>\r\n            <td>Suture failuer of EAC</td>\r\n            <td>100 ml</td>\r\n            <td>&nbsp;           Cochlear CI24</td>\r\n            <td>0/22</td>\r\n            <td>105dB</td>\r\n            <td>30dB</td>\r\n            <td>Word 48% Sentense 61%</td>\r\n            <td>45M</td>\r\n        </tr>\r\n        <tr>\r\n            <td>2</td>\r\n            <td>72</td>\r\n            <td>M</td>\r\n            <td>Rt</td>\r\n            <td>Redical cavity</td>\r\n            <td>Blind sac closure to EAC    Canal wall down    mastoidectomy<br />\r\n            middle ear and mastoid obliteration by abdominal fat closure of<br />\r\n            the eustachian tube</td>\r\n            <td>No</td>\r\n            <td>&lt;5 ml</td>\r\n            <td>Cochlear CI24</td>\r\n            <td>0/22</td>\r\n            <td>105dB</td>\r\n            <td>28dB</td>\r\n            <td>Word 60% Sentense 40%</td>\r\n            <td>31M</td>\r\n        </tr>\r\n        <tr>\r\n            <td>3</td>\r\n            <td>79</td>\r\n            <td>M</td>\r\n            <td>Lt</td>\r\n            <td>atelectasis</td>\r\n            <td>Subtotal petrosectomy blind sac closure of EAC middle ear and mastoid obliteration by abdominal    fat closure of the eustachian tube</td>\r\n            <td>No</td>\r\n            <td>&lt;5 ml</td>\r\n            <td>Cochlear CI24</td>\r\n            <td>0/22</td>\r\n            <td>103.8dB</td>\r\n            <td>25dB</td>\r\n            <td>Word 64% Sentense 71%</td>\r\n            <td>21M</td>\r\n        </tr>\r\n        <tr>\r\n            <td>4</td>\r\n            <td>64</td>\r\n            <td>M</td>\r\n            <td>Lt</td>\r\n            <td>Eosinophilic otitis media</td>\r\n            <td>Subtotal petrosectomy blind sac closure of EAC middle ear and mastoid obliteration by abdominal    fat closure of the eustachian tube</td>\r\n            <td>No</td>\r\n            <td>170 ml</td>\r\n            <td>Cochlear CI24</td>\r\n            <td>0/22</td>\r\n            <td>105dB</td>\r\n            <td>30dB</td>\r\n            <td>Word 96% Sentense 91%</td>\r\n            <td>31M</td>\r\n        </tr>\r\n        <tr>\r\n            <td>5</td>\r\n            <td>71</td>\r\n            <td>M</td>\r\n            <td>Rt</td>\r\n            <td>Eosinophilic otitis media</td>\r\n            <td>Subtotal petrosectomy blind sac closure of EAC middle ear and mastoid obliteration by abdominal    fat closure of the eustachian tube</td>\r\n            <td>No</td>\r\n            <td>50 ml</td>\r\n            <td>Cochlear CI24</td>\r\n            <td>0/22</td>\r\n            <td>102.5dB</td>\r\n            <td>34dB</td>\r\n            <td>Word 60% Sentense 71%</td>\r\n            <td>18M</td>\r\n        </tr>\r\n        <tr>\r\n            <td height=\"103\">6</td>\r\n            <td>9</td>\r\n            <td>M</td>\r\n            <td>Lt</td>\r\n            <td>Inner ear Malformation</td>\r\n            <td>Blind sac closure of EAC Canal wall down mastoidectomy</td>\r\n            <td>No</td>\r\n            <td>50 ml</td>\r\n            <td>Cochlear CI24</td>\r\n            <td>0/22</td>\r\n            <td>105dB</td>\r\n            <td>35dB</td>\r\n            <td>Word 0% Sentense 0%</td>\r\n            <td>57M</td>\r\n        </tr>\r\n        <tr>\r\n            <td>7</td>\r\n            <td>41</td>\r\n            <td>M</td>\r\n            <td>Rt</td>\r\n            <td>Inner ear Malformation</td>\r\n            <td>Blind sac closure of EAC Canal wall down mastoidectomy</td>\r\n            <td>No</td>\r\n            <td>&lt;5 ml</td>\r\n            <td>Cochlear CI24</td>\r\n            <td>0/22</td>\r\n            <td>97.5dB</td>\r\n            <td>30dB</td>\r\n            <td>Word 2% Sentense 100%</td>\r\n            <td>52M</td>\r\n        </tr>\r\n    </tbody>\r\n</table>\r\n</div>\r\n<p><strong>Table 1.</strong> Summary of seven special cases.</p>\r\n<p>For one of the two cases of post radical   mastoidectomy closure of the external   auditory canal using blind sac closure,   cochlear implantation, and obliteration   of the mastoid using abdominal fat were   carried out (<strong>Fig. 2</strong>). For the other case of   Post radical mastoidectomy, the external   auditory canal was closed, but blind sac   closure was not used. Mastoid obliteration   was also not performed. For a case of   Adhesive otitis media, canal wall down   mastoidectomy, cochlear implantation, and mastoid obliteration using abdominal   fat were carried out. For the two cases of   Temporal bone malformation, closure of   the external auditory canal using blind sac   closure, canal wall down mastoidectomy   and cochlear implantation were carried out. Obliteration of the mastoid was   not carried out. Complications, hearing   threshold results, word recognition, and   bleeding were the four items analyzed   in these seven cases. Permission for this   retrospective study was obtained from   the Kanazawa University Hospital, the   local Ethics Committee approved the   study protocol. Informed written consent   was obtained from all patients.</p>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\" height=\"103\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-patient-13-1-1-g001.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-patient-13-1-1-g001.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-patient\" title=\"canadian-hearing-report-patient\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig 1.</strong> Left ear of patient 4 after subtotal petrosectomy. A good field of view and ample working space was ensured.</p>\r\n</div>\r\n</div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Postoperative-13-1-1-g002.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Postoperative-13-1-1-g002.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Postoperative\" title=\"canadian-hearing-report-Postoperative\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig 2.</strong> Postoperative CT scan of Patient 2 (right ear).</p>\r\n</div>\r\n</div>\r\n</div>\r\n<h4>RESULTS</h4>\r\n<p>The average period of observation was   36.4 months. Six of the patients were   male, and one was female. Patient age   ranged from nine to 79 years with and   average age of 57.9. All of the surgical   techniques employed in each case were   carried out as one combined operation.   For all of the cases cochlear implantation   was performed using Cochlear CI24 with   zero electrodes outside of the cochlear.   For one of the cases of Post radical   mastoidectomy the patient suffered a   breakdown of the EAC closure. In this   case ear discharge continued for three   months following the procedure, but this   complication disappeared with the EAC   finally closing again naturally. In this case   blind sac closure was not performed   and the middle ear and the mastoid   were not obliterated. There were no   complications in any of the other cases.   Hearing threshold results following the   procedures ranged from 25 to 35dB with   an average of 30.3dB. Word recognition   results were 0 to 96% with an average   of 60% in the case of words, and 0 to   100% with an average of 62% in the case   of sentences. The volume of blood loss varied between less than 5 mL and 170   mL. Blood transfusion was not required in   any of the cases.</p>\r\n<h4>DISCUSSION</h4>\r\n<p>We have used the &quot;Subtotal petrosectomy&quot;   or &quot;Canal wall down mastoidectomy&quot;   technique to approach for kinds of difficult   cases related to cochlear implantation.   A detailed discussion of the cochlear   implant technique as it was applied in   each of these four clinical states follows.</p>\r\n<h4>EARS AFTER RADICAL   MASTOIDECTOMY</h4>\r\n<p>Of the two cases of ears following radical   mastoidectomy in this study, there was   a suture failure of the EAC in the first   case. In this case we didn\'t use the blind   sac closure technique when suturing the   EAC. Furthermore, obliteration of the   mastoid was not carried out. Since the   diameter of the EAC following radical   mastoidectomy is larger as compared to   that of a normal EAC, a simple suturing   of the EAC may lead to imperfect closure.   Fisch considered the EAC suturing using   blind sac closure to be a safe, effective   procedure [<a href=\"#15\" title=\"15\">15</a>]. It is also an advisable   application when carrying out cochlear   implantations in radical cavities. In the   second case, the lateral semicircular   canal in the right ear had been destroyed   in a previous operation. Prior to this   operation a caloric test was conducted   and CP (canal paresis) was pointed out.   Due to this and in order to preserve   vestibular function, an operation was   carried out on the previously destroyed   lateral semicircular canal in the right ear.   The period of hearing loss in the right ear   had been long, but following the operation   an improvement in the hearing level of up   to 25dB was attained. The canal paresis   on the right side caused a remarkable   reduction in the patient\'s QOL. Therefore,   despite the long period of hearing loss, it   is recommended to proceed with caution.</p>\r\n<h4>ADHESIVE OTITIS MEDIA</h4>\r\n<p>Xenellis et al. reported about cochlear   implantations for four patients who were   suffering from adhesive otitis media.   They concluded that Blind-sac closure   of the external auditory canal without   obliteration is a rather safe surgical   procedure in cases with atelectasis, and   a 2-stage procedure may not always   be necessary and indeed might best be   limited to those patients who have active   inflammatory disease at the time of   the primary procedure [<a href=\"#16\" title=\"16\">16</a>]. The cases   that we dealt with in this study had no   inflammation, so the operations were   carried out as single, comprehensive   procedures. There were no complications   in these cases. The difference between   our cases and those reported by Xenellis   et al. was as concerns the inclusion of   Mastoid obliteration. We perform mastoid   obliteration to prevent hemorrhage   effusion and prevent infection in the   post-operative dead space. However, we   believe that the most important purpose   of mastoid obliteration is to counter   post-operative spinal fluid leakage. It is   not necessarily always required to take   these precautions in cases of adhesive   otitis media in which these risks are not   present. In order to determine which is best, more reports from further cases are   required. In the cases related to this study   a caloric test was carried out, the absence   of canal paresis was confirmed, and the   operative side was selected. Similar to   the cases of mastoidectomy, we feel that   consideration of the vestibular function in   cases of adhesive otitis media is important   for selecting the operative side.</p>\r\n<h4>EOSINOPHILIC OTITIS MEDIA</h4>\r\n<p>In this study there were two cases   of eosinophilic otitis media for which   cochlear implantation was performed.   The surgical procedure was a subtotal   petrosectomy. The concepts of the   surgery consist of the following two   points: (i) Removal of mucosa from the   middle ear and the mastoid cavity as   completely as possible in order to remove   the theater of eosinophilic infiltration;   (ii) Closure of the Eustachian tube and   the external auditory canal in order to   prevent leaching of foreign substances   and entry of stimuli which are the cause   of eosinophilic inflammations. There   were no complications or recurrent   inflammation following surgery in the   cases of both patients. Following the   procedure, the hearing threshold results   of the two patients were 30dB and 34dB   [<a href=\"#17\" title=\"17\">17</a>]. This is the first discussion focusing   on cochlear implantations for cases   of eosinophilic otitis media. To further   confirm the efficacy and safety of our   surgical concept, we need to administer   this treatment concept for a larger   number of cases in a future study.</p>\r\n<h4>TEMPORAL BONE MALFORMATION</h4>\r\n<p>As for the cases of temporal bone   malformation, because the anatomical   landmark cannot be trusted, the   identification of the place to open the   cochlea is problematic. Furthermore, in   cases of temporal bone malformation   it has been reported that carrying   out the cochleostomy can result in   gushers. Therefore, for temporal bone   malformation cases we feel it is critical to   ensure that there is a good operative field   of view and ample working space. Canal   wall down mastoidectomy technique   resolves these two problems. Mistakes in   the location for opening the cochlea are   reduced. What\'s more, the measures for   dealing with gushers become much easier.</p>\r\n<p>In the first temporal bone malformation   case in this study, the first operation   employed was a classical facial recess   technique. However, due to a traveling   abnormality of the facial nerve and a   deformity in the inner ear, we couldn\'t   identify the location to open the cochlea.   In the second operation a subtotal   petrosectomy was employed resulting   in a good operative field of view. Thus,   we could open the cochlea. Therefore,   we think that in cases of temporal   bone malformation this canal wall down   technique is extremely useful for cochlear   implantation.</p>\r\n<h4>SUBTOTAL PETROSECTOMY   AND CANAL WALL DOWN   MASTOIDECTOMY</h4>\r\n<p>Ensuring a good operative field and   ample working space are two common,   important points when performing   cochlear implantation for special cases.   Use of subtotal petrosectomy and canal   wall down mastoidectomy can overcome   difficulties related to these two points.   Also, closure of the Eustachian tube   and the EAC can isolate them from the   exterior preventing operation related   infection [<a href=\"#18\" title=\"18\">18</a>]. Thus we feel that for   special cases this is a useful procedure.</p>\r\n<h4>STAGED OPERATION</h4>\r\n<p>Linder et al. recommended a staged   operation for cases with the following   four conditions: 1. Suppurative and   continuously draining otitis media, 2.   Previous tympanomastoid surgeries   with &quot;unstable&quot; disease, 3. Extended   cholesteatomas, and 4. Previously   irradiated temporal bone [<a href=\"#14\" title=\"14\">14</a>]. We   regard this strategy as appropriate. For   the cases in this study none of these   four conditions applied. Thus, a single   operation was selected. There were no   severe complications.</p>\r\n<h4>MASTOID OBLITERATION</h4>\r\n<p>Whether or not to employ mastoid   obliteration is an essential topic that must   be discussed. In cases where mastoid   obliteration is employed, the choice of the   obliterating materials is also an important   issue. We feel that it is necessary to fill   the mastoid space in cases for which   post-operative inflammation is possible.   We especially feel that in cases in which dura mater is exposed or in which   there is CSF leakage, filling the mastoid   space is necessary. Following radical   mastoidectomy, eosinophilic otitis media,   and adhesive otitis media, amongst   other conditions, it is favorable to fill the   mastoid space to prevent inflammation   caused by exuded liquid or blood. On   the other hand, in cases such as temporal   bone malformation in which there has   been no inflammation and the dura   mater or CSF leakage is not occurring,   filling the mastoid space is not necessary.   Previous reports indicate that for blood   flow in the temporal muscle, abdominal   fat is the filling material used. Hellingman   suggests that the most suitable material   to obliterate the cavity appears to be   abdominal fat because of its resistance   to necrosis and easy removal if cochlear   implantation is performed later. On the   other hand, Fisch et al. propose that, after   subtotal petrosectomy, if dura mater   exposure or CSF leakage are involved   and there is inflammation, then the   temporal muscle with blood flow or the   sternocleidomastoid muscle should be   adopted [<a href=\"#15\" title=\"15\">15</a>]. For our cases in this study   there was no exposure of dura mater   nor was there any CSF leakage involved,   so abdominal fat was adopted as the   filling material, and there were no postoperative   complications.</p>\r\n<h4>VESTIBULAR FUNCTION</h4>\r\n<p>When selecting on which side to perform   the procedure, evaluation of the vestibular   function is essential. Especially in cases of   Radical cavity or ears following inner ear   procedures, it is necessary to administer   the caloric test and confirm the presence   or absence of paralysis of the semicircular   canal. Bilateral loss of vestibular function   is a complication that must be avoided,   and we believe this takes priority over   post-operative hearing acquisition. We   think that compared to more mainstream   cases, cochlear implantation following   radical mastoidectomies and other   special cases can result in a higher risk of   deterioration of vestibular function, so as   much as possible it is necessary to make   pre-operative evaluations.</p>\r\n<h4>CONCLUSION</h4>\r\n<p>We have performed cochlear   implantations in cases of Radical cavity Adhesive otitis media?Eosinophilic otitis   media, and Temporal bone malformation.   For all of the cases subtotal petrosectomy   or canal wall down mastoidectomy was   applied. We also added the &quot;Blind sac   closure of EAC&quot; and &quot;Middle ear and   mastoid Obliteration by abdominal fat&quot;   technique as necessary. As a result of the   combination of these methods, a good   field of view and ample working space   were ensured. Except for EAC breakdown,   there were no complications. Hearing   threshold results and word recognition   were markedly improved following the   operation, and blood loss volume was   extremely small. In the future we hope   to increase the number of patients with   special cases who will receive the benefits   of this cochlear implant method.</p>\r\n<h4>REFERENCES</h4>\r\n<ol>\r\n    <li id=\"Reference_Title_Link\" value=\"1\"><a name=\"1\" id=\"1\"></a><a href=\"https://doi.org/10.1017/s002221510014602x\" target=\"_blank\">Proops DW, Stoddart  RL, Donaldson I (1999) Medical, surgical and audiological complications of the  first 100 adult cochlear implant patients in Birmingham. The Journal of  Laryngology &amp; Otologyy 113: 14-17.</a></li>\r\n    <li id=\"Reference_Title_Link\" value=\"2\"><a name=\"2\" id=\"2\"></a><a href=\"https://www.ncbi.nlm.nih.gov/pubmed/7668733\" target=\"_blank\">Hoffman RA, Cohen  NL (1995) Complications of cochlear implant surgery. 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The  Annals of otology, rhinology, and laryngology 25: 485- 494</a></li>\r\n    <li id=\"Reference_Title_Link\" value=\"14\"><a name=\"14\" id=\"14\"></a><a href=\"https://doi.org/10.1007/s00405-015-3573-1\" target=\"_blank\">Szymanski M, Ataide  A, Linder T (2016) The use of subtotal petrosectomy in cochlear implant  candidates with chronic otitis media. European archives of oto-rhino-laryngology  273: 363- 370.</a></li>\r\n    <li id=\"Reference_Title_Link\" value=\"15\"><a name=\"15\" id=\"15\"></a>Fisch U, Mattox, D (1998) Microsurgery of the skull base.Thieme.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"16\"><a name=\"16\" id=\"16\"></a><a href=\"https://doi.org/10.1097/mao.0b013e31816a8986\" target=\"_blank\">Xenellis J,  Nikolopoulos TP, Marangoudakis P, Vlastarakos PV, Tsangaroulakis A, et al.  (2008) Cochlear implantation in atelectasis and chronic otitis media: long-term  follow-up.&quot; Otology &amp; neurotology 29: 499-501</a></li>\r\n    <li id=\"Reference_Title_Link\" value=\"17\"><a name=\"17\" id=\"17\"></a><a href=\"https://doi.org/10.1007/s00405-016-4091-5\" target=\"_blank\">Sugimoto H, Hatano  M, Noda M, Hasegawa H, Yoshizaki T (2016) Cochlear implantation in deaf  patients with eosinophilic otitis media using subtotal petrosectomy and mastoid  obliteration. European archives of oto-rhino-laryngology 274: 1173-1177.</a></li>\r\n    <li id=\"Reference_Title_Link\" value=\"18\"><a name=\"18\" id=\"18\"></a><a href=\"https://doi.org/10.1177/0003489415620427\" target=\"_blank\">Polo R, Del Mar Medina M,  Ar&iacute;stegui M, Lassaletta L, Gutierrez A, et al. (2015) Subtotal Petrosectomy for  Cochlear Implantation: Lessons Learned After 110 Cases. The Annals of otology,  rhinology, and laryngology 125 (2015): 485-494.</a></li>\r\n</ol>\r\n<h4>Central Vestibular Compensation</h4>\r\n<p><strong>Madalina Georgescu<sup><a href=\"#corr\">*</a></sup></strong></p>\r\n<p>University of Medicine and Pharmacy &lsquo;Carol Davila&rsquo; Bucharest, Romania</p>\r\n<p>*madalina.georgescu@gecad.com</p>\r\n<h4>ABSTRACT</h4>\r\n<p>Vestibular system is one of the three sensorial systems involved in equilibrium. Any lesion at this level has   consequences on quality of life, in terms of dizziness and/or disequilibrium or ataxia. Unilateral vestibular   loss (UVL) represents a stable permanent peripheral vestibular lesion with long-term effects and symptoms.   These symptoms are caused by lower than normal gains of vestibulo ocular and vestibulospinal   reflexes secondary to UVL. Central vestibular compensation is a natural healing model for UVL, based on   the neuroplasticity of the central vestibular structures. It is a long-lasting and incomplete phenomenon,   but it enables a comfortable daily life. It can be accelerated and enlarged by customised vestibular rehabilitation   programmes and appropriate drug treatment..</p>\r\n<h4>KEYWORDS</h4>\r\n<p>Unilateral vestibular   loss, Central vestibular compensation,   Neuroplasticity, Vestibular rehabilitation</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>Equilibrium is essential for normal daily   life. It allows normal walking, performing   basic activities (housekeeping, grocery,   and working) without risk of fall and   injury. Three sensorial systems are   involved in this process, a real network   based on normal sensorial input and good   matching in between the information:</p>\r\n<p>somatosensorial, visual and vestibular   system. Disequilibrium worsen the   health-related quality of life (HRQoL)   with a negative impact on their social   life and work performance, leading not   only to psychological damage (low selfconfidence,   depression, frustration), but   also economic losses (long medical leave,   poor concentration, and performance).</p>\r\n<p>Briefly, from anatomical point of view, it   is important to know that the peripheral   vestibular system includes five sensorial   structures for each inner ear, three   ampullary cristae and two maculae. The   ampullary crista is located in the ampule   of each semi-circular canal (horizontal,   superior and posterior) and senses   angular movements of head or body   due to their position-perpendicular one   to each other, so in all directions of the   three-dimensional space we are living   in. The maculae are located one in the   utricle and one in the saccule and senses linear movements due to the otolithic   membrane which increases specific   weight of the maculae, compared with   endolymph density (<strong>fig. 1</strong>).</p>\r\n<p>From these sensorial structures,   information is transmitted in the   vestibular nerve in a very specific   manner &ndash; horizontal and superior semicircular   canals ampullary cristae and   utricular macula are connected to the   superior vestibular nerve and posterior   semi-circular canal ampullary crista and   saccular macula are connected to the   inferior vestibular nerve (<strong>fig. 2</strong>).</p>\r\n<p>Vestibular nuclei are made up of a group   of neurons placed on the floor of the   IV ventricle, laterally bounded by the   restiform body, ventrally by the nucleus   and spinal tract of the trigeminal nerve,   and medially by the pontine reticular   substance. From the anatomical point   of view, four groups of neurons can be   identified: medial, lateral, superior and   inferior. Although there is overlapping,   most of the fibers in the utricle and   saccule reach the lateral and inferior   nuclei, and most of the fibers coming from   the semi-circular canals reach the upper   and middle nuclei.</p>\r\n<p>Vestibular nuclei receive information from the cerebellum, spinal cord, and adjacent   reticular substance, in addition to the   information received from the vestibular   afferent fibers projections. Also, there   are many commissural fibers linking the   two groups of vestibular nuclei (right and   left). Based on the combined connections   between afferent and afferent fibers, the   lateral and inferior vestibular nuclei are   important linking stations in vestibulospinal   reflex control, while upper and   middle nuclei are critical stations in the   control of vestibulo ocular reflexes (<strong>fig. 3</strong>).</p>\r\n<p>Vestibular system is anatomically   developed at birth, but it gets functional in   the child&rsquo;s first year of life. While getting   control on his neck muscles, crawling,   standing, and walking, vestibular cortex   develops reaction patterns specific to   each movement activity. Based on these   patterns, equilibrium is a subconscious   process as long as vestibular system works   normally and sense motion of head and   body and uses this information to control   movement and posture. This is based on   rest discharging rate from vestibular hair   cells and changes in firing rate secondary   to rotations which stimulates the inner towards the movement is performed and   inhibits the other ear (<strong>fig. 4</strong>).</p>\r\n<p>Vestibular lesions impede on this   normal reaction and patients experience   disequilibrium, vertigo or dizziness. Loss   of peripheral vestibular function induces   an asymmetry in vestibular sensorial   discharge (lesion in the inner ear) or in   vestibular ganglia cells activity (in neural   lesions). This asymmetry reaching the   vestibular nuclei level is interpreted   as a rotation towards the part with   higher activity, so vertigo sensation and   accompanying nystagmus appears.   In unilateral vestibular lesions (UVL)   a central process becomes available   &ndash; central compensation, which aims   regaining symmetry between the two   vestibular pathways.</p>\r\n<p>Vestibular system ensures equilibrium   by two different reflexes-vestibulocular   and vestibulospinal reflex which enables   an oculomotor effect (stable image   on the retina while movement), a   postural effect (head aligned with   body, vertical stance, and walking) and   also an appropriate cortical perception   (verticality, orientation in space). All these   three have to be taken into account when   assessing a vestibular lesion, because when   vestibular pathways become imbalanced,   they do not react fully to head, or body   movements and pathological symptoms   related to all three effects should be   addressed in management of UVL.</p>\r\n<p>There are three main categories of UVLstable   deficit (like vestibular neuritis),   fluctuant deficit (like in Meni&egrave;re disease)   and slowly progressive deficit (like in vestibular schwannoma/acoustic   neurinoma).</p>\r\n<p>Central vestibular compensation process   acts only in stable deficits with sudden   onset or progressive course and it is   visible and very important for recovery   in sudden UVL with total vestibular   impairment (complete vestibular neuritis,   for example). Fluctuant vestibular function   cannot trigger central compensation   because or irregular error signals coming   from the affected ear (Meni&egrave;re disease   or vestibular paroxismia). ENTE UVL   leads to two main different categories   of impairments: static and dynamic   vestibular deficit.</p>\r\n<p>Static deficits are present from the   very beginning of the lesion onset   due to asymmetry in vestibular nuclei   activity, are very severe as symptoms and   characteristic signs are present without   any head or body movement. They   resume completely at most in one week.   Static deficit signs are:</p>\r\n<p>&bull; Oculomotor reaction &ndash; spontaneous   nystagmus, skew-deviation (vertical   misalignment of the eyes).</p>\r\n<p>&bull; Postural reactions &ndash; postural asymmetry   (head and/or body tilt), ocular-tilt reaction   (<strong>fig. 5</strong>) (OTR=skew-deviation, head tilt   and ocular torsion), severe imbalance.</p>\r\n<p>&bull; Perception signs &ndash; vertigo, subjective   vertical deviation.</p>\r\n<p>Dynamic deficits appear due to   changings in the vestibular reflexes gain and   are present only during head movements.   Their highest degree of severity is at   one week after the UVL onset, but they last for longer periods (one year) and   might never by fully compensated in   the recovery process. For example, high   frequency movements of the head (over   2Hz) might always induce dizziness and   disequilibrium. Head-shaking induced   nystagmus is used to assess long-term   level of recovery of the UVL.</p>\r\n<p>Dynamic deficit signs are present from all   three vestibular effects mentioned:</p>\r\n<p>&bull; Oculomotor signs &ndash; diminished   vestibulocular reflex induces limitations   in head&rsquo;s velocity movements due to   movement-induced visual disturbances   and secondary dizziness.</p>\r\n<p>&bull; Postural signs &ndash; decreased gain of   vestibulospinal reflex leads to weaker   balance skills, ataxia, and gait disturbances   which all induce behavioural changes in   order to minimise the risk of fall: stance   becomes conscious, a voluntary act,   patients are more cautious while moving   and former daily activities like running,   jumping, high heights activity, sports in   general are limited.</p>\r\n<p>&bull; Perception signs of vestibular dynamic   deficit might include spatial disorientation,   oculo-gravitational illusions (objects   are tilted, corners appear rounded) or   incorrect perception of acceleration   (patients develop motion sickness).</p>\r\n<p>All these dynamic deficits lead to avoidance   behaviour to sudden or challenging   movements, difficulties in tender, subtle   or complex motor activities.</p>\r\n<p>Vestibular compensation, known as   central compensation is a central   nervous system process for physiological   healing after a vestibular deficit, aiming   to reinforce symmetry in vestibular pathways&rsquo; tone and to readjust the gain of   vestibular reflexes in order to equal gain   1, as in healthy persons. Of course, any   lesion of the central vestibular structures   involved in central compensation process   (vestibular nuclei, thalamus, limbic system,   vestibular cortical areas, or cerebellum)   impairs recovery of the UVL [<a href=\"#11\" title=\"1\">1</a>-<a href=\"#3\" title=\"3\">3</a>]. For this   reason, central vestibular compensation   research focussed mainly on peripheral   vestibular lesions.</p>\r\n<p>Vestibular central compensation is a   model of neuroplasticity phenomena   which allows spontaneous recovery   after a UVL (<strong>fig. 6</strong>). In complete unilateral   vestibular deficit, central compensation   is a long-lasting process (over three   month), imperfect and incomplete (high   acceleration or velocity head movements   are not always compensated). This natural   recovery process can be improved and   accelerated by vestibular rehabilitation   programmes and appropriate drug   treatment.</p>\r\n<p>In sudden UVL, the following changes   occur in the vestibular pathway [<a href=\"#4\" title=\"4\">4</a>-<a href=\"#9\" title=\"9\">9</a>]:</p>\r\n<p>A. High asymmetry between the two   vestibular nuclei complex in the acute   phase due to:</p>\r\n<p>a. Inactivity on the lesion side.</p>\r\n<p>b. Increased resting discharge rate on the   contralateral side due to lack of inhibitory   feedback from the injures side through   the flocculus (commissural inhibitory   inputs are removed by the UVL) [<a href=\"#10\" title=\"10\">10</a>,<a href=\"#11\" title=\"11\">11</a>].</p>\r\n<p>B. Regaining symmetry in vestibular nuclei   resting discharge by:</p>\r\n<p>a. Regeneration of a new basic discharge   on the lesion side through various   mechanisms [<a href=\"#12\" title=\"12\">12</a>,<a href=\"#13\" title=\"13\">13</a>]:</p>\r\n<p>i. Opening of existing synapses in the   ipsilateral peripheral vestibular structures.</p>\r\n<p>ii. New sprouting in the peripheral   vestibular pathway.</p>\r\n<p>iii. Recovery and maintenance of the   medial vestibular nucleus spontaneous   activity on the lesion side in chronic stage   of the UVL by slowing down the inhibitory   cerebellar activity and activation of the   vestibular-hypothalamic-vestibular loop.</p>\r\n<p>iv. Adaptive changes in the sensitivity of   central vestibular neurons to inhibitory   neurotransmitters.</p>\r\n<p>v. Changes in the intrinsic cell membrane   properties of the vestibular nuclei   neurons.</p>\r\n<p>vi. Higher density receptors on vestibular   nuclei surface; both last two mechanisms   reflect the internal rebalancing of the   vestibular brainstem related to internal   feedback loops.</p>\r\n<p>vii. Inhibition of the resting discharge rate   in contralateral medial vestibular nucleus   during acute phase of sudden UVL   through high cerebellar inhibitory signals.</p>\r\n<p>The effect of central compensation   differs greatly between static and dynamic   symptoms. Static oculomotor, postural and   perception signs are rapidly and completely   compensated due to important recovery   of spontaneous resting firing rate in the   ipsilateral vestibular nuclei, denervation   hypersensitivity to vestibular input in the   vestibular nucleus and greater reliance on   commissures, deep cerebellar nuclei, and   inferior olive. This occurs immediately   after the acute onset of the UVL and for   this reason patients must move their head   as soon as possible and they must not stay   still in bed more than 2-3 days after the   onset of the vestibular lesion.</p>\r\n<p>Dynamic symptoms evolution is very   different-in significant much longer   period of time (one year, even) symptoms   compensate variably due to different   methods of compensation involved in   recovery and also because functional   changes occurs in cerebellum and   hippocampus, anatomical structures with   huge influence on central compensation   process. Recent studies showed   the importance of otolithic system in facilitating the central vestibular   compensation [<a href=\"#14\" title=\"14\">14</a>-<a href=\"#16\" title=\"16\">16</a>].</p>\r\n<p>The degree of central compensation   depends on the severity degree of stable   vestibular lesion, quantified by caloric,   head-impulse (HIT) and vestibular evoked   cervical myogenic potentials (cVEMP)   test. Caloric reflexivity and HIT allows   evaluation of the superior vestibular   nerve function and cVEMP of the inferior   vestibular nerve (<strong>fig. 7</strong>). Dynamic vestibular   symptoms are better compensated   (disappearance of head-shaking induced   nystagmus and of motion-induced   dizziness) when initial vestibular deficit is   smaller (lower caloric canal paresis and   lower asymmetry in cVEMP&rsquo;s amplitude).</p>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Sensorial-13-1-1-g008.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Sensorial-13-1-1-g008.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Sensorial\" title=\"canadian-hearing-report-Sensorial\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig. 1. </strong>Sensorial vestibular structures in the inner ear Encyclopedia Britannica.</p>\r\n</div>\r\n</div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Vestibular-13-1-1-g009.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Vestibular-13-1-1-g009.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Vestibular\" title=\"canadian-hearing-report-Vestibular\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig. 2.</strong> Vestibular nerve.</p>\r\n</div>\r\n</div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-nuclei-13-1-1-g0010.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-nuclei-13-1-1-g0010.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-nuclei\" title=\"canadian-hearing-report-nuclei\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig. 3. </strong>Vestibular nuclei.</p>\r\n</div>\r\n</div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Changes-13-1-1-g0011.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Changes-13-1-1-g0011.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Changes\" title=\"canadian-hearing-report-Changes\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig. 4. </strong>Changes in firing rate from hair cells in horizontal semi-circular canal (HSC).</p>\r\n</div>\r\n</div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Ocular-13-1-1-g0012.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Ocular-13-1-1-g0012.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Ocular\" title=\"canadian-hearing-report-Ocular\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig. 5. </strong>Ocular tilt reaction.</p>\r\n</div>\r\n</div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-compensation-13-1-1-g0013.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-compensation-13-1-1-g0013.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-compensation\" title=\"canadian-hearing-report-compensation\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig. 6. </strong>Central vestibular compensation (with Mylan Company permission).</p>\r\n</div>\r\n</div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Pathological-13-1-1-g0014.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Pathological-13-1-1-g0014.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Pathological\" title=\"canadian-hearing-report-Pathological\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p>Fig. 7. Pathological results in a patient with left complete UVL:<br />\r\na) 100% caloric paresis and right-beating spontaneous nystagmus.<br />\r\nb) positive HIT test on left ear - (gain&lt;0.7, &ldquo;overt&rdquo; and &ldquo;covert&rdquo; saccades).<br />\r\nc) absent cVEMP in left ear.</p>\r\n</div>\r\n</div>\r\n</div>\r\n<p>Recovery is best for low velocities and/   or accelerations, maybe due to saturation   phenomena or substitution strategies   used for regaining equilibrium [<a href=\"#17\" title=\"17\">17</a>-<a href=\"#20\" title=\"20\">20</a>].</p>\r\n<p>As previously mentioned, central   compensation of dynamic symptoms   involves multiple processes:</p>\r\n<p>&bull; Restoration of peripheral function.</p>\r\n<p>&bull; Compensatory readjustments of   brainstem vestibular processing.</p>\r\n<p>&bull; Sensorial substitution of the impaired   vestibular function by other sensorial systems (visual and somatosensorial) &ndash;   use of smooth pursuit instead of the nonfunctional   vestibulocular reflex (VOR), for   example.</p>\r\n<p>&bull; Functional substitution &ndash; use of   alternative strategies, with different   effectors than the damaged vestibular   ones: prediction, saccades instead of VOR   or extensive use of cervical inputs.</p>\r\n<p>&bull; Behavioural changes in order to minimise   vestibular challenges and demands.</p>\r\n<p>All above mentioned processes except   the first one (restoration of peripheral   function) acts competitively: all start   simultaneously and act redundantly but   using of one of them may eliminate the   need for others. This selection of main   central compensation process is one of   the explanations for variable outcomes   of the same process in different patients   &ndash; dependence on visual substitution   impedes upon somatosensorial   substitution mechanisms and vice versa.</p>\r\n<p>Customised vestibular rehabilitation   programmes might diminish this limit   of the natural recovery phenomena   [<a href=\"#21\" title=\"21\">21</a>-<a href=\"#25\" title=\"25\">25</a>], as well as specific drug therapy   [<a href=\"#26\" title=\"26\">26</a>]. The overall outcome of central   compensation process is also influenced   by its delay in action. There is a critical   period when neuroplasticity of the   vestibular central structures is highest   (first month after the acute injury) and   patients must take advantage of this timewindow   opportunity in order to trigger   early recovery mechanisms [<a href=\"#27\" title=\"27\">27</a>,<a href=\"#28\" title=\"28\">28</a>]. Lying   still in bed, stiffed neck movements and   vestibular suppressants should be limited   to three days at most, in order to manage   properly the UVL&rsquo;s long-term functional   symptoms.</p>\r\n<h4>CONCLUSION</h4>\r\n<p>Central compensation represents a   natural, physiologic healing process of   an acute unilateral vestibular loss. Its   benefit is greater if process starts early,   vestibular central structures are lesionfree,   substitution sensorial systems   (vision and somatosensorial) are normal   and early available. Customised vestibular   rehabilitation programmes and drugs   which facilitate specific neurotransmitters   discharge in vestibular pathway are   recommended in order to enhance,   enlarge and fulfil recovery of the dynamic   vestibular deficits.</p>\r\n<h4>REFERENCES</h4>\r\n<ol>\r\n    <li id=\"Reference_Title_Link\" value=\"1\"><a name=\"1\" id=\"1\"></a>de Waele C, Vidal PP, Tran Ba Huy P, Freyss G (1990) Vestibular compensation. 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Brain Res 239: 251-257. doi: 10.1016/0006- 8993(82)90847-2 PMID: 7093679</li>\r\n    <li id=\"Reference_Title_Link\" value=\"11\"><a name=\"11\" id=\"11\"></a>Llinas R, Walton K (1977) Significance of the olivo-cerebellar system in compensation of ocular position following  unilateral labyrinthectomy. In: Baker R, Berthoz A (Eds). Control of gaze by brainstem neurons pp 399-408.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"12\"><a name=\"12\" id=\"12\"></a>Darlington CL, Smith PF (2000) Molecular mechanisms of recovery from vestibular damage  in mammals: recent advances. Prog Neurobiol  62: 313-325. doi: 10.1016/S0301- 0082(00)00002-2 PMID: 10840152.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"13\"><a name=\"13\" id=\"13\"></a>Kitahara T, Takeda  N, Kiyama H, Kubo T</li>\r\n    <li id=\"Reference_Title_Link\" value=\"14\"><a name=\"14\" id=\"14\"></a>Allum JHJ, Yamane M, Pfaltz CR (1988) Long-term modifications of vertical and horizontal vestibulo-ocular reflex dynamics in man. Acta Otolaryngol 105: 328-337.  doi: 10.3109/00016488809097015 PMID: 3389119.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"15\"><a name=\"15\" id=\"15\"></a>Baloh RW,  Honrubia V, Yee RD, Hess K (1984) Changes in human vestibulo-ocular reflex after loss of  peripheral sensitivity. Ann Neurol 16: 222- 228. doi: 10.1002/ana.410160209 PMID: 6476793.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"16\"><a name=\"16\" id=\"16\"></a>McDonnell MN, Hillier SL (2015)  Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane  Database Syst Rev 17: CD005397. doi:  10.1002/14651858.CD005397 PMID: 25581507.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"17\"><a name=\"17\" id=\"17\"></a>Bronstein Am, Hood JD (1986) The  cervico- ocular reflex in normal subjects and patients with absent vestibular  function. Brain Res 373: 399-408. doi: 10.1016/0006-8993(86)90355-0 PMID: 3487371.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"18\"><a name=\"18\" id=\"18\"></a>Halmagyi GM, Curthoys IS, Cremer PD, Henderson  CJ, Todd MJ, et al. (1990) The human horizontal vestibulo-ocular reflex in response  to high-acceleration stimulation before and after unilateral vestibular neurectomy. Exp Brain Res 81: 479-490. doi:  10.1007/bf02423496 PMID: 2226683</li>\r\n    <li id=\"Reference_Title_Link\" value=\"19\"><a name=\"19\" id=\"19\"></a>Halmagyi M,  Curthoys I (1996) How does the brain  compensate for vestibular lesions? In: Baloh,  Halmagyi (editors), Disorders of the Vestibular System.  Oxford.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"20\"><a name=\"20\" id=\"20\"></a>Maioli C, Precht W (1983) On the  role of vestibulo-ocular reflex plasticity in recovery after  unilateral peripheral vestibular lesions. Exp  Brain Res 59: 267-272. doi:  10.1007/bf00230906 PMID: 3875498.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"21\"><a name=\"21\" id=\"21\"></a>Hall CD1, Herdman SJ, Whitney SL, Cass SP,  Clendaniel RA, et al. (2016) Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Evidence-Based Clinical Practice  Guideline. J Neurol Phys Ther 40: 124-155. doi: 10.1097/NPT.0000000000000120 PMID: 26913496.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"22\"><a name=\"22\" id=\"22\"></a>Georgescu M, Sorina S (2011) Vestibular neuronitis in pregnancy,  Gineco eu 7: 58-61.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"23\"><a name=\"23\" id=\"23\"></a>Georgescu Madalina, Stoian Sorina, Mogoan??  Carmen Aurelia, Ciubotaru Gh.V. Vestibulary rehabilitation &ndash; election treatment  method for compensating vestibular  impairment, Romanian Journal of  Morphology and Embryology 2012, 53 (3):651-656, ISSN (print) 1220-0522, ISSN (on- line) 2066-8279.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"24\"><a name=\"24\" id=\"24\"></a>Georgescu M (2017) Vestibular Rehabilitation &ndash; Recommended Treatment  for Permanent Unilateral Vestibular Loss, Int J Neurorehabilitation Eng 4: 4. doi: 10.4172/2376-0281.1000282.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"25\"><a name=\"25\" id=\"25\"></a>Herdman SJ (2014) Vestibular Rehabilitation 4th Edition.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"26\"><a name=\"26\" id=\"26\"></a>Smith PF,  Darlington CL, Curthoys IS (1986) Vestibular compensation without brainstem commissures in the guinea pig. Neurosci  Lett 65: 209-21. doi: 10.1016/0304-3940(86)90306-x PMID: 3487051.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"27\"><a name=\"27\" id=\"27\"></a>Smith PF,  Darlington CL, Curthoys IS (1986) The effect of visual deprivation in  vestibular compensation in the guinea pig. Brain Res 364: 195-198. doi: 10.1016/0006-8993(86)91004-8.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"28\"><a name=\"28\" id=\"28\"></a>Zee DS.  Vestibular Adaptation in Vestibular Rehabilitation. In: Herdman S (editor) F.A. Davis, 19.</li>\r\n</ol>\r\n<h4>Successful Cochlear Implantation under Local   Anesthesia and Sedation: A case Report</h4>\r\n<p><strong>Barbara Stanek, Bernhard Gradl, Astrid Magele, Georg Mathias Sprinzl<sup><a href=\"#corr\">*</a></sup></strong></p>\r\n<h4>ABSTRACT</h4>\r\n<p>With the increasing life expectancy, also the number of patients suffering from age-related severe to profound   hearing loss is rising. In the past Cochlear Implantation in elderly was performed with low expectations   in improved hearing performance and handled as a high risk intervention due to age related health   challenges. Latest studies showed that Cochlear Implantation is a safe procedure in elderly patients and   that this group of patients is able to benefit regarding speech perception and life quality. Usually hearing   device implantations are performed under general anesthesia, which may pose a restrictive factor for   surgery, especially in elderly patients presenting with comorbidities. The here presented case describes   how anesthesia may be circumvented by performing Cochlear Implantation under local anesthesia and   sedation. A 72-year old man presented himself with acute severe to profound sensorineural hearing loss   in his right ear, due to herpes zoster oticus. In addition he suffered from pre-existing deafness in his left   ear. No improvement in hearing and no benefit after trialing a conventional hearing aid for a period of six   months were noted. Further examinations revealed the patient to be a suitable candidate for Cochlear   Implantation in his right ear. Due to significant comorbidities, general anesthesia was contraindicated.   Thus surgery was performed under local anesthesia and sedation. The procedure was successfully performed   and no adverse events or surgical complications occurred. Cochlear Implantation under local   anesthesia and sedation may serve as a valuable option for patients not suitable for general anesthesia.</p>\r\n<h4>KEYWORDS</h4>\r\n<p>Cochlear implantation,   Elderly patients, Local anesthesia</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>Hearing loss is one of the most common   sensory impairments with the elderly   population being predominantly affected.   Depending on the degree of hearing loss,   many candidates can be successfully fitted   with hearing aids. Cochlear Implants   represent the current treatment for   patients of all ages affected by profound   sensorineural hearing loss in one or   both ears. For individuals with this type   of hearing loss, hearing aids provide   little or no benefit. Thus surgery has   been performed for more than 30 years   featuring a low rate of complications [<a href=\"#1\" title=\"1\">1</a>].   Due to the increasing life expectancy,   interest in hearing rehabilitation of   elderly patients has progressively risen   in the recent years. Demographic data   reports that in industrialized countries   the proportion of people over the age of   65 years will increase from 28% in 2015   to 40% in 2035 [<a href=\"#2\" title=\"2\">2</a>]. Age-related processes   within the Cochlear cause damage of   the inner hair cells followed by a low to   moderate hearing loss which may progress   into severe hearing loss up to deafness. In   cases where conventional hearing aids do   not achieve any improvement in hearing,   Cochlear Implantation poses a feasible   and safe treatment option. Unfortunately   in many elderly patients the decision of   hearing rehabilitation surgery is often   handled reluctantly as the risk of surgery   is deliberated against the benefits of   hearing gain. Additional reasons against   a Cochlear Implantation are possible   difficulties with the handling of the   audio processor as well as comorbidities   prohibiting general anesthesia. This paper   describes a case in which Cochlear   Implantation was performed under local   anesthesia and sedation in a 72 year old   male.</p>\r\n<h4>CASE REPORT</h4>\r\n<p>A 72-year-old male with herpes zoster   oticus with a vestibulocochlear lesion   and accompanying acute profound   sensorineural hearing loss and a   neuropathy vestibularis in the right ear   presented to our clinic. The patient   suffered from a right sided facial palsy   occurring a few days after his visit. The   left ear was diagnosed 20 years ago   with chronic recidivating otorrhea in   terms of otitis media chronica simplex   resulting in a deaf left ear. Further   anesthesia hindering co-morbidities were   coronary heart disease, left ventricular   dysfunction, COPD (chronic obstructive   pulmonary disease), diabetes mellitus,   essential hypertonia and dyslipidemia.   The audiogram showed a decline in bone   conduction thresholds on the right side   from 50dB HL at 250Hz to 80dB HL at   3000Hz with an air-bone gap of 10dB. On   the left side the air- and bone conduction threshold were 90dB HL to 110dB HL (<strong>Fig.     1</strong>). Monosyllabic intelligibility tests scored   10% at 95dB and 55% at 110dB on his right   ear and 0% at 110dB on his left ear (<strong>Fig.     2</strong>). Given the severity of his hearing loss,   communication of the patient was only   possible in written form. At that time the   patient was already suffering from social   exclusion and incipient depression. The   patient was administered to hospital and   received intravenously valaciclovir and   corticosteroids. Despite of six months   of treatment therapy no improvement in   hearing on his right ear was observed. The   patient was provided with a behind-theear   hearing aid, which did not generate   subjective nor audiological benefit. The   recognition of speech was 0% at 65dB   and 10% at 80dB with its best possible   setting. Thereupon the evaluation   regarding Cochlear Implantation   started: Computed Tomography of the   petrous bone conducted for previous   diagnosis purposes, further audiological   examinations, Magnetic Resonance   Tomography and a Vestibulometry were   initiated. The patient met the indication   criteria for Cochlear Implantation. Preoperative   multidisciplinary examinations   (echocardiography, pulmonary function,   ECG, internal survey) revealed that   general anesthesia was too risky due to   afore mentioned comorbidities. After   discussing the options with the patient,   it was decided to perform Cochlear   Implantation under local anesthesia.</p>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-operative-13-1-1-g003.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-operative-13-1-1-g003.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-operative\" title=\"canadian-hearing-report-operative\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig 1. </strong>Pre- operative pure tone audiogram.</p>\r\n</div>\r\n</div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-speech-13-1-1-g004.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-speech-13-1-1-g004.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-speech\" title=\"canadian-hearing-report-speech\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig 2. </strong>Pre- operative speech audiometry (red-right ear, blue-left ear) (monosyllables).</p>\r\n</div>\r\n</div>\r\n</div>\r\n<h4>SURGICAL RECORD</h4>\r\n<p>A Cochlear SYNCHRONY Standard   Electrode from MED-EL (Innsbruck,   Austria) was implanted. Due to the local   anesthesia no facial monitoring was   performed. The local anesthesia protocol   included at first 5 ml Xylonest&reg; 1%   with epinephrine 1:200.000 injection   solution submitted into the retro   auricular region. A retro auricular cut,   following a mastoidectomy and posterior   tympanotomy with a bony implant bed   were performed. Cochleostomy approach   for electrode insertion was conducted   due to the round window anatomy. ART   (auditory nerve response telemetry)   and impedance measurements were   undertaken intra-operatively without   abnormal occurrences. The surgical   intervention lasted 60 minutes and no   complications were reported. No pain of   the patient himself was indicated during   the intervention.</p>\r\n<h4>ANESTHESIA RECORD</h4>\r\n<p>The surgery was executed with an   anesthesiology in standby. Pre-operatively   the patient received Midazolam. Intraoperative   monitoring included an ECG, a   pulse oximetry as well as constant blood   pressure measurements. Oxygen (4 L/min) was delivered through an oronasal   mask. To initiate and maintain a mild   sedation, the patient received in total   0.05 mg Fentanyl and 10 mg Ketanest   administered in a small bolus based on   patients&rsquo; comfort. Furthermore 4 mg of   Dexamethasone and 4 mg of Zofran were   given as a prophylactic antiemetic.</p>\r\n<h4>RESULTS</h4>\r\n<p>Post-operatively no pain, nausea or   vomiting occurred. The patient reported   dizziness which was already present   pre-operatively. For infection prevention   intravenous antibiotics were applied for   five days. The patient was released on the   fifth post-operative day. Following implant   activation, one month after surgery, verbal   communication was immediately possible,   which was not feasible pre-operatively.   CI-aided free field measurements on the   right ear revealed 45dB HL at 250Hz,   30dB at 1.000Hz, 35dB HL at 2.000Hz   and 35dB at 4.000Hz (<strong>Fig. 3</strong>). The Freiburg   monosyllables test revealed 10% word   recognition scores at 65dB and 40%   at 80dB in the CI aided condition after   one month. The Freiburg number test   resulted in 100% understanding at 65dB   (<strong>Fig. 4</strong>). The three months follow-up free   field measurements remained constant.   The monosyllabic intelligibility of the   patient improved about 35% at 65dB and   55% at 80dB (<strong>Fig. 5</strong>). The satisfaction and   benefit of the patient remained high and   he stated to undergo surgery under local   anesthesia again.</p>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-month-13-1-1-g005.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-month-13-1-1-g005.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-month\" title=\"canadian-hearing-report-month\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig 3. </strong>Free field audiogram 1 month post-operative.</p>\r\n</div>\r\n</div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Audiometry-13-1-1-g006.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Audiometry-13-1-1-g006.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Audiometry\" title=\"canadian-hearing-report-Audiometry\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig 4.</strong> Speech Audiometry 1 month post- operative [Numbers (Z) and Monosyllables (E)].</p>\r\n</div>\r\n</div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-months-13-1-1-g007.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-months-13-1-1-g007.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-months\" title=\"canadian-hearing-report-months\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig 5. </strong>Speech Audiometry 3 months post- operative [Numbers (Z) and Monosyllables (E)].</p>\r\n</div>\r\n</div>\r\n</div>\r\n<h4>DISCUSSION</h4>\r\n<p>Due to the increasing life expectancy   typical diseases related to elderly people   are undoubtedly rising as well. For instance   the WHO estimates disabling hearing loss   in persons above 65 years of age in over   30% of the population. Understandably,   due to this demographic tendency,   hearing impaired patients as well as the   public&rsquo;s interest on possible treatment   options is ever increasing. At the St.</p>\r\n<p>P&ouml;lten University Medical Center the   average implantation age raised from 48   years in 2014 to 51 years in 2017. Studies   revealed that untreated hearing loss   poses a risk factor for the development   of dementia, cognitive decline, anxiety and   depression [<a href=\"#3\" title=\"3\">3</a>-<a href=\"#5\" title=\"5\">5</a>]. The here presented case   reported of such depressive moods due   to the distinctive discomfort and isolation   already shortly after losing his hearing.   Unfortunately, Cochlear Implantation in   elderly is often associated with increased   operative risks and therefore other, less   satisfying, therapies are opted for. Coelho   et al. and B&uuml;chsensch&uuml;tz et al. proved that   Cochlear Implantation is a safe procedure   in healthy patients regardless of age [<a href=\"#6\" title=\"6\">6</a>,<a href=\"#7\" title=\"7\">7</a>]   also vertigo and wound healing difficulties   were not reported more frequently in   the elderly population [<a href=\"#8\" title=\"8\">8</a>]. Importantly, this group of patients benefits especially   from an implantation in terms of speech   recognition and improved Quality of Life   [<a href=\"#9\" title=\"9\">9</a>,<a href=\"#10\" title=\"10\">10</a>]. Typically Cochlear Implantation   is undertaken under general anesthesia   representing an additional risk factor   for elderly people. If comorbidities are   present, as in the here presented case,   general anesthesia poses a considerable   risk, which may, even given appropriate   indication for Cochlear Implantation,   results in a rejection of surgery for the   patient. Since a number of different ear   surgeries are routinely performed under   local anesthesia, it only seems obvious,   that Cochlear Implantation may be   performed under local anesthesia as well.   Previous studies clearly showed that the   complication rate and the post-operative   duration of hospitalization of Cochlear   Implantation under local anesthesia did   not differ compared to general anesthesia.   No differences related to vertigo, nausea   and post-operative pain were observed.   This is in agreement with our observation.   The mean duration of the surgical   intervention in the group of the Cochlear   Implants under local anesthesia was   significantly lower compared to surgeries   under general anesthesia, representing   an additional positive effect for elderly   patients [<a href=\"#11\" title=\"11\">11</a>-<a href=\"#13\" title=\"13\">13</a>].</p>\r\n<h4>CONCLUSION</h4>\r\n<p>Cochlear implantation surgery proved to   be a good and viable option for hearing   rehabilitation in the elderly population.   Profoundly deaf patients may still be   implanted under local anesthesia without   generating additional health issues caused   by present comorbidities.</p>\r\n<h4>SUMMARY</h4>\r\n<p>&bull; Case report of a 72-year old man.</p>\r\n<p>&bull; Patient suffered acute severe to   profound sensorineural hearing loss   (right ear) and pre-existing deafness   (left ear).</p>\r\n<p>&bull; Patient reported social isolation   followed by depression due to hearing   impairment.</p>\r\n<p>&bull; The patient unsuccessfully trialed   conventional hearing aids for 6   months.</p>\r\n<p>&bull; Patient was indicated for Cochlear   Implantation (right ear) but significant   comorbidities contraindicated surgery   under general anesthesia.</p>\r\n<p>&bull; Therefore surgery was performed   under local anesthesia and sedation.</p>\r\n<p>&bull; Intervention lasted 60 minutes and   procedure was successfully performed   and no adverse events or surgical   complications occurred.</p>\r\n<p>&bull; Hearing rehabilitation was successful   one month post-operative and   improved further. Communication   immediately possible again after   activation.</p>\r\n<p>&bull; The patient reported improved   hearing benefit and Quality of Life.</p>\r\n<h4>REFERENCES</h4>\r\n<ol>\r\n    <li id=\"Reference_Title_Link\" value=\"1\"><a name=\"1\" id=\"1\"></a>Lenarz T (2017)  Cochlear Implant - State of the Art.  Laryngo-rhino-otologie 96: S123-S151. DOI: 10.1055/s-0043-101812 PMID: 28499298</li>\r\n    <li id=\"Reference_Title_Link\" value=\"2\"><a name=\"2\" id=\"2\"></a>Nations U (2015)  World Population Prospects: The 2015 Revision, Methodology of the United Nations Population Estimates and  Projections.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"3\"><a name=\"3\" id=\"3\"></a> Contrera KJ,  Betz J, Deal JA, Choi JS, Ayonayon HN, et al. (2016) Association of hearing impairment and emotional vitality  in older adults. J Gerontol B Psychol Sci Soc Sci. 71: 400-404.  doi: 10.1093/geronb/gbw005 PMID: 26883806.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"4\"><a name=\"4\" id=\"4\"></a>Deal JA, Betz J, Yaffe K, Harris  T, Purchase- Helzner E, et al. (2017) Hearing impairment and incident dementia and cognitive decline in older  adults: the health abc study. J Gerontol A  Biol Sci Med Sci 72: 703-709. doi:  10.1093/gerona/glw069 PMID: 27071780.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"5\"><a name=\"5\" id=\"5\"></a>Lin FR,  Metter EJ, O\'Brien RJ, Resnick SM,  Zonderman AB, et al. (2011) Hearing  loss and incident dementia.  Arch Neurol. 68: 214-20. doi: 10.1001/archneurol.2010.362 PMID: 21320988.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"6\"><a name=\"6\" id=\"6\"></a>Coelho DH, Yeh  J, Kim JT, Lalwani AK (2009) Cochlear implantation is associated with minimal anesthetic  risk in the elderly. Laryngoscope 119: 355-358. doi: 10.1002/lary.20067  PMID: 19160385.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"7\"><a name=\"7\" id=\"7\"></a>B&uuml;chsensch&uuml;tz K, Arnolds J, Bagus H, Fahimi F, G&uuml;nnicker M, et al. (2015) Surgical risk profile and audiological outcome in the elderly after cochlea-implantation. Laryngo-rhino-otologie 94: 670-675. doi: 10.1055/s-0034-1390454  PMID: 25437836.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"8\"><a name=\"8\" id=\"8\"></a>Holinski F, Elhajzein F, Scholz G, Sedlmaier B (2012) Vestibular disorders after  cochlear implant in  adults. HNO 60: 880-885. doi:  10.1007/ s00106-012-2526-x PMID: 22733278.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"9\"><a name=\"9\" id=\"9\"></a>Ramos A, Guerra-Jim&eacute;nez G, Rodriguez C, Borkoski  S, Falc&oacute;n JC, et al. (2013) Cochlear implants in adults over 60: a study of communicative benefits and the impact on quality  of life. Cochlear Implants Int 14: 241-245. doi:  10.1179/1754762812Y.0000000028 PMID: 23510755.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"10\"><a name=\"10\" id=\"10\"></a>Jin SH, Liu C, Sladen DP (2014) The effects of aging on  speech perception in noise: comparison between  normal-hearing and cochlear-implant listeners. J Am Acad Audiol 25: 656-665. doi: 10.3766/jaaa.25.7.4 PMID: 25365368.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"11\"><a name=\"11\" id=\"11\"></a>Mistry SG, Carr  S, Martin J, Strachan DR, Raine CH, et al. (2017) Cochlear  implantation under local anaesthesia - Our  experience and a validated patient satisfaction questionnaire. Cochlear Implants Int, 18: 180-185. doi: 10.1080/14670100.2017.1296986PMID:28274186.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"12\"><a name=\"12\" id=\"12\"></a> Toner F,  Jackson CP, Toner JG (2013)  How we do it: Local anaesthetic  cochlear implantation. Cochlear  Implants Int, 2013. 14: 232-235. doi: 10.1179/1754762812Y.0000000016 PMID: 24001710.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"13\"><a name=\"13\" id=\"13\"></a>Hamerschmidt R,  Moreira AT, Wiemes GR, Ten&oacute;rio SB, T&acirc;mbara EM (2013) Cochlear implant surgery  with local anesthesia and sedation: comparison with general anesthesia. Otol Neurotol 34: 75-78. doi: 10.1097/  MAO.0b013e318278c1b2  PMID:  23187931.</li>\r\n</ol>',NULL,'2022-11-16'),(14,5375,'ajchr','http://www.andrewjohnpublishing.com/','','<h4>Hearing Intervention in Early Years</h4>\r\n<p><strong>Ruchita Mehta<sup><a href=\"#corr\">*</a></sup></strong></p>\r\n<p>RCI registered, International Affiliation ASHA, Lifetime membership ISHA &amp; MISHA, India</p>\r\n<p>*risetoshine.slp@gmail.com</p>\r\n<h4>EDITORIAL</h4>\r\n<p>Surely, early intervention does make a   difference in the life of young ones with   special needs, once it is detected. Parents   of special children are also aware of the   importance of timely intervention. But   what if despite all the awareness of the   special needs and efforts taken by the   parents, things don&rsquo;t go as planned for   that special young one? Who and where   should we pick to put a finger on? Is it   our system where not many concrete   regulations are in place in medical world?   Is it lack of funding due to which we don&rsquo;t   have enough instruments and man power   to take the responsibility of achieving the   goals of early intervention? Or is it the   personnel handling the case on hand, and   their lack of motivation to handle the   many pending cases waiting in queue? Pick   one or all the reasons from the above to   suit the best explanation, but nothing   justifies to the loss of timely intervention   to this young one with Down&rsquo;s syndrome.</p>\r\n<p>Hearing impairment is one of the   conditions that may not be detected at   the time of birth. Also, not many hospitals   are equipped to provide neonatal   hearing screening. In such cases, hearing   impairment is not detected until sometime   after birth and thus, loosing many early   years of hearing intervention. A variety   of autosomal chromosome abnormalities   can affect not only hearing channels but   also communication development. One   such case is of Down&rsquo;s syndrome, Down&rsquo;s   syndrome appears in about 1 of every 800   live births in United States. Besides, the   symptoms of hypotonia, mild to moderate   mental retardation, characteristic facial   features, and hyper flexibility of joints,   there are ear abnormalities such as small   ear canals and may have conductive or   sensorineural hearing loss or both related   to Otitis Media. With already so much   going on, what if the child is missed out   on getting provision of hearing screening   at the time of birth in a hospital setting.   To add to this plight, when the child is   brought for hearing tests, at the age of 3   years, and once again his hearing abilities   are not confirmed in a private practice   setting. So much is lost on the way to   its speech, language and communication   development and also in the journey of   getting adequate treatment options.   Even if hearing ability could not be   confirmed at the time of testing, there are   ways to handle the case in many pending   cases waiting in queue-</p>\r\n<p>1. The parents of the child should have   been given counseling on the testing   results.</p>\r\n<p>2. The personnel should have counseled   to the parents to do home- training of   conditioning the child and re-scheduling   for another appointment of hearing   testing.</p>\r\n<p>3. Despite all the efforts failing with PTA,   personnel could have chosen another   hearing test from the various battery   of hearing tests that have come into   existence in today&rsquo;s time.</p>\r\n<p>So much could have been done in this   case; however, it was just left alone with   no concrete report nor help. After all the   ordeal of last 5 years, the child is brought   for speech therapy, he is 8 years old now   and is finally going for a thorough hearing   check- up, hoping that there wouldn&rsquo;t   be any hidden hearing impairment and   further loss of time.</p>\r\n<h4>Cochlear Implantation in Patients with Special   Situation</h4>\r\n<p><strong>Hisashi Sugimoto1, Makoto Ito2, Miyako Hatano1, Hiroki Hasegawa1, Masao Noda1, Tomokazu Yoshizaki1*</strong></p>\r\n<p><sup>1</sup><a name=\"a1\" id=\"a1\"></a>Department of Otolaryngology-Head and Neck Surgery, Kanazawa University Graduate School of Medical Science, Kanazawa, Japan</p>\r\n<p><sup>2</sup><a name=\"a2\" id=\"a2\"></a>Pediatric Otolaryngology, Jichi Children\'s Medical Center Tochigi, Jichi Medical University</p>\r\n<p>*tomoy@med.kanazawa-u.ac.jp.</p>\r\n<h4>Abstract</h4>\r\n<p>Objectives: We have been using the &quot;Subtotal petrosectomy&quot; or &quot;Canal wall down mastoidectomy&quot; technique   for the cochlear implantation of difficult cases. We also added the &quot;Blind sac closure of external auditory   canal (EAC)&quot; and &quot;Middle ear and mastoid Obliteration by abdominal fat&quot; technique as necessary.</p>\r\n<p>Methods: Retrospective analysis of seven special cases of cochlear implantation was carried out. The detailed   breakdown of the cases is as follows: Post radical mastoidectomy -- 2 cases, Adhesive otitis media   -- 1 case, Eosinophilic otitis media -- 2 cases, Temporal bone malformation -- 2 cases. Complications,   hearing threshold results, word recognition, and bleeding were analyzed.</p>\r\n<p>Results: For one of the cases of Post radical mastoidectomy, the patient suffered from a breakdown   of the EAC closure. The hearing threshold following the procedures ranged from 25 to 35 dB with an   average of 30.3dB. The word recognition results were 0 to 96% with an average of 60% and sentence   recognition results ranged from 0 to 100% with an average of 62%. The volume of blood loss ranged   between less than 5 mL and 170 mL.</p>\r\n<p>Conclusuons: The combination of these techniques has potential to be effective for the cochlear   implantation of such difficult cases.</p>\r\n<h4>KEYWORDS</h4>\r\n<p>Petrosectomy, Cochlear   implantation, Auditory canal, Post radical   mastoidectomy</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>Patients with profound hearing loss   are able to acquire the ability to hear   by receiving an operation to emplace   a cochlear implant, and this result in a   remarkable improvement in their quality   of life. As of this time, many patients have   enjoyed the benefits of this procedure.   For patients in which the middle and inner   ear present a normal form and in which   there is no pathological change to the   temporal bone, the classical facial recess   technique is usually used with extremely   few resultant complications. Previous   studies of the classic technique report   major complication rates of between   3.0 and 13.7% [<a href=\"#1\" title=\"1\">1</a>-<a href=\"#4\" title=\"4\">4</a>]. On the other hand,   there are quite a few difficult cases for   which classical facial recess technique for   cochlear implant cannot be employed. Fisch   et al. proposed subtotal petrosectomy in   1988, and five years after that Parnes et   al. employed this approach for the first   time in a difficult cochlear implant case.   This procedure involved a closure of the   external auditory canal (EAC) and the   Eustachian tube and obliteration of the   surgical cavity. Following this case, this   procedure became the standard cochlear   implant method used for difficult cases,   and this in turn has led to debate over the   usefulness and safety of the procedure   [<a href=\"#5\" title=\"5\">5</a>-<a href=\"#14\" title=\"14\">14</a>]. However, since the total number   of cases is small, the validity and safety   cannot be irrefutably established. Thus, it   is extremely important to ascertain the as   of yet hypothetical usefulness and safety   for patients undergoing such special   cases of cochlear implant procedures. In   this report we present our experiences   with seven such special cases of cochlear   implants. In this report we wish to   contribute further to the investigation   about the safety and suitability so that   even if only by a small amount more   patients with difficult cases can enjoy the   benefit of cochlear implant.</p>\r\n<h4>MATERIAL AND METHODS   PATIENTS</h4>\r\n<p>We did a retrospective analysis of seven   special cases of cochlear implantation   carried out in the Department of   Otorhinolaryngology at the Kanazawa   University Hospital between 2012   and 2016. The detailed breakdown of   the cases is as follows: Post radical   mastoidectomy -- 2 cases, Adhesive otitis   media -- 1 case, Eosinophilic otitis media   -- 2 cases, Temporal bone malformation   -- 2 cases (<strong>Table 1</strong>). For the two cases   of eosinophilic otitis media subtotal   petrosectomy, cochlear implantation,   and obliteration of the mastoid using   abdominal fat was carried out (<strong>Fig. 1</strong>).</p>\r\n<div class=\"table-responsive\">\r\n<table class=\"table table-sm table-bordered\">\r\n    <thead>\r\n        <tr>\r\n            <th>Patient</th>\r\n            <th>Age</th>\r\n            <th>Sex</th>\r\n            <th>Side</th>\r\n            <th>Etilogy</th>\r\n            <th>Operative procedure</th>\r\n            <th>Complications</th>\r\n            <th>Bleeding</th>\r\n            <th>Implant</th>\r\n            <th>Electrode outside cochlear</th>\r\n            <th>Hearing threshold before CI</th>\r\n            <th>Hearing threshold after    CI</th>\r\n            <th>Speech preception (CI2004)</th>\r\n            <th>Follow up</th>\r\n        </tr>\r\n    </thead>\r\n    <tbody>\r\n        <tr>\r\n            <td>1</td>\r\n            <td>69</td>\r\n            <td>F</td>\r\n            <td>Lt</td>\r\n            <td>Redical cavity</td>\r\n            <td>Simple    suture of EAC Canal    wall<br />\r\n            mastoidectomy closure<br />\r\n            of the eustachian tube</td>\r\n            <td>Suture failuer of EAC</td>\r\n            <td>100 ml</td>\r\n            <td>&nbsp;           Cochlear CI24</td>\r\n            <td>0/22</td>\r\n            <td>105dB</td>\r\n            <td>30dB</td>\r\n            <td>Word 48% Sentense 61%</td>\r\n            <td>45M</td>\r\n        </tr>\r\n        <tr>\r\n            <td>2</td>\r\n            <td>72</td>\r\n            <td>M</td>\r\n            <td>Rt</td>\r\n            <td>Redical cavity</td>\r\n            <td>Blind sac closure to EAC    Canal wall down    mastoidectomy<br />\r\n            middle ear and mastoid obliteration by abdominal fat closure of<br />\r\n            the eustachian tube</td>\r\n            <td>No</td>\r\n            <td>&lt;5 ml</td>\r\n            <td>Cochlear CI24</td>\r\n            <td>0/22</td>\r\n            <td>105dB</td>\r\n            <td>28dB</td>\r\n            <td>Word 60% Sentense 40%</td>\r\n            <td>31M</td>\r\n        </tr>\r\n        <tr>\r\n            <td>3</td>\r\n            <td>79</td>\r\n            <td>M</td>\r\n            <td>Lt</td>\r\n            <td>atelectasis</td>\r\n            <td>Subtotal petrosectomy blind sac closure of EAC middle ear and mastoid obliteration by abdominal    fat closure of the eustachian tube</td>\r\n            <td>No</td>\r\n            <td>&lt;5 ml</td>\r\n            <td>Cochlear CI24</td>\r\n            <td>0/22</td>\r\n            <td>103.8dB</td>\r\n            <td>25dB</td>\r\n            <td>Word 64% Sentense 71%</td>\r\n            <td>21M</td>\r\n        </tr>\r\n        <tr>\r\n            <td>4</td>\r\n            <td>64</td>\r\n            <td>M</td>\r\n            <td>Lt</td>\r\n            <td>Eosinophilic otitis media</td>\r\n            <td>Subtotal petrosectomy blind sac closure of EAC middle ear and mastoid obliteration by abdominal    fat closure of the eustachian tube</td>\r\n            <td>No</td>\r\n            <td>170 ml</td>\r\n            <td>Cochlear CI24</td>\r\n            <td>0/22</td>\r\n            <td>105dB</td>\r\n            <td>30dB</td>\r\n            <td>Word 96% Sentense 91%</td>\r\n            <td>31M</td>\r\n        </tr>\r\n        <tr>\r\n            <td>5</td>\r\n            <td>71</td>\r\n            <td>M</td>\r\n            <td>Rt</td>\r\n            <td>Eosinophilic otitis media</td>\r\n            <td>Subtotal petrosectomy blind sac closure of EAC middle ear and mastoid obliteration by abdominal    fat closure of the eustachian tube</td>\r\n            <td>No</td>\r\n            <td>50 ml</td>\r\n            <td>Cochlear CI24</td>\r\n            <td>0/22</td>\r\n            <td>102.5dB</td>\r\n            <td>34dB</td>\r\n            <td>Word 60% Sentense 71%</td>\r\n            <td>18M</td>\r\n        </tr>\r\n        <tr>\r\n            <td height=\"103\">6</td>\r\n            <td>9</td>\r\n            <td>M</td>\r\n            <td>Lt</td>\r\n            <td>Inner ear Malformation</td>\r\n            <td>Blind sac closure of EAC Canal wall down mastoidectomy</td>\r\n            <td>No</td>\r\n            <td>50 ml</td>\r\n            <td>Cochlear CI24</td>\r\n            <td>0/22</td>\r\n            <td>105dB</td>\r\n            <td>35dB</td>\r\n            <td>Word 0% Sentense 0%</td>\r\n            <td>57M</td>\r\n        </tr>\r\n        <tr>\r\n            <td>7</td>\r\n            <td>41</td>\r\n            <td>M</td>\r\n            <td>Rt</td>\r\n            <td>Inner ear Malformation</td>\r\n            <td>Blind sac closure of EAC Canal wall down mastoidectomy</td>\r\n            <td>No</td>\r\n            <td>&lt;5 ml</td>\r\n            <td>Cochlear CI24</td>\r\n            <td>0/22</td>\r\n            <td>97.5dB</td>\r\n            <td>30dB</td>\r\n            <td>Word 2% Sentense 100%</td>\r\n            <td>52M</td>\r\n        </tr>\r\n    </tbody>\r\n</table>\r\n</div>\r\n<p><strong>Table 1.</strong> Summary of seven special cases.</p>\r\n<p>For one of the two cases of post radical   mastoidectomy closure of the external   auditory canal using blind sac closure,   cochlear implantation, and obliteration   of the mastoid using abdominal fat were   carried out (<strong>Fig. 2</strong>). For the other case of   Post radical mastoidectomy, the external   auditory canal was closed, but blind sac   closure was not used. Mastoid obliteration   was also not performed. For a case of   Adhesive otitis media, canal wall down   mastoidectomy, cochlear implantation, and mastoid obliteration using abdominal   fat were carried out. For the two cases of   Temporal bone malformation, closure of   the external auditory canal using blind sac   closure, canal wall down mastoidectomy   and cochlear implantation were carried out. Obliteration of the mastoid was   not carried out. Complications, hearing   threshold results, word recognition, and   bleeding were the four items analyzed   in these seven cases. Permission for this   retrospective study was obtained from   the Kanazawa University Hospital, the   local Ethics Committee approved the   study protocol. Informed written consent   was obtained from all patients.</p>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\" height=\"103\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-patient-13-1-1-g001.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-patient-13-1-1-g001.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-patient\" title=\"canadian-hearing-report-patient\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig 1.</strong> Left ear of patient 4 after subtotal petrosectomy. A good field of view and ample working space was ensured.</p>\r\n</div>\r\n</div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Postoperative-13-1-1-g002.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Postoperative-13-1-1-g002.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Postoperative\" title=\"canadian-hearing-report-Postoperative\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig 2.</strong> Postoperative CT scan of Patient 2 (right ear).</p>\r\n</div>\r\n</div>\r\n</div>\r\n<h4>RESULTS</h4>\r\n<p>The average period of observation was   36.4 months. Six of the patients were   male, and one was female. Patient age   ranged from nine to 79 years with and   average age of 57.9. All of the surgical   techniques employed in each case were   carried out as one combined operation.   For all of the cases cochlear implantation   was performed using Cochlear CI24 with   zero electrodes outside of the cochlear.   For one of the cases of Post radical   mastoidectomy the patient suffered a   breakdown of the EAC closure. In this   case ear discharge continued for three   months following the procedure, but this   complication disappeared with the EAC   finally closing again naturally. In this case   blind sac closure was not performed   and the middle ear and the mastoid   were not obliterated. There were no   complications in any of the other cases.   Hearing threshold results following the   procedures ranged from 25 to 35dB with   an average of 30.3dB. Word recognition   results were 0 to 96% with an average   of 60% in the case of words, and 0 to   100% with an average of 62% in the case   of sentences. The volume of blood loss varied between less than 5 mL and 170   mL. Blood transfusion was not required in   any of the cases.</p>\r\n<h4>DISCUSSION</h4>\r\n<p>We have used the &quot;Subtotal petrosectomy&quot;   or &quot;Canal wall down mastoidectomy&quot;   technique to approach for kinds of difficult   cases related to cochlear implantation.   A detailed discussion of the cochlear   implant technique as it was applied in   each of these four clinical states follows.</p>\r\n<h4>EARS AFTER RADICAL   MASTOIDECTOMY</h4>\r\n<p>Of the two cases of ears following radical   mastoidectomy in this study, there was   a suture failure of the EAC in the first   case. In this case we didn\'t use the blind   sac closure technique when suturing the   EAC. Furthermore, obliteration of the   mastoid was not carried out. Since the   diameter of the EAC following radical   mastoidectomy is larger as compared to   that of a normal EAC, a simple suturing   of the EAC may lead to imperfect closure.   Fisch considered the EAC suturing using   blind sac closure to be a safe, effective   procedure [<a href=\"#15\" title=\"15\">15</a>]. It is also an advisable   application when carrying out cochlear   implantations in radical cavities. In the   second case, the lateral semicircular   canal in the right ear had been destroyed   in a previous operation. Prior to this   operation a caloric test was conducted   and CP (canal paresis) was pointed out.   Due to this and in order to preserve   vestibular function, an operation was   carried out on the previously destroyed   lateral semicircular canal in the right ear.   The period of hearing loss in the right ear   had been long, but following the operation   an improvement in the hearing level of up   to 25dB was attained. The canal paresis   on the right side caused a remarkable   reduction in the patient\'s QOL. Therefore,   despite the long period of hearing loss, it   is recommended to proceed with caution.</p>\r\n<h4>ADHESIVE OTITIS MEDIA</h4>\r\n<p>Xenellis et al. reported about cochlear   implantations for four patients who were   suffering from adhesive otitis media.   They concluded that Blind-sac closure   of the external auditory canal without   obliteration is a rather safe surgical   procedure in cases with atelectasis, and   a 2-stage procedure may not always   be necessary and indeed might best be   limited to those patients who have active   inflammatory disease at the time of   the primary procedure [<a href=\"#16\" title=\"16\">16</a>]. The cases   that we dealt with in this study had no   inflammation, so the operations were   carried out as single, comprehensive   procedures. There were no complications   in these cases. The difference between   our cases and those reported by Xenellis   et al. was as concerns the inclusion of   Mastoid obliteration. We perform mastoid   obliteration to prevent hemorrhage   effusion and prevent infection in the   post-operative dead space. However, we   believe that the most important purpose   of mastoid obliteration is to counter   post-operative spinal fluid leakage. It is   not necessarily always required to take   these precautions in cases of adhesive   otitis media in which these risks are not   present. In order to determine which is best, more reports from further cases are   required. In the cases related to this study   a caloric test was carried out, the absence   of canal paresis was confirmed, and the   operative side was selected. Similar to   the cases of mastoidectomy, we feel that   consideration of the vestibular function in   cases of adhesive otitis media is important   for selecting the operative side.</p>\r\n<h4>EOSINOPHILIC OTITIS MEDIA</h4>\r\n<p>In this study there were two cases   of eosinophilic otitis media for which   cochlear implantation was performed.   The surgical procedure was a subtotal   petrosectomy. The concepts of the   surgery consist of the following two   points: (i) Removal of mucosa from the   middle ear and the mastoid cavity as   completely as possible in order to remove   the theater of eosinophilic infiltration;   (ii) Closure of the Eustachian tube and   the external auditory canal in order to   prevent leaching of foreign substances   and entry of stimuli which are the cause   of eosinophilic inflammations. There   were no complications or recurrent   inflammation following surgery in the   cases of both patients. Following the   procedure, the hearing threshold results   of the two patients were 30dB and 34dB   [<a href=\"#17\" title=\"17\">17</a>]. This is the first discussion focusing   on cochlear implantations for cases   of eosinophilic otitis media. To further   confirm the efficacy and safety of our   surgical concept, we need to administer   this treatment concept for a larger   number of cases in a future study.</p>\r\n<h4>TEMPORAL BONE MALFORMATION</h4>\r\n<p>As for the cases of temporal bone   malformation, because the anatomical   landmark cannot be trusted, the   identification of the place to open the   cochlea is problematic. Furthermore, in   cases of temporal bone malformation   it has been reported that carrying   out the cochleostomy can result in   gushers. Therefore, for temporal bone   malformation cases we feel it is critical to   ensure that there is a good operative field   of view and ample working space. Canal   wall down mastoidectomy technique   resolves these two problems. Mistakes in   the location for opening the cochlea are   reduced. What\'s more, the measures for   dealing with gushers become much easier.</p>\r\n<p>In the first temporal bone malformation   case in this study, the first operation   employed was a classical facial recess   technique. However, due to a traveling   abnormality of the facial nerve and a   deformity in the inner ear, we couldn\'t   identify the location to open the cochlea.   In the second operation a subtotal   petrosectomy was employed resulting   in a good operative field of view. Thus,   we could open the cochlea. Therefore,   we think that in cases of temporal   bone malformation this canal wall down   technique is extremely useful for cochlear   implantation.</p>\r\n<h4>SUBTOTAL PETROSECTOMY   AND CANAL WALL DOWN   MASTOIDECTOMY</h4>\r\n<p>Ensuring a good operative field and   ample working space are two common,   important points when performing   cochlear implantation for special cases.   Use of subtotal petrosectomy and canal   wall down mastoidectomy can overcome   difficulties related to these two points.   Also, closure of the Eustachian tube   and the EAC can isolate them from the   exterior preventing operation related   infection [<a href=\"#18\" title=\"18\">18</a>]. Thus we feel that for   special cases this is a useful procedure.</p>\r\n<h4>STAGED OPERATION</h4>\r\n<p>Linder et al. recommended a staged   operation for cases with the following   four conditions: 1. Suppurative and   continuously draining otitis media, 2.   Previous tympanomastoid surgeries   with &quot;unstable&quot; disease, 3. Extended   cholesteatomas, and 4. Previously   irradiated temporal bone [<a href=\"#14\" title=\"14\">14</a>]. We   regard this strategy as appropriate. For   the cases in this study none of these   four conditions applied. Thus, a single   operation was selected. There were no   severe complications.</p>\r\n<h4>MASTOID OBLITERATION</h4>\r\n<p>Whether or not to employ mastoid   obliteration is an essential topic that must   be discussed. In cases where mastoid   obliteration is employed, the choice of the   obliterating materials is also an important   issue. We feel that it is necessary to fill   the mastoid space in cases for which   post-operative inflammation is possible.   We especially feel that in cases in which dura mater is exposed or in which   there is CSF leakage, filling the mastoid   space is necessary. Following radical   mastoidectomy, eosinophilic otitis media,   and adhesive otitis media, amongst   other conditions, it is favorable to fill the   mastoid space to prevent inflammation   caused by exuded liquid or blood. On   the other hand, in cases such as temporal   bone malformation in which there has   been no inflammation and the dura   mater or CSF leakage is not occurring,   filling the mastoid space is not necessary.   Previous reports indicate that for blood   flow in the temporal muscle, abdominal   fat is the filling material used. Hellingman   suggests that the most suitable material   to obliterate the cavity appears to be   abdominal fat because of its resistance   to necrosis and easy removal if cochlear   implantation is performed later. On the   other hand, Fisch et al. propose that, after   subtotal petrosectomy, if dura mater   exposure or CSF leakage are involved   and there is inflammation, then the   temporal muscle with blood flow or the   sternocleidomastoid muscle should be   adopted [<a href=\"#15\" title=\"15\">15</a>]. For our cases in this study   there was no exposure of dura mater   nor was there any CSF leakage involved,   so abdominal fat was adopted as the   filling material, and there were no postoperative   complications.</p>\r\n<h4>VESTIBULAR FUNCTION</h4>\r\n<p>When selecting on which side to perform   the procedure, evaluation of the vestibular   function is essential. Especially in cases of   Radical cavity or ears following inner ear   procedures, it is necessary to administer   the caloric test and confirm the presence   or absence of paralysis of the semicircular   canal. Bilateral loss of vestibular function   is a complication that must be avoided,   and we believe this takes priority over   post-operative hearing acquisition. We   think that compared to more mainstream   cases, cochlear implantation following   radical mastoidectomies and other   special cases can result in a higher risk of   deterioration of vestibular function, so as   much as possible it is necessary to make   pre-operative evaluations.</p>\r\n<h4>CONCLUSION</h4>\r\n<p>We have performed cochlear   implantations in cases of Radical cavity Adhesive otitis media?Eosinophilic otitis   media, and Temporal bone malformation.   For all of the cases subtotal petrosectomy   or canal wall down mastoidectomy was   applied. We also added the &quot;Blind sac   closure of EAC&quot; and &quot;Middle ear and   mastoid Obliteration by abdominal fat&quot;   technique as necessary. As a result of the   combination of these methods, a good   field of view and ample working space   were ensured. Except for EAC breakdown,   there were no complications. Hearing   threshold results and word recognition   were markedly improved following the   operation, and blood loss volume was   extremely small. In the future we hope   to increase the number of patients with   special cases who will receive the benefits   of this cochlear implant method.</p>\r\n<h4>REFERENCES</h4>\r\n<ol>\r\n    <li id=\"Reference_Title_Link\" value=\"1\"><a name=\"1\" id=\"1\"></a><a href=\"https://doi.org/10.1017/s002221510014602x\" target=\"_blank\">Proops DW, Stoddart  RL, Donaldson I (1999) Medical, surgical and audiological complications of the  first 100 adult cochlear implant patients in Birmingham. The Journal of  Laryngology &amp; Otologyy 113: 14-17.</a></li>\r\n    <li id=\"Reference_Title_Link\" value=\"2\"><a name=\"2\" id=\"2\"></a><a href=\"https://www.ncbi.nlm.nih.gov/pubmed/7668733\" target=\"_blank\">Hoffman RA, Cohen  NL (1995) Complications of cochlear implant surgery. The Annals of otology,  rhinology &amp; laryngology. Supplement 166: 420- 422.</a></li>\r\n    <li id=\"Reference_Title_Link\" value=\"3\"><a name=\"3\" id=\"3\"></a><a href=\"https://doi.org/10.1017/s0022215100137235\" target=\"_blank\">Collins MM,  Hawthorne MH, El-Hmd K (1997) Cochlear implantation in a district general  hospital: problems and complications in the first five years.The Journal of  Laryngology &amp; Otology 111: 325-332.</a></li>\r\n    <li id=\"Reference_Title_Link\" value=\"4\"><a name=\"4\" id=\"4\"></a><a href=\"https://doi.org/10.1159/000058982\" target=\"_blank\">Aschendorff A, Marangos N,  Laszig R (1997) Complications and reimplantation. Advances in  Oto-Rhino-Laryngology 52: 167-170.</a></li>\r\n    <li id=\"Reference_Title_Link\" value=\"5\"><a name=\"5\" id=\"5\"></a><a href=\"https://doi.org/10.1007/s00405-008-0828-0\" target=\"_blank\">Hellingman CA,  Dunnebier EA (2009) Cochlear implantation in patients with acute or chronic  middle ear infectious disease: a review of the literature. European Archives of  Oto-Rhino- Laryngology 266: 171-176</a></li>\r\n    <li id=\"Reference_Title_Link\" value=\"6\"><a name=\"6\" id=\"6\"></a><a href=\"https://doi.org/10.1097/mao.0b013e3182a006b6\" target=\"_blank\">Baranano CF,  Kopelovich JC, Dunn CC, Gantz BJ, Hansen MR (2013) Subtotal petrosectomy and  mastoid obliteration in adult and pediatric cochlear implant recipients.  Otology &amp; Neurotology 34: 1656-1659.</a></li>\r\n    <li id=\"Reference_Title_Link\" value=\"7\"><a name=\"7\" id=\"7\"></a><a href=\"https://doi.org/10.1007/s00405-004-0907-9\" target=\"_blank\">Basavaraj S, Shanks  M, Sivaji N, Allen AA (2005) Cochlear implantation and management of chronic  suppurative otitis media: single stage procedure?. European Archives of  Oto-Rhino- Laryngology 262: 852-855.</a></li>\r\n    <li id=\"Reference_Title_Link\" value=\"8\"><a name=\"8\" id=\"8\"></a><a href=\"https://doi.org/10.1067/mhn.2002.129822\" target=\"_blank\">Pasanisi E, Vincenti  V, Bacciu A, Guida M, Berghenti T et al. (2002) Multichannel cochlear  implantation in radical mastoidectomy cavities. Otolaryngology-Head and Neck  Surgery 127: 432-436.</a></li>\r\n    <li id=\"Reference_Title_Link\" value=\"9\"><a name=\"9\" id=\"9\"></a><a href=\"https://doi.org/10.1159/000422560\" target=\"_blank\">Babighian, G (1993) Problems  in cochlear implant surgery.Advances in Oto-Rhino-Laryngology, 48: 65-69.</a></li>\r\n    <li id=\"Reference_Title_Link\" value=\"10\"><a name=\"10\" id=\"10\"></a><a href=\"https://doi.org/10.1017/s0022215100136977\" target=\"_blank\">Axon PR, Mawman DJ,  Upile T, Ramsden RT (1997) Cochlear implantation in the presence of chronic  suppurative otitis media. The Journal of Laryngology &amp; Otology 111: 228-232</a></li>\r\n    <li id=\"Reference_Title_Link\" value=\"11\"><a name=\"11\" id=\"11\"></a><a href=\"https://doi.org/10.1097/01.mao.0000265187.45216.71\" target=\"_blank\">Leung, R,  Briggs RJ (2007) Indications for and outcomes of mastoid obliteration in  cochlear implantation. Otology &amp; Neurotology 28: 330- 334.</a></li>\r\n    <li id=\"Reference_Title_Link\" value=\"12\"><a name=\"12\" id=\"12\"></a><a href=\"https://doi.org/10.1055/s-2008-1058571\" target=\"_blank\">Issing PR, Schonermark  MP,Winkelmann S, Kempf HG, Ernst A (1998) Cochlear implantation in patients  with chronic otitis: indications for subtotal petrosectomy and obliteration of  the middle ear. Skull base surgery 8: 127-131</a></li>\r\n    <li id=\"Reference_Title_Link\" value=\"13\"><a name=\"13\" id=\"13\"></a><a href=\"https://doi.org/10.1177/0003489415620427\" target=\"_blank\">Polo R, Del Mar  Medina M, Ar&iacute;stegui M, Lassaletta L, Gutierrez A, et al. (2015) Subtotal  Petrosectomy for Cochlear Implantation: Lessons Learned After 110 Cases. The  Annals of otology, rhinology, and laryngology 25: 485- 494</a></li>\r\n    <li id=\"Reference_Title_Link\" value=\"14\"><a name=\"14\" id=\"14\"></a><a href=\"https://doi.org/10.1007/s00405-015-3573-1\" target=\"_blank\">Szymanski M, Ataide  A, Linder T (2016) The use of subtotal petrosectomy in cochlear implant  candidates with chronic otitis media. European archives of oto-rhino-laryngology  273: 363- 370.</a></li>\r\n    <li id=\"Reference_Title_Link\" value=\"15\"><a name=\"15\" id=\"15\"></a>Fisch U, Mattox, D (1998) Microsurgery of the skull base.Thieme.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"16\"><a name=\"16\" id=\"16\"></a><a href=\"https://doi.org/10.1097/mao.0b013e31816a8986\" target=\"_blank\">Xenellis J,  Nikolopoulos TP, Marangoudakis P, Vlastarakos PV, Tsangaroulakis A, et al.  (2008) Cochlear implantation in atelectasis and chronic otitis media: long-term  follow-up.&quot; Otology &amp; neurotology 29: 499-501</a></li>\r\n    <li id=\"Reference_Title_Link\" value=\"17\"><a name=\"17\" id=\"17\"></a><a href=\"https://doi.org/10.1007/s00405-016-4091-5\" target=\"_blank\">Sugimoto H, Hatano  M, Noda M, Hasegawa H, Yoshizaki T (2016) Cochlear implantation in deaf  patients with eosinophilic otitis media using subtotal petrosectomy and mastoid  obliteration. European archives of oto-rhino-laryngology 274: 1173-1177.</a></li>\r\n    <li id=\"Reference_Title_Link\" value=\"18\"><a name=\"18\" id=\"18\"></a><a href=\"https://doi.org/10.1177/0003489415620427\" target=\"_blank\">Polo R, Del Mar Medina M,  Ar&iacute;stegui M, Lassaletta L, Gutierrez A, et al. (2015) Subtotal Petrosectomy for  Cochlear Implantation: Lessons Learned After 110 Cases. The Annals of otology,  rhinology, and laryngology 125 (2015): 485-494.</a></li>\r\n</ol>\r\n<h4>Central Vestibular Compensation</h4>\r\n<p><strong>Madalina Georgescu<sup><a href=\"#corr\">*</a></sup></strong></p>\r\n<p>University of Medicine and Pharmacy &lsquo;Carol Davila&rsquo; Bucharest, Romania</p>\r\n<p>*madalina.georgescu@gecad.com</p>\r\n<h4>ABSTRACT</h4>\r\n<p>Vestibular system is one of the three sensorial systems involved in equilibrium. Any lesion at this level has   consequences on quality of life, in terms of dizziness and/or disequilibrium or ataxia. Unilateral vestibular   loss (UVL) represents a stable permanent peripheral vestibular lesion with long-term effects and symptoms.   These symptoms are caused by lower than normal gains of vestibulo ocular and vestibulospinal   reflexes secondary to UVL. Central vestibular compensation is a natural healing model for UVL, based on   the neuroplasticity of the central vestibular structures. It is a long-lasting and incomplete phenomenon,   but it enables a comfortable daily life. It can be accelerated and enlarged by customised vestibular rehabilitation   programmes and appropriate drug treatment..</p>\r\n<h4>KEYWORDS</h4>\r\n<p>Unilateral vestibular   loss, Central vestibular compensation,   Neuroplasticity, Vestibular rehabilitation</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>Equilibrium is essential for normal daily   life. It allows normal walking, performing   basic activities (housekeeping, grocery,   and working) without risk of fall and   injury. Three sensorial systems are   involved in this process, a real network   based on normal sensorial input and good   matching in between the information:</p>\r\n<p>somatosensorial, visual and vestibular   system. Disequilibrium worsen the   health-related quality of life (HRQoL)   with a negative impact on their social   life and work performance, leading not   only to psychological damage (low selfconfidence,   depression, frustration), but   also economic losses (long medical leave,   poor concentration, and performance).</p>\r\n<p>Briefly, from anatomical point of view, it   is important to know that the peripheral   vestibular system includes five sensorial   structures for each inner ear, three   ampullary cristae and two maculae. The   ampullary crista is located in the ampule   of each semi-circular canal (horizontal,   superior and posterior) and senses   angular movements of head or body   due to their position-perpendicular one   to each other, so in all directions of the   three-dimensional space we are living   in. The maculae are located one in the   utricle and one in the saccule and senses linear movements due to the otolithic   membrane which increases specific   weight of the maculae, compared with   endolymph density (<strong>fig. 1</strong>).</p>\r\n<p>From these sensorial structures,   information is transmitted in the   vestibular nerve in a very specific   manner &ndash; horizontal and superior semicircular   canals ampullary cristae and   utricular macula are connected to the   superior vestibular nerve and posterior   semi-circular canal ampullary crista and   saccular macula are connected to the   inferior vestibular nerve (<strong>fig. 2</strong>).</p>\r\n<p>Vestibular nuclei are made up of a group   of neurons placed on the floor of the   IV ventricle, laterally bounded by the   restiform body, ventrally by the nucleus   and spinal tract of the trigeminal nerve,   and medially by the pontine reticular   substance. From the anatomical point   of view, four groups of neurons can be   identified: medial, lateral, superior and   inferior. Although there is overlapping,   most of the fibers in the utricle and   saccule reach the lateral and inferior   nuclei, and most of the fibers coming from   the semi-circular canals reach the upper   and middle nuclei.</p>\r\n<p>Vestibular nuclei receive information from the cerebellum, spinal cord, and adjacent   reticular substance, in addition to the   information received from the vestibular   afferent fibers projections. Also, there   are many commissural fibers linking the   two groups of vestibular nuclei (right and   left). Based on the combined connections   between afferent and afferent fibers, the   lateral and inferior vestibular nuclei are   important linking stations in vestibulospinal   reflex control, while upper and   middle nuclei are critical stations in the   control of vestibulo ocular reflexes (<strong>fig. 3</strong>).</p>\r\n<p>Vestibular system is anatomically   developed at birth, but it gets functional in   the child&rsquo;s first year of life. While getting   control on his neck muscles, crawling,   standing, and walking, vestibular cortex   develops reaction patterns specific to   each movement activity. Based on these   patterns, equilibrium is a subconscious   process as long as vestibular system works   normally and sense motion of head and   body and uses this information to control   movement and posture. This is based on   rest discharging rate from vestibular hair   cells and changes in firing rate secondary   to rotations which stimulates the inner towards the movement is performed and   inhibits the other ear (<strong>fig. 4</strong>).</p>\r\n<p>Vestibular lesions impede on this   normal reaction and patients experience   disequilibrium, vertigo or dizziness. Loss   of peripheral vestibular function induces   an asymmetry in vestibular sensorial   discharge (lesion in the inner ear) or in   vestibular ganglia cells activity (in neural   lesions). This asymmetry reaching the   vestibular nuclei level is interpreted   as a rotation towards the part with   higher activity, so vertigo sensation and   accompanying nystagmus appears.   In unilateral vestibular lesions (UVL)   a central process becomes available   &ndash; central compensation, which aims   regaining symmetry between the two   vestibular pathways.</p>\r\n<p>Vestibular system ensures equilibrium   by two different reflexes-vestibulocular   and vestibulospinal reflex which enables   an oculomotor effect (stable image   on the retina while movement), a   postural effect (head aligned with   body, vertical stance, and walking) and   also an appropriate cortical perception   (verticality, orientation in space). All these   three have to be taken into account when   assessing a vestibular lesion, because when   vestibular pathways become imbalanced,   they do not react fully to head, or body   movements and pathological symptoms   related to all three effects should be   addressed in management of UVL.</p>\r\n<p>There are three main categories of UVLstable   deficit (like vestibular neuritis),   fluctuant deficit (like in Meni&egrave;re disease)   and slowly progressive deficit (like in vestibular schwannoma/acoustic   neurinoma).</p>\r\n<p>Central vestibular compensation process   acts only in stable deficits with sudden   onset or progressive course and it is   visible and very important for recovery   in sudden UVL with total vestibular   impairment (complete vestibular neuritis,   for example). Fluctuant vestibular function   cannot trigger central compensation   because or irregular error signals coming   from the affected ear (Meni&egrave;re disease   or vestibular paroxismia). ENTE UVL   leads to two main different categories   of impairments: static and dynamic   vestibular deficit.</p>\r\n<p>Static deficits are present from the   very beginning of the lesion onset   due to asymmetry in vestibular nuclei   activity, are very severe as symptoms and   characteristic signs are present without   any head or body movement. They   resume completely at most in one week.   Static deficit signs are:</p>\r\n<p>&bull; Oculomotor reaction &ndash; spontaneous   nystagmus, skew-deviation (vertical   misalignment of the eyes).</p>\r\n<p>&bull; Postural reactions &ndash; postural asymmetry   (head and/or body tilt), ocular-tilt reaction   (<strong>fig. 5</strong>) (OTR=skew-deviation, head tilt   and ocular torsion), severe imbalance.</p>\r\n<p>&bull; Perception signs &ndash; vertigo, subjective   vertical deviation.</p>\r\n<p>Dynamic deficits appear due to   changings in the vestibular reflexes gain and   are present only during head movements.   Their highest degree of severity is at   one week after the UVL onset, but they last for longer periods (one year) and   might never by fully compensated in   the recovery process. For example, high   frequency movements of the head (over   2Hz) might always induce dizziness and   disequilibrium. Head-shaking induced   nystagmus is used to assess long-term   level of recovery of the UVL.</p>\r\n<p>Dynamic deficit signs are present from all   three vestibular effects mentioned:</p>\r\n<p>&bull; Oculomotor signs &ndash; diminished   vestibulocular reflex induces limitations   in head&rsquo;s velocity movements due to   movement-induced visual disturbances   and secondary dizziness.</p>\r\n<p>&bull; Postural signs &ndash; decreased gain of   vestibulospinal reflex leads to weaker   balance skills, ataxia, and gait disturbances   which all induce behavioural changes in   order to minimise the risk of fall: stance   becomes conscious, a voluntary act,   patients are more cautious while moving   and former daily activities like running,   jumping, high heights activity, sports in   general are limited.</p>\r\n<p>&bull; Perception signs of vestibular dynamic   deficit might include spatial disorientation,   oculo-gravitational illusions (objects   are tilted, corners appear rounded) or   incorrect perception of acceleration   (patients develop motion sickness).</p>\r\n<p>All these dynamic deficits lead to avoidance   behaviour to sudden or challenging   movements, difficulties in tender, subtle   or complex motor activities.</p>\r\n<p>Vestibular compensation, known as   central compensation is a central   nervous system process for physiological   healing after a vestibular deficit, aiming   to reinforce symmetry in vestibular pathways&rsquo; tone and to readjust the gain of   vestibular reflexes in order to equal gain   1, as in healthy persons. Of course, any   lesion of the central vestibular structures   involved in central compensation process   (vestibular nuclei, thalamus, limbic system,   vestibular cortical areas, or cerebellum)   impairs recovery of the UVL [<a href=\"#11\" title=\"1\">1</a>-<a href=\"#3\" title=\"3\">3</a>]. For this   reason, central vestibular compensation   research focussed mainly on peripheral   vestibular lesions.</p>\r\n<p>Vestibular central compensation is a   model of neuroplasticity phenomena   which allows spontaneous recovery   after a UVL (<strong>fig. 6</strong>). In complete unilateral   vestibular deficit, central compensation   is a long-lasting process (over three   month), imperfect and incomplete (high   acceleration or velocity head movements   are not always compensated). This natural   recovery process can be improved and   accelerated by vestibular rehabilitation   programmes and appropriate drug   treatment.</p>\r\n<p>In sudden UVL, the following changes   occur in the vestibular pathway [<a href=\"#4\" title=\"4\">4</a>-<a href=\"#9\" title=\"9\">9</a>]:</p>\r\n<p>A. High asymmetry between the two   vestibular nuclei complex in the acute   phase due to:</p>\r\n<p>a. Inactivity on the lesion side.</p>\r\n<p>b. Increased resting discharge rate on the   contralateral side due to lack of inhibitory   feedback from the injures side through   the flocculus (commissural inhibitory   inputs are removed by the UVL) [<a href=\"#10\" title=\"10\">10</a>,<a href=\"#11\" title=\"11\">11</a>].</p>\r\n<p>B. Regaining symmetry in vestibular nuclei   resting discharge by:</p>\r\n<p>a. Regeneration of a new basic discharge   on the lesion side through various   mechanisms [<a href=\"#12\" title=\"12\">12</a>,<a href=\"#13\" title=\"13\">13</a>]:</p>\r\n<p>i. Opening of existing synapses in the   ipsilateral peripheral vestibular structures.</p>\r\n<p>ii. New sprouting in the peripheral   vestibular pathway.</p>\r\n<p>iii. Recovery and maintenance of the   medial vestibular nucleus spontaneous   activity on the lesion side in chronic stage   of the UVL by slowing down the inhibitory   cerebellar activity and activation of the   vestibular-hypothalamic-vestibular loop.</p>\r\n<p>iv. Adaptive changes in the sensitivity of   central vestibular neurons to inhibitory   neurotransmitters.</p>\r\n<p>v. Changes in the intrinsic cell membrane   properties of the vestibular nuclei   neurons.</p>\r\n<p>vi. Higher density receptors on vestibular   nuclei surface; both last two mechanisms   reflect the internal rebalancing of the   vestibular brainstem related to internal   feedback loops.</p>\r\n<p>vii. Inhibition of the resting discharge rate   in contralateral medial vestibular nucleus   during acute phase of sudden UVL   through high cerebellar inhibitory signals.</p>\r\n<p>The effect of central compensation   differs greatly between static and dynamic   symptoms. Static oculomotor, postural and   perception signs are rapidly and completely   compensated due to important recovery   of spontaneous resting firing rate in the   ipsilateral vestibular nuclei, denervation   hypersensitivity to vestibular input in the   vestibular nucleus and greater reliance on   commissures, deep cerebellar nuclei, and   inferior olive. This occurs immediately   after the acute onset of the UVL and for   this reason patients must move their head   as soon as possible and they must not stay   still in bed more than 2-3 days after the   onset of the vestibular lesion.</p>\r\n<p>Dynamic symptoms evolution is very   different-in significant much longer   period of time (one year, even) symptoms   compensate variably due to different   methods of compensation involved in   recovery and also because functional   changes occurs in cerebellum and   hippocampus, anatomical structures with   huge influence on central compensation   process. Recent studies showed   the importance of otolithic system in facilitating the central vestibular   compensation [<a href=\"#14\" title=\"14\">14</a>-<a href=\"#16\" title=\"16\">16</a>].</p>\r\n<p>The degree of central compensation   depends on the severity degree of stable   vestibular lesion, quantified by caloric,   head-impulse (HIT) and vestibular evoked   cervical myogenic potentials (cVEMP)   test. Caloric reflexivity and HIT allows   evaluation of the superior vestibular   nerve function and cVEMP of the inferior   vestibular nerve (<strong>fig. 7</strong>). Dynamic vestibular   symptoms are better compensated   (disappearance of head-shaking induced   nystagmus and of motion-induced   dizziness) when initial vestibular deficit is   smaller (lower caloric canal paresis and   lower asymmetry in cVEMP&rsquo;s amplitude).</p>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Sensorial-13-1-1-g008.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Sensorial-13-1-1-g008.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Sensorial\" title=\"canadian-hearing-report-Sensorial\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig. 1. </strong>Sensorial vestibular structures in the inner ear Encyclopedia Britannica.</p>\r\n</div>\r\n</div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Vestibular-13-1-1-g009.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Vestibular-13-1-1-g009.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Vestibular\" title=\"canadian-hearing-report-Vestibular\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig. 2.</strong> Vestibular nerve.</p>\r\n</div>\r\n</div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-nuclei-13-1-1-g0010.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-nuclei-13-1-1-g0010.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-nuclei\" title=\"canadian-hearing-report-nuclei\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig. 3. </strong>Vestibular nuclei.</p>\r\n</div>\r\n</div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Changes-13-1-1-g0011.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Changes-13-1-1-g0011.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Changes\" title=\"canadian-hearing-report-Changes\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig. 4. </strong>Changes in firing rate from hair cells in horizontal semi-circular canal (HSC).</p>\r\n</div>\r\n</div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Ocular-13-1-1-g0012.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Ocular-13-1-1-g0012.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Ocular\" title=\"canadian-hearing-report-Ocular\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig. 5. </strong>Ocular tilt reaction.</p>\r\n</div>\r\n</div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-compensation-13-1-1-g0013.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-compensation-13-1-1-g0013.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-compensation\" title=\"canadian-hearing-report-compensation\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig. 6. </strong>Central vestibular compensation (with Mylan Company permission).</p>\r\n</div>\r\n</div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Pathological-13-1-1-g0014.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Pathological-13-1-1-g0014.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Pathological\" title=\"canadian-hearing-report-Pathological\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p>Fig. 7. Pathological results in a patient with left complete UVL:<br />\r\na) 100% caloric paresis and right-beating spontaneous nystagmus.<br />\r\nb) positive HIT test on left ear - (gain&lt;0.7, &ldquo;overt&rdquo; and &ldquo;covert&rdquo; saccades).<br />\r\nc) absent cVEMP in left ear.</p>\r\n</div>\r\n</div>\r\n</div>\r\n<p>Recovery is best for low velocities and/   or accelerations, maybe due to saturation   phenomena or substitution strategies   used for regaining equilibrium [<a href=\"#17\" title=\"17\">17</a>-<a href=\"#20\" title=\"20\">20</a>].</p>\r\n<p>As previously mentioned, central   compensation of dynamic symptoms   involves multiple processes:</p>\r\n<p>&bull; Restoration of peripheral function.</p>\r\n<p>&bull; Compensatory readjustments of   brainstem vestibular processing.</p>\r\n<p>&bull; Sensorial substitution of the impaired   vestibular function by other sensorial systems (visual and somatosensorial) &ndash;   use of smooth pursuit instead of the nonfunctional   vestibulocular reflex (VOR), for   example.</p>\r\n<p>&bull; Functional substitution &ndash; use of   alternative strategies, with different   effectors than the damaged vestibular   ones: prediction, saccades instead of VOR   or extensive use of cervical inputs.</p>\r\n<p>&bull; Behavioural changes in order to minimise   vestibular challenges and demands.</p>\r\n<p>All above mentioned processes except   the first one (restoration of peripheral   function) acts competitively: all start   simultaneously and act redundantly but   using of one of them may eliminate the   need for others. This selection of main   central compensation process is one of   the explanations for variable outcomes   of the same process in different patients   &ndash; dependence on visual substitution   impedes upon somatosensorial   substitution mechanisms and vice versa.</p>\r\n<p>Customised vestibular rehabilitation   programmes might diminish this limit   of the natural recovery phenomena   [<a href=\"#21\" title=\"21\">21</a>-<a href=\"#25\" title=\"25\">25</a>], as well as specific drug therapy   [<a href=\"#26\" title=\"26\">26</a>]. The overall outcome of central   compensation process is also influenced   by its delay in action. There is a critical   period when neuroplasticity of the   vestibular central structures is highest   (first month after the acute injury) and   patients must take advantage of this timewindow   opportunity in order to trigger   early recovery mechanisms [<a href=\"#27\" title=\"27\">27</a>,<a href=\"#28\" title=\"28\">28</a>]. Lying   still in bed, stiffed neck movements and   vestibular suppressants should be limited   to three days at most, in order to manage   properly the UVL&rsquo;s long-term functional   symptoms.</p>\r\n<h4>CONCLUSION</h4>\r\n<p>Central compensation represents a   natural, physiologic healing process of   an acute unilateral vestibular loss. Its   benefit is greater if process starts early,   vestibular central structures are lesionfree,   substitution sensorial systems   (vision and somatosensorial) are normal   and early available. Customised vestibular   rehabilitation programmes and drugs   which facilitate specific neurotransmitters   discharge in vestibular pathway are   recommended in order to enhance,   enlarge and fulfil recovery of the dynamic   vestibular deficits.</p>\r\n<h4>REFERENCES</h4>\r\n<ol>\r\n    <li id=\"Reference_Title_Link\" value=\"1\"><a name=\"1\" id=\"1\"></a>de Waele C, Vidal PP, Tran Ba Huy P, Freyss G (1990) Vestibular compensation. Review of the  literature and clinical applications. Ann Otolaryngol Chir Cervicofac. 107: 285-98. PMID: 2221721.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"2\"><a name=\"2\" id=\"2\"></a>Lacour M (1989) Vestibular Compensation: Facts, Theories,  and Clinical Perspectives. Elsevier, Amsterdam.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"3\"><a name=\"3\" id=\"3\"></a>Pfaltz CR, Kamath R (1970) Central  compensation of  vestibular dysfunction-peripheral lesion. Pract  Otorhinolaryngol 32: 335-349. doi: 10.1159/000274957  PMID: 5313795.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"4\"><a name=\"4\" id=\"4\"></a>Markham CH, Yagi T, Curthoys IS (1977) The contribution of the contralateral labyrinth to second order vestibular  neural activity in the cat. Brain Res 138: 99-109. doi: 10.1016/0006- 8993(77)90786-7 PMID:  589471.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"5\"><a name=\"5\" id=\"5\"></a>Markham CH, Yagi T (1984) Brainstem  changes in vestibular  compensation. Acta Otol Suppl 406: 83-86. doi: 10.3109/00016488309123009 PMID: 6591718.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"6\"><a name=\"6\" id=\"6\"></a>Melvill Jones G  (1996) How and why does the vestibulo-ocular  reflex adapt? In: Baloh and Halmagyi (ed), Disorders of the Vestibular System, Oxford.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"7\"><a name=\"7\" id=\"7\"></a>Newlands SD, Perachio AA (1990) Compensation of horizontal canal related activity  in the medial vestibular nucleus following unilateral labyrinth ablation in the decerebrate gerbil. I. Type I neurons Exp Brain Res 82: 359- 372. doi : 10.1007/BF00231255 PMID: 2286238.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"8\"><a name=\"8\" id=\"8\"></a>Newlands SD, Perachio AA (1990) Compensation of horizontal canal related activity  in the medial vestibular nucleus following unilateral labyrinth ablation in the decerebrate gerbil. II. Type II neurons Exp Brain Res  82: 373- 383. doi: 10.1007/BF00231256 PMID: 2286239.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"9\"><a name=\"9\" id=\"9\"></a>Lacour M, Sterkers O. (2001) CNS drugs. 15: 853-570.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"10\"><a name=\"10\" id=\"10\"></a>Courjon JH, Flandrin JM, Jeannerod M, Schmid R (1982) The role of the flocculus in vestibular compensation  after hemilabyrinthectomy. Brain Res 239: 251-257. doi: 10.1016/0006- 8993(82)90847-2 PMID: 7093679</li>\r\n    <li id=\"Reference_Title_Link\" value=\"11\"><a name=\"11\" id=\"11\"></a>Llinas R, Walton K (1977) Significance of the olivo-cerebellar system in compensation of ocular position following  unilateral labyrinthectomy. In: Baker R, Berthoz A (Eds). Control of gaze by brainstem neurons pp 399-408.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"12\"><a name=\"12\" id=\"12\"></a>Darlington CL, Smith PF (2000) Molecular mechanisms of recovery from vestibular damage  in mammals: recent advances. Prog Neurobiol  62: 313-325. doi: 10.1016/S0301- 0082(00)00002-2 PMID: 10840152.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"13\"><a name=\"13\" id=\"13\"></a>Kitahara T, Takeda  N, Kiyama H, Kubo T</li>\r\n    <li id=\"Reference_Title_Link\" value=\"14\"><a name=\"14\" id=\"14\"></a>Allum JHJ, Yamane M, Pfaltz CR (1988) Long-term modifications of vertical and horizontal vestibulo-ocular reflex dynamics in man. Acta Otolaryngol 105: 328-337.  doi: 10.3109/00016488809097015 PMID: 3389119.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"15\"><a name=\"15\" id=\"15\"></a>Baloh RW,  Honrubia V, Yee RD, Hess K (1984) Changes in human vestibulo-ocular reflex after loss of  peripheral sensitivity. Ann Neurol 16: 222- 228. doi: 10.1002/ana.410160209 PMID: 6476793.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"16\"><a name=\"16\" id=\"16\"></a>McDonnell MN, Hillier SL (2015)  Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane  Database Syst Rev 17: CD005397. doi:  10.1002/14651858.CD005397 PMID: 25581507.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"17\"><a name=\"17\" id=\"17\"></a>Bronstein Am, Hood JD (1986) The  cervico- ocular reflex in normal subjects and patients with absent vestibular  function. Brain Res 373: 399-408. doi: 10.1016/0006-8993(86)90355-0 PMID: 3487371.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"18\"><a name=\"18\" id=\"18\"></a>Halmagyi GM, Curthoys IS, Cremer PD, Henderson  CJ, Todd MJ, et al. (1990) The human horizontal vestibulo-ocular reflex in response  to high-acceleration stimulation before and after unilateral vestibular neurectomy. Exp Brain Res 81: 479-490. doi:  10.1007/bf02423496 PMID: 2226683</li>\r\n    <li id=\"Reference_Title_Link\" value=\"19\"><a name=\"19\" id=\"19\"></a>Halmagyi M,  Curthoys I (1996) How does the brain  compensate for vestibular lesions? In: Baloh,  Halmagyi (editors), Disorders of the Vestibular System.  Oxford.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"20\"><a name=\"20\" id=\"20\"></a>Maioli C, Precht W (1983) On the  role of vestibulo-ocular reflex plasticity in recovery after  unilateral peripheral vestibular lesions. Exp  Brain Res 59: 267-272. doi:  10.1007/bf00230906 PMID: 3875498.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"21\"><a name=\"21\" id=\"21\"></a>Hall CD1, Herdman SJ, Whitney SL, Cass SP,  Clendaniel RA, et al. (2016) Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Evidence-Based Clinical Practice  Guideline. J Neurol Phys Ther 40: 124-155. doi: 10.1097/NPT.0000000000000120 PMID: 26913496.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"22\"><a name=\"22\" id=\"22\"></a>Georgescu M, Sorina S (2011) Vestibular neuronitis in pregnancy,  Gineco eu 7: 58-61.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"23\"><a name=\"23\" id=\"23\"></a>Georgescu Madalina, Stoian Sorina, Mogoan??  Carmen Aurelia, Ciubotaru Gh.V. Vestibulary rehabilitation &ndash; election treatment  method for compensating vestibular  impairment, Romanian Journal of  Morphology and Embryology 2012, 53 (3):651-656, ISSN (print) 1220-0522, ISSN (on- line) 2066-8279.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"24\"><a name=\"24\" id=\"24\"></a>Georgescu M (2017) Vestibular Rehabilitation &ndash; Recommended Treatment  for Permanent Unilateral Vestibular Loss, Int J Neurorehabilitation Eng 4: 4. doi: 10.4172/2376-0281.1000282.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"25\"><a name=\"25\" id=\"25\"></a>Herdman SJ (2014) Vestibular Rehabilitation 4th Edition.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"26\"><a name=\"26\" id=\"26\"></a>Smith PF,  Darlington CL, Curthoys IS (1986) Vestibular compensation without brainstem commissures in the guinea pig. Neurosci  Lett 65: 209-21. doi: 10.1016/0304-3940(86)90306-x PMID: 3487051.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"27\"><a name=\"27\" id=\"27\"></a>Smith PF,  Darlington CL, Curthoys IS (1986) The effect of visual deprivation in  vestibular compensation in the guinea pig. Brain Res 364: 195-198. doi: 10.1016/0006-8993(86)91004-8.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"28\"><a name=\"28\" id=\"28\"></a>Zee DS.  Vestibular Adaptation in Vestibular Rehabilitation. In: Herdman S (editor) F.A. Davis, 19.</li>\r\n</ol>\r\n<h4>Successful Cochlear Implantation under Local   Anesthesia and Sedation: A case Report</h4>\r\n<p><strong>Barbara Stanek, Bernhard Gradl, Astrid Magele, Georg Mathias Sprinzl<sup><a href=\"#corr\">*</a></sup></strong></p>\r\n<h4>ABSTRACT</h4>\r\n<p>With the increasing life expectancy, also the number of patients suffering from age-related severe to profound   hearing loss is rising. In the past Cochlear Implantation in elderly was performed with low expectations   in improved hearing performance and handled as a high risk intervention due to age related health   challenges. Latest studies showed that Cochlear Implantation is a safe procedure in elderly patients and   that this group of patients is able to benefit regarding speech perception and life quality. Usually hearing   device implantations are performed under general anesthesia, which may pose a restrictive factor for   surgery, especially in elderly patients presenting with comorbidities. The here presented case describes   how anesthesia may be circumvented by performing Cochlear Implantation under local anesthesia and   sedation. A 72-year old man presented himself with acute severe to profound sensorineural hearing loss   in his right ear, due to herpes zoster oticus. In addition he suffered from pre-existing deafness in his left   ear. No improvement in hearing and no benefit after trialing a conventional hearing aid for a period of six   months were noted. Further examinations revealed the patient to be a suitable candidate for Cochlear   Implantation in his right ear. Due to significant comorbidities, general anesthesia was contraindicated.   Thus surgery was performed under local anesthesia and sedation. The procedure was successfully performed   and no adverse events or surgical complications occurred. Cochlear Implantation under local   anesthesia and sedation may serve as a valuable option for patients not suitable for general anesthesia.</p>\r\n<h4>KEYWORDS</h4>\r\n<p>Cochlear implantation,   Elderly patients, Local anesthesia</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>Hearing loss is one of the most common   sensory impairments with the elderly   population being predominantly affected.   Depending on the degree of hearing loss,   many candidates can be successfully fitted   with hearing aids. Cochlear Implants   represent the current treatment for   patients of all ages affected by profound   sensorineural hearing loss in one or   both ears. For individuals with this type   of hearing loss, hearing aids provide   little or no benefit. Thus surgery has   been performed for more than 30 years   featuring a low rate of complications [<a href=\"#1\" title=\"1\">1</a>].   Due to the increasing life expectancy,   interest in hearing rehabilitation of   elderly patients has progressively risen   in the recent years. Demographic data   reports that in industrialized countries   the proportion of people over the age of   65 years will increase from 28% in 2015   to 40% in 2035 [<a href=\"#2\" title=\"2\">2</a>]. Age-related processes   within the Cochlear cause damage of   the inner hair cells followed by a low to   moderate hearing loss which may progress   into severe hearing loss up to deafness. In   cases where conventional hearing aids do   not achieve any improvement in hearing,   Cochlear Implantation poses a feasible   and safe treatment option. Unfortunately   in many elderly patients the decision of   hearing rehabilitation surgery is often   handled reluctantly as the risk of surgery   is deliberated against the benefits of   hearing gain. Additional reasons against   a Cochlear Implantation are possible   difficulties with the handling of the   audio processor as well as comorbidities   prohibiting general anesthesia. This paper   describes a case in which Cochlear   Implantation was performed under local   anesthesia and sedation in a 72 year old   male.</p>\r\n<h4>CASE REPORT</h4>\r\n<p>A 72-year-old male with herpes zoster   oticus with a vestibulocochlear lesion   and accompanying acute profound   sensorineural hearing loss and a   neuropathy vestibularis in the right ear   presented to our clinic. The patient   suffered from a right sided facial palsy   occurring a few days after his visit. The   left ear was diagnosed 20 years ago   with chronic recidivating otorrhea in   terms of otitis media chronica simplex   resulting in a deaf left ear. Further   anesthesia hindering co-morbidities were   coronary heart disease, left ventricular   dysfunction, COPD (chronic obstructive   pulmonary disease), diabetes mellitus,   essential hypertonia and dyslipidemia.   The audiogram showed a decline in bone   conduction thresholds on the right side   from 50dB HL at 250Hz to 80dB HL at   3000Hz with an air-bone gap of 10dB. On   the left side the air- and bone conduction threshold were 90dB HL to 110dB HL (<strong>Fig.     1</strong>). Monosyllabic intelligibility tests scored   10% at 95dB and 55% at 110dB on his right   ear and 0% at 110dB on his left ear (<strong>Fig.     2</strong>). Given the severity of his hearing loss,   communication of the patient was only   possible in written form. At that time the   patient was already suffering from social   exclusion and incipient depression. The   patient was administered to hospital and   received intravenously valaciclovir and   corticosteroids. Despite of six months   of treatment therapy no improvement in   hearing on his right ear was observed. The   patient was provided with a behind-theear   hearing aid, which did not generate   subjective nor audiological benefit. The   recognition of speech was 0% at 65dB   and 10% at 80dB with its best possible   setting. Thereupon the evaluation   regarding Cochlear Implantation   started: Computed Tomography of the   petrous bone conducted for previous   diagnosis purposes, further audiological   examinations, Magnetic Resonance   Tomography and a Vestibulometry were   initiated. The patient met the indication   criteria for Cochlear Implantation. Preoperative   multidisciplinary examinations   (echocardiography, pulmonary function,   ECG, internal survey) revealed that   general anesthesia was too risky due to   afore mentioned comorbidities. After   discussing the options with the patient,   it was decided to perform Cochlear   Implantation under local anesthesia.</p>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-operative-13-1-1-g003.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-operative-13-1-1-g003.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-operative\" title=\"canadian-hearing-report-operative\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig 1. </strong>Pre- operative pure tone audiogram.</p>\r\n</div>\r\n</div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-speech-13-1-1-g004.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-speech-13-1-1-g004.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-speech\" title=\"canadian-hearing-report-speech\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig 2. </strong>Pre- operative speech audiometry (red-right ear, blue-left ear) (monosyllables).</p>\r\n</div>\r\n</div>\r\n</div>\r\n<h4>SURGICAL RECORD</h4>\r\n<p>A Cochlear SYNCHRONY Standard   Electrode from MED-EL (Innsbruck,   Austria) was implanted. Due to the local   anesthesia no facial monitoring was   performed. The local anesthesia protocol   included at first 5 ml Xylonest&reg; 1%   with epinephrine 1:200.000 injection   solution submitted into the retro   auricular region. A retro auricular cut,   following a mastoidectomy and posterior   tympanotomy with a bony implant bed   were performed. Cochleostomy approach   for electrode insertion was conducted   due to the round window anatomy. ART   (auditory nerve response telemetry)   and impedance measurements were   undertaken intra-operatively without   abnormal occurrences. The surgical   intervention lasted 60 minutes and no   complications were reported. No pain of   the patient himself was indicated during   the intervention.</p>\r\n<h4>ANESTHESIA RECORD</h4>\r\n<p>The surgery was executed with an   anesthesiology in standby. Pre-operatively   the patient received Midazolam. Intraoperative   monitoring included an ECG, a   pulse oximetry as well as constant blood   pressure measurements. Oxygen (4 L/min) was delivered through an oronasal   mask. To initiate and maintain a mild   sedation, the patient received in total   0.05 mg Fentanyl and 10 mg Ketanest   administered in a small bolus based on   patients&rsquo; comfort. Furthermore 4 mg of   Dexamethasone and 4 mg of Zofran were   given as a prophylactic antiemetic.</p>\r\n<h4>RESULTS</h4>\r\n<p>Post-operatively no pain, nausea or   vomiting occurred. The patient reported   dizziness which was already present   pre-operatively. For infection prevention   intravenous antibiotics were applied for   five days. The patient was released on the   fifth post-operative day. Following implant   activation, one month after surgery, verbal   communication was immediately possible,   which was not feasible pre-operatively.   CI-aided free field measurements on the   right ear revealed 45dB HL at 250Hz,   30dB at 1.000Hz, 35dB HL at 2.000Hz   and 35dB at 4.000Hz (<strong>Fig. 3</strong>). The Freiburg   monosyllables test revealed 10% word   recognition scores at 65dB and 40%   at 80dB in the CI aided condition after   one month. The Freiburg number test   resulted in 100% understanding at 65dB   (<strong>Fig. 4</strong>). The three months follow-up free   field measurements remained constant.   The monosyllabic intelligibility of the   patient improved about 35% at 65dB and   55% at 80dB (<strong>Fig. 5</strong>). The satisfaction and   benefit of the patient remained high and   he stated to undergo surgery under local   anesthesia again.</p>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-month-13-1-1-g005.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-month-13-1-1-g005.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-month\" title=\"canadian-hearing-report-month\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig 3. </strong>Free field audiogram 1 month post-operative.</p>\r\n</div>\r\n</div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Audiometry-13-1-1-g006.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-Audiometry-13-1-1-g006.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-Audiometry\" title=\"canadian-hearing-report-Audiometry\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig 4.</strong> Speech Audiometry 1 month post- operative [Numbers (Z) and Monosyllables (E)].</p>\r\n</div>\r\n</div>\r\n</div>\r\n<div class=\"well well-sm\">\r\n<div class=\"row\">\r\n<div class=\"col-xs-12 col-md-2\"><a onclick=\"openimage(\'https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-months-13-1-1-g007.png\',\'\',\'scrollbars=yes,resizable=yes,width=500,height=330\')\" class=\"thumbnail\"><img src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-months-13-1-1-g007.png\" class=\"img-responsive\" alt=\"canadian-hearing-report-months\" title=\"canadian-hearing-report-months\" /></a></div>\r\n<div class=\"col-xs-12 col-md-10\">\r\n<p><strong>Fig 5. </strong>Speech Audiometry 3 months post- operative [Numbers (Z) and Monosyllables (E)].</p>\r\n</div>\r\n</div>\r\n</div>\r\n<h4>DISCUSSION</h4>\r\n<p>Due to the increasing life expectancy   typical diseases related to elderly people   are undoubtedly rising as well. For instance   the WHO estimates disabling hearing loss   in persons above 65 years of age in over   30% of the population. Understandably,   due to this demographic tendency,   hearing impaired patients as well as the   public&rsquo;s interest on possible treatment   options is ever increasing. At the St.</p>\r\n<p>P&ouml;lten University Medical Center the   average implantation age raised from 48   years in 2014 to 51 years in 2017. Studies   revealed that untreated hearing loss   poses a risk factor for the development   of dementia, cognitive decline, anxiety and   depression [<a href=\"#3\" title=\"3\">3</a>-<a href=\"#5\" title=\"5\">5</a>]. The here presented case   reported of such depressive moods due   to the distinctive discomfort and isolation   already shortly after losing his hearing.   Unfortunately, Cochlear Implantation in   elderly is often associated with increased   operative risks and therefore other, less   satisfying, therapies are opted for. Coelho   et al. and B&uuml;chsensch&uuml;tz et al. proved that   Cochlear Implantation is a safe procedure   in healthy patients regardless of age [<a href=\"#6\" title=\"6\">6</a>,<a href=\"#7\" title=\"7\">7</a>]   also vertigo and wound healing difficulties   were not reported more frequently in   the elderly population [<a href=\"#8\" title=\"8\">8</a>]. Importantly, this group of patients benefits especially   from an implantation in terms of speech   recognition and improved Quality of Life   [<a href=\"#9\" title=\"9\">9</a>,<a href=\"#10\" title=\"10\">10</a>]. Typically Cochlear Implantation   is undertaken under general anesthesia   representing an additional risk factor   for elderly people. If comorbidities are   present, as in the here presented case,   general anesthesia poses a considerable   risk, which may, even given appropriate   indication for Cochlear Implantation,   results in a rejection of surgery for the   patient. Since a number of different ear   surgeries are routinely performed under   local anesthesia, it only seems obvious,   that Cochlear Implantation may be   performed under local anesthesia as well.   Previous studies clearly showed that the   complication rate and the post-operative   duration of hospitalization of Cochlear   Implantation under local anesthesia did   not differ compared to general anesthesia.   No differences related to vertigo, nausea   and post-operative pain were observed.   This is in agreement with our observation.   The mean duration of the surgical   intervention in the group of the Cochlear   Implants under local anesthesia was   significantly lower compared to surgeries   under general anesthesia, representing   an additional positive effect for elderly   patients [<a href=\"#11\" title=\"11\">11</a>-<a href=\"#13\" title=\"13\">13</a>].</p>\r\n<h4>CONCLUSION</h4>\r\n<p>Cochlear implantation surgery proved to   be a good and viable option for hearing   rehabilitation in the elderly population.   Profoundly deaf patients may still be   implanted under local anesthesia without   generating additional health issues caused   by present comorbidities.</p>\r\n<h4>SUMMARY</h4>\r\n<p>&bull; Case report of a 72-year old man.</p>\r\n<p>&bull; Patient suffered acute severe to   profound sensorineural hearing loss   (right ear) and pre-existing deafness   (left ear).</p>\r\n<p>&bull; Patient reported social isolation   followed by depression due to hearing   impairment.</p>\r\n<p>&bull; The patient unsuccessfully trialed   conventional hearing aids for 6   months.</p>\r\n<p>&bull; Patient was indicated for Cochlear   Implantation (right ear) but significant   comorbidities contraindicated surgery   under general anesthesia.</p>\r\n<p>&bull; Therefore surgery was performed   under local anesthesia and sedation.</p>\r\n<p>&bull; Intervention lasted 60 minutes and   procedure was successfully performed   and no adverse events or surgical   complications occurred.</p>\r\n<p>&bull; Hearing rehabilitation was successful   one month post-operative and   improved further. Communication   immediately possible again after   activation.</p>\r\n<p>&bull; The patient reported improved   hearing benefit and Quality of Life.</p>\r\n<h4>REFERENCES</h4>\r\n<ol>\r\n    <li id=\"Reference_Title_Link\" value=\"1\"><a name=\"1\" id=\"1\"></a>Lenarz T (2017)  Cochlear Implant - State of the Art.  Laryngo-rhino-otologie 96: S123-S151. DOI: 10.1055/s-0043-101812 PMID: 28499298</li>\r\n    <li id=\"Reference_Title_Link\" value=\"2\"><a name=\"2\" id=\"2\"></a>Nations U (2015)  World Population Prospects: The 2015 Revision, Methodology of the United Nations Population Estimates and  Projections.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"3\"><a name=\"3\" id=\"3\"></a> Contrera KJ,  Betz J, Deal JA, Choi JS, Ayonayon HN, et al. (2016) Association of hearing impairment and emotional vitality  in older adults. J Gerontol B Psychol Sci Soc Sci. 71: 400-404.  doi: 10.1093/geronb/gbw005 PMID: 26883806.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"4\"><a name=\"4\" id=\"4\"></a>Deal JA, Betz J, Yaffe K, Harris  T, Purchase- Helzner E, et al. (2017) Hearing impairment and incident dementia and cognitive decline in older  adults: the health abc study. J Gerontol A  Biol Sci Med Sci 72: 703-709. doi:  10.1093/gerona/glw069 PMID: 27071780.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"5\"><a name=\"5\" id=\"5\"></a>Lin FR,  Metter EJ, O\'Brien RJ, Resnick SM,  Zonderman AB, et al. (2011) Hearing  loss and incident dementia.  Arch Neurol. 68: 214-20. doi: 10.1001/archneurol.2010.362 PMID: 21320988.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"6\"><a name=\"6\" id=\"6\"></a>Coelho DH, Yeh  J, Kim JT, Lalwani AK (2009) Cochlear implantation is associated with minimal anesthetic  risk in the elderly. Laryngoscope 119: 355-358. doi: 10.1002/lary.20067  PMID: 19160385.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"7\"><a name=\"7\" id=\"7\"></a>B&uuml;chsensch&uuml;tz K, Arnolds J, Bagus H, Fahimi F, G&uuml;nnicker M, et al. (2015) Surgical risk profile and audiological outcome in the elderly after cochlea-implantation. Laryngo-rhino-otologie 94: 670-675. doi: 10.1055/s-0034-1390454  PMID: 25437836.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"8\"><a name=\"8\" id=\"8\"></a>Holinski F, Elhajzein F, Scholz G, Sedlmaier B (2012) Vestibular disorders after  cochlear implant in  adults. HNO 60: 880-885. doi:  10.1007/ s00106-012-2526-x PMID: 22733278.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"9\"><a name=\"9\" id=\"9\"></a>Ramos A, Guerra-Jim&eacute;nez G, Rodriguez C, Borkoski  S, Falc&oacute;n JC, et al. (2013) Cochlear implants in adults over 60: a study of communicative benefits and the impact on quality  of life. Cochlear Implants Int 14: 241-245. doi:  10.1179/1754762812Y.0000000028 PMID: 23510755.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"10\"><a name=\"10\" id=\"10\"></a>Jin SH, Liu C, Sladen DP (2014) The effects of aging on  speech perception in noise: comparison between  normal-hearing and cochlear-implant listeners. J Am Acad Audiol 25: 656-665. doi: 10.3766/jaaa.25.7.4 PMID: 25365368.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"11\"><a name=\"11\" id=\"11\"></a>Mistry SG, Carr  S, Martin J, Strachan DR, Raine CH, et al. (2017) Cochlear  implantation under local anaesthesia - Our  experience and a validated patient satisfaction questionnaire. Cochlear Implants Int, 18: 180-185. doi: 10.1080/14670100.2017.1296986PMID:28274186.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"12\"><a name=\"12\" id=\"12\"></a> Toner F,  Jackson CP, Toner JG (2013)  How we do it: Local anaesthetic  cochlear implantation. Cochlear  Implants Int, 2013. 14: 232-235. doi: 10.1179/1754762812Y.0000000016 PMID: 24001710.</li>\r\n    <li id=\"Reference_Title_Link\" value=\"13\"><a name=\"13\" id=\"13\"></a>Hamerschmidt R,  Moreira AT, Wiemes GR, Ten&oacute;rio SB, T&acirc;mbara EM (2013) Cochlear implant surgery  with local anesthesia and sedation: comparison with general anesthesia. Otol Neurotol 34: 75-78. doi: 10.1097/  MAO.0b013e318278c1b2  PMID:  23187931.</li>\r\n</ol>',NULL,'2022-11-16'),(15,3467,'ajchr','http://www.andrewjohnpublishing.com/','<p><strong>Frank E. Musiek, PhD, CCC-A, and Diane E. Cheek, BA</strong></p>\r\n<p>Frank E. Musiek is professor, Dept. of Speech Language and Hearing Sciences University of Arizona. He is internationally known for his many formative contributions in auditory processing disorder and neuroaudiology. He is the 2007 AAA recipient of the James Jerger Career Award for Research in Audiology, the 2010 recipient of ?The Honors of The American Speech, Language and Hearing Association for his contributions to Audiology and Auditory Neuroscience?, and recipient of ?Book of the Year Award? for the 2007 Handbook of Central Processing Disorder Vol. I and II (with Gail Chermak co-editor). He has published over 200 articles and book chapters in the areas of auditory evoked potentials, central auditory disorders, neuroaudiology and auditory neuroanatomy. He has authored or edited 11 books. He has served on numerous national and international committees, editorial boards and task forces including chairing the 2010 AAA task force for clinical practice guidelines for CAPD and co-chairing the AAA Global Conference in 2012 and 2014.</p>\r\n<p>Diane E. Cheek will be a second-year student in the Doctor of Audiology program at the University of Arizona this fall. She graduated with honors from the University of West Florida with a Bachelors of Arts in International Studies and served in the United States Air Force before discovering the discipline of audiology. Diane enjoys all aspects of diagnostic and rehabilitative audiology, particularly matters concerning central auditory and speech processing. She has assisted with research investigating infant speech perception using cortical auditory evoked potentials and is currently investigating the modulating effects that attention has on the mediocochlear reflex in children. In the Neuroaudiology Lab, Diane works with dichotic listening tests and investigates their various clinical applications. This past academic year, Diane served as the University of Arizona?s Student Academy of Audiology (SAA) secretary and is looking forward to leading SAA as president in the upcoming year. Outside of school, she stays active with many philanthropic efforts aimed at advancing the audiologic health of southern Arizona?s and northern Mexico?s underserved communities.</p>','<h4>INTRODUCTION</h4>\r\n<p>The motivation for this article comes from informal observations and interactions with audiologists and patients with multiple sclerosis (MS). These observations made by the first author of this article indicate that audiologists, at least some audiologists, are not aware of the possible auditory consequences related to MS. Despite a fair amount of literature devoted to hearing difficulties associated with MS many audiologists do not adequately evaluate these patients and therefore fall short in properly managing them. This is especially of concern when in fact, sensitive tests such as dichotic listening are available to evaluate patients with MS. It should be remembered that in most instances audiologic tests like dichotic listening is not utilized to diagnose or help diagnose MS. Rather, in individuals already diagnosed with MS, when auditory symptoms occur, they can determine if the hearing deficit is a result of advancing MS or something else. Our focus here is to discuss dichotic listening and review its value in MS to remind the audiologist of his or her potential role in helping the MS patient with auditory problems.</p>\r\n<h4>WHAT IS MULTIPLE SCLEROSIS?</h4>\r\n<p>As an inflammatory demyelinating disease of the central nervous system (CNS), MS can be unpredictable with regard to which sensory systems are affected and disease progression. Worldwide, it affects approximately 2.3 million people with an average age of onset of 30 years, making it the primary neurological insult in young  and middle-aged adults.1  Prevalence rates of MS increases with latitude; therefore, age-adjusted estimates in the US can range from 47 per 100,000 in Texas to 177 per 100,000 in Minnesota.2,3</p>\r\n<p>MS is largely viewed as a white matter pathology, with demyelinating lesions forming along the myelin that sheathes neural fibers in the brain, brainstem, and spinal cord.4  These lesions routinely develop in particular CNS areas such as the periventricular, juxtacortical, infratentorial (brainstem to include the cerebellum), and spinal cord areas, affecting both motor and sensory modalities.5  However, MS is not solely restricted to CNS white matter. Lesions have also been discovered within gray matter and along the white-gray matter demarcation early in the disease process although the exact pathologic mechanism for these lesions is unknown.6&ndash;8 Theorized mechanisms for these gray matter lesions include myelinotoxin-induced degeneration independent of white matter pathology and secondary axonal insult following overlying white matter pathology.7</p>\r\n<p>Gray matter is also subject to atrophy due to the disease process, which Sailer et al.9  report as being most significant in areas with high white matter lesion volume, notably, the frontal and temporal lobes. Specifically, they found that both superior and medial temporal gyri exhibited the most atrophy within the temporal lobe, even in patients with mild disability. Charil et al.10 report similar findings when they examined the relationship between white matter lesion load and cortical thickness in 425 MS patients. They found an inverse correlation between white matter lesion volume and underlying gray matter atrophy with significant associations in areas  such as the cingulate gyrus, insula, and temporal lobe.</p>\r\n<h4>SYMPTOMS AND AUDITORY INVOLVEMENT</h4>\r\n<p>Due to the indiscriminate nature of these pathologic changes, an individual with MS may experience an array of symptoms and difficulties with varying degrees of severity. These include tingling, numbness, imbalance, bladder dysfunction, and visual changes. Diagnosing MS involves the identification of demyelinating lesions that demonstrate dissemination in space and time. That is, lesions must arise in two separate CNS areas at two different periods of time, both of which can be confirmed by magnetic resonance imaging (MRI) (for complete diagnosis criteria, see Polman et al.5 ).</p>\r\n<p>The auditory system is not immune to the pathologic changes that occur with MS, though symptoms of auditory impairment may be the most subtle.11 Demyelination along the myelinated portion of the auditory nerve can result in hearing loss, but this occurs only in a small number of patients (up to 4%) and tends to be transient and of mild degree.11,12 More commonly, MS patients may first experience functional auditory deficits before the more overt and disabling neurologic symptoms develop.13 For example, up to 54% of MS patients readily report hearing difficulties, particularity in background noise, despite having normal audiometric thresholds.11,14 Identifying these subtle functional deficits, especially in the newly diagnosed, could aid in the monitoring of disease progression and therapy effectiveness.15 One tool within our audiologic test arsenal suited to detect these deficits is dichotic listening. But before we can discuss the clinical utility of dichotic listening, we must first discuss how and why such tasks work.</p>\r\n<h4>THE CORPUS CALLOSUM</h4>\r\n<p>Our two cerebral hemispheres are joined by an immense network of predominately myelinated nerve fibers that make up an axonal tract called the corpus callosum (CC). The human CC is estimated to have more than 200 million such fibers which serve as the mechanism through which interhemispheric transfer of cortical information travels.16 Myelinated fiber diameters range from 0.4 to 15 &micro;m, with the thicker fibers having faster neural conduction rates between hemispheres.16 Fiber myelination is typically not complete until the adolescent years of a child&rsquo;s development up to which point children may exhibit slowed interhemispheric transfer.17</p>\r\n<p>Since most CC fibers are homotopic in nature, whereby they facilitate communication between equivalent areas of each hemispheric region, the CC transforms into a topographically organized structure.16 With this perspective in mind, the CC can be divided into five anterior-to-posterior sections: rostrum, genu, trunk, sulcus (also termed isthmus), and splenium. It is primarily within the sulcus where fibers responsible for transferring auditory information can be found.18 Hemispheric communication is vital for proper auditory processing since each hemisphere is specialized for different processing tasks; Gestalt processing such as pattern recognition is accomplished in the right hemisphere while the left hemisphere performs detailed, analytic processing such as speech segmentation.19 The CC also facilitates heterotopic connections where neural fibers from one hemispheric area connect to a dissimilar area in the opposite hemisphere.20</p>\r\n<p>For example, heterotopic connections between right inferior temporal cortex, site for visual recognition, and left Broca&rsquo;s and Wernicke&rsquo;s areas, sites for language processing, are thought to facilitate visual-auditory matching and naming.21</p>\r\n<p>Nerve fiber composition, diameter, and density are not homogeneous across the CC. While the CC contains an overwhelming preponderance of myelinated fibers as a whole (~95% myelinated), a higher proportion of thinner, unmyelinated fibers can be found in the genu relative to the other callosal sections (~16% unmyelinated).22 Additionally, as one travels anteriorly to posteriorly, fiber diameters increase with the faster conducting fibers (&gt;3 &micro;m) residing in the trunk, sulcus, and splenium.16 With regard to fiber densities, small diameter fibers have a peak density in the genu while large diameter fibers are most plentiful in the midbody of the CC.22 Overall, the CC&rsquo;s immense, yet intricate network of fibers is what enables our auditory system to efficiently process dichotically presented stimuli.</p>\r\n<p><strong>CORPUS CALLOSUM&rsquo;S ROLE IN DICHOTIC LISTENING</strong></p>\r\n<p>When auditory input is simultaneously presented to the right and left ears, information from each ear will travel through the central auditory nervous system (CANS) primarily along contralateral (crossed) pathways which begin their contralateral ascent at cochlear nucleus. Contralateral pathways within the CANS are greater in number than ipsilateral (uncrossed) pathways and are believed to have an inhibitory effect on ipsilateral afferent activity during dichotic listening.23 Given that the left temporal lobe is the site for language processing in a large majority of individuals,right ear auditory input will directly ascend via the contralateral pathway to the left hemisphere for language processing.24,25 Left ear auditory input, on the other hand, will first be delivered to the right hemisphere only to then traverse the CC in order to reach the left hemispheric processing centers.18 Figure 1 shows the auditory pathways involved during dichotic listening. Since the right ear has a direct pathway to the left hemisphere, it is generally afforded an advantage over the left ear in dichotic listening tasks. This right ear advantage (REA) demonstrates the cerebral lateralization and hemispheric asymmetry found in non-pathologic individuals who have language specialization in the left hemisphere.26,27 Conversely, lateralization to the right hemisphere is revealed during dichotically presented non-verbal stimuli, such as music, and lends itself to a left ear advantage (LEA).28 LEA may also be found in nonpathologic individuals who process language in their right hemisphere.</p>\r\n<p>Handedness may offer clues into which hemisphere is dominant for language processing, and thus, which ear advantage should be revealed: 95% of right-handers have left hemispheric processing (revealing a REA), 60% of left-handers have right hemispheric processing (revealing a LEA), and 20%   of left-handers have bilateral processing (revealing a no-ear advantage, or NEA).29 In summary, dichotic listening tasks were designed to evaluate the right-left laterality index and can reveal impairments of interhemispheric transfer if pathology exists anywhere along the central auditory pathway, to include the CC.</p>\r\n<h4>DICHOTIC LISTENING IN THE MS POPULATION</h4>\r\n<p>The myelin-rich content of the CC makes it a common target for demyelinating MS lesions. As the myelin sheathes surrounding CC fibers deteriorate, neural transmission rates along the fibers slows down.11 Signs of demyelination along the CC&rsquo;s inner surface have been observed on MRI in 55&ndash;95% of MS patients.30 The CC is also subject to global atrophy during the disease process, even in the early stages of MS when individuals only exhibit mild disability.31,32</p>\r\n<p>Putting this all into context, a lesioned or atrophic CC that is left ill-equipped to perform rapid interhemispheric transfer of auditory information to the left hemisphere will typically exhibit a reduced LEA and/or an enhanced REA. In most individuals, left ear auditory input that is delivered contralaterally to the right hemisphere will need to traverse the CC to the left hemisphere for speech processing. If the CC cannot facilitate this interhemispheric transfer, then left ear input will fail to reach the left hemisphere for processing and a patient&rsquo;s performance in identifying left ear stimuli will suffer.</p>\r\n<p>Conversely, given that right ear auditory input is delivered directly to the left hemisphere via contralateral pathways, an impaired CC will bear no negative impact on dichotic listening performance with regard to right ear stimuli. In fact, impaired interhemispheric transfer can enhance the identification of right ear stimuli among MS patients.33 This enhancement is thought to be a result of a release from central competition between the two cerebral hemispheres.33 That is, in non-pathologic CCs auditory information crossing from the right to the left hemisphere competes with the auditory information that is contralaterally delivered to the left hemisphere. However, patients with impaired interhemispheric transfer are spared this right hemisphere competition, and this is the driving force behind their enhanced right ear performance relative to normal controls on dichotic listening tasks. An extreme REA could also be interpreted as an extreme left ear deficit in situations where right-left interhemispheric transfer is severely impaired.34 Such test results can occur in MS patients, depending on the location and severity of damage along central auditory pathway. Figure 2 shows the results on dichotic digits of a MS patient with an extreme left ear deficit.</p>\r\n<p>Dichotic listening deficits as described above are well documented in MS patients. Generally, these patients exhibit reduced LEA and either normal or increased REA using syllable and digit pairs as stimuli.15,18,33,35&ndash;37 This suggests an interruption in interhemispheric transmission from the right to left hemisphere due to demyelinating lesions resulting in a release from central competition.34 Studies using MRI and diffusion tensor imaging have also associated atrophic CCs with greater left ear deficits and right ear enhancements.34,38,43 This is not surprising considering that CC atrophy in MS patients is global in nature and not confined to a particular callosal area.40 But how sensitive are dichotic listening tests to MS pathology? For that, we can turn to studies that have investigated this very question in patients without MS given that CANS damage, regardless of etiology, will evoke similar dichotic listening deficits. Musiek44 administered the Dichotic Digits test to 21 patients with either cortical or brainstem lesions and found that almost 81% of the cohort exhibited deficits with the deficits being more prevalent among those with cortical lesions. Upon closer examination of those with cortical lesions, Musiek44 found that 6 of the 10 patients with unilateral lesions had significantly larger deficits for the ear contralateral to the lesion than for the ipsilateral ear while both patients with bilateral lesions exhibited bilateral deficits. Similar contralateral deficits have been seen with the Staggered Spondaic Word dichotic listening test in unilateral lesioned patients of varied pathology.45 Musiek44 also administered the Dichotic Digits test to 21 subjects with cochlear hearing loss and found specificity to be 81% and 95% when abnormal test score criterions of &lt;90% (for normal hearing subjects) and &lt;80% (for cochlear hearing loss subjects) were used, respectively.</p>\r\n<h4>EFFECTS OF NON-CALLOSAL INVOLVEMENT</h4>\r\n<p>As previously discussed, MS may leave patients with non-callosal white matter lesions, gray matter lesions, or atrophy of the temporal lobe in addition to callosal degeneration. Another region along the central auditory pathway susceptible to MS lesions is the brainstem, with the pons and medulla oblongata seeming to be most affected.46,48 In one study of 68 MS patients with periventricular lesions, 71% also had lesions in the pons and 50% with lesions in the medulla oblongata.49 As expected, dichotic listening deficits have also been demonstrated in patients with brainstem lesions. Jacobson et al.35 found REAs in 80% of their MS cohort (16 of 20 patients) all of whom had brainstem lesions and abnormal auditory brainstem responses (long latencies and irregular morphologies). The fact that about half of Jacobson et al.&rsquo;s cohort who exhibited REAs did not have accompanying lesions in the cerebrum makes a case for brainstem lesions being capable of interrupting interhemispheric transfer before higher level processing can take place.</p>\r\n<p>While test-retest reliability of dichotic listening tasks has been shown to be 0.85&ndash;0.90, sensitivity within the MS population is less predictable.50 That is, there tends to be high variability with regard to degree of lateralization across studies. Factors likely influencing this variability warrant a brief discussion.</p>\r\n<h4>HETEROGENEITY OF DICHOTIC PERFORMANCE</h4>\r\n<p>First and foremost, it must not be forgotten that some cases of MS may not affect the auditory pathway at all. Dichotic listening in these patients would presumably be normal. But with the help of imaging technology, researchers can better determine which CNS structures are affected and select cohorts based on their findings. However, even after carefully selecting for disease location, a cohort&rsquo;s disease progression can influence the degree of lateralization seen within studies.38 For example, patients in Lindeboom and ter Horst&rsquo;s36 study demonstrated greater REA than those in Barkhof et al.&rsquo;s38 study. It was postulated that the longer disease duration and severity among Lindeboom and ter Horst&rsquo;s36 patients may have resulted in the greater lateralization of right ear stimuli.38 This may be due to a greater impairment of interhemispheric transfer and a release from competition of left ear stimuli.</p>\r\n<p>Another variable is the degree and location of CC atrophy. Callosal atrophy was found to be associated with greater LEA suppression, with suppression being most profound when the posterior section of the CC was affected.40 The relationship between greater LEA suppression and posterior CC atrophy was also found by Reinvang et al.42 These studies highlight the tonotopic nature of the CC whereby interhemispheric fibers carrying auditory information are generally located in the CC&rsquo;s posterior section.18 Looking at the CC as a whole, Rao et al.41 found that only when the CC atrophied to less than 5 cm2  in size did significant left ear suppression occur relative to controls (6.27 cm2  mean CC size in healthy individuals51). MS patients that maintained a callosal area  of at least 5 cm2  did not significantly differ in performance compared to control subjects.</p>\r\n<p>Lastly, the characteristics of the dichotic stimuli can certainly influence dichotic listening performance. Rubens et al.15 point out that word pairs that share greater phonetic and acoustic similarity (can/pan versus ship/door) will result in greater test sensitivity for interhemispheric dysfunction. Test sensitivity would increase not only as a result of greater ipsilateral pathway suppression from the minimal contrasting pairs, but more difficult stimuli would reduce ceiling effects and better expose laterality differences between pathologic and non-pathologic individuals. Test sensitivity can also be improved by achieving better temporal synchrony between stimuli onsets since poor alignment can result in an artificial right ear deficit.18 For example, after finding that simultaneous onsets generally produce a 14% REA in control subjects, Berlin et al.52 determined that this REA could be overcome when left ear onsets lagged right ear onsets by as little as 30 msec. During these moments of stimuli dyssynchrony, true dichotic listening is lost and the full inhibitory effect of ipsilateral pathways by the stronger contralateral pathways may be reduced.19 Consequently, enough auditory information may ascend ipsilaterally during these dyssynchronous moments to falsely elevate ear performance.19</p>\r\n<h4>SUMMARY</h4>\r\n<p>To conclude, patients with MS are often overlooked as a population having functional auditory deficits. However, reports of subtle hearing difficulties in those suspected with or have been newly diagnosed with MS should prompt audiologists to include dichotic listening in their audiologic test battery. This is because damage to central auditory pathways can occur even in patients experiencing only mild MS symptoms.9,31,32 Performance on dichotic listening tests can be used to help monitor disease progression and validate patient concerns of having increased listening difficulties. All in all, the value of dichotic listening should not be overlooked in the MS population given its relatively strong sensitivity to detect abnormalities that may otherwise be undetectable with other audiologic tests.</p>\r\n<h4>KEY POINTS &ndash; DICHOTIC LISTENING AND MULTIPLE SCLEROSIS</h4>\r\n<p>&bull; Worldwide, multiple sclerosis (MS) is the primary neurological insult in young and middle-aged adults and is indiscriminate with regard to which central nervous system structures are affected</p>\r\n<p>&bull; About half of MS patients readily report functional hearing deficits, notably in background noise, yet audiometrically less than 5% exhibit measurable hearing loss</p>\r\n<p>&bull; Subtle auditory deficits may appear before the more overt and disabling symptoms of MS, making identification of these deficits in the newly diagnosed helpful in monitoring disease progression and therapy effectiveness</p>\r\n<p>&bull; Although corpus callosum is a prime target for demyelinating MS lesions, pathologic lesions and atrophy can occur anywhere along the central auditory pathway to include the auditory nerve, brainstem, noncallosal white matter, and underlying gray matter</p>\r\n<p>&bull; On dichotic listening tasks MS patients generally exhibit left ear deficits and increased right ear advantages due to an interruption of normal interhemispheric transfer of auditory information and a release from central competition between the two cerebral hemispheres</p>\r\n<p>&bull; Dichotic listening&rsquo;s sensitivity, specificity, and test-retest reliability make it a valuable and appropriate tool to be included in test batteries for the MS population</p>\r\n<h4>REFERENCES</h4>\r\n<p>1. Multiple Sclerosis International Federation. Atlas of MS 2013. Available at: http://www. msif.org/wp-content/uploads/2014/09/Atlasof-MS.pdf.</p>\r\n<p>2. Mayr WT, Pittock SJ, McClelland RL, et al. Incidence and prevalence of multiple sclerosis in Olmsted County, Minnesota, 1985&ndash;2000. Neurology 2003;61:1373&ndash;77.</p>\r\n<p>3. Noonan CW, Williamson DM, Henry JP, et al. The prevalence of multiple sclerosis in 3 US communities. Prevent Chron Dis 2010;7:1&ndash;8.</p>\r\n<p>4. Kutzelnigg A, Lucchinetti CF, Stadelmann C, et al. Cortical demyelination and diffuse white matter injury in multiple sclerosis. Brain 2005;128:2705&ndash;12.</p>\r\n<p>5. Polman CH, Reingold SC, Banwell B, et al. Diagnostic criteria for multiple sclerosis: 2010 revisions to the McDonald criteria. Ann Neurol 2011;69:292&ndash;302.</p>\r\n<p>6. Fisher E, Lee JC, Nakamura K, et al. Gray matter atrophy in multiple sclerosis: A longitudinal study. Ann Neurol 2008;64:255&ndash;65.</p>\r\n<p>7. Geurts JJ, Barkhof F. Grey matter pathology in multiple sclerosis. Lancet Neurol 2008;7:841&ndash; 851.</p>\r\n<p>8. Rao SM. Neuropsychology of multiple sclerosis: A critical review. J Clin Experiment Neuropsychol 1986;8:503&ndash;42.</p>\r\n<p>9. Sailer M, Fischl B, Salat D, et al. Focal thinning of the cerebral cortex in multiple sclerosis. Brain 2003;126:1734&ndash;44.</p>\r\n<p>10. Charil A, Dagher A, Lerch JP, et al. Focal cortical atrophy in multiple sclerosis: Relation to lesion load and disability. Neuroimage 2007;34:509&ndash;17.</p>\r\n<p>11. Mustillo P. Auditory deficits in multiple sclerosis: A review. Int J Audiol 1984;23:145&ndash; 64.</p>\r\n<p>12. Coelho A, Ceranic B, Prasher D, et al. Auditory efferent function is affected in multiple sclerosis. Ear Hear 2007;28:593&ndash;604.</p>\r\n<p>13. Bacon JH, Kister I, Bacon TE, et al. Sound lateralization test distinguishes unimpaired MS patients from healthy controls. Multiple Sclerosis Internat 2014;2014:1&ndash;5</p>\r\n<p>14. Musiek FE, Gollegly KM, Kibbe KS, et al. Electrophysiologic and behavioral auditory findings in multiple sclerosis. Otol Neurotol 1989;10:343&ndash;44.</p>\r\n<p>15. Rubens AB, Froehling B, Slater G, et al. Left ear suppression on verbal dichotic tests in patients with multiple sclerosis. Ann Neurol 1985;18:459&ndash;463.</p>\r\n<p>16. Aboitiz F, Ide A, Olivares R. Corpus callosum morphology in relation to cerebral asymmetries in the postmortem human. In: Zaidel E, M. Iacoboni, eds. The parallel brain: The cognitive neuroscience of the corpus callosum. Cambridge, MA: MIT Press; 2003:33&ndash;46.</p>\r\n<p>17. Musiek FE, Gollegly KM, Baran JA. Myelination of the corpus callosum and auditory processing problems in children: Theoretical and clinical correlates. Semin Hear 1984b;5:231&ndash;240.</p>\r\n<p>18. Musiek FE, Weihing J. Perspectives on dichotic listening and the corpus callosum. Brain Cognit 2011;76:225&ndash;32.</p>\r\n<p>19. Musiek FE, Kibbe K, Baran JA. Neuroaudiological results from split-brain patients. Semin Hear 1984a;5:219&ndash;29.</p>\r\n<p>20. Clarke S. Complexity of human interhemispheric connections. In: Zaidel E, Iacoboni M, eds, The parallel brain: The cognitive neuroscience of the corpus callosum. Cambridge, MA: MIT Press; 2003:47&ndash;49.</p>\r\n<p>21. Di Virgilio G, Clarke S. Direct interhemispheric visual input to human speech areas. Human Brain Map 1997;5:347&ndash;54.</p>\r\n<p>22. Aboitiz F, Scheibel AB, Fisher RS, et al. Fiber composition of the human corpus callosum. Brain Res 1992;598:143&ndash;53.</p>\r\n<p>23. Kimura D. Functional asymmetry of the brain in dichotic listening. Cortex 1967;3:163&ndash;78.</p>\r\n<p>24. Hugdahl K. Dichotic listening: Probing temporal lobe functional integrity. In: Davidson RJ, Hugdahl K, eds, Brain Asymmetry. Cambridge, MA: MIT Press; 1998:123&ndash;56.</p>\r\n<p>25. Moffat SD, Hampson E, Lee DH. Morphology of the planum temporale and corpus callosum in left handers with evidence of left and right hemisphere speech representation. Brain 1998;121:2369&ndash;79.</p>\r\n<p>26. Kimura D. Some effects of temporal-lobe damage on auditory perception. Can J Psychol/Revue canadienne de psychologie 1961a;15:156&ndash;65.</p>\r\n<p>27. Kimura D. Cerebral dominance and the perception of verbal stimuli. Can J Psychol/Revue canadienne de psychologie 1961b;15:166&ndash;71.</p>\r\n<p>28. Kimura D. Left-right differences in the perception of melodies. Quart J Experiment Psychol 1964;16:355&ndash;58.</p>\r\n<p>29. Bryden MP. An overview of the dichotic listening procedure and its relation to cerebral organization. In: Hugdahl K, ed, Handbook of dichotic listening: Theory, methods and research. Chichester, UK: John Wiley &amp; Sons; 1988:1&ndash;43.</p>\r\n<p>30. Garg N, Reddel SW, Miller DH, et al. The corpus callosum in the diagnosis of multiple sclerosis and other CNS demyelinating and inflammatory diseases. J Neurol Neurosurg Psychiar Published Online First: 9 April 2015;doi:10.1136/jnnp2014-309649:1-9.</p>\r\n<p>31. Klawiter EC, Ceccarelli A, Arora A, et al. Corpus callosum atrophy correlates with gray matter atrophy in patients with multiple sclerosis. J Neuroimag 2015;25:62&ndash;67.</p>\r\n<p>32. Pelletier J, Suchet L, Witjas T, et al. A longitudinal study of callosal atrophy and interhemispheric dysfunction in relapsing-remitting multiple sclerosis. Arch Neurol 2001;58:105&ndash;111.</p>\r\n<p>33. Wishart HA, Strauss E, Hunter M, et al. Interhemispheric transfer in multiple sclerosis. J Clin Experiment Neuropsychol 1995;17(6):937&ndash;40.</p>\r\n<p>34. Gadea M, Marti-Bonmat&iacute; L, Arana E, et al. Dichotic listening and corpus callosum magnetic resonance imaging in relapsingremitting multiple sclerosis with emphasis on sex differences. Neuropsychol 2002:16:275&ndash;81.</p>\r\n<p>35. Jacobson JT, Deppe U, Murray TJ. Dichotic paradigms in multiple sclerosis. Ear Hear 1983;4:311&ndash;17.</p>\r\n<p>36. Lindeboom J, ter Horst R. Interhemispheric disconnection effects in multiple sclerosis. J Neurol Neurosurg Psychiatr 1988;51:1445&ndash;47.</p>\r\n<p>37. Westerhausen R, Hugdahl K. The corpus callosum in dichotic listening studies of hemispheric asymmetry: A review of clinical and experimental evidence. Neurosci Biobehavior Rev 2008;32:1044&ndash;54.</p>\r\n<p>38. Barkhof F, Tas MW, Valk J, et al. Functional correlates of callosal atrophy in relapsingremitting multiple sclerosis patients. A preliminary MRI study. J Neurol 1998;245:153&ndash; 58.</p>\r\n<p>39. Gadea M, Marti-Bonmat&iacute; L, Arana E, et al. Corpus callosum function in verbal dichotic listening: Inferences from a longitudinal follow-up of relapsing-remitting multiple sclerosis patients. Brain and Language 2009;110:101&ndash;105.</p>\r\n<p>40. Pelletier J, Habib M, Lyon-Caen O, et al. Functional and magnetic resonance imaging correlates of callosal involvement in multiple sclerosis. Arch Neurol 1993;50:1077&ndash;82.</p>\r\n<p>41. Rao SM, Bernardin L, Leo GJ, et al. Cerebral disconnection in multiple sclerosis: Relationship to atrophy of the corpus callosum. Arch Neurol 1989;46:918&ndash;20.</p>\r\n<p>42. Reinvang I, Bakke SJ, Hugdahl K, et al. Dichotic listening performance in relation to callosal area on the MRI scan. Neuropsychology 1994;8:445&ndash; 50.</p>\r\n<p>43. Westerhausen R, Woerner W, Kreuder F, et al. The role of the corpus callosum in dichotic listening: A combined morphological and diffusion tensor imaging study. Neuropsychology 2006;20:272&ndash;79.</p>\r\n<p>44. Musiek FE. Assessment of central auditory dysfunction: The Dichotic Digit Test revisited. Ear Hear 1983a;4:79&ndash;83.</p>\r\n<p>45. Musiek FE. Results of three dichotic speech tests on subjects with intracranial lesions. Ear Hear 1983b;4:318&ndash;23.</p>\r\n<p>46. Huh SY, Min JH, Kim W, et al. The usefulness of brain MRI at onset in the differentiation of multiple sclerosis and seropositive neuromyelitis optica spectrum disorders. Multip Sclerosis J 2014;20:695&ndash;704.</p>\r\n<p>47. Lu Z, Zhang B, Qiu W, et al. Comparative brain stem lesions on MRI of acute disseminated encephalomyelitis, neuromyelitis optica, and multiple sclerosis. PLoS One 2011;6:e22766.</p>\r\n<p>48. Renard D, Castelnovo G, Bousquet PJ, et al. Brain MRI findings in long-standing and disabling multiple sclerosis in 84 patients. Clin Neurol Neurosurg 2010;112:286&ndash;90.</p>\r\n<p>49. Brainin M, Reisner T, Neuhold A, et al. Topological characteristics of brainstem lesions in clinically definite and clinically probable cases of multiple sclerosis: An MRI-study. Neuroradiol 1987;29:530&ndash;34.</p>\r\n<p>50. Hugdahl K. Fifty years of dichotic listening research&ndash;Still going and going and&hellip; Brain Cognit 2011;76:211&ndash;13.</p>\r\n<p>51. Mitchell TN, Free SL, Merschhemke M, et al. Reliable callosal measurement: Population normative data confirm sex-related differences. Am J Neuroradiol 2003;24:410&ndash;18.</p>\r\n<p>52. Berlin CI, Lowe-Bell SS, Cullen Jr JK, et al. Dichotic speech perception: An interpretation of right-ear advantage and temporal offset effects. J Acoust Soc Amer 1973;53:699&ndash;709.</p>\r\n<p>By Ted Venema, PhD</p>\r\n<p>Ted Venema taught at Conestoga College in Kitchener, Ontario, and was the founder and director of its program for hearing instrument specialists. He has a PhD in audiology from the University of Oklahoma. Ted frequently gives presentations on hearing, hearing loss and hearing aids and is author of the textbook Compression for Clinicians, published by Cengage and now in its second edition.</p>\r\n<p>Some 10 years ago, Peter Blamey, PhD from Melbourne Australia introduced the strategy and performance of adaptive dynamic range optimization (ADRO). It was initially applied to cochlear implants and also to a &ldquo;bimodal&rdquo; way of amplification, involving a cochlear implant in one ear and a hearing aid in the other ear. Still later, its application extended to hearing aids per se. For first-hand information on ADRO as it began, the interested reader is referred to an early article on this whole topic.1 ADRO is quite unique in that it offers an alternative to WDRC, in the form of a &ldquo;sliding&rdquo; usage of linear gain. Two main rules of &ldquo;audibility&rdquo; and &ldquo;comfort&rdquo; are applied to the output from this linear gain, and these rules are based on the client&rsquo;s subjective loudness judgements during the fitting. If the output exceeds the listener&rsquo;s comfort level, the linear gain decreases; if the output falls below the listener&rsquo;s audibility, the linear gain then increases. The main thing to note is that unlike WDRC, the gain for input speech is linear. The very nature of WDRC necessarily distorts the speech input sound waveform. The way in which linear gain is provided by ADRO; however, is intended to position the mean average of an input speech spectrum &minus; free of distortion &minus; into the client&rsquo;s reduced dynamic range. The purpose of this article is to introduce the concepts and procedures of ADRO; basically, how it works.</p>\r\n<p>Before going further, two questions come to mind: (1) where is ADRO now, and (2) compared to WDRC, how would ADRO show up on Real Ear Measurement? With regard to (1), ADRO was originally implemented on the Toccata digital processor, developed by DSPFactory LTD in Waterloo Ontario! It was not adopted for usage by Unitron or other hearing aid manufacturers, until Interton picked it up. Today, ADRO is used and sold by Hearing Lab Technology LLC in the USA. They distribute hearing aids using ADRO through four different brands: Liberty Hearing Aids dispensed at Sam&rsquo;s Club, Assure Hearing Aids dispensed at Meijer&rsquo;s, America Hears Hearing Aids dispensed at Bristol PA and Bend Oregon, and at Walkers Hearing Aids dispensed through Cabela Hearing Ctrs. Regarding (2) we know the unaided speech input spectrum has a range or width of about 30 dB. The resultant aided speech output with WDRC is often narrower in width; this would be due to its method of compression. It may very well be that with ADRO, the range or width would also be narrower, but this would be due to the fact that the very loudest and very softest portions of the input speech spectrum are truncated or cut off. With ADRO, the main focus is the undistorted mean average of the input speech spectrum. Food for thought&hellip;</p>\r\n<h4>INPUT/OUTPUT (I/O) FUNCTIONS AND LINEAR GAIN CHANGES</h4>\r\n<p>To understand ADRO the &ldquo;language&rdquo; of ADRO, it is very important to know how to interpret I/O functions, and to know how to read them. Figure 4 shows that on I/O functions, changes in linear gain result in left-right changes in the position of the 450 line or function on the graph. The length of the 450 line means nothing in terms of amount of gain; a long line simply means the same linear gain was given over a wider range of inputs. Also, contrary to what one might think, moving the line to the right means the linear gain went down, not up.</p>\r\n<h4>DYNAMIC RANGE OF INPUT SPEECH</h4>\r\n<p>In changing its linear gain over time, ADRO not only considers the reduced dynamic range that occurs with SNHL, but it also keeps in mind the dynamic range of the input; whether it is speech, music, or any other sound. There are two common and complementary ways to display the frequency, intensity, and time dimensions of sound: (1) sounds waves and (2) frequency spectra. Figure 5 shows a fictitious sentence of speech spoken at a conversational listening level as a sound wave (top) and a spectrum (bottom). When looking at the sound wave, it can be seen that WDRC would give more gain to the soft-intensity valleys of the sound wave than to the louder peaks of the sound wave. On the other hand, linear gain would preserve the peak-to-valley contrast of the speech sound wave and thus, preserve all the acoustical speech cues that are so necessary for optimal speech understanding. SNHL results from loss of cochlear hair cell function which tends to decrease one&rsquo;s ability to discriminate speech; it thus behooves of us to deteriorate the wave forms of speech as little as possible.</p>\r\n<p>The frequency spectrum of average conversational speech is shown at the bottom of Figure 2. In contrast to a sound wave which shows time horizontally and amplitude vertically, a spectrum shows frequency horizontally and amplitude vertically (unlike sound waves then, a frequency spectrum does not show time, it averages over time instead). Here we can see that speech is a broadband sound comprised of many different frequencies. The typical spectrum for average intensity speech spans an intensity from about 45 to 75 dB SPL; thus it has a dynamic range of 30 dB. In other words, the loudest elements are about 30 dB louder than the softest parts. With ADRO, linear gain is applied so that the most important parts &ndash; mean average &minus; of the speech spectrum are amplified into the listener&rsquo;s dynamic range of hearing.</p>\r\n<p>As an aside, one interesting thing to note about the speech spectrum is that the mean or average intensity does not lie at the centre of the dynamic range; the mean or average intensity of average conversational speech is about 65 dB SPL or about 55&minus;60 dB HL. This is due to the fact that the intensity of spoken speech (vowels-to-consonants-to vowels, etc) fluctuates rapidly in intensity over time. In contrast, the  intensity of ongoing noise, such as that from a fan, air conditioner, or even background speech babble is much steadier in its intensity over time. As a result, the mean or average intensity of such noise would lie more toward the center of its overall dynamic range of intensity. By the way, this is how most digital noise reduction works: staccatolike sounds are interpreted as speech and are given most gain across the channels of the hearing aid, while sounds of more constant intensity over time are given a reduced amount of gain.</p>\r\n<h4>APPLYING THE COMFORT AND AUDIBILITY RULES</h4>\r\n<p>ADRO assumes that for any particular client, the most important acoustic information required to understand speech will lie between the listener&rsquo;s AT and CT. Figure 6 shows how the rules are applied in order to keep the most important parts of the speech dynamic range within the client&rsquo;s reduced dynamic range. The bump in the middle is known as a &ldquo;distribution.&rdquo; Think of a bell curve showing grades in a class. The grades A, B, C, and D would be shown horizontally along the bottom. The number of students who got those grades would be shown vertically. The distribution here in Figure 3 indicates the output intensities horizontally, and the amount of times those outputs occurred vertically. Hearing aid outputs  constantly change over time and ADRO uses statistics in order to constantly apply its Comfort and Audibility rules in each channel over time. While the outputs are constantly increasing and decreasing in each channel of the hearing aid, the rules ADRO applies remain constant. If the outputs exceed the CT more than 10% of the time, the linear gain decreases. If the outputs fall below the AT more than 30% of the time, the linear gain increases. If neither of these rules is violated, the linear gain stays the same.</p>\r\n<p>In general, the focus is to keep the most important part of the input speech dynamic range both audibly and comfortably situated within the listener&rsquo;s reduced dynamic range of hearing. The tiny amount that is above the CT (10%) is not the focus, nor is the 30% below the AT.  and Comfort rules of ADRO can be seen on an I/O function (Figure 7). This shows how ADRO applies its changing linear gain in any one channel over time. For listening environments with soft inputs, the linear gain will provide some specified output, depending of course, on the client&rsquo;s hearing levels and established CT.</p>\r\n<p>As the soft inputs increase, the outputs will increase at a 1:1 ratio along with them. This is simply linear gain at the MG gain value. Once the outputs exceed the CT 10% of the time however, the comfort rule is applied, and the linear gain is reduced in order to keep the output at the set CT. If input levels decrease from this point, the output will drop linearly, at a 1:1 ratio along with the input. This is simply linear gain again, although it is now at a reduced amount compared to our beginning amount of MG linear gain. With continuing decreases to inputs, however, the outputs will fall to the AT. Here, the Audibility rule is applied, and the gain will be increased in order to keep the output audible. In keeping with the Background Noise rule however, this gain increase will continue only up until the MG level. From here, the outputs will drop once again at a 1:1 ratio with the inputs. We have just done a clockwise loop.</p>\r\n<h4>ADRO PROCESSING IS THUS, TO BE SHARPLY CONTRASTED WITH THAT OF WDRC</h4>\r\n<p>ADRO uses linear gain until one of its rules is violated. This results in linear gain being applied to a fairly wide dynamic range of input sound intensities. WDRC uses compression with a fixed kneepoint and fixed compression ratio. The static compression is applied to a wide dynamic range of sound inputs, while linear gain is applied only to very soft input intensities. The results can easily be visualized in Figure 8, 9, 10 and 11.</p>\r\n<h4>SUMMARY</h4>\r\n<p>1. The normal loudness relationship between the lowfrequency vowels and high-frequency consonants is changed with WDRC, but not with ADRO</p>\r\n<p>2. ADRO therefore provides for the listener a bright and clear sound, untainted by the squeezing (read &ldquo;distorted&rdquo;) effects of compression</p>\r\n<p>3. ADRO&rsquo;s three &ldquo;calling cards&rdquo; are its: Audibility rule, Comfort rule, and client-centered fitting method which asks for subjective loudness judgements</p>\r\n<p>4. ADRO uses in-situ loudness measurements</p>\r\n<p>5. Fitting methods used today (e.g., NAL-NL2) espouse Audibility &amp; Comfort, but really they focus on Audibility alone; they hope for resultant Comfort to follow along as a logical end-point or conclusion. ADRO actually measures comfort.</p>\r\n<p>6. ADRO takes dynamic range of: a. Input b. client&rsquo;s audiometric data</p>\r\n<p>7. ADRO has a circular I/O function, enabling it to utilize linear gain for a maximal amount of inputs. WDRC on the other hand uses linear gain for very soft inputs</p>\r\n<h4>REFERENCE</h4>\r\n<p>1. Blamey P. Adaptive dynamic range optimization (ADRO): a digital amplification strategy for hearing aids and cochlear implants. Trends in Amplification 2005;9(2).</p>\r\n<p>By Sarah Orlowski</p>\r\n<p>Sarah Orlowski is a graduate of Ontario College of Art &amp; Design. She went on to become a Master Herbalist, graduating from the Wild Rose College of Natural Healing. Sarah has been fortunate to have also trained in First Nations herbal traditions and also has her Permaculture Design Certificate. She enjoys music and as such, highly values hearing. Sarah has taught for many education institutions, including Simon Fraser University, Boucher Institute of Naturopathic Medicine, Canadian College of Traditional Chinese Medicine, Vancouver School Board, Van Dusen Gardens, Squamish First Nations, Capilano College and Douglas College. Currently, Sarah and her husband run an organic fruit &amp; nut orchard/medicinal herb farm in Grand Forks, BC, where she makes her herbal products &amp; trains student apprentices.</p>\r\n<p>Our son Rowan has had hearing problems since a very young age, although this was not always all that noticeable, especially since I tend to use a loud voice a lot of the time. We first found out when he was about 2 &frac12; years old. We had recently moved into a rural area of BC, and the nextdoor neighbour kindly looked after him upon occasion. Fortuitously, she was the audiologist technician in the nearby town. After a while, she suggested that we bring him in for a hearing test because she suspected that he had hearing trouble. Sure enough, his hearing was below normal, especially for his left ear. This was the beginning of a long journey of ear escapades in which our son was the central character. Rowan had regular ear exams, but his hearing at best never got above the low end of normal on hearing tests, and testing also consistently showed bilateral middle ear dysfunction. Eventually, my husband John and I took him to see Dr. Riding, an ear, nose and throat (ENT) physician at Children&rsquo;s Hospital in Vancouver. Rowan had PE tubes inserted during a bilateral myringotomy. Our caring audiologist technician then fit him with custom-made earplugs so that he would not have to give up swimming, which we both loved.</p>\r\n<h4>CHOLESTEATOMA #1</h4>\r\n<p>By grade 5, a noticeable mass was building up in his left ear. Dr. Riding said that he would book a tentative surgery date but prescribed him eardrops first just to see if the condition would clear up. The eardrops clearly did not work (as the doctor was predicting); our son had a benign cholesteatoma tumour, and so we made plans to proceed with the surgery. Dr. Riding explained that the name &ldquo;cholesteatoma&rdquo; was actually a misnomer because originally it was thought that these tumours were due to cholesterol build-up, but we now know that this is not the case (Figure 1).</p>\r\n<p>We had never seen the little PE tubes after they were self-ejected, as they are supposed to, and at one point, Dr. Riding suggested that there was the possibility that one had not ejected, and that the mass of cholesteatoma had formed around it. He stressed the urgency for the tumour removal because of its fast growth rate and close proximity to the brain. It was strange seeing my little guy going into a giant magnetic resonance imaging machine, but he stayed very still as requested. After that first surgery, life went on as usual. Sometimes he had some inflammation or infection, but very rarely did he ever have any pain. He has always had occasional, inexplicable headaches, sometimes quite severe, so I have wondered if there is any connection between them and his ears or the tumour. He still gets these headaches periodically.</p>\r\n<p>Dr. Riding performed Rowan&rsquo;s first surgery to remove the cholesteotoma in spring of grade 5. This required three months without swimming, so it was unfortunate timing, as the summer was quite hot. Come September when the three months were finally up, he played in the ocean waves all day and barely ever came out. Dr. Riding was a superlative doctor, who really took time with patients. He had an excellent bedside manner, with respect and humility in spite of his high standing. Upon completing Rowan&rsquo;s surgery, he came to see me in the waiting room. He drew a sketch of the procedure for me and explained that the cholesteotoma was so large that they had to abandon the idea of going in through the ear canal. Instead, they cut through the bone behind the ear. They discovered that there was so much erosion of the anvil, due to the tumour, that the ossicle was no longer of any use. The tumour itself was providing the conductive hearing in Rowan&rsquo;s left ear! So once the tumour was removed his hearing level actually went down.</p>\r\n<p>Dr. Riding recommended that once Rowan had completed his physical growth, he should get a prosthetic ossicle. He also advised that we keep a close eye on Rowan&rsquo;s ear, as the cholesteatoma was fuelled by growth hormone and were known to grow somewhat aggressively. Rowan appears to have abundant growth hormone as he has always been large for his age: his 12-year molars were in place by age 10, which his dentist said he had never seen before, and he wore size 15 shoes by the time he was 13 years old. Life carried on as usual although Rowan&rsquo;s hearing was always an issue, as well as his periodic headaches. He did very well at school, nonetheless, and for the most part people did not know that he had a hearing problem. I made sure to tell his new teacher each year. When he reached grade 7, he had a teacher who was not much of a disciplinarian, so the average noise level of the classroom was quite loud and Rowan was having a hard time in class. Without his conductive hearing loss, he had difficulty locating the teacher&rsquo;s voice out of the general milieu. It was also harder for him to concentrate on his work due to the noisy classroom and she suggested that he sit out in the hall to do it, which I thought was a rather poor solution. Halfway through that school year; however, we moved to a new town in the BC Interior. Dr. Riding had by then retired and each of our follow-up appointments at Vancouver Children&rsquo;s Hospital had been with different doctors. So we travelled to Trail to see Dr. Cook, an ENT specialist who was then doing Rowan&rsquo;s ear exams. After a few visits, he noticed the cholesteatoma beginning to grow back. Grateful to Dr. Cook for spotting it, we looked for an experienced ear surgeon and ended up with Dr. Kramer, an ENT in Kelowna, who had been trained by Dr. Riding.</p>\r\n<h4>CHOLESTEATOMA #2</h4>\r\n<p>By grade 12, Rowan&rsquo;s cholesteotoma was growing back yet again. This time, Dr. Kramer recommended that another ENT, Dr. Mick do the surgery. They now shared a practice in Kelowna. Having had a fellowship from U of T, Dr. Mick was young and experienced in the new techniques. So in March of this year, Rowan underwent surgery for his third cholesteatoma removal. Like the previous surgeries, Dr. Mick went in behind the ear, although by now there was a lot of scar tissue from the previous surgeries, so he had to cut the old scar out and add new skin to the region, resulting in a slightly raised scar. Because it&rsquo;s behind the ear; however, it does not show. After removing the latest cholesteotoma tumour, Dr. Mick inserted a Total Ossicular Replacement Prosthesis (Figure 2). This is a titanium ossicular chain and Rowan now has a walletsized card declaring that he has titanium in his head. Like the previous time, this was a very long surgery and Rowan once again had the dreaded gauze tubing inserted to keep the cavity from collapsing. Pain was immediately relieved upon its subsequent removal.</p>\r\n<p>I am happy to say that Rowan has recovered well from all these surgeries, and we feel that we were in good hands at all times with some of the best ear surgeons in Canada working on our son. He has graduated with scholarships and honours from high school and will be attending UBCO in Kelowna, so he will be able to attend his ear appointments on his own from now on. Rowan, however, has told us that in spite of all the work done, his hearing levels have not really changed and he has not noticed an increase in hearing ability, even with the new ossicular prosthesis in place. At first we thought that this might change once the inflammation was gone and the post-surgical healing had taken place. But the surgery was five months ago now and he has still not noticed an improvement in hearing. I don&rsquo;t know why, but nonetheless, I am glad that the cholesteotomas are gone. I am aware that there is a chance that it could grow back yet again, as it is possible that Rowan may still grow some more and that the growth hormone might fuel some more tumour growth (you know what they say about puppies with big paws). In any case, I am grateful to live in Canada with universal health care and excellent doctors. I hope that this is something upon which we can always rely.</p>',NULL,'2022-11-16'),(16,3466,'ajchr','http://www.andrewjohnpublishing.com/','<p><strong>Robbyn Brodie, MSc, Registered Audiologist, Tinnitis Training Therapist</strong></p>\r\n<p>Robbyn obtained her undergrad degree at UBC and her Master?s Degree in Audiology from Dalhousie University in Halifax. She worked at the Children?s Hospital of Eastern Ontario (CHEO) and the Ottawa Civic Hospital for five years before moving back to the West Coast and settling in Victoria with her husband and two children. She now works in private practice at NexGen Hearing Clinic (Royal Oak) and has been practicing Tinnitus Retraining Therapy since 2011.</p>','<p><strong>Why or how did you get into audiology?</strong></p>\r\n<p>Growing up, both of my parents had significant hearing loss &ndash; my mom is deaf in one ear and my father has severe noise-induced loss &ndash; and I watched my grandfather withdraw into isolation as he stubbornly refused to wear his hearing aids. Then, while I was researching different career path options, I was volunteering in a speechpathology clinic in Vancouver and within this clinic I discovered a tiny audiology department. I worked there for a bit and found it was a perfect fit.</p>\r\n<p><strong>You&rsquo;re originally from White Rock BC but went to Dalhousie to study audiology, right? How come?</strong></p>\r\n<p>There are so few options for places to study audiology (in English) within Canada &ndash; UBC, Western, and Dal! I did my undergrad at UBC and wanted a change for my master&rsquo;s degree. Dalhousie had a great program and the East Coast seemed to call to me more than Ontario (no offence Ted!)&hellip;.little did I know that I would head to Ottawa for five years, right after finishing at up at Dal. Both my kids were born in Ontario!</p>\r\n<p><strong>At NexGen Hearing, you are one of the consultants with a specialty in tinnitus; when did you become interested in tinnitus?</strong></p>\r\n<p>As a student, I did a placement with Mark Gulliver at Nova Scotia Hearing and Speech Centre &ndash; he led group tinnitus sessions. I learned a lot there. In Victoria, there were few services for those who struggled with their tinnitus. I was seeing many patients whose primary complaint was tinnitus, not hearing loss. I could give them a little information, but felt that I would like to offer more.</p>\r\n<p><strong>As you know, there are lots of different and varying approaches to treating tinnitus; what is yours?</strong></p>\r\n<p><strong> </strong>I use Tinnitus Retraining Therapy (TRT) principles to treat tinnitus. In 2011 I travelled to Maryland to study TRT under Dr. Pawel Jastreboff. TRT is based on the neurophysiological model of tinnitus developed in the late 1980s by Drs. Jastreboff and Jonathan Hazell. This model of tinnitus suggests that it is the limbic system &ndash; the parts of the brain responsible for emotions &ndash; that assigns importance to tinnitus sounds (Figure 1). According to this model, if we perceive tinnitus sounds to be a threat or a danger (Figure 2), this provokes an emotional response, which in turn can provoke a stress response from the autonomic nervous system. Our awareness of tinnitus is heightened and so we perceive it to be louder or more persistent. This becomes a vicious cycle.</p>\r\n<p>TRT combines counselling and low-level sound therapy. When we demystify tinnitus while simultaneously reducing awareness of the tinnitus, over time one&rsquo;s awareness of the tinnitus is reduced, and should only be noticeable when focused upon. This is known as &lsquo;habituation&rsquo; and is the ultimate goal of TRT.</p>\r\n<p>What do you think is the most common cause of tinnitus? Well, noise-induced hearing loss is a big one, but I find that STRESS is definitely a common denominator in many of those with tinnitus. When someone is in the throes of great stress or anxiety, it is very difficult for them to &ldquo;tune out&rdquo; the tinnitus. Stress in turn can cause sleep issues, and when stressed and tired, coping mechanisms often go out the window.</p>\r\n<p><strong>What do you think is the most common cause of tinnitus?</strong></p>\r\n<p>Well, noise-induced hearing loss is a big one, but I find that STRESS is definitely a common denominator in many of those with tinnitus. When someone is in the throes of great stress or anxiety, it is very difficult for them to &ldquo;tune out&rdquo; the tinnitus. Stress in turn can cause sleep issues, and when stressed and tired, coping mechanisms often go out the window.</p>\r\n<p><strong>Is there any kind of audiogram you often associate with tinnitus?</strong></p>\r\n<p>Typically a high-frequency loss, such as the typical noise-induced hearing loss pattern (Figure 3) though any shape of loss, conductive, and even perfectly normal hearing, is common too.</p>\r\n<p><strong>So how do you get going in treating clients with tinnitus? What steps do you go through?</strong></p>\r\n<p>First, I start by having them fill out some questionnaires which inquire about how their tinnitus sounds to them, which ear, how bothersome it is, their medical history, stress levels and sleep patterns, and also whether they have hearing loss. I then do a hearing assessment and I measure the tinnitus. Here, I get them to subjectively match the pitch and volume of their tinnitus. I also try to find the minimum masking level, and if there is any residual inhibition (Figure 4). Using all the gathered information, I decide which TRT category they fall into, which determines the appropriate treatment for them.</p>\r\n<p>For some clients, basic information and education about their hearing (whether they have normal hearing or hearing loss) and tinnitus, and some brainstorming of ideas on use of environmental sound therapy to manage their tinnitus works wonders. Questions I hear often are &ldquo;Will my tinnitus keep getting louder and louder?&rdquo; &ldquo;Will I go deaf?&rdquo; &ldquo;Do I have a tumour?&rdquo; Many are relieved to find out that tinnitus is a fairly common issue and doesn&rsquo;t necessarily mean they have a tumour or disease (of course, I recommend further assessment where required), and this knowledge can be a help in learning to habituate to the tinnitus. For those with hearing loss and mildly bothersome tinnitus, often fitting them with hearing aids (and always the counselling and educational component) brings in enough environmental sound that sound generators may not be required. However, hearing loss accompanied by a moderate or severe degree of tinnitus may require a combination device of hearing aid and sound generator in one.</p>\r\n<p>There are two major components of TRT: educational counselling and sound therapy. The protocol is tailored to the client, as far as number of treatments, direction of counselling,   and type of sound, ear-level device or environmental sound etc., but always involves counselling and sound therapy.</p>\r\n<p><strong>What do you think is the most important thing a client has to do when going for treatment of tinnitus?</strong></p>\r\n<p>They need to be willing to believe that their situation can improve. If they believe they have an unknown underlying disease or tumour which is causing the tinnitus, no degree of counselling or sound therapy will get them to habituation. This is why it is important that, when they start TRT, they have seen their doctors, had various tests done (i.e., MRI), have been assured that the tinnitus is not a symptom of something more sinister. The educational component of TRT is about demystifying tinnitus, and if they continue to believe the worst, the treatment will be unsuccessful.</p>\r\n<p><strong>A clinician not specialized in tinnitus has a client with tinnitus; what should they do?</strong></p>\r\n<p>I think that most audiologists and HIPs, with a bit of effort, can be well-equipped to deal with tinnitus. Education and patience are important in equal amounts!</p>\r\n<p><strong>I ask because Richard Tyler is now involved with International Hearing Society (IHS) in developing a tinnitus training program</strong>. The more hearing specialists equipped to work with tinnitus patients, the better! I&rsquo;m all forit, as long as the professional is educated in treating tinnitus.</p>\r\n<p>&ldquo;Notched Sound Therapy&rdquo; is a term derived from how the therapy is made &ndash; you take unprocessed audio input such as music or white noise, and &ldquo;notch out&rdquo; sound energy at and around the tinnitus frequency of the user. Notched Sound Therapy is audio sound input that has been processed with a &ldquo;notch&rdquo; centred   at the frequency of a patient&rsquo;s tinnitus.2 In this context, a &ldquo;notch&rdquo; is made in the audio by a computer algorithm that removes the sound energy at and around the patient&rsquo;s tinnitus frequency. Different researchers have used different notch widths, ranging from one octave to one equivalent rectangular bandwidth. The effects of Notched White Noise has been studied in a randomized control trial (where subjects were randomly assigned to placebo and treatment groups). The effects of Notched Music has been studied in a group of small pseudorandomized control trials (where the subjects were not randomly assigned to placebo and treatment groups). Both studies have demonstrated that listening to Notched Sound Therapy can directly lower the volume of tinnitus, and in doing so, reduce the psychological annoyance caused by the tinnitus tone.2&ndash;4 The experiments ran with treatment cycles of twelve month&rsquo;s duration, however, significant reductions in tinnitus volume can be seen as early as one week into therapy (provided that it is intense in duration).4</p>\r\n<p>The Notched Sound Therapy approach is limited to people who have tinnitus tones that can be successfully localized with either our on-line tuner or with the aid of an audiologist. The mechanism of action isn&rsquo;t understood, but it&rsquo;s thought to occur through strengthening lateral inhibition networks between healthy auditory neurons and the aberrant neurons that spontaneously fire, causing the perception of tinnitus. Thus, a combination of lateral inhibition and subsequent changes in the auditory cortex via cortical plasticity appear to be implicated.2  Selectively stimulating the auditory neurons that don&rsquo;t produce the tinnitus frequency appears to laterally inhibit the auditory neurons that do produce the tinnitus frequency.2 Sustained lateral inhibition rewires the connections between neurons in the auditory cortex so that the baseline level of inhibition increases (even when users aren&rsquo;t listening to the music).2 Therefore the tinnitus volume decreases. One of the advantages of Notched Sound Therapy is that the approach has been successfully replicated by two groups of researchers. Replication is one of the most important concepts in experimental science. The basic idea is that if an experiment discovers a treatment to be truly effective, then this finding should be able to be generalized (replicated) elsewhere in the world. The original research on Notched Sound therapy came out of Germany and the research group of Dr. Christo Pantev. Subsequently, additional research from an analogous (but not identical) form of sound therapy came out of Italy. Whereas Dr. Pantev placed an auditory notch in music and provided this as therapy, the Italian researchers placed a &ldquo;window&rdquo; (which, functionally, was a notch) into broadband noise (which sounds like static). http://www. tinnitusjournal.com/imagebank/pdf/ v15n1a05.pdf. Both experimental groups found a positive treatment effect, sometimes large, in their participants. This example of cross verification is why I believe that, for some people, Notched Sound Therapy does indeed work. Again, the claims of efficacy around Notched Sound Therapy should be modest. It works for some people, some of the time, and seems to provide a moderate effect in the people that it does help. We have published our internal results here on our blog (choppy and low quality though the  Notched Sound Therapy represents a new approach to sound therapy for tinnitus. It has two virtues: (1) it has been independently researched with positive therapeutic results, by two different European research groups (only one of which has attempted to commercialize their therapy afterwards), and (2) it is available at low cost to patients via third party proprietors.</p>\r\n<h4>HOW IT WORKS</h4>\r\n<p>Notched Sound Therapy takes place in three steps.3  In step one, patients determine the frequency of their tinnitus. This can be done in one of two ways: either with the use of a web-based tinnitus tuner, http:// www.audionotch.com/app/tune/ or alternatively, inside of an audiology clinic. In step two, patients choose the audio they wish to have &ldquo;notched,&rdquo; which includes options ranging from music to white noise.2,3 The sound is then &ldquo;notched&rdquo; by a special software algorithm. In step three, patients listen to their Tailor-Made Notched Sound Therapy.2  This can be done with any device capable of playing MP3 music files. The lack of a proprietary device is what allows the cost of Notched Sound Therapy to be dramatically lower than its competitors. After months of listening for several hours per day, a patient&rsquo;s tinnitus volume decreases.3  Again, although the exact mechanism of action is unknown, researchers believe that the therapy utilized cortical neuroplasticity to reduce the spontaneous firing of the neurons responsible for the tinnitus percept by strengthening  existing networks of lateral inhibition from undamaged cochlear hair cells.2</p>\r\n<h4>REFERENCES</h4>\r\n<p>1. Eggermont JJ and Roberts LE. The neuroscience of tinnitus. Trends Neurosci 2004;27:676&ndash;82.</p>\r\n<p>2. Okamoto H, Stracke H, Stoll W, Pantev C. Listening to tailor-made notched music reduces tinnitus loudness and tinnitus-related auditory cortex activity. Proc Natl Acad Sci U S A 2010;107:1207&ndash;10.</p>\r\n<p>3. Lugli M, Romani R, Ponzi S, Bacciu S, Parmigiani S. The windowed sound therapy: a new empirical approach for an effective personalized treatment of tinnitus. Int Tinnitus J 2009;15:51&ndash;61.</p>\r\n<p>4. Teismann, H., Okamoto, H., Pantev, C. Short and intense tailor-made notched music training against tinnitus: The tinnitus frequency matters. Plos ONE 2011;6:1&ndash;8.</p>',NULL,'2022-11-16'),(17,3465,'ajchr','http://www.andrewjohnpublishing.com/','<p><strong>Ted Venema, PhD</strong></p>\r\n<p>Ted Venema taught at Conestoga College in Kitchener, Ontario, and was the founder and director of its program for hearing instrument specialists. He has a PhD in audiology from the University of Oklahoma. Ted frequently gives presentations on hearing, hearing loss and hearing aids and is author of the textbook Compression for Clinicians, published by Cengage and now in its second edition.</p>','<p>I believe there is a huge gap between the science of middle ear transmission and the clinical application of tympanometry. This is especially apparent for the clinician who attempts to make the leap from typical tympanometry to multifrequency tympanometry. It concerns the vertical axis of the tympanogram. Obfuscation (look it up) offers lots of Impedance but little Admittance to an understanding of Tympanometry. The horizontal axis on the tympanogram is always &ldquo;friendly.&rdquo; It shows positive, neutral, and negative air pressure, in units of mm H2O or dekaPascals (these units are essentially the same in value). The vertical axis, in my opinion, is a source of audiometric consternation. Tympanometry measures the amount of sound bouncing back off the TM (tympanic membrane) and being picked up by the probe microphone as a function of changes in air pressure (Figure 1). Why then, does the vertical axis not simply read in &ldquo;dB SPL that bounced back&rdquo;?</p>\r\n<p>Let me tell you why. The vertical axis does not read in dB SPL that is picked up by the probe microphone because, if it did, the resultant values would vary hugely across individuals, and so would the size of their tympanograms! This huge variation results from things like different probe insertion depths that would change the ear canal volume in any one person. In addition, ear canals themselves vary in size across individuals.</p>\r\n<p>An alternative, then, is to measure the physical properties of the middle ear. The middle ear is a &ldquo;stiffness-dominated  system,&rdquo; and so it makes sense that we would want to quantify its stiffness (or its inverse, compliance) per se. This actually does allow for a fairly standard range of tympanogram sizes and shapes to be used as normative. It also renders similar-sized tympanograms independently from the depth of probe insertion or ear canal size. In tympanometry then, the less sound picked up by the probe microphone, the more compliance you have.</p>\r\n<p>The confusion to me, however, stems from the fact that while we actually measure dB SPL picked up by a probe microphone, we do this in order to quantify something else, namely, compliance!</p>\r\n<p><strong>COMING TO TERMS WITH SOME TERM</strong><strong>S</strong></p>\r\n<p>To better understand compliance and the vertical axis of a tympanogram, we had best look at some things that impede the transmission of sound through a system like the middle ear:</p>\r\n<p>&bull; Stiffness: opposes transmission of low Hz and passes high Hz; the chief factor in middle ear impedance</p>\r\n<p>&bull; Mass: opposes transmission of high Hz and passes low Hz</p>\r\n<p>&bull; Resistance: like simple friction; in any system it is the same for all Hz</p>\r\n<p>&bull; Impedance: combination of the above</p>\r\n<p>Since the middle ear is stiffness dominated, mass and resistance do not play much of a role in its overall impedance; the ossicles are tiny, and the ligaments holding the ossicular chain in place don&rsquo;t give much friction. Today&rsquo;s tympanometry, however, measures what the middle ear admits, rather than what it impedes. Here are some admittance terms:</p>\r\n<p>&bull; Inverse of stiffness is compliance; audiology textbooks often call it &ldquo;compliance susceptance&rdquo;</p>\r\n<p>&bull; Inverse of mass is not given a short name (since the middle ear is stiffness dominated); audiology textbooks often call it &ldquo;mass susceptance&rdquo;</p>\r\n<p>&bull; Inverse of resistance is called &ldquo;conductance&rdquo;</p>\r\n<p>&bull; Inverse of impedance is called &ldquo;admittance&rdquo;; it&rsquo;s a combination of the above</p>\r\n<p>For admittance then, the &ldquo;camel&rdquo; in the room is Compliance, along with two &ldquo;mice&rdquo; called Mass Susceptance and Conductance. The ohm is a unit used to describe Impedance; for admittance, the word &ldquo;ohm&rdquo; is simply flipped around to read &ldquo;mho.&rdquo; Since the ear is small, it is more practical to use thousandths of a mho or millimhos (mmho&rsquo;s) to indicate units for compliance on the vertical axis of the tympanogram.</p>\r\n<p><strong>MULLING OVER MULTI-HZ TYMPANOMETRY</strong></p>\r\n<p>The fun really begins when we attempt to move to multi-frequency tympanometry. The chasm here is filled with opaque concepts and, in my opinion, the bridge to take you across the chasm is hard to find. But let me give it a try: In multi-frequency tympanometry, not only is the probe tone Hz manipulated, but three different tympanograms can be measured for each Hz! The combined contributions of the &ldquo;camel of compliance&rdquo; and a &ldquo;mouse of mass&rdquo; are called &ldquo;susceptance.&rdquo; These are plotted as what is called a &ldquo;B&rdquo; tympanogram. The other &ldquo;mouse,&rdquo; called &ldquo;Conductance,&rdquo; is plotted as a &lsquo;G&rdquo; tympanogram. The sum total of these is admittance, which is plotted as &ldquo;Y&rdquo; tympanogram.</p>\r\n<p>Note: For the normal middle ear, the Y tympanogram will be quite similar to the B tympanogram, because the main component of admittance is compliance. With multi-frequency tympanometry, however, the course of various middle ear pathologies can be tracked by the interactions among these three tympanograms at any one probe Hz. The interaction of middle ear susceptance and conductance is often shown as vectors, much like those that would be drawn to show how a blowing wind might affect the passage of a boat floating along with the water current (Figure 2). Regarding the middle ear, the vector normally radiates upward, showing that it is mainly controlled by its stiffness; if the vector radiates downward it is mainly controlled by its mass. The vector length would show the overall strength by which any sound transmission system is controlled by all of these three interacting elements.</p>\r\n<p>The resonance of a sound transmission system like the middle ear is found when its admittance due to compliance (compliance susceptance) is equal to its admittance due to mass (mass susceptance). When these cancel each other out to give an admittance of 0 mmho, the only player in overall admittance is conductance (Figure 3). Multi-frequency tympanometry shows that the normal middle ear has an overall resonance to Hz just above 1000 Hz. Various types of middle ear pathology affect middle ear resonance. Negative middle ear pressure or otosclerosis will stiffen the system, resulting in a higher resonating Hz. A monomeric TM, PE tubes, or disarticulated ossicles will decrease the stiffness and accordingly, lower the resonating Hz.</p>\r\n<p>By Lisa Hunter, PhD, FAAA</p>\r\n<p>Lisa L. Hunter, PhD FAAA is the scientific director for audiology in the Communication Sciences Research Center at Cincinnati Children&rsquo;s Hospital Medical Center, and associate professor of Otolaryngology and Communication Sciences and Disorders at the University of Cincinnati. An avid commuting cyclist and painter, Lisa has over 25 years of clinical, research and teaching experience, and a passion for audiology education. A graduate and former faculty member of the University of Minnesota, she developed and directed the AuD program in at the University of Utah. Lisa has authored over 60 peer-reviewed articles, chapters and books in pediatric audiology, has given over 120 national and international presentations. She is currently directing a longitudinal study of newborn hearing loss, funded by the National Institute on Deafness and other Communication Disorders, collaborating with Dr. Douglas Keefe and Dr. Patrick Feeney. Lisa is currently the chair of the Accreditation Commission for Audiology Education (ACAE) and is a past member of the Board of Directors of the American Academy of Audiology.</p>\r\n<p>Tympanometry is at once one of our most basic and necessary, yet neglected and misunderstood clinical tools. Tympanometry was invented before almost anyone writing or reading this article was born, by Otto Metz in 1946.1 In the 50s and 60s, tympanometry provided a new window into the opaque middle ear, previously accessible only with myringotomy or exploratory surgery. Otoacoustic emissions (OAE) were discovered 30 years later by David Kemp. Kemp noted the linkage between the middle ear and the cochlea,&ldquo;if there were physical resonances occurring inside the cochlea it should be possible to detect these from outside, acoustically in the ear canal, because of the way the middle ear links the cochlea and the ear drum.&rdquo;2 Comparisons between these two physiologic measures in patients soon revealed an intimate relation between middle ear function as revealed by tympanometry; and cochlear function, as revealed by OAE. Because the middle ear is the doorway to the cochlea, anything significant happening there affects transmission of stimuli to generate OAE. As a result, middle ear problems as benign as positive or negative pressure may obliterate OAE responses, meaning that cochlear function cannot be ascertained. A frequent problem in screening and assessing infants and children is that middle ear effusion eliminates measurable OAEs in approximately 70% of ears. Significant conductive hearing loss of any cause nearly always eliminates OAEs. Even when hearing is normal, the presence of a perforation or a PE tube can reduce OAEs in 25&ndash;50% of cases, depending on the size and location of the perforation or tube. The middle ear doorway is an apt analogy, because it swings  bi-directionally. Thus, not only is the stimulus reduced getting to the cochlea, but the OAE is reduced traveling back through the middle ear to the outer ear, where it is detected clinically. This is why OAEs are so affected by fairly small middle ear problems &ndash; they are affected both coming (stimulus into the ear) and going (emission from the cochlea).</p>\r\n<h4>HOW ARE TYMPANOMETRY MEASURES MADE?</h4>\r\n<p>An understanding of this is necessary in order to properly interpret the results. We start with a pure tone stimulus, traditionally 226 Hz, but any pure tone up to about 1000 Hz can be used. Above that frequency, standing waves cause problems with the measurement. New reflectance techniques allow us to measure up to 10,000 Hz, but more on that later. The pure tone stimulus is calibrated for sound pressure level (SPL) and phase angle in a hard-walled metal cavity. The stimulus is introduced into the human ear, which changes both the SPL and the phase angle due to the impedance load of the middle ear. A large part of the change is due to the ear canal characteristics. In order to determine how much of the change is due to the ear canal versus the middle ear, we have to compensate out the outer ear canal effects. This is most easily done by pressurizing the ear canal to a high positive or negative pressure, which makes the ear canal act like a hard-wall cavity (except in newborns, but we&rsquo;ll get to that later). The tympanogram is measured by varying the ear canal air pressure, and monitoring the SPL and phase as the pressure is varied. So, we end up with the familiar admittance as a function of pressure graphs as in Figure 1. As Venema noted, the magnitude measurement (y-axis) is not plotted in SPL, rather it is plotted in physical units that correspond to the ear volume (cc) or admittance (mmho), relative to the probe tone (SPL).3  The term &ldquo;admittance&rdquo; can be remembered with the doorway analogy (the middle ear is the doorway, admitting sound to the cochlea). This is because we are trying to measure the physical properties of the ear, not the sound level of the probe tone. At 226 Hz, cc and mmho are equivalent units. What is a mmho (millimho) anyway? Well, a mmho is the inverse of the more well-known ohm. An ohm is a unit of impedance, while a mmho is a unit of admittance (the inverse of impedance). = The mmho measures the total admittance to the middle ear. =Have a look at your immittance instrument&rsquo;s vertical axis plot to see if it is plotted in cc, mL, or mmho. Some manufacturers choose to plot cc or mL because this is the unit of equivalent ear canal volume. Other manufacturers choose to plot mmho, because this is the unit of middle ear admittance. You can simply convert one unit to another with a 1:1 ratio, meaning 1 cc = 1 mL = 1 mmho. Easier than Pi!</p>\r\n<h4>HOW SENSITIVE AND SPECIFIC IS TYMPANOMETRY?</h4>\r\n<p>While standard 226-Hz and now, 1000- Hz tympanometry has stood the test of time in terms of convenience, simplicity, comfort, time, and cost, it is not terribly sensitive to many middle ear disorders that matter. Additionally, it is impossible to relate 226 or 1000 Hz tympanometry to other audiologic tests which are across a wider range of frequency. Otoacoustic emissions are not the only audiologic tests affected by middle ear changes. In fact, all &ldquo;upstream&rdquo; measures, be they behavioral (pure tone audiometry, speech thresholds and recognition in quiet and noise) or physiologic (acoustic stapedial reflexes, OAE, ABR, ASSR, etc.) are affected. Thus, audiologists need a highly sensitive and maximally specific middle ear measurement to be able to accurately detect middle ear disorders that affect the patient&rsquo;s functioning and other test results.</p>\r\n<p>In infants under 4 months old, the sensitivity and specificity of 226-Hz tympanometry to middle ear effusion (MEE) is only about 50%, so you might as well flip a coin instead. A more sensitive measure is 1000-Hz tympanometry. Why does 226-Hz tympanometry fail to detect MEE and OME in newborns? The reason is that the infant&rsquo;s flaccid ear canal walls transmit low frequency probe tones, so that as pressure changes in the ear canal, the sound is transmitted through the canal walls rather than the eardrum or middle ear. At frequencies of 1000 Hz and above, the sound does not get absorbed so easily, and the true state of the middle ear can be measured. A wider, clearer window into the middle ear via a test called Wideband Acoustic Immittance (WAI) is now available to audiologists. WAI uses click or chirp stimuli, and improved calibration principles that allow accurate determination of the absorbance (or reflection) of the middle ear across a wide frequency range from 200 to 10,000 Hz.4&ndash;6 WAI is quite simply a ratio measure of energy reflected from the TM and middle ear, compared to energy due to the calibrated stimulus in the ear canal. WAI takes standing waves into account in the calibration technique, and is generally independent of the location of the probe in the ear canal and to ear canal characteristics (in adult ears) between 250 and 8000 Hz. Thus, baseline compensation methods that are necessary for standard tympanometry are not necessary for WAI. WAI can be done either at ambient pressure or with pressurization, and a wideband absorbance tympanogram can be obtained, as shown in Figure 2. Absorbance is a ratio measure of the energy absorbed by the middle ear divided by the energy that was put into the ear (the clicks). Thus, no absorbance into the middle ear = 0, and maximal absorbance =1.0. Both magnitude and phase measurements can be obtained using absorbance.</p>\r\n<p>Very different wideband absorbance patterns are observed in normal ears (2a), ears with OME (2b), ears with negative pressure and ears with patent PE tubes. Compared to standard tympanometry, these measures are across all audiometric frequencies, so can be compared to OAE, ABR, and audiometry. Normative and pathology data are available from a number of studies.7  These wideband measurements are easily converted into admittance units and phase, so that individual tympanograms can also be seen for reference. But, there is really no need since the absorbance tympanograms have several advantages to conventional tympanometry. These include: simple ratio measurement, no need for ear canal compensation, wide frequency range, better reliability due to averaging and uses of clicks rather than pure tones.</p>\r\n<h4>SUMMARY</h4>\r\n<p>A better understanding of the physical units and principle underlying tympanometry can help audiologists to get more useful diagnostic information from this tried and true test. In order to advance our understanding, new techniques are available that allow us to see how the middle ear transfers energy across a wide frequency range. No longer do we have to be limited to 226, 660 or 1000 Hz. Even better, only one test that takes a few seconds can give us the whole frequency range, as well as multiple measures (absorbance, reflectance, phase angle, admittance).</p>\r\n<h4>REFERENCES</h4>\r\n<p>1. Metz O. The acoustic impedance measured on normal and pathological ears. Acta Otolar 1946;Suppl 63.</p>\r\n<p>2. Kemp DT. Stimulated acoustic emissions from within the human auditory system. JASA 64:1978:1386&ndash;91.</p>\r\n<p>3. Venema T. Tympanometry: Do we really understand the vertical axis? 2013. Retrieved from http://hearinghealthmatters.org/ hearingviews/2013/tympanometry-do-we-reallyunderstand-its-vertical-axis/</p>\r\n<p>4. Keefe, Ling, Bulen. Method to measure acoustic impedance and reflection coefficient. JASA 1992;91:470&ndash;85.</p>\r\n<p>5. Lynch TJ, III, Peake WT, Rosowski JJ. Measurements of the acoustic input-impedance of cat ears: 10 Hz to 20 kHz. JASA1994;96:2184&ndash; 209.</p>\r\n<p>6. Voss SE, Allen JB. Measurement of acoustic impedance and reflectance in the human ear canal. JASA 1994;95:372&ndash;84.</p>\r\n<p>7. Hunter LL and Shahnaz N. Handbook of acoustic immittance. San Diego: Plural Publishing; 2013.</p>\r\n<p>By Calvin Staples, MSc</p>\r\n<p>Calvin Staples has been an audiologist for over 10 years. His employment history covers a wide range of experiences and skills. Currently, he is the Hearing Aid program coordinator and faculty member at Conestoga College and lead audiologist and owner of Grand River Hearing Centre. His teaching responsibilities include: Professional Ethics, Audiometric Testing, Hearing Aid Technology, Hearing Aid Verification, Anatomy and Physiology of the Ear and Counselling. Professionally his interests are hearing aid technology, hearing loss and aging, and tinnitus. Previously, he was employed at Bernafon Canada Ltd. as their technical support and educational audiologist. His clinical experience developed through time spent at Hamilton Health Sciences (McMaster Hospital), Eastern Oklahoma Ear, Nose, and Throat and his current position at Grand River Hearing Centre. Calvin&rsquo;s role as a clinical audiologist dealt primarily with paediatric and adult audiology and hearing aids. Calvin provides monthly submissions to the Canadian Audiologist online publication and routinely lectures across the country. His education was completed at Missouri State University whereby he received a Master&rsquo;s Degree in Communication Sciences and Disorders with an emphasis in audiology</p>\r\n<p>Just under six years ago I was recruited to come and work at Conestoga College Institute of Technology and Advanced Learning in the Hearing Instrument Specialist (HIS) program. At the time, Ted Venema was the program coordinator, and he told tales of his adventures and the rewards of teaching which not only inspired me, but also helped solidify my belief that teaching at Conestoga College was the next step in my career. A few years later Ted left to &ldquo;go west, because life is peaceful there,&rdquo; and I was tasked with holding the reigns for the program &ndash; all the while attempting to figure out how to make it even better: no easy chore! The first step to that task is thankfully, already complete. The direction of the program was to foster an evidenceinformed, patient-centered approach to hearing health care, and the plan was to find and a faculty member who aligned with this ethos, and who was also an incredible teacher. Ross Harwell (AuD) fits that bill. Ross comes to Conestoga College by way of Hear Toronto (an independent hearing health care provider) and Oticon Canada Ltd. As a Doctor of Audiology, Ross is now a full-time professor at Conestoga College. The program has benefitted significantly from his experience and knowledge and Ross demonstrates an extremely thoughtful and intentional approach to teaching. In his short time here, his contribution to the Conestoga HIS program is undeniable. It would be hard to argue against the incredible education the Conestoga College HIS students are receiving. This leads me to my second point. At Conestoga we often consider what the appropriate goal of the HIS Program should be. Is it to teach the students to simply sell hearing aids and pass a licensing exam, or is it to teach the students to &ldquo;think about what they just thought about&rdquo;; to critically evaluate the clinical situation and use best evidence within a sound clinical reasoning framework to serve their patients? We categorically believe it should be the latter, and our intention is to create graduates that are valued contributors and respected amongst their peers. A hearing instrument specialist should engender trust and confidence in their patients. This is the foundation of the therapeutic relationship which allows the HIS to enrich the lives of those they serve. Further to this point, the HIS student at Conestoga has both didactic learning and experiential training. The Cowan Health Sciences Centre at Conestoga College houses the Hearing Health Lab (see photos), where students practice their skills in a formal and informal manner.</p>\r\n<p>Our industry is changing rapidly and has morphed from a private practice model where clinicians were the dominant owners &ndash; to a corporate retail model where sales appear of utmost importance. No matter what the context, however, well trained hearing health care providers must have patient care as their highest accountability. Our goal is to train &ldquo;best practice&rdquo; clinicians. I believe the goal of an academic institution is to prepare students for practice today, and also equip them for the emerging needs of tomorrow. This model suites our program and I am hopeful encourages our students to invest wisely in their experiences at Conestoga, so their patients will be best served in their communities. Conestoga College&rsquo;s model is &ldquo;What you do in here, counts out there,&rdquo; I could not agree more! (Good!)</p>\r\n<p>In looking to the future of our program, we are embarking on our first major program review; to that end, the Conestoga HIS program is investigating exactly how we evaluate and thread the themes of the industry throughout the program. Conestoga&rsquo;s HIS program must continue to emphasize the highest standards of patient care and experience, based on best practice standards. In most of the literature we read as clinicians, the outcomes reflect &ldquo;best practice&rdquo;. It is our goal to ensure best practice is threaded throughout our program in order to ensure our graduates are equipped with the tools to best serve their patients. Our commitment to the field is to continue to uphold this position. I am excited to show the province the new Conestoga HIS program in the not-so distant future.</p>\r\n<p>In the short time I have been at Conestoga I have witnessed significant change. I have seen a change in the type of student that attends the program and the vision the college has for its graduates. When I arrived, the HIS program still had part-time industryrelated students that dominated the flare and feel of the program. Now the program is a full-time 2-year program that has everything from students directly out of high school to students with years of prior post-secondary education and experience. It truly is an amazing canvas for the workplace our students will be exposed to upon graduation. The combination of the above ingredients makes Conestoga College a fascinating and great place to work and provides our students a wonderful learning experience. The future is an exciting one&hellip;.. Below is the website to Conestoga&rsquo;s HIS Program. It will lead the interested reader to program details, course descriptions, etc. http://www.conestogac.on.ca/ fulltime/1176.jsp</p>',NULL,'2022-11-16'),(18,3263,'ajchr','http://www.andrewjohnpublishing.com/','<p><strong>TedVenema, PhD </strong></p>\r\n<p>Ted Venema taught at Conestoga College in Kitchener, Ontario, and was the founder and director of its program for hearing instrument specialists. He has a PhD in audiology from the University of Oklahoma. Ted frequently gives presentations on hearing, hearing loss and hearing aids and is author of the textbook Compression for Clinicians, published by Cengage and now in its second edition.</p>','<h4>COMPRESSION FROMYESTERDAY TOTODAY</h4>\r\n<p>My career in this field began in the late 1980s, 1987 to be exact. I was a new audiologist in Toronto, working at The Canadian Hearing Society on 271 Spadina Rd. Almost all hearing aids were analog and provided linear gain, although a few compression circuits did exist. These used a rudimentary form of output limiting compression, with its obligatory high knee-point and high compression ratio. One could raise or lower the knee-point which correspondingly, raised or lowered the maximum power output (MPO). The same compression hearing aids also almost exclusively used output compression, meaning that the volume control changed the gain, but not the MPO. A few inputcompression specimens from Siemens tended to float around, where the volume control adjusted both the gain and the MPO together. I recall one of these even used something called ASP (automatic signal processing). Most of us hadn&rsquo;t really figured out what that was, but basically it turned out to be a precursor of BILL (bass increase at low levels). BILL as we all know (right?) was actually a type of frequency dependent compression that emerged a few years later... Wide dynamic range compression (WDRC) entered the scene with a mighty splash right around 1990. Research on cochlear hair cells had become distilled into the clinical arena. The action of the outer hair cells (OHCs) was now understood by clinicians as being distinct from that of the inner hair cells (IHCs). As we all know today, the OHCs enable the IHCs to sense soft incoming sounds below around 50 dB SPL. As a newcomer to compression, WDRC was seen as a rather &ldquo;intellectual&rdquo; type of compression, in that it sought to imitate the role of the OHCs. With its low knee-point and a low compression ratio, the focus of WDRC is to elevate the &ldquo;floor&rdquo; of hearing sensitivity, rather than on limit the MPO or &ldquo;ceiling&rdquo; of loudness tolerance. ReSound was a big proponent of this type of compression, with its focus on &ldquo;restoring normal loudness growth.&rdquo; I was in the PhD program at the University of Oklahoma, and I distinctly recall one of my profs saying how happy he was that finally some intellectual research was being &ldquo;heard&rdquo; by a manufacturer. Of course, it is no coincidence that oto-acoustic emissions (OAEs) &ndash; also known to arise from the action of the OHCs - suddenly emerged as part of clinical practice.</p>\r\n<p>By the mid 90s, I had moved to Canada and now worked at Unitron, Canada&rsquo;s only home-grown hearing aid manufacturer. The &ldquo;gospel&rdquo; of WDRC had not yet reached the ears of all those in clinical practice&hellip;I remember fielding customer service calls with upset clinicians wondering why their adjustments of WDRC weren&rsquo;t raising or lowering the MPO. We had to tell them, &ldquo;No, when you change the knee-point in WDRC, you are actually adjusting the amount of gain provided for soft input sounds!&rdquo; WDRC itself soon split into two camps, BILL and TILL. Oticon was a big promoter of BILL, which is basically WDRC confined to the lower frequencies. Mead Killion then offered his KAMPTM circuit, which used TILL (treble increase at low levels). This was basically WDRC confined to the higher frequencies. Are we having fun yet?</p>\r\n<p>Hey, this was about as bad as it got! Honestly. Compression in today&rsquo;s digital hearing aids hasn&rsquo;t really changed all that much from that used in those nowvintage hearing aids. We continue to use both output limiting compression and WDRC. The point I really want to make here is that 1990s was the &ldquo;golden age&rdquo; of compression, and here is why: the analog hearing aids of that time used either one type of compression or another. Clinicians had to know their compression types, because their hearing selection for any client depended on this knowledge. Manufacturer fitting software did not yet exist. On the other hand, today&rsquo;s digital hearing aids are programmed by software. Once the audiogram is entered through Noah, the hearing aid signal processing is automatically programmed to provide output or input compression, output limiting compression or WDRC, whatever. We&rsquo;ve become &ldquo;dumbed down,&rdquo; because we no longer have to know how to apply the compression. The manufacturer fitting software takes care of all of that!</p>\r\n<h4>TODAY&rsquo;S FITTING MADNESS</h4>\r\n<p>With the advent of digital hearing aids in 1997, the madness of fitting software began to emerge. On a semi-annual basis, the bells and whistles chimed and screamed as they grew in number. With goals and deadlines of their product management cycles, manufacturers are pounding out digital hearing aids in spades. The cacophony of their escalating product releases has become deafening. What&rsquo;s more, they come with all kinds of dongles, Bluetooth, remotes, and gadgets.</p>\r\n<p>Digital technology and software certainly do add flexibility; they also however, invite their best friend, complexity. There are so many parameters involved with fitting now. Let&rsquo;s look at a few: noise reduction amounts and types, directional microphones and associated polar plots, feedback suppression adjustments, linking binaural hearing aids, and don&rsquo;t forget about the battery indicator beeps! There&rsquo;s more. Yes, we now must make combinations of the above-said parameters, in order to specifically address various different listening situations, such as quiet, conversations, and traffic. HASANYONE SEEN ANSI? WHERE&rsquo;D IT GO? Sometime during the late 1990s, with the advent of digital hearing aids in 1997, ANSI slipped away. It happened in the middle of the night. Since the 1950s for hearing aids, ANSI was intended to be a measurement standard for hearing aid hardware, which consists of the microphone, amplifier, and receiver (aka speaker). Add in a few capacitors, resistors, inductors (and trimmers to adjust their behaviours), and you still have nothing but analog hardware. Such is the consistency of analog hearing aids. ANSI ruled in the analog land of hardware. Fitting software now rules; quaint concerns about stuff like OSPL90, Reference Test gain, Harmonic Distortion, and Equivalent Input Noise have almost faded from our collective clinical memory. Today it&rsquo;s all about software. Most clinicians today never bother with ANSI because they are just trying to figure out the fitting software. No, I&rsquo;m not trying to be a Luddite, just stating the facts.</p>\r\n<h4>THE CORDS,THE CORDS,THE CORDS&hellip;</h4>\r\n<p>The emergence of the cords actually began in the very late 1980s, with the first &ldquo;programmable&rdquo; analog hearing aids. For these hearing aids, a cord from a computer (or more often a hand held programming device) could be plugged into a socket on the faceplate of an ITE or on backside of a BTE. Adjustments could be made via this &ldquo;digital screwdriver,&rdquo; thus eliminating the need for individual trimmers being turned by a screwdriver. Most hearing aid adjustment in days of yore (less than 20 years ago), however, was done by trimmers, trim pots, potentiometers, whatever they were called (Figure 1). Clinicians simply turned these clockwise or counterclockwise, in order to raise or lower the MPO, gain, low-cut, high-cut, etc. Talk about simple. No cords, no Bluetooth, no dongles, no muss, no fuss. I used to laugh that if the original settings were somehow lost, one could simply set all the trimmers half way; that way, one could maximally be only half wrong. All kidding aside, Real Ear Measures (REM) were around back then, and the better clinicians among us used it too, make no mistake about that. In 2001 I left Unitron for teaching full time at Western (aka U of Western Ontario), in London, and later on at Conestoga College in Kitchener. The days of digital hearing aids and fitting software were upon us by then. Still, whenever I demonstrated hearing aids in classes, I always had to go for my vintage green Unitron case with its store of analog BTEs. The reason why, is because I could demonstrate the effects of adjustments so easily, just by turning the screwdriver. Student simply listened while turning the screws. If I wanted to do the same with today&rsquo;s digital hearing aids, I&rsquo;d have to turn on the computer, make sure the HIPRO or NoahLink is ready, and most importantly, be absolutely sure I have the right cords to plug into the hearing aids! The cord issue is not at all new, as I am not the first to complain about that. It is truly amazing just how  figure it all out. Clients were often amazingly patient with me. Some would say, &ldquo;You&rsquo;re not very good at this, are you?&rdquo; Then they&rsquo;d say, &ldquo;I really like the way you explain things though, you really should have been a teacher!&rdquo; I&rsquo;d put my head in my hands and reply, &ldquo;I used to be one!&rdquo; Honestly though, those dangling cords always gave me the creeps.</p>\r\n<p>Last year, I ran an office with NexGen Hearing in Victoria BC. I always felt a little embarrassed when I had to grab two cords, one for each ear, from a rack I had made on the wall. I&rsquo;d then connect them to this weird looking hook that I&rsquo;d hang around the client&rsquo;s neck. I&rsquo;d then sit in front of my computer, hoping and praying the software would read the hearing aids. It often didn&rsquo;t, but not because the manufacturer did anything wrong. No, it was usually because I was just trying to figure it all out. The manufacturers got to know me very well, but no longer as a teacher who&rsquo;d bring his students in to visit their facilities. No, now they were helping out this customer who just couldn&rsquo;t seem to figure it all out. Clients were often amazingly patient with me. Some would say, &ldquo;You&rsquo;re not very good at this, are you?&rdquo; Then they&rsquo;d say, &ldquo;I really like the way you explain things though, you really should have been a teacher!&rdquo; I&rsquo;d put my head in my hands and reply, &ldquo;I used to be one!&rdquo; Honestly though, those dangling cords always gave me the creeps.</p>\r\n<h4>EXPLAININGTECHNOLOGYTO THE ELDERLY</h4>\r\n<p>It is one thing to program what I believe to be overly complex hearing aids along with their Bluetooth remotes and gadgets; it&rsquo;s quite another thing to then try to get elderly people to make sense of it all! Clinicians today are constantly &ldquo;putting out fires,&rdquo; and I think they are doing so far more today that they ever used to do in the past. Clients would come into my office with small bags containing unused cords, boxes, and television streaming devices and dongles. I truly believe that in marketing to the elderly, the manufacturers have gone &ldquo;out to lunch.&rdquo; Murphy&rsquo;s law rules: if something can go wrong, it will. The more complex something becomes, the more easily something goes wrong. As a clinician, I was endlessly repeating and demonstrating how to pair Bluetooth devices to television sets and telephones. In an effort to be extra helpful, I&rsquo;d actually find myself at clients&rsquo; homes crawling behind dusty television sets, and calling from other rooms to demonstrate telephone usage. On my way home I&rsquo;d think, &ldquo;I used to be a prof, now I feel like Ted the cable guy.&rdquo; It&rsquo;s just not audiology anymore; at least not the way I understand it.</p>\r\n<p>People and hearing aids have mixed like oil and water since Lybarger&rsquo;s day more than a half a century ago. It&rsquo;s true that hearing aids are far better now than they were. The disappointing thing though, is that the rate of client satisfaction has not risen at the same rate as hearing aid development and complexity, and I think the key word here is &ldquo;complexity.&rdquo; The unwanted by-product from complexity is confusion, and it is felt by both clinicians and clients.</p>\r\n<p>We have made amazing strides in technology, digital algorithms and features (although manufacturers continue to give similar features completely different names). The downside is that it has all come at a cost, literally and figuratively, to clients and clinicians. With all the recent &ldquo;progress,&rdquo; I&rsquo;m not sure clinicians feel that fittings are easier today than they used to be. I also do not believe the monetary cost of hearing aids compared to eyeglasses is at all well understood by clients. If we could return to more direct simplicity, I think both clients and clinicians would both be a lot happier. There was a philosopher some 700 years ago named William of Occam, who came up with a maxim called &ldquo;Occam&rsquo;s Razor.&rdquo; It says, &ldquo;The simplest explanation is the best one.&rdquo; In the world of hearing loss and hearing aids, clients and clinicians, might it just be possible to take this one step further? Maybe the simplest explanation is the correct one!</p>\r\n<h4>WHEN FITTING HIGH-TECH HEARING AIDS, DON&rsquo;T PROMISE THE MOON</h4>\r\n<p>Today&rsquo;s advanced hearing aids offer lots of features that consumers may find pretty amazing. As a result, hearing care providers may be tempted to parade these high-tech wonders in front of their patients to get them excited about what they offer. In my opinion, this is a huge mistake! If you promise too much, the patient will expect too much, and you will end up spending too much time and energy dealing with unhappy, disappointed patients. The fact is, most people purchase hearing aids for simple, basic reasons: They have difficulty hearing their family; they want to hear better at religious services; they need to hear better at work.</p>\r\n<p>like &ldquo;frequency transposition&rdquo; and &ldquo;automatic environmental adaption&rdquo; and on trying to persuade patients that these state-of-the-art features make a pair of hearing aids worth $6000, you are setting yourself up for a fall. Today&rsquo;s hearing aids do have some remarkable capabilities. They enable you to hear on your cell phone using a Bluetooth connection. A hearing aid&rsquo;s directional-microphone system tracks the location of sound, which allows you to converse with a person sitting behind you in the back seat of your car. These features are wonderful, and some consumers go crazy over them. But to most patients who come into your office, they are the icing on the cake&mdash; not the cake.</p>\r\n<h4>ONE BASE AT ATIME</h4>\r\n<p>I tell my hearing aid patients that the process we are going to follow is like scoring a run in baseball: We have to get to &ldquo;first base&rdquo; first, then to &ldquo;second  base&rdquo; and &ldquo;third.&rdquo; We can&rsquo;t expect to hit a home run on the first pitch. I don&rsquo;t want to overload and overwhelm the patient with a long list of &ldquo;do thises and do thats.&rdquo; My goal is to give them excellent hearing&hellip;slowly&hellip;emphasis on the word &ldquo;slowly.&rdquo; Solve the most basic problem the first week. Then, solve another problem, deal with a different situation, the second week. Eventually you will implement all the features of the system and maximize its potential benefits. But, doing this takes time, patience, and a good deal of work. So, to reduce frustration to a minimum, limit the patient&rsquo;s expectations to &ldquo;doable&rdquo; levels.</p>\r\n<p>Adam had the good opportunity in 1991 to work in a hearing aid shell lab cleaning up on night shift. From there here worked in service and repair. Following this he worked for a great entrepreneur who taught him fitting, troubleshooting, and the satisfaction of helping people hear betterevery day.He has also worked in the hearing instrumentspecialistcourse at Conestoga College and currently works in the Hearing Instrument Specialist course at George Brown College.</p>\r\n<p>for 5 years, then you should stipulate this up front. Keep in mind that working for someone and following their practices in &ldquo;your&rdquo; clinic can be difficult, painful and perhaps impossible. A 3&ndash;5 year contract can be a long haul and be immensely stressful for both you and your former staff. An alternate strategy to selling your business to a corporation would be to take on an associate. This would be ideal in cases where you want to maintain the practice as it is and as it operates. As the years go by you could transfer the business to the associate and take a declining role, or you could become a part-time member of the office and maintain full ownership while working much less hours. Whatever route you might pursue it is again vital to have accounting and legal assistance. A smile and handshake are not sufficient and countless examples exist of the failure of such an arrangement.</p>\r\n<p>Be certain that if you want to stay on with the purchaser&rsquo;s organization after the sale and that you establish this before close. Items like salary, contract duration, and your roles and responsibilities must be predetermined in writing and in advance of close. Also remember that you can&rsquo;t expect to keep the salary and benefits that you enjoyed as an owner when you become an employee. (Or pending the status of your business maybe you will enjoy more?) Make no assumptions as to your role with the future organization, or your place in their organization. Ensure that you know how the purchaser has and currently runs their operation, and what they intend to do in the future. Also, make sure that you are comfortable with all aspects of their intentions. Read and understand everything that you sign, or don&rsquo;t sign it. As has been proven over and over again in acquisitions, if you don&rsquo;t have statements in writing &ndash; you have nothing. Just like making a major purchase decision like a car or house, you do need to shop around. Don&rsquo;t sign a nondisclosure or confidentiality agreement until you are committed to dealing with a given purchaser. Some non-disclosure agreements make it prohibitive for you to open negotiations with another possible buyer for 6&ndash; 12 months after discussions with the first one. There may also be a first right of refusal. This means that if you were to start discussions with Buyer A, and then stop them to start again with Buyer B, Buyer A may still have the right to meet or better the offer of any other buyer. So, do your homework well in advance of signing any paperwork.</p>\r\n<p><strong>SOME PRELIMINARYTHINGSTO DO</strong></p>\r\n<p>Investigate your possible purchasers.</p>\r\n<p>&bull; How long have they been around in their current structure?</p>\r\n<p>&bull; What is their current corporate philosophy? Not just their official one, but look at how they behave as corporate citizens. Winning the employer of the year award is not a solid indicator of what kind of company you are dealing with; check and see how they treat their staff, current and former.</p>\r\n<p>&bull; How do they treat their patients? Is patient care truly #1? Is repeat business #1? Is a resale every 3 years #1? Are they able to balance all three?</p>\r\n<p>Who owns the purchaser? Are they interested in establishing lines of delivery from engineering through manufacturing to end patient care, or do they have other goals? Do you agree with these goals? Possibly the most important: Ask other people who have sold to them what they thought of the process, and what they think of the company post-purchase. Specifically find references from other people who sold their practice and then contact these people to ask how the transition went, did the company deliver on their stated promises, and would they do it again? Make sure your company is financially presentable. You will likely require financial statements for the last three years including annual Profit and Loss, and financial statements.</p>\r\n<p>Investigate your own business. Are you charging the recommended fee guide for dispensing fees? Do you enjoy the possible tax write-offs that a private business enjoys? Is your business set up as a tax shelter for your retirement (or should it be)? You don&rsquo;t have to be judgemental with your answers; they simply provide you with the structure to compare against what your business will be post sale. (Will you be happy with that?)</p>\r\n<p><strong>HANDING OVER THE NUMBERS</strong></p>\r\n<p>Before you make a dozen copies of your company&rsquo;s financials please remember who you are giving these too. If a letter of confidentiality is not in place (it should protect you, not just the purchaser), you are basically handing over some pretty vital information to some possible would be competitors. You can have your statements ready, and give out just the pertinent numbers for discussion purposes.</p>\r\n<p>What should you expect when you hand over numbers? If a confidentiality agreement is not in place you can have a discussion and ballpark numbers. Purchase price, like anything else of this importance is negotiable. You will require an accountant and a lawyer. This is vital for the protection of you and your company. Most of us are not accountants or lawyers and you will be doing yourself immense disservice if you decide to do everything on your own. Sign nothing until the lawyer has checked it over. If you do not understand or disagree, then STOP until you do!</p>\r\n<p>Don&rsquo;t expect an accountant to evaluate the price of your business in this climate. It is up to you to shop around. Expect that this step could take up to a year if you are being diligent. There are no common business models that correctly evaluate our type of business. The accountant needs to help you with tax planning on topics like retained earnings, capital gains exemptions, and other tax minimizing strategies which could save you many thousands of dollars. The last thing you want to do is to trigger massive tax payments that will seriously eat into your selling price.</p>\r\n<h4>HOW DOYOUWANT TO SELL THE BUSINESS?</h4>\r\n<p>Do you want the cheque on Friday and you will give them the keys? This can happen but is not preferred. Most purchasers want the former owners to stay on for 2&ndash;5 years post sale to help train staff and provide continuity to the patients. The purchase price will probably be spread out as payments over the course of a few years. There may be a portion withheld and paid out upon your business hitting predetermined performance targets. Be sure that you think they are attainable, they may not be renegotiated later. Alternatively, a portion may be withheld and paid out pending your continued employment. Regarding purchase price paid out related to performance, check the purchaser&rsquo;s references. You may be shocked to find out how seldom this portion is ever paid out! Also, have a good look at the targets &ndash; in one example the targets for payout were over 10% growth per year. You shouldn&rsquo;t be selling a mature business if it is capable of 10% growth per year for the next 3 years. In many cases, negotiate what you want for the purchase price to be delivered on close; the remainder will probably be unachievable and never realized. Oh yes, also expect a significant noncompete clause. Typically such a clause will prevent you from working within a certain distance of current clinics for a given amount of years.</p>\r\n<p>Also expect change, a lot of change. Back to the beginning now: Yes, you may have provided excellent service in the years that you owned your practice, but large companies bring their own systems and procedures with them. How the purchaser will operate is something that you should learn when you are investigating them. Expect that you will have to implement their methods after you have sold. You may have to change computer systems, the sign above the door, how your patients are contacted, marketing, bookkeeping, and advertising (know in advance how these expenses will be allotted or could impact your earn-out). Your roles and responsibilities may increase or decrease. Investigate thoroughly what will happen after you sell and be sure that you are comfortable with it. In one example, the previous owner was not allowed to advertise during their 3 year earn-out and was saddled with all the labour of bookkeeping and expense of computer systems upgrades that the head company downloaded. This resulted in much more paperwork, less time spent with patients and less incoming traffic which meant that the planned earn-out was not possible or achieved.</p>\r\n<p>Do seriously consider selling to an associate, colleague, or family member. If you examine the possible price that a buyer might pay on close (ignore earnouts) and examine long-term tax strategies you could conceivably come out ahead and ensure a positive transition for both yourself, your staff and your patients.</p>\r\n<p>ByTim Kelsall Noise andVibration, Hatch Energy</p>\r\n<p>Tim Kelsall is an experienced practitioner in noise assessment and control in heavy industry, including metals processing, mining, transportation, and energy. Tim is the chair of the Canadian noise standards committees. His specialties include: accoustics, noise control, noise assessment, human vibration, Canadian and International noise standards. tkelsall@hatch.ca.</p>\r\n<p>More and more people are wearing headsets at work. They are found in retail stores, drive through restaurants and call centres as well as more traditional occupations like pilot and radio operator. CSA Z107.56 is a well known Canadian Standard used to measure the noise exposure of employees under many different situations. However it does not yet provide information about measuring the noise exposure of people who are wearing headsets. A new appendix has been written to address this shortcoming. The appendix is based in part on ISO and Australian standards which use one of two methods. The microphone in real ear method involves a small microphone placed inside the headset. The Mannequin method involves measurement of the signal from the headset using a either a specially constructed mannequin or an artificial ear.</p>\r\n<p>Because these measurements require equipment and expertise beyond the normal range of industrial hygienists and safety personnel, there was a worry that reliance on these measurements might severely limit the workplaces where the employee noise exposure from headsets could be measured. This would have been counter-productive. In many common cases, such as call centers, retail stores, fast food, etc. the sound level from the headset is adjusted to allow it to be heard over the existing reverberant background noise. In many such cases, there was the possibility that the exposure measurements could end up costing almost as much as it would cost to reduce the background sound level by controlling reverberation, use of barriers or headsets inside conventional muff type hearing protectors.</p>\r\n<p>The calculation method proposed in the new draft Appendix of Z107.56 provides a simpler approach which can be carried out by an industrial hygienist or safety officer using the same equipment used to measure noise exposure. While recognizing the lower accuracy inherent in such an assessment, it can provide a first step in assessing and resolving these situations. Measurements have shown that in many cases the sound level produced by a headset is adjusted by the user to be about 15 dB above the existing background noise under the headset. This simple fact provides the basis for the method. The measurement procedures are the same as used for employees without headsets. The sound level under the headset is calculated by subtracting the published headset attenuation from the sound level measured in the area using standard techniques. The sound level from the headphone signal is assumed to be 15 dB higher and the noise exposure is calculated based on the times the headphone signal is on and off during a typical workday  For a regulated limit of 85 dBA, this would mean that the combination of the background noise coming through the headset and the expected noise produced by the headset signal (itself 15 dB above the background noise inside the headset) should be no louder than 85 dBA. Most headsets provide little or no protection against external noise. Accordingly, the noise reduction of the headset is assumed to be zero unless the manufacturer can provide user fit octave band insertion loss data taken according to ANSI S12.6. The calculation must also account for the time the headset signal is on.</p>\r\n<p>An example of a simple calculation without and with headset attenuation is given below in Tables 1 and 2. The calculations shown here are simplified. The actual noise reduction of the ambient by the headset would have to be calculated in either octave or 1/3 octave bands. This calculation is not shown here since it is straightforward to do and adds little to the discussion. Note that unless the use of the headset is extremely intermittent, the Lex from the ambient inside the headset is much lower than the sound from the headset. If the headset is used more than 1 hour per day, the ambient has less than 1 dB effect on the result. In such cases the sound level under the headset can be calculated by simply adding 15 dB to the Lex,8h measured outside the headset (corrected for headset signal duration), reduced by the NR of the headset (which is zero for most headsets).</p>\r\n<p>Another way to look at it is that unless the headset can be shown through subject fit data to reduce the sound level by more than 15 dB, using the headset will increase the noise exposure of the employee above the Lex,8h measured outside the headset unless the headphone signal is used very rarely. For example, a normal headphone in use all day in an ambient of 80 dBA would produce a noise exposure of 95 dBA. Reducing the headset use to 2 hours a day would still give an exposure of 90 dBA. Only if the headset gave at least a 20 dB reduction (typical of a reasonably good muff) would it start to give as little as 5 dB of protection to someone using the headset continually</p>\r\n<p>This change gives us a new capability for assessing the noise exposure of employees who could not be assessed before. It also points up the potential for headsets to be a significant source of noise exposure to those who wear them in even moderately noisy environments and the effect even a small amount of headset use can have on the protection provided even by very good muffs. Industrial hygienists are going to have to take a good look at any situation where employees use muffs for both protection and communication. In many such cases they may not be getting the protection they need.</p>\r\n<h4>REFERENCES</h4>\r\n<p>1. Turner R. Masking Redux I: an optimized masking method. J Am Acad Audiol 2004;15:17&ndash;28.</p>\r\n<p>2. Killion M, Wilber L, Gudmundsen G. Insert earphones for more interaural attenuation. Hearing Instruments 1985;36:34&ndash;36.</p>',NULL,'2022-11-16'),(19,3262,'ajchr','http://www.andrewjohnpublishing.com/','<p><strong>By Gael Hannan hannangd@gmail.com</strong></p>\r\n<p>Gael Hannan is a writer, actor, and public speaker who grew up with a progressive hearing loss that is now severe-to-profound. She is a director on the national board of the Canadian Hard of Hearing Association (CHHA) and an advocate whose work includes speechreading instruction, hearing awareness, workshops for youth with hearing loss, and work on hearing access committees. Gael is a sought-after speaker for her humorous and insightful performances about hearing loss. Unheard Voices and EarRage! are ground-breaking solo shows that illuminate the profound impact of hearing loss on a person&rsquo;s life and relationships, and which Gael has presented to appreciative audiences around Canada, the United States and New Zealand. A DVD/video version of Unheard Voices is now available. She has received several awards for her work, including the Consumer Advocacy Award from the Canadian Association of Speech Language Pathologists and Audiologists.</p>','<p>Never judge a book by its cover &ndash; even an inexpensive photocopied one &ndash; because what&rsquo;s inside might be jaw-dropping. This week, sorting through 20 years&rsquo; accumulation of hearing loss material, I was about to pitch out a spiral-bound booklet called 80 Years of Looking &amp; Learning. I opened it and was mesmerized. Compiled in 2001 by the early lip reading advocate Dorothy Scott, the mimeographed pages not only tell the story of the Toronto Hard of Hearing Club formed in 1921 &ndash; but they also give an amazing, humorous look at life with hearing loss over the past 100 years. Thank you to the existing members of the Toronto Hard of Hearing Club for sharing this written history.</p>\r\n<p>from the booklet with only minor grammatical changes and notes. Some terminology may be considered politically incorrect by today&rsquo;s standards. 1921 &ndash; A small group in a then rather small Toronto got together to form the Toronto Lip Reading Club &ndash; the &ldquo;First in the British Commonwealth&rdquo;. Who started it? Why then? Who had hearing loss in 1921? The Hard of Hearing populace then, as now, included those born with defective hearing or who developed a loss in infancy, but with impairment mild enough to enable the child to learn to communicate through speech and hearing  the &lsquo;War to End All Wars&rdquo; had dragged to its exhausted end. The lads had come home with their memories &ndash; of mud and pain and gas and the screams of dying comrades. Some had a constant reminder &ndash; they had to learn to live with Hearing Loss. Gunfire, wounds, shock, meningitis and ear infections had changed their lives forever.</p>\r\n<p>Hearing loss was not confined to veterans. In the day before antibiotics, immunization and middle-ear surgical correction, those who suffered from partial deafness were often children and young adults. In the early years of the century, young Alec of Dundee developed scarlet fever. He did recover, but with ever-increasing deafness. In school, the top children sat at the front of the class. If your grades deteriorated, you were moved back and back until  you sat with the failures in the rear, where poor confused Alec, who had confidently hoped for university, eventually found himself.</p>\r\n<p>There were lots of Alecs in Toronto. There was no way of diagnosing partial deafness in early childhood until defective speech gave some clue. Even if you did find out that the problem was poor hearing, not mental incapacity, what could you do? One option for children over 7 was the School for the Deaf and Dumb in Belleville [now Sir James Whitney School for the Deaf], founded in 1907, which ran a 9-month, no-holiday term designed to prepare the child for nonverbal workplace activities &ndash; printing, saddle-making, domestic service, etc. The brochure stated, &ldquo;It is not desirable that parents come often (to visit) or remain long.&rdquo; But although it was a good school, at the forefront of deaf education, many deaf children were kept at home by their parents.</p>\r\n<p>There were lots of Alecs in Toronto. There was no way of diagnosing partial deafness in early childhood until defective speech gave some clue. Even if you did find out that the problem was poor hearing, not mental incapacity, what could you do? One option for children over 7 was the School for the Deaf and Dumb in Belleville [now Sir James Whitney School for the Deaf], founded in 1907, which ran a 9-month, no-holiday term designed to prepare the child for nonverbal workplace activities &ndash; printing, saddle-making, domestic service, etc. The brochure stated, &ldquo;It is not desirable that parents come often (to visit) or remain long.&rdquo; But although it was a good school, at the forefront of deaf education, many deaf children were kept at home by their parents.</p>\r\n<p>With the returning soldiers came new wives, often accompanied by &lsquo;unmarried sisters.&rsquo; And so K. Grace Wadleigh came to Toronto. She was a trained Teacher of Lipreading and Education of the Deaf and little was known about her except that she was Terrific. The Toronto School Board of the time had no place for her in her chosen field, although she did later work with them. But that didn&rsquo;t stop Miss Wadleigh. She became the founding teacher of the Toronto Lip Reading Club, formed in February 1921. The annual membership fee was $1.00; by making the annual fee very small it was hoped no one would be prevented from joining. Meetings were held at the  YMCA Thursday evenings and Saturday afternoons with teachers Miss G. Wadleigh, (the &ldquo;First Teacher Of Lip Reading To Adults In Canada&rdquo;), Miss G. Tuller and Miss M. Faircloth, both teachers of the deaf. What kind of training would these ladies have had? Certainly they all had their teaching certificate and probably were hard of hearing. By 1923 there were 73 members and the annual fee had doubled to $2.00. &ldquo;Silver teas&rdquo; were held to raise money, whereby participants left donations in a strategically placed bowl. By the 1930s, things were beginning to hum in the hearing field! Universities and teaching hospitals were setting up Deaf and Hearing research facilities. Although the 4A Phono-Audiometer was introduced in 1926 to screen hearing, findings were pretty subjective. Most testing was still the old &ldquo;Can you hear my watch?&rdquo; The Hearing Eye was the &ldquo;Official Publication of the Canadian Federation of Lipreading Organizations&rdquo;, formed in 1933. L.M. Montgomery, the author of Canada&rsquo;s beloved Anne of Green Gables, was a frequent contributor and in 1935 she gave a talk to the club. She stood on a wobbly platform with a lamp shining on her face so that it would be visible. &ldquo;She enunciated so clearly that lipreaders were well repaid.&rsquo; The same year, the Toronto Lip Reading Club was divided into three departments &ndash; Women, Men and Young People &ndash; and the first Theatre Amplifier was introduced in six movie theatres. This service involved sitting in a pew at the front using a telephone-like device. Only the boldest allowed themselves to be so helped &ndash; to be hard of hearing was still thought slightly shameful.</p>\r\n<p>By Cammie Kaulback, Manager of Hearing Services, Deaf &amp; Hear Alberta</p>\r\n<p>Afew years ago my sister-in-law sent my son a birthday present in the mail. The rather large package turned out to be a toy weed-whacker. It was eerily similar to the one in my garage and from 10 paces it could have been mistaken for the real thing. Not only did it look like a real garden trimmer, but when you powered it up it made the same indisputable roar. So realistic was the sound that once you heard it you instinctively clamped your hands over your ears to protect your hearing. The weed-whacker was sent by my sister-in-law partly as a joke and partly out of revenge. A few years earlier I had sent my nephew a shiny red fire truck with a siren that was also ear splitting. Like many parents we found the noisy toys annoying, but I don&rsquo;t think we understood how dangerous they were to our child&rsquo;s hearing health. Every day, children experience sound in their environment. Normally, these sounds are at safe levels that don&rsquo;t damage their hearing. However, repeated and extended exposure to loud noise is one of the most common causes of noise-induced hearing loss. Parents need to realize that every time a child holds a loud toy to his ear he may be permanently damaging the delicate hair cells in the inner ear. The damage might not be noticeable right away, but over time our children&rsquo;s hearing is being impacted by a noisy world that also includes traffic noise, thundering sporting events and loud music from personal music players. Is it any wonder that it is now estimated that one in five children between the ages of 12 and 18 has some level of hearing loss?</p>\r\n<p>The consequences of hearing loss can be devastating, but particularly for children. The Centers for Disease Control and Prevention report that even a small degree of hearing loss can affect a child&rsquo;s speech and language comprehension. Hearing Loss can also impact a child&rsquo;s classroom learning and social interaction with her peers. In Canada, regulations under the Canadian Consumer Product Safety Act state that a toy &ldquo;must not make or emit noise of more than 100 dB (equivalent to the noise of mowing your lawn with a gas-powered lawn mower) when measured at the distance that the toy would ordinarily be from the ear of the child who is using it.&rdquo; The obvious problem with this is that children don&rsquo;t always play with toys in their intended manner.</p>\r\n<p>Young children, in particular, will often bring toys close to their face and ears as part of play. This means that the danger of noisy toys is even greater than the 100 decibel level implies. A toy which exposes a child to 100 decibels when played at arm&rsquo;s length can expose her to 120 dB of sound when held to her ear. That&rsquo;s equivalent to the sound of a jet plane taking off. Back in 2006 the Canadian Association of Speech-Language Pathologists and Audiologists started to lobby members of parliament and Health Canada to lower the 100 decibel limit. They also created a public awareness campaign which highlighted the dangers of noisy toys to the hearing health of children. Their valiant efforts to move the needle of this issue raised awareness, but ultimately it did not change the government&rsquo;s 100 dB rules for manufacturers, importers or distributors of toys in Canada. So where does that leave us in 2014? It means that parents, grandparents and caregivers have to be increasingly vigilant and educate themselves about the dangers of noisy toys and act accordingly. We need to recognize that Health Canada&rsquo;s guidelines as to which toys have safe noise levels do not take into account how toys are actually used in the hands of a child.</p>\r\n<p>Parents, grandparents and caregivers need to rely on their own common sense to protect children&rsquo;s hearing. Here are some hints to help keep things safe:</p>\r\n<p>1. Listen to a toy before you purchase it. If a toy sounds loud in the store, it will be loud at home.</p>\r\n<p>2. Consider downloading a decibel meter app to your smart phone and get a reading on a toy before you head to the checkout. Reconsider anything that reads over 85 dB. (There are several good decibel apps out there, but I like Decibel Meter which you can download for free.)</p>\r\n<p>3. Look for toys with volume controls and on/off switches.</p>\r\n<p>4. Supervise your children when they are playing with a toy that emits sound and teach them how to do so safely. Teach them not to place the toy near their heads and ears.</p>\r\n<p>5. Remove the batteries from a noisy toy.</p>\r\n<p>6. If all else fails, get out the duct tape. My son&rsquo;s infamous weed-whacker was tamed by affixing a piece of foam and some duct tape over the toy&rsquo;s speaker. It may not have looked pretty, but my do-it-yourself modification meant he could continue to play with the now much quieter toy.</p>\r\n<p>ByTedVenema, PhD</p>\r\n<p>Ted Venema taught at Conestoga College in Kitchener, Ontario, and was the founder and director of its program for hearing instrument specialists. He has a PhD in audiology from the University of Oklahoma. Ted frequently gives presentations on hearing, hearing loss and hearing aids and is author of the textbook Compression for Clinicians, published by Cengage and now in its second edition.</p>\r\n<p>I n the beginning was Functional Gain. Real-Ear measures did not exist. All hearing aids were linear. These lines sound like they come from an ancient narrative of the origins of life, but things in our hearing aids world truly had to begin somewhere, and they did. Today&rsquo;s hearing aid fitting methods really go back to Sam Lybarger, back in 1944. He&rsquo;d stand a Texas yard away from the listener who wore the hearing aid, he&rsquo;d speak in a normal conversational voice, and ask the client what sounded comfortably loud. With good old empirical &ldquo;check it out&rdquo; methodology, he found the listener wanted or preferred gain that was close to about &frac12; of the client&rsquo;s hearing loss at each frequency. Lybarger knew this made sense; with sensorineural hearing loss (SNHL), one&rsquo;s hearing thresholds increase but loudness tolerance does not increase by much, if at all. In other words, the &ldquo;floor&rdquo; is raised but the &ldquo;ceiling&rdquo; is not. Lybarger also knew that input plus gain equals output. For most  clients with SNHL, an input of conversational speech intensity, plus amplification by the total amount of the client&rsquo;s hearing loss, would make the resultant output far too loud to tolerate. Thus the &ldquo;&frac12; gain rule&rdquo; hearing aid fitting method was born.</p>\r\n<p>The purpose of this article is not to sketch out the development of fitting methods; that has been done time and time again and readers know where and how to find that information. Rather, it is of interest here to describe the evolution of measurements used to apply fitting methods, because these measurements frame how clinicians &ldquo;see&rdquo; the results of their fitting methods. In the old days clinicians had to imagine the end outcomes. Our present Real Ear method involves the literal mapping of aided speech on to the client&rsquo;s audiogram. The results of the fitting are splayed out there on the client&rsquo;s residual dynamic range, as seen on a computer screen. If Lybarger could only have seen this!</p>\r\n<h4>FUNCTIONAL GAIN MEASURES WERE FIRST</h4>\r\n<p>The development of hearing aid fitting methods can largely be described according to what was being measured, and how this was being measured. Functional gain came first, then came Real Ear and Insertion gain, and finally today we use Real Ear measuring In Situ Output. Functional gain means behaviourally measured gain, or gain that is measured as a voluntary response of the client. This is how we did it, from the 1940s all the way to the mid 1980s. A client&rsquo;s aided thresholds in a sound field with a hearing aid (yes, usually just one) at a comfortable volume control setting were compared to his or her unaided thresholds measured with headphones. Aided thresholds were always measured with &ldquo;warble tones,&rdquo; and this was done in order to reduce any possible reverberation in the sound field of the sound booth. I remember well presenting warble tones in a sound field.</p>\r\n<p>I felt like I was playing an organ, especially with the low-frequency tones. Just like measuring thresholds under headphones, the client would raise a hand when the aided tones were audible. A successful fitting was signified by little letter A&rsquo;s written across the audiogram, showing a lift of thresholds about halfway up toward the 0 dB HL line. The idea was that average speech inputs, plus the hearing aid gain, would give an output that fell within the client&rsquo;s dynamic range (Figure 1). Fitting methods continued to evolve in the late 1970s and 80s from various different philosophies (Berger, POGO, Libby, NAL), and so exactly where you&rsquo;d want the little letter A&rsquo;s to appear on the audiogram would differ slightly from method to method. All fitting methods however, had the &frac12; gain rule as their spinal cord.</p>\r\n<p>What functional gain all too often left unstated and unillustrated, however, was the goal of the &frac12; gain rule; namely, that the aided speech output (Figure 1) would thus be placed within the client&rsquo;s residual dynamic range! The outcome of aided speech output was almost never described or pictured as it would appear on an audiogram. Speaking for myself, I think this was always a missing step in terms of my own understanding of hearing aid fittings. My professors had never described it to me like that, but in hindsight, I sure wish they had. It surely would have made it easier for me to digest the DSL fitting method and the mapping of aided speech when these came around.</p>\r\n<h4>THEN CAME REAL EAR AND INSERTION GAIN</h4>\r\n<p>Then, in the late 1980s, came Real Ear and Insertion gain. At the time, I was a new audiologist at the Canadian Hearing Society. Inside each of their four sound booths there was a new Real Ear device called &ldquo;Rastronics.&rdquo; It had a black screen and I recall all the tracings were green. Fitting Methods had not changed, and hearing aids were almost all still linear, but Insertion Gain became the new order of the day. It was faster than Functional Gain, and yielded objective, non-behavioural results. You&rsquo;d simply enter the client&rsquo;s audiogram into the Real Ear system, choose a fitting method, and the aided &ldquo;target&rdquo; gain would then instantly appear on the screen. As with Functional Gain, this target could be based on the &frac12; gain rule, or any of the above-mentioned fitting methods (Berger, POGO, NAL-R, etc).</p>\r\n<p>The important thing to note is that although the actual Insertion Gain values did not differ from Functional Gain values, the display of Insertion Gain was completely new. Instead of decibels (dB) in HL increasing as you looked down the audiogram, dB were displayed in terms of SPL and they increased as you went upwards on the new graph. The difference between unaided ear canal dB SPL versus aided ear canal dB SPL was Insertion gain. The whole idea was to compare the Real Ear Unaided Response (REUR) to the Real Ear Aided Response (REAR),  with the difference being Real Ear Insertion Gain (REIG). Since the hearing aids were Linear, you could simply say like they do at the carnival, &ldquo;Pick an input&hellip;any input&hellip;&rdquo; In order to make the input audible above ambient room noise, an input of 55 dB SPL was almost always selected. At any rate, the bottom line was, if your REIG matched the target of the particular fitting method you were using, you were good to go (Figure 2)!</p>\r\n<p>But now just try counseling a client from the perspective illustrated on Figure 2: &ldquo;Well, you see, this line is what we&rsquo;re supposed to hit and this little lighter line is right near it, so your hearing aid is doing what it&rsquo;s supposed to do.&rdquo; The main problem here was that the audiogram was not visually part of the picture, so aided speech outputs simply had to be imagined. In this way, Insertion Gain was actually worse than Functional Gain. Interesting too, was that REUR wasn&rsquo;t incorporated at all in the unaided testing under headphones, but oh well. Non-behavioral Real Ear measures were certainly a whole lot faster than testing someone&rsquo;s thresholds twice! Another good thing about Insertion Gain was that if someone came in saying the new hearing aid just didn&rsquo;t sound like the old one, you could do a quick Real Ear measure on the old one, and then make the new hearing aid do the same thing. Of course you could also do this with ANSI measures&hellip;Still, however, some objective data is much better than completely relying on the old saw, &ldquo;How does that sound?&rdquo;</p>\r\n<h4>IN SITU OUTPUT CHANGES REAL EAR</h4>\r\n<p>Richard Seewald really is the father of newer Real-Ear measures. His Desired Sensation Level (DSL) fitting method arose in the early 1980s, and with it, came the SPL-o-Gram. Insertion Gain and REUR were unceremoniously tossed onto the garbage heap of audiologic history, and Real Ear measures took on a whole new look. Now the whole focus was on in situ output, also known as REAR. Trouble was, only Seewald and his followers used the SPL-o-Gram and DSL. Most clinicians in North America, including myself, plodded on with Insertion Gain Real-Ear measures. I remember returning back to Canada in 1995 from Alabama where I taught audiology at Auburn University for a couple of years. I was a new employee at Unitron Hearing in Kitchener. Here in this pink Commonwealth country of Canada, DSL loomed large as the recommended fitting method. I attended a DSL workshop held at Western, where Seewald, Cornelisse, and Moodie diligently presented on DSL. I have to admit that I still didn&rsquo;t really get it. I&rsquo;d echo the columnist Allan Fotheringham who used to say, &ldquo;Elucidate the nebulosity of your phantasmagorical perceptions.&rdquo; Insertion Gain just seemed so easy, lots less busy, fewer lines and like an old friend, just so familiar.</p>\r\n<p>It then came to me suddenly, upon a midnight clear. I remember &ldquo;the hour I first believed.&rdquo; It may seem blasphemous to the Cardinals of DSL, but the &ldquo;trick&rdquo; to my own understanding DSL was in looking at the missing piece, the unsung goal of Functional gain; recall Figure 1, and its display of where aided speech would lie within one&rsquo;s dynamicrange. DSL used Real Ear to display the SPL-o-Gram of each client. With its SPL-o-Gram, DSL pioneered a way to instantly display what Functional gain measures intended, but did not tend to show. With Real Ear measures, we now actually had the technology to display the audiogram, along with aided speech outputs, all on one graph, all in dB SPL, and all this right-side up! Let&rsquo;s look at the SPL-o-Gram (Figure 3). Everything including normal hearing and the client&rsquo;s own thresholds is plotted according to output, and in terms of dB SPL. Now hearing loss and hearing aids are speaking the same language. &ldquo;More&rdquo; on the graph now goes up, like every other graph in the world (except the Oddiogram). Normal hearing thresholds are placed on the bottom and Loudness Discomfort Levels (LDLs) are placed on the top. The patient&rsquo;s hearing loss is placed part way up on the graph, thus showing a reduced dynamic range (the &ldquo;floor&rdquo; is elevated but the LDL &ldquo;ceiling&rdquo; is the same). One can show and compare unaided to aided speech. Clients can readily see what parts of speech were inaudible without hearing aids, and what parts have now become audible when aided.</p>\r\n<p>Since compression hearing aids give different gains and output for different input levels, three targets are shown for: soft, medium, and loud inputs. The idea is to aid the listener so that soft speech input sounds soft, average speech input sounds average, and loud speech input sounds loud. Now there&rsquo;s an improvement for counseling! As we say in Canada, &ldquo;Neat, eh?&rdquo; The trouble with Functional Gain was its lack of displaying its goal; namely, putting aided outputs nicely with the client&rsquo;s dynamic range. How could it be blamed for this; the technology of Real Ear had yet to make the scene. The trouble with Insertion gain was that the goal seemed to be all about hitting those targets. I recall feeling quite good about things as I drove home from my day&rsquo;s work, thinking, &ldquo;I hit the target 4 times today!&rdquo; Ensuring that aided in situ outputs were positioned properly within the client&rsquo;s dynamic range is just not a natural or logical extension of Real Ear Insertion gain measures. Counselling with it was next to impossible!</p>\r\n<p>In 1997, NAL-NL1 emerged from another large pink commonwealth country (Australia) on the globe, and I remember how it very gradually began to follow suit with DSL&rsquo;s SPL-o-Gram. One could initially see NAL-NL1&rsquo;s simultaneous usage of both Insertion gain and in situ output, but this was followed within about a year by their rather quick dumping of Insertion gain. For DSL then, imitation could be considered the finest form of flattery. The &ldquo;rub&rdquo; is that even though fitting methods all differ in various ways they are all actually trying to accomplish what the SPL-o-Gram shows! Placing aided outputs properly into a client&rsquo;s dynamic range is what it&rsquo;s all about. It&rsquo;s just that in the past, we didn&rsquo;t have the equipment to show this. Up until DSL, gain was always the order of the day. Functional gain compared aided to unaided thresholds, and Insertion gain compared REAR to REUR. The SPL-oGram changed everything by focusing on output instead of gain. Output is king; gain is just a means to an end. Output is the groceries delivered to the doorstep of one&rsquo;s eardrum; gain is like asking how did you get to the store, by driving or cycling. The SPL-o-Gram allowed us to visualize (1) normal hearing, the client&rsquo;s audiogram and the reduced dynamic range, and (2) unaided and aided speech outputs all on one graph. While this may have seemed like a &ldquo;small step&rdquo; for a print job, it really was a &ldquo;giant leap&rdquo; for audiology. Neil Armstrong taught us that we all need to look at the moon from time to time &hellip; Richard Seewald I understand enjoys photography &hellip; but I digress.</p>\r\n<p>There&rsquo;s another twist, however, to this story. The main two kids on the block, the DSL and NAL fitting methods have  each evolved over the past few years. DSL 4 became DSL 5, and NAL-NL1 became NAL-NL2. They have evolved, however, to become more similar than different. In fact their adult versions are so similar that if you don&rsquo;t compare them carefully, you may not even notice the differences. Check out the target comparisons for yourselves (Figure 4).</p>\r\n<p><strong>ISLANDS INTHE SETTING SUN?</strong></p>\r\n<p>The use of today&rsquo;s Real Ear measures, along with the similarity of the two major fitting method heavyweights can lead us to paint with broad strokes, at least for the adult population. Clinicians know all too well that the hearing aid manufacturers all have the major fitting methods in their fitting software, along with their own proprietary fitting methods. We also know that we don&rsquo;t always slavishly  adhere to the targets of a particular fitting method. Rather, we tweak the hearing aid settings according to the adult client?s perceptions and drift to some sort of general compromise.</p>\r\n<p>Although there are minor differences between the adult version of DSL 5 and NAL-NL2, one can easily see the general trends as to how soft, average and loud inputs are literally mapped or placed into the adult client?s dynamic range. If you place soft input speech so that when aided, the output speech surrounds the thresholds, you?ll find that the patient can barely hear it. That?s normal; neither can you or I. Average speech inputs should be aided so its outputs sit in the dynamic range about 1/3 above the thresholds. Loud speech inputs should be aided so they sound loud, but remain below LDLs. Isn?t that what all fitting methods are basically trying to do in the first place? Isn?t that what Lybarger would have wanted to see? For adults (not the pediatric population, of course) it looks as if fitting methods can actually recede away from a frontal focus. To borrow a phrase from the songwriter Paul Simon, they are becoming ?islands in the setting sun.? Ensuring that aided speech outputs are placed within one?s dynamic range is a relatively easy objective to achieve without the use of any Fitting Method targets. To continue with Paul Simon?s lyric, mapping of speech is rapidly becoming the ?bottom line for everyone.?</p>\r\n<p>By Mark Caffery, MA</p>\r\n<p>Mark Caffrey, AuD, Doctor of Audiology. Owner/founder of Caffrey &amp; Associates Audiology with offices in Gloversville and Amsterdam, NY. Dr. Caffrey specializes in vestibular diagnostics and vestibular rehabilitation. Additionally, being hearing impaired himself, he also specializes in diagnostic audiologic evaluations and in hearing aid dispensing. He is a fellow of the American Academy of Audiology, the Academy of Doctors of Audiology, and the New York State Speech-LanguageHearing Association.</p>\r\n<p>I was chatting recently with a patient during a videonystagmography (VNG) evaluation. I was informed, by this surprisingly technology savvy 80-plusyear-old woman, that in her web search for ?dizziness specialists,? audiologists did not get even an honorable mention! She was actually shocked, she continued, when her physician referred her to me, her ?hearing aid doctor,? for testing and possible diagnosis of her dizziness complaints. This particular patient has been a hearing aid patient of mine for more than 8 years. I admit that I too was both shocked and even a little hurt by her disclosure.</p>\r\n<p>Later I retired to my laptop and began my own internet search ... like a patient. I avoided the professional websites that we so easily utilize as audiologists and instead began my search like a patient would; I turned to Google, Yahoo, and Bing. My search topics included: Dizziness, Dizziness Specialists, Who Tests for Dizziness, Who Treats Dizziness, and the same searches using ?BPPV? instead of the word ?Dizziness?. Each of these searches resulted in essentially the same results.</p>\r\n<p>Unfortunately, my search results were no different than my patient\'s findings. With just a single exception, audiologists are not mentioned at all. Since, by definition, audiologists are ?trained to diagnose, manage and/or treat hearing or balance problems?1 this was disheartening to say the least. Most search results (YahooAnswers.com, Healthboards.com, MedLine.com, WebMD.com, UIHealthcare.org, Medicine.net, MedScape.com, and HealthCommunities.com) did not mention the audiologist in any capacity. The suggested sources for the diagnosis of dizziness were overwhelmingly in favor of the primary care physician, which we could concede is a logical place for patients to start, but then the search results directed prospective patients to the neurologist next, then the ear, nose and throat physician, and lastly to physical therapists; even neurotologists managed to obtain only one mention. One of the sites, MedLinePlus, the website of the National Institute of Health/National Library of Medicine, stated that the primary physician might order hearing testing and ENG testing but failed to mention what specialist would provide those specific services. 2 Regarding the treatment of dizziness and/or BPPV, the various sources listed the primary care physician, the ENT, the Physical Therapist, and even the Occupational Therapist. Again, the audiologist was omitted.</p>\r\n<p>One solitary site during my search specifically listed audiologists as a source for the diagnosis and/or treatment of dizziness. This site is ShareCare.com. In fact, at this source, ShareCare.com, the Honor Society of Nursing lists the audiologist as the preferred source, followed by ENTs and neurologists only if the dizziness is linked to brain anomalies. 3 These mostly unflattering search results reminded me of a NYSSLHA conference a couple of years ago when one of the presenters asked the audience how many audiologists in attendance were treating BPPV in the office; sadly, I was the only one to raise my hand. All this brings me  to the ultimate purpose of this article. The American Academy of Audiology, in its bylaws, has challenged audiologists to advance ?the science and practice of audiology, and [achieve] public recognition of audiologists as experts in hearing and balance.?4Audiologists need to do a more effective job representing themselves as more than hearing experts; we need to step up to the plate and fulfill our mission completely. We have clearly not achieved public recognition as experts in balance disorders.</p>\r\n<p>Many audiologists simply may not wish to get involved with VNG assessment or may not have the funds necessary to invest $35,000?75,000 in a vestibular diagnostics lab, let alone have the physical space required to provide complete vestibular/balance rehabilitation services. However, for a very modest investment of about $300, any audiologist could begin to provide diagnosis and remediation for the most common form of dizziness. Benign paroxysmal positional vertigo (BPPV) accounts for half of all the dizziness complaints of our elderly patients. 5 A simple Dix-Hallpike maneuver, performed on a very basic flat therapy table, costing about $300, will allow you to determine if BPPV is present. The positive Dix-Hallpike will yield a torsional (rotary) nystagmus that has latency,short duration (paroxysmal), and fatigues; this will be accompanied by vertigo and sometimes nausea. This torsional nystagmus will beat toward the affected ear. 5 While use of Frenzel lenses or VNG recording assures that even the most subtle variations of BPPV are identified, nearly all BPPV can be visualized with the naked eye.</p>\r\n<p>Once identified, the same inexpensive therapy table can then be used to perform any of the canalith repositioning procedures to treat BPPV. The Epley maneuver is the most widely used method in the United States, but I personally prefer the Semont maneuver, which is more commonly utilized in Europe. The Epley maneuver is gentler on the back and is easier to perform on larger patients and patients unable to move rapidly, but it does require a headhanging position which can be difficult for some elderly patients with limited neck mobility. 5 It also requires a bit more time. The Semont maneuver entails moving the patient very rapidly, which can be difficult with arthritic or frail patients or patients with bad backs, but does not require a head-hanging position. The Semont maneuver requires less time and it has a success rate of approximately 90%. 5Reimbursement for audiologists is often problematic with all canalith repositioning, but having the patient sign an ABN (advanced beneficiary notice) resolves this. With such a meager investment, audiologists in nearly all practice settings could begin to diagnose and treat at least the most common cause of dizziness for our patients. If the Dix-Hallpike test is negative, a referral to a colleague that offers VNG and possibly vestibular rehabilitation services would be appropriate. We need to utilize each other and should not fear losing this patient to a competitor. Very few of us consistently provide comprehensive central auditory processing evaluations but may perform a screening and/or provide a referral to a colleague; even fewer of us are directly involved with cochlear implants, but we certainly have the capacity to refer potential candidates to the appropriate facility for further evaluation and treatment. We should therefore exercise the same ethical duty to our patient\'s well being by referring them to other colleagues when necessary for more advanced diagnosis and treatment of vestibular disorders. Our  wonderful profession is not only about hearing aid sales. If we do not represent ourselves as THE specialists for the diagnosis and remediation of vestibular and balance disorders, why would the primary care physician, who will most likely make such a referral, do so? The provision of this very minimal diagnostic procedure and subsequent remediation will not only provide very significant benefit to our vertiginous patients, but will also help our profession better meet its mission to establish ourselves as the experts in hearing AND balance disorders.</p>\r\n<p>Additional discussion regarding the specifics of performing the Epley versus. Semont versus Brandt-Daroff maneuvers for the remediation of BPPV, the myriad of other possible diagnoses from more in depth vestibular assessment, as well as other types of vestibular therapy and balance retraining therapy are reserved for possible other, future article(s). The reader is otherwise referred to his/her vestibular text books for immediate clarification.</p>\r\n<h4>REFERENCES</h4>\r\n<p>1. Wikipedia. Definition of Audiologist. Retrieived January 15, 2014 from http://en.wikipedia.org/ wiki/Audiologist</p>\r\n<p>2. MedLinePlus.com. Dizziness. Retreived December 21, 2013 from http://www.nlm.nih.gov/medline plus/ency/article/003093.htm.</p>\r\n<p>3. The Honor Society of Nursing. What Type of Specialist Treats Vertigo &amp; Dizziness? Retreived December 21, 2013 from http://www.sharecare.com/health/vertigodizziness-treatment/what-specialists-treat-vertigo -&amp;-dizziness.htm.</p>\r\n<p>4. American Academy of Audiology. Bylaws. Retrieved on January 15, 2014 from http://www.audiology.org/about/leadership/bylaw s/Pages/default.aspx.</p>\r\n<p>5. Hain TC. Benign Paroxysmal Postional Vertigo. Dizziness-and-Balance.com, January 8, 2014. Retreived January 15, 2014 from http://www.dizziness-andbalance.com/disorders/bppv/bppv.html.</p>\r\n<p>By Ashlee Smith</p>\r\n<p>Ashlee Smith is the manager of communications with the Canadian Wireless Telecommunications Association (CWTA). The Ottawa-based group is the authority wireless issues, trends and developments in Canada. Ms. Smith can be reached at asmith@cwta.ca.</p>\r\n<p>Very few people could have predicted a decade ago how dramatically the power of wireless would totally transform the lives of Canadians &ndash; not only in how we communicate with each other &ndash; but in almost every aspect of our day-to-day lives in the home, in the workplace and anywhere and anytime in between. The speed at which wireless technology has evolved is truly incredible. Every day, it seems there are new advances that are reshaping our world for the better. The days of the cell phone that just simply made phone calls are long gone. In addition to sending text messages and emails and browsing the Internet at lightning fast speeds, we can do things like monitor our homes and provide critical medical information to our doctors directly from our smartphones. Canada now has well over 28 million wireless subscribers. This number is staggering considering just 10 years ago there were only 13 million users. And, Canada has some of the fastest, most advanced wireless networks on the planet, and we are among the fastest adopters of the latest and greatest smartphones in the world.</p>\r\n<p>But beyond calling, texting and watching videos, wireless is also quickly becoming a game changer for those in vulnerable communities. A new text-messaging based wireless service is connecting those in the deaf, deafened, hard of hearing or speech impaired (DHHSI) communities to emergency services in Canada. Text with 9-1-1, or commonly referred to as T9-1-1, provides 9-1-1 call centres with the ability to converse with a DHHSI person during an emergency, using text messaging. When a DHHSI person requires 9-1-1 services, they dial 9-1-1 on their cell phone. There is no need for a caller to speak or hear, as the 9-1-1 call taker will normally receive an indicator from registered users that tells them to communicate with the caller via text messaging. The 9-1-1 call taker then initiates a text message conversation with the caller to address the emergency.</p>\r\n<p>This unique Canadian solution was developed by the CRTC Interconnection Steering Committee (CISC) Emergency Services Working Group (ESWG), comprised of members from emergency services, telecommunications service providers, vendors and other stakeholders. After examining the ways in which emergency services could be more readily access by those in the DHHSI community, T9-1-1 was put to the test in 2012 in Vancouver, Toronto, the Peel Region, and Montreal. The results of these trials showed that while limitations exist with the service, it would be a dramatic improvement to the current system. Since that time, wireless carriers across the country have completed all of the required network upgrades to implement T9-1-1. However, before the T9-1-1 service can be made available to DHHSI cell phone users, 9-1-1 call centres must also complete technology upgrades as well.</p>\r\n<p>All members of the DHHSI community across Canada can start to register for the service, even though the service is not yet available nation-wide. National registration allows those who need it to  utilize the service only when they are within a specific region that has deployed T9-1-1. At this time, the T9-1-1 service is only available in Metro Vancouver, the City of Calgary, and the Peel Region. The service will be implemented by 9-1-1 call centres in different municipalities or regions at different time periods over the next several years. DHHSI citizens should check the new www.Textwith911.ca Web site frequently to see which new areas or regions have rolled out the service. Those who wish to register for the service must do so through their wireless service provider. Without taking this crucial step, important information may not be relayed to the user such as checking to make sure that the user&rsquo;s device is compatible with the service. Some devices are not able to make a voice call and send and received text messages simultaneously, so it is critical to double check this when registering for the service. Links to the wireless service provider&rsquo;s Web sites are also available at www.Textwith911.ca.</p>\r\n<p>This service is an exciting step in the right direction in ensuring that all Canadians will have access to life-saving emergency services. However, as with any new technology, limitations do exist. For example, no text messaging service can guarantee that a message will be sent or received in a timely manner. Additionally, mobile devices are, well, mobile, and staying within the footprint of a service area may also present challenges for those who utilize the service. Also, voice calling remains the only way to communicate with 9-1-1 services for a person that is not deaf, deafened, hard of hearing, or have speech impairment. Text messages sent directly to the digits &ldquo;9-1-1&rdquo; do not reach emergency services. Text with 9-1-1 for the public at large is expected to be deployed at a later date. We must keep in mind that when 9-1-1 first became available for Canadians last century, the concept of a cellular phone, let alone text messaging, was something out of science-fiction. 9-1-1 was not created in such a way that combining this type of sophisticated technology with emergency services would be easy nor that it would be seamless. The goal for Text with 9-1-1 for now is to do a better job at connecting vulnerable Canadians than ever before.</p>\r\n<p>By Chester Pirzanski, BSc</p>\r\n<p>Chester Pirzanski is ITE process engineer in R&amp;D at Unitron Corp, Kitchener, ON, Canada. Correspondence can be addressed to Chester Pirzanski, Unitron, 20 Beasley Dr, Kitchener, ON N2E 1Y6, email: Chester.Pirzanski@unitron.com</p>\r\n<p>The occlusion effect and acoustic feedback are the oldest and most common problems associated with hearing aid fittings. Both are considered a major deterrent for wearing hearing aids; both are linked to each other in a fine relationship: a sound leak from the ear canal diminishes the occlusion effect but increases the risk of acoustic feedback. A total earmold seal prevents feedback but elevates the sensation of occlusion.</p>\r\n<p>It was 1979 when Huntington1 asked How near is the end of feedback? and believed that the answer was in the newly introduced vinyl earmold. This soft material was supposed to seal the ear canal effectively enough to make hearing instruments feedback free. This did not happen at that time. We needed a couple of decades more before effective feedback cancelation algorithms were developed. Interestingly, it was the advancement in electronics, not material technology, that brought the end to acoustic feedback. A study done in 1985 and later research, reported that 30% of hearing instrument users had problems with their own voice. 2 They perceived it hollow or booming, or echoing. Two factors contributing to this complaint were established: a shell origin and an amplifier origin. 3</p>\r\n<p>A review of what we know about the occlusion effect and the most recent technological advancements will help us to conclude if modern hearing instruments are able to manage the occlusion effect effectively.</p>\r\n<p><strong>THE OCCLUSION AND AMPCLUSION EFFECT</strong></p>\r\n<p>There are two principle paths by which one hears one&rsquo;s own voice when speaking. The first is a direct path via the bone and cartilaginous structures of the head, and the second is an indirect path via air conduction. Echo-like sounds are caused by boneconducted sound vibrationsreverberating off the object filling the ear canal. When talking or chewing, these vibrations normally escape through an open ear canal; most people are unaware of their existence. When the ear canal is blocked,</p>\r\n<p>the vibrations are reflected back toward the eardrum. Compared to an open ear canal, this can boost low frequency sound pressure in the ear canal by 20 dB or more. This is called the occlusion effect. 4 A person with normal hearing can experience this by sticking their finger into their ear and talking. Otherwise, this effect is often experienced by hearing aid users who only have a mild to moderate high-frequency hearing loss and use hearing aids which block the ear canal. The introduction of amplification impacts the overall voice perception because the intensity of the wearer&rsquo;s own voice at the hearing aid microphone is considerably greater than the sounds coming from the environment. This effect, combined with occlusion is termed ampclusion, 5 and is most noticeable for individuals with a good low frequency hearing. With increasing hearing loss, the wearer relies less on bone conduction and leakage through the vent, and more on amplification through the hearing aid, and the ampclusion effect is less noticeable.</p>\r\n<h4>TOTALACOUSTIC SEAL</h4>\r\n<p>Zwislocki found that extending the medial end of the earmold into the bony portion of the ear canal significantly reduced the occlusion effect. Killion6 established that a deeply sealed earmold was able to diminish the occlusion effect to the level of sound pressure measured with the open ear canal. Bryant 7 followed this with a comparison of several   traditionally built full shell ITEs and ITEs made with a minimum contact technology (MCT). The MCT instruments had shells with long canals sealed at the bony portion. The rest of the shell in the canal area was reduced to help with the aid insertion and comfort. Real ear measurements established that the MCT aids were able to reduce the occlusion effect by 10 dB at 200 Hz compared to the standard ITE. Pirzanski 8 investigated the relationship between the mold insertion depth and the magnitude of the occlusion effect with a set of soft unvented earmolds with varying canal lengths. It was found that the increase in canal length past the canal aperture elevated the occlusion effect, as provided in Figure 1. Then, as the canal length increased, a progressive reduction was noted. The greatest reduction occurred with the change from mold M5 to M6. Mold 7 eliminated the occlusion effect. These findings correspond with the well-known Berger&rsquo;s9 chart showing that the occlusion effect is minimized with deeply inserted plugs, increases in magnitude as the plug is withdrawn,  peaks when the canal is capped by a semi-aural device, and continues to diminish with an earmuff.</p>\r\n<p>Despite these encouraging research results the concept of building deeply sealed ear pieces was not implemented in manufacturing hearing aids and earmolds because it was commonly noted that deeply fitted molds caused discomfort to the wearer. The author estimates that approximately 80% of users may have difficulty accepting the instrument if the mold makes contact with the bony portion of the ear canal.</p>\r\n<h4>VENTING</h4>\r\n<p>Since the occlusion effect comes from occluding the ear with an earpiece, researchers tried to establish how much ventilation though the earmold is needed to bring the occlusion to an acceptable level, or to eliminate it. Revit 10 found that a 2 mm vent was able to reduce the occlusion effect by 8.5 dB at 200 Hz. However, at 500 Hz the venting had no effect. A small 0.6 mm vent reduced the effect only by 2 dB. These results of venting are common and have been reported by numerous researchers. Dillion11 considers a 2 mm vent a starting point and advises to use a 3 mm vent, if possible. Fulton12 investigated the effectiveness of a 2 mm vent on 29 ears. She found that the average occlusion effect was 19.5 dB for a fully occluded ear, and varied from 9 dB to 32 dB, depending on the individual. When the vent was added, only 7 ears had a reduction in SPL of more than 5 dB, and of these 4 ears had a reduction of more than 10 dB. For the other 22 ears, the average impact of the 2 mm vent was 2.8 dB. This is consistent with May13 who found that a 2 mm vent reduced the sound pressure level between 4 and 5 dB in 10 subjects.</p>\r\n<p>Kampe14 found that real-ear measurements were unable to predict how the user would perceive his/her own voice when the vent diameter was changed. In addition, he found that in a number of subjects the vent enlargement increased the occlusion effect for one vowel and reduced for another. This should not be a surprise if we consider that the occlusion effect results from the skull vibrations. Since the skull is composed of different bone plates, having different density and vibration characteristics, the vibratory behaviour is quite complicated. Therefore the vibrating effect may vary from person to person. A major limitation in manufacturing custom hearing aids with a 2 mm vent at the time of the research was that such a vent could not be accommodated in most CICs and many ITCs assembled with the traditional acrylic shell: the size of the receiver along with the thickness of the shell and vent wall limited the space for a larger vent.</p>\r\n<p>While research established some  consistencies, variability was common. Based on testing 15 ears Sweetow15 concluded there was virtually no correlation between subjective voice perception and objectively measured ampclusion: only one ear demonstrated a statistically significant correlation between the amount of objectively measured ampclusion and the subjective ratings. In repeated measures, the occlusion effect varied by as much as 10 dB, furthermore, this variability was not consistent over frequency. It was observed that the magnitude of occlusion may be quite different for each ear within a given individual.</p>\r\n<p>Not long ago, telling the patient that they will need to get used to the occlusion effect was still the most common and in many cases the most sound advice they could get.</p>\r\n<h4>RIC HEARING AIDS</h4>\r\n<p>A breakthrough came around 2005 when receiver-in-canal (RIC) hearing aids were introduced. These hearing aids had the receiver fitted deeply in the ear canal in a small 80% open soft dome. This deep receiver placement made the instrument less susceptible to acoustic feedback and the open dome allowed for enough ventilation to eliminate the feeling of occlusion. ADVANCED SHELL TECHNOLOGY Today&rsquo;s digital shell technology allows for making hearing aids with optimized component placement and thinner walls. This allows for larger vents. Most manufactures offer now a 2.5 mm or larger vent as a standard. Group Companies under Sonova, Unitron, and Phonak, offer the Acoustically Optimized Vent (AOV), or the Intellivent. The diameter of the vent is automatically calculated during the shell modeling process based on the patient audiogram and the length of the vent.</p>\r\n<p>Figure 2 shows the process of AOV modelling. The operator optimizes the position of the vent entrance and exit so that the vent is not covered by the ear wall, then ensures that the vent size falls within the green target area. Each vent is modeled individually, often the vent size is different for the right and left ear of the same patient. At the end of the modelling, a six digit coupling code is generated which is later entered into the fitting software when the hearing aid is programmed with the customer settings. This creates an occlusion free fitting for most patients. Minor in-office adjustments in the fitting software may be necessary for some wearers. ADVANCED AMPLIFICATION Recent fitting software offers an occlusion manager that can be used to adjust the gain response curve in lower frequencies. In Unitron hearing aids, the clinician can adjust the gain by moving the on-screen slider to mild, moderate, or maximum, see an example in Figure 3. These changes are done when the patient wears the hearing aids, often wirelessly, and in real time. The real time option is particularly important because the wearer can instantly hear the change and select the response that gives him/her the best sound quality.</p>\r\n<p>The ampclusion effect can also be managed with an automatic adaptation manager that will increase the initial fitting gain over time at a fixed rate (commonly 5% every two weeks, from 80 to 100%). This will soften the sensation of occlusion and allow the time for the user to get used to the sound. Digital hearing aids can also adaptively change their low frequency gain according to input levels and reduce the perception of hollowness. Unitron offers a unique Flex:trial program under which the patient is fitted at no cost, no obligation to purchase, with a set of BTE or RIC hearing aids for a period of four weeks. This gives them the opportunity to determine the technology level they need to manage their listening situations and the style of the coupling, a dome or earmold, that provides the least occlusion and best physical fit in the ear. Huntington might be happy today. His dream of having feedback free hearing aids has become the reality. In addition, modern digital hearing instrument technologies are bringing the end to the occlusion effect. The two can be put at rest, finally</p>\r\n<h4>REFERENCES</h4>\r\n<p>1. Huntington A. How near is the end of feedback? J Brit Assn Teachers of Deaf 1979;3(4):123.</p>\r\n<p>2. Lazenby B, Logan S. Ahlstrom J, Bess F. Selfassessment questionnaire for the elderly: hearing aid dispensary use. Paper presented at the 1985 American Speech and Hearing Association Convention.</p>\r\n<p>3. Kuk F, Ludvigsen C. Occlusion management 101: understanding variables. Hear Rev 2002;9(8):22&minus;32.</p>\r\n<p>4. Tonndorf J. Bone conduction. In: JV Tobias, ed. Foundations of Modern Auditory Theory. New York: Academic Press, 1972:195&minus;273.</p>\r\n<p>5. Painton S. Objective measure of low frequency reduction in canal hearing aids with adaptive circuitry. J Am Acad Audiol 1993;4:152&minus;56.</p>\r\n<p>6. Killion M, Wilber L, Gudmundsen G. Zwislocki was right: A potential solution to the &quot;hollow voice&quot; problem (amplified occlusion effect) with deeply sealed earmolds. Hear Instrum 1988;39(1):14&minus;18.</p>\r\n<p>7. Bryant M, Mueller G, Northern J. Minimal contact long canal ITE hearing instruments. Hear Instrum 1991;42(1):12&minus;15.</p>\r\n<p>8. Pirzanski C. Diminishing the occlusion effect: clinician/manufacturer factors. Hear J 1998; 51(4):66&minus;78.</p>\r\n<p>9. Berger E. EARlog, Tips for fitting hearing protectors. Sound Vibr 1988;22(10):22&minus;25.</p>\r\n<p>10. Revit L. Two techniques for dealing with the occlusion effect, Hear Instrum 1992;43:16&minus;18.</p>\r\n<p>11. Dillion H. Hearing Aids. New York: Thieme; 2001, 132.</p>\r\n<p>12. Fulton B, Martin L. Drilling a vent often fails to give relief from occlusion. Hear J 2006; 59(7):40&minus;45.</p>\r\n<p>13. May A, Dillon H. A comparison of physical measurements of the hearing aid occlusion effect with subjective report. Presented at Audiological Society of Australia Conference, Adelaide, 1992.</p>\r\n<p>14. Kampe S, Wynne M. The influence of venting on the occlusion effect. Hear J 1996;49(4):59&minus;66.</p>\r\n<p>15. Sweetow R, Valla A. Effect of electroacoustic parameters on ampclusion in CIC hearing instruments. Hear Rev 1997;4:8&minus;12.</p>',NULL,'2022-11-16');
INSERT INTO `fulltext_content` VALUES (20,3261,'ajchr','http://www.andrewjohnpublishing.com/','','<p>I&rsquo;d like to welcome you, once again to another\r\n  issue of Canadian Hearing Report, so let&rsquo;s get\r\n  right to it.</p>\r\n<p>The wonderful Gael Hannan starts us off by\r\n  encouraging people with hearing loss to get out\r\n  and meat others like themselves. Connecting\r\n  with other people with hearing loss can be\r\n  powerful and life-changing experience.</p>\r\n<p>Next up is the return of our New on the Shelves\r\n  feature. In this issue we profile Jerry Northern\r\n  and Marion Downs&rsquo; Hearing in Children, 6th\r\n  Edition and Sandin&rsquo;s Textbook of Hearing Aid\r\n  Amplification edited by Michael J. Metz.</p>\r\n<p>The feature articles in this issue are really worth\r\n  checking out as well. Brian Taylor tell us that, in\r\n  an elective medical field, like hearing aid\r\n  dispensing and audiology, patients have a choice as to where to spend their hard earned dollars,\r\n  and very often their view of a quality health care\r\n  experience is much broader than simply getting\r\n  the hearing problem solved. Issues such as wait\r\n  time, a friendly interaction with the staff, and a\r\n  feeling of not being rushed can all contribute to\r\n  the perception of a quality experience with the\r\n  practice.</p>\r\n<p>Last, but certainly not least, Patty Niquette from\r\n  Etymotic Research tells us while noise-induced\r\n  hearing loss (NIHL) and the associated disorders\r\n  of tinnitus, hyperacusis, and diplacusis are all\r\n  irreversible, the keys to prevention are in\r\n  understanding the risks and consistently acting\r\n  to minimize the risks.</p>\r\n<p><strong>TWO WAYS TO SHOW\r\n  PATIENTS THEIR HEARING\r\n  AIDS ARE HELPING</strong></p>\r\n<p><strong>By Bob Martin</strong></p>\r\n<p>If you are an audiologist, it is easy to\r\n  delude yourself into thinking that\r\n  people will listen to you and accept\r\n  what you are saying. You spent a lot of\r\n  time and energy going to graduate\r\n  school, and you have a license to\r\n  practice Audiology. So, because you are\r\n  a trusting individual, you believe other\r\n  people will listen to you, and trust you.\r\n  Sadly, this is often not the case.\r\n  One of the great weaknesses of any\r\n  profession, including ours, is that our\r\n  professional training does not give us a\r\n  &ldquo;real world&rdquo; orientation. Audiology\r\n  students in a typical graduate school do\r\n  not learn much about the realities of life\r\n  and business. All too often, new\r\n  graduates enter practice without a good\r\n  understanding of the basic human\r\n  nature of the patients they will be caring\r\n  for.</p>\r\n<p>People have their own &ldquo;judgment\r\n  systems&rdquo; that are strongly influenced by\r\n  their age, culture, and individual\r\n  differences. If you become adept at\r\n  relating to a wide range of people and\r\n  if you learn how to sell and fit hearing\r\n  aids, you will become successful. If you\r\n  don&rsquo;t, you won&rsquo;t. Like a lot of\r\n  audiologists, my greatest weakness is\r\n  not in technology, it is in salesmanship.</p>\r\n<p><strong>SOME TIPS FOR THE NEXT\r\n  GENERATION</strong></p>\r\n<p>Speaking as a veteran audiologist, let\r\n  me offer some fatherly advice to young\r\n  audiologists.</p>\r\n<p>Every time you see a patient, use some\r\n  type of demonstration that starkly\r\n  contrasts the difference between aided\r\n  and unaided hearing. From the patient&rsquo;s\r\n  perspective, this demonstration needs\r\n  to be black and white. It should leave them saying to themselves, &ldquo;I hear with\r\n  these hearing aids. I cannot hear\r\n  without them.&rdquo;</p>\r\n<p><strong>EFFECTIVE DEMONSTRATIONS</strong></p>\r\n<p>Here are a couple of ways to make this\r\n  demonstration successful.\r\n  Study the patient&rsquo;s audiogram. If the\r\n  speech-reception thresholds (SRTs) are\r\n  above 40 dB and the thresholds for\r\n  1000-6000 Hz are above 50 or 60 dB,\r\n  patients will have trouble hearing the\r\n  noise they make when they rub their\r\n  hands together. </p>\r\n<p>The demonstration goes like this: Fit\r\n  the aids; adjust the volume to a\r\n  comfortable level; remove the aids. You\r\n  should also try the hearing aids on your\r\n  own ears, or measure their output in a\r\n  test box to make sure you have\r\n  substantial amplification. Don&rsquo;t start the\r\n  demonstration until you&rsquo;re sure\r\n  everything is working correctly.</p>\r\n<p>Then, put a hearing aid on the patient&rsquo;s\r\n  ear and tell them to rub their hands\r\n  together. They should be able to hear\r\n  this noise easily with their aided ear.\r\n  Tell the patient, &ldquo;Keep rubbing,&rdquo; and\r\n  then reach over and remove the hearing\r\n  aid. If you do this correctly, it will be a\r\n  dramatic demonstration to the patient\r\n  that the hearing aid enables them to\r\n  hear sound that is inaudible to them\r\n  unaided.</p>\r\n<p><strong>SHOW IMPROVED WORD\r\n  UNDERSTANDING</strong></p>\r\n<p>Here&rsquo;s another idea. The Tennessee\r\n  Tonality Words are &ldquo;test words,&rdquo; which\r\n  are grouped by pitch into five tonal\r\n  groups: Low-pitch (L), Low-Mid (L-M),\r\n  Mid (M), Mid-High (MH), and High (H).</p>\r\n<p>I use these words to do another type of\r\n  black-and-white demonstration that\r\n  shows patients how well they hear\r\n  words with the hearing aids and how\r\n  poorly they understand without them.</p>\r\n<p>I ask patients to repeat the words I say.\r\n  I speak in a normal voice, but cover my\r\n  mouth so patients can&rsquo;t read my lips. I\r\n  adjust the hearing aid to a comfortable\r\n  level, then remove it. Standing three\r\n  feet away from the patient, I start\r\n  uttering some high-pitched words:\r\n  &ldquo;itch, teach, ship, beach&hellip;&rdquo; After saying\r\n  two or three words, I ask the patient to\r\n  repeat them. If the patient does so\r\n  correctly, I increase the distance\r\n  between us and repeat the test.</p>\r\n<p>At some point the patient will no longer\r\n  be able to hear and repeat the words.\r\n  For this example, suppose the patient\r\n  can no longer repeat what I say from 12\r\n  feet away. I turn to the family members\r\n  and ask them, &ldquo;Can you hear the\r\n  words?&rdquo; They usually say, &ldquo;Yes, easily.&rdquo;\r\n  I then put the hearing aid back in the\r\n  patient&rsquo;s ear and ask them to repeat the\r\n  same words, which I say standing at the\r\n  same place where the patient was\r\n  unable to hear me unaided.</p>\r\n<p>If I have set up this demonstration\r\n  correctly, the patient will be able to hear\r\n  all the words with the hearing aid, and\r\n  none of the words without it. I\r\n  emphasize the difference by asking the\r\n  family, &ldquo;Are the hearing aids working?&rdquo;\r\n  At this point, the patient&rsquo;s family\r\n  members become a very important part\r\n  of the demonstration, because they\r\n  typically become excited and are\r\n  overjoyed that their husband or father\r\n  will be able to hear.</p>\r\n<p>Demonstrations like these do more than\r\n  show patients the benefit of the hearing\r\n  aids. They also keep us honest. If for\r\n  any reason the fitting is not working\r\n  correctly, the demonstration will fail.\r\n  That tells us that something is not\r\n  working properly and that we need to\r\n  put extra effort into fine-tuning the\r\n  fitting.</p>\r\n<p>June 4th, 2014 - Kitchener, ON, Canada\r\n  &ndash; Unitron is proudly celebrating 50 years\r\n  of building strong relationships with\r\n  hearing health care professionals and\r\n  delivering great products and services to\r\n  support them with their patients.</p>\r\n<p>Founded in 1964 in Newfoundland,\r\n  Canada, by partners Fred Stork, Rolf\r\n  Strothmann, and Rolf Dohmer, Unitron\r\n  became the first Canadian manufacturer\r\n  of hearing aid technology. Unitron is now\r\n  one of the fastest growing hearing\r\n  instrument companies in the world, with\r\n  global and Canadian headquarters\r\n  located in Waterloo Region, Canada&rsquo;s\r\n  &lsquo;&ldquo;Silicon Valley.&rdquo;&rsquo;. Today, Unitron\r\n  delivers hearing instruments in 70\r\n  countries through 20 international\r\n  offices and a network of distribution partners. Throughout its history, Unitron\r\n  has thrived and grown, always guided by\r\n  the belief that this business is built on\r\n  the strength of personal relationships,\r\n  and that its products are really\r\n  opportunities to make life better for\r\n  people with hearing loss.</p>\r\n<p><strong>A History of Innovating to Make\r\n  Life Better</strong></p>\r\n<p>Since Unitron&rsquo;s founding, its product\r\n  development has focused on products\r\n  and features that offer real benefits to\r\n  the people who use them. In the 1960s\r\n  through mid-1980s &ndash; the analog years &ndash;\r\n  Unitron became a leader in power BTEs\r\n  for people with severe to profound\r\n  hearing losses. By the 1990s,\r\n  programmable hearing aids and fitting\r\n  software were changing the face of the industry: Unitron was there with userfriendly,\r\n  intuitive fitting software\r\n  advancements that made fittings more\r\n  streamlined and helped improve first-fit\r\n  acceptance. The digital revolution\r\n  followed next and was an industry game\r\n  changer. Unitron first introduced Unison,\r\n  the product that made digital technology\r\n  accessible to all, and today the Company\r\n  continues to develop signature features\r\n  to specifically address speech\r\n  preservation and intelligibility, including\r\n  the award-winning AntiShock&trade;,\r\n  SmartFocus&trade;, and most recently\r\n  SpeechZone&trade; 2.</p>\r\n<p>Relationships Remain a Constant\r\n  While innovation has always been a vital\r\n  part of Unitron&rsquo;s product history, the\r\n  Company has also remained steadfast in\r\n  its belief that relationships are the\r\n  foundation of its business and its\r\n  customers&rsquo; success. Explains Unitron\r\n  President, Jan Metzdorff, &ldquo;Since our\r\n  earliest days, Unitron has understood\r\n  that this business is personal. That was\r\n  true 50 years ago and it holds today. The\r\n  relationships we have established with\r\n  hearing healthcare professionals, and\r\n  how we support them in forming strong\r\n  relationships with their patients has\r\n  never been more important.&rdquo;</p>\r\n<p>Another constant in the Unitron story is\r\n  people. Continues Metzdorff, &ldquo;Our local\r\n  and global teams have always worked\r\n  tirelessly to support our hearing health\r\n  care professional customers, while\r\n  moving us forward as a thriving global organization. Their skill, innovation and\r\n  compassion, and the great connections\r\n  they have forged with our customers,\r\n  have proudly made us the Unitron we\r\n  are today.&rdquo;</p>\r\n<p>Unitron will mark its 50th year with local\r\n  events that celebrate the &ldquo;&lsquo;favourite&rsquo;&rdquo;\r\n  sounds of the past 50 years.</p>\r\n<p><strong>About Unitron</strong></p>\r\n<p>Unitron is a global company that\r\n  understands the hearing healthcare\r\n  business is built on strong, personal\r\n  relationships. The Unitron team works\r\n  closely with hearing healthcare\r\n  professionals to improve the lives of\r\n  people with hearing loss. A member of\r\n  the Sonova Group, Unitron has a proven\r\n  track record of developing hearing\r\n  innovations that provide natural sound\r\n  with exceptional speech understanding.\r\n  Headquartered in Canada, Unitron\r\n  distributes its full line of hearing\r\n  instruments to customers in over 70\r\n  countries. For more information, please\r\n  visit unitron.com.</p>\r\n<p>Contact:</p>\r\n<p>Ann Marie Lang</p>\r\n<p>Corporate Media Relations</p>\r\n<p>(519) 895-0100 ext. 2104</p>\r\n<p>annmarie.lang@unitron.com</p>\r\n<h4>Have You Met Someone Else Like You?</h4>\r\n<p><strong>About the Author</strong></p>\r\n<p>Gael Hannan is a writer, actor, and public speaker who grew up with a progressive hearing loss that\r\n  is now severe-to-profound. She is a director on the national board of the Canadian Hard of Hearing\r\n  Association (CHHA) and an advocate whose work includes speechreading instruction, hearing\r\n  awareness, workshops for youth with hearing loss, and work on hearing access committees.</p>\r\n<p>Gael is a sought-after speaker for her humorous and insightful performances about hearing loss.\r\n  Unheard Voices and EarRage! are ground-breaking solo shows that illuminate the profound impact\r\n  of hearing loss on a person&rsquo;s life and relationships, and which Gael has presented to appreciative\r\n  audiences around Canada, the United States and New Zealand. A DVD/video version of Unheard\r\n  Voices is now available. She has received several awards for her work, including the Consumer\r\n  Advocacy Award from the Canadian Association of Speech Language Pathologists and Audiologists.</p>\r\n<p>While the relationship between\r\n  people with hearing loss and\r\n  their hearing care professional (HCP)\r\n  can be complicated, as we work to\r\n  improve standards and models of\r\n  service, the individual connection is a\r\n  no-brainer: as a hard of hearing person,\r\n  I depend on my hearing care\r\n  professional to fit me with technology to\r\n  help me hear.</p>\r\n<p>But an equally important connection is\r\n  between peers, the people with hearing\r\n  loss. While I&rsquo;ve been going to HCPs my\r\n  entire life, it wasn&rsquo;t until I met other\r\n  people who had the same issues as me,\r\n  that I finally understood my hearing loss\r\n  and learned how to deal with it\r\n  successfully using strategies that go\r\n  beyond amplification.</p>\r\n<p>The author Cheryl Strayed says in her book Tiny Beautiful Things: &ldquo;The healing\r\n  power of even the most microscopic\r\n  exchange with someone who knows in\r\n  a flash precisely what you&rsquo;re talking\r\n  about because they experienced that\r\n  thing too, cannot be overestimated.&rdquo; I\r\n  can&rsquo;t say it any better than that.</p>\r\n<p>Growing up, I knew no other people\r\n  with hearing loss, except my greatgrandmother\r\n  who lived to be 99. All I\r\n  learned from her is that if you have\r\n  hearing loss, you&rsquo;ll have a voice like a\r\n  foghorn and you&rsquo;ll say inappropriate\r\n  things and the family will laugh at you.</p>\r\n<p>At the age of 41, I met my peers for the\r\n  first time. It was like falling in love &ndash; not\r\n  only with this new world of hearing loss\r\n  awareness, but with myself. My new\r\n  confidence and identity as a successful\r\n  person with hearing loss made me happier with myself.</p>\r\n<p>Connecting with other people with\r\n  hearing loss can be powerful. My friend\r\n  Myrtle Barrett, president of the Canadian\r\n  Hard of Hearing Association, often tells\r\n  this story, which mirrored her own\r\n  experience of connecting with others.\r\n  I was in a lineup at Tim Hortons,\r\n  picking up supper after a long day.</p>\r\n<p>I gave the girl my order &ndash; and I\r\n  kept on telling her, because she\r\n  didn&rsquo;t understand me. Finally I\r\n  asked, &ldquo;What am I doing wrong!&rdquo;\r\n  Her eyes filled up. She turned red\r\n  and said, &ldquo;It&rsquo;s not you, I have a\r\n  hearing loss!&rdquo; A co-worker helped\r\n  her get my order, and I decided to\r\n  eat in &ndash; because I needed to talk to\r\n  her.</p>\r\n<p>When she wasn&rsquo;t busy, I apologized\r\n  for my impatience and asked if she\r\n  would like to talk when she\r\n  finished work. I told her I was deaf.\r\n  Her face lit up. She was only 16\r\n  years old and we talked for a long\r\n  time. Her boss didn&rsquo;t know, and\r\n  she was afraid to lose her job. I\r\n  gave her some suggestions about\r\n  workplace accommodations and\r\n  about our local support group. She\r\n  joined the youth group and\r\n  became a great advocate. Most\r\n  importantly, she became\r\n  empowered and successful &ndash; all\r\n  because of a chance meeting with\r\n  someone who was just like her.</p>\r\n<p>Most of my family, and the people in the\r\n  social circle my husband and I share, do\r\n  not have hearing loss. Well, apart from\r\n  my elderly father and a couple of our\r\n  friends are now hearing aid users, but\r\n  they prefer not to talk about it, thank\r\n  you very much! But I also live in a\r\n  parallel universe where everyone has\r\n  hearing loss and we love to talk about it\r\n  and gather strength and ideas from each\r\n  other. And yes, sometimes we gripe\r\n  about those insensitive hearing people,\r\n  and how can we get them to face us when they talk. In this parallel universe,\r\n  we carry no shame about our hearing\r\n  loss. There are no embarrassing\r\n  moments &ndash; just laughable ones. Every\r\n  moment spent in this hearing loss world\r\n  empowers our sense of dignity in the\r\n  real world, and helps us deal with our\r\n  communication challenges.</p>\r\n<p>This peer connection can be a lifeline for\r\n  someone struggling with hearing loss. It\r\n  can happen unexpectedly, as in Myrtle&rsquo;s\r\n  story, or through a social media group,\r\n  or through consumer hearing loss\r\n  associations, such as the Canadian Hard\r\n  of Hearing Association. Every person, if\r\n  possible, should go to a live meeting,\r\n  even if just once, to connect with other\r\n  people who are walking, talking\r\n  demonstrations of communication\r\n  success. When I went to my first hearing\r\n  loss conference, I did so with an\r\n  unconscious desire to distance myself\r\n  from the people I was going to meet. As\r\n  Groucho Marx said,&ldquo;I don&rsquo;t want to\r\n  belong to any club that will accept\r\n  people like me as a member.&rdquo; Deep\r\n  down, I was thinking, &ldquo;Do I really want\r\n  to associate with a bunch of hard of\r\n  hearing people? Other people will think\r\n  I&rsquo;m like them, disabled or something.&rdquo;</p>\r\n<p>Two amazing, inspiring days later, I was\r\n  a new person. After the closing banquet,\r\n  a few of us celebrated at a pub &ndash; and\r\n  there is nothing on this earth is louder\r\n  than a dozen hard of hearing and oral\r\n  deaf people having drinks. I was a bit\r\n  embarrassed by the stares we were\r\n  drawing from the other people in the\r\n  pub.</p>\r\n<p>And then it happened.</p>\r\n<p>I thought, so what if we were loud? We\r\n  had hearing loss, yes, and we were also\r\n  smart, happy, and enlightened. It was a\r\n  life-changing moment. Rocky Stone,\r\n  founder of Self Help for Hard of Hearing\r\n  People, once said, &ldquo;You can&rsquo;t change the\r\n  world. You can change yourself and\r\n  improve your immediate area with the\r\n  spirit of love and concern for other\r\n  people.&rdquo;</p>\r\n<p>If you have hearing loss, reach out.\r\n  Someone is waiting to talk to you,\r\n  because they have been through the\r\n  same thing.</p>\r\n<p>Canadian Hearing Report 2014;9(3):10-11.</p>\r\n<p><strong>SANDIN&rsquo;S TEXTBOOK OF HEARING AID AMPLIFICATION:\r\n  TECHNICAL AND CLINICAL CONSIDERATIONS, THIRD EDITION</strong></p>\r\n<p>Edited by: Michael J. Metz, PhD</p>\r\n<p><strong>ABOUT THE BOOK</strong></p>\r\n<p>The comprehensive Sandlin\'s Textbook of Hearing Aid Amplification, now in its\r\n  third edition, provides the hearing health professional with an overview of the\r\n  technological advances related to hearing aid devices. The authors give\r\n  particular emphasis to the most current advances in clinical assessment\r\n  techniques and hearing instrument technology, and provide a detailed analysis\r\n  of the application of digital signal processing. Clinical insights into the\r\n  psychology of hearing health are included to help professionals meet clients&rsquo;\r\n  emotional as well as acoustic needs. This is a valuable text for academic and\r\n  clinical professionals involved in the selection and fitting of hearing aid devices\r\n  for the acoustically impaired.</p>\r\n<p>New to the third edition:</p>\r\n<p>&bull; Updated chapters on earmold and earshell acoustics; principles and\r\n  applications of high-fidelity amplitude compression; and microphone\r\n  technology</p>\r\n<p>&bull; Major revisions to chapters on digital signal processing; hearing aid\r\n  selection, fitting, and verification; mathematical formulae for applying\r\n  amplification; measures of validity and verification; and surgicallyimplanted\r\n  hearing devices for unilateral hearing loss</p>\r\n<p>&bull; Discussion of distribution methods; considerations for treating children;\r\n  elements of design and implementation of DSP circuits; the evolution\r\n  from analog to digital hearing aids; and future consideration for the field\r\n  This text is regularly used by clinicians at the graduate level of training in the\r\n  70 to 90 universities offering graduate degrees in audiology. Furthermore,\r\n  practicing clinicians in countries all over the world have included this\r\n  recognized text in their professional libraries.</p>\r\n<p>CONTENTS</p>\r\n<p>Foreword by Michael J. Metz</p>\r\n<p>Preface</p>\r\n<p>Acknowledgements</p>\r\n<p>Contributors</p>\r\n<p>1. A Historical View\r\n  Samuel F. Lybarger, Edward H. Lybarger</p>\r\n<p>2. Speech Perception and Hearing Aids\r\n  William H. McFarland, Karen Spayd</p>\r\n<p>3. Custom Hearing Aid Earshells and Earmolds\r\n  Chester Z. Pirzanski</p>\r\n<p>4. Principles of High-Fidelity Hearing Aid Amplification\r\n  Mead C. Killion, Patricia A. Johnson</p>\r\n<p>5. The Many Faces of Compression\r\n  Theodore H. Venema</p>\r\n<p>6. Use of Directional Microphone\r\n  Technology to Improve User\r\n  Performance in Noise</p>\r\n<p>Yu-Hsiang Wu, Ruth A. Bentler\r\n  7. DSP Hearing Instruments\r\n  Ingo Holuba, Henning Puder,\r\n  Therese M. Velde</p>\r\n<p>8. From Analog to Digital Hearing\r\n  Aids</p>\r\n<p>S&oslash;ren Westermann, Hanne Pernille\r\n  Anderson, Lars B&aelig;kgaard, et al.</p>\r\n<p>9. Technical Considerations for\r\n  Sound Field Audiometry\r\n  Gary Walker</p>\r\n<p>10. Psychology of Individuals with\r\n  Hearing Impairment\r\n  Robert W. Sweetow, Julie Bier</p>\r\n<p>11. Considerations for Selecting and\r\n  Fitting of Amplification for\r\n  Geriatric Adults\r\n  Robert E. Novak</p>\r\n<p>12. Hearing Technology for Children\r\n  Jace Wolfe, Sara Neumann</p>\r\n<p>13. Principles and Clinical Utility of\r\n  Hearing Aid Fitting Formulas\r\n  Phillip T. McCandless</p>\r\n<p>14. Real Ear Measures\r\n  George Frye</p>\r\n<p>15. Making Hearing-Aid-Fitting\r\n  Decisions\r\n  Robert L. Martin</p>\r\n<p>16. Inventories of Self-Assessment\r\n  Measurements of Hearing Aid\r\n  Outcomes\r\n  Judy L. Huch</p>\r\n<p>17. Assistive Technologies for the\r\n  Hearing Impaired\r\n  Joseph J. Smaldino, Brian M. Kreisman</p>\r\n<p>18. Cochlear Implants\r\n  Dawn Burton Koch, Mary Jo Osberger</p>\r\n<p>19. Fitting Options for Adult Patients\r\n  with Unilateral Hearing Loss\r\n  Michael Valente, L. Maureen Valente</p>\r\n<p>20. Future Considerations\r\n  Michael J. Metz, Robert E. Sandlin\r\n  Appendix A: American Academy of\r\n  Audiology Ethical Practice Guideline\r\n  for Relationships with Industry</p>\r\n<p><strong>HEARING IN CHILDREN, SIXTH EDITION</strong></p>\r\n<p>Jerry L. Northern, PhD\r\n  Marion Downs</p>\r\n<p><strong>ABOUT THE BOOK</strong></p>\r\n<p>In this completely updated sixth edition, Hearing in Children thoroughly\r\n  examines the current knowledge of pediatric audiology, and provides a medical\r\n  perspective on the identification, diagnosis, and management of hearing loss\r\n  in children. This enduring text, written by two universally recognized pediatric\r\n  audiologists, has been the chief pediatric hearing resource used worldwide by\r\n  audiologists for nearly 40 years.</p>\r\n<p><strong> KEY FEATURES</strong></p>\r\n<p>&bull; An expanded review of the medical aspects&mdash;early intervention, genetics,\r\n  diseases and disorders, and treatments&mdash;of pediatric hearing loss as well\r\n  as hearing and auditory disorders in infants, toddlers, and young children</p>\r\n<p>&bull; Practical descriptions of age-specific testing protocols and hearing\r\n  screening technologies, and early hearing loss detection and intervention\r\n  procedures</p>\r\n<p>&bull; Comprehensive coverage of amplification for children with hearing loss,\r\n  including fitting and management issues in hearing aids, cochlear\r\n  implants, and assistive listening devices</p>\r\n<p>&bull; Valuable information on the role of family-centered services related to all\r\n  aspects of childhood deafness</p>\r\n<p>&bull; A revised appendix of hearing disorders that includes 90 syndromes and\r\n  disorders associated with childhood deafness</p>\r\n<p>&bull; Nearly 500 new and current references</p>\r\n<p><strong>CONTENTS</strong></p>\r\n<p>Dedication</p>\r\n<p>Preface: Jerry L. Northern, Ph.D.\r\n  Forward: Marion P. Downs, D.H.S.,\r\n  D.S.</p>\r\n<p>Acknowledgements</p>\r\n<p>Chapter 1: Hearing and Hearing Loss\r\n  in Children</p>\r\n<p>Chapter 2: Early Development</p>\r\n<p>Chapter 3: Auditory and Speech-\r\n  Language Development</p>\r\n<p>Chapter 4: Medical Aspects</p>\r\n<p>Chapter 5: Early Intervention</p>\r\n<p>Chapter 6: Behavioral Hearing Tests</p>\r\n<p>Chapter 7: Physiologic Hearing Tests</p>\r\n<p>Chapter 8: Hearing Screening</p>\r\n<p>Chapter 9: Amplification</p>\r\n<p>Chapter 10: Education</p>\r\n<p>Appendix i: Pediatric Hearing</p>\r\n<p>Disorders</p>\r\n<p>Appendix ii: Guidelines for\r\n  Identification and Management of\r\n  Infants and Young Children with\r\n  Auditory Neuropathy Spectrum\r\n  Disorder</p>\r\n<h4>Managing Quality at the Point of Sale</h4>\r\n<p align=\"right\"> By Brian Taylor, AuD</p>\r\n<p>As hearing care professionals we have\r\n  been taught to provide the highest\r\n  quality care to the best of our abilities.\r\n  For most professionals this means\r\n  providing an effective treatment solution\r\n  (hearing aids) to a quantifiable problem\r\n  (sensorineural hearing loss). From a\r\n  medical perspective, this is a perfectly\r\n  acceptable principle, and one that all of\r\n  us must continue to strive to achieve.\r\n  Unfortunately, in an elective medical\r\n  field, like hearing aid dispensing and\r\n  audiology, this narrow view of quality can\r\n  be problematic. Patients have a choice as\r\n  to where to spend their hard earned\r\n  dollars, and very often their view of a\r\n  quality health care experience is much\r\n  broader than simply getting the hearing\r\n  problem solved. Dimensions such as wait\r\n  time, a friendly phone interaction with\r\n  the receptionist, and a feeling of not\r\n  being rushed with the doctor all\r\n  contribute to the perception of a quality\r\n  experience with the practice.</p>\r\n<p>A broad view of quality is an important\r\n  differentiator among practices. Not only\r\n  are practices that compete on all aspects\r\n  quality (not just achieving outstanding\r\n  treatment results) able to command a\r\n  significantly higher average selling price,\r\n  practices that differentiate themselves on\r\n  quality have another unique competitive\r\n  advantage: they are able to generate more\r\n  word-of-mouth referrals. In a low\r\n  volume &ndash; high margin industry, like\r\n  commercial hearing aid dispensing, a\r\n  large number of practice promoters is\r\n  vitally important to success. For these\r\n  reasons managers need to have a passion\r\n  for improving all dimensions of quality.\r\n  In the April, 2010 issue of the Hearing\r\n  Review Sergei Kochkin and several coauthors\r\n  suggested that a simple, common\r\n  sense fitting approach that can enhance\r\n  quality involves the following nine\r\n  procedures1:</p>\r\n<p>1. Physical evaluation of the ear and\r\n  case history</p>\r\n<p>2. Measurement of the patient&rsquo;s\r\n  hearing loss</p>\r\n<p>3. Selection of the most appropriate\r\n  hearing aid technology</p>\r\n<p>4. Assessment of the patient&rsquo;s\r\n  expectations</p>\r\n<p>5. Quality control measures using a\r\n  hearing aid analyzer</p>\r\n<p>6. Prescriptive fitting with the use of\r\n  probe microphone measures to\r\n  verify a reasonable match of the\r\n  fitting target</p>\r\n<p>7. Fine tuning of the instruments\r\n  using patient-specific test measures,\r\n  such as Loudness Discomfort\r\n  Levels</p>\r\n<p>8. Use of self report and laboratory\r\n  measures of hearing aid outcome</p>\r\n<p>9. Counseling and rehabilitative\r\n  services</p>\r\n<p>In a similar unpublished report, the\r\n  Hearing Instrument Association (HIA),\r\n  using scientifically-derived research data,\r\n  created a Top 10 reasons for hearing aid\r\n  delight.2 This list highlights procedures\r\n  and behaviours audiologists and their\r\n  support staff can engage in with the\r\n  patient in order to generate higher levels of satisfaction and loyalty. This list\r\n  includes:</p>\r\n<p>1. Hearing aids must provide benefit\r\n  in multiple listening situations</p>\r\n<p>2. Motivated patients seek out\r\n  information, oftentimes on the\r\n  Internet</p>\r\n<p>3. Office, including the reception area\r\n  must look professional</p>\r\n<p>4. Many patients desire a high tech,\r\n  engaging pre-fitting and fitting\r\n  process</p>\r\n<p>5. Comprehensive counseling\r\n  processes, including aural\r\n  rehabilitation services</p>\r\n<p>6. Providers that make a confident\r\n  treatment recommendation based\r\n  on evidence</p>\r\n<p>7. Use of a live hearing aid\r\n  demonstration during the prefitting\r\n  process</p>\r\n<p>8. Use of verification and validation to\r\n  ensure the hearing aids are\r\n  performing up to specification and\r\n  benefitting the patient in everyday\r\n  listening</p>\r\n<p>9. A strong relationship between the\r\n  patient and provider, which is\r\n  formed through periodic face-toface\r\n  office visits</p>\r\n<p>10. A dedicated hearing care\r\n  professional that engenders trust</p>\r\n<p>The key to unlocking the value of your\r\n  practice to patients and prospects is\r\n  understanding how to bring these two\r\n  lists to life. This article provides five\r\n  actionable ideas they can use to leverage\r\n  the findings from these timely HIA and THR studies.</p>\r\n<p><strong>DEVELOP A CUSTOMIZED LEADGENERATING\r\n  WEBSITE</strong></p>\r\n<p>The fastest growing segment of Internet\r\n  users are people over the age of 70,\r\n  which is approximately the same age as\r\n  the average age of initial hearing aid use.\r\n  Numerous studies, cited in the HIA\r\n  report2 have suggested that many people\r\n  go to the Internet to find information\r\n  about an ailment or condition before\r\n  they seek a personal consultation with a\r\n  medical professional. For this reason\r\n  alone, it&rsquo;s imperative to have a presence\r\n  online. There are some anecdotal reports\r\n  suggesting that practitioners with a\r\n  website receive one to two new prospects\r\n  per month via the Internet channel.</p>\r\n<p>In addition to being a lead generator, a\r\n  customized website can be used to\r\n  educate existing patients. For example,\r\n  several short instructional videos can be\r\n  added to your site. These videos reinforce\r\n  your message about acclimatization and\r\n  orientation to hearing aids and better\r\n  communication. By posting instructional\r\n  video on your website, you foster a\r\n  deeper relationship with patients.</p>\r\n<p><strong>UNDERSTAND MELU AND USE IT\r\n  TO DISPENSE HEARING AIDS AT A\r\n  HIGHER PRICE POINT</strong></p>\r\n<p>Most clinicians have heard about or even\r\n  use the Client Oriented Scale of\r\n  Improvement.3 The results of the prefitting\r\n  COSI is often used to begin a\r\n  conversation with the patient about the\r\n  need for premium products with\r\n  advanced features. What many clinicians\r\n  fail to realize, however, is that there is a\r\n  direct and systematic relationship\r\n  between overall satisfaction and the\r\n  number of listening situations effectively\r\n  addressed with amplification. Leveraging\r\n  the findings of MELU and overall\r\n  satisfaction from several MarkeTrak\r\n  studies,4,5 clinicians can build a case for the need for premium technology for\r\n  many patients.</p>\r\n<p>One of the significant findings from the\r\n  MarkeTrak surveys is that the more\r\n  listening situations you can satisfy with\r\n  amplification, the higher the overall\r\n  satisfaction of the patient, and the more\r\n  willing the patient is to refer other\r\n  prospective patients to your practice.\r\n  These findings suggest that professionals\r\n  target 10 or more unique listening\r\n  situations for improvement during the\r\n  pre-fitting communication assessment.\r\n  Importantly, the relationship between\r\n  overall satisfaction and the need for\r\n  premium products and advanced\r\n  features for improved communication in\r\n  multiple listening environments can be\r\n  used as a vehicle for discussing the need\r\n  for telecoils, Bluetooth gateway devices,\r\n  remote controls, along with a myriad of\r\n  other advanced features found only in\r\n  premium and business class product\r\n  lines.</p>\r\n<p><strong>USE COMPUTER-BASED TESTING\r\n  DURING THE PRE-FIT\r\n  APPOINTMENT</strong></p>\r\n<p>Based on the HIA Top 10 reasons for\r\n  hearing aid delight study, promoters of\r\n  your practice are captivated when tests\r\n  are conducted that have the perception\r\n  of being high tech. Video otoscopy\r\n  serves as an excellent example. From\r\n  the vantage point of the professional\r\n  there is little value in conducting\r\n  otoscopy with a video camera.\r\n  However, viewed through the lens of a\r\n  patient, the ability to see a high\r\n  resolution image of the ear canal adds\r\n  a tremendous amount of value.</p>\r\n<p>Another example is the use of speechin-\r\n  noise testing. In order to save time,\r\n  most professionals continue to rely on\r\n  live voice testing when conducting\r\n  routine tests, like MCL, UCL and word\r\n  recognition.6 Not only are recorded tests more accurate but, according to\r\n  the HIA report, they have the\r\n  perception of being high tech. This\r\n  unquestionable adds value to the\r\n  patient&rsquo;s clinical experience and\r\n  contributes to their perception of\r\n  quality. Tests such as the Quick SIN7\r\n  (Etymotic Research) and the Acceptable\r\n  Noise Level test8 (Frye Electronics)\r\n  should replace more traditional tests\r\n  like MCL and speech audiometry in\r\n  quiet with live voice whenever possible.</p>\r\n<p><strong>PAY ATTENTION TO CLINIC\r\n  WORKFLOW</strong></p>\r\n<p>There are a finite number of hours in the\r\n  day and your ability to manage your\r\n  appointment is imperative to success.\r\n  Clinic workflow and time spent with\r\n  each patient is one important way to\r\n  gauge the efficiency of your practice. For\r\n  each &ldquo;touch point&rdquo; that your practice\r\n  engages the patient, it&rsquo;s important to have\r\n  some idea how much time is needed to\r\n  optimize satisfaction.</p>\r\n<p>The amount of time spent is also\r\n  indicated for each &ldquo;touch point.&rdquo;\r\n  Although there is no data outlining the\r\n  optimal amount of time for each point of\r\n  contact, Sergei Kochkin&rsquo;s data suggested\r\n  that satisfaction was maximized when 2\r\n  to 3 hours of collective time was spend\r\n  face-to-face with a patient over several\r\n  office visits.</p>\r\n<p><strong> MEASURING SEVEN DIMENSIONS\r\n  OF QUALITY</strong></p>\r\n<p>As previously stated, patients&rsquo; perception\r\n  of quality go well beyond the\r\n  professional&rsquo;s ability to solve their\r\n  problem. Their perception of quality is\r\n  wide-ranging and many times takes into\r\n  consideration things the professional\r\n  easily overlooks. In order to stay focused\r\n  on all dimensions of quality from the\r\n  patients&rsquo; perspective, you can rely on\r\n  measuring quality along seven\r\n  dimensions.</p>\r\n<p>Here are some helpful, easy-to-use tools\r\n  that busy clinicians can use to measure\r\n  quality. These seven dimensions\r\n  represent the various phases of the\r\n  patient&rsquo;s journey from initial contact with\r\n  the office until initial use with hearing\r\n  aids. By taking the time to measure these\r\n  quality dimensions, hearing professionals can manage the entire process and begin\r\n  to ensure that each patient is highly\r\n  satisfied with all aspects of his or her\r\n  experience.</p>\r\n<p><strong> WAIT TIME AND INITIAL\r\n  GREETING OF THE PATIENT IN\r\n  THE CLINIC</strong></p>\r\n<p>Woody Allen once said that 80% of\r\n  success is simply showing up, and in any\r\n  customer service business this is certainly\r\n  true. Little things, like when the office\r\n  manager answers the telephone with a\r\n  friendly voice go a long way toward\r\n  improving quality. Armed with this\r\n  information, managers can train their\r\n  front office staff to warmly greet every\r\n  patient over the phone or when they\r\n  arrive in the clinic. Communication\r\n  experts agree that standing up, squarely\r\n  facing the patient, smiling and offering a\r\n  handshake are components of an ideal\r\n  greeting, and the ability of front office\r\n  staff to perform these behaviors can be\r\n  tracked using a form like the one shown\r\n  in Table 1.</p>\r\n<p>APP<strong>EARANCE OF PHYSICAL\r\n  LOCATION</strong></p>\r\n<p>The reception area or waiting room is\r\n  one of the most easily overlooked aspects\r\n  of a practice, but often the most\r\n  important first impression for patients. It\r\n  may seem obvious that when patients\r\n  enter a practice location, they expect the\r\n  facilities to reflect their perceptions of a\r\n  professional business. Beyond the\r\n  reception area, the entire physical\r\n  location of the practice needs to be\r\n  routinely inspected. A simple approach\r\n  to measuring the quality of any physical\r\n  location is to maintain a checklist that the\r\n  office manager or front office professional\r\n  marks daily with meticulous attention to\r\n  detail. The physical location checklist is\r\n  completed each morning by the office\r\n  manager, and a written copy is shared\r\n  with the owner or managing director. All deficient areas in need of upgrades or\r\n  repair are recorded at the bottom of the\r\n  form.</p>\r\n<p><strong>INTERPERSONAL\r\n  COMMUNICATION SKILLS OF\r\n  THE HEARING CARE\r\n  PROFESSIONAL</strong></p>\r\n<p>An audiologist&rsquo;s effectiveness is largely\r\n  determined by their ability to form\r\n  strong relationships with patients. Any\r\n  investment managers can make to\r\n  improve the relationship building skills\r\n  of their employees is likely to pay off in\r\n  improved service delivery. Good listening\r\n  skills, the ability to ask open-ended\r\n  questions, and clear and concise\r\n  explanations of test results are a few of\r\n  the &ldquo;people skills&rdquo; needed to build\r\n  effective relationships with patients and\r\n  enhance patient satisfaction.</p>\r\n<p>Interpersonal or relationship-building\r\n  skills can be directly measured by\r\n  patients. Using a comment card with five\r\n  or six important components of\r\n  interpersonal skills, like the one shown\r\n  in Figure 4, patients can directly measure\r\n  the effectiveness of this dimension of\r\n  quality. Once you have collected a\r\n  representative data sample (15 to 20\r\n  responses per month for the typical\r\n  practice), you can begin the process of\r\n  improving behaviours that have the\r\n  largest impact on patient satisfaction</p>\r\n<p>. <strong>TECHNICAL SKILLS OF THE\r\n  SERVICE PROVIDER</strong></p>\r\n<p>The ability of a hearing professional to\r\n  conduct a comprehensive hearing\r\n  evaluation, as well as program, fit and\r\n  troubleshoot hearing devices can be\r\n  indirectly measured by assessing the\r\n  professional&rsquo;s adherence to a clinical\r\n  protocol. There is no shortage of clinical\r\n  hearing aid selection and fitting\r\n  protocols. The most current clinical\r\n  hearing aid selection and fitting protocol\r\n  sanctioned by the American Academy of nonusers.\r\n  In addition, lower rates of usage\r\n  are reported for patients with negative\r\n  attitude towards amplification,10 and\r\n  those who consider hearing aid use to be\r\n  stigmatizing.</p>\r\n<p>Hearing aid use rate can be measured\r\n  either subjectively or objectively.\r\n  Subjective measures of use time would\r\n  be considered to be diaries or\r\n  questionnaires that the patient\r\n  completes. Research has found that\r\n  subjective reports of usage are\r\n  unreliable.11 Fortunately, objective\r\n  measures of usage can be obtained using\r\n  data logging, which is found in many\r\n  modern hearing aids. One of the\r\n  advantages of data logging is that it\r\n  objectively tracks the total number of\r\n  hours of hearing aid use. Part time and\r\n  non-users can be managed differently\r\n  than full time users. For example, a\r\n  patient with a low use rate, which has\r\n  been objectively verified with data\r\n  logging, might have a problem with\r\n  annoyance from noise as measured on\r\n  the acceptable noise level (ANL) test. The\r\n  low use time combined with the high\r\n  unaided ANL score might be an\r\n  indication that the patient needs a more\r\n  aggressive noise reduction strategy.</p>\r\n<p><strong>LABORATORY AND SELF REPORTS\r\n  OF HEARING AID BENEFIT</strong></p>\r\n<p>Benefit is simply the difference between\r\n  the unaided and aided condition.\r\n  Hearing aid benefit can be measured in\r\n  a number of different ways, including\r\n  laboratory measures and self-reports or\r\n  questionnaires. Considering the findings\r\n  of Cox and Alexander12 a workaday\r\n  approach to measuring benefit would be\r\n  to use some combination of laboratory\r\n  and self-reports.</p>\r\n<p>Laboratory measures of benefit\r\n  complement probe microphone\r\n  verification measures, as they can be used to objectively demonstrate to the\r\n  patient that certain features within the\r\n  hearing aid are functioning properly. For\r\n  example, the Quick SIN can be\r\n  presented at a low intensity level (45 dB\r\n  HL) in the unaided and aided condition.\r\n  The difference between these two scores\r\n  would be the aided benefit on a speech\r\n  recognition task. When the QuickSIN is\r\n  conducted at a low intensity level, it\r\n  provides the patient with meaningful\r\n  information on how improved audibility\r\n  usually translates into improved speech\r\n  intelligibility in noise. Taylor has written\r\n  a useful article posted at\r\n  www.audiologyonline that details how\r\n  laboratory measures of outcome can be\r\n  used in a busy clinic to cross check real\r\n  ear verification measures and\r\n  complement self-reports of benefit.14</p>\r\n<p>Self-reports or questionnaires\r\n  compliment laboratory measures of\r\n  benefit because they ask the patient to\r\n  rate their success with amplification in\r\n  everyday listening, using some type of a\r\n  scale. Dozens of self-reports have been\r\n  created and validated, and they\r\n  subjectively measure real world benefit.\r\n  They also are an integral part of an\r\n  evidence-based practice paradigm. Three\r\n  of the most useful self-reports are\r\n  reviewed below. Hearing professionals\r\n  are encouraged to choose two of the\r\n  three listed here and use them routinely\r\n  to measure the user benefit and\r\n  satisfaction dimensions of quality.</p>\r\n<p><strong>CLIENT ORIENTED SCALE OF\r\n  IMPROVEMENT</strong></p>\r\n<p>The COSI is an open-ended scale in\r\n  which a patient targets up to five\r\n  listening situations (from a list of 16) for\r\n  improvement with amplification. The\r\n  goal of the COSI is for the patient to\r\n  target specific listening situations and\r\n  report the degree of benefit obtained\r\n  compared to that expected for the\r\n  population in similar listening situations.</p>\r\n<p>Many hearing aid manufacturers now\r\n  include the COSI in their fitting software.</p>\r\n<p><strong>ABBREVIATED PROFILE OF\r\n  HEARING AID BENEFIT (APHAB)</strong></p>\r\n<p>In an attempt to develop a more clinicfriendly\r\n  measure of outcome, the APHAB\r\n  was developed.15 The goal of the APHAB\r\n  is to quantify the disability caused by\r\n  hearing loss, and the reduction of that\r\n  disability achieved with hearing aids. The\r\n  APHAB uses 24 items covering four\r\n  subscales: ease of communication,\r\n  reverberation, back-ground noise and\r\n  aversiveness to sounds. The APHAB has\r\n  been normed on 128 elderly adults with\r\n  mild to moderate hearing loss. The\r\n  APHAB can be downloaded from the\r\n  University of Memphis Hearing Aid\r\n  Research Lab (HARL) website.</p>\r\n<p><strong>INTERNATIONAL OUTCOME\r\n  INVENTORY FOR HEARING AIDS\r\n  (IOI-HA)</strong></p>\r\n<p>Consisting of seven questions on a five\r\n  point rating scale, the goal of the IOI-HA\r\n  is to assess benefit, satisfaction and\r\n  quality of life changes associated with\r\n  hearing aid use. The IOI-HA has been\r\n  normed on 154 adults.16 The IOI-HA\r\n  was designed to be used with other selfreport\r\n  tools, like the APHAB. Available in\r\n  several languages, it can be downloaded\r\n  from the University of Memphis HARL\r\n  website.</p>\r\n<p><strong> WHAT SELF-REPORT OUTCOME\r\n  MEASURE SHOULD BE USED?</strong></p>\r\n<p>Due to the abundance of self-reports\r\n  available to clinicians, it is difficult to\r\n  know which ones work the best. When\r\n  making this decision, it is important to\r\n  examine exactly what dimension of real\r\n  world outcome you are trying to capture\r\n  in the most time-efficient manner. Cox\r\n  and Alexander14 examined the\r\n  relationship between self-reports of\r\n  outcome and personality. Analyses of the\r\n  collection of outcome measures</p>\r\n<p>produced a set of three components that\r\n  were interpreted as a Device component,\r\n  a Success component, and an Acceptance\r\n  component. Results suggest that\r\n  personality is more closely linked to selfreports\r\n  of hearing aid outcome than\r\n  conventional laboratory measures, like\r\n  the audiogram. Their findings suggests\r\n  that both self-reports and laboratorybased\r\n  of outcome are needed to\r\n  accurately access hearing aid benefit.\r\n  Measuring each of the seven dimensions\r\n  of quality, using a combination of direct\r\n  and proxy measures, enables the\r\n  professional to identify performance gaps\r\n  and begin the process of eliminating\r\n  them. Managing today&rsquo;s modern\r\n  audiology practice requires judicious\r\n  application of quality metrics that\r\n  compliment traditional productivity\r\n  measures.</p>\r\n<p>It goes without saying that systematically\r\n  measuring quality along seven patient\r\n  centric dimensions is not an end in itself.\r\n  Rather, the purpose of measuring is to\r\n  gain deeper insight into how your\r\n  practice creates a premium office\r\n  experience and generates word of mouth\r\n  referrals, which are proven generators of\r\n  significant revenue and growth over a\r\n  long period of time.16 As professionals we\r\n  know that what gets measured gets done.\r\n  In an industry in which the most\r\n  common metric for quality is a low\r\n  return for credit rate, it time to broaden\r\n  our scope and examine the entire patient\r\n  experience and how it relates to quality\r\n  in our practices.</p>\r\n<h4> REFERENCES</h4>\r\n<p>1. Kochkin S. et al. MarkeTrak VIII: The impact\r\n  of the hearing healthcare professional on\r\n  hearing aid user success. Hear Rev\r\n  2010;17(4)12&ndash;34.</p>\r\n<p>2. Rogin C. Top 10 reasons for consumer delight.\r\n  Washington D.C.: Hearing Instruments\r\n  Association; 2010.</p>\r\n<p>3. Dillon H., James A., Ginis J. The Client\r\n  Oriented Scale of Improvement (COSI) and its relationship to several other measures of benefit\r\n  and satisfaction provided by hearing aids. J Am\r\n  Acad Audiol 1997;8(2):27&ndash;43.</p>\r\n<p>4. Kochkin S. MartkeTrak VIII: Customer\r\n  satisfaction with hearing aids is slowly\r\n  increasing. Hear J 2010;63(1):11&ndash;19.</p>\r\n<p>5. Kochkin S. MarkeTrak VII: obstacles to adult\r\n  non-users adoption of hearing aids. Hear J\r\n  2007;60(4):27&ndash;43.</p>\r\n<p>6. Kirkwood D. Survey probes dispensers&rsquo; view\r\n  on key issues raised by Consumer Reports.\r\n  Hear J 2010;63(5)17&ndash;26.</p>\r\n<p>7. Etymotic Research, Elk Grove Village, IL; 2001.</p>\r\n<p>8. Nabalek A. Acceptable noise level: A clinical\r\n  measure for predicting hearing aid outcome. J Am Acad Audiol 2006;17(9)626&ndash;39.</p>\r\n<p>9. Humes L. As outcome measures proliferate,\r\n  how do you choose which ones to use? Hear J\r\n  2004;57(4)10&ndash;17</p>\r\n<p>10. Wilson C. and Stephens D. Reasons for referral\r\n  and attitudes toward hearing aids: do they affect\r\n  outcome? Clin Otolaryngol 2003;28(2):81&ndash;84.</p>\r\n<p>11. Taubman l, Palmer C, Durrant J, and Pratt S.\r\n  Accuracy of hearing aid use time as reported by\r\n  experienced hearing aid users. Ear Hear\r\n  1999;20(4):299&ndash;305.</p>\r\n<p>12. Cox R and Alexander G. Personality, hearing\r\n  problems, and amplification characteristics:\r\n  contributions to self-report hearing aid\r\n  outcomes. Ear Hear 2007;28(2):141&ndash;62.</p>\r\n<p>13. Taylor B. Laboratory measures of hearing aid\r\n  outcome: more than just nostalgia for the &lsquo;70s.\r\n  2008. Posted at www.audiologyonline.com.\r\n  Downloaded June 2, 2010.</p>\r\n<p>14. Cox R and Alexander G. (1995) The\r\n  Abbreviated Profile of Hearing Aid Benefit\r\n  (APHAB). Ear Hear 1995;16:176&ndash;86.</p>\r\n<p>15. Cox R Alexander G, Beyer C. Norms for the\r\n  international inventory for hearing aids. Int J\r\n  Audiol 2003;14(8):403&ndash;13.</p>\r\n<p>16. Fornell C. The satisfied customer: winners and\r\n  losers in the battle for buyer preference. New\r\n  York: Palgrave Macmillan Press; 2008.\r\n  Canadian Hearing Report 2014;9(3):15-21.</p>\r\n<h4>Noise Exposure: Explanation of OSHA and\r\n  NIOSH Safe-Exposure Limits and the\r\n  Importance of Noise Dosimetry</h4>\r\n<p><strong>About the Author</strong></p>\r\n<p>Patty Niquette is an audiologist with Etymotic Research where she has the great privilege of\r\n  working with Mead Killion and many other talented scientists, audiologists, and engineers in their\r\n  shared mission of developing products to measure, improve and protect one of humankind&rsquo;s most\r\n  precious senses: hearing.</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>It&rsquo;s a noisy world, and hearing damage\r\n  from loud sound affects millions of\r\n  people. Noise-induced hearing loss\r\n  (NIHL) and associated disorders of\r\n  tinnitus, hyperacusis, and diplacusis are\r\n  all irreversible. This is a tragedy,\r\n  considering that these often debilitating\r\n  conditions are preventable. The keys to\r\n  prevention are in understanding the\r\n  risks and consistently acting to minimize\r\n  the risks.</p>\r\n<p><strong>NEW EVIDENCE FOR URGENCY</strong></p>\r\n<p>NIHL and associated disorders (which,\r\n  for simplification, will be included in the\r\n  acronym &ldquo;NIHL&rdquo;) are caused by\r\n  overexposure: listening to sound that&rsquo;s\r\n  too loud, for too long. NIHL can occur\r\n  from a single activity such as an\r\n  explosion or a loud concert, but it\r\n  usually occurs gradually over many\r\n  years. Decades of data have shown that\r\n  noise-related shifts in hearing appeared\r\n  to be temporary, a phenomenon known\r\n  as temporary threshold shift (TTS). With\r\n  TTS, hearing thresholds typically recover\r\n  to pre-noise exposure levels after a\r\n  period of auditory quiet. Because of this\r\n  recovery, many of us assumed that the\r\n  structure and function of the auditory\r\n  system was affected only temporarily by\r\n  noise, returning to normal (or preexposure)\r\n  levels after a period of quiet.</p>\r\n<p>We believed that permanent changes in\r\n  auditory anatomy transpired only after\r\n  repeated auditory insults occurring over\r\n  many years. However, research on noise\r\n  exposure in animal models by Kujawa\r\n  and Liberman (2009) challenges these\r\n  assumptions.</p>\r\n<p>Kujawa and Liberman (2009) found that\r\n  while outer hair cells do recover postexposure\r\n  (with a corresponding recovery\r\n  of hearing thresholds and otoacoustic\r\n  emissions [OAEs]) other changes in the\r\n  basal region of the cochlea do not\r\n  recover: there is dramatic degeneration\r\n  of both pre- and post-synaptic elements\r\n  of the inner hair cells and spiral ganglion\r\n  cells. Not only is this damage\r\n  undetectable using current test protocols\r\n  (pure tone thresholds, OAEs and\r\n  Auditory Brainstem Response [ABR]) but\r\n  the loss of spiral ganglion cells is not\r\n  seen until weeks or months postexposure.</p>\r\n<p>Kujawa and Liberman suggest\r\n  that noise-induced hearing damage has\r\n  progressive consequences that may not\r\n  manifest until much later. This damage\r\n  may be expressed as difficulty hearing in\r\n  noise and/or in associated auditory\r\n  disorders (tinnitus, hyperacusis, etc.).</p>\r\n<p>The implication of this research is that\r\n  noise can produce subclinical damage\r\n  that goes undetected, progresses\r\n  unnoticed, and finally manifests itself\r\n  long after the fact. We can&rsquo;t measure this\r\n  subclinical damage using audiometric\r\n  tests, including the &ldquo;gold standard&rdquo; for testing NIHL: pure tone hearing\r\n  thresholds. Data collected over many\r\n  years from persons exposed to industrial\r\n  noise shows that most NIHL develops\r\n  over the first 10-15 years of noise\r\n  exposure and then asymptotes (levels\r\n  off). From a preventive standpoint, the\r\n  sooner we identify hearing risk and\r\n  minimize it, the better. We need to\r\n  educate our young people and equip\r\n  them to protect their hearing at an early\r\n  age, ideally before damage occurs. To do\r\n  this we must monitor noise exposures to\r\n  assess risk and use hearing protection\r\n  when necessary to reduce the risk of\r\n  NIHL.</p>\r\n<p><strong>WHO GOVERNS NOISE\r\n  EXPOSURE</strong>?</p>\r\n<p>In the United States, concern with\r\n  noise exposures began primarily in the\r\n  workplace. Guidelines for occupational\r\n  noise exposure were established by the\r\n  Occupational Safety and Health\r\n  Administration (OSHA, 1983) and the\r\n  National Institute for Occupational\r\n  Safety and Health (NIOSH, 1998). Both\r\n  OSHA and NIOSH were created by the\r\n  Occupational Safety and Health Act of\r\n  1970 (see www.cdc.gov/niosh/about.html).</p>\r\n<p>OSHA is part of the U.S. Department of\r\n  Labor and is responsible for developing\r\n  and enforcing workplace safety and\r\n  health regulations. The OSHA standard\r\n  (29CFR1910.95) carries behind it the\r\n  force of law and employers in the\r\n  industrial sector are bound to comply\r\n  with it. Those employed in mining, railroad, coast guard, military, and\r\n  construction are bound by their own\r\n  standards.</p>\r\n<p>NIOSH is part of the Centers for Disease\r\n  Control and Prevention (CDC) in the\r\n  U.S. Department of Health and Human\r\n  Services. NIOSH conducts research and\r\n  provides information, education,\r\n  training, and recommendations\r\n  regarding occupational safety and\r\n  health. As such, NIOSH is in a position\r\n  to recommend standards and best\r\n  practices, but it is not in a position to\r\n  regulate or enforce standards.</p>\r\n<p><strong> LIMITING NOISE EXPOSURE:\r\n  DAMAGE-RISK CRITERIA</strong></p>\r\n<p>How long and how loud can we listen\r\n  to sound without risking hearing\r\n  damage? Damage-risk criteria provide\r\n  the basis for recommending noise\r\n  exposure limits based on noise level\r\n  and exposure time. OSHA and NIOSH\r\n  criteria are shown in Figure 1.</p>\r\n<p>OSHA permits exposures of 85 dBA for\r\n  16 hours per day, and uses a 5-dB timeintensity\r\n  tradeoff: for every 5 dB increase\r\n  in noise level, the allowable exposure\r\n  time is reduced by half. For every 5 dB\r\n  decrease in noise level, the allowable\r\n  exposure time is doubled. All\r\n  time/intensity values shown on the\r\n  OSHA PEL line in Figure 1 are assumed\r\n  to have equal risk to each other, that is,\r\n  16 hours at 85 dB carries the same\r\n  auditory risk as 8 hours at 90 dB, 4 hours\r\n  at 95 dB, 2 hours at 100 dB, and so on.</p>\r\n<p>NIOSH recommends an exposure limit\r\n  of 85 dBA for 8 hours per day, and uses\r\n  a 3 dB time-intensity tradeoff: for every\r\n  3 dB increase in noise level, the\r\n  allowable exposure time is reduced by\r\n  half. For every 3 dB decrease in noise\r\n  level, the allowable exposure time is\r\n  doubled. The time/intensity values\r\n  shown on the NIOSH REL line in Figure\r\n  1 are assumed to have equal risk to each\r\n  other, that is, 8 hours at 85 dB carries\r\n  the same auditory risk as 4 hours at 88\r\n  dB, 2 hours at 91 dB, and so on. The\r\n  differences in OSHA criteria and NIOSH\r\n  recommendations for exposure limits\r\n  produce different outcomes: the more\r\n  lenient OSHA values allow for higher\r\n  exposures for longer durations and the\r\n  more conservative NIOSH values\r\n  recommend lower exposures for shorter\r\n  durations. The NIOSH values are based\r\n  on scientific studies relating noise\r\n  exposure to hearing loss, and are more\r\n  protective of hearing. It should be noted\r\n  that both standards are based on the\r\n  assumption that the noise occurs as part\r\n  of a work environment, and both\r\n  assume non-occupational quiet. That is,\r\n  the limits are based on an 8-hour\r\n  workday, five days per week over a 40-\r\n  year working lifetime, and the time the\r\n  individual is not at work (the other 16\r\n  hours in a day, as well as weekends) is\r\n  assumed to be quiet. The standards do\r\n  not account for noisy activities and\r\n  hobbies (e.g., concerts, ATVs,\r\n  snowmobiles, power tools, car races, live\r\n  music, etc.) which mayincrease risk for\r\n  NIHL.</p>\r\n<p><strong> ORIGIN OF DAMAGE-RISK\r\n  CRITERIA</strong></p>\r\n<p>The NIOSH Recommended Exposure\r\n  Limit (REL) is based on scientific data\r\n  relating noise-induced permanent\r\n  threshold shift (NIPTS) to the level and\r\n  duration of noise exposures (NIOSH,\r\n  1998). In contrast, the OSHA Permissible Exposure Limit (PEL) was\r\n  the result of debate and compromises\r\n  that are a part of enacting any legislation\r\n  (OSHA, 1983). Neither guideline is\r\n  completely protective in nature; both\r\n  allow for some NIPTS based on their\r\n  individual definitions of material hearing\r\n  impairment and the percentage of the\r\n  population for whom this risk is deemed\r\n  acceptable. Additionally, standards are\r\n  based on average risk (rather than\r\n  individual susceptibility) so certain\r\n  individuals may be at greater or lesser\r\n  risk for developing NIHL.</p>\r\n<p><strong> Definition of Material Hearing\r\n  Impairment</strong></p>\r\n<p>The time/intensity limits comprising the\r\n  OSHA PELs and NIOSH RELs are in\r\n  part based on each organization&rsquo;s\r\n  definition of material hearing\r\n  impairment and the excess risk of\r\n  developing that impairment.</p>\r\n<p>OSHA defines material hearing\r\n  impairment as average hearing\r\n  thresholds exceeding 25 dB HL at 1k, 2k\r\n  and 3k Hz, bilaterally. NIOSH uses the same definition, except that\r\n  thresholds at 4 kHz (where the\r\n  effects of noise are usually seen\r\n  first and/or worst) are included.\r\n  The inclusion of 4k Hz is an\r\n  improvement over the OSHA\r\n  definition; however, the\r\n  averaging of thresholds across\r\n  frequencies and ears means that\r\n  significant hearing loss can\r\n  occur before either formula\r\n  labels it as hearing impairment. The\r\n  audiogram shown in Figure 2 reveals a\r\n  mild to moderate high-frequency\r\n  hearing loss, but this audiogram does\r\n  not meet the definition of material\r\n  hearing impairment under either the\r\n  OSHA or NIOSH standards.</p>\r\n<p>Both OSHA and NIOSH definitions\r\n  include 1k and 2k Hz, where NIHL is\r\n  not likely to be seen. This has the effect\r\n  of &ldquo;watering down&rdquo; the average loss\r\n  across frequencies. In the presence of\r\n  normal low-to- mid frequency hearing,\r\n  there must be moderate to moderatelysevere\r\n  high frequency hearing loss in\r\n  both ears to produce a 3-frequency or 4-\r\n  frequency average exceeding 25 dB.\r\n  Significant hearing loss can occur before\r\n  it is labeled as such by these definitions.</p>\r\n<p><strong>Excess Risk</strong></p>\r\n<p>Excess risk is defined as the percentage\r\n  of people in a noise-exposed population\r\n  who develop a material hearing\r\n  impairment (as defined by OSHA or\r\n  NIOSH) above and beyond the\r\n  percentage of people in a non-noiseexposed\r\n  population who develop a\r\n  material hearing impairment. Excess risk\r\n  is calculated based on the exposure level\r\n  and assumes an 8-hour work day, 5 days\r\n  per week, over a 40-year working\r\n  lifetime. Figure 3 shows the excess risk\r\n  of developing material hearing\r\n  impairment for different exposure levels,\r\n  based on the NIOSH definition of\r\n  material hearing impairment.</p>\r\n<p>As can be seen in Figure 3, a 90 dB\r\n  exposure incurred 8 hours per work day\r\n  over a working lifetime, results in 25%\r\n  excess risk of developing material hearing\r\n  impairment, while an 85 dB exposure\r\n  results in 8% excess risk of developing\r\n  material hearing impairment. While\r\n  neither criterion protects all workers, the\r\n  NIOSH limit of 85 dB is more protective\r\n  and if followed, results in fewer workers sustaining material hearing impairment.</p>\r\n<p><strong>Individual Susceptibility</strong></p>\r\n<p>Individual susceptibility for NIPTS\r\n  depends on genetic predisposition\r\n  (&ldquo;tough ears&rdquo; vs. &ldquo;tender ears&rdquo;),\r\n  environmental contaminants (e.g.,\r\n  chemicals and solvents), medications\r\n  (e.g., chemotherapy or antibiotic agents\r\n  that react synergistically with noise and\r\n  exacerbate NIHL), medical conditions\r\n  (e.g., diabetes, heart disease) and\r\n  behaviors (e.g., smoking). Environment,\r\n  health and lifestyle issues, combined\r\n  with occupational and non-occupational\r\n  noise, determine an individual&rsquo;s risk for\r\n  developing NIHL. An individual could\r\n  adhere to the limits of the more conservative NIOSH recommendations\r\n  and still develop NIHL due to individual\r\n  risk factors that can&rsquo;t be accounted for in\r\n  standards.</p>\r\n<p>In summary, both the OSHA and\r\n  NIOSH limits seek to reduce risk for the\r\n  average person, rather than to prevent\r\n  NIHL for all individuals.</p>\r\n<h4> MEASURING NOISE EXPOSURES</h4>\r\n<p>To assess risk of NIHL we need to know\r\n  the level and duration of noise exposures\r\n  so we can compare them to the RELs.\r\n  Noise can be measured using a sound\r\n  level meter or a noise dosimeter.\r\n  A sound level meter measures sound\r\n  level at a single point in time, which is\r\n  useful when sound is steady-state with\r\n  little variation in level. Sound level\r\n  meters are inexpensive, widely available,\r\n  and relatively simple to use. When\r\n  sound exposures vary in level and\r\n  duration it&rsquo;s difficult to accurately\r\n  estimate exposure using a sound level\r\n  meter, and a noise dosimeter should be\r\n  used instead.\r\n  A noise dosimeter measures sound levels\r\n  continuously over time and integrates\r\n  them into a single value, the noise dose.\r\n  A dosimeter provides a more accurate\r\n  estimate of noise exposure when sound\r\n  levels fluctuate and/or exposure\r\n  durations vary, and can alert the user in real time to the need for hearing\r\n  protection based on the accumulated\r\n  noise dose. Noise dosimeters have\r\n  traditionally been expensive and\r\n  complicated to operate, limiting their\r\n  use to special applications by highly\r\n  trained individuals.</p>\r\n<p>Etymotic Research, in collaboration with\r\n  Greg Flamme, Ph.D., developed two\r\n  low-cost personal noise dosimeters that\r\n  are easy to operate and can be used for a\r\n  wide variety of applications.</p>\r\n<p><strong> NOISE DOSE</strong></p>\r\n<p>Noise dose is expressed as a percentage\r\n  of a predetermined maximum, defined\r\n  by the standard you choose (e.g., OSHA\r\n  or NIOSH). Dose is calculated based on\r\n  the criterion level, threshold level and\r\n  exchange rate. Criterion level is the\r\n  sound level which, if continuously\r\n  applied for 8 hours, would result in a\r\n  100% noise dose. Threshold level is the\r\n  level below which the dosimeter\r\n  produces no noise dose accumulation\r\n  (values below that level are effectively\r\n  considered to be zero). Exchange rate is\r\n  based on the equal-energy hypothesis,\r\n  which assumes that equal amounts of\r\n  sound energy will produce equal\r\n  amounts of hearing impairment.</p>\r\n<p>OSHA uses a criterion level of 90 dB, a\r\n  threshold level of 80 dB, and an\r\n  exchange rate of 5 dB. An OSHA 100% noise dose is 90 dB for 8 hours, 95 dB\r\n  for 4 hours, 100 dB for 2 hours, and so\r\n  on (OSHA decreases the PEL to 85 dB\r\n  for 8 hours if the employee has a\r\n  documented threshold shift; see 29CFR\r\n  1910.95 for additional details).\r\n  NIOSH uses a criterion level of 85 dB, a\r\n  threshold level of 75 dB, and an\r\n  exchange rate of 3 dB. A NIOSH 100%\r\n  noise dose is 85 dB for 8 hours, 88 dB\r\n  for 4 hours, 91dB for 2 hours, and so on\r\n  (see Figure 1).</p>\r\n<p>Since OSHA and NIOSH define dose\r\n  differently, the first rule of interpretation\r\n  is to know which standard the dose\r\n  calculation was based on. As illustrated\r\n  previously, the NIOSH and OSHA\r\n  allowable sound levels and times differ,\r\n  so each define a 100% dosedifferently\r\n  (see Figure 4).</p>\r\n<p>The differences in the OSHA and\r\n  NIOSH standards become noticeable at\r\n  high noise levels: OSHA allows a 100 dB\r\n  noise exposure for two hours, while\r\n  NIOSH limits it to 15 minutes; OSHA\r\n  allows a 115 dB noise exposure for 15\r\n  minutes, while NIOSH limits it to 28\r\n  seconds (not shown). These differences\r\n  undoubtedly produce differences in risk\r\n  for NIHL, with the OSHA criteria\r\n  carrying higher risk. The exposure used\r\n  by Kujawa and Liberman (2009) was\r\n  100 dB for 2 hours, which constitutes a\r\n  100% dose as defined by OSHA. This\r\n  single exposure produced irreparable\r\n  damage to IHC afferent nerve terminals\r\n  and associated degeneration of the\r\n  cochlear nerve.</p>\r\n<p>An important point about noise dose is\r\n  that it is cumulative; noise dose never\r\n  decreases over time. While sound levels\r\n  may go up and down over time, noise\r\n  dose only increases or plateaus over\r\n  time. This is because you can&rsquo;t remove the exposure once it has occurred, much\r\n  the same way you can&rsquo;t undo sun\r\n  exposure after the fact. When the\r\n  combination of sound levels and\r\n  duration exceed those shown in Figure\r\n  4, noise dose increases to values greater\r\n  than 100% (see Figure 5).</p>\r\n<p>A 200% noise dose is two times the\r\n  allowable limit (equivalent to two days&rsquo;\r\n  worth of noise exposure); a 400% noise\r\n  dose is four times the allowable limit\r\n  (equivalent to four days&rsquo; worth of noise\r\n  exposure), and so on. Do exposures like\r\n  this occur often enough for us to be\r\n  concerned? Absolutely! Measurements\r\n  taken during a drum line demonstration\r\n  in the band room at a local high school,\r\n  with only half of the drum line students\r\n  resulted in a 1400% noise dose after\r\n  only 45 minutes.</p>\r\n<p>Using Dosimetry Results to\r\n  Recommend Hearing Protection\r\n  The simplest way to use noise dosimetry\r\n  results is to recommend use of hearing\r\n  protection whenever noise dose exceeds\r\n  50%, particularly if that dose is reached\r\n  early in the noise exposure period.\r\n  Initiating protection at a 50% noise dose\r\n  is more protective, especially for\r\n  individuals with higher than average\r\n  susceptibility to NIHL. This also\r\n  recognizes the potential for exposure to\r\n  noise throughout the day, rather than\r\n  limiting potential exposure to the work\r\n  day only.</p>\r\n<h4> REFERENCES</h4>\r\n<p>ANSI S1.25 &ndash; 1991 (R2002). Specification for\r\n  personal noise dosimeters.\r\n  Kujawa SG, Liberman MC (2009). Adding\r\n  Insult to Injury: Cochlear Nerve Degeneration After\r\n  &ldquo;Temporary&rdquo; Noise-Induced Hearing Loss. J Neurosci\r\n  29(45):14077-14085.</p>\r\n<p>National Institute for Occupational Safety and\r\n  Health (1998). Criteria for a recommended standard:\r\n  Occupational noise exposure. U.S. Department of\r\n  Health and Human Services, Centers for Disease\r\n  Control and Prevention.</p>\r\n<p>Occupational Safety and Health Administration\r\n  (1983). 29CFR1910.95 Occupational Noise\r\n  Exposure: Hearing Conservation Amendment.\r\n  Canadian Hearing Report 2014;9(3):22-26.</p>',NULL,'2022-11-23'),(21,3259,'','','<p><strong>Gael Hannan<sup><sup><a href=\"#corr\">*</a></sup></sup></strong></p>\r\n<p>Gael Hannan is a writer, actor, and public speaker who grew up with a progressive hearing loss that is now severe-to-profound. She is a director on the national board of the Canadian Hard of Hearing Association (CHHA) and an advocate whose work includes speechreading instruction, hearing awareness, workshops for youth with hearing loss, and work on hearing access committees.</p>\r\n<p>Gael is a sought-after speaker for her humorous and insightful performances about hearing loss. Unheard Voices and EarRage! are ground-breaking solo shows that illuminate the profound impact of hearing loss on a person?s life and relationships, and which Gael has presented to appreciative audiences around Canada, the United States and New Zealand. A DVD/video version of Unheard Voices is now available. She has received several awards for her work, including the Consumer Advocacy Award from the Canadian Association of Speech Language Pathologists and Audiologists. Gael lives with her husband and son in Toronto.</p>','<p>Welcome to the first issue of Canadian Hearing Report for 2014 and to the Happy HoH, a column that explores the life with hearing loss. (Note: HoH is an acronym for Hard of Hearing &ndash; and it sounds like it looks. So, I&rsquo;m careful not to identify myself as a HoH when I go to the store, because I&rsquo;m looking for milk, not trouble.)</p>\r\n<p>I&rsquo;ve lots of experience being a HoH &ndash; since birth, apparently. I live and breathe the barriers and challenges of hearing loss. As an advocate, I talk about the communication strategies that can break them down. Are they easy? Do I use all the strategies, regularly, that can help me to succeed in the constant presence of hearing difficulties?</p>\r\n<p>Please, I&rsquo;m only human! Just because I know what&rsquo;s good for me doesn&rsquo;t mean that I actually practice it with every word I listen to, or speak. Life with hearing loss is complex, and to communicate well requires a big bag of tricks that involve emotions, endless hours of effort and more than a few dollars of hard-earned money. And although I often slip into some bad communication habits, I think after a few decades, I&rsquo;ve more or less got it down to a fine art. It&rsquo;s just not always easy. Mind you, some things are&hellip; It&rsquo;s EASY to convince ourselves that we&rsquo;re doing &ldquo;fine&rdquo; with our hearing loss:</p>\r\n<p>That we&rsquo;re catching most of what&rsquo;s said Well, at least the important stuff &ndash; the rest&rsquo;s not really worth listening to, right? And no, we don&rsquo;t intend to do anything about it Like getting a hearing aid or cochlear implant &ndash; Those are for other people, who have real problems. It&rsquo;s EASY to give in to frustration and the emotional roller coaster of hearing loss: Because nothing has ever prepared us for this &ndash; This&hellip;invisible separation&hellip;from the life we&rsquo;re used to, And the people we were close to. It&rsquo;s like standing outside, looking through a window Rapping on the glass and trying to talk to our family on the inside. It hurts.</p>\r\n<p>It&rsquo;s EASY to slip into bad habits of bluffing, of tuning out: Because we just can&rsquo;t get what&rsquo;s being said, Even though we&rsquo;re trying so hard to follow. It makes us tired And before we even realize it, We&rsquo;re nodding and smiling as if we&rsquo;re totally in the conversation And we hope no one calls us on it. Because we would be embarrassed &ndash; and they would be irritated. It&rsquo;s EASY to blame other people for communication breakdowns: &ldquo;They won&rsquo;t face me, They forget all the time, They just&hellip;they just don&rsquo;t understand. Even though I&rsquo;ve explained it Over and over again. I&rsquo;ve done all I can and now it&rsquo;s up to them. Hell, I&rsquo;m the one with the damn hearing loss! How about a little consideration?&rdquo; It&rsquo;s EASY to blame our hearing loss for everything that&rsquo;s not going right:</p>\r\n<p>&ldquo;My marriage would be better if it wasn&rsquo;t for my hearing My kids wouldn&rsquo;t laugh or take advantage of me I would be happier at work, I&rsquo;d feel better about myself And I could focus my energy on making things better Instead of using it all up On trying to communicate, Or even hiding it completely And don&rsquo;t tell me that&rsquo;s wrong, that I shouldn&rsquo;t do it &ndash; I&rsquo;d like to see you struggling every day, all day, With hearing loss like mine.&rdquo; It&rsquo;s EASY to let hearing loss define us: Life was better before. Now it&rsquo;s not. My hearing loss affects everything, Everything I do, everyone I talk to. I am my hearing loss. No one ever said that being a HoH is easy. But it doesn&rsquo;t have to be this hard, either. We &ndash; all of us &ndash; have bad hearing days when we want to crawl into bed, pull the covers over our head, and cry in frustration over the relentless pressure of communication gone wrong. But if we stay in hiding, if we keep crying, our negative attitudes will harden into cement and we won&rsquo;t be able to break free.</p>\r\n<p>There&rsquo;s another easy lesson if we want to take it: help is available, standing by, waiting. If you &ndash; or anyone you know &ndash; is struggling with hearing loss, reach out for help. Read this magazine and other publications. Speak to your doctor or visit a hearing care professional. Contact a hearing loss group in your community, or online, where there are people with hearing loss who understand what you&rsquo;re going through. They can help, because they&rsquo;ve been there, too. Reach out. It&rsquo;s the easiest lesson of hearing loss. Here&rsquo;s to the new Allied Hearing Health magazine! When you&rsquo;re done reading, pass it along, because you probably know someone else with hearing loss who needs help, too.</p>\r\n<h4>Earl Harford</h4>\r\n<p>CHR: When you hear the name Earl Harford one normally thinks of CROS hearing aids. Specifically, Harford and Berry (1965) in the Journal of Speech and Hearing Disorders was the article when I first read about your work with what to become known as the CROS hearing aid. What led you to do work in this area? Earl Harford: I worked in an audiology/otolaryngology clinic that we held once a week at Northwestern University in Chicago and there was an otolaryngologist that I worked with named George Shambaugh, a distinguished otolaryngologist and a long-time editor of the Archives of Otolaryngology. One day we had a patient come in with a unilateral hearing loss. We counseled him in the routine manner for at that time delete there was nothing that could be done in a medical or surgical manner and from the standpoint of using a hearing aid he was not a candidate because his good ear was too good and his bad ear was too bad to make any sense of amplified sound.</p>\r\n<p>We told him he can compensate for this to some degree by ensuring that his good ear is aimed towards the speaker and to seat where he would always favor his good ear &ndash; we discharged the patient in the usual manner. Then Dr. Shambaugh turned to me and asked whether I had every considered putting a microphone on the bad ear and running a polyethylene tube around and sticking it in the good ear. That would carry the sound across the head. I hadn&rsquo;t really thought too much about that since there would be too much loss of the higher frequencies due to the presence of this long tube. I went back to Evanston, Illinois (these clinics were always held in the medical school in Chicago) and I told Joe Barry, my grad assistant, about this and we both laughed and thought that thisidea would not work. After a few days of thinking about it, it occurred to me that we don&rsquo;t have to use a tube &ndash; we could use a wire.</p>\r\n<p>Perhaps I could get a couple of hearing aid companies to make such a device for me and we could do a little study on it. I had access to Zenith, Maico, and Beltone at that time &ndash; Zenith and Beltone were housed in factories in and around Chicago at that time and it made it easy, and I had a good working relationship with Maico as well. We tested quite a few people and it turned out that it really worked quite  well. In the Harford and Berry (1965) paper we emphasized that the best success was when a person had a high frequency hearing loss in the good ear. Many people forget this and the greater the high frequency hearing loss that a person would have in their good ear, the more difficulty a person would have in compensating for their unilateral hearing loss. Consequently the experience of greater benefit and also greater acceptance of the device was seen with those who also had a high frequency hearing loss in their good ear. Another thing that we pointed out in the 1965 article was that the more recent the hearing loss in the bad ear, the more acceptance we had with the CROS aids. Conversely if a person is congenitally deaf on one side, he becomes so adjusted to that, he won&rsquo;t appreciate much improvement from the CROS aid. Still we had some people (even some with congenital losses) who accepted the CROS and used it on a regular basis.</p>\r\n<p>CROS hearing aids are still being used. Soon, we branched off from the original CROS and did a lot of work with different devices that sought to address the issue of imbalance between the two ears. These included a multitude of names and acronyms such as BICROS, HI-CROS and the power CROS Versions of the CROS Hearing Aid. The power CROS is really the same thing that Roy Sullivan referred to as the transcranial CROS.</p>\r\n<p>Jim Curran (who was then with Maico and later with Starkey) used to tell a romantic story of one of the first CROS aids that went from side to side with a black headband &ndash; I believe that he was a lawyer. After using it in court, the lawyer refused to give it up. We had some people that when we took the prototypes back from them they were really concerned and didn&rsquo;t want to give them up. Elizabeth Dodds was a speech pathology student and after taking my clinical audiology course, she switched over to audiology. I then hired her as a clinical supervisor when she graduated. She was a ballerina before she went into audiology, so this being her &ldquo;second career&rdquo; meant that we were of a comparable age. In 1968 Elizabeth and I published an article in the Journal of Speech and Hearing Research entitled &ldquo;Modified Earpieces and CROS for High FrequencyHearing Loss,&rdquo;</p>\r\n<p>At the time we were not aware, but it ultimately stimulated some people to think about open ear canal fittings. We followed that up in 1970 with &ldquo;Followup-Report on Modified Earpieces and CROS for High Frequency Hearing Loss,&rdquo; (Elizabeth Dodds and Earl Harford, 1970, JSHR, Vol.13, #1, 41-43). We still didn&rsquo;t realize what an impact that would have on open canal fittings. Jim Curran has pointed this out to me several times and from that time on I always vented as much as I could except under extreme circumstances with very severe losses.</p>\r\n<p>I remember when I had students at the University of Minnesota I told them step #1 was use binaural whenever possible; step #2 is to cut the lower frequencies; step #3 was vent as much as you can; and step #4 use in-the-ear fittings because you were taking advantage of the auricle and the various structures of the pinna to amplify high frequency sounds prior to reaching the actual hearing aid. And to this day I would not change those basic four rules. I wear in-the-ear hearing aids to this very day and favour them over behind the ear hearing aids whenever possible. I received my master&rsquo;s from Vanderbilt and then went to Northwestern University in Chicago for my PhD in 1955. There were three faculty member there &ndash; Ray Carhart, Jim Jerger, and John Gaeth. John Gaeth later went to Wayne State. After I completed my PhD studies, I moved to Montreal, Quebec and joined the faculty at McGill University and established the Audiology Clinic at the Royal Victoria Hospital in 1958. After about a year in Canada, I was invited back to the faculty at Northwestern and apparently to fill John Gaeth&rsquo;s vacancy. I was a faculty colleague of Raymond Carhart for over 16 year. Jim Jerger stayed until 1961 then left for the VA in Washington, DC, and then down to the Baylor College of Medicine in Texas where he spent many years. Tom Tillman was the next to come on to the faculty and then Bill Rintelmann and also Bill Carver came through the postdoctorate program there. Bill Rintelmann and Wayne Olsen both ultimately joined the faculty at Northwestern. Noel Matkin came from the University of Connecticut &ndash; we had a great faculty there for many years.</p>\r\n<p>CHR: After moving from Northwestern I understand that you moved to Vanderbilt and later to the University of Minnesota. You had some famous students at that time. EH: Yes. Over the yearsI had some super students who ultimately contributed greatly to the field &ndash; Jay Hall, Bob Johnson, Deborah Hayes, Wayne Olsen, and Brad Stach to name just a few. CHR:Let&rsquo;s switch over to the fact that many people call you &ldquo;Dr. Real Ear Measurement.&rdquo; I guess that we can&rsquo;t really talk about real ear measurement unless we mention the name of David Preves in the same breath. EH: I started to work on real ear measurement in 1975 which was my last full year at Northwestern University. I went to Vanderbilt on January 1, 1976 but my last few months at Northwestern David Preves and I got together and talked about Knowles new, tiny (at the time) microphones being placed in the ear canal. I don&rsquo;t know how it all began but it was David or myself that thought about putting the actual microphone in the ear canal. Later, Starkey called this the RE-4 and was marketed in the mid to late 1980s as a probe microphone (and not a probe tube microphone). CHR:I recall that up to 3000 Hz the RE4 was actually quite good but above that (due to the physical volume of the microphone itself and the fact that it could turn sideways in the ear canal) the higher frequencies were suspect.</p>\r\n<p>EH: It was pretty crude &ndash; the microphones were large and we had to use rather crude equipment. When I left Northwestern, I went to Vanderbilt and became an administrator. I became the director of the Bill Wilkinson Hearing and Speech Center and Head of the Division of Hearing and Speech Sciences so I was a busy guy pushing papers and solving people-problems. I didn&rsquo;t do any research while at Vanderbilt but I did write some articles while I was there.</p>\r\n<p>One was with Jennifer Fox called &ldquo;The Use of High-Pass Amplification for Broad-Frequency Sensorineural Hearing Loss,&rdquo; where we emphasized the importance of cutting the lower frequencies for people with flat sensorineural hearing loss. I ultimately married Jennifer Fox and she and I have been married for 35 years. Actually Jennifer followed a similar path as Elizabeth Dodds and she eventually became my graduate assistant but I never really got to know her until about five years after she left the program. I see her every day now and we only talk about the benefits of high pass amplification &hellip; (just joking, we also talk about other things).</p>\r\n<p>Then when I went to Minnesota I was 10-15 minutes away from David Preves at Starkey and we had a regular pipeline of these miniature microphones. We were ruining the microphones every couple of days and at first we didn&rsquo;t understand it. It turned out that there was a build-up of an electro-static charge on them by walking across a carpeted floor in the sound rooms. I ran over 8000 measurements in the Medical School Audiology Clinic because we had a lot of patients there. The equipment was working very well and we were able to collect a lot of data &ndash; I felt like Jim Jerger! If you had your protocol set up correctly you could gather a lot of data. The first article that actually appeared in Ear and Hearing in 1980 but the first paper I wrote wasn&rsquo;t actually published until several years later in the proceedings of a University of Minnesota  conference on sensorineural hearing loss, tinnitus and vertigo held in September 1979. The most inspiring thing happened after my presentation. Dr Hallowell Davis attended the symposium delete and told me that I was on the right track and we should have been looking at this many years ago. He was the senior author of the first text book of audiology (Hearing and Deafness, A Guide for Laymen) that I had studied back when I was 20 years old. I&rsquo;ll never forget his words of encouragement. CHR: I understand that other than being Dr. CROS and Dr. Real Ear Measurement, you were also known as Dr. Tympanometry?</p>\r\n<p>EH: I did some early work on tympanometry with Gunnar Liden from Sweden. He and I were very close colleagues and we had spent some sabbaticals together. When I was at Northwestern he came over and spent 15 months and he brought with him the notion of tympanometry from Sweden (based on the work of Henry Anderson and Klockoff at the Karolinska Institute of Technology [KTH]). To digress, we used to ski together and one day we were discussing what other work we could do together so that he could have a reason come back to the States to work (and ski). On a chair lift in Utah we discussed the BAHA that he was doing some work with Anders Tjellstrom at the University of Gothenburg and we thought that we would develop this. Ultimately he spent  two years at the University of Minnesota where we did early research on BAHA (1983&ndash;1985).</p>\r\n<p>To come back to tympanometry in the mid 1960s at Northwestern we had to use two bottles of water mounted on a wall rack and we would move them up and down for high pressure and low pressure while a tube was connected to a subject&rsquo;s ear canal. Electronic manometers were not available to us. We never did actually publish an article on that unfortunately. We were preoccupied on trying to get the apparatus to work, but we did run some very early tympanograms. Audiology was so romantic back then delete. I never remembered a day I resented going to work. In the early years we had to do everything by hand. For example, my first 80&ndash;90 publications were done without a computer they all had to be done on a typewriter with no errors and had to be submitted with carbon copies. I took my first course in audiology at Florida State University in 1950 and never looked back. I was about 20 years old then. I&rsquo;ve been in audiology for about 62 years now and I&rsquo;ve seen a lot of changes. It&rsquo;s been a whole lot of fun.</p>\r\n<p>CHR: It&rsquo;s been a pleasure talking to you. Thank you for your contributions to the field.</p>\r\n<h4>James R. Curran is a consultant with Starkey Hearing Technologies</h4>\r\n<p>I f you were asked to name the most significant developments in hearing aids over the last fifty years, which ones would you consider? Digital signal processing? The custom ITE/ITC family? The directional microphone? First fit algorithms? Technologies for feedback control? They are all very worthy of inclusion, but there are those who would place the introduction of CROS amplification very near the top of that list. In point of fact, the CROS concept, introduced over fifty years ago, was the impetus for a revolution in the thinking of hearing care professionals of the day, and it spawned any number of understandings over the next decades that remain an influence in our modern approach to fitting. Recall that CROS is an acronym for Contralateral Routing of Signals, a hearing aid system first recommended (and still fitted today) for unilateral hearing losses where the patient&rsquo;s hearing is good on one side and a loss is on the other. Originally conceived for use with eyeglass aids, a microphone in the temple of the unaidable side picked up the signal that was transmitted by a thin wire/cord connected to the circuitry and receiver in the other temple. The amplified sound was delivered by a tubing to an open ear, obviating the use ofstandard earmolds. Later, the industry developed wireless CROS instruments that did away with the need to use wires and cords to connect each side.</p>\r\n<p>In 1970, Al Dunlavy, a hearing aid dispenser in Manhattan wrote an article for Audecibel, a publication of the National Hearing Aid Society, 1 with the title, &ldquo;CROS: The New Miracle Worker.&rdquo; Why would he call CROS, of all things, a miracle? And was it really? This article deals with the specific and unique application of the CROS aid that he wrote of that was never originally intended, but that eventually became its most significant form of usage, such as, a solution to the problem of feedback. Until the advent of CROS fittings, problems with feedback dogged the industry. Today open canal fittings are routine, seldom requiring a second thought to feedback issues. Feedback cancellation algorithms make bilateral high frequency fittings a walk in the park. One can literally grab a couple of unoccluded ear buds from off the shelf and fit without ever giving a thought to the issues faced years ago. THE HARVARD REPORT ON HEARINGAIDS To get a fuller appreciation of the impact of CROS on the practices of the day, we can go all the way back to 1947, about the time audiology began. That year a famous research monograph on hearing aids was published, referred to as the Harvard Report. 2 At the time the PsychoAcoustics Laboratory at Harvard University wasthe single most influential research center in the United States on matters auditory and acoustic. The report recommended that a flat or 6 dB per octave slope frequency response was adequate for the majority of patients who needed a hearing aid, and it severely criticized other methods of fitting, implying they were a waste of time.</p>\r\n<p>At about the time of the Harvard Report, Raymond Carhart, generally considered the &ldquo;father of audiology&rdquo; in North America, published procedures for selecting the appropriate hearing aid. 3&ndash;5 Although criticized by the Harvard Report, this(comparative) method gained much ascendancy in the university clinics. Aids were pre-selected from clinic stock for inclusion according to the best judgment and preferences of the professional. Only body aids were available then, and during the evaluation, the instrument&rsquo;s case was placed on a (baffle) board alongside the patient. The patient was tested in a sound field, usually but not always, with stock molds,  and often, but not always, without venting. Feedback problems were not a big issue unless the loss was substantial, for the aid&rsquo;s microphone and receiver were at a good distance from each other. Importantly, conventional wisdom at that time held that on average, aided word recognition scores were not expected to exceed the unaided score, which served as a target. The best performing aids were those that provided aided scores approximating the unaided score obtained under circumaural earphones, for it was expected by comparison, that the degraded signals provided by the hearing aid would result in lowerscores. 6</p>\r\n<p>TheHarvard Report recommendationsled the early audiology world astray for years. Fitting hearing aids with a flat response or a 6 dB per octave response on patients having other than flat or moderately sloping threshold configurations led to many dissatisfied, poorly performing patients. And easily accessible information regarding the effect of the earmold on the amplified response was, for all intents and purposes, nearly nonexistent. Fitting problems multiplied when the first BTE and eyeglass aids reached the market in the early 1950s. The two transducers were positioned much closer to each other in head worn instruments, and manufacturers had a difficult time keeping receiver vibrations from spilling over into the microphone. Further, wider bandwidth was possible with head worn aids, and thisincreased the probability of acoustic feedback problems. The result was a high incidence of internal and external feedback issues. One could use full shell earmolds having minimal or no venting in order to eliminate external feedback, but that exacerbated the occlusion effect for many patients. Professionals were fitting rather unrefined aids with little or no understanding of earmold acoustics to patients who, then as now, invariably presented with losses having a high frequency component. The usual outcome was frustration on the part of the professional, and dissatisfaction on the part of the patient.</p>\r\n<p>It is no wonder that hearing aid fitting became one of the least desirable aspects of audiology during those years. Few if any students opted for making hearing aids the major focus of their studies; in fact it was regarded as somewhat d&eacute;class&eacute; if one did, and pity the brave instructor who taught amplification, for reliable facts were few and far between</p>\r\n<p><strong>THE BEGINNING OFWISDOM</strong></p>\r\n<p>Fully five years prior to Dunlavy&rsquo;s article mentioned above, Earl Harford, a professor at Northwestern University, began to document the advantage of the CROS concept and reported it to the scientific community. 7 He and his colleagues published a series of studies in the professional journals exploring its potential and its benefits. 8&ndash;12 Almost immediately professionals recognized that CROS was not just a solution for unilateral hearing loss, but rather, because the microphone and receiver were on separate sides, it was possible to provide high gain, high frequency amplification withoutencountering feedback for patients with high frequency losses. Since nearly all fittings in those days were monaural anyway, every patient who presented with a bilateral (or unilateral) sloping high frequency loss was a candidate, and was assured of a nearly perfect fitting in at least one ear using an open mold. It was finally possible to deliver the satisfaction that the hearing aid advertisements promised.</p>\r\n<p>In one fell swoop this unique CROS application dealt with a number of issues. Papers began to appear in the audiological literature showing that aided discrimination scores actually did improve markedly with open canal amplification compared to scores that had been obtained under earphones or with occluded earmolds. 13&ndash;16 This was a surprise to many for although it was known that test scores varied as test conditions changed (talker, level, transducers, test stimuli, etc,) for some reason this understanding had never fully registered in the case of hearing aid fittings. The improvement in scores resulted from, 1) the high frequencies receiving markedly greater amplification than had been possible heretofore, 2) the high frequency amplification bandwidth being significantly wider than was previously achievable, 3) the occlusion effect being virtually eliminated, and, 4) as a bonus, upward spread of masking effects being reduced due to the absence of amplification in the low frequencies. These results set in motion countless research studies over the years dealing with the benefits and usefulness of high frequency amplification and its contribution to word recognition in both children and adults, and produced many studies dealing with the effect of the earmold/coupling on the frequency response.</p>\r\n<p><strong>ACHIEVING MIRACLES</strong></p>\r\n<p>It is instructive to visit the steps of hearing aid dispensers who were fitting CROS hearing aids, (prior to the introduction of wireless CROS). First, the patient had to be wearing zyl (special plastic) eyeglasses, or the patient was persuaded to purchase a pair. If he/she did not wear glasses, they were asked to get a pair with plain glass lenses. The frames had to have so-called &ldquo;standard hinges&rdquo; because the graduated temple terminations furnished with the eyeglass  hearing aids were only available with this type of hinge. Then a small circular motor-tool saw blade was used to cut a trench across the back of the plastic frame, from hinge to hinge. A very thin plastic cable containing two or three extremely fine wires was placed in the trench and covered over with a plastic sealant. After it had dried, the inside covers of both hearing aid temples were removed, and the fine wires were soldered to the microphone on one side and to the circuitry and receiver on the other. The temple covers were then reglued or screwed back into place. The eyeglass temples and frame were heated, bent and adjusted so that the patient was comfortable with the glasses. A shaveddown pipe cleaner was inserted into a length of earmold tubing and bent to the right shape for secure placement in the ear canal. The tubing was heated with a blower until it set. If needed, the hearing aid&rsquo;s response could be manipulated somewhat by changing the depth of the tubing in the ear canal or by using tubing with different exterior dimensions.</p>\r\n<p>Why would professionals go through such a complicated, lengthy and convoluted process? The answer is that they never had so many grinning, enthusiastic, happy customers. Handholding just about disappeared if the patients were fitted with CROS; most old and new customers experienced wearing success right out of the box. Even with all the rigamarole that attended CROS installation and fitting, countless professionals routinely chose to recommend and to fit them. To them, fittings without feedback problems were indeed miracles. In the early 1970s, the records show that in some years CROS fittings accounted for nearly 20% of all head worn aids. By 1974, Harford and Dodds11 suggested that CROS fittings had probably reached close to 40% of all recommendations in University audiology clinics. The CROS concept and the children that it spawned (IROS, BiCROS, Hi-CROS, etc) became a somewhat neglected fitting option in ensuing years, as custom ITE aids grew in importance. The wonderful solution to feedback issues that CROS provided was essentially forgotten, and CROS was seen again solely as an application suitable for fitting unilateral losses. The advantage of an open canal fitting however, never disappeared, and when it appeared feasible again as a result of modern feedback control methods, the miracle happened all over again.</p>\r\n<p>During an audiology convention a few years ago, a speaker remarked to the audience that the open canal technology of today shouldn&rsquo;t be confused with the old CROS and IROS fittings of years ago. The speaker was in error, of course, for it&rsquo;s the same idea. Today&rsquo;s professionals are standing on the shoulders of some very tough and committed professionals who developed the original technique, changed a lot of widely held assumptions, and brought to the fore many of the important understandings we hold today about providing acceptable amplification for high frequency losses.</p>\r\n<h4>REFERENCES</h4>\r\n<p>1. Dunlavy AR CROS: The new miracle worker. Audecibel 1970;141&ndash;8.</p>\r\n<p>2. Davis H, Stevens SS, Nichols RH, et al. Hearing aids: An experimental study of design objectives. Cambridge: Harvard University Press; 1947.</p>\r\n<p>3. Carhart R. Selection of hearing aids. Arch Otolaryng 1946;44:1&ndash;18.</p>\r\n<p>4. Carhart, R. Testsfor the selection of hearing aids. Laryngoscope 1946;56:780&ndash;94.</p>\r\n<p>5. Carhart R. Hearing aid selection by university clinics, J Speech Hearing Dis 1950;15:106&ndash;13.</p>\r\n<p>6. Hirsh LJ. The measurement of hearing. New York: McGraw-Hill; 1952.</p>\r\n<p>7. Harford E and Barry J. A rehabilitative approach to the problem of unilateral hearing impairment: the contralateral routing of signals (CROS). J Speech Hearing Dis 1965;30:121&ndash;38.</p>\r\n<p>8. Harford E. Bilateral CROS. Two-sided hearing with one hearing aid. Arch Otolaryngol 1966;84:426&ndash;32.</p>\r\n<p>9. Harford E. Innovationsin the use of the modern hearing aid. Internat Audiol 1967;6:311&ndash;14.</p>\r\n<p>10. Harford D. Recent development in the use of ear&ndash;level hearing aids. Maico Audiological Series 1968;5(3):10&ndash;13.</p>\r\n<p>11. Harford E and Dodds E. Versions of CROS hearing aids. Arch Otolaryngol 1974;100:50&ndash; 57.</p>\r\n<p>12. Dodds E and Harford E. Modified earpieces and CROS for high frequency hearing loss. J Speech Hearing Dis 1968;11:204&ndash;18.</p>\r\n<p>13. McClellan, M. Aided speech discrimination scores in noise with vented and unvented earmolds. J Aud Res 1967;13:93&ndash;99.</p>\r\n<p>14. Green D and Ross M. The effect of a conventional versus a nonoccluding (CROS type) earmold upon the frequency response of a hearing aid. J Speech Hearing Res 1968;11:638&ndash;47.</p>\r\n<p>15. Hodgson W and Murdock C. Effect of the earmold on speech intelligibility in hearing aid use. J Speech Hearing Res 1970;13:290&ndash;97.</p>\r\n<p>16. Jetty A and Rintelmann W. Acoustic coupler effects on speech audiometer scores using a CROS hearing aid. J Speech Hearing Res 1970;13:101&ndash;14.</p>\r\n<h4>Eirini Mihanatzidou, MA(Hons), M.Aud,Aud(C), Reg. CASLPO, and Rhonda Kerlew, RN, BScN, MBA</h4>\r\n<p>Correspondence: Hearing Solutions, 620 Wilson Avenue, Suite 200, Toronto, ON, M3K 1Z3, T: (416) 231-3003, F: (416) 623-1245, www.hearingsolutions.ca</p>\r\n<p>Eirini Mihanatzidou (far left) is an audiologist with Hearing Solutions, Toronto, Ontario.</p>\r\n<p>Rhonda Kerlew is director of business development with Hearing Solutions, Toronto, Ontario.</p>\r\n<p>Diabetes Mellitus (DM) is one of the fastest growing chronic diseases of our era. Recent studies suggest that sensorineural hearing loss is more prevalent in diabetic patients than in people without the condition. The aim of this article is to review the existing literature on the relationship between hearing loss and diabetes. Data was obtained by literature search using the MEDLINE, EMBASE and PubMed databases.</p>\r\n<p>Diabetes mellitus is a group of metabolic disorders characterized by an elevated blood sugar and abnormalities in insulin secretion and action. 1 This group of disorders disrupts the metabolism of protein fats and carbohydrates rendering the body unable to utilize these nutrients. The resultant hyperglycemia can lead to dysfunction of several organs. Damage is noted in the nervous system, eyes, kidneys, heart and blood vessels. 2 In the non-diabetic individual blood glucose levels are controlled by insulin, a hormone produced by the beta-cells of the pancreas. When glucose levels rise in the blood stream (for example after a meal) insulin is released to normalize glucose levels. In the diabetic patient insulin production is either severely deficient in the pancreas or the pancreas is producing insulin but the body is unable to utilize it. 3</p>\r\n<p>There are two major types of diabetes. DM type I results from autoimmune destruction of the beta-cells of the pancreas. Ten percent of all diabetics in the United States are typically diagnosed in childhood or adolescence. Patients with DM I are insulin dependent and require close monitoring of blood sugar levels to ensure blood glucose is controlled throughout the day. This type of diabetes was formerly known as insulin-dependent diabetes mellitus (IDDM). 4 DM type II is characterized by resistance such as a lack of response to insulin by the cells of the body (mainly fat and muscle cells), along with increased insulin production by the liver to overcome this resistance. It accounts for 90% of all cases of diabetes. It is typically diagnosed in adulthood and is closely associated with obesity. DM II is managed by diet, weight management, oral medications and/or insulin. 5 Type II diabetes was formerly known as noninsulin-dependent diabetes mellitus (NIDDM), but this term has been abandoned since most of the patients with DM II will require insulin treatment at some point in the course of their condition. 6 The prevalence of diabetes among adults within the 20&ndash;79 year range was estimated to be 6.4% in 2010, affecting 285 million people worldwide. The prevalence is expected to rise to 7.7% and 439 million adults by 2030. 7</p>\r\n<p>Both types of diabetes are associated with a number of chronic complications and co-morbidities. The most prevalent and well known complications include retinopathy, nephropathy, and peripheral neuropathy. 8 Each of these complications carries its own set of losses and dysfunction such as blindness, kidney failure, and peripheral vascular disease requiring amputation. 9 Another, less well known complication of diabetes is hearing impairment. Accumulating evidence suggests that there is a higher prevalence of hearing loss in the diabetic versus the non-diabetic population. 10&ndash;12 The hearing loss is bilateral, sensorineural, symmetrical, and tends to affect the high frequencies more than the low/mid ones. 13,14</p>\r\n<p>More specifically, Dalton et al. found that 59% of diabetic subjects had a hearing loss as opposed to 44% of non-diabetic subjects. 15 The association between diabetes and hearing loss was significant when results were analyzed excluding subjects with non age-related hearing loss. In a study conducted by Bainbridge et al. 68% of patients with diabetes were found to have some high-frequency hearing loss compared to 31% of subjects without diabetes. 16 The prevalence of low/mid frequency hearing loss was 28% in the diabetic patients as opposed to 9% in the non-diabetic group. The association between diabetes and hearing loss remained even after controlling for age, race, sex, poverty level, history of noise exposure, ototoxic medication use, and smoking status. The study by Mitchel et al. is in line with the above findings. 17 More specifically, hearing loss was found in 50% of diabetic patients compared to 38% of the non-diabetic subjects after adjusting for multiple risk factors. Furthermore, a study by Uchida et al. found that diabetes may affect the high-frequencies more strongly in the age bracket of 40&ndash; 64 years of age than at age 65 and above. 18 Finally, a study conducted in 2009 by Cheng et al. revealed that the prevalence of hearing loss amongst diabetics has remained high over the decades when compared to non-diabetic persons. 19 More specifically, the authors compared the two cross-sectional National Health and Nutrition Examination Surveys of 1971-1973 and 1999-2004 (NHANES I and NHANES II). They discovered that from 1971 to 2004 in adults without diabetes aged 25&ndash; 69, the unadjusted prevalence of hearing loss decreased by 9% whereas in the diabetic population there was no significant change.</p>\r\n<p>With regards to the risk factors for hearing impairment in the diabetic population, evidence is conflicting. A number of studies have shown that hearing loss is correlated with glycaemic control (i.e. with the blood glucose levels) and duration of disease. 20&ndash;22 More specifically, Okhovat et al. compared the hearing thresholds of 100 patients with DM I aged 5&ndash;18 years. 23 They found that 21% of them had a hearing impairment and that the hearing thresholds were positively correlated with poor metabolic control (defined as an annual HbA1C of more than 7.5%). Furthermore, thresholds were significantly higher in patients with a history of diabetes of more than five years. Additionally, two studies by Lerman-Garber et al. and KonradMartin et al. reported a positive association between poor glycaemic control and impaired auditory brainstem responses in DM II patients. 24,25 Pudar et al. examined the effects of peripheral neuropathy and retinopathy on hearing impairment in 50 patients with DM I and found that the average sensorineural hearing loss was increased by 73% in the presence of neuropathy, and by 50% in the presence of retinopathy. 26 Bainbridge et al. found a strong correlation between neuropathy, duration of disease and highfrequency hearing impairment in 536 diabetic patients, whereas Dabrowski et al. found higher mid frequency thresholds in 31 patients with DM I and retinopathy. 27,28 However, both of these studies, as well as a third study by Asma et al., failed to find a correlation between glucose levels and hearing loss. 29 Recent studies suggest that diabetes may also increase the susceptibility to noiseinduced hearing loss and sudden idiopathic sensorineural hearing loss (SISNHL). More specifically, Wu et al. and more recently Fujita et al. reported on an animalstudy in which diabetic rats had a significantly impaired recovery from a temporary noise-induced threshold shift. 30,31 Furthermore, Jang et al. found that the hearing thresholds at 4 kHz in 2,612 automobile factory workers were significantly worse in subjects with impaired fasting glucose and diabetes than in non-diabetic subjects. 32 Aimoni et al. studied the prevalence of diabetes in patients with sudden idiopathic sensorineural hearing loss and found that it was almost doubled when compared with the normal hearing subject group. 33 It has been suggested that diabetes can mediate SISNHL through cerebral microangiopathy and changes in blood viscosity. 34,35</p>\r\n<p>The exact mechanism involved in the pathogenesis of hearing loss in diabetic patients remains unknown. A number of histopathological studies conducted in humansfound thickening of the capillary walls of the stria vacsularis, the basilar membrane and the endolymphatic sac, atherosclerotic narrowing of the internal auditory artery, atrophy of the stria vascularis, loss of outer hair cells especially in the lower basal cochlear</p>\r\n<p>turn, spiral ganglion neural atrophy, and VIII cranial nerve demyelination. 36&ndash;39 In all, hearing impairment is one of the less well known complications of diabetes. More research is needed to delineate associated risk factors and mediatorsin its pathogenesis. Untreated hearing loss can negatively impact the social and emotional wellbeing of individuals. 40&ndash;43 The proportion of hearing impairment in the diabetic population in comparison with the non-diabetic population is high. In light of its high prevalence and its detrimental psychosocial effects, health care providers, primary care physicians and endocrinologists should consider referring all diabetic patientsfor a hearing test. Audiometry should be a routine evaluation in the annual test battery of all diabetic patients.</p>\r\n<h4>REFERENCES</h4>\r\n<p>1. Unglaub Silverthorn D, Human Physiolology: An Integrated Approach. San Fransisco: Pearson Education Inc., 2007.</p>\r\n<p>2. Kutty K, Schapira RM, Van Ruiswyk J, eds. Kochar&rsquo;s Concise Textbook of Medicine. 4th ed. Philadelphia: Lippincott Willians &amp; Wilkins, 2003.</p>\r\n<p>3. Anderoli TE, Carpenter CCJ, Griggs RC, Benjamin IJ, eds. Cecil Essentials of Medicine. 7th ed. Philadelphia: Elsevier Saunders, 2007.</p>\r\n<p>4. Guyton AC, Hall JE, Textbook of Medical Physiology. 11th ed. Philadelphia: Elsevier Saunders, 2006.</p>\r\n<p>5. Runge MS, Greganti MA, Netter&rsquo;s Internal Medicine. 2nd ed. Philadelphia: Elsevier Saunders, 2008.</p>\r\n<p>6. Henske JA, Griffith ML, Fowler MJ. Initiating and titrating insulin in patients with type 2 diabetes. Clin Diabet 2009;27(2):72&ndash;6.</p>\r\n<p>7. Shaw JE, Sicree RA, Zimmet PZ. Global estimates for the prevalence of diabetes for 2010 and 2030. Diabet Res Clin Pract 2010;87(1):4&ndash; 14.</p>\r\n<p>8. Longo D, Fauci A, Kasper D, Hauser S (eds.), Harisson&rsquo;s Principles of Internal Medicine. New York : McGraw-Hill, 2011.</p>\r\n<p>9. Kasper DL, Fauci AS, Longo DL, et al. eds. Harrison&rsquo;s Principles of Internal Medicine. 16th ed. New York: Mc Graw-Hill, 2004.</p>\r\n<p>10. D&iacute;az de Le&oacute;n-Morales LV, J&aacute;uregui-Renaud K, Garay-Sevilla ME, et al. Auditory impairment in patients with type 2 diabetes mellitus. Arch Med Res 2005 Sep-Oct;36(5):507&ndash;10</p>\r\n<p>11. Austin DF, Konrad-Martin D, Griest S, et al. Diabates-related changes in hearing. Laryngoscope 2009;119(9):1788&ndash;96.</p>\r\n<p>12. Bamanie AH, Al-Noury KI. Prevalence of hearing loss among type 2 diabetic patients. Saudi Med J 2011 Mar;32(3):271&ndash;4.</p>\r\n<p>13. Diniz TH, Guida HL. Hearing loss in patients with diabetes mellitus. Braz J Otolaryngol 2009 July/Aug;75(4): 573&ndash;8.</p>\r\n<p>14. Malucelli DA, Malucelli FJ, Fonseca VR, et al. Hearing loss prevalence in patients with diabetes mellitus type 1. Braz J Otolaryngol 2012 May/June;78(3):105&ndash;15.</p>\r\n<p>15. Dalton DS, Cruickshanks KJ, Klein BE, et al. Association of NIDDM and hearing loss. Diabetes Care 1998;21:1540&ndash;4.</p>\r\n<p>16. Bainbridge KE, Hoffman HJ, Cowie CC. Diabetes and hearing impairment in the United States: audiometric evidence from the National Health and Nutrition Examination Survey, 1999 to 2004. Ann Intern Med 2008;149(1):1&ndash;10.</p>\r\n<p>17. Mitchell P, Gopinath B, McMahon CM, et al. Relationship of type 2 diabetesto the prevalence, incidence and progression of age-related hearing loss. Diabet Med 2009 May;26(5):483&ndash;8.</p>\r\n<p>18. Uchida Y, Sugiura S, Ando F, et al. Diabetes reduces auditory sensitivity in middle-aged listeners more than in elderly listeners: a population-based study of age-related hearing loss. Med Sci Monit 2010;16(7):PH63&ndash;8.</p>\r\n<p>19. Cheng YJ, Gregg EW, Saaddine JB, et al. three decade change in the prevalence of hearing impairment and its association with diabetes in the US. Prev Med 2009 Nov;49(5):360&ndash;4.</p>\r\n<p>20. Pudar G, Vlaski L, Filipovic D, Tanackov I. Functional hearing examinations in patients suffering from diabetes mellitustype 1 in regards to disease duration. Med Pregl 2010 MayJun;63(5&ndash;6):318&ndash;23.</p>\r\n<p>21. Mozaffari M, Tajik A, Ariaei N, et al. Diabetes mellitus and sensorineural hearing loss among elderly people. East Mediterr Health J 2010 Sep;16(9):947&ndash;52.</p>\r\n<p>22. Sunkum AJ, Pingile S. A clinical study of audiological profile in diabetes mellitus patients. Eur Arch Otorhinolaryngol 2012 Jun 14 [Epub ahead of print], PMID: 22695875.</p>\r\n<p>23. Okhovat SA, Moaddab MH, Okhovat SH, et al. Evaluation of hearing loss in juvenile insulin dependent patients with diabetes mellitus. J Res Med Sci 2011;16(2):179&ndash;84.</p>\r\n<p>24. Konrad-Martin D, Austin DF, Griest S, et al. Diabetes-related changes in auditory brainstem responses. Laryngoscope 2010;120(1):150&ndash;8.</p>\r\n<p>25. Lerman-Garber I, Cuevas-Ramos D, Valdes S, et al. Sensorineural Hearing Loss &ndash; A common finding in early-onset type 2 diabetes mellitus, Endocr Pract 2012;18(4):549&ndash;57.</p>\r\n<p>26. Pudar G, Vlaski L, Filipovic D, Tanackov I. Corellation of hearing function findings in regards to other, subsequent complication of diabetes mellitustype 1. Med Pregl 2009;62(11&ndash; 12):517&ndash;21.</p>\r\n<p>27. Bainbridge KE, Hoffman HJ, Cowie CC. Risk factors for hearing impairment among US adults with diabetes. Diabetes Care 2011;34:1540&ndash;5.</p>\r\n<p>28. Dabrowski M, Mielnik-Niedzielska G, Nowakowski A. Involvement of the auditory organ in Type 1 diabetes mellitus. Endokrynol Pol 2011;62(2):138&ndash;44.</p>\r\n<p>29. Asma A, Azmi MN, Mazita A, et al. A Single blinded randomized controlled study of the effect of conventional oral hypoglycemic agents versus intensive short-term insulin therapy on pure-tone audiometry in type II diabetes mellitus. Indian J Otolaryngol Head Neck Surg 2011;63(2):114&ndash;8.</p>\r\n<p>30. Wu HP, Cheng TJ, Tan CT, et al. Diabetes impairs recovery from noise-induced temporary hearing loss. Laryngoscope 2009;119:1190&ndash;4.</p>\r\n<p>31. Fujita T, Yamashita D, Katsunuma S, et al. Increased inner ear susceptibility to noise injury in mice with streptozotocin-induced diabetes. Diabetes 2012. [Epub ahead of print], PMID: 22851574.</p>\r\n<p>32. Jang TW, Kim BG, Kwon YJ, Im HJ. The association between impaired fasting glucose and noise-induced hearing loss. J Occup Health 2011;53:274&ndash;79.</p>\r\n<p>33. Aimoni C, Bianchini C, Borin M, et al. Diabetes. cardiovascular risk factors and idiopathic sudden sensorineural hearing loss: a case-control study. Audiol Neurootol 2010;15(2):111&ndash;5.</p>\r\n<p>34. Garcia Callejo FJ, Orts Alborch MH, Mprant Ventura A, Marco Algarra J. Neurosensory deafness, blood hyperviscosity syndrome, and diabetes mellitus. Acta Otorrinolaringol Esp 2002 Mar;53(3):2221&ndash;4.</p>\r\n<p>35. Nagaoka J, Anjos MF, Takata TT, et al. Idiopathic sudden sensorineural hearing loss: evolution in the presence of hypertention, diabetes mellitus and dislipidemias. Braz J Otorhinolaryngol 2010;76(3):363&ndash;9.</p>\r\n<p>36. Wackym PA, Linthicum FH Jr. Diabetes mellitus and hearing loss: clinical and histopathological relationships. Am J Otol 1986;7:176&ndash;82.</p>\r\n<p>37. Makishima K, Tanaka K. Pathological changes of the inner ear and central auditory pathways in diabetics. Ann Otol Rhinol Laryngol 1971;80:218&ndash;28.</p>\r\n<p>38. Fukushima H, Cureoglu S, Schachern PA, et al. Effects of type 2 diabetes mellitus on cochlear structure in humans. Arch Otolaryngol Head Neck Surg 2006;132(9):934&ndash;8.</p>\r\n<p>39. Fukushima H, Cureoglu S, Schachern PA, et al. Cochlear changes in patients with type 1 diabetes mellitus. Otolaryngol Head Neck Surg 2005;133(1):100&ndash;6.</p>\r\n<p>40. DeNino LA. Quality-of-life changes and hearing impairment: a randomized trial. Annals of Internal Medicine 1990;113(3):188&ndash;94.</p>\r\n<p>41. Kaland M, Salvatore K. The psychology of hearing loss. The ASHA Leader. 2002;7(5):4&ndash; 5:14&ndash;15.</p>\r\n<p>42. Boi R, Racca L, Cavallero A, et al.. Hearing loss and depressive symptoms in elderly patients. Geriatr Gerontol Int 2012 Jul;12(3):440&ndash;5.</p>\r\n<p>43. Pronk M, Deeg DJ, Smits C, et al. Prospective effects of hearing status on loneliness and depression in older persons: identification of subgroups. Int J Audiol 2011;50(12):887&ndash;96</p>\r\n<p>&nbsp;</p>',NULL,'2022-11-23'),(22,3260,'ajchr','http://www.andrewjohnpublishing.com/','','<p><strong>TO HELP PATIENTS   COMMUNICATE BETTER, WE   NEED TO SHARPEN OUR   OWN COMMUNICATION   SKILLS</strong></p>\r\n<p>By Bob Martin   Posted April 16, 2014   As audiologists and hearing aid specialists,   we are all in the communication   business. It&rsquo;s our job to help our patients   communicate better.</p>\r\n<p>It&rsquo;s only natural, then, that there will be   times and situations in the practice of   our profession that we are called upon   to make an extra effort to communicate   effectively with the people who come to   us for help. In these cases we need to   draw upon all our communication skills.   Let&rsquo;s consider several such situations.</p>\r\n<p><strong>PATIENTS WITH PROBLEM EARS</strong></p>\r\n<p>Occasionally we see patients with truly   &ldquo;ugly&rdquo; ears. They may be infected, there   may be an abrasion in the ear, or they   may be exuding foul-smelling &ldquo;gunk.&rdquo;   In cases like these, we are dealing with   problems of significant magnitude. That   makes it essential for us to establish   excellent communication not only with   the patient, but also with the patient&rsquo;s   family and with their physician. We also   have to make sure our records fully and   accurately describe the patient&rsquo;s   condition.</p>\r\n<p>When I see a patient like this, I make   sure a medical appointment is made,   and I write some notes for the MD (on   my practice&rsquo;s letterhead). I also note in   the patient&rsquo;s chart, &ldquo;Needs to see MD.   Made appointment with Dr. Jones&rdquo; and   I make sure the family understands the problem and the need for referral. I put   a re-check note on my desk and I later   check to see that the patient kept the   appointment.</p>\r\n<p><strong>TEACHING TELEPHONE   STRATEGIES</strong></p>\r\n<p>Another type of situation that places a   premium on good communication   occurs when we teach patients how to   use their hearing aid in specific   situations, such as on the telephone.   The habit of putting a telephone on   your ear is almost impossible to break.   Yet, many hard-of-hearing people   cannot use their hearing aids if they do   that. Their substantial hearing loss   prevents them from hearing voices on   the phone, and when you add earmolds   to the ear (for a BTE fitting), you have,   in effect, applied &ldquo;noise plugs&rdquo; to the   ear. As a result, the patient has no   chance at all of hearing on the phone   when they place it directly on the ear.</p>\r\n<p>What you need to teach patients to   solve this problem is to hold the   telephone near the hearing aid. In the   case of a BTE instrument, have them   move the telephone upward so it is   actually touching the hearing   instrument. Unfortunately, many   patients have trouble remembering to   do this, so you need to use your   &ldquo;enhanced&rdquo; communication skills to   help them establish a new habit.   I use a &ldquo;Telephone card&rdquo; that I give to   all patients who need it. It says: Turn   the telephone switch to &ldquo;T.&rdquo; Increase the   volume (if needed). Hold the telephone   against the hearing aid, not the ear.&rdquo;   When I do rechecks, I ask patients how   they are hearing. If they are having   difficulties with the telephone, I   practice with them and give them   another card.</p>\r\n<p><strong>SPECIAL ATTENTION FOR WAXY   EARS</strong></p>\r\n<p>A few patients have excessive amounts   of wax in their ear canals. They need   special attention because the wax will   significantly increase the incidence of   hearing aid malfunctions unless we get   it out.</p>\r\n<p>Schedule patients like these for   checkups every three months, and keep   track of the people on this list. If their   ears are kept clear, the number of   repairs drops markedly. These people   need reminder notes and reminder   phone calls to make sure they keep   appointments.</p>\r\n<p><strong>LEARN THE REPAIR SHOP LINGO</strong></p>\r\n<p>Here&rsquo;s one last idea to improve your   ability to communicate. We all have a   list of people at the hearing aid and   earmold companies that we contact   when we need help.</p>\r\n<p>Ask your favorite contacts to tell you   what words to put on repair orders, etc.   If you keep experiencing the same   problem, e.g., the aid goes dead, you   may be dealing with a different problem   than you thought. Manufacturers speak   their own language, so it helps you to   learn the &ldquo;buzz words&rdquo; that factory   repair departments use.</p>\r\n<p>http://hearinghealthmatters.org/hearinpriv   atepractice/</p>\r\n<p>Canadian Hearing Report 2014;9(2):6-8.</p>\r\n<h4>20Q: 25 Years of MarkeTrak - The Highlights</h4>\r\n<p>Sergei Kochkin, Ph.D., Better Hearing Institute</p>\r\n<p>Reprinted with permission of AudiologyOnline, www.audiologyonline.com</p>\r\n<p>Remember the spring of 1990? You were   probably talking about the movie that had   just been released starring Richard Gere and   Julia Roberts. And maybe listening to some   good Tom Petty music from the 1989 CD,   Full Moon Fever. If you happened to travel   through Colorado about that time, you no   doubt heard about this guy named Jeff   Lebesch, who was brewing a unique Belgium   beer in his basement called &ldquo;Fat Tire.&rdquo; And,   if you were reading about audiology at that   time, you may have picked up the May   1990 issue of The Hearing Journal, and   noticed an article entitled, &ldquo;Introducing   MarkeTrak: A consumer tracking survey of   the hearing instrument market.&rdquo; The actual   data collection process for this 1990 report   started a couple years earlier, which means   that MarkeTrak is now turning 25. And over   those years, we&rsquo;ve had eight, make that VIII,   large scale MarkeTrak reports</p>\r\n<p>It was in the early 1980s that the Hearing   Industry Associates (HIA) began looking   into consumers&rsquo; satisfaction with and   attitudes about hearing aids. In 1984 the   HIA published a lengthy report based on a   survey of hearing aid owners and hearingimpaired   non-owners, which set the tone for   many of the MarkeTrak surveys to follow. I   recall a couple findings from that early   report that caught my eye: Most hearingimpaired   non-owners went to their family   doctor for help, and the majority (55%) was   told that their hearing loss &ldquo;wasn&rsquo;t severe   enough&rdquo; to warrant the use of hearing aids.   Another striking finding was that about 14%   of the people who owned hearing aids never   used them. Funny thing&mdash;those data are not   much different than what is happening   today</p>\r\n<p>Through the years, the MarkeTrak surveys   have become the &ldquo;go-to reference&rdquo; for most   anything we&rsquo;d like to know about the   hearing aid market, the opinions of hearing   aid owners or hearing-impaired nonowners.   It would take pages just to list the   titles of all the different issues and topics that   have been reported in the 35-40 publications   surrounding these studies. While the initial   surveys were funded by Knowles Electronics,   Inc. and the more recent ones conducted   under the direction of the Better Hearing   Institute, there is one person whose name   has become synonymous with MarkeTrak&mdash;   Dr. Sergei Kochkin. It only seems reasonable   to have him stop by 20Q to provide us the   highlights from these 25 years of data   collection.</p>\r\n<p>Sergei Kochkin, PhD, is Executive Director   of the Better Hearing Institute in   Washington DC. Previously he was Director   of Market Development &amp; Market Research   at Knowles Electronics and served as   chairman of the Market Development   Committee of HIA. His background is in   industrial psychology and marketing,</p>\r\n<p>although he has more publications in   audiology trade journals than most   audiologists&mdash;including clinical topics such   as best practice for hearing aid verification   and validation. He also is recognized   worldwide for his presentations and   workshops, and the data he has provided   over the years has been studied and   absorbed by entrepreneurs, hearing aid   manufacturers, audiologists, hearing   instrument specialists and consumers. While   Sergei&rsquo;s extensive library of publications   from MarkeTrak data are known to be   heavily laden with charts and tables, it&rsquo;s   rather ironic that his most read publication   about hearing aids does not include even one   chart or table. In case you&rsquo;re one of the few   who have missed this article, it&rsquo;s titled:   Hearing Aids - An Unexpected Way to   Improve Your Sex Life</p>\r\n<p>Dr. Kochkin&rsquo;s undergraduate training was   in anthropology, as his career goal at that   time was to be an archeologist. We are   thankful that in later years he re-focused his   digging toward the MarkeTrak data, to help   us better understand what consumers are   feeling and thinking, and what we can do to   make things better. Sergei joins us at 20Q to   discuss some of the treasurers that were   unearthed from his many years of   excavations.</p>\r\n<p>Gus Mueller, Ph.D.</p>\r\n<p>Contributing Editor</p>\r\n<p>June 2012</p>\r\n<p>To browse the complete collection of 20Q</p>\r\n<p>with Gus Mueller articles, please visit</p>\r\n<p>www.audiologyonline.com/20Q</p>\r\n<p><strong>1. You\'re that guy that keeps doing   surveys, right?</strong></p>\r\n<p>I guess you can call me the &ldquo;survey guy   with a purpose&rdquo; although some people   mistakenly think I am a just a statistician   who has an illicit love affair with   numbers! Actually, I am a marketing   oriented psychologist. Through my role   at the Better Hearing Institute (BHI), I   use my expertise in quantitative analysis   to engage the hearing health industry in   a dialogue on core issues concerning   hearing healthcare. Our explicit goal at   BHI is to improve hearing healthcare   and ultimately to help more people with   their hearing loss. When I came into this   industry from United Airlines in 1988 to   work for Knowles Electronics, the goal   was for me to find ways of expanding   the market for hearing aids and therefore   their [Knowles] components. The   perplexing question was and still   continues to be, why is the adoption rate   for hearing aids so stubbornly low and   what can be done to expand the market?   I heard lots of opinions when I first   entered the industry. And when I hear   opinions, some which don\'t make   intuitive sense, it motivates me to find   the facts.</p>\r\n<p><strong>2. So to find the facts, you started   doing surveys?</strong></p>\r\n<p>Actually, the first thing I did was to look   at the 1984 Hearing Industries   Association survey; this in my opinion   was really the first MarkeTrak and I   continue to use the methodology started   in that ground-breaking research. In   addition I read every market   development article and dissertation on   the subject that I could get my hands on.   In MarkeTrak I and II, which were   conducted around 1989, we used only   a short screening survey and at first</p>\r\n<p>intended to simply administer this every   six months to discern trends over time.   We learned after these first 2 rounds that   the market did not change very fast to   warrant a survey every six months and   that the surveys were not in depth   enough to provide very many insights   into the hearing health market. So   starting with MarkeTrak III we used the   National Family Opinion panel to screen   80,000 households to find people with   hearing loss and hearing aids. Then, we   went back to people with hearing loss   with a detailed survey for hearing aid   owners and another one for nonadopters.   3. Where did the term &ldquo;MarkeTrak&rdquo;   come from?</p>\r\n<p>I was an MBA student in the marketing   department at Knowles and we   introduced it as &quot;A tracking survey of the   hearing instrument market&quot;. This was a   name I gave it while at Knowles to   denote its market orientation. A more   descriptive name might be something   like, The National Hearing Health Tracking   Survey (NHHTS), especially now that   the survey is done through the Better   Hearing Institute.</p>\r\n<p>4. Well, we&rsquo;re all familiar with   MarkeTrak now, so don&rsquo;t change it   and confuse us. I believe that   recently I&rsquo;ve been seeing reports   from MarkeTrak VIII? There have   been eight big surveys?</p>\r\n<p>Yes, this is the eighth MarkeTrak survey,   and we just completed our 11th   publication from these data. Over the   years we&rsquo;ve also administered several   versions of the hearing aid owner survey   to many samples of hearing aid owners,   working with manufacturers to see if we   could discern differences in satisfaction   with various types of hearing aids. For   instance, in a study of more than a dozen   technologies in the early 90\'s it appeared that people with hearing aids that had   directional technology had a much   higher level of satisfaction than those   without directional technology,   regardless of the number of channels   and memories. I think that stimulated   consumer and clinical research into the   benefits of directional hearing aids. At   that time less than 20,000 directional   hearing aids were sold worldwide and   only one manufacturer routinely   implemented the technology; now it is a   standard feature for most BTE and ITE   hearing aids across all manufacturers.</p>\r\n<p>The end result is a real incremental   benefit in some noisy situations for some   consumers, though not as dramatic as I   had envisioned considering some of the   work of Brian Walden and Todd   Ricketts.</p>\r\n<p><strong>5. So is all this MarkeTrak VIII data   just more satisfaction stuff, or is   there something new?</strong></p>\r\n<p>As it evolved, every MarkeTrak survey   has new components to it and some that   do not change for tracking and trending   purposes. But we do continue to look at   satisfaction in depth, since I think it is   one of the key drivers of consumer   acceptance of hearing aids. An   interesting thing I discovered in   designing MarkeTrak is that very little   had been done on customer satisfaction   with hearing aids prior to 1988 with the   exception of some doctoral dissertations.   At United Airlines I was involved with   the development of the onboard   consumer satisfaction survey. This was   considered a critical area of consumer   intelligence since negative ratings   pushed the consumer away from your   product while positive ratings drew   them toward your product. We also   knew from the work of W. Edwards   Deming, an international consultant on   quality and productivity, in his landmark   book Out of the Crisis (1982) that quality does determine the success or failure of   a product or a service. So it was rather   perplexing to me that customer   satisfaction was not on the radar when I   first entered the hearing industry.</p>\r\n<p><strong> 6. Interesting, but back to my   question?</strong></p>\r\n<p>The short answer is yes, when our   analysis is completed, MarkeTrak VIII   will be comprised of at least 15   publications on a large variety of topics.   Since the entire MarkeTrak process has   been a 25 year effort, as well as dialogue   with the hearing health industry, I   should first tell you the scope of all the   topics published across all MarkeTraks   and then we can go from there:</p>\r\n<p>&bull; Prevalence of hearing impairments in   the U.S.</p>\r\n<p>&bull; Demography of the U.S. population   with hearing loss</p>\r\n<p>&bull; What is the real adoption rate of   hearing aids?</p>\r\n<p>&bull; 20 year trends in customer   satisfaction with hearing aids</p>\r\n<p>&bull; Why people delay adoption of   hearing aids or what are the key   obstacles to hearing aid adoption?</p>\r\n<p>&bull; How long do people really wait to get   hearing aids once they learn they have   a hearing loss?</p>\r\n<p>&bull; Prevalence of tinnitus and efficacy of   treatments</p>\r\n<p>&bull; Impact of hearing loss and hearing   loss treatment on quality of life</p>\r\n<p>&bull; The impact of the hearing health   professional on real world success   with hearing aids</p>\r\n<p>&bull; Pediatric hearing loss and the reasons   for their low adoption rate of hearing   aids</p>\r\n<p>&bull; Impact of the physician on hearing   aid adoption</p>\r\n<p>&bull; The impact of hearing loss treatment   on job performance</p>\r\n<p>&bull; Would lower prices grow the market for hearing aids?   &bull; Why are so many hearing aids in the   drawer?</p>\r\n<p>&bull; What would expedite demand for   hearing aids?</p>\r\n<p>&bull; Is there a relationship between price   and customer satisfaction with   hearing aids?</p>\r\n<p>&bull; Does stigma really impact hearing aid   acceptance?</p>\r\n<p>&bull; What first motivates a person to get   hearing aids?</p>\r\n<p>&bull; Is there a relationship between price   paid for hearing aids and customer   satisfaction?</p>\r\n<p>&bull; Are bilateral loss subjects happier   with one or two hearing aids?</p>\r\n<p>&bull; What improvements do people want   in their hearing aids?</p>\r\n<p>&bull; What is the impact of direct mail and   personal sound amplifying products   on the hearing aid market?</p>\r\n<p>&bull; Do people really need a volume   control on their hearing aid?</p>\r\n<p><strong>7. Wow, that is quite a list of topics.   Everyone seems to be interested in   hearing aid market penetration, so   let&rsquo;s start there. What&rsquo;s the latest   news?</strong></p>\r\n<p>Thanks. You started with one of the   more complicated issues. Maybe the   &ldquo;latest news&rdquo; is a publication from Johns   Hopkins (Chien &amp; Lin, 2011) that   reports even lower hearing aid market   penetration than what we have reported   in MarkeTrak, which I believe is slightly   less than 25%. But I have some   comments on this. First, I now think   that the figures that we have been using   over the last 30 years are not really an   accurate description of what is going on.   There had been an inherent assumption   that anyone with admitted or   measurable hearing loss is a candidate   for hearing aids. The most prevalent   number out there emanating out of the   1984 study is only one in five people with hearing loss use hearing aids. Some   messages are even worse stating only 1   in 5 people choose to do anything about   their hearing loss (because they don\'t buy   hearing aids). Somehow by demonstrating   such poor utilization, it is   believed this will stimulate demand for   hearing aids. If I were a person with a   hearing loss I would ask one of two   questions: first, &quot;What\'s wrong with   hearing aids since hardly anyone uses   them?&quot;; and second, &quot;Do I want to be an   outlier? You must really have to be   disabled to use hearing aids.&quot; When they   then look at the type of person wearing   hearing aids, typically the very elderly,   the potential younger candidate must   enter into an existential crisis thinking   that their need for hearing aids is a sign   of impending death. Not surprisingly,   they may go into denial.</p>\r\n<p>8. You make a great point. I&rsquo;d never   really looked at it that way before.   I am also a slower learner, unfortunately.   It was not until MarkeTrak VII (2004)   that we decided that we need to look at   hearing aid adoption and barriers to   adoption as a function of hearing loss.   All the signs as far back as MarkeTrak III   (1990) stated that the number one   reason people don\'t buy hearing aids is   some variation of the reason &quot;My hearing   loss is too mild&quot; or &quot;I&rsquo;m hearing well   enough in most situations&quot;. Now the   market-centric individual will say &quot;these   people simply are in denial&quot;. But   intuitively I believe the consumer.</p>\r\n<p><strong>9. So how do you account for this?</strong></p>\r\n<p>I devised a method to segment people   into hearing loss by developing a   composite measure of hearing loss on a   number of subjective self-reported   measures. By extracting the common   variance through factor analysis, I then   divided the entire hearing loss   population into deciles where 10% = the bottom 10% of people with the lowest   reported hearing loss, and 100%= the   top 10% of people with the highest   reported hearing loss. The clinical   purists may balk at such a   methodology. However, subsequent   research with Dr. Ruth Bentler on   11,000 subjects using the BHI Quick   Hearing Check (signs of hearing loss)   demonstrated that subjective measures   are correlated with objective measures   of hearing loss, that such inventories of   signs of hearing loss have high   reliability, and that they have   impressive correlations both   subjectively (other self-measures) and   concurrently (quality of life issues   tangentially related to stated hearing   loss) (Kochkin &amp; Bentler, 2010).</p>\r\n<p>10. Was this segmentation helpful   for understanding the population?   Very much so&mdash;a clear pattern   emerged. Market penetration is highly   related to degree of hearing loss. For   instance only 4% of people in decile 1   own hearing aids compared to 65% in   decile 10. I think a better definition of   market penetration is: 40% of people   with moderate through profound   hearing loss own hearing aids (deciles   5-10) compared to 9% of people with   mild hearing loss (deciles 1-4); and,   65% of people with severe-profound   hearing loss (deciles 9-10) own hearing   aids. A further complication is how to   classify the 13 million people with   reported tinnitus who report they do   not have hearing loss. In all likelihood   they have mild hearing loss, but their   tinnitus overwhelms their hearing loss.</p>\r\n<p>Perhaps this is why the recent Johns   Hopkins study found 48 million people   with hearing loss. In MarkeTrak we   report 34.5 million people with   admitted hearing loss; when combined   with the 13 million tinnitus subjects we   arrive at 47.5. If we consider that there   are 8.4 million hearing aid owners, one   could up with a ludicrous hearing aid   adoption rate of 18%, which is   clinically correct but practically wrong.</p>\r\n<p><strong> 11. So what do you think is the real   hearing aid adoption rate?</strong></p>\r\n<p>I think hearing aid candidacy, and   therefore adoption rates, should be a   function of hearing loss and recognized   need. In other words, to be considered   a hearing aid candidate, the individual\'s   life must be negatively impacted in a   meaningful way as a direct result of   their hearing loss. I hope to improve   our methodology in the future to   provide a more accurate measure of   hearing aid adoption rates. I venture to   predict that real market penetration   taking into account hearing loss and   need (it impacts the individual\'s life in a   meaningful way) is probably around   50%.</p>\r\n<p><strong>12. It certainly is a complex issue.   What about the demography of   these hearing aid users and nonadopters   that you&rsquo;ve studied?</strong></p>\r\n<p>For starters, it&rsquo;s important to point out   that 60% of people with hearing loss   are below retirement age (this is based   on our survey of 2008). This should be   in all of our major marketing messages   as a method of combating age-related   stigma. Among non-adopters the #1   cause of reported hearing loss is noise   from their occupation, followed by age   and then recreational noise.</p>\r\n<p>A second point is that contrary to   recent (and I might add irresponsible)   media reports of an epidemic in hearing   loss, the prevalence of self-reported   hearing loss has been between 10-11%   of the U.S. population over the last 25   years...hardly an epidemic. If it is an   epidemic, certainly the people with   hearing loss don\'t know about it or   don\'t feel it. I tend to believe the finding   of the Beaver Dam project, which   demonstrated that boomers had better   hearing than their parents had at the   same age (Zhan et al., 2010).</p>\r\n<p><strong> 13. Using your hearing loss   segmentation methodology, what do   you think the remaining   opportunity is for increased   adoption of hearing aids?</strong></p>\r\n<p>The cut-point for me when looking at   hearing aid candidacy is where do more   than 80% of our current hearing aid   customers reside in terms of their   degree of hearing loss as measured in   deciles? Well, that turns out to be   deciles 5-10. However, only 43% of   non-adopters have hearing loss this   bad, meaning the probable remaining   market is 11 million people. Let us not   forget though, that there are 13 million   people with tinnitus and a majority of   them would probably come into   hearing health professional offices if we   offered them hope in mitigating their   tinnitus. My recent research with Dr.   Richard Tyler demonstrated that indeed   about 30% of people with tinnitus   report moderate to substantial relief   from their tinnitus by using hearing   aids; this figure can climb to about 50%   or more if the hearing health   professional engages in best practices in   fitting hearing aids.</p>\r\n<p><strong>14. If we only look at your &ldquo;real   candidates&rdquo; for hearing aids, what   are the key barriers to hearing aid   adoption from the non-adopters   perspective?</strong></p>\r\n<p>That&rsquo;s a great question, with a fairly   complex answer. In a recent Hearing   Review article I summarized this   topic&mdash;I think you really need to break   it down into four different categories:   hearing aid features, hearing aid utility,   psychosocial factors and financial (Kochkin, 2012). Where do you want   to start?</p>\r\n<p><strong> 15. I want to hear about all, but   hearing aid features sounds   intriguing.</strong></p>\r\n<p>Sounds good. Understand that when I&rsquo;m   talking about &ldquo;features,&rdquo; I&rsquo;m mostly   referring to the benefit that is obtained   from these features, as that is what will   drive adoption. In previous MarkeTrak   studies I asked potential consumers to   state why they don\'t use hearing aids for   their hearing loss. In the most recent   publication I presented the potential   consumer with 53 what-if scenarios, and   asked them to rate the likelihood that it   would expedite their purchase of   hearing aids (Kochkin, 2012). With   respect to the hearing aid itself, the top   issue for potential consumers is a money   back guarantee (#2 among 53 issues) if   they don\'t derive benefit.</p>\r\n<p><strong> 16. What? Our patients already have   a money back guarantee, at least for   the first 30 days.</strong></p>\r\n<p>I know, that is a good point and deserves   in depth study; I&rsquo;m just reporting the   data we collected. My best guess is they   learned from other hearing aid owners.   Consider that more than a million of our   8.4 million customers have their hearing   aids in the drawer and about half of   these aids are 5 years old or less. And if   we look at people wearing their hearing   aids less than 4 hours a day the number   is quite staggering. It seems illogical that   a consumer would spend so much   money on a product only to put it in the   drawer or seldom use it. What I&rsquo;m   saying is that the friends and relatives of   these people who do not use their   hearing aids probably assume that the   person was never offered a &ldquo;money back   guarantee.&rdquo;</p>\r\n<p><strong> 17. I really didn&rsquo;t realize that there   were that many people not using their   hearing aids. Do we know why?</strong></p>\r\n<p>That&rsquo;s certainly something we&rsquo;ve studied   over the years. The #1 reason for putting   the hearing aid in the drawer all the way   back to MarkeTrak III was &quot;lack of   benefit&quot;. Now, hearing aids have come a   long way since the analog days so it   would be interesting to look into this in   the digital age. In terms of guarantees,   also rated high was a 90 day trial period.   Perhaps a measurable benefit guarantee   would help in assuring the reluctant   consumer. In terms of a best practice   protocol that would mean that all   consumers would receive a pre/post   measure of benefit achieved so that they   know what was accomplished. And   while we are on this topic, I believe we   need to get rid of measures of absolute   benefit and begin talking about relative   benefit which would be some form of   percentage change in handicap or   benefit (aided versus unaided). This of   course would put pressure on the   hearing healthcare professional because   they would have to enter into a   discussion eye-ball to eye-ball with the   consumer along the lines of &quot;Let me tell   you how much better you can hear since you   met me&quot;....not unlike the type of dialog   that currently goes on with an   optometrist.</p>\r\n<p><strong> 18. I know you looked at benefit in   general, but were there specific   hearing aid features that were rated   high?</strong></p>\r\n<p>Yes there were. Product features   garnering high ratings were: reduction   in whistling/feedback, greater comfort,   better sound quality and a volume   control. With respect to the latter we   really need to reconsider the lack of a   volume control on such sophisticated   technology. With the diminishing VC we   have also seen lower ratings over the last   20 years in terms of customer   satisfaction. Some consumers want to   adjust their hearing aids &ldquo;seldom to   occasionally.&rdquo; When they can\'t, I bet it   makes some consumers really angry.   This indirectly relates back to best   practices&mdash;were the hearing aids fitted   correctly&mdash;a topic that carries through a   lot of these issues.</p>\r\n<p><strong> 19. Benefit is probably related to   listening situations. Where do these   consumers really want to hear better?</strong></p>\r\n<p>While I did not present the consumer   with an all-inclusive list (only   representative)of listening situations, I   was surprised that they value the ability   to hear soft sounds most important,   followed by hearing aids that work   perfectly on the phone. Considering   advances in technology and how much   time people spend on the phone it is   surprising that only 55% and 52% are   &quot;very satisfied&quot; or &quot;satisfied&quot; when using   their hearing aid on the telephone and   cell phone respectively. The numbers are   higher if you consider &quot;somewhat   satisfied&quot;; but I would discount the latter   as not being impressive to a potential   consumer. People don\'t rave about   products, services or people that make   them &quot;somewhat satisfied&quot;.</p>\r\n<p><strong>20. Well I can tell you that I certainly   have been more than &ldquo;somewhat   satisfied&rdquo; with all the information   you&rsquo;ve provided, and I can&rsquo;t believe   my 20 Questions are up already. Can   we continue this discussion on   hearing aid adoption and overall   satisfaction?</strong></p>\r\n<p>Most certainly&mdash;I was just getting   started! If you&rsquo;d like to do some   background reading on all this in the   meantime, all MarkeTrak survey   publications are available at:   http://www.betterhearing.org</p>\r\n<p>Editor\'s Note: Please check out the July 20Q column   when our curious Question Man continues his   inquiries with Dr. Kochkin regarding the highlights   of 25 years of MarkeTrak. It will be found in our 20Q   library at: www.audiologyonline.com/20Q</p>\r\n<h4>REFERENCES</h4>\r\n<p>Chien, W. &amp; Lin, F.R. (2012). Prevalence of   hearing aid use among older adults in the United   States. Archives of Internal Medicine, 172(3):292&ndash;   293. doi:10.1001/archinternmed.2011.1408</p>\r\n<p>Deming, W.E. (1982). Out of the crisis.</p>\r\n<p>Cambridge, MA: The MIT Press.</p>\r\n<p>Kochkin, S. (2012). MarkeTrak VIII: The key   influencing factors in hearing aid purchase intent.   Hearing Review, 19(3),12-25.</p>\r\n<p>Kochkin, S. &amp; Bentler, R. (2010). The validity and   reliability of the BHI Quick Hearing Check. Hearing   Review, 17(12), 12 &ndash; 28.</p>\r\n<p>Zhan, W., Cruickshanks, K.J., Klein, B.E.K., Klein,   R., Huang, G-H., Pankow, J.S., Gangnon, R.E., &amp;   Tweed, T.S. (2010). Generational differences in the   prevalence of hearing impairment in older adults.</p>\r\n<p>American Journal of Epidemiology, 171(2), 260 &ndash;   266.</p>\r\n<p>All MarkeTrak publications can be found at:   http://www.betterhearing.org</p>\r\n<p>Canadian Hearing Report 2014;9(2):8-13.</p>\r\n<h4>Fitting Methods: Islands in the Setting Sun?</h4>\r\n<p><strong>IN THE BEGINNING WAS   FUNCTIONAL GAIN</strong></p>\r\n<p>All hearing aids were Linear. Real ear   measures did not exist. Sam Lybarger   stood a Texas yard from the listener   who wore the hearing aid, spoke in a   normal conversational voice, and asked   the client to say what sounded   comfortably loud. He found the listener   wanted gain that was close to about &frac12;   of the hearing loss, especially for   frequencies between 1000 and 4000   Hz. The &ldquo;&frac12; gain rule&rdquo; was born. For   lower frequencies, maybe a little less   than &frac12; gain was recommended, so as to   reduce the upward spread of masking.</p>\r\n<p>Functional Gain was a behavioural   measure of aided thresholds in a sound   field with a hearing aid set at a   comfortable volume control setting,   compared to unaided thresholds   measured with headphones. Aided   thresholds were always measured with   &ldquo;warble tones,&rdquo; in order to reduce any   possible reverberation in the sound   field. I remember while holding the   interrupter button down, feeling like I   was playing an organ, especially with   the low-frequency tones. For Functional   Gain, a successful fitting would result in   little letter A&rsquo;s (for aided threshold)   written across the audiogram, showing   a lift of thresholds about half way up   toward the 0dB HL line. The idea here   was that average speech inputs, plus the   &frac12; gain, would give an output of aided   speech that sat nicely within the client&rsquo;s   dynamic range (Figure 1).</p>\r\n<p>Although this goal was often stated, the   outcome of aided speech output was   almost never described or pictured as it   would appear on an audiogram.   Speaking for myself, I think this was   always a missing step in terms of my   own understanding of hearing aid   fittings. My professors had never   described it to me like that, but in   hindsight, I wish they had.</p>\r\n<p>Fitting methods evolved over the heady   years of the 1970s and 80s from various   different philosophies (Berger, POGO,   Libby, NAL). Accordingly, where you&rsquo;d   want the little letter As to sit exactly on a   client&rsquo;s audiogram would differ slightly   from method to method. I suppose these   variations in letter A positions for the   different Fitting Methods could be   considered as different &ldquo;Targets.&rdquo; All   Fitting Methods, however, had as their   spinal cord or backbone, the &frac12; gain rule.</p>\r\n<p><strong>THEN CAME REAL EAR</strong></p>\r\n<p>It was the mid 1980s. Hearing aids were   almost all still linear. I was a new   audiologist at the Canadian Hearing   Society. Inside each of the four sound   booths they had at that time, there was   a new Real Ear device called &ldquo;Rastronics   CCI-10.&rdquo; It had a black screen and I   recall all the tracings were green. Fitting   Methods did not change, but Insertion   Gain became the order of the day. It was   faster than Functional Gain, and yielded   objective, non-behavioural results. You&rsquo;d   simply enter the client&rsquo;s audiogram,   choose a Fitting Method, and the   objective, the aided Target, would   instantly appear on the screen. The   whole idea was to compare the Real Ear   Unaided Response (REUR) to the Real   Ear Aided Response (REAR), with the   difference being Real Ear Insertion Gain   (REIG). Since the hearing aids were   linear, you could simply (like they say at   the carnival) &ldquo;pick an input&hellip;any   input&hellip;&rdquo; If your REIG matched the   Fitting Method Target, you were good to   go! See Figure 2.</p>\r\n<p>Try counselling a client however, from   this perspective: &ldquo;Well, you see, this line   is what we&rsquo;re supposed to hit and this   little lighter line is right near it, and   therefore your hearing aid is doing what   it&rsquo;s supposed to do.&rdquo; The main problem   here was that the audiogram was not visually part of the picture! Aided speech   outputs had to be imagined. In this way,   Insertion Gain was worse than   Functional Gain. Interesting too, was   that REUR wasn&rsquo;t incorporated at all in   the unaided testing under headphones,   but Oh well. Non-behavioural Real Ear   measures were certainly a whole lot   faster than testing someone&rsquo;s thresholds   twice! Another good thing about good   old Insertion Gain was that if someone   came in saying the new hearing aid just   didn&rsquo;t sound like the old one, you could   do a quick Real Ear measure on the old   one, and then make the new hearing aid   do the same thing. Of course you could   also do this with ANSI measures. Still,   however, it&rsquo;s much better than relying   on, &ldquo;How does that sound?&rdquo;</p>\r\n<p><strong>RICHARD SEEWALD REALLY IS   THE FATHER OF NEWER REAL   EAR MEASURES</strong></p>\r\n<p>The DSL Fitting Method arose in the   early 1980s, and with it, the SPL-o-   Gram. Insertion Gain and REUR were   unceremoniously tossed on to the   garbage heap. The whole focus was now   upon In situ Output, also known as   REAR. Trouble was, only Seewald and   his followers used the SPL-o-Gram and   DSL. Most clinicians including myself,   plodded on with Insertion Gain Real Ear   measures. I remember returning back to   Canada in 1995 from Alabama where I   taught for a couple of years. Here in this   pink Commonwealth country DSL   loomed large as the recommended   Fitting Method. The disciples of DSL   were ubiquitous and they wouldn&rsquo;t   suffer fools gladly. I felt like an American   infidel, so, as a new employee at   Unitron, I attended a DSL workshop   held at Western, where Seewald,   Cornelisse, and Moodie diligently   presented on DSL. I have to admit that I   still didn&rsquo;t get it. Insertion Gain just   seemed so easy, lots less busy, fewer lines   and like an old friend, just so familiar.</p>\r\n<p>I wanted, as the columnist Allan   Fotheringham used to say, someone to   &ldquo;Elucidate the nebulosity of my   phantasmagorical perceptions.&rdquo; It came   upon a midnight clear. I remember the   hour of my epiphany, &ldquo;the day I first   believed.&rdquo; It may seem blasphemous to   the Cardinals of DSL, but the &ldquo;trick&rdquo; to   my own understanding DSL was in tying   it together with the whole unsung goal   of Functional Gain; namely, displaying   where aided speech would lie within one&rsquo;s   dynamic range. Now, however, we   actually had the tools or technology to   display the audiogram, along with aided   speech outputs, all on one graph, all in   dB SPL, and this time, right-side up! The   main trouble with Insertion Gain was   picturing your purpose. Counselling   with it was impossible! In 1997, NALNL1   emerged, and I remember how it   very gradually began to follow suit with   DSL&rsquo;s SPL-o-Gram. One could initially   see their simultaneous usage of both   Insertion Gain and in situ output, but   this was followed within about a year by everything. Visualizing 1) normal   hearing, the client&rsquo;s audiogram and the   reduced dynamic range, and 2) unaided   and aided speech outputs all on one   graph may have seemed like a &ldquo;small   step&rdquo; for a print job, but it really was a   &ldquo;giant leap&rdquo; for audiology. Neil   Armstrong taught us that we all need to   look at the moon from time to time&hellip;   Check out the SPL-o-Gram (Figure 3).   Everything is now in plotted according   to Output, and in terms of dB SPL, so   now hearing loss and hearing aids are   now speaking the same language.   &ldquo;More&rdquo; on the graph now goes up, like   every other graph in the world (except   the Oddiogram). Normal hearing   thresholds are placed on the bottom and   LDLs are placed on the top. The client&rsquo;s   hearing loss is placed part way up on the   graph, thus showing a reduced dynamic   range.   Today&rsquo;s Real Ear is actually easier than   yesterday&rsquo;s Real Ear with Insertion Gain.   Compression hearing aids give different   gains for different input levels, but they   also give different outputs for different   input levels. These different outputs can   be displayed for soft, medium and loud   inputs. Gain is now yesterday&rsquo;s news; it&rsquo;s   simply a means to an end. Output is   &ldquo;king;&rdquo; it is the &ldquo;groceries that are   delivered to the TM. No one cares how   you got to the store; the main point is,   &ldquo;Did you get the bread?&rdquo; The idea is to   aid the listener so that the outputs for   soft speech inputs sound soft, the   outputs for average speech inputs sound   average, and the outputs for loud speech   input sound loud. Now there&rsquo;s an   improvement for counselling! Clients   can readily see what parts of speech were   inaudible without hearing aids, and   what has now become audible when   aided. As we say in Canada, &ldquo;Neat, eh?&rdquo;</p>\r\n<p><strong>THERE&rsquo;S ANOTHER TWIST,   HOWEVER, TO THIS STORY</strong></p>\r\n<p>Fitting Methods have become so similar   that if you don&rsquo;t compare them closely,   you may not even notice the differences!   Check out the target comparisons for   yourselves, especially for mild-moderate   SNHL. In 2005, DSL 5 for adults slid a   slippery slope to nudge much closer to   NAL-NL1. After that, NAL-NL2 seemed   to abandon its ever-vigilant zeal to keep   all aided adjacent speech frequencies   equally loud. &ldquo;Czech&rdquo; out how the everpresent   trademark of NAL Fitting   Methods - the hump in the mid   frequencies &ndash; is now virtually gone with   NAL-NL2.</p>\r\n<p>DSL 5 for adults and NAL-NL2 are quite   similar, and have become &ldquo;friends.&rdquo; Both   place soft input speech so that when   aided the output speech surrounds the   thresholds. Here, you&rsquo;ll find that the   client can barely hear it. That&rsquo;s normal;   neither can you and I. Both place   average speech inputs so that the aided   outputs sit in the dynamic range about   1/3 above the thresholds. Both place   loud speech inputs so that aided outputs   sound loud but remain below LDLs. Isn&rsquo;t   that what Lybarger would have wanted?   Isn&rsquo;t that what all Fitting Methods were   all trying to do in the first place? Guess   what? Perhaps with proper dynamic range   considerations, we don&rsquo;t need Fitting   Methods anymore!</p>\r\n<p>I&rsquo;ll confine my comments to adults here.   For them, it looks like Fitting Methods   are becoming obsolete. They originally   emerged a lot like beliefs or faiths do, to   which various adherents had subscribed   vehemently. The SPL-o-Gram with its in   situ outputs, however, provides proof for   the objectives of one&rsquo;s faith. To borrow   from Paul Simon: &ldquo;Faith (Fitting   Methods as a whole) is an island in the   setting sun; Proof (mapping of speech   into a client&rsquo;s dynamic range) has   become the bottom line for everyone.&rdquo;   Canadian Hearing Report 2014;9(2):14-16</p>\r\n<h4>Demystifying the Auto-Phone</h4>\r\n<p>As an audiologist, one of the   improvements I have seen in   hearing aids over the last 23 years is the   flexibility now available for both the   clinician and end user. When it comes to   phone use, there are choices such as   telecoil, auto phone, auto telecoil. What   does all this mean? With so many names   for the various telephone/telecoil features   found in hearing aids, coupled with the   fact that different manufacturers have   different names for the same or a similar   feature, it is no wonder things are so   confusing. So, let\'s review the telecoil   and its many options.</p>\r\n<p>Telecoils have been available in hearing   aids since 1947. It is the activation of this   telecoil that becomes confusing to both   end users and clinicians. A telecoil is a   metal rod or core with fine wire coiled   around it. This coil is meant to detect   electromagnetic energy and convert it to   electrical energy which is then processed   by the hearing aid, making it much   easier to hear a signal transmitted   through the telephone. Accessing the   telecoil via the push button on the   hearing aid is a familiar option for   clinicians. What if, however, the end   user is unable or unwilling to use the   push button but still would like access   to a telecoil program in their hearing aid.</p>\r\n<p>A telecoil in itself does not activate   &quot;automatically&quot;, therefore making the   term &quot;auto-coil&quot; somewhat misleading.   The &quot;auto&quot; portion is actually a second   coil or reed switch, separate from the   telecoil that will put the hearing aid into   another &quot;program&quot; when it detects   magnetic energy. As a result, an   &ldquo;autophone&rdquo; could lead to several   different results.</p>\r\n<p>In many hearing aids, the following   telephone scenarios are possible:   1. Push button into a telecoil program   (If there is a telecoil in the hearing   aid)</p>\r\n<p>2. Push button into an acoustic phone   program (if no telecoil in the hearing   aid)</p>\r\n<p>3. AutoPhone: reed switch automatically   puts the hearing aid into a   telecoil program if the hearing aid   has a telecoil</p>\r\n<p>4. AutoPhone: reed switch automatically   puts the hearing aid into an   autophone program if the hearing   aid does not have a telecoil   In addition to putting a hearing aid into   a telephone program, either through   telecoil or acoustic setting, some   manufacturers allow you to put the   hearing aid into programs that are not   related to telephone listening with   activation of the auto switch.</p>\r\n<p>Don&rsquo;t forget that reed switches may be   located in different spots from hearing   aid to hearing aid, especially in custom   products. The end user must learn   where the best spot is on their hearing   aids. Also remember that different   phones will give off different amounts of   magnetic energy, therefore, some may   require the addition of a magnet to   trigger the reed switch and some may   trigger with just the phone.</p>\r\n<p>My best advice is to be aware of what   each of the telephone related terms   means for the particular hearing aid you   are working with so that you can make   the best choices for your end user.   Canadian Hearing Report 2014;9(2):17</p>\r\n<h4>Otologics Fully Implantable Hearing System</h4>\r\n<p>According to the Canadian Public   Health Service,1 1 in 10 Canadians   have some type of hearing impairment   and, among those 65 years of age or   older, 50% or more are affected by   reduced hearing acuity. The incidence of   hearing impairment notwithstanding,   Canadians have much in common with   their hearing impaired counterparts in   other countries as the treatment for most   of these losses is the use of traditional   amplification devices, or hearing aids.</p>\r\n<p>In the past 10 years or so, technological   advances in traditional hearing   instruments have substantially improved   sound quality, feedback control,   frequency range, noise reduction, and   other areas making these products much   more beneficial than ever before. In   some countries, such a Switzerland,   today&rsquo;s advanced performance traditional   digital hearing aids enjoy as much as an   80% success rate.2While these products   continue to evolve technologically and   progress in user acceptance, George   indicates that only 21.4% of the   estimated twenty-eight million hearing   impaired Americans utilize amplification   regularly, a figure that holds when   applied to populations across the world.3   In an interview by Strom, Kochkin   presented that of the approximately 6   million hearing instrument users,   35&minus;50% are not satisfied with the benefit   obtained from their instruments.4 The   typical concerns of hearing impaired   patients leading to reduced use of   amplification vary, but poor sound   quality, feedback, limited frequency   range, occlusion, pain or irritation,   moisture, social stigma, and cosmetic   issues are frequently cited as major   concerns. Recognizing that stigma and   sound quality would always be issues to   those that use traditional hearing   instruments, audiologic and otologic   research has been on a quest to find an   efficient, practical method of middle ear   implantation that would counter-act   many of the concerns and difficulties of   hearing aid use.</p>\r\n<p><strong> DEVELOPMENT OF THE   OTOLOGICS MET TRANSDUCER</strong></p>\r\n<p>Although some otologic researchers felt   that electromagnetic or peizoelectric   techniques would offer an effective and   efficient middle ear implant; Dr. John   Frederickson, a 1970s research   otolaryngologist at Washington   University, St Louis, Missouri, expressed   concern that these crude technologies   lacked the bandwidth and acoustic   output to be practical applications. With   funding from Washington University   and Storz Instruments, Frederickson and   colleagues developed and refined the   electromechanical motorized transducer   (Figure 1) and continued experiments   with various transducer placement sites   within the middle ear. While evaluating   placement of an electromechanical,   motorized transducer (now called the   Middle Ear Transducer [MET])   projecting into a laser drilled hole in the   incus of Rhesus monkeys in 1995;   Fredrickson, Coticchia, and Khosla   demonstrated that there could be a safe,   efficient method of transmitting sound   energy to the ossicular chain. Proof of   the benefit derived from the MET was   demonstrated by pre/post acoustic and   mechanical (bone conducted) ABRs   conducted on the Rhesus monkeys   implanted with the MET device. In   evaluating the implanted monkeys,   Fredrickson et al. found no significant   pre/post changes in latency/intensity   functions, suggesting that the   implantation of the middle ear   transducer did not cause detectable   conductive or sensorineural hearing loss.   Further, they also demonstrated the   fidelity of the implanted device by   detection of distortion product   otoacoustic emissions (DPOE) generated   through the implanted device.5</p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-9-2-1-g001.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-9-2-1-g002.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-9-2-1-g003.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-9-2-1-g004.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-9-2-1-g005.png\" alt=\"image\" /></p>\r\n<p>surgeon implant the transducer through   a mastoidectomy and facial recess. The   facial recess is the most common surgical   approach employed in cochlear implant   surgery, as well as for some chronic   cholesteatoma conditions. The facial   recess approach is also used when   implanting some middle ear implant   devices.</p>\r\n<p><strong> CANDIDACY FOR THE   OTOLOGICS FULLY IMPLANTABLE   MET AND MET-V DEVICES</strong></p>\r\n<p>The MET Ossicular Stimulator is   intended to compensate auditory   deficits in adults with a moderate to   severe sensorineural hearing loss. The   MET V Ossicular Stimulator is intended   to compensate for mild to severe   conductive or mixed type hearing loss   due to congenital aural atresia or   ossicular abnormalities based on the   bone-conduction component of the   loss (Figures 17 and 18).   PERFORMANCE   World wide, more than 500 patients   have been implanted with the Carina   device. On average, no differences   between preoperative and postoperative   unaided pure tone averages occurred.   Pure tone average implant aided   thresholds are equivalent to that of walkin-   aided condition. Word recognition   scores and hearing in noise scores were   similar between the walk-in-aided and   for the implant-aided condition. Patients   also tend to prefer the implant compared   to their hearing aid on subjective benefit   scores such as APHAB.</p>\r\n<h4>SUMMARY</h4>\r\n<p>This presentation has been a discussion   of the development of the Otologics   Fully Implantable MET and MET-V   devices. Although available throughout   Europe, Asia, and Latin America; the   Otologics Fully Implantable MET device   is currently limited by Federal Law to   investigational use in the United States.   The MET V is currently not being   investigated in the US, but will be in   clinical trial later this year in the United   States and Canada. Otologics estimates   that FDA approval of the MET and MET   V could come as early as the beginning   of 2011. At that time the devices will be   introduced to both the US and Canada.   In addition, Otologics is currently   designing a smaller fully implantable   electronics/battery capsule for the MET   and MET V, a smaller more efficient   transducer and a fully implantable   module which will be able to provide   power and audio signal for a fully   implantable cochlear implant.</p>\r\n<p>If patients are interested in obtaining   information about involvement in the   clinical trial for the Fully Implantable   MET device in the US, they should go to   www.otologics.com or call 800-390-   5506 for further information.</p>\r\n<h4>REFERENCES</h4>\r\n<p>1. Canadian Public Health Service. Hearing loss   info sheet for seniors. Ottawa: Author; 2006.   Retrieved April 2009: http://www.phacaspc.   gc.ca/seniors-aines/pubs/info_sheets/heari   ng_loss/index.htm#top</p>\r\n<p>2. Bertoli S, Straehelin K, Zemp E, et al. Survey on   hearing aid use and satisfaction in Switzerland   and their determinants. International Journal of   Audiology 2009;48(4):183&minus;95.</p>\r\n<p>3. George L. Report of the Medical Technology   Assessment Working Group. Durham, NC:   Duke University; 2006.</p>\r\n<p>4. Strom K. HR Interviews&hellip;Sergi Kochkin.   Hearing Review 2005; 12(10).</p>\r\n<p>5. Fredrickson J, Cotcchia J, and Kohosla S.   Investigations into an implantable   electromagnetic hearing device for moderate to   severe sensorineural loss. The Otolargologic   Clinics of North America 1995;28(1):107&minus;20.   Canadian Hearing Report 2014;9(2):18&ndash;23.</p>\r\n<h4>Roles in Successful Hearing Aid Fitting:   Consumers, Audiologists, and Manufacturer   By Julie K. Purdy, PhD, CCC-A</h4>\r\n<p>Approximately 10 years ago, I gave a   presentation that culminated in an   article designed to convince   manufacturers, consumers and   audiologists that we needed to take steps   to improve our hearing aid fittings. At   the time I bemoaned the fact that even   as technology had improved with   improved software and fitting tools,   return rates were not appreciably lowerhovering   at around 20%. In addition,   market penetration was not higher   despite the implementation and   application of such tools. I outlined the   joint responsibility that consumers,   audiologists and manufacturers shared   in improving the process. Ten years have   passed-are we doing any better? While I   suspect it is a matter open for discussion   and one that is really a matter of personal   opinion, I do believe we have all   improved remarkably during the past   few years. It is also my belief that there   are areas the consumer, the   manufacturer and the audiologist can   continue to improve if we wish to   increase patient satisfaction, lower return   rates and allow the consumer to function   to the best of all of our abilities.</p>\r\n<p><strong> A. RESPONSIBILITIES OF THE   PATIENT/CONSUMER</strong></p>\r\n<p>Ten years ago I addressed seven areas of   concern I had on the part of the   consumer. They were: (1) the   responsibility of the consumer to   purchase a hearing aid via a clinical   venue; (2) the responsibility of the   consumer to be self-educated regarding   hearing aids; (3) the responsibility of the   consumer to pick a style of amplification   that they could manipulate and were   WILLING to wear; (4) the responsibility   of the consumer to pick the most   sophisticated form of amplification that   they can afford; (5) the responsibility of   the consumer to include their family   members in the rehabilitation process;   (6) the responsibility of the consumer to   manage their own listening   environment; and (7) the responsibility   of the consumer to truly wish to improve   their communication ability. So, has 10   years brought us any progress? I believe   it has.   For many of the issues that I identified   10 years ago as areas the patient needed   to improve, manufacturing has made   significant improvements-enough so that   we have really assisted the consumer on   a few of these responsibilities. For   example, Kaplan found that the primary   reason hearing aids were not worn was   the inability on the part of the patient to   manipulate the hearing aid.1</p>\r\n<p>Manufacturers have greatly helped to   reduce Kaplan&rsquo;s issue of manipulation.   We have allowed hearing aids to be   automatic in many functions from the   use of algorithms to control listening   environment, to automatic directional   microphone switching to automatic gain   reductions. For patients that wish to   control their instruments, we have   offered easier switching options, often   with voice commands or unique tones to   allow the consumer to know what   changes have been made to their hearing   aids. Recently, T-2 programming (shown   in Figure 1) was introduced which will   give the patient the ability to make   changes by way of their phone.</p>\r\n<p>Switching to memories, changes in   volume and introducing a mute are all   accomplished by means of the   telephone. Manufacturers have insured   that patients are able to manipulate their   hearing aids. If only the batteries could   insert themselves, we would be in luck!   In addition to manipulation, 10 years   ago patients did not always like the look   of the hearing aids that they were   &ldquo;forced&rdquo; to wear. In a study conducted   with baby boomers in Canada for   Starkey Labs, Antenna Research found   that consumers resisted wearing their   hearing aids as they were &ldquo;big, brown</p>\r\n<p>and ugly&rdquo; and that they &ldquo;looked like the   hearing aids their grandparents would   wear.&rdquo;2 We have made considerable   strides to insure that hearing aids are   sleek and attractive, that they are   functional AND beautiful</p>\r\n<p>Another area where manufacturers have   assisted the consumer is on the managing   of difficult listening situations. Certainly,   the hearing aid doesn&rsquo;t tell the patient   which position in a crowded room   would be acoustically advantageous (yet,   but give us a few years!) but they do   assist in reducing the detrimental effects   of background noise. Built in algorithms   allow for better classification and   alteration of the acoustic signal being fed   to the patient. Current algorithms allow   for analysis of: (a) Overall Input Level;   (b) Steady-State Input; (c) Modulated   Input; (d) SNR Calculation; (e) Omni   and Directional Path Power Estimate;   and (f) Magnetic Field Detection in order   to provide classification into six different   &ldquo;AudioScapes&rdquo; (Quiet, Mechanical Noise,   Wind, Noise, Speech and Noise and   Speech) with a variety of programming   options to accommodate a patient&rsquo;s   unique listening environments. The   patient&rsquo;s hearing aid does the work that   the patient would have to be trained to   do.</p>\r\n<p>And what types of hearing aids are   patients selecting? Receiver-in-the canal   hearing aids have become an increasing   large percentage of the products selected   by patients in Canada. In addition,   consumers are getting the message that   higher end technology is worth the cost,   that the additional features and options   assist the consumer. During the past few   years higher end technology had crept   upward in percentage with approximately   21% of all hearing aids sold high end   technology. Clearly this means that a   great number of patients are not taking   advantage of this technology but at least   the trend is going in the positive   direction!</p>\r\n<p>So where else can the consumer do   better? They can be sure to include their   family members in the fitting process.   And if they don&rsquo;t, we as the consumer   can encourage the family members to   participate and to make sure that they   understand the issues confronting the   consumer. One easy way to demonstrate   this issue is through the use of a hearing   loss simulator. Simulators are available   in a variety of formats.</p>\r\n<p>An example is shown in Figure 2 of a   simulator that can demonstrate how   loud variety of environmental sounds or   recorded speech sound with the patient&rsquo;s   own audiogram.</p>\r\n<p>Another area of potential improvement   would occur if consumers would   become better gatherers of information   and therefore more informed consumers   prior to arriving at the audiologist&rsquo;s   office. While numerous websites exist   specifically designed to educate   consumer and encourage them to see an   audiologist (see freehearingtest.ca), in a   study performed by Antenna research   for Starkey Labs, it was noted that baby   boomers were MOST likely to obtain   information about their hearing losses   from their family physicians.2 Now we   know that while many family physicians   are very up-to-date on the latest issues   in amplification, others are not so it is   not the ideal place for a consumer to   gather information. In the interim,   educating family physicians in our local   areas might be an approach to insuring   that the consumer becomes, in term, a   more informed consumer before   entering into the evaluation process.</p>\r\n<p><strong>B. RESPONSIBILITIES OF THE   AUDIOLOGIST</strong></p>\r\n<p>Ten years ago I had six recommendations   for the audiologists. They   included: (1) The responsibility of the testing required to order, select and fit   appropriate amplification; (2) The   responsibility to remain current in our   field; (3) The responsibility to inform   patients regarding assistive listening   technology; (4) The responsibility to   behave professionally at all times; (5)   The responsibility to promote our   profession; and (6) The responsibility of   keeping costs low by providing skilled   services, thereby eliminating need for   &ldquo;remaking&rdquo; hearing aids or repeating   procedures over and over. Ten years   later, how are we doing? I think we have   made considerable progress in some   areas.</p>\r\n<p>Manufactures have assisted the   audiologists in some of their duties.   Integrated/live real ear techniques have   been offered as part of the fitting process   (see Figure 3). We have included better   &ldquo;best fit&rdquo; algorithms which have been   tested on patients and for which data   exists to validate their existence. Both of   these additions allow audiologists to   provide more efficient and therefore less   costly service to their patients. An   interesting event that has occurred   during the past 10 years is that return   rates, for the first time, have lowered   substantially to 12.40%.3</p>\r\n<p>In his discussion on the reasons behind   lowered return rates, Strom   hypothesizes that much of this lowering   has to be due to &ldquo;better educated and   skilled personnel who are using betterfitting   and better-performing digital   hearing aids.&rdquo; He continues with the   point that using nonlinear fitting   rationales do a better job in approaching   final targets and that many hearing care   professionals now feel more comfortable   with advanced technology. He also   points out that the use of high viscosity   impression materials along with   impressions that extend beyond the   second bend has played a role in this   return rate reduction. A study   conducted at Starkey Canada helps to   illustrate the importance of this on   improvement. Ear molds for new orders   were coded to determine if they were   taken at least 4 mms beyond the second   bend and judged to be an adequate   impression without pits or voids.   Dispensers were divided into two   groups: Those with lower than average   remake rates and those with higher than   average remake rates.</p>\r\n<p>As can be seen in Figure 4, for the group   with the lowest remake rates, 70% of the   impressions met the criteria of being at   least 4 mm beyond the second bend and   an impression without pits or voids.   When we look at the same two groups return for remakes we can draw the   conclusion that the impression and skill   taking the impression does matter.   Returns for remake for both loose fits   and tight fits were lower for those whose   impressions were typically longer   (shown in Figure 5)   What more can we do? We can offer   additional information to consumers.   Kochin found that patient satisfaction   with amplification increased significantly   as the amount of instruction time   increased.4 Certainly, use of aural   rehabilitation has been linked to reduced   return rates. Northern et.al. reported   data gathered by HearEx using a   program entitled Hearing Education and   Listening Program (H.E.L.P) in which   recently fit patients were encouraged to   attend three aural rehabilitation   sessions.5 Sessions included:   Class 1. Hearing Loss and Hearing   Aids   &ndash; The hearing process   &ndash; What to expect from your hearing   aids   &ndash; Use and care of hearing aids   &ndash; The value of binaural amplification   Class 2: Overcoming hearing loss   &ndash; How to overcome and accept   hearing loss   &ndash; Tips for communicating effectively   &ndash; Learning to listen   Class 3: Total communication   &ndash; Cues to help speech understanding   &ndash; Controlling the listening environment   &ndash; Hearing enhancement products   Data was gathered for 73 centers located   in five states and information was   gathered over a seven year period on a   total of 7,178 patients. While only   42.3% of all newly fit patients completed   the entire 3-week rehabilitation course,   the return rate for those who did attend   was only 3% &ndash; substantially lower than   the average.   Kochkin reported the use of Consumer   Handbook on Hearing Loss and Hearing   Aids in a rehabilitation program.4 Thirtyone   dispensers participated in the   project with 289 patients assigned to   read three chapters of the book. Book   chapters were assigned based upon   concerns raised in the rehabilitation   courses. Of those who participated in   the classes, the return rate was 8%. Of   those who participated AND read the   chapters, the return rate was only 3.3%.   While I challenged concerns regarding   becoming educated about their hearing   aids, such programs clearly show that   audiologists can facilitate that process   through rehabilitation programs which   notable results.   An article by Sweetow et al., went so far   as to be entitled &ldquo;WARNING: Do NOT   add on Aural Rehabilitation or Auditory   Training to your Fitting Procedures.&rdquo;6   Obviously, this group was not advocating   against the use of aural rehabilitation or   auditory training, rather that they are   &ldquo;integral components of the holistic   approach we should be providing our   patients.&rdquo; They can&rsquo;t just be considered   add-ons that we use when we feel as if   we have the time. They must be a part of   every fitting for every patient.   So where else haven&rsquo;t we made any   improvement in the past 10 years? I   believe in the area of assistive listening   devices. As I wrote 10 years ago &ldquo;It is the   responsibility of the audiologist to   discuss, explore and demonstrate   Assistive Listening Devices (ALDs) with   every patient. ALDs aren&rsquo;t highly   profitable when sold and they take a   large amount of time to discuss, explore   and demonstrate. Yet, ALDs can often   make or break a patient&rsquo;s ability to   function in a given environment. The   satisfaction of knowing patients are   communicating well is worth the extra   time and effort&rdquo;.</p>\r\n<p>C. RESPONSIBILITIES OF THE   MANUFACTURER</p>\r\n<p>Ten years ago I stated that manufactures   had five core responsibilities: (1) The   responsibility of the manufacturer to   provide audiologists with increased   fitting flexibility; (2) The responsibility   of the manufacturer to address problem   areas such as cerumen; (3) The   responsibility of the manufacturer to   provide a decent price for their   technology; (4) The responsibility of the   manufacturer to develop better fitting   tools and paradigms; and (5) The   responsibility of the manufacturer to   provide outcome data.   We know that major improvements have   been made in the industry during the   past 10 years, improvements on   feedback reduction, improvements in   algorithms to correctly identify and   reduce issues with noise, improvements return for remakes we can draw the   conclusion that the impression and skill   taking the impression does matter.   Returns for remake for both loose fits   and tight fits were lower for those whose   impressions were typically longer   (shown in Figure 5)   What more can we do? We can offer   additional information to consumers.   Kochin found that patient satisfaction   with amplification increased significantly   as the amount of instruction time   increased.4 Certainly, use of aural   rehabilitation has been linked to reduced   return rates. Northern et.al. reported   data gathered by HearEx using a   program entitled Hearing Education and   Listening Program (H.E.L.P) in which   recently fit patients were encouraged to   attend three aural rehabilitation   sessions.5 Sessions included:   Class 1. Hearing Loss and Hearing   Aids   &ndash; The hearing process   &ndash; What to expect from your hearing   aids   &ndash; Use and care of hearing aids   &ndash; The value of binaural amplification   Class 2: Overcoming hearing loss   &ndash; How to overcome and accept   hearing loss</p>\r\n<p>&ndash; Tips for communicating effectively   &ndash; Learning to listen</p>\r\n<p>Class 3: Total communication   &ndash; Cues to help speech understanding   &ndash; Controlling the listening environment   &ndash; Hearing enhancement products   Data was gathered for 73 centers located   in five states and information was   gathered over a seven year period on a   total of 7,178 patients. While only   42.3% of all newly fit patients completed   the entire 3-week rehabilitation course,   the return rate for those who did attend   was only 3% &ndash; substantially lower than   the average.</p>\r\n<p>Kochkin reported the use of Consumer   Handbook on Hearing Loss and Hearing   Aids in a rehabilitation program.4 Thirtyone   dispensers participated in the   project with 289 patients assigned to   read three chapters of the book. Book   chapters were assigned based upon   concerns raised in the rehabilitation   courses. Of those who participated in   the classes, the return rate was 8%. Of   those who participated AND read the   chapters, the return rate was only 3.3%.   While I challenged concerns regarding   becoming educated about their hearing   aids, such programs clearly show that   audiologists can facilitate that process   through rehabilitation programs which   notable results.</p>\r\n<p>An article by Sweetow et al., went so far   as to be entitled &ldquo;WARNING: Do NOT   add on Aural Rehabilitation or Auditory   Training to your Fitting Procedures.&rdquo;6   Obviously, this group was not advocating   against the use of aural rehabilitation or   auditory training, rather that they are   &ldquo;integral components of the holistic   approach we should be providing our   patients.&rdquo; They can&rsquo;t just be considered   add-ons that we use when we feel as if   we have the time. They must be a part of   every fitting for every patient.   So where else haven&rsquo;t we made any   improvement in the past 10 years? I   believe in the area of assistive listening   devices. As I wrote 10 years ago &ldquo;It is the   responsibility of the audiologist to   discuss, explore and demonstrate   Assistive Listening Devices (ALDs) with   every patient. ALDs aren&rsquo;t highly   profitable when sold and they take a   large amount of time to discuss, explore   and demonstrate. Yet, ALDs can often   make or break a patient&rsquo;s ability to   function in a given environment. The   satisfaction of knowing patients are   communicating well is worth the extra   time and effort&rdquo;.</p>\r\n<p><strong>C. RESPONSIBILITIES OF THE   MANUFACTURER</strong></p>\r\n<p>Ten years ago I stated that manufactures   had five core responsibilities: (1) The   responsibility of the manufacturer to   provide audiologists with increased   fitting flexibility; (2) The responsibility   of the manufacturer to address problem   areas such as cerumen; (3) The   responsibility of the manufacturer to   provide a decent price for their   technology; (4) The responsibility of the   manufacturer to develop better fitting   tools and paradigms; and (5) The   responsibility of the manufacturer to   provide outcome data.</p>\r\n<p>We know that major improvements have   been made in the industry during the   past 10 years, improvements on   feedback reduction, improvements in   algorithms to correctly identify and   reduce issues with noise, improvements individuals to go on line and not only   see the documentation that is used to   submstanticte our claims but also show   how the studies were conducted with   enough detail to allow for the claims to   be reproduced. For example, the study   that compared Starkey&rsquo;s integrated realear   system with stand-alone real-ear   systems is on starkeyevidence.com so   that the raw data can be viewed and the   procedure can be duplicated by anyone   who is interested in doing so.</p>\r\n<p>So where can manfucturing do better?   Certainly the issue with cost remains   with many consumers siteing cost as an   issue for lack of hearing aid use. Issues   with cerumen remain (and I am afraid   will always remain) regardless of how   hard manufacturers try to reduce issues   with cerumen. We have made   improvements on moisture issuesintroducing   water resistent hearing aids.   We can continue to work on our best fit   algorithms and provide transparent   algorithms so that it is readily apparent   what controls alter which hearing aid   characteristics. We have room for   growth during the next 10 years!</p>\r\n<p><strong>SUMMARY</strong></p>\r\n<p>All in all, the past 10 years have been a   time of substantial improvement for all   three concerned parties: the consumer,   the audiologist and the manufacturer. At   the time I wrote the article 10 years ago,   it seemed to me that meaningful   relationships between these three groups   happened seldom, and yet the last ten   years have brought us an increased   understanding that we are all in this   together. Blaming the manufacturer for   failure or the patient for not trying hard   enough seems to have decreased. We   are working together more successfully.   Here&rsquo;s to the next 10 years!</p>\r\n<h4>REFERENCES</h4>\r\n<p>1. Kaplan H. Benefits and limitations of   amplification and speech reading for the elderly.   In Adjustment to Adult Hearing Loss (ed. H.   Orleans). San Diego, CA: Singular Press; 1991.</p>\r\n<p>2. Antenna Marketing, Baby boomer qualitative   research report. Minneapolis, MN: Author;   2005.</p>\r\n<p>3. Strom K. Reasons for optimism: A look at the   2004-2005 hearing instrument market. Hearing   Instruments, 2005.</p>\r\n<p>4. Kochkin S Marke Trak V: Consumer satisfaction   revisited. Hearing Journal 1999;53(1):38&ndash;55.</p>\r\n<p>5. Northern J and Beyer C. Reducing hearing aid   returns through patient education. Audiology   Today 1999;11(2):10&ndash;11.</p>\r\n<p>6. Sweetow R, Corti D, Edwards B, Moodie S,   Sabes J. WARNING: Do NOT add on aural   rehabilitation or auditory training to your fitting   procedures. Hearing Review, 2007.</p>\r\n<p>Canadian Hearing Report 2014;9(2):24&ndash;29 .</p>',NULL,'2022-11-23'),(23,3258,'','','','<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g001.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g002.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g003.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g004.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g005.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g006.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g007.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g008.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g009.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0010.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0011.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0012.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0013.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0014.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0015.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0016.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0017.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0018.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0019.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0020.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0021.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0022.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0023.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0024.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0025.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0026.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0027.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0028.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0029.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0030.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0031.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0032.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0033.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0034.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0035.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0036.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-5-1-g0037.png\" alt=\"image\" /></p>',NULL,'2022-11-23'),(24,3227,'ajchr','http://www.andrewjohnpublishing.com/','','<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-2-e001.png\" alt=\"image\" /></p>',NULL,'2022-11-24'),(25,3223,'ajchr','http://www.andrewjohnpublishing.com/','','<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e001.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e002.png\" alt=\"image\" /></p>\r\n<h4>Let us hear from you!</h4>\r\n<p>Andrew John Publishing Inc. is proud to bring you Canadian Hearing Report (CHR), the only\r\n  Canadian magazine of its kind to bring together working practitioners and members of the\r\n  industry. In CHR, we have created a forum for the sharing of ideas, knowledge, news, and events.</p>\r\n<p>In the inaugural issue of this format, we bring you an article by Rachelle\r\n  Zral, an audiologist and seasoned Yukoner who lives and practises in\r\n  Whitehorse. We also meet Johan Hammarstr&ouml;m, a twenty-eight-year-old,\r\n  hearing-impaired pilot from Sweden who is preparing to fly around the\r\n  world in a single-engine plane. He hopes to raise awareness of hearing\r\n  impairment and the modern technology available to help those affected\r\n  reduce the impact of their disability.</p>\r\n<p>On the technology front, Ross Harwell,\r\n  audiology manager at Oticon Canada,\r\n  introduces us to datalogging, an innovative\r\n  new tool to improve hearing aid fittings.\r\n  And Dr. Ian Bruce from McMaster\r\n  University in Hamilton, Ontario, takes us\r\n  behind the scenes of the research he and\r\n  his team are doing in hearing loss and\r\n  optimal amplification.</p>\r\n<p> In addition, we keep you up to date with\r\n  news from the industry and upcoming\r\n  events, such as the 4th Widex Congress of\r\n  Paediatric Audiology being held in Ottawa\r\n  this May.</p>\r\n<p> But Canadian Hearing Report cannot exist\r\n  without your input. This magazine is for\r\n  you&mdash;the practitioners and the industry\r\n  that supports them. We need you to let us\r\n  know about interesting stories, research,\r\n  news, and products.</p>\r\n<p> To audiologists and hearing instrument\r\n  practitioners: Do you have an inspiring\r\n  story you would like to share with your\r\n  colleagues? Do you know someone who is\r\n  exceptional in the profession? Are you\r\n  someone who works in an interesting setting,\r\n  or on a dedicated team that garners\r\n  impressive results?</p>\r\n<p>To members of the industry: Has a member\r\n  of your team really made a difference?\r\n  Is your company participating in or sponsoring\r\n  events to improve quality of life for\r\n  the hearing-impaired community? What\r\n  new products would you like to share\r\n  with the readers?</p>\r\n<p> We are also interested in sharing insight\r\n  into such general issues as third-party\r\n  financing, running a family business, community\r\n  awareness, improvements/challenges\r\n  in screening, remote practice/treatment,\r\n  noise in workplace/everyday life,\r\n  and changes in funding and how they\r\n  affect both clients and practitioners.</p>\r\n<p> Please contact us with your news, stories,\r\n  and insights, and help us to make\r\n  Canadian Hearing Report an interesting\r\n  and informative tool for our readers. You\r\n  can contact me directly with your ideas and\r\n  comments at suemharrison@aol.com.</p>\r\n<p><strong>Sound Off</strong></p>\r\n<p> <strong>Like what you read? Feel inspired to share an idea?</strong></p>\r\n<p> We welcome your input. Please send your letters and comments, via e-mail, to suemharrison@aol.com, subject: Letter to the Editor.</p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e003.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e004.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e005.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e006.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e007.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e008.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e009.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e010.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e011.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e012.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e013.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e014.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e015.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e016.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e017.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e018.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e019.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e020.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e021.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e022.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e023.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e024.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e025.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e026.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e027.png\" alt=\"image\" /></p>',NULL,'2022-11-24'),(26,3242,'','','','<p><strong>A TRUE WIRELESS SOLUTION</strong></p>\r\n<p>Almost 30 years ago, my first job was as a staff audiologist at the Canadian Hearing Society. The sound booths were located in a converted garage in a three story house that once was the Finnish embassy. I had three colleagues (Tani Nixon was my boss and mentor, Glen Sutherland who knew everything about aural rehabilitation and knew the best restaurants in Toronto, and the third was another Marshall &ndash; Marshall Rosner). If Tani came into our shared offices and said &ldquo;Marshall!&rdquo; we became very adept at figuring out who was in trouble. Our first jobs in audiology are always important. They teach you the &ldquo;ropes&rdquo; that you didn&rsquo;t learn about in school. And to this day, I have close friendships with all these colleagues. The Canadian Hearing Society is now celebrating their 70th anniversary and Rex Banks (the current Tani) gives us a nice overview of where they were and where they are today</p>\r\n<p>Speaking of anniversaries, the School of Communication Sciences and Disorders at the University of Western Ontario is celebrating their 40th anniversary. Dr. JB Orange gives an excellent overview of their program and the celebrations. And does anyone know what the &ldquo;JB&rdquo; stands for?</p>\r\n<p>On a different topic, I always knew that doing my push ups (and sit ups and crunches, and&hellip;) was supposed to be good for me, but now we have data showing that being in good cardiovascular shape actually minimizes the chances of sensori-neural hearing loss down the line. A peer-reviewed article (Canadian Hearing Report does offer the opportunity of having a submission peer reviewed) has been submitted by Doctors Hutchinson and Alessio showing that elderly couch potatoes actually have a greater sensori-neural hearing loss than their age-matched physically fit colleagues. It seems that presbycusis is not inevitable, or at least not to the same degree.</p>\r\n<p>I recently ran into Scott Lake who is an engineer with Westone Laboratories at an American Academy of Audiology meeting and I managed to &ldquo;persuade&rdquo; him to write an article for us on one of my favourite topics &ndash; the acoustics of Helmholtz resonators. We have them everywhere in audiology, from the vent-associated resonance to a study of room acoustics, and this article extends our knowledge of what we already thought we knew about Helmholtz resonators. Scott&rsquo;s previous incarnation was in the automotive industry and some of the examples derive from his tenure there. The science and even some of the technology is easily transferable to the field of audiology</p>\r\n<p>Phillipe Fournier has written on the perceived benefits of using FM systems with cochlear implants. Like hearing aids, cochlear implants are limited in many situations and the use of assistive listening devices to improve the signal to noise ratio is always useful. I am actually quite surprised by how infrequently assistive listening devices such as FM systems are being recommended by our colleagues. Phillipe is a student at the University of Ottawa and an abstract of his work appears under the banner of &ldquo;From the Classrooms.&rdquo; Isabelle-Anne Pleau, also a student at the University of Ottawa, has sent in an abstract as well and has tried to tease apart threshold information (with and without masking) in an attempt to delineate the relative contributions of sensory and non-sensory contributions as a function of age.</p>\r\n<p>To round out this issue of the Canadian Hearing Report, we have a short piece that is written &ldquo;For the Consumer&rdquo; on noise cancelling headphones. Please note that this article can be freely copied and given out to clients as desired. Noise cancellation has been around since the 1930s but only recently has it found its way into consumer products and hearing aids. It is hoped that this is the first of many free-use &ldquo;For the Consumer&rdquo; information sheets that will appear in upcoming issues of Canadian Hearing Report.</p>\r\n<p>I would like to take this opportunity to wish everyone and their families a pleasant and peaceful holiday season.</p>\r\n<p>Mon premier emploi, pr&egrave;s de 30 ans maintenant, a &eacute;t&eacute; &agrave; la Soci&eacute;t&eacute; canadienne de l\'ou&iuml;e en tant qu\'audilogiste. Les cabines de sons &eacute;taient situ&eacute;es dans un garage converti en maison de trois &eacute;tages qui abritait jadis l\'ambassade de la Finlande. J\'avais trois coll&egrave;gues (Tani Nixon &eacute;tait ma patronne et ma conseill&egrave;re, Glen Sutherland savait tout sur la r&eacute;habilitation auditive et les meilleurs restaurants de Toronto, et le troisi&egrave;me &eacute;tait un autre Marshall &ndash;Marshall Rosner). Si Tani venait dans le bureau qu\'on partageait et appelait &ldquo;Marshall!&rdquo;, nous savions pertinemment qui, de nous , &eacute;tait en difficult&eacute;. Nos premiers emplois en audiologie sont toujours importants. Ils vous enseignent les &ldquo;rouages&rdquo; que vous n\'avez pas appris &agrave; l\'&eacute;cole. Et &agrave; jour, j\'ai des relations d\'amiti&eacute;s &eacute;troites avec tous ces coll&egrave;gues. La Soci&eacute;t&eacute; canadienne de l\'ou&iuml;e c&eacute;l&egrave;bre maintenant son 70i&egrave;me anniversaire et Rex Banks ( le Tani d\'aujourd\'hui) nous donne une belle vue d\'ensemble du pass&eacute; et du pr&eacute;sent.</p>\r\n<p>En parlant d\'anniversaires, the School of Communication Sciences and Disorders de l\'universit&eacute; de Western Ontario c&eacute;l&egrave;bre son 40i&egrave;me anniversaire. Dr. JB Orange nous offre une excellente vue d\'ensemble de leur programme et des c&eacute;l&eacute;brations. Et est ce quelqu\'un connait la signification du &ldquo;JB&rdquo;?</p>\r\n<p>Passant &agrave; autres chose, j\'ai toujours su que faire mes tractions sur les mains (et redressements assis et enroulements abdominaux, et... ) &eacute;tait sens&eacute; m\'&ecirc;tre salutaire, mais nous avons maintenant des donn&eacute;es qui montrent qu\'&ecirc;tre en bonne forme cardiovasculaire minimise les chances de surdit&eacute; neurosensorielle en fin de compte. Un article &eacute;valu&eacute; par les pairs ( la Revue canadienne d\'audition offre l\'opportunit&eacute; de recevoir des soumissions &eacute;valu&eacute;es par les pairs) a &eacute;t&eacute; soumis par Dr Hutchinson et Dr Alessio montrant que les personnes &acirc;g&eacute;es s&eacute;dentaires ont une plus grande surdit&eacute; neurosensorielle que les personnes &acirc;g&eacute;es du m&ecirc;me &acirc;ge mais physiquement actives. Apparemment, la presbyacousie n\'est pas in&eacute;vitable, ou tout au moins pas au m&ecirc;me degr&eacute;.</p>\r\n<p>Je suis tomb&eacute; derni&egrave;rement sur Scott Lake qui est un ing&eacute;nieur avec Westone Laoratories au cours d\'une r&eacute;union de l\'American Academy of Audiology, et j\'ai r&eacute;ussi &agrave; le &ldquo;persuader&rdquo; de nous &eacute;crire un article sur un de mes sujets de pr&eacute;dilection&ndash; l\'acoustique des r&eacute;sonateurs de Helmholtz. Nous les avons partout en audiologie, de la r&eacute;sonance associ&eacute;e &agrave; l\'&eacute;vent &agrave; l\'&eacute;tude de l\'acoustique de chambre, et cet article &eacute;largit notre savoir au sujet des r&eacute;sonateurs d\'Helmholtz. Scott, dans une autre vie, est pass&eacute; par l\'industrie automobile et certains des exemples d&eacute;coulent de son passage. La science et m&ecirc;me certaines technologies sont facilement transf&eacute;rables au domaine de l\'audiologie.</p>\r\n<p>Phillipe Fournier a d&eacute;j&agrave; &eacute;crit au sujet des avantages pr&eacute;sum&eacute;s de l\'utilisation des syst&egrave;mes MF avec les implants cochl&eacute;aires. Comme les appareils auditifs, les implants cochl&eacute;aires sont limit&eacute;s dans plusieurs situations et l\'utilisation des appareils fonctionnels pour malentendants pour am&eacute;liorer le rapport signal/bruit est toujours utile. En fait, je suis assez surpris que nos coll&egrave;gues ne recommandent pas plus souvent les appareils fonctionnels pour malentendants comme les syst&egrave;mes MF. Phillipe est &eacute;tudiant &agrave; l\'universit&eacute; d\'Ottawa et un r&eacute;sum&eacute; de son travail appara&icirc;t sous la banni&egrave;re &ldquo;From the Classrooms.&rdquo;. Isabelle-Anne Pleau, aussi &eacute;tudiante &agrave; l\'universit&eacute; d\'Ottawa, a envoy&eacute; aussi un r&eacute;sum&eacute; et a essay&eacute; de dissocier le seuil de l\'information (avec ou sans masquage) dans une tentative de d&eacute;limiter les contributions relatives des contributions sensorielles et non sensorielles comme une fonction de l\'&acirc;ge.</p>\r\n<p>Pour terminer en beaut&eacute; ce num&eacute;ro de la Revue canadienne d\'audition, nous avons un papier court qui est &eacute;crit &ldquo;Pour le consommateur&rdquo; traitant des &eacute;couteurs suppresseurs de bruit. Veuillez noter que cet article peut &ecirc;tre librement copi&eacute; et donn&eacute; au clients selon son bon vouloir. La suppression de bruit est pr&eacute;sente depuis les ann&eacute;es 30, mais seulement derni&egrave;rement, elle a trouv&eacute; son chemin dans les produits pour consommateurs et appareils auditifs. Nous esp&eacute;rons que ce sera le premier de plusieurs papiers &ldquo;Pour le consommateur&rdquo; libres d\'utilisation qui vont appara&icirc;tre dans les prochains num&eacute;ros de la Revue canadienne d\'audition.</p>\r\n<p>Je voudrai saisir cette opportunit&eacute; pour souhaiter &agrave; toutes et &agrave; tous ainsi que vos familles des temps de f&ecirc;tes paisibles .</p>\r\n<p><strong>&ldquo;QUICK NOTES&rdquo; FROM THE EXECUTIVE DIRECTOR</strong></p>\r\n<p>Avery busy fall season for CAA began in earnest with our 2010 Conference and Exhibition held October 5&ndash;8 at Le Centre Sheraton in Montreal. Delegates heard from an outstanding line-up of international speakers, highlighted by Dr. Richard Gans who gave the keynote address. Social highlights included a &ldquo;CAA&rsquo;s Got Talent Show&rdquo; during the Opening Reception, and a Soiree Evening with live entertainment by impressionist/ comedian Mat Gauthier. The CAA Trade Show once again provided a wealth of information about latest trends in audiology services and hearing equipment and supplies. I wish to thank our sponsors, manufacturers, and suppliers as well as all those who attended the conference for their continuing support.</p>\r\n<p>This year&rsquo;s President&rsquo;s Award recipient was Anne Griffin, a renowned audiologist with the Central Health Care Board in Grand Falls, Newfoundland.</p>\r\n<p>The Jean Kienapple Award for Clinical Excellence went to Sonia Marazzi, a respected audiologist with the North Shore Children&rsquo;s Hearing Clinic in North Vancouver, British Columbia.</p>\r\n<p>The recipient of the Student Poster Award for Outstanding Research was Christine Turgeon from the University of Montreal. Other Student Award winners as nominated by their respective schools were:</p>\r\n<p>&bull; Emilie Gosselin, University of Montreal</p>\r\n<p>&bull; Bonnie Lampe, University of Western Ontario</p>\r\n<p>&bull; Maxime Maheu, University of Ottawa</p>\r\n<p>&bull; Mary MacDonald, University of British Columbia</p>\r\n<p>&bull; Robert Murphy, Dalhousie University</p>\r\n<p>The Canadian Inter-organizational Steering Group for Audiology and Speech-Language Pathology recently released proposed Competency Profiles for the profession, and asked its member organizations, including CAA, to provide feedback by November 30, 2010. In addition, CAA is taking the lead role in a project to develop Guidelines for the Assessment, Diagnosis and Intervention/Mediation of Auditory Processing Disorders (APD). The guidelines should be available early in 2011.</p>\r\n<p>The Federal Healthcare Partners (FHP) / Third Party Payers Group met again with representatives of CAA and CASLPA in Montreal during the CAA Conference to discuss items of concern to Canadian audiologists. The FHP Group includes Veterans Affairs Canada (VAC), NonInsured Health Benefits (NIHB), Department of National Defense (DND), the RCMP, and Blue Cross. A full report on decisions and recommendations coming out of our meeting will be posted soon on the Third Party Payer page of our website.</p>\r\n<p>A further meeting was held with the NIHB group on September 30th to discuss the many questions from CAA members specific to NIHB.</p>\r\n<p>We recently celebrated National Audiology Week (October 18&ndash;24, 2010). The CAA marketing team produced an online Media Tool Kit to assist CAA members in promoting the profession. Go to www.canadianaudiology.ca/myNAW to tell us about your National Audiology Week activities.</p>\r\n<p>Now that our bid to co-host with CASLPA the International Society of Audiology Congress in Vancouver, British Columbia, in October 2016 has been accepted, we will be searching for a hotel venue, recruiting conference cochairs and members to participate on the Planning Committee, and a professional congress organizer to manage the event. If you are interested or know of someone who is within CAA, contact me at director@canadianaudiology.ca</p>\r\n<p>Finally, the 2nd Annual CAA Spring Audiology Seminar will be held at the beautiful Delta Beausejour Hotel in Moncton, New Brunswick. After last year&rsquo;s very successful inaugural event in Richmond, British Columbia, we will once again be featuring Dr. Michael Valente, director, Division of Adult Audiology, Washington University School of Medicine in St. Louis, Missouri. Online registration at www.canadian audiology.ca opens on December 1 and space will be limited</p>\r\n<p><strong>&ldquo;DEPECHES RAPIDES&rdquo; DU DIRECTEUR EXECUTIF</strong></p>\r\n<p>Une saison d\'automne bien charg&eacute;e a commenc&eacute; avec notre Conf&eacute;rence et exposition 2010 qui s\'est tenue du 5 au 8 Octobre au Centre Sheraton &agrave; Montr&eacute;al. Nos d&eacute;l&eacute;gu&eacute;s(es) ont eu droit &agrave; des conf&eacute;renciers exceptionnels de renomm&eacute;e internationale, le tout couronn&eacute; par Dr . Richard Gans qui a &eacute;t&eacute; le conf&eacute;rencier d\'honneur. Parmi les moments sociaux phares, le spectacle &ldquo;CAA&rsquo;s Got Talent &rdquo; &agrave; la r&eacute;ception d\'ouverture, et une Soir&eacute;e Evening avec le spectacle sur sc&egrave;ne de l\'impressionniste/ humoriste Mat Gauthier. Le Salon professionnel de l\'ACA a encore une fois fournit une richesse en informations sur les derni&egrave;res tendances en services audiologiques, &eacute;quipements et fournitures auditifs. Je voudrais remercier nos commanditaires, fabricants, et fournisseurs ainsi que tous ceux et toutes celles qui ont particip&eacute; &agrave; la conf&eacute;rence pour leur soutien continu.</p>\r\n<p>La r&eacute;cipiendaire du Prix du pr&eacute;sident de cette ann&eacute;e est Anne Griffin, une audiologiste de renom du Central Health Care Board &agrave; Grand Falls, &agrave; Terre Neuve.</p>\r\n<p>La r&eacute;cipiendaire du Prix du m&eacute;rite pour la pr&eacute;sentation d\'un poster en recherche exceptionnelle par un(e)&eacute;tudiant(e) est Christine Turgeon de l\'universit&eacute; de Montr&eacute;al. Les autres gagnant(es), dont les candidatures ont &eacute;t&eacute; avanc&eacute;es par leurs &eacute;coles respectives, du Prix pour &eacute;tudiant sont</p>\r\n<p>&bull; Emilie Gosselin, Universit&eacute; de Montr&eacute;al</p>\r\n<p>&bull; Bonnie Lampe, University of Western Ontario</p>\r\n<p>&bull; Maxime Maheu, Universit&eacute; d\'Ottawa</p>\r\n<p>&bull; Mary MacDonald, University of British Columbia</p>\r\n<p>&bull; Robert Murphy, Dalhousie University</p>\r\n<p>Le groupe directeur interorganisations pour l\'audiologie et l\'orthophonie a derni&egrave;rement publi&eacute; les profiles de comp&eacute;tences propos&eacute;s pour la profession, et a demand&eacute; aux organisations membres, y compris l\'ACA, de fournir une r&eacute;troaction au plus tard le 30 Novembre 2010. De plus, l\'ACA joue un r&ocirc;le de chef de file dans un projet qui vise &agrave; d&eacute;velopper Des lignes directrices pour l\'&eacute;valuation, le diagnostic et l\'intervention/ m&eacute;diation des troubles des traitements des informations auditives. Les lignes directrices devraient &ecirc;tre disponibles t&ocirc;t en 2011.</p>\r\n<p>Le groupe Partenaires au niveau f&eacute;d&eacute;ral en mati&egrave;re de soins de sant&eacute;/Tiers payants s\'est encore r&eacute;unit avec des repr&eacute;sentants(es) de l\'ACA et l\'ACOA &agrave; Montr&eacute;al pendant la conf&eacute;rence de l\'ACA, pour discuter des sujets de pr&eacute;occupations des audiologistes canadiens. Parmi le groupe des partenaires au niveau f&eacute;d&eacute;ral en mati&egrave;re de soins de sant&eacute;, les Anciens Combattants Canada (ACC), Services de sant&eacute; non assur&eacute;s (SSNA), le Minist&egrave;re de la d&eacute;fense nationale (MDN), la GRC et la Croix Bleue. Un rapport complet des d&eacute;cisions et recommandations r&eacute;sultant de notre r&eacute;union sera publi&eacute; sur la page Tiers payants de notre site web.</p>\r\n<p>Une r&eacute;union suppl&eacute;mentaire s\'est tenue avec le groupe SSNA le 30 septembre pour discuter des plusieurs questions sp&eacute;cifiques au SSNA &eacute;manant des membres de l\'ACA.</p>\r\n<p>Nous avons c&eacute;l&eacute;br&eacute; derni&egrave;rement La semaine nationale de l\'Audiologie (du 18 au 24 Octobre, 2010). L\'&eacute;quipe marketing de l\'ACA a produit une Trousse d\'outils Media en ligne pour assister les membres de l\'ACA dans leurs efforts pour promouvoir la profession. Veillez visiter le www.canadianaudiology.ca/myNAW pour nous faire part de vos activit&eacute;s durant la semaine nationale de l\'audiologie.</p>\r\n<p>Maintenant que notre soumission pour &ecirc;tre le co-h&ocirc;te avec l\'ACOA, du Congr&egrave;s de la Soci&eacute;t&eacute; internationale d\'audiologie &agrave; Vancouver, en Colombie Britannique en Octobre 2016, a &eacute;t&eacute; accept&eacute;e, nous allons faire la recherche de l\'h&ocirc;tel, le recrutement du pr&eacute;sident ou de la pr&eacute;sidente et des membres pour participer au comit&eacute; de planification, et le recrutement d\'un groupe professionnel de planification de congr&egrave;s pour g&eacute;rer l\'&eacute;v&eacute;nement. Si vous &ecirc;tes ou connaissez quelqu\'un de L\'ACA qui serait int&eacute;ress&eacute;(e), veuillez me contacter au director@canadianaudiology.ca.</p>\r\n<p>Finalement, le 2eme s&eacute;minaire annuel du printemps de l\'audiologie se tiendra au beau h&ocirc;tel Delta Beausejour &agrave; Moncton, dans le Nouveau Brunswick. Suite &agrave; l\'&eacute;v&eacute;nement inaugural tr&egrave;s r&eacute;ussi de l\'ann&eacute;e derni&egrave;re &agrave; Richmond, en Colombie Britannique, nous recevrons encore Dr . Michael Valente, directeur, division de l\'audiologie chez les adultes, de la facult&eacute; de m&eacute;decine de l\'universit&eacute; de Washington &agrave; St. Louis, dans le Missouri. L\'inscription en ligne au www.canadianaudiology.ca sera lanc&eacute;e le 1er d&eacute;cembre et l\'espace sera limit&eacute;.</p>\r\n<p><strong>2nd Annual Spring CAA Audiology Seminar</strong></p>\r\n<p>The Canadian Hearing Society is the largest organization of its kind in North America serving the needs of culturally Deaf, oral deaf, deafened, and hard of hearing people across Ontario and Canada.</p>\r\n<p>Often associated with advocacy issues pertaining to the Deaf community, what many audiologists don&rsquo;t know is that since its inception in 1940, The Canadian Hearing Society has not only embraced the field of audiology, but has proven itself to be both a leader and innovator in the early days of the audiology profession in Canada. Along with establishing a national agency concerning itself with jobs for Deaf and hard of hearing individuals, the standardization and costs of hearing aids, rehabilitation of ex-servicemen and the distribution of expertise and information were key core components of the original mandate of CHS &ndash; which was initially known as The National Association for the Deaf and Hard of Hearing</p>\r\n<p>To further these causes, in June of 1940, noted otologist of the time, Dr. G. Alexander Fee, was retained as a medical consultant to CHS. Dr. Fee examined approximately 25% of all new clients, administered functional tests with and without hearing aids, and advised clients as to possible benefit from treatment, hearing aids, and lip-reading. Additionally, Dr. Fee also answered inquires from distant points on behalf of the society.</p>\r\n<p>The Second World War had just ended and much of the work of the society was focused on helping veterans who had returned from war service with severe hearing loss. CHS obtained a grant from the Department of Veteran Affairs to assist in providing amplification to 5,000 deafened servicemen. At the very same time and for the same reasons, the profession of audiology was in its infancy in the United States. Already, CHS&rsquo; sense of the necessity of audiology was proving to be cutting edge and revolutionary</p>\r\n<p>Hearing aids were a focus of the1947&ndash; 48 Annual Report. Dr. Fee described among his findings his patients&rsquo; resistance to hearing aids, particularly in the younger age groups with moderate hearing losses. Fast forward to 2010, CHS audiologists are still concerned about this issue and are working with researchers at The University of Toronto to study the relationship between the stigma associated with hearing loss and/or aging and how these social perceptions affect the adjustment of hearing loss and the use of hearing aids</p>\r\n<p>In the 1950s, the first of many grants to subsidize hearing aids for children was received and in 1952 CHS purchased its first audiometer at a cost of $845. This was a significant expenditure at the time but was deemed important and necessary as CHS began exploring this component of service. In 1962, a &ldquo;sound-proof room&rdquo; and audiometer were installed at the &ldquo;Head Office.&rdquo; Two staff people were trained to administer hearing tests while the search for an audiologist commenced; an ambitious undertaking as there were no Canadian audiology training programs in existence at the time.</p>\r\n<p>In 1967 audiologist Errol Davis was hired. He was the first audiologist in Toronto and soon reorganized the department into the most up-to-date audiological facility in Canada. The CHS Audiology Department set the standard for audiology clinics in teaching hospitals in Toronto and throughout the province.</p>\r\n<p>From 1940 through the 1970s CHS conducted thousands of hearing aid evaluations and continued to expand its Audiology and Hearing Aid Programs along with the institution of a hearing screening van, which was donated by IBM and equipped by The Lions Club</p>\r\n<p>In the early 1980s CHS supported the regulation of audiologists in conjunction with OSLA and worked closely with what was then called The Association of Hearing Aid Dispensers, responding to issues which arose from the Health Professions Legislation Review. CHS audiologists were also involved in helping establish the criteria for a governmental definition of deafness. After the Minister of Health announced the details of the newly established Assistive Device Program, CHS was contracted to provide expertise and administration to the Hearing Aid Services Monitoring Board (later known as the Advisory Committee on Hearing Aid Services).</p>\r\n<p>In addition to audiological testing, hearing aid evaluations, electrophysiological assessment, aural rehabilitation, and hearing aid dispensing, in the 1980s the program grew to provide a significant role in the education of the professions of audiology and speechlanguage pathology. CHS became a recognized training site for all university audiology programs in Canada, the Speech-Language Pathology Program at the University of Toronto and the department into the most up-to-date audiological facility in Canada. The CHS Audiology Department set the standard for audiology clinics in teaching hospitals in Toronto and throughout the province.</p>\r\n<p>From 1940 through the 1970s CHS conducted thousands of hearing aid evaluations and continued to expand its Audiology and Hearing Aid Programs along with the institution of a hearing screening van, which was donated by IBM and equipped by The Lions Club</p>\r\n<p>In the early 1980s CHS supported the regulation of audiologists in conjunction with OSLA and worked closely with what was then called The Association of Hearing Aid Dispensers, responding to issues which arose from the Health Professions Legislation Review. CHS audiologists were also involved in helping establish the criteria for a governmental definition of deafness. After the Minister of Health announced the details of the newly established Assistive Device Program, CHS was contracted to provide expertise and administration to the Hearing Aid Services Monitoring Board (later known as the Advisory Committee on Hearing Aid Services).</p>\r\n<p>In addition to audiological testing, hearing aid evaluations, electrophysiological assessment, aural rehabilitation, and hearing aid dispensing, in the 1980s the program grew to provide a significant role in the education of the professions of audiology and speechlanguage pathology. CHS became a recognized training site for all university audiology programs in Canada, the Speech-Language Pathology Program at the University of Toronto and the Communicative Disorders Assistant (CDA) program at Georgian College. CHS&rsquo; audiology alumni list of volunteers, students and clinicians boasts some of the most well-known audiologists in Canada.</p>\r\n<p>Today, The Canadian Hearing Society employs a provincial network of audiologists approaching hearing health care from a holistically minded point of view. CHS provides services, products and information relating to hearing loss as well as offering a wide-range of complementary education and support programs for both children and adults in an accessible environment. The Audiology Department remains integral to the fabric of CHS, touching virtually every department and affecting thousands consumers every year.</p>\r\n<p><strong>Celebrating 40 Years of Academic Excellence in Audiology and Speech-Language Pathology at the University of western Ontario</strong></p>\r\n<p>The first and largest event was a combination scientific symposium and gala luncheon and dinner held at the UWO on Friday the October 1, 2010. Support for the day&rsquo;s events came from the Daniel Ling Speaker Series Fund, the Faculty of Health Sciences at the UWO, The Harmonize for Speech Foundation, The School of Communication Sciences and Disorders, and the National Centre for Audiology. Over 125 alumnae/alumni, current students, local and regional clinicians and faculty attended half-day symposium sessions in audiology and speech-language pathology. Registrants heard Dr. Robert Harrison, from the University of Toronto and SickKids Hospital, speak at the Hearing Science Seminar on the topic of &ldquo;Auditory System Development and Plasticity.&rdquo; Others attended the Siemens Symposium led by Dr. Bill Hodgetts from the University of Alberta&rsquo;s Department of Speech Pathology and Audiology on the subject of &ldquo;Bone Conduction Amplification: Present and Future Considerations.&rdquo; Other registrants attended the session titled &ldquo;Recent Developments in Acquired Apraxia of Speech&rdquo; given by Dr. Julie Wambaugh from the Department of Communication Sciences and Disorders at the University of Utah. Other delegates heard Drs. Lisa Archibald and Daniel Ansari, from our school and the Department of Psychology at the UWO, respectively, discuss the topics of &ldquo;Numeracy and Arithmetic: The Roles of Development and Individuals Differences&rdquo; and &ldquo;The Psycho-educational Assessment from a Speech and Language Perspective.&rdquo; The academic portion of the day ended with tours of faculty members&rsquo; laboratories and individualized demonstrations of research activities.</p>\r\n<p>The evening gala dinner, opened ceremoniously by the splendid bagpiping of one of our faculty members Dr. Ewan Macpherson, was marked by the official renaming of four student academic entrance and academic continuing awards in honour of Mr. Cam Miller, a longstanding barbershop singer and trustee of the Harmonize for Speech Fund. These awards will henceforth bear Cam&rsquo;s name. Cam worked tirelessly for many decades as a champion of our students, their research, and the academic mission of our school. Special guests included Cam and his wife Mary, Mr. George Shields and Mrs. Gail Shields, where George is the chairman of the Harmonize for Speech Fund. George delivered a moving and eloquent tribute to Cam, describing Cam&rsquo;s boundless energy, enduring support, and determined philanthropic focus on those with speech, language, hearing, and voice problems. During dinner, guests were serenaded by the London Men of A Chord, a close to 20 person barbershop singing chorus who honoured Cam and the school with exquisite in-tune melodies sprinkled with comical interludes. Former department/school co-directors Drs. Richard Seewald and Joseph Corcoran reminisced publically about their splendid time as co-directors. A PowerPoint slide show presentation, assembled by a group of current student volunteers, contained photos of former and current faculty with decades-marking clothing, hair-dos, and eyeglasses and which ran throughout the evening, yielding many laughs and comments such as, &ldquo;Oh my goodness, is that &hellip;&hellip;&hellip;!&rdquo;</p>\r\n<p>Other planned events to mark the School&rsquo;s 40th Anniversary include Dr. Ewan Macpherson presenting at the Annual Conference of the Canadian Academy of Audiology held in October 2010 in Montreal. Dr. Macpherson&rsquo;s talk addressed the importance of multidimensional spatial sound cues for sound localization among individuals with normal and impaired hearing. In addition, Dr. Ruth Martin, an award-winning neuroscientist and speech-language pathology faculty in our school, will be our sponsored speaker at the next Annual Conference of the Canadian Association of SpeechLanguage Pathologists and Audiologists being held in Montreal in late April 2011. Dr. Martin will address in her session the latest empirical evidence surrounding the concepts of swallowing neuroplasticity and efficacious approaches to rehabilitation of dysphagia.</p>\r\n<p>Careful reflection on the numerous and cutting-edge academic, clinical and professional accomplishments of students, alumnae/alumni, and faculty from the school over the past 40 years shows that there is much to celebrate and to acknowledge. Our graduates and faculty have helped advance multiple scientific bases of foundational knowledge related to hearing, speech, language, voice, cognitivecommunication and swallowing disorders, and of innovative evidencebased rehabilitation approaches. The coming decades at the school will undoubtedly lead to additional exemplary leadership contributions that will advance scholarly thinking and clinician-scientist based practice patterns in audiology and speechlanguage pathology.</p>',NULL,'2022-11-24'),(27,3226,'ajchr','http://www.andrewjohnpublishing.com/','','<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e001.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e002.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e003.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e004.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" 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src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e029.png\" alt=\"image\"/></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e030.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e031.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e032.png\" alt=\"image\" /></p>',NULL,'2022-11-24'),(28,3228,'ajchr','http://www.andrewjohnpublishing.com/','','<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-3-e001.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-3-e002.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-3-e003.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-3-e004.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-3-e005.png\" alt=\"image\" /></p\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-3-e006.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-3-e007.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-3-e008.png\" alt=\"image\" /></p>\r\n<p><img 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src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-3-e027.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-3-e028.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-3-e029.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-3-e030.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-3-e031.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-3-e032.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-3-e033.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-3-e034.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-3-e035.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-3-e036.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-3-e037.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-3-e038.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-3-e039.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-3-e040.png\" alt=\"image\" /></p>',NULL,'2022-11-24'),(29,3250,'ajchr','http://www.andrewjohnpublishing.com/','','',NULL,'2022-11-24'),(30,3238,'ajchr','http://www.andrewjohnpublishing.com/','','<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g001.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g002.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g003.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g004.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g005.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g006.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g007.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g008.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g009.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g010.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g011.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g012.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g013.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g014.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g015.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g016.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" 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alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g024.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g025.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g026.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g027.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g028.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g029.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" 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alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g037.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g038.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g039.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g040.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g041.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g042.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g043.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g044.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g045.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g046.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g047.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g048.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/Androw-jhon-figure-5-1-g049.png\" alt=\"image\" /></p>',NULL,'2022-11-25'),(31,3257,'','','','<p>Ce num&eacute;ro de la Revue canadienne d&rsquo;audition porte sur certains sujets et nous n&rsquo;avons pas toutes les r&eacute;ponses. En ce qui me concerne, c&rsquo;est souvent le domaine des troubles vestibulaires et des ph&eacute;nom&egrave;nes neurologiques. A l&rsquo;instar de la plupart des audiologistes, je suis plus &agrave; l&rsquo;aise avec la r&eacute;alit&eacute; des tests objectifs et des v&eacute;rifications. Dans ce num&eacute;ro, la rubrique Spotlight on Science plonge dans le domaine des proth&egrave;ses pour la perte vestibulaire, et comme le nom le sugg&egrave;re, offre une vue de profondeur des th&eacute;rapies possibles pour nos clients qui pr&eacute;sentent des dysfonctionnements vestibulaires.</p>\r\n<p>Et pour ne pas s&rsquo;en tenir juste l&agrave;, Sean Lennox et Uta Stewart vont s&rsquo;attaquer aux domaines des troubles d&rsquo;&eacute;quilibre et du vieillissement. Les troubles d&rsquo;&eacute;quilibre ne sont pas n&eacute;cessairement un effet secondaire parce qu&rsquo;on a 80 ans et on ne peut pas les n&eacute;gliger chez nos clients seulement &agrave; cause de l&rsquo;&acirc;ge. Et, pour les jeunes, Iman Ibrahim, Rebecca Malcolmson-Cronin, Mary-Beth Jennings, et Meg Cheesman, de Western University examinent les casques t&eacute;l&eacute;phoniques qui r&eacute;duisent le bruit et leurs effets sur les capacit&eacute;s de localisation des utilisateurs des appareils auditifs portatifs. Ce n&rsquo;est pas seulement un domaine d&rsquo;int&eacute;r&ecirc;t acoustique et psycho acoustique significatif, mais il a ses ramifications en ce qui a trait &agrave; la s&eacute;curit&eacute; quand on porte des &eacute;couteurs dans une rue urbaine peupl&eacute;e. Tourner   la t&ecirc;te &agrave; droite quand le camion arrive par la gauche, n&rsquo;est pas la r&eacute;ponse souhait&eacute;e! (y-a-t-il quelqu&rsquo;un qui connait le vrai nom de Meg- Que signifie Meg?) L&rsquo;article suivant est un de mes pr&eacute;f&eacute;r&eacute;s. Jessica Merrett et Kevin Munro de over the pond en Angleterre, touchent le sujet de la plasticit&eacute; de courte dur&eacute;e et l&rsquo;utilisation des appareils auditifs. Aurions-nous un contr&ocirc;le neurologique interne du son et que vient faire la plasticit&eacute; synaptique dans la d&eacute;termination du volume du son de nos appareils auditifs ?</p>\r\n<p>Il y&rsquo;a tr&egrave;s longtemps, je venais juste de commencer dans ce domaine, on m&rsquo;a demand&eacute; de g&eacute;rer un stand &agrave; une foire sur la sant&eacute;. Dans ce cas-ci, des citoyens &acirc;g&eacute;s venaient et en 3 minutes, je leur disais tous ce qu&rsquo;ils devaient savoir sur l&rsquo;ou&iuml;e, la perte auditive et leurs rem&eacute;diations. Bon, quand j&rsquo;ai commenc&eacute; dans ce domaine, j&rsquo;avais besoin juste de 3 minutes pour dire &agrave; quelqu&rsquo;un tout ce que je savais. La personne dans le stand voisin &eacute;tait de the Diabetes Association of Canada, et quand on n&rsquo;avait pas de visiteurs, on bavardait. Je me souviens que je lui avais pos&eacute; la question sur la relation entre le diab&egrave;te sucr&eacute; et la perte auditive et elle m&rsquo;avait imm&eacute;diatement r&eacute;pondu &ldquo;No! Il n&rsquo;y a pas de relation!&rdquo; J&rsquo;ai pens&eacute; que c&rsquo;&eacute;tait &eacute;trange &eacute;tant donn&eacute; que toute perturbation du flux sanguin, sp&eacute;cialement si cette perturbation est dans l&rsquo;approvisionnement du sang dans la cochl&eacute;e, devrait affecter l&rsquo;int&eacute;grit&eacute; neurosensorielle de l&rsquo;oreille. Ca date de plus de 30 ans, mais au fil des ann&eacute;es plusieurs articles semblent certifier l&rsquo;existence de cette relation, mais tous ne concluent pas la m&ecirc;me chose. Nous avons dans ce num&eacute;ro un article par Eirini Mihanatzidou et Rhonda Kerlew qui traite de ce m&ecirc;me enjeu &ndash; &ldquo;The link between diabetes mellitus and sensorineural hearing loss: A summary of the evidence.. Bien que ce ne soit pas coutumier de faire la rubrique de nouveau livre, je veux mentionner un livre tr&egrave;s enchanteur que j&rsquo;ai r&eacute;vis&eacute; pour ce num&eacute;ro de la Revue canadienne d&rsquo;audition et que vous trouverez dans la section From the library. C&rsquo;est Roeser&rsquo;s Audiology Desk Reference &hellip;. de Ross Roeser. On m&rsquo;a demand&eacute; de r&eacute;viser le livre et j&rsquo;&eacute;tais &eacute;pouvant&eacute; par la t&acirc;che. Le livre sur mon bureau, au fil de la semaine, je me suis rendu compte que j&rsquo;en faisais usage moim&ecirc;me. C&rsquo;est un de rares livres qui restent sur mon bureau et non pas class&eacute; dans une &eacute;tag&egrave;re de biblioth&egrave;que. Ce livre est accessible, convivial (m&ecirc;me pour moi) et une addition n&eacute;cessaire &agrave; la biblioth&egrave;que de toutes et tous (ou poste de travail). J&rsquo;esp&egrave;re que vous avez eu toutes et tous une merveilleuse saison d&rsquo;automne&ndash; ma saison pr&eacute;f&eacute;r&eacute;e de toutes. Et pour celles et ceux d&rsquo;entre vous qui avez assist&eacute; &agrave; la conf&eacute;rence annuelle de l&rsquo;ACA &agrave; St. John&rsquo;s, &agrave; Terre neuve et Labrador, j&rsquo;esp&egrave;re que vous avez eu des moments formidables. Il n&rsquo;y a rien de mieux que l&rsquo;hospitalit&eacute; des gens de la r&eacute;gion atlantique.</p>\r\n<p>Calvin Staples, MSc</p>\r\n<p>Hearing Instrument Specialist Faculty/Coordinator, Conestoga College CStaples@conestogac.on.ca</p>\r\n<p>&ldquo;Those that can\'t, teach.&rdquo; Until I began to work clinically again, the preceding statement felt like my life, and at times still does. However, time in the clinic truly determines what you know and most definitely what you do not. I have been fortunate enough to be able to marry both academic and clinical work quite well and find myself trying to merge more and more of the literature into my practice regularly. As recent as last week, I was trying to figure out the guidelines for sudden sensorineural hearing loss (SSHL) and reached out to some of my colleagues for additional input. However, I could have easily turned to hearinghealthmatters.org as I was able to start to answer my question in a few short minutes. The blogs here are a wonderful resource for all of us in hearing health care.</p>\r\n<p><strong>REACTION TIME AND SUDDEN DECREASE IN HEARING</strong></p>\r\n<p>By, Jennifer Lamfers, AuD We all know that turning the volume up too high or standing too close to speakers is going to permanently damage our hearing and once ringing occurs or we experience a sudden decrease in hearing, there is permanent damage. That is true. But what if that reaction is also partly protective?</p>\r\n<p>A study in Australia shows that in mice, those who were able to have a sudden hearing decrease reaction had a lower degree of permanent loss than those mice whose genes were alerted to deter that reaction. The researchers uncovered this by breeding mice to lack a specific gene thought to protect the inner ear. The mice in the control group and the specifically bred mice were then exposed to a moderately loud noise for a sustained time of 12 hours. Those mice whose genes were altered experienced less temporary effects but suffered more permanent damage. The results showed that although a sudden decrease in hearing and sudden increase in ringing (tinnitus) means that there is damage, it could have been worse. People who are experiencing sudden sensorineural hearing loss (SSHL) should consult their physician right away. SSHL can also be linked to side effects to certain prescription medications and they should discuss discontinuing possible casual medications or if warranted, seeking a steroid treatment with their physician if medically appropriate. Some patients recover completely without medical intervention, often within the first three days, and others get better slowly over a one to two week period. David Kirkwood had published the Otolaryngology Foundation&rsquo;s guidelines for SSHL last year. The general rule to use is this: if the sudden sensorineural hearing loss from loud noise has been present for more than two weeks it will likely not recover on its own and it is time to seek a comprehensive audiological evaluation and consultation regarding amplification.</p>\r\n<p>If you or a loved one experiences sudden hearing loss (SSHL) in one or both ears, getting a prompt and accurate diagnosis &ndash; and treatment, if necessary &ndash; is important in reducing the chance that the loss will become permanent. So says the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HSNF) in its new Clinical Practice Guideline on Sudden Hearing Loss (SHL) published March 1 as a supplement to Otolaryngology-Head and Neck Surgery SSHL is a frightening condition that may result from a variety of causes and that most often prompts urgent medical care. The foundation&rsquo;s guideline provides evidencebased recommendations for the diagnosis, management, and follow-up of adults who present with SHL. According to the foundation, prompt, accurate recognition and management of sudden sensorineural hearing loss (SSHL), a subset of SHL, may improve hearing recovery and patient quality of life. SSHL affects 5 to 20 per 100,000 people, with about 4000 new cases a year in the United States. The guideline is intended to help any clinician who may encounter patients with SSHL. By focusing on opportunities for quality improvement, the guideline seeks to improve diagnostic accuracy, facilitate prompt intervention, decrease variations in management, reduce unnecessary tests and imaging procedures, and improve hearing and rehabilitative outcomes for affected patients.</p>\r\n<p>SSHL is a frightening condition that may result from a variety of causes and that most often prompts urgent medical care. The foundation&rsquo;s guideline provides evidencebased recommendations for the diagnosis, management, and follow-up of adults who present with SHL. According to the foundation, prompt, accurate recognition and management of sudden sensorineural hearing loss (SSHL), a subset of SHL, may improve hearing recovery and patient quality of life. SSHL affects 5 to 20 per 100,000 people, with about 4000 new cases a year in the United States. The guideline is intended to help any clinician who may encounter patients with SSHL. By focusing on opportunities for quality improvement, the guideline seeks to improve diagnostic accuracy, facilitate prompt intervention, decrease variations in management, reduce unnecessary tests and imaging procedures, and improve hearing and rehabilitative outcomes for affected patients.</p>\r\n<p>(2) Unnecessary tests and treatments should be avoided: (A) Routine head/brain CT scans, often ordered in the ER setting, are not helpful and expose the patient to ionizing radiation. (B) Routine, non-targeted, laboratory testing is not recommended. (3) Initial therapy for SSHL may include corticosteroids. (4) Follow-up and counseling is important: (A) Physicians should educate patients with ISSNHL about the natural history of the condition, the benefits and risks of medical interventions, and the limitations of existing evidence regarding efficacy. (B) Physicians should obtain follow-up audiometry within six months of diagnosis for patients with SSHL. (C) Physicians should counsel patients with incomplete hearing recovery about the possible benefits of amplification and hearing assistive technology and other supportive measures.</p>\r\n<p><strong>NEUROMA OR SCHWANNOMA &ndash; EITHER WAY IT&rsquo;S A TUMOUR</strong></p>\r\n<p><strong> </strong>By Judy Huch</p>\r\n<p>As an audiologist I was taught about the hearing test early on. Though I do have to keep my eye out for many disorders, there is one condition that always seems to be on the top of my mind, acoustic neuroma, or vestibular schwannoma. This is a slow-growing, (1.5 mm a year) benign tumor (non-spreading, nonmalignant) found on the acoustic nerve from the cells making the myelin sheath. The VIII cranial nerve, the acoustic nerve, controls hearing and balance and lies very close to the VII cranial nerve, the facial nerve, which supplies the neural pathway for motion to the muscles for facial expression. In fact, both cranial nerves pass through a bony canal, which is named the internal auditory canal. Early symptoms are hearing loss, which is worse on one side (in most cases if the tumour is on only one side, type 1) as well as tinnitus on the affected side. Later, as the tumour grows, balance and facial muscle symptoms can develop. Alan Desmond has discussed audiometric testing in detail in a 2011 post.</p>\r\n<p>When I look at the numbers, I see that only a very small number of individuals develop this condition, yet it seems that this is the top worry whenever I test. A study in Denmark, published in 2004, had a very large sampling showing 2 people out of 100,000 will have an acoustic tumour. Some argue that the incidence is rising, but this is most likely due to better diagnostics, including the advancements of MRI scanning and better referrals for those experiencing symptoms. The general consensus is that  both sexes are affected equally and is usually diagnosed between the ages of 30 and 60. There is usually only one side affected by the tumour. David Kirkwood reported last year how an ENT was sued over missing an acoustic tumour, which is most likely why it is on my mind during diagnostic testing. I would not want to be the provider to miss this.</p>\r\n<p>How does a tumour form? It is not entirely understood, but some suggest genetically there is a breakdown in tumour suppression genes that allows the tumour to grow. There is no concrete proof that an external factor such as cell phones create these tumours. There is a condition, neurofibromatosis (NF2), which is a genetic disorder affecting 1 in 50,000 births. With this condition, tumors grow in both sides of the head on the acoustic nerve. If this occurs there is a chance of losing the hearing on both sides leading to complete deafness. Treatment consists of three areas &ndash; observation, radiation, and surgical removal. Since the tumour surrounds the nerve, a specialist should be used for consultation. Neurosurgeons and/or neurotologists are surgeons who specialize in the ear area and perform delicate surgeries. They depend on a team of other providers to cover other areas that may be affected. No one treatment is right for every patient. If the tumour is very slow growing and the patient is not in good health, the best option might be to watch and wait.</p>\r\n<p>Surgical removal may be an option in the case of NF2 with a smaller tumor or faster growing tumors in young healthy persons. The last option is radiation. There are  two techniques &ndash; one delivered as a single dose, stereotactic radiosurgery (SRS), and the other is multi-session fractionated stereotactic radiotherapy (FSR). Each is targeted to stop growth and kill the tumor (necrosis). With radiation there is a chance for some hearing to be retained in the treated ear, which must be monitored during and after treatment. The Acoustic Neuroma Association provides education and support to those faced with this type of condition. The ANA also has a Facebook page.</p>\r\n<p>I n Canada, we don\'t do heroes very well. Not in the way that other countries put people, deserving or not, up on pedestals to be lauded and adored. In Canada, we have countless citizens just as deserving of heroic adjectives &ndash; but we just don&rsquo;t celebrate them very well. We&rsquo;re not a splashy lot, reluctant to go overboard in extended public displays of affection. American-style hero worship makes us uncomfortable; we wouldn&rsquo;t be caught dead in adoring mobs, punching sticks in the air with pictures of the objects of our affection. No, we&rsquo;re more likely &ndash; from the comfort of our seat in front of the television or computer screen &ndash; to give a heartfelt but reserved, Way to go, eh! When we do recognize incredible feats of courage and citizenship, in quiet ceremonies at city hall or on Parliament Hill. But maybe we need to change a bit, shake things up. We need to strike up the band more often, because we need heroes to inspire us, to give us a chance to celebrate what is wonderful in life. We need some hearing loss heroes. The hearing health care industry needs to recognize and applaud not just its own members, but also the people it serves.</p>\r\n<p>Some hearing aid manufacturers in the US recognize outstanding people with hearing loss who have made a difference in their community or on the national scene. One company uses the online nomination-and-voting process that brings them a huge consumer response and some good publicity. Could we not do that here in Canada? Canadians with hearing loss are fighting for increased awareness of our disability. We are struggling to articulate that our needs go beyond hearing aids and cochlear implants; we need public recognition, accessibility, laws, and opportunities. We are finding ways to identify our accessibility needs and demanding access from governments and businesses. We are bringing hearing loss out of the closet and while we&rsquo;re at it we&rsquo;re asking questions, not all of them comfortable, of our hearing healthcare and technology providers. We are holding meetings and conferences, teaching speechreading, and connecting on online forums where we share questions and ideas.</p>\r\n<p>We&rsquo;re doing this not only to help ourselves but to make life with hearing loss easier for everyone who has it &ndash; and those who are going to have it. And, quite frankly, we do all of this with little recognition from the professional players. Many consumer organizations such as the Canadian Hard of Hearing Association celebrate our luminous members through annual awards and scholarships. We also celebrate outstanding professionals. So, how about returning the favour, national hearing-related organizations, retailers, and manufacturers? Why not celebrate your &ldquo;consumers&rdquo; through awards, scholarships &ndash; or even simple recognition on your websites?</p>\r\n<p>And it can happen at the local level, too. Individual clinics could recognize a Client of the Month in newsletters that go to your client base. Why not an article about what that person has done to live more successfully with hearing loss &ndash; or what he or she is doing to help others? Or go completely out there and put their picture up in your clinic as a shining example of success. For many, simply breaking through the taboo of hearing aids or admitting a hearing loss is a monumental act of courage. As consumers with hearing loss, we value and depend on the expertise and comfort we get from our hearing health care providers. You are our partners in hearing health. So let&rsquo;s work together to inspire thousands, millions, of Canadians to finally accept their hearing loss &ndash; and to not accept the discriminatory practices that still exist in our society. Let&rsquo;s celebrate our hearing loss heroes &ndash; because we have many</p>\r\n<p>By Christopher Phillips and Jay T. Rubinstein Department of Otolaryngology &ndash; Head and Neck Surgery, University of Washington, Seattle, WA</p>\r\n<p>Vestibular disorders are both common and debilitating. According to the National Institutes of Health, dizziness and vertigo are among the top 25 reasons that patients seek medical care in the United States, accounting for more than 5 million visits to a doctor each year. 36% of the U.S. population will see their doctor with a complaint of dizziness at least once in their lifetime.1 For most patients, the dizziness is either short lived or can be treated effectively by their primary care physician. In some cases, however, an acute attack of dizziness can lead to a permanent and debilitating condition of chronic disequilibrium. Typically, this is due to a loss of the hair cell receptors or vestibular afferent neurons of the inner ear. This condition cannot be effectively reversed by current therapies. Patients can, in most cases, adapt to this loss of function, a process that can be aided by vestibular rehabilitation specialists, who work to assure that the final compensation state is appropriate for a range of activities and environmental conditions. However, for many other patients, the compensation is not adequate to allow a return to a normal life. Meniere&rsquo;s disease is an example of a condition where recurring acute attacks of vertigo, over time, leads to a permanent loss of vestibular function. Patients with Meniere&rsquo;s disease are commonly young to middle age adults, many of whom lead active lives. Typically,  these patients present with episodic low frequency hearing loss, tinnitus, aural fullness and profound attacks of vertigo. Frequently, such patients experience nausea and vomiting with their attacks, which can last for several hours, after which the patients slowly recover function and can return to low levels of activity. Between attacks, most patients with early Meneire&rsquo;s disease are essentially normal. Although the exact pathophysiology of Meniere&rsquo;s disease is not known, it is thought that the disorder arises from endolymphatic hydrops, an accumulation of fluid in the inner ear, resulting in distention and then rupture of the membranes that provide the electrical potentials that drive the sensory processes. When the rupture occurs, the afferent fibers, which constantly convey information centrally from the vestibular end organs, may suddenly decrease their firing rate. If this occurs unilaterally, as it usually does, the brain interprets the difference between a robust signal from the non-affected ear and an abnormal signal from the affected ear as arising from a continuous rotation away from the affected ear. As the ear heals from the rupture and the potentials are reestablished, the normal activity is restored, and the vestibular system functions normally. After repeated attacks, however, this process takes its toll on the function of the inner ear. This means that late Meniere&rsquo;s patients can experience an increasing sense of disequilibrium between their attacks, as  the end organs of the inner ear slowly lose the ability to transduce motion.</p>\r\n<p>While the natural history of Meniere&rsquo;s disease leads to a chronic loss of vestibular function, the many medical treatments for Meneire&rsquo;s disease themselves may also intentionally hasten this process. To eliminate the debilitating fluctuation in function, neurotologists often offer a destructive therapy to reduce or eliminate function in the affected ear. The physician may perform a labyrinthectomy of the affected ear, which permanently eliminates hearing and balance information from that ear. They may propose a nerve section of the vestibular branch of the 8th nerve, which spares hearing but eliminates vestibular function in the affected ear. Finally, they may inject an ototoxic aminoglycoside antibiotic into the affected ear, which progressively reduces vestibular function in that ear, and may spare hearing. All of these interventions reduce and eventually eliminate vestibular function. Optimally, the patient is now free of attacks, but must deal with the chronic loss of vestibular function for which, if symptomatic, there is no current solution.</p>\r\n<p>For these reasons, there is a great need for new, rehabilitative treatment strategies, which restore vestibular function for patients with vestibular loss. Cochlear implants have proven to be a remarkably successful technology for  restoring hearing in patients with sensorineural hearing loss. Peripheral vestibular loss is a comparable problem: when the transduction mechanisms in the vestibular labyrinth cease to function normally either through the course of disease or following a destructive medical intervention, the afferent fibers themselves may remain intact and remain capable of conveying information centrally. Encouraged by this, some research groups have begun investigating chronically implantable vestibular neurostimulators, similar to cochlear implants, which act as vestibular prosthetics by directly stimulating these afferent fibers.</p>\r\n<p>Some particular aspects of the vestibular anatomy and physiology are encouraging for the development of such a device. First, afferents innervating the vestibular end organs are sensitive to galvanic stimulation, similar to those located in the cochlea. These afferents encode head linear acceleration or rotational velocity information by modulating their firing rate around a baseline resting rate: rotation of the head towards the ear is excitatory and increases the firing rate of the afferent, while rotations in the opposite direction have the opposite effect. Early experiments in vestibular neurophysiology have shown that localized galvanic stimulation can be used to directly modulate the firing rate of vestibular afferents. Furthermore, this same stimulation drives behavior mediated by vestibular reflexes.3&ndash;4 Second, while the afferents innervating the cochlea are arranged tonotopically, those innervating the vestibular end organs are arranged based on their specific directional sensitivity. Within the three semicircular canals (SCCs), which are the sensory organs for rotational motion, all of the hair cells in each ampulla are plane polarized, such that they have a uniform directional sensitivity that is maximally sensitive to rotations in the plane of their canal. In contrast, the hair cells located in the maculae of the otolith organs, the saccule and utricle, which sense linear motion, are oriented around a central line that divides the tissue. As a result, each area of the macula is sensitive to motion in a unique direction. Because electrical stimulation techniques are not capable of directing current to specific regions of these tissues, much work on the development of vestibular prostheses has excluded the otolith organs and instead focused on the three SCCs, where stimulation of an entire ampulla encodes motion in a single direction.</p>\r\n<p>Finally, the vestibular nerve branches innervating a given SCC are anatomically distinct, such that localized electrical stimulation of a single canal without unwanted activation of afferents with different directional sensitivity is possible. Taken together, a multichannel vestibular prosthesis that can selectively deliver localized stimulation within the ampullae of individual SCCs, in conjunction with a head mounted rotational sensor, could serve as a functional vestibular prosthesis. Results in the laboratory have been encouraging for this line of reasoning. Implantable single channel (i.e., with a single stimulating site) and multi channel neurostimulators have been developed and tested in animal models. One such device, developed by our group at the University of Washington, is a modified Nucleus Freedom cochlear implant (Cochlear, Ltd., Sydney). This device contains three separate leads, each of which contains multiple stimulation sites at the distal end of each lead. During surgical implantation, the tips of each lead are inserted into the vestibular labyrinth adjacent to the ampulla of each SCC through small fenestrations in the bony labyrinth. In animal models, implantation is well tolerated and the devices remain functional over long periods of time.5 Similar to the results of early neurophysiology experiments, these chronically implanted devices are capable of driving afferent neurons and eliciting behavioral responses through electrical stimulation. The UW/Cochlear vestibular prosthesis employs trains of biphasic stimulation pulses, which can be modulated in frequency or current amplitude, effectively modulating the rate at which afferent neurons are driven to fire or the size of the afferent population affected by stimulation, respectively. Recordings made in the vestibular nuclei during stimulation trains show that secondary vestibular neurons &ndash; those receiving information from the vestibular end organs &ndash; are driven similarly to the afferent neurons. This suggests that the artificially induced signal produced by the neurostimulator is propagated within the central vestibular system. The behaviors most readily used to study the vestibular system are the eye movements from the vestibulo-ocular reflex (VOR). VOR assists in stabilizing the visual field on the retina by compulsory movements of the eyes opposite to movements of the head. In the clinic, VOR responses to passive rotation can be a powerful tool for identifying vestibular deficits. Electrical stimulation from these devices also elicits eye movements comparable to those from VOR during natural rotation.</p>\r\n<p>Electrical stimulation drives eye movements parametrically. Stimulation delivered to the lateral SCC alone will elicit eye movements directed in the horizontal plane, as would mechanical manipulation of a healthy lateral canal (similar to the effects of warm water  calorics, as conducted in the clinic) or a yaw rotation of the body or head. In contrast, stimulation of either of the two vertical canals yields eye movements with vertical and torsional components. Modulation of the pulse rate or the current amplitude modulates the velocity of the eye movements, such that increasing either will result in a faster slow phase eye movement. Together, these findings in animal models show that selective stimulation of individual canals does result in controlled eye movements that are identical to those produced naturally during rotation.</p>\r\n<p>VOR is a well studied and understood aspect of the vestibular system and for that reason is an ideal system to evaluate the efficacy of vestibular neurostimulators. However, the vestibular system is multimodal and clinical manifestations of dysfunctional VOR, such as oscillopsia &ndash; the sensation of world movement during self-motion due to a lack of the stabilizing eye movements arising from VOR &ndash; are often not the sole or even the most debilitating aspect of vestibular loss. The effects of vestibular stimulation on balance and perception of motion must be studied carefully in order to develop a vestibular prosthetic that addresses patient needs. Some experiments have been conducted in animal models that suggest that these other modalities of the vestibular system are similarly affected by stimulation.7 However, it is more difficult to assess postural or perceptual responses in animal models. In addition, it is difficult to translate those results to those that we might expect from human subjects.</p>\r\n<p>To date, our group has implanted four human subjects suffering from severe unilateral Meniere&rsquo;s disease with the UW/Cochlear vestibular prosthesis. These patients had previously failed conservative treatment of their Meniere&rsquo;s disease. As a treatment for Meniere&rsquo;s, the neurostimulator is not connected to a rotational sensor, nor is the device delivering constant stimulation, as you would want to provide for a complete vestibular prosthetic. Instead, the device is intended to act as a vestibular pacemaker. When the patients experience a Meniere&rsquo;s episode, they can activate the device to stimulate at a constant rate and current to drive the vestibular afferents. This stimulation can remain on until the episode subsides and the vestibular system can resume a baseline level of activity without the aid of the device. These patients, followed by another group of patients in Maastricht and Geneva using a different device,8 are the first to receive a therapy of this type as a treatment for vestibular loss. The device implanted in the human Meniere&rsquo;s patients is identical in design to those used in previous studies in nonhuman primates. The effects of vestibular stimulation in human subjects are in many ways similar to those observed in animal models.9 Electrical stimulation is well tolerated by human subjects. Eye movements elicited by stimulation are not accompanied by auditory sensations, facial nerve activation, or pain. This suggests that the vestibular nerve can be activated without activating the adjacent facial or cochlear nerve. As in animal models, the direction and velocity of the elicited eye movements could be controlled by selectively stimulating individual SCC ampullae at different frequencies or current amplitudes. However, the velocities elicited in human subjects typically were lower than those elicited in non-human primates at comparable stimulation levels. This may be a product of the larger anatomy of the human inner ear, which could be compensated for by redesigning the neurostimulator to include larger stimulation sites. Despite the lower velocities, that the eye movement responses of humans are roughly comparable to those from non-human primates is an encouraging result for the development of a vestibular prosthesis.</p>\r\n<p>Results from human subjects show that electrical stimulation affects multiple vestibular modalities concurrently. While seated, electrical stimulation elicits a perception of self motion typically opposite in direction to the elicited eye movement. While standing upright in quiet stance, the same stimulation elicits a postural response in the form of whole body sway.10 Both the postural and perceptual responses, like eye movement responses, can be controlled in direction and magnitude by selecting the location of stimulation and the current or frequency of the stimulus. However, early results from these experiments suggest that different vestibular subsystems may be driven unequally by the electrical stimulation employed by current devices. Stimulation at a given current may elicit a sensation of turning 180 degrees while the concurrent eye movement response would be much smaller in amplitude. Nevertheless, these early results are encouraging for a vestibular prosthesis as a restorative treatment for vestibular loss, where VOR, postural, and perceptual deficits can all be handicaps.</p>\r\n<p>There are many challenges remaining for the full development and implementation of a vestibular prosthesis, which represent future directions for research. Vestibular prostheses need to be extensively studied in humans. It is important that we study processes such as perception of motion and postural performance during daily activity as well. These may be difficult or impossible to assess adequately in animal models, and there may be significant differences between human and animal vestibular  responses to stimulation with these devices. We must extensively study these behaviours and the systems that produce them in human subjects in order to optimize stimulation parameters across modalities and behavioral contexts. Our early results suggest that electrical stimulation may produce a mismatch in the motion commands to the various subsystems that utilize vestibular information, producing poorly aligned sensation, posture, and eye movement. This challenge may be overcome by the adaptive capability of the central nervous system, but it is likely that we will discover new and better ways of driving vestibular sensation through continued experimentation, which will facilitate this adaptation and produce a better therapeutic result.</p>\r\n<p>Second, we must develop strategies for and evaluate the effects of, long-term continuous electrical stimulation of the vestibular system with a prosthesis. This work can and should proceed in human subjects and in animal models. Our results in humans and animals with intermittent stimulation suggest that there is both preservation of effective stimulation for months to years, and also high variability in the longevity of stimulation to different electrodes, different end organs, and different subjects. This variability suggests that strategies may need to be developed for the continuous tuning of stimulation maps to compensate for the changes in efficacy that result over time. Finally, we really have very little data on the effect of electrical stimulation with a vestibular prosthesis on the central nervous system. We empirically understand the short-term behaviours that such stimulation evokes, but the underlying mechanism is largely unexplored. Neurophysiological experiments need to be undertaken to study the central processes that allow for integration of the abnormally synchronous neural inputs from vestibular prostheses, and then combine these signals with the information from other sensory modalities. Only a thorough understanding of these processes will allow future engineers to design devices that maximize benefit to the patient while minimizing the other effects of what is essentially a new sensory system, combining the pathways and surviving elements of a damaged vestibular system with a novel technology for signaling motion to the brain.</p>\r\n<p><strong>REFERENCES </strong></p>\r\n<p>1. Agrawal Y. Disorders of Balance and Vestibular Function in US Adults: Data From the National Health and Nutrition Examination Survey, 2001-2004 (vol 169, pg 938, 2009). Archives of Internal Medicine 2009;169(15):1419&ndash;19.</p>\r\n<p>2. Rubinstein, JT, Della Santina, CC. Development of a biophysical model for vestibular prosthesis research. J Vestib Res Equilib Orientat 2002;12:69&ndash;76.</p>\r\n<p>3. Cohen B, Suzuki J, Bender MB. Eye movements from semicircular canal nerve stimulation in cat. Ann Otol Rhinol Laryngol 1964;73:153&ndash; 69.</p>\r\n<p>4. Goldberg JM, Smith CE, Fernandez C. Relation between discharge regularity and responses to externally applied galvanic currents in vestibular nerve afferents of the squirrel monkey. J Neurophysiol 1984;51:1236&ndash;56.</p>\r\n<p>5. Rubinstein JT, Bierer S, Kaneko C, Ling L, Nie K, Oxford T, Newlands S, Santos F, Risi F, Abbas PJ. Implantation of the semicircular canals with preservation of hearing and rotational sensitivity: a vestibular neurostimulator suitable for clinical research. Otol Neurotol 2012;33:789&ndash;96.</p>\r\n<p>6. Davidovics NS, Rahman MA, Dai C, et al. Multichannel vestibular prosthesis employing modulation of pulse rate and current with alignment precompensation elicits improved VOR performance in monkeys. J Assoc Res Otolaryngol 2013;Apr;14(2):233&ndash;48</p>\r\n<p>7. Thompson LA, Haburcakova C, Gong W, et al. Responses evoked by a vestibular implant providing chronic stimulation. J Vestib Res 2012;22:11&ndash;15.</p>\r\n<p>8. van de Berg R, Guinand N, Guyot JP, wt al. The modified ampullar approach for vestibular implant surgery: feasibility and its first application in a human with a long-term vestibular loss. Front Neurol 2012; Feb 20;3&ndash;18</p>\r\n<p>9. Golub J, Ling L. Nie K, et al. Prosthetic implantation of the human vestibular system. Otology &amp; Neurotology, in press.</p>\r\n<p>10. Phillips C, DeFrancisci C, Ling L, et al. Postural responses to electrical stimulation of the vestibular end organs in human subjects. Exp Brain Res 2013;229:181&ndash;95.</p>\r\n<p>By Jessica F. Merrett and Kevin J. Munro jfmerrett@gmail.com</p>\r\n<p>Jessica Merrett completed her MSc in audiology at the University of Manchester in 2010-2011. Currently, she is working as a trainee clinical scientist at Bradford Royal Infirmary, UK. Kevin Munro is a professor with the School of Psychological Sciences, University of Manchester, Manchester, United Kingdom.</p>\r\n<p>The auditory system is far from being a hard-wired processing machine. It boasts a dynamically connected map of ipsilateral and contralateral pathways that retain a great deal of plasticity throughout adulthood. &ldquo;Auditory plasticity&rdquo; is a term used to describe changes in the anatomical and physiological properties of neurons in the brain, following a change in auditory input or experience.1 Such experience related physiological reorganisation is often accompanied by perceptual changes which may, or may not, be helpful to the individual.</p>\r\n<p>The main cause of auditory plasticity in humans results from a reduction in auditory input to the central auditory system due to a sensorineural or conductive hearing loss. Reintroducing auditory input through hearing aid use or cochlear implantation has been shown to induce secondary plasticity.2 The implications of long term deprivation and stimulation have been found to affect a range of physiological and perceptual measures including loudness perception, intensity discrimination, the auditory brainstem response and the acoustic reflex threshold (ART).3 Some of these changes are thought to result from a &ldquo;central gain mechanism.&rdquo; The central gain mechanism can be likened to an internal volume control. Recent neurophysiologic research has proposed that high levels of neural gain are implicated in the disorders of tinnitus and hyperacusis.4,5 It has been suggested that a central homeostatic mechanism causes an abnormal increase in central gain in response to auditory deprivation or trauma.6 Consequently, a possible solution is to find ways to decrease central gain.</p>\r\n<p>Previous research suggests that it is possible to manipulate central gain. Perceptual and physiological changes have been found to occur following short term auditory deprivation. Munro and Blout fitted 11 normal hearing adults with monaural ear plugs.7 They found that after seven days of regular use the level required to elicit the acoustic reflex in the treatment ear (i.e., the ear with the earplug) decreased by 5&ndash;7 dB, relative to pre-treatment levels. Measurements made seven days post-treatment showed that the ART had returned to baseline values. It was hypothesised that because the plugged ear is deprived of input, neural processes increase the gain in order to restore average neural activity and this is revealed by a lower sound level required to elicit an acoustic reflex. When the earplug is removed, gain reverts back to pre-treatment levels and this is accompanied by an increase in the level required to elicit an acoustic reflex.In addition to physiological changes, previous research has shown that it is possible to induce perceptual changes following short term auditory deprivation and stimulation. Formby and colleagues reported on 10 normalhearing listeners who wore bilateral earplugs (deprivation) or noise generators (stimulation) for 2&ndash;4 weeks.8 After earplug experience, listeners required a decrease in level of around 6&ndash; 8 dB to match pre-treatment loudness for moderate and high stimulus presentation levels. Conversely, listeners required an increase in level of around 6&ndash;8 dB after noise generator experience.</p>\r\n<p>In summary, previous work suggests that short-term auditory deprivation results in a decrease in the ART, an increase in loudness of sounds and thus an increase in central gain. These findings were the motivation for our recent study; is it possible to induce plasticity in response to short term auditory stimulation? The main aim of the study was to investigate the effect of short-term use of low-gain hearing aids on ARTs and loudness. We recruited 21 normal hearing adults for the study. The participants were fitted monaurally with a Starkey S series, non-occluding, receiver in the canal (RIC) hearing instrument (Figure 1.) The hearing aid settings were adjusted so that real-ear insertion gain such as the difference in response between the aided and unaided conditions, was 0 dB at 0.5 kHz and 15&ndash; 20 dB at 2&ndash;4 kHz. Amplification was given at 2&ndash;4 kHz only, so that we could assess whether the treatment could induce frequency specific changes. The participants were asked to wear the device continuously for five days, except while in bed. ARTs and loudness ratings for the fitted ear and the control ear were made on three occasions over a five day period: immediately before hearing aid fitting (day zero), after three days of hearing aid use and after five days of hearing aid use (Figure 2.). Ipsilateral ARTs were measured using a 0.5 kHz, 2 kHz and broadband noise (BBN) stimulus. Loudness judgements were obtained with a 0.5 kHz and 3 kHz tone using the Contour Test of Loudness Perception.9 Listeners used a response pad to assign one of seven loudness categories to a train of pulsed warble tones. The loudness categories ranged from &ldquo;very soft&rdquo; to &ldquo;uncomfortably loud.&rdquo; The mean change in ART at day five, relative to baseline, is shown in Figure 3. The data presented in this article compares the change at day five only. However, all the findings have been reported in Munro and Merrett.10 For the 0.5 kHz tone, the change was less than 2 dB in the fitted ear. For the 2 kHz tone, the change was greatest at day five, where the mean difference between ears was around 3 dB, primarily due to an increase in ART in the fitted ear. For BBN, there was a mean difference between ears of around 3&ndash;4 dB at day five.</p>\r\n<p>The mean level change at each loudness category is shown in Figure. 4. For the fitted ear, listeners generally needed more intense stimuli (+3 to +5 dB) after wearing the hearing aid in order to give the same loudness judgements. In contrast, changes for the control ear were small and generally &lt;1 dB. The effect of amplification-induced stimulation is opposite to the effect of earplug-induced deprivation. Our results show an increase in the ART and an increase in loudness tolerance in the fitted ear following short term amplification. The change in ARTs provides support for a gain control mechanism. Because the fitted ear is provided with an &lsquo;enhanced&rsquo; input, the gain is reduced and this is revealed by a higher sound level required to elicit the acoustic reflex. In comparison to the loudness judgement changes, the changes in the ARTs appear to be relatively frequency specific. This may reflect different characteristics of the gain mechanism at different levels within the auditory system. The findings in the present study may have implications for patients with tinnitus and/or sound tolerance problems. It is possible that ear plug use may increase neural gain and exacerbate perceptions such as tinnitus and hyperacusis. Computational models have illustrated how auditory deprivation may result in an increase in neural gain as homeostatic plasticity attempts to restore average neuronal activity</p>\r\n<p>However, it would be important to replicate the study with a larger sample size, a longer treatment period and to make a comparison between solely high and low frequency stimulation.</p>\r\n<p><strong>REFERENCES</strong></p>\r\n<p>1. Tremblay KL &amp; Kraus, N. (2002). Beyond the ear: central auditory plasticity. Otorinolaringol, 52, 93-100.</p>\r\n<p>2. Willott, J.F. (1996). Physiological plasticity in the auditory system and its possible relevance to hearing aid use, deprivation effects, and acclimatisation.Ear.Hear.,17(3), 66-77.</p>\r\n<p>3. Munro, K.J. (2008). Reorganisation of the adult auditory system: perceptual and physiological evidence from monaural fitting of hearing aids. Trends in Amplification, 12(2), 1-18.</p>\r\n<p>4. Jastreboff, P.J. &amp;Hazell, J.W.P. (1993). A neurophysiological approach to tinnitus: clinical implications. British Journal of Audiology, 27, 7-17.</p>\r\n<p>5. Melcher, J.R., Levine, R.A., Bergevin, C. &amp; Norris, B. (2009). The auditory midbrain of people with tinnitus: Abnormal sound-evoked activity revisited. Hearing Research, 113, 165- 172.</p>\r\n<p>6. Norena, A., J., and Cherry-Croze, S. (2007). &ldquo;Enriched acoustic environment rescales auditory sensitivity,&rdquo; NeuroReport. 18, 1251- 1255.</p>\r\n<p>7. Munro, K. J., Blount, J. (2009). &ldquo;Adaptive plasticity in brainstem of adult listeners following earplug-induced deprivation (L),&rdquo; J. Acoust. Soc. Am. 126, 568-571.</p>\r\n<p>8. Formby, C., Sherlock, L. P., and Gold, S. L. (2003). &ldquo;Adaptive plasticity of loudness induced by chronic attenuation and enhancement of the acoustic background (L),&rdquo; J. Acoust. Soc. Am. 114, 55-58. 9. Cox, R. M., Alexander, G., C., Taylor, I. M., and Gray, C. A. (1997). &ldquo;The contour test of loudness perception,&rdquo; Ear. Hear. 18, 338-400. 10. Munro, K.J. and Merrett, J.F. (2013). Brainstem plasticity and modified loudness following short-term use of hearing aids. J Acoust Soc Am, 113(1), 343-349. 11. Schaette, R., Turtle, C., Munro K. J. (2012). Reversible induction of phantom auditory sensations through simulated unilateral hearing loss. PLos ONE 7, e35238. Doi: 10.1371/journal.pone.0035238</p>\r\n<p>By Iman Ibrahim, Rebecca Malcolmson-Cronin, Mary-Beth Jennings, Meg F. Cheesman iibrahi7@uwo.ca</p>\r\n<p>Iman Ibrahim (far left), Mary-Beth Jennings, and Meg F. Cheesman are with the National Centre for Audiology, Faculty of Health &amp; Rehabilitation Sciences, Western University, London, Ontario. Rebecca Malcolmson-Cronin (near left) is with The Hospital for Sick Children, Toronto, Ontario.</p>\r\n<p><strong>ABSTRACT</strong></p>\r\n<p>Noise reduction headphones and earphones are available for use with portable audio devices. These head- and earphones may result in a reduction of music-induced hearing loss. By blocking some external background noise, noise reduction phones may result in lower preferred listening levels (PLLs). However, as a result of attenuating environmental warning sounds and modifying localization cues, the localization abilities of wearers may be diminished, posing another risk of physical harm. To test this, sound localization abilities of thirty-nine normally hearing participants (age 21 to 30) who owned and regularly used portable audio devices were measured when wearing an audio device. Real-ear PLLs and localization abilities in a hemi-anechoic chamber were measured under two background noise conditions (ambient room noise and traffic noise) with</p>\r\n<p>Portable audio devices (PADs) have flooded the markets in recent years. These devices store and play audio files and include smart phones and devices such as iPods and MP3 players. Such devices are increasing in popularity, especially among young adults, and their sales are increasing yearly as demonstrated by the National Product Development (NDP) group reports.1,2 PADs are frequently used in noisy backgrounds such as during commuting by bus or walking in the street. In such environments, users typically tend to increase the volume setting to maintain a comfortable music-to-noise ratio.3&ndash;5 The National Institute for Occupational Safety and Health guidelines6 recommends an exposure limit of 85 dBA for an eight hour time-weighted average in order to minimize the risk of noise-induced hearing loss. Portnuff et al. measured the output of five different PADs and found them to have similar output levels especially at the highest volume control settings.7 Based on their measurements, and the NIOSH guidelines, they calculated guidelines for the recommended daily use of these devices: with the volume set at 70%, listeners should be able to listen to PADs for up to 4.6 hours/day without exceeding the NIOSH guidelines. However, when the volume is increased to 100%, listeners should restrict device use to no more than five minutes/day.</p>\r\n<p>By increasing the volume control setting to overcome some of the masking produced by external noises, wearers may be increasing their risk of music induced hearing loss.4,8,9 Consumers are purchasing headphones and insert earphones that reduce the noise levels in the ear canal to reduce the masking effect of environmental sounds. These headphones may attenuate the external noise by fitting tightly in or around the ear, in the manner of earplugs or earmuffs. Alternatively some ear- and headphones use active noise cancellation circuitry to reduce the output for frequencies below 1000 Hz, while providing a boost to frequencies above 1000 Hz.5 By blocking or attenuating environmental noises, noise-reduction headphones can help reduce the risk of music-induced hearing loss by obviating the need to increase the level of the music.10</p>\r\n<p>While PLLs may decrease when noisereduction headphones are worn, the attenuation of environmental sounds poses another safety issue. It is known that hearing protective devices degrade sound localization.11,12 Not only do hearing protection devices reduce the intensity of environmental sounds, but they also may degrade the interaural loudness cues for sound localization. As a result, they may pose a risk of physical harm by degrading the user&rsquo;s ability to spatially locate important environmental sounds, such as approaching vehicles, sirens, and car horns. News reports of pedestrians and bicyclists who are wearing portable music devices being involved in vehicle-pedestrian collisions are so frequent that one New York City senator proposed legislation to ban the use of portable electronic devices, including PADs, for pedestrians while crossing the street.13 Such pedestrianvehicle collisions may be caused, at least in part, by three factors: (1) PAD wearers may be unable to detect the oncoming vehicle because of the environmental sound attenuation caused by the phones  and the masking caused by the PAD music; (2) if the oncoming vehicle is detected, the wearer may not be able to localize the source of the hazard which makes the wearer unable to react quickly to the hazard; and (3) the music may provide social isolation that reduces the wearer&rsquo;s attention to environmental sounds. In order to investigate the effects of headphones and music on the localization of warning sound perception, the effects of several headphone types on PLLs and horizontal sound localization in both quiet and traffic noise were examined.</p>\r\n<p><strong>STUDY DESIGN </strong></p>\r\n<p>The 39 participants had normal hearing, owned and used PADs for the purpose of listening to music, and ranged from 21&ndash;30 years of age (mean = 25.3 &plusmn; 2.8). Two tasks were conducted while the participants were wearing a Samsung (YP-T9JBQP) PAD and listening to a 60-second music selection: (1) real-ear measurement of the listener&rsquo;s preferred listening level (PLL) and (2) sound localization. All testing was completed in a hemianechoic chamber. Participants were seated 1.5 meters from all speakers in the center of a 64-speaker array. All sounds were presented via a subset of eight speakers spaced 45&deg; apart at the height of the listener&rsquo;s ear. Each listener completed the tasks with four types of earphones. Group 1 (n = 20) was tested under the following phone conditions: (1) open ear canal (i.e., no headphone) &ndash; localization task only, (2) ear-bud (Samsung EP370 earbuds), (3) over-the-ear headphones (Sony MDR 210-LP), and (4) noisereduction inserts (Skullcandy Smokin&rsquo;</p>\r\n<p>Buds SCBUDP). Group 1 testing was completed both in quiet and in 83 dBA recorded stereo traffic noise. Group 2 (n = 19) was tested under the following phone conditions: (1) open ear canal &ndash; localization task only, (2) noise reduction inserts (Etymotic Research ER6i Isolator In-Ear Earphones), (3) noise-reduction over-the-ear (Sony MDR-NC6 Noise Cancelling), and (4) noise-reduction around-the-ear (Bose QuietComfort2 Acoustic Noise Cancelling). Group 2 testing was completed both in quiet and in 70 dBA recorded stereo traffic noise. Noise cancellation was activated during testing, where applicable. All headphones and/or earphones were adjusted by the experimenter to avoid changing the position of the probe tube microphone and to ensure proper insertion of ER6i inserts. The car horn level for both groups was 67 dBA. Because groups 1 and 2 completed the study at different times, with different headphone types and noise levels, separate repeated-measures ANOVAs were performed for the data in each group.</p>\r\n<p><strong>Task 1: </strong>Preferred Listening Levels Following otoscopic examination of the canal, an ER-7C probe tube microphone system was placed in the left ear canal of each participant medial to the output of the earphone. The probe tube was inserted 28 mm for females and 30 mm for males from the intra-tragal notch. Otoscopy was performed a second time to verify that the tip of the probe tube was within 5 mm from the participant&rsquo;s tympanic membrane.14 The probe tube was secured by tape to ensure the placement was maintained with each change of the headphone. SpectraPlus software was used to record and store the microphone data and compute the A-weighted sound levels in the ear canal. Output levels of the PAD in the ear canal, as adjusted by each participant, were measured across all conditions. Beginning with the PAD player set to a volume level of 0 (mute), the participants were instructed to adjust the music volume to &ldquo;where it sounds best to you.&rdquo; Participants were not able to see the numerical volume display on the PAD during this adjustment. Under each headphone condition, the sound levels in the ear canal were measured and the numeric volume setting of the device was documented and used to set the volume control for the sound localization task. No corrections were made to transform the PLLs to diffuse field equivalents.</p>\r\n<p><strong>Task 2:</strong> Sound Localization A sound localization task in quiet and background noise was conducted while music was simultaneously presented via ear/headphones at the PLL determined for the given headphone and noise condition. Following a training session using noise bursts only, participants were presented with a recording of a car horn from one of the eight speakers. The car horn was presented in a background of stereo traffic noise. Participants were instructed to orient their head towards the speaker that emitted the horn and register their response with a press of a button. An electromagnetic head tracking device determined their head position. Twenty-four presentations (3 from each of the 8 target speakers) were presented for each headphone and noise condition. There was a total of eight (2 noise conditions &times; 4 headphones) listening conditions per participant. Responses that were greater than 22.5&deg; (i.e., midway between the target speakers) from the sound source speaker were scored as errors</p>\r\n<p><strong>RESULTS </strong></p>\r\n<p>Participants reported using their PADs for 4.6 &plusmn; 1.6 days per week with a typical listening session, on average, of 1.1 &plusmn; 1.4 hours. This is consistent with Ahmed et al. who noted that half of the participants reported using their PADs for 5 to 7 days per week, for 2 hours/session3 and Zogby et al.15 None of our participants reported using their devices more than 4 hours/session. The self-reported duration of use appears to be related to the age of participants; Cheesman et al. revealed that high school students participate in noisy activities for longer periods (24.4 hours per week) than do university and college students (19.5 and 20.2 hours per week, respectively).</p>\r\n<p>Both groups had a significant main effect of headphone type (Group 1: [F(2, 18) = 19.69, p &lt;.001]; Group 2 type [F(2, 16) = 30.28, p &lt;.001), of background noise (Group 1: [F(1, 19) = 124.65, p &lt; .001]; Group 2 [F(1, 17) = 41.27, p &lt; .001]), and an interaction between headphone type and background noise (Group 1: [F(2, 18) = 12. 33, p &lt; .001]; Group 2: ([F(2, 16) = 14. 58, p &lt; .001]). Figure 1 illustrates the mean PLLs, as measured in the ear canal, for each headphone type.</p>\r\n<p><strong>Effect of the Listening Environment</strong></p>\r\n<p>The presence of traffic noise resulted in significantly higher PLLs for all headphone types (Group 1: [F (1, 19) = 542. 13, N = 20, p &lt; .001]; Group 2: [F(1, 17) = 141.91, N = 19, p &lt; .001). Effect of the Earphone Style Headphone attenuation: An estimate of the amount of attenuation of environmental sounds provided by each headphone type was made by computing the difference of the sound level of the traffic noise in the open ear canal and when the headphone is worn without the music playing. Figure 2 shows the estimated attenuation for the six headphones.</p>\r\n<p><strong>Localization Errors</strong></p>\r\n<p>Participants in both groups generally made more errors in the traffic noise condition (Figure 3). Group 2 participants made significantly more localization errors than Group 1 despite the lower traffic noise intensity, where only one insert phone (Skullcandy) was of the noise-cancelling type. For Group 1, a repeated-measures ANOVA revealed a significant main effect of background noise (F [1, 19] = 35.97, N = 20, p &lt;.001) and Headphone Type (F [3, 57] = 10.99, N = 20, p &lt; .001). Localization errors increased in the Traffic Noise condition and with the use of the noisecancelling insert phones in the Quiet condition. There was no significant interaction between Background Noise and Headphone Type. Repeatedmeasures ANOVA for the Group 2 data revealed no significant effect of background noise, headphone type, or any interactions between background noise and headphone type.</p>\r\n<p><strong>DISCUSSION</strong></p>\r\n<p>The results of the current studies support the notion that using PADs in the presence of background noise results in an increase in PLLs. Hodgetts et al.5 and Henry and Foots,17 have demonstrated similar effects of background noise on PLLs. The results also demonstrate that the use of different types of ear/head phones can result in significantly different PLLs. Fligor and Cox measured the maximum outputs of portable music players measured through a Knowles Electronics Manikin for Acoustic Research (KEMAR) and converted to free-field equivalent values.18 They found a general trend that PLLs increase as the headphones decrease in size. Following Fligor and Cox, Hodgetts et al.5 and Henry and Foots17 have demonstrated similar findings, where the use of earbuds resulted in higher PLLs than either the larger-sized headphones, or when earbuds were combined with earmuffs. It is worth noting that Henry and Foots corrected the PLLs measured at the ear canal to free field equivalent values, while Hodgetts et al., as well as the current study, reported uncorrected PLLs measured at the ear canal. These findings are consistent with the result for the ER6i inserts, which produced significantly higher PLLs than the other two (over-the-ear and around-the-ear) headphones in quiet worn by the same listeners. However, Group 1 did not show similar results, where the over-theear headphones had higher PLLs than the other two inserts, one of which is a noise reduction insert &ldquo;Skullcandy,&rdquo; that provided 12.95 &plusmn; 2.5 dB of noise attenuation. More attenuation of the traffic noise was observed for the noisereduction and noise-cancelling headphones and earphones (for example, the ER6i provided 9.2 &plusmn; 0.4 dB, and Bose provided 13.04 &plusmn; 1.7 dB of attenuation) indicating that these devices were, indeed, effective at reducing the environmental noise reaching the wearer&rsquo;s ear. Furthermore, the noise-reduction and noise-cancelling devices resulted in lower overall sound levels in the ear canals when the devices were set to the listeners&rsquo; PLLs (Figure 1). However, the noise-reduction and noisecancelling head/ear phones resulted in higher localization errors when compared with the regular head/ear phones, as revealed from the results of Group 1. The presence of background noise also resulted in an increase in the localization errors. ER6i inserts were expected to provide &gt; 30 dB of attenuation; however, in the current study they produced only about 10 dB of attenuation. This could be attributed to the spectral differences between the stimuli in the current study and the stimuli used to measure the attenuation.</p>\r\n<p><strong>CONCLUSION</strong></p>\r\n<p>The noise-cancelling headphones and insert phones tested here provided variable amounts of attenuation for the traffic noise that resulted in lower overall sound levels in the ear canals. From this perspective they may contribute to a decreased risk of music-induced hearing loss. However, these phones also significantly degraded the spatial localization abilities of the users, as revealed by the increased localization errors, even with the relative large (45&deg;) spatial separation of target sounds used in the present study. This lack of good spatial hearing may expose the wearer to other risks of physical harm such as inability to quickly locate environmental sounds or warning signals. It should be noted that PLLs reported here reflect levels in the ear canal, thus cannot be compared to current damage-risk criteria,6 but are still valid in terms of relative risk. Attention is an important factor in localizing alerting sounds; however, it was not possible in the current studies&rsquo; settings to separate the relative contribution of inattention due to listening to a favorite music from the contribution of attenuated environmental alerting sounds (the car horn) on the localization errors. Further research is required in this direction. According to Shah et al.,19 85% of PAD users are aware of the possibility of acquiring a music-induced hearing loss. Although noise-reduction headphones or insert phones may be an effective way to decrease that risk, when considering the selection of a headphone type, the preservation of sound localization abilities and the risk of potential hearing damage may present a tradeoff. In light of these data and reports of vehiclepedestrian collisions, where the pedestrians and/or bicyclists are wearing portable audio devices, users should be well-informed about both the benefits and the drawbacks of noise cancelling head/ear phones, and they should be cautious when using noise-cancelling headphones or insert phones where the risk of physical harm exists.</p>\r\n<p><strong>SUMMARY</strong></p>\r\n<p>&bull; Noise-cancelling headphones and insert phones were introduced into the market with the aim of cancelling the environmental noise, reducing PLLs, and hence contribute to the prevention of music-induced hearing loss.</p>\r\n<p>&bull; The current study revealed that noise-reduction headphones and insert phones provided various amounts of attenuation for the environmental noise.</p>\r\n<p>&bull; The attenuation provided by the noise-cancelling head/insert phones allowed PAD users to listen to music at lower intensity levels and this may contribute to decreasing the risk of music-induced hearing loss.</p>\r\n<p>&bull; The current study also demonstrates that the localization abilities are degraded when noisecancelling headphones or insert phones are used, increasing the potential risk of physical harm to the users due to reduced awareness of environmental sounds.</p>\r\n<p>&bull; Portable audio device users should be aware of both the benefits and drawbacks of the noise-cancelling phones and either avoid them or become cautious with using these phones when there is a potential for physical harm.</p>\r\n<p><strong>ACKNOWLEDGEMENTS AND NOTES</strong></p>\r\n<p>This study was performed under the approval of the Office of Research Ethics, The University of Western Ontario. Review # 13429E. The help of Laura Ann Coates, Steve Beaulac, David Grainger, and Jeff Crukley is gratefully acknowledged. The Canada Foundation for Innovation and Ontario Research Fund provided financial support.</p>\r\n<p><strong>REFERENCES</strong></p>\r\n<p>1. National Product Development Group report 2005. MP3 Players Top the Consumer Electronics Market. http://www.npd.com/press/ releases/press_050818.html</p>\r\n<p>2. National Product Development Group report 2006. Service will sell and MP3 Players will be Music to Retailers&rsquo; Ears This Holiday Season. http://www.npd.com/press/releases/ press_060925a.html.</p>\r\n<p>3. Ahmed S, King M, Morrish TW, et al. A survey of the use of portable audio devices by university students. Can Acoust 2006;34:64&ndash; 65.</p>\r\n<p>4. Fligor BJ and Ives TE. Does earphone type affect risk for recreational noise induced hearing loss? [PowerPoint slides]. The National Hearing Conservation Associations\' Conference on Noise-Induced Hearing Loss in Children at Work and Play 2006; Covington, Kentucky.</p>\r\n<p>5. Hodgetts WE, Rieger JM, Szarko RA. The effects of listening environment and earphone style on preferred listening levels of normal hearing adults using an mp3 player. Ear Hear 2007;28:290&ndash;97.</p>\r\n<p>6. National Institute for Occupational Safety and Health 1996. Preventing occupational hearing loss &ndash; a practical guide. Cincinnati, OH: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 95-105.</p>\r\n<p>7. Portnuff CDF and Fligor BJ. Output levels for portable digital music players. [PowerPoint slides] The National Hearing Conservation Association&rsquo;s conference on Noise Induced Hearing Loss in Children at Work and Play. Covington, Kentucky, October 19, 2006. Available [http://www.hearingconservation.org/ conf_childconf_program_thurs.html].</p>\r\n<p>8. Muchnik C, Amir N, Shabtai E, &amp; KaplanNeeman R. Preferred listening levels of personal listening devices in youngteenagers: Self reports and physical measurements. Int J Audiol 2012;51:287&ndash;93.</p>\r\n<p>9. Portnuff CDF, Fligor BJ, and Arehart KH. Teenage MP3 player use: A risk to hearing? J Am Acad Audiol 2011;22:663&ndash;77.</p>\r\n<p>10. Liang M, Zhao F, French D, Zheng Y. Characteristics of noise-canceling headphones to reduce the hearing hazard for MP3 users. J Acoust Soc Am 2012;131(6):4526&ndash;534.</p>\r\n<p>11. Getzmann S. A comparison of the contrast effects in sound localization in the horizontal and vertical planes. Exp Psychol 2003;50(2):131&ndash;41.</p>\r\n<p>12. Noble W, Murray N, and Waugh R. The effect of various hearing protectors on sound localization in the horizontal and vertical planes. Am Ind Hyg Assoc J 1990;51:370&ndash;77.</p>\r\n<p>13. Zeller T. (2007, February 7). Taking aim at &ldquo;ipod oblivion&rdquo;. The New York Times. Retrieved March 16, 2012. Available [http://thelede.blogs.nytimes.com/2007/ 02/07/taking-aim-at-ipod-oblivion/].</p>\r\n<p>14. Audioscan. (2007). Verify hearing instrument fitting guide (Version 3.0) Dorchester, Ontario. Available: http://www.audioscan.com/resources/ userguides/currentverifitguide.pdf].</p>\r\n<p>15. Zogby J. Survey of teens and adults about the use of personal electronic devices and head phones. 2006. Retrieved from http://www.nsslha.org/NR/rdonlyres/ 10B67FA1-002C-4C7BBAOB1C0A3AF98A63/0/zogbysurvey2006.pdf.</p>\r\n<p>16. Cheesman MF, Ciona L, Mendoza S, et al. Participation rates in noisy leisure activities by three samples of students. Can Acoust 2001;29:42&ndash;43.</p>\r\n<p>17. Henry P and Foots A. Comparison of user volume control settings for portable music players with three earphone configurations in quiet and noisy environments. J Am Acad Audiol 2012;23:182&ndash;91.</p>\r\n<p>18. Fligor BJ and Cox LC. Output levels of commercially available portable compact disc players and the potential risk to hearing. Ear Hear 2004;25 (6):513&ndash;27.</p>\r\n<p>19. Shah S, Gopal B, Reis J, Novak M. Hear today, gone tomorrow: an assessment of portable entertainment player use and hearing acuity in a community sample. J Am Board Fam Med 2009;22:17&ndash;23.</p>',NULL,'2022-11-26'),(32,3256,'ajchr','http://www.andrewjohnpublishing.com/','','<p>The word war rages on, is it sensori-neural? Sensory neural? Sensoryneural? Or sensory-neural? This may seem like a trivial issue like word recognition score versus speech discrimination score, but the ramifications are more far reaching. Is an issue of hearing related to the cochlea (sensory) or is it neural, or perhaps both? Does a pathology in one area affect the function in another?</p>\r\n<p>Certain tests can demonstrate problems in one area that other tests cannot &ndash; we have known this since long before advanced imaging technology has been available. In 1962, Jack Katz came out with the SSW test that demonstrated clearly areas of auditory dysfunction that could not be shown with &ldquo;routine&rdquo; audiometry. With the advent of new audiology tests, new imaging techniques, and new paradigms, we are better able now to distinguish between peripheral pathology (cochlear) and central pathology (neural and cortical). Terms like sensori-neural (or however we end up writing it) demonstrates a certain level of ignorance. We don&rsquo;t really know whether its sensory or whether its neural, or both, so like the proverbial waste paper basket, we just dump it all in and use a difficult to spell longer word. This issue of the Canadian Hearing Report begins with a letter to the editor about this very issue. It was written by Fred Martin and John Greer Clark. If the names sound familiar, and they should, these are the two authors behind a very successful audiology text book. In writing their book, Doctors Martin and Clark had to be consistent with the usage of this term (these terms?). Personally I am in the midst of being an associate editor for Jack Katz&rsquo;s seventh issue of his Handbook of Clinical Audiology, and like Doctors Martin and Clark, we needed to settle on a consistent and up-to-date term.</p>\r\n<p>It is no coincidence that we had invited Drs. Martin and Clark to write the Letter to the Editor. This is an issue that has been guest edited by Dr. Lendra Friesen whom many will recognize for her longstanding contributions to Spotlight on Science in previous issues of the Canadian Hearing Report (now written by Sheila Moody and Steve Aiken). Lendra has put together a wonderful overview of some of the audiology areas that span the sensory and the neural auditory domains. In this issue we have articles by Steve Aiken and Philippe Fournier called &ldquo;Tinnitus: The Dark Side of Neuroplasticity.&rdquo; Tinnitus is something that is frequently noticed after a peripheral insult but is central in origin, and central in treatment. And, there is no better way to appreciate the role of the central auditory pathways than to examine the topic of binaural hearing which Karen Gordon and Blake Papsin write about &ldquo;Why Children Need to Hear from Both Ears.&rdquo; Bernhard Ross writes about &ldquo;The Auditory Evoked P2 Response Indicates Effects of Aging on Central Auditory Processing,&rdquo; and Laurel Trainor tackles the topic of the &ldquo;Development of Pitch Perception and the Processing of Simultaneous Sounds in Infancy.&rdquo; I would like to thank Lendra for her past contributions to the Canadian Hearing Report as well as putting this issue together as the guest editor. It not only makes my life a bit easier, but more importantly this issue will serve to contribute to the richness of all of our readers&rsquo; central academic neurons (or is it peripheral?).</p>\r\n<p>La guerre des mots est d&eacute;clench&eacute;e, est ce neuro-sensoriel? Neurosensoriel ? Neuro sensoriel? Ce qui semble &ecirc;tre un enjeu insignifiant tel la note de reconnaissance des mots versus celle de la discrimination des mots, mais les ramifications sont beaucoup plus profondes. Est-ce un enjeu d&rsquo;ou&iuml;e li&eacute; &agrave; la cochl&eacute;e (sensoriel) ou est-ce neuronal, ou peut-&ecirc;tre les deux ? Est-ce que la pathologie d\'un domaine affecte la fonction de l&rsquo;autre?   Certain tests peuvent montrer des probl&egrave;mes dans un domaine que d&rsquo;autres tests ne peuvent pas &ndash; Nous le savions bien avant que la technologie avanc&eacute;e de l&rsquo;imagerie ne soit disponible. En 1962, Jack Katz a invent&eacute; le test SSW qui a clairement montr&eacute; des domaines de disfonctionnements auditifs qui ne pouvaient &ecirc;tre montr&eacute;s avec l&rsquo;audiom&eacute;trie de &ldquo;routine&rdquo;. Avec l&rsquo;av&egrave;nement de nouveaux tests audiologiques, de nouvelles techniques d&rsquo;imagerie, et nouveaux paradigmes, nous pouvons maintenant mieux distinguer la pathologie p&eacute;riph&eacute;rique (cochl&eacute;aire) de la pathologie centrale (neuronale et corticale).</p>\r\n<p>Des termes tel neurosensoriel (peu importe comment on finira par l&rsquo;&eacute;crire) d&eacute;montre une certaine ignorance. Nous ne savons pas r&eacute;ellement si c&rsquo;est sensoriel ou neuronal, ou les deux, alors on tasse le tout et on utilise la difficult&eacute; pour &eacute;crire l&rsquo;orthographe d&rsquo;un mot plus long. Ce num&eacute;ro de la Revue Canadienne d&rsquo;audition d&eacute;bute avec une lettre au r&eacute;dacteur au sujet de cet enjeu m&ecirc;me. Lettre r&eacute;dig&eacute;e par Fred Martin et John Greer Clark. Si ces noms vous semblent familiers, et ils devraient l&rsquo;&ecirc;tre, ce sont les auteurs d&rsquo;un manuel d&rsquo;&eacute;tude en audiologie &agrave; tr&egrave;s grand succ&egrave;s. Les docteurs Martin et Clark se devaient d&rsquo;&ecirc;tre consistants avec l&rsquo;utilisation de ce terme (ces termes?) tout le long de leur travail sur leur manuel. Personnellement, je suis en plein processus d&rsquo;&ecirc;tre r&eacute;dacteur associ&eacute; du septi&egrave;me num&eacute;ro du Handbook of Clinical Audiology de Jack Katz, et comme les docteurs Martin et Clark, il fallait qu&rsquo;on se mette d&rsquo;accord sur un terme consistent et &agrave; jour. Ce n&rsquo;est pas une co&iuml;ncidence que nous ayons invit&eacute; les docteurs Martin et Clark &agrave; &eacute;crire une lettre au r&eacute;dacteur. La r&eacute;dactrice invit&eacute;e de ce num&eacute;ro est Dr. Lendra Friesen que plusieurs vont reconnaitre pour ses contributions de longue date &agrave; la chronique Spotlight on Science dans des num&eacute;ros pr&eacute;c&eacute;dents de la Revue Canadienne d&rsquo;audition (maintenant r&eacute;dig&eacute;e par Sheila Moody et Steve Aiken). Lendra a mis ensemble un aper&ccedil;u superbe de certains domaines de l&rsquo;audiologie qui s&rsquo;&eacute;tend sur les domaines auditifs sensoriel et neuronal.</p>\r\n<p>Dans ce num&eacute;ro, nous avons des articles par Steven Aiken et Philippe Fournier intitul&eacute; &ldquo;Tinnitus: La face obscure de la plasticit&eacute; synaptique.&rdquo; Le tinnitus est fr&eacute;quemment constat&eacute; apr&egrave;s un accident p&eacute;riph&eacute;rique mais son origine est centrale, et son traitement est central. Et pour appr&eacute;cier le r&ocirc;le des chaines auditives centrales, rien de mieux que de se pencher sur le sujet de l&rsquo;ou&iuml;e binaurale que Karen Gordon et Blake Papsin examine dans &ldquo;Pourquoi les enfants ontils besoin d&rsquo;utiliser leurs deux oreilles pour entendre.&rdquo; Bernhard Ross r&eacute;dige son papier &ldquo; Le potentiel &eacute;voqu&eacute; auditif P2 indique les effets du vieillissement sur le processus auditif central,&rdquo; et Laurel Trainor s&rsquo;attaque au sujet du &ldquo;D&eacute;veloppement de la perception des tons et traitement des sons simultan&eacute;s chez les nourrissons.&rdquo; Je voudrai remercier Lendra pour ses contributions pass&eacute;es &agrave; la Revue Canadienne d&rsquo;audition et aussi pour pr&eacute;parer ce num&eacute;ro en tant que r&eacute;dactrice invit&eacute;e. Non seulement &ccedil;a facilite un peu ma vie, mais plus important, ce num&eacute;ro va contribuer &agrave; la richesse des neurones acad&eacute;miques centraux de nos lecteurs (ou sont-ils p&eacute;riph&eacute;riques?).</p>\r\n<p>This issue of the Canadian Hearing Report is about the role of the brain and neural plasticity in the field of hearing. We are in an exciting time where we have the technology to examine changes in the brain that occur with many different populations including those in the stages of development and aging, those undergoing auditory training or auditory deprivation, those receiving different types of stimulation (amplification or electrical as is used with a cochlear implant, or CI), or experiencing various disease processes, as well as many others.</p>\r\n<p>In this day and age we can examine different levels of the brain, beginning with the auditory nerve and moving up to higher centers in the auditory cortex. We can use technology such as auditory evoked potentials (AEPs), or magnetencephalography (MEG), to name only a few of the available techniques to measure neural activity. We are featuring several groups of researchers that are examining different processes in the brain using a variety of techniques and different technology. Although I will not define all the terms in this particular article, they will be defined in each individual paper. Karen Gordon and Blake Papsin investigate the importance of binaural hearing in young children implanted with CIs at The Hospital for Sick Children, using the auditory brainstem response (ABR) and cortical responses. Laurel Trainor, from McMaster University, explores the development of pitch processing in infants using a preconscious discrimination cortical response, the mismatch negativity (MMN). Bernhard Ross, from the Rotman Research Center at Baycrest, examines the effects of aging in elderly adults, specifically examining the P2 waveform of the cortical P1-N1-P2 response, recorded using magnet-encephalography (MEG) in different experiments. Steve Aiken, from Dalhousie Univeristy and Philippe Fournier from the University of Montreal, discuss the relationship between neuroplasticity and tinnitus, a world that is virtually unknown. And finally, our lab at the Sunnybrook Health Sciences Centre, examines hearing preservation in CI users and the underlying neural effects, examining eCAP responses from the level of the auditory nerve, as well as cortical responses. Our goal is to provide the reader with new insights into what types of auditory neural research are being investigated and the importance of remembering the brain&rsquo;s role in hearing.</p>\r\n<p>Ce num&eacute;ro de la Revue Canadienne d&rsquo;audition est au sujet du r&ocirc;le du cerveau et de la plasticit&eacute; synaptique dans le domaine de l&rsquo;ou&iuml;e. Nous passons par des temps stimulants, nous avons les technologies pour examiner les changements au niveau du cerveau qui surviennent pour beaucoup de populations diff&eacute;rentes, populations en cours de d&eacute;veloppement et vieillissement, celles en cours d&rsquo;&eacute;ducation auditive ou en privation auditive, celles recevant diff&eacute;rents types de stimulation (amplification ou &eacute;lectrique utilis&eacute;es avec les implants cochl&eacute;aires, ou CI) ou populations touch&eacute;es par des maladies vari&eacute;es, et aussi tant d&rsquo;autres. Ces temps-ci, on peut examiner les diff&eacute;rents niveaux du cerveau, commen&ccedil;ant avec le nerf auditif et avan&ccedil;ant le long de centres sup&eacute;rieurs dans le cortex auditif. Nous pouvons utiliser des technologies telles les potentiels auditifs &eacute;voqu&eacute;s, ou l&rsquo;enc&eacute;phalographie magn&eacute;tique, pour citer quelques-unes des techniques disponibles pour mesurer l&rsquo;activit&eacute; neuronale. Nous pr&eacute;sentons plusieurs groupes de chercheurs qui examinant diff&eacute;rents processus du cerveau utilisant une vari&eacute;t&eacute; de techniques et de technologies diff&eacute;rentes. M&ecirc;me si je ne vais pas d&eacute;finir tous les termes dans cet article en particulier, ce sera fait dans chaque article individuel. Karen Gordon et Blake Papsin enqu&ecirc;te sur l&rsquo;importance de l&rsquo;audition binaurale chez des jeunes enfants auxquels on a implant&eacute; des implants cochl&eacute;aires &agrave; l&rsquo;h&ocirc;pital pour enfants malades, en utilisant la r&eacute;ponse auditive &eacute;voqu&eacute;e du tronc c&eacute;r&eacute;bral et les r&eacute;ponses corticales. Laurel Trainor, de McMaster University, explore le d&eacute;veloppement du traitement des tons chez les nourrissons en utilisant une r&eacute;ponse corticale de discrimination pr&eacute;consciente, la n&eacute;gativit&eacute; discordante. Bernhard Ross, du centre de recherche Rotman &agrave; Baycrest, examine les effets du vieillissement sur les personnes  &acirc;g&eacute;es, sp&eacute;cifiquement l&rsquo;onde P2 de la r&eacute;ponse corticale P1-N1-P2, enregistr&eacute;e par enc&eacute;phalographie magn&eacute;tique dans diff&eacute;rentes exp&eacute;rimentations. Steve Aiken, de Dalhousie University, touche &agrave; la relation entre la plasticit&eacute; synaptique et le tinnitus, un monde qui est virtuellement inconnu. Et finalement, notre laboratoire au centre des sciences de la sant&eacute; de Synnybrook, examine la pr&eacute;servation de l&rsquo;ou&iuml;e chez les utilisateurs d&rsquo;implants cochl&eacute;aires et les effets nerveux sous-jacents, en examinant autant les r&eacute;ponses eCAP au niveau du nerf auditif, que les r&eacute;ponses corticales. Notre objectif est de fournir au lecteur de nouvelles perspectives au sujet des types de recherche en nerf auditif et l&rsquo;importance de se rappeler le r&ocirc;le du cerveau dans l&rsquo;ou&iuml;e.</p>\r\n<p>In past years the first terms encountered in university classes and in the literature to describe hearing losses that result from lesions of the cochlea or auditory nerve were &ldquo;nerve type hearing loss&rdquo; and &ldquo;perceptive hearing loss.&rdquo; The former, unfortunately, is still in common parlance even though the majority of losses do not involve the auditory nerve at all. The latter is wholly inaccurate for these lesions are not expected to involve perception. In the 1960s the term &ldquo;sensorineural&rdquo; was coined which was greatly welcomed. This term was designed to imply that the hearing loss was caused by a sensory (inner ear) lesion, a neural (auditory nerve) lesion, or both. The problem with this one-word term is that it does not suggest the separation between these two anatomical sites. Of course, in the 1960s, the profession had only relatively crude site-of-lesion tests for attempted separation of the two subcategories of sensory/neural hearing loss. The ability to accurately separate sensory from neural lesions has increased dramatically. Since introduction of the term &ldquo;sensorineural,&rdquo; other spellings have emerged such as &ldquo;sensory neural&rdquo; and &ldquo;sensory-neural.&rdquo; Beginning with the 11th edition of our book, Introduction to Audiology, and continuing to the 12th, which is now in press, we began the use of the spelling &ldquo;sensory/neural.&rdquo; Our reasoning is based on the fact that the dictionary describes the dash (-) as a &ldquo;horizontal stroke in writing or printing to mark a pause or break in sense, or to represent omitted letters or words,&rdquo; and the slash as &ldquo;an oblique stroke (/) in print or writing used between alternatives (e.g., and/or).&rdquo; This spelling meets the criteria for accurate terminology in audiology It is our hope that the profession of audiology will rally around use of a spelling that is a more accurate reflection of the lesion when a clear differentiation between sensory and neural cannot be made. When test results clearly differentiate between these two lesion sites, audiologists can facilitate patient management by distinctly stating that the loss is cochlear (sensory) or neural in nature. We have long recognized that our profession, despite the zeal with which practitioners accept new scientific procedures, is slow to change in the adoption of new terminology. Consider the continued use of &ldquo;speech discrimination score&rdquo; despite the obviously improved and more accurate &ldquo;speech recognition score.&rdquo; Another example is &ldquo;speech reception threshold&rdquo; rather than &ldquo;speech recognition threshold&rdquo; for the very commonly practiced SRT. We hope that this communication may serve to raise consciousness about the spelling &ldquo;sensory/neural&rdquo; as a replacement for previous spellings and that it may serve as an impetus for adoption of its use. We believe that this moreaccurate orthography clearly states that a hearing-loss producing lesion may be found in the cochlea, the auditory nerve, or both. It is to our betterment as a profession that a commonality of accurate terms and spellings is used in audiological communication.</p>\r\n<p>By Calvin Staples, MSc Hearing Instrument Specialist Faculty/Coordinator, Conestoga College CStaples@conestogac.on.ca</p>\r\n<p>I hope this finds you all enjoying your summer. I opted to submit blogs that focus on children and hearing. My wife and I recently welcomed our third child into our family. We have had the great experience of watching our older children care and learn about the development of a newborn. Once we checked off major health concerns such as breathing, 10 fingers, 10 toes, etc, I was quick to be sure he was hearing. Our two older children easily helped to establish the startle. I thought the submissions below would provide some insight into the wonderful world of hearing for children. I know as an audiologist, helping a child hear is at the top of the list in terms of professional reward. I hope you enjoy the blogs.</p>\r\n<p><strong>MUSIC TRAINING HEARING</strong></p>\r\n<p>By Jane Madell The world is a very noisy place and much of what children learn, they have to learn listening in noise. Hearing in noise requires the ability to hear with both ears. Binaural hearing enables us to focus on the speech signal and ignore the noise. Language is a left-brain activity and the majority of the input to the right ear goes to the left brain. Our primary focus in working with children with hearing loss (and also children without hearing loss) is to develop language skills. Therefore, the right ear has been considered the more important ear. While the right ear certainly is critical, To hear in noise, we also have to build skills in the left ear, which sends the majority of the information going to the right brain. MUSIC AND THE BRAIN Nina Kraus, PhD, director of the Auditory Neuroscience Laboratory at Northwestern University, has studied the effect of musical training on the brain. She has demonstrated that musicians excel in vocabulary, reading, non-verbal reasoning, perception of speech in background noise, auditory memory and attention. She has concluded that musical training causes the brain to undergo neurological changes. For example, string players demonstrate a reorganization of the motor cortex related to the left hand, which performs extensive intricate fingering. There are many examples of brain changes in musicians explicitly involving auditory centers.</p>\r\n<p><strong>MUSIC TRAINING AND CHILDREN</strong></p>\r\n<p>Music training is associated with increased vocabulary, reading and phonologic processing, attention and reasoning skills in children. Kraus reports on the tie in between musicianship and literacy. Learning to read is closely related to phonics and being able to decipher the sounds of language. So musical practice can hone the auditory system providing a channel towards literacy. Her research also demonstrates the relationship between music and hearing in noise.</p>\r\n<p><strong>MUSIC AND CHILDREN WITH LANGUAGE LEARNING DISORDERS</strong></p>\r\n<p>Some of Kraus&rsquo;s work supports music as a therapy for children with a language learning disorder and difficulties with speech in noise. Her work suggests that music can help children with auditory processing disorders improving listening in noise.</p>\r\n<p><strong>WHAT DOES THIS MEAN FOR CHILDREN WITH HEARING LOSS?</strong></p>\r\n<p>Well, we do not absolutely know. But we do know that, in general, music can help develop the auditory brain. I have always encouraged children with hearing loss to study music because, as a rule, I think music is a good thing. In addition, we know that music is a right-brain activity and improving right-brain functioning improves the ability to hear in noisy situations. Since noise is a difficult problem for children with hearing loss, music training seems like a good idea. If, in addition, it has a significant effect on literacy, it is a win-win situation.</p>\r\n<p><strong>NEW PHONE APP LETS PARENTS TEST THEIR CHILDREN FOR HEARING LOSS AT HOME</strong></p>\r\n<p>By David Kirkwood For 69 pence (about $1.15), parents in Great Britain can obtain a phone app that can be used with a smartphone or an iPad to help them assess their children&rsquo;s hearing without taking them to an audiology clinic. The Early Ears app was developed by British scientists at Aston University in Birmingham, who say that it can offer parents &ldquo;immediate reassurance&rdquo; for worries about hearing loss. The app presents a series of eight images and the children must correctly touch the image that responds to the app&rsquo;s audio instructions&ndash;which are broadcast at different volumes. Robert Morse, PhD, from Aston University&rsquo;s Health Care Clinics, said, &ldquo;Our Early Ears app provides parents with a simple, but reliable, resource to test their children&rsquo;s hearing. For three decades the McCormick toy test has been used by audiologists to identify common causes of hearing loss in kids. This app brings that test into the home, offering parents immediate reassurance or recommendations to seek expert medical advice if they suspect their child may have a hearing problem.&rdquo;</p>\r\n<p><strong>STUDY FINDS OBESITY IN ADOLESCENTS IS LINKED TO HEIGHTENED RATE OF HEARING LOSS</strong></p>\r\n<p>By David Kirkwood Anil K. Lalwani, MD, lead author of a new study showing an association between hearing loss and obesity among adolescents, recommends that obese adolescents &ldquo;receive regular hearing screening so they can be treated appropriately to avoid cognitive and behavioral issues.&rdquo; The study, published June 17 in The Laryngoscope, found that obesity in adolescents is associated with sensorineural hearing loss across all frequencies. The highest rates were for low-frequency hearing loss &ndash; 15.2% among obese adolescents compared with 7.9% in non-obese adolescents. Lalwani, who is vice-chair for research in the Department of Otolaryngology/ Head &amp; Neck Surgery at Columbia University Medical Center (CUMC), told the CUMC news office, &ldquo;This is the first paper to show that obesity is associated with hearing loss in adolescents.&rdquo;</p>\r\n<p>Lalwani, who is also an otolaryngologist at New York-Presbyterian Hospital/ Columbia University Medical Center, noted that the results of the study &ldquo;have several important public health implications.&rdquo; Because it has been found that 80% of adolescents with hearing loss are unaware of their hearing difficulty, he said it is important that those whose obesity puts them in a highrisk category be routinely screened for hearing loss. About 17% of children in the U.S. are obese. &ldquo;Furthermore,&rdquo; Lalwani said, &ldquo;hearing loss should be added to the growing list of the negative health consequences of obesity that affect both children and adults &ndash; adding to the impetus to reduce obesity among people of all ages.&rdquo; Lalwani called for additional research on the adverse consequences of this early hearing loss on social development, academic performance, and behavioral and cognitive function. He also said that more research would be needed to determine the mechanisms involved in hearing loss among obese adolescents. He speculated that obesity-induced inflammation may contribute to hearing loss. Low plasma levels of adiponectin, an anti-inflammatory protein, have been found in obese children, and low levels in obese adults have been associated with high-frequency hearing loss. The study, whose other authors are Karin Katz, MD; Ying-Hua Liu, MD, PhD; Sarah Kim, BA; and Michael Weitzman, MD, all from the New York University Langone Medical Center, analyzed data from nearly 1500 adolescents in the National Health and Nutrition Examination Survey, conducted 2005-2006 by the National Center for Health Statistics of the Centers for Disease Control and Prevention.</p>\r\n<p><strong>HOW MANY HOURS A DAY DOES A CHILD NEED TO HEAR?</strong></p>\r\n<p>By Jane Madell We know, for sure, that kids need to hear all day long in order to learn language, and to be ready to read. Typical hearing kids hear 24 hours a day. Children with hearing loss hear only when they have their technology on. Here is what else we know:</p>\r\n<p>&bull; Typical children hear 46 million words by age 4 years</p>\r\n<p>&bull; Children need 20,000 hours of listening to learn to read. (That would mean listening for 12 hour days for 1,667 days)</p>\r\n<p>&bull; Children with hearing loss require three times the exposure to learn new words and concepts.</p>\r\n<p><strong>SO, WHAT DOES THIS MEAN FOR A CHILD WITH HEARING LOSS?</strong></p>\r\n<p>If a child wears hearing aids 4 hours a day, it will take 6 years for the child to hear what a typical child who does not need hearing aids hears in one year. That means that the child with hearing loss will have significantly less auditory input, resulting in less language exposure, which will result in poorer language and poorer reading. What can we do to change this outcome? We need to help families to keep hearing aids and other technology on their child&rsquo;s head. For children with hearing loss, time is of the essence. There is no turning back. We cannot make up for lost listening time when the child is older. When children do not receive sufficient auditory exposure, the auditory portion of the brain will shrink and the visual cortex will expand to take over the area usually associated with audition.</p>\r\n<p><strong>WHAT CAN WE DO TO HELP FAMILIES KEEP TECHNOLOGY ON A CHILD&rsquo;S HEAD?</strong></p>\r\n<p>1. We need to help families understand how important it is to use technology full time.</p>\r\n<p>2. We need to help families find the appropriate retention devices that will keep the hearing aids on the child&rsquo;s head full time. These may include devices such as Huggies, Ear Gear, Critter Clips, and toupee tape.</p>\r\n<p>3. We need to teach families to make sure that their children&rsquo;s technology is working each and every day. Parents can never assume. They need to check their kids&rsquo; hearing aids every day.</p>\r\n<p>4. We need to test to be sure that a child is receiving enough benefit from the hearing aids, and can hear both normal and soft speech.</p>\r\n<p><strong>IT IS EVERYONE&rsquo;S JOB</strong></p>\r\n<p>Making sure technology is working and on is everyone&rsquo;s responsibility. Audiologists need to be sure parents understand why technology is important and how to check technology. Parents need to check technology daily and take action if it is not working. Children need to be taught to pay attention to whether or not technology is working and report problems. Teachers and therapists need to pay attention to whether the child is responding well with technology and, if not, get help. No one person can do this job alone, but if we all work together, we can be certain that we are providing good auditory access to kids with hearing loss.</p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g001.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g002.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g003.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g004.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g005.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g006.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g007.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g008.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g009.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g0010.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g0011.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g0012.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g0013.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g0014.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g0015.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g0016.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g0017.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g0018.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g0019.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g0020.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g0021.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g0022.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g0023.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g0024.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g0025.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g0026.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-3-1-g0027.png\" alt=\"image\" /></p>',NULL,'2022-11-26'),(33,3246,'ajchr','http://www.andrewjohnpublishing.com/','','<p>Marshall Chasin, AuD, Reg. CASLPO Editor-in-Chief</p>\r\n<p>I magine the field of audiology without Dr. Mead Killion. It brings to mind the 1946 Frank Capra movie starring Jimmy Stewart called It&rsquo;s a Wonderful Life where an angel named Clarence comes to show the Jimmy Stewart character what life would be like without him. I have asked Clarence to help me write this editorial. For those of you who have never seen this movie (which by the way requires a full box of Kleenex even for the most macho among us) sometimes a person&rsquo;s contributions can best be recognized if one can imagine what would happen if they had never made them.</p>\r\n<p>We probably would only have had hearing aids that went out to 4,000 Hz, microphones would still be very large which would obviate the entire range of custom hearing aids, an entire generation of young musicians would have hearing loss, we would still be testing hearing with the TDH-39 earphones, RECDs would still be in their infancy, we wouldn&rsquo;t know how to build a hearing aid that can transduce loud music with virtually no distortion, and we wouldn&rsquo;t really understand the benefits of a smooth frequency response. CORFIG and &ldquo;Count the Dots&rdquo; would only be games sold at Christmas time, and inexpensive dosimetry and otoacoustic emissions would still be on the horizon. And oh yes, we wouldn&rsquo;t know the name Elmer Carlson whose innovations and inventions would have gone unrecognized. Elmer&rsquo;s work was instrumental in the development of the Musicians&rsquo; Earplugs&trade;, and the insert earphone.</p>\r\n<p>This issue of the Canadian Hearing Report is not about Mead Killion. It is about the many innovations that Mead has spearheaded and convinced us that we, as a field, required. I began my working career at about the same time as Mead&rsquo;s 1981 JSHD article came out on &ldquo;Earmold Options for Wideband Hearing Aids&rdquo;&ndash; this introduced an entire generation of audiologists to the benefits of flared earmold tubing and the judicious use of acoustic resistance. It wasn&rsquo;t too long after that I purchased my first pair of insert earphones which among other things, could allow me to test people with bilateral conductive hearing losses with minimal or no masking. About this same time, a series of non-occluding earhooks were introduced that gave up to 40 dB low frequency insertion gain. This allowed our patients with mastoid cavities and other significant conductive pathologies, substantial low- and mid-frequency amplification with no occlusion of the ear canal. The late 1980s saw the introduction of uniform hearing protection that has become the mainstay for musicians. About that same time, the world&rsquo;s first truly high fidelity hearing aid was developed and to this day is better than the vast majority of digital hearing aids for listening to music. The past 20 years has seen the development of a range of accessible testing that go beyond the traditional measures of hearing. Although this issue is about Mead&rsquo;s innovations and not Mead, I would be remiss if I did not mention that he has always been willing to answer questions and never once told me I was silly when I asked a silly question. The website of his company &ndash; www.etymotic.com, is a wealth of information that is available to anyone, with a series of articles (under Publications) on virtually any topic. I could envision a graduate-level reading course designed to just read through every article on the site and it would probably be voted the best course ever. In this issue we have a range of short articles by people who over the last 30 years, worked directly with Mead to develop an innovation for the field of audiology. Each one gives the history, the reasons for the innovation, and in many cases, an inside look at how Mead likes to work. We also are fortunate enough to have received permission to reprint several of Mead&rsquo;s important articles. These include the first page of &ldquo;Earmold Options for Wideband Hearing Aids&rdquo; from the Journal of Speech and Hearing Disorders, and the entire articles on the ER-15 Musicians Earplugs&trade; and the K-AMP&reg; hearing aid from The Hearing Journal and Hearing Instruments.</p>\r\n<p>Thank you Mead.</p>\r\n<p>Marshall Chasin, AuD, Reg. CASLPO &Eacute;diteur en chef</p>\r\n<p>I maginez le domaine de l&rsquo;audiologie sans Dr. Mead Killion. &Ccedil;a rappelle le film La vie est belle de Frank Capra sorti en 1946 dans lequel un ange du nom de Clarence montre au h&eacute;ros du film jou&eacute; par Jimmy Stewart que serait la vie sans lui. J&rsquo;ai demand&eacute; &agrave; Clarence de m&rsquo;aider &agrave; &eacute;laborer cet &eacute;ditorial. Pour ceux ou celles d&rsquo;entre vous qui n&rsquo;avaient jamais vu ce film (qui en passant exige une boite pleine de Kleenex m&ecirc;me pour les plus machos entre nous), des fois la contribution d&rsquo;une personne peut &ecirc;tre mieux reconnue si on peut imaginer ce qui se passerait s&rsquo;elle ne l&rsquo;avait jamais faite.</p>\r\n<p>Nous en serions probablement encore aux appareils auditifs qui portent sur 4,000 Hz, les microphones seraient encore tr&egrave;s larges ce qui rendrait inutile la vaste rang&eacute;e des appareils sur mesure, une g&eacute;n&eacute;ration enti&egrave;re de jeunes musiciens aurait une perte auditive, nous en serions encore &agrave; conduire des tests auditifs avec des &eacute;couteurs t&eacute;l&eacute;phoniques TDH-39, les diff&eacute;rences entre l&rsquo;oreille r&eacute;elle et le coupleur seraient encore &agrave; leur stade infantile. On ne saurait pas comment confectionner un appareil auditif qui peut traduire la musique intense virtuellement sans distorsion, et on ne comprendrait pas les avantages d&rsquo;une r&eacute;ponse de fr&eacute;quence calme. CORFIG et &ldquo;relier les pointill&eacute;s&rdquo; seraient seulement des jeux vendus &agrave; Noel, et la dosim&eacute;trie bon march&eacute; et &eacute;missions oto-acoustiques seraient encore &agrave; l&rsquo;horizon. Et oh oui, nous ne saurions rien du nom d&rsquo;Elmer Carlson dont les innovations et inventions seraient rest&eacute;es sans reconnaissance. Le travail d&rsquo;Elmer &eacute;tait essentiel pour le d&eacute;veloppement des capsules protectrices pour les musiciens, et des &eacute;couteurs internes.</p>\r\n<p>Ce num&eacute;ro de la revue canadienne d&rsquo;audition n&rsquo;est pas sur Mead Killion. C&rsquo;est au sujet des innovations multiples dont Mead a &eacute;t&eacute; &agrave; l&rsquo;avant garde et nous a convaincu que notre domaine les exigeait. J&rsquo;ai commenc&eacute; ma carri&egrave;re professionnelle &agrave; la m&ecirc;me p&eacute;riode de la sortie de l&rsquo;article JSHD de Mead en 1981 au sujet des &ldquo;Options d&rsquo;embouts auriculaires pour les appareils auditifs &agrave; bande large&rdquo; &ndash; Ceci a initi&eacute; une g&eacute;n&eacute;ration enti&egrave;re d&rsquo;audiologistes aux avantages des embouts auriculaires arrondis et &agrave; l&rsquo;utilisation judicieuse de la r&eacute;sistance acoustique. Peu de temps apr&egrave;s, j&rsquo;ai achet&eacute; ma premi&egrave;re paire d&rsquo;&eacute;couteur interne qui, entre autres, me permettrait de tester les gens avec une perte auditive de transmission bilat&eacute;rale avec minimum ou sans masquage. A la m&ecirc;me &eacute;poque, une s&eacute;rie de crochets auriculaires non occlusifs &eacute;taient pr&eacute;sent&eacute;e qui conc&eacute;dait des gains en insertion des fr&eacute;quences basses de 40dB. Ce qui a permis &agrave; nos patients qui pr&eacute;sentaient des cavit&eacute;s masto&iuml;diennes et autres pathologies de transmission significatives, des amplifications substantielles des fr&eacute;quences basses et moyennes sans occlusion du canal auriculaire. La fin des ann&eacute;es 80 a vu l&rsquo;introduction de la protection uniforme de l&rsquo;ou&iuml;e qui est devenu le soutien principal pour les musiciens. Au m&ecirc;me moment, le premier vrai appareil auditif haute-fid&eacute;lit&eacute; du monde est d&eacute;velopp&eacute; et jusqu&rsquo;&agrave; date est meilleur que la vaste majorit&eacute; des appareils auditifs num&eacute;riques pour &eacute;couter la musique. Les derni&egrave;res 20 ann&eacute;es ont vu le d&eacute;veloppement d&rsquo;une gamme de tests accessibles qui vont au-del&agrave; des mesures traditionnelles de l&rsquo;ou&iuml;e. M&ecirc;me si ce num&eacute;ro est d&eacute;di&eacute; aux innovations de Mead et pas &agrave; Mead, je serai n&eacute;gligent si je ne mentionne pas qu&rsquo;il a toujours &eacute;t&eacute; pr&ecirc;t &agrave; r&eacute;pondre aux questions et pas une seule fois m&rsquo;a-t-il dit que j&rsquo;&eacute;tais absurde quand je posais des questions absurdes. Le site web de sa soci&eacute;t&eacute; &ndash; www.etymotic.com, est une mine de renseignements qui sont disponibles pour tous, avec une s&eacute;rie articles (sous publications) touchant virtuellement tous sujets. J&rsquo;ai la vision d&rsquo;un cours de lecture de deuxi&egrave;me cycle universitaire con&ccedil;u pour lire chaque article sur le site et il serait probablement vot&eacute; le meilleur cours de tous les temps. Dans ce num&eacute;ro, une gamme d&rsquo;articles courts de personnes qui, sur les derni&egrave;res 30 ann&eacute;es, ont travaill&eacute; directement avec Mead pour d&eacute;velopper l&rsquo;innovation dans le domaine de l&rsquo;audiologie. Chacun raconte l&rsquo;histoire, les raisons de l&rsquo;innovation, et dans plusieurs cas, une vue en profondeur de la fa&ccedil;on de travailler de Mead. Nous sommes aussi privil&eacute;gi&eacute;s d&rsquo;avoir la permission de r&eacute;imprimer plusieurs des articles importants de Mead. Parmi eux, la premi&egrave;re page de &ldquo; Les options d&rsquo;embouts auriculaires pour les appareils auditifs &agrave; bande large&rdquo; dans Journal of Speech and Hearing Disorders, et les articles au complet sur les capsules protectrices pour les musiciens ER-15 (marque de commerce) et l&rsquo;appareil auditif K-AMP&reg; dans The Hearing Journal et Hearing Instruments.</p>\r\n<p>Merci Mead.</p>\r\n<p>By Calvin Staples, MSc</p>\r\n<p>I n honour of Mead Killion&rsquo;s contribution to our field I have selected blogs that reflect his work in music and hearing aids..</p>\r\n<p>i WouLd rather not Mention speCifiC hearing aids for MusiC &hellip; here&rsquo;s Why By Marshall Chasin</p>\r\n<p>I received this recent reply to my &ldquo;The &minus;6 dB rule&rdquo; blog entry and thought that I would reply in some semi-specific terms&hellip; Comment: I&rsquo;m a musician (flutist), about to purchase a new set of hearing aids. I&rsquo;ve read several articles by Dr. Chasin and others that tell me that hearing aids are made for speech, not music, and that the peak input level should be high enough for musical sounds. But NOBODY can tell me which hearing aids, of the hundreds of available brands and models would be best for me, a musician with a mild to moderate hearing loss. I&rsquo;m about to spend $5,000 on equipment with no information as to what would work best for me as a musician. My audiologist (not a musician) controls the software, so it&rsquo;s hit or miss on the adjustments. As far as I can see, the software is not available to me to do my  own adjustments. Please tell me exactly which brand(s) and model(s) of hearing aids would be best for me. I actually receive e-mails and phone calls such as this on a weekly basis, and I am hesitant to give explicit answers. An exact hearing aid prescription is a complex endeavour and is not just a listing of electro-acoustic features. There is the entire realm of auditory training, aural rehabilitation, and use of assistive listening devices, not to mention the personal interaction with the hearing health care professional. An exact hearing aid prescription through the Internet would do an end-run around these important aspects. I usually respond by saying that here are some general approaches that work well with music, and that if there is interest, I would be happy to work with your local hearing health care professional. Having said this, here are several semispecific approaches that have been shown to work well with musicians and people who like to listen to music. These two approaches are based on ensuring that the more intense components of music do not overdrive (or distort) the front end of the hearing aid. This typically refers to ensuring that the analog to digital (A/D) converter is not overdriven since most A/D converters cannot handle inputs in excess of 96 dB SPL. This is equivalent to, as our reader states, &ldquo;the peak input level should be high enough for musical sounds.&rdquo; In some sense, analog hearing aids of the 1990s such as the K-AMP&reg;, were (and still are) much better for music than most of the modern digital hearing aids.</p>\r\n<p>There are essentially two technical routes. 1. Reduce the sensitivity of the low frequency region of the hearing aid microphone. This can be implemented in a wide range of hearing aids regardless of the manufacturer. A low cut (or &minus;6 dB/octave) microphone is less sensitive to the intense low frequency components of the music, such that intense low frequency fundamental musical energy is reduced at the level of the A/D converter. In turn, this intense low frequency energy enters the ear canal directly, by-passing the hearing aid completely. Understandably this is best for those who do not require significant amounts of gain and output in the lower frequency region, and these clients are typically fit with a non-occluding ear mold. It is a low-tech innovation that preconditions music such that we can reduce the probability of front-end related distortion. 2. Alter the operating range of the A/D converter. There are currently two approaches to accomplish this. One is to &ldquo;auto-range&rdquo; the front end which means that the operating range of the A/D converter keeps changing depending on what is entering the hearing aid. This technology derives from a third party manufacturer of IC circuits and is called HRX, or &ldquo;head room extension.&rdquo; This is a trademark of a gem of a company who sells their components to virtually every hearing aid manufacturer in the world. Up until recently, it was called Gennum, then Sound Design, and has since been purchased by On Semi Conductors. This HRX technology serves as the basis behind the modern version of the KAMP, called Digi-K, as well as many other manufacturer&rsquo;s products. Another &ldquo;alter the operating range of the A/D converter&rdquo; approach is a modification of the front-end that simply allows inputs of up to 115 dB SPL to get through the hearing aid undistorted. Most 16 bit hearing aids have a maximum capability to handle inputs of 96 dB SPL, but actually the &ldquo;true&rdquo; science is that 16 bit hearing aids have a 96 dB &ldquo;dynamic range.&rdquo; Nobody said that this range needed to go from 0 dB&ndash; 96 dB SPL&ndash; just that the range between the quietest and the most intense had to be 96 dB. This alternative implementation allows inputs from 15 dB SPL to 111 dB SPL- everything is shifted up by 15 dB&hellip;. Still a 96 dB dynamic range, but the range is now more appropriate for music. Feel free to share this blog with your hearing health care professional. These two approaches are very useful for music but there is more to a hearing aid than these technical front end innovations. And I would be happy to discuss the specifics of which hearing aids have these technologies with the hearing health care professionals involved in your care.</p>\r\n<p>By Marshall Chasin</p>\r\n<p>I f you look through the literature, there are literally tons (or in Canada, tonnes) of articles about the noise levels measured in an orchestra. I am certainly guilty of this and have been doing this since the mid-1980s. But, am I wasting my time? Does it really matter whether the sound level in a large string section is 104 dBA or 102 dBA? Our recommendations and actions will still be the same &hellip; wear hearing protection, at least while rehearsing if not all of the time; and perhaps some environmental strategies (see a recent blog on moving the entire orchestra back 2 meters from the lip of the stage). What about a sound level measurement of 106 dBA or 99 dBA &ndash; again, will this really change what we have to say? I may sound cynical but why do things that don&rsquo;t really matter. Further, it&rsquo;s not only the intensity but also the duration, hence it&rsquo;s the dosage of their music exposure that really counts. A 100 dBA exposure for 15 seconds is not damaging, and with proper hearing protection, 100 dBA may not contribute at all to the music exposure dose (e.g. 100 dB &ndash; 15 dB = 85 dB).</p>\r\n<p>If we are lucky enough to get the attention of a large orchestra or even a rock band whose members want to protect their hearing, at most we will have one hour&hellip; perhaps during a rehearsal, or an intermission, or preshow sound check. Hearing loss prevention is important, but it should not disturb a performing artist&rsquo;s preshow routine, whatever that may be (and it can be quite odd&hellip; I have been doing this for about 30 years now and some &ldquo;routines&rdquo; are not all that routine). Here is a list of priorities that I have found to be useful in the education of the musician, and you won&rsquo;t find a sound level assessment among them:</p>\r\n<p>1. Explaining that intense music is not necessarily loud music.</p>\r\n<p>2. Alleviate their fears that hearing protection will take away their music- usually when it comes to music, &ldquo;less is more.&rdquo; A 15 dB reduction (e.g. ER-15) means that they can be exposed 32 times as long.</p>\r\n<p>3. Moderation- Explain that loud music is OK from time to time &ndash; if your favourite song comes on, turn up the volume; just reduce it afterwards.</p>\r\n<p>4. It&rsquo;s fine to relocate the amplifier/speaker, or even put the trumpet players on risers. I have it on good authority that Mozart would have done this if he were alive today.</p>\r\n<p>Assessing the sound level in the horn section doesn&rsquo;t really add to anything. Having said this, it can be fun sitting in a professional orchestra during an actual performance if you&rsquo;ve never done this before. Usually orchestras don&rsquo;t mind AS LONG AS YOU WEAR ONLY BLACK, and don&rsquo;t bring a tape recorder. You want to leave the musicians (and the management) with the feeling that some simple things can be done, and in most cases, this will not be expensive. Hearing protection (and its verification) is a one-time expense and many orchestras can build that into their operating budget &ndash; it may take a year to obtain approval but your ally is the musician who needs to sit downwind of the trumpets or near the tympani. &ldquo;Politically&rdquo; there may be an advantage for doing a noise assessment, perhaps to demonstrate that something needs to be done, but I have found that most musicians (classical and rock) are now pretty much aware that hearing loss is a potential issue in their job. Once your  foot is in the door though, I wouldn&rsquo;t waste time measuring something which is well documented and whose results will not end up changing your recommendations.</p>\r\n<p>Just my 2 cents worth (which I should point out is almost 2.1 cents US with the current Canadian/American exchange rate). Etymotic Research (www.etymotic.com &hellip;. and no, I am not a share holder) has a wonderful program called Adopt-ABand. They have a nice listing of some of the sound levels from a marching band (along with the contribution to the daily music exposure dose). Here is a sampling: Mellophone* 92&ndash;111 dB Flute 100&ndash;112 dB Piccolo 102&ndash;112 dB Snare drum 102&ndash;113 dB Clarinet 93&ndash;119 dB Cymbals 118&ndash;121 dB * I have no idea what a &ldquo;Mellophone&rdquo; is but it sure sounds loud!</p>\r\n<p>Of topics that are confusing to many who fit hearing aids are the distinctions between the TK Control, WDRC, and Expansion. Understanding the differences between these and how they are used for providing appropriate amplification is a critical part of hearing aid selection and consumer satisfaction.</p>\r\n<p>Basics Basic definitions to help in understanding these differences:</p>\r\n<p>1. Linear Amplification: 1:1 input/output ratio. 45 degree angle.</p>\r\n<p>2. Compression: Less than 1:1 amplification. Less than 45 degree angle</p>\r\n<p>3. Expansion: Opposite of Compression. Greater than 1:1 amplification. Greater than 45 degree angle. One way to control the potential for circuit noise or feedback in quiet environments. It is easier to implement this action in digital than in analog.</p>\r\n<p>4. WDRC (Wide Dynamic Range Compression) = input compression having a low knee point.</p>\r\n<p>5. TK Control: One way to adjust the compression of a WDRC AGC aid to avoid circuit noise or to reduce feedback in quiet environments.</p>\r\n<p>6. TILL: Trebel increases at low levels.1 WDRC vs. Expansion Study the two graphs in Figures 1 and 2. They show Expansion versus WDRC two different ways &ndash; first with respect to output, and second, with respect to gain. Figure 1 shows the comparison in the more traditional way, The WDRC curve shows 40 dB gain (0 dB input and 40 dB output = 40 dB gain, as does a 20 dB input and 60 dB output, etc.) up to the knee, after which amplification becomes a 2:1 compression, or 1 dB out for each 2 dB input. So, the WDRC has the same amount of gain (40 dB in this case) from soft up to the knee. Very soft inputs are amplified to 40 dB. Under these circumstances, all soft sounds are made louder, including the mic noise (about 25 dB SPL). An additional problem occurs with WDRC in that in quiet a person may experience a hissing sound, or even feedback, but not when the signal input is stronger. Again, the reason for this is because the aid has maximum gain for soft sounds (40 dB gain in our example). In hearing aids that have a TILL processor (K-AMP and almost every other aid that says it makes soft speech loud and loud sounds soft), the maximum gain is in the high frequencies, just where feedback is most likely to occur. On the other hand, the expansion shows that at 20 dB input there is 40 dB output, or a gain of 20 dB. This is half the gain of the WDRC, and as a result, soft sounds are not amplified to the same extent as is the WDRC managed signal. At 40 dB input the output is 80 dB, which is now a 40 dB gain, the same at this point as the WDRC had from 0 dB input. So, you can see that expansion has its greatest amount of gain exactly at the knee point, and less gain for softer input signals.</p>\r\n<p>A way to adjust the AGC (compression) of an aid This controls gain for soft input sounds only by adjusting the compression kneepoint over a relatively low input level range (typically from about 40 to 55 dB). As such, it is a gain booster for soft sounds. So, if there is too much circuit noise heard for soft sounds, move the kneepoint to a higher value, which will result in less gain for soft sounds. However, it will not affect the level of the MPO.</p>\r\n<p><strong>Reference</strong></p>\r\n<p>1. Killion M, Preves D, and Staab W. Classifying Automatic Signal Processors, Hearing Instruments 1990:41(8):24&ndash;26.</p>\r\n<p>Music is what feelings sound like (author unknown). Music is poetry in the air (Richter). And once you have experienced music, it becomes fundamental to life. ?What sound would you miss most if you couldn?t hear it anymore?? I ask this to elementary students receiving Sound Sense, a presentation on hearing loss prevention.</p>\r\n<p>?Music!? they yell. They are smart, these kids, because people with acquired hearing loss often mourn for the ability to enjoy music as they once did. As a descendant of song-and-dance men and hymn-singing preachers, music is in my blood, and a source of both joy and grief. When the hearing-music gods are aligned, I can listen with pleasure. But when hearing barriers kick in, it can be emotionally painful. I can?t carry a tune. My mother said I had the unique ability to sing a four-line song in four different keys. I attributed this to my hearing loss, until I met hard of hearing people with perfect pitch (Damn them!). But I sing anyway, and I sound great, to me. And as Cervantes said, he who sings scares away his woes.</p>\r\n<p>Singing is one thing, listening is another. Making out the lyrics is often impossible, because I can?t understand words if I can?t see them. Background instruments turn lyrics into soup, so through the years I have unconsciously developed my own lyrics for favourite songs, most of which are nonsense-verse and bear no resemblance to the song title. I remember when music came alive for me; I discovered the power of print translation one glorious day when I was 10. Inside a boxed set of Gilbert &amp; Sullivan?s ?The Pirates of Penzance,? I found the complete libretto along with the recordings. What a treasure! For the first time in my life, I could understand the music, following along with my very own script, drinking in every note and word. Although it would be years before I saw printed lyrics again, I soon found another way to ?get the words? ? through the lips of my sister Louise. We would lie on the floor by the radio, face to face, and I would make her sing along with the songs. Once I saw the words on her lips, they made complete sense from then on. This process wasn?t as meaningful for my sister, however, and I sometimes had to lie on her to make her sing. Or I?d play the poor-hard-of-hearing-kid card, and put up such a fuss that my mom would yell, ?Louise, sing to your sister this minute!?</p>\r\n<p>Orchestral music has always been a joy, even when my hearing can?t differentiate the instruments; I need a strong melody line. If the violins or flutes carry the melody too high, the music seems to just disappear until the notes ?come back down.? When I go to the symphony, I find myself watching the musicians? physical movements to see who is producing which sounds ? it?s somewhat like reading lips. Listening to classical music in the car gives me personal surround sound, and I sometimes just drive around, soaking it up. Today, hearing aids and assistive technology have given me new access to music, although discerning the lyrics and different instruments is still difficult. I can take walks listening to my MP3 player via a neckloop, avoiding hydro lines which cause buzzing. And, with better hearing technology, I have new breath-stopping moments of music. My young son was playing classical guitar and I sat close by, watching him. I heard every note. The beauty ripped through me in waves and I was grateful, once again, for the power of music. And, once again, I grieved briefly for all the beautiful music that is just beyond the reach of my hearing. So, along with millions of people with hearing loss, congenital or acquired, I applaud every technical advancement that can give us back.</p>\r\n<p>There are many texts on music and hearing loss, but what makes this volume unique is that this book is a book that audiologists can share with their patients who are musicians. It is written in non-technical language for the layman, and begins by explaining how the human ear hears sound. It covers the interplay between music, speech and hearing devices and discusses hearing conservation for musicians. The final chapter contains inspiring narratives from eleven deaf or hard of hearing musicians belonging to the Association of Adult Musicians with Hearing Loss. These 11 stories describe using a variety of strategies to integrate hearing loss and music making. Musicians new to hearing loss, hearing-impaired adults wanting to learn a musical instrument, audiologists, music educators, and music researchers will also find this book a valuable addition to their library collection. Edited by Cherisse Miller, DMA., this collaborative work is written by audiologists Dr. Marshall Chasin and Dr. Brad Ingrao, and includes stories by 11 adult musicians with hearing loss who are members of the Association of Adult Musicians with Hearing Loss (AAMHL).</p>\r\n<p>The editor, Dr. Cherisse Miller is a pianist, organist, and Music Teacher?s National Association certified piano teacher. In 2009, she obtained her doctor of musical arts in piano pedagogy at the University of South Carolina. Dr. Miller has published two online journal articles for Pedagogy Forum in 2002 and The Hearing Review in 2009, where she discusses the challenges and strategies of musicians with hearing loss. Her dissertation is titled Musicians with Hearing Loss: A Basic Guide for Teachers and Performers. Dr. Marshall Chasin is the director of auditory research at the Musicians\' Clinics of Canada in Toronto, the coordinator of research at the Canadian Hearing Society, and the director of research at ListenUp! Canada. Dr. Chasin has been involved with hearing and hearing aid assessment since 1981, having graduated with a master?s of science from the University of British Columbia. He has authored several books on hearing, hearing aids, musicians and noise exposure and over 100 clinically based articles. In 2003, he obtained his AuD from the Arizona School of Health Sciences. Dr. Brad Ingrao has a long history of responding to the needs of consumers, parents and colleagues through his participation on over a dozen hearing loss-related listservs and a pro-bono website for parents. As the coordinator of audiology information services of the Hearing Instrument Manufacturers\' Software Association, he addressed quality and accessibility issues in software used for fitting hearing aids. Dr. Ingrao is now principal audiologist and consultant for www.e-audiology.net</p>\r\n<p>By Marshall Chasin, AuD Editor-in-Chief</p>\r\n<p>Marshall Chasin: The first time that I heard your name was when I was reading the 1981 JSHD article on &ldquo;Earmold Options for Wideband Hearing Aids&rdquo; (Journal of Speech and Hearing Disorders 1981;46[2]:10&ndash;20). Was that part of your PhD? Mead Killion: No that was before my PhD. I was interested in earmold acoustics for years to achieve a sufficient amount of gain in the high frequencies, and most of the hearing aids at the time clipped badly in the higher frequencies so the distortion with louder inputs such as a cocktail party, would significantly reduce speech intelligibility. I became interested in this back in the 1960s about the same time that Dr. Keller (a German researcher) wrote that it was too bad that the Knowles transducers of the time had so many peaks in them because that degraded the sound quality of the hearing aids. I had already shown that the peaks were not in the hearing aid but in the tubing (tubing related resonances) and Hugh Knowles and I were sufficiently concerned about this at the time that we co-authored a paper (&ldquo;Frequency Characteristics of Recent Broad Band Receivers.&rdquo; Knowles HS and Killion MC. Journal of Audiological Technique 1978;17:136&ndash;40) showing that with sufficient damping and an acoustic flaring (plumbing) or horn, we could obtain a flatter frequency response. I wanted to call it acoustic plumbing but Hugh thought otherwise: He didn&rsquo;t like the image it evoked.</p>\r\n<p>MC: Starting with the 1981 JSHD article and with the subsequent advent of earmolds with great names such as the 8CR, and 6R12, you seemed to feel that an acoustic high frequency amplification was probably better than an electrical one. Do you still feel that this is the case? MK: It was only true when most hearing aid amplifiers clipped badly at high frequencies. That problem was solved in the late 1980s with the advent of the class D amplifier, and continues to be solved with the switching output stage in digital hearing aids. Before that, the common class A amplifier required either an excessive amount of battery drain or they use receivers with so many turns on the coil that they &ldquo;voltage clipped&rdquo; when even a moderately loud high-frequency sound came along. (If you recall, with a Class A amplifier, half of the peak current is on all of the time, continuously draining the battery even in a quiet environment. That&rsquo;s why one could predict exactly the battery life of these old-style hearing aids regardless of the level of the input and the volume control used). Back in those days, it was always better to have the acoustic plumbing pick up 8&ndash;10 dB, which required only onethird the output voltage (roughly one-tenth the power) at high frequencies. I always enjoyed Hans Bergenstoff&rsquo;s answer to an audience question in Chicago in 1980: &ldquo;You could get the same response with electrical equalization, but that would be like driving a car with one foot on the brake and one on the gas.&rdquo; Switching amplifiers are so efficient that you could (and still can) afford to do that, although some modern hearing aids could still use the response smoothing of a good horn earmold. MC: Most people know you as an audiologist, but prior to that they would have known you as an engineer. Yet, I understand that you were a mathematician and never took any engineering classes. MK: That&rsquo;s true in terms of formal classes. I have an undergraduate and a master&rsquo;s degree in mathematics. For my master&rsquo;s thesis my professor gave me what I thought was an interesting problem and I solved it in two weeks. I brought it back and was told that it wasn&rsquo;t very interesting. He then gave me what I thought was an impossible problem involving two-dimensional surfaces in four-dimensional Euclidean space. I worked on for five years, at the end of which I finally found a way to solve it. My professor liked it so much he had me defend it twice before the faculty. There were two parts to the problem &ndash; an easy part and a difficult one. He suggested I use the easier part for my master&rsquo;s and the more difficult part for my PhD dissertation. I might have become a mathematician, but in the course of solving that problem, I realized that I didn&rsquo;t like pure mathematics nearly as much as engineering and its applied mathematics.</p>\r\n<p>MC: What led you to discover our field? MK: I found a technical job working for an engineer&rsquo;s engineer named Elmer Carlson, director of engineering at Industrial Research Products (a Knowles Company). He was a wonderful inventor and mentor, and even more of a mathematician than I was. After 21 years under his teaching, in 1983 I decided to try my own wings and started Etymotic Research. I started it knowing that 80% of new businesses did not succeed, but only later found out later that those were mostly restaurants; and in fact 80% of new businesses started by engineers who had previously designed saleable products, succeeded. MC: Tell me about Elmer Carlson and what was to become known as the ER15 musicians&rsquo; earplug. MK: Elmer became interested in the fact that a lot of people required less attenuation and a flatter frequency response. I believe that it was Larry and Julia Royster that were quoted as saying that only about 1/3 of the workforce needed any hearing protection at all, and that 3/4 of those needed less than 10 dB of attenuation. So, Elmer thought a moderate-attenuation, say 15 dB reduction, earplug would be useful for almost everyone, even in industry, but especially for musicians. Being the superb acoustician that he was, he designed such an earplug. When Elliott Berger tested it in his EAR-CAL laboratory years later, he found that it was indeed flat, within 1&ndash;2 dB dB or so from 80 Hz to 16,000 Hz: What we now call the ER15 Musicians Earplug reduced the pressure at the eardrum by almost exactly 15 dB, compared to the open ear, at all frequencies. It stayed on the shelf because it appeared that the market for such an expensive earplug would be too small to justify the cost of introducing it. Fortunately, one of the viola players in the Chicago Symphony Orchestra ended up with a frightening temporary threshold shift after a concert where 200 musicians and singers were so crowded on stage that his head was almost in the bell of the trombone player behind him. He and a couple colleagues formed a &ldquo;sound level committee&rdquo; which resonated (sorry) across the county. I was invited to be a consultant, and once attended a meeting with the orchestra directors and union representative from the six major U.S. symphonies. After that meeting I approached Knowles about the Carlson earplug, and they very generously licensed it to us to produce under the Carlson patent. He himself was quite modest, and strongly declined to have it called the &ldquo;Carlson Earplug,&rdquo; so we decided to call it the Musicians Earplug. Oddly enough, some viola players who thought that that was too much attenuation, and we later came out with the ER-9 following Elmer&rsquo;s basic approach. Still later, several drummers said that for jazz and orchestral work the ER-15 was fine, but it wasn&rsquo;t enough for rock. (Even unamplified, a drum can be beaten within an inch of its life to produce 135 dB peaks, as demonstrated to us recently by one of our engineers!) MC: Before continuing on with the &ldquo;ER&rdquo; or &ldquo;K&rdquo;-prefaced other innovations, I recall in the mid-1980s you came out with a series of odd looking ear hooks, one of which was called the K-Bass (or Low-Pass) ear hook, which would allow significant (40 dB) low frequency gain with a non-occluding fitting. I have used it often for those with chronic middle ear dysfunction who require both low frequency amplification and a nonoccluding vented hearing aid fitting. MK: It&rsquo;s ironic because we are now seeing people lecturing that we can only get high frequency gain and output with a non-occluding tube fitting. The &ldquo;KBass&rdquo; hearing aid was our first product in 1983, designed for someone with normal high frequency hearing which you didn&rsquo;t want to interfere with. We started with an old Zenith power behind the ear hearing aid that could deliver 135 dB at 125 Hz. Even with the 20 dB loss for an open mold fitting, that still left 115 dB undistorted output at that frequency (which is more than some aids have now). We then coiled a long, small, tube inside the hearing aid to resonate the low-frequency response. An open-ear fitting naturally rolls off the lowfrequency response at 6 dB per octave. In the final K-Bass design, the 2 cc coupler response rises at 6 dB per octave to compensate, with the result that a nearly constant 20 dB of gain was obtained from 150 to 1,500 Hz with a nonoccluding tube fit. Chuck Berlin and I joked that it should have been called the Killion/Berlin ear hook since he asked if it could be done for one of his patients. The idea of a low frequency fitting with an open canal seems to have been lost but it&rsquo;s entirely practical, even now.</p>\r\n<p>MC: Would this be able to be redesigned to give you a broadband signal with an open mold tube fit, using today&rsquo;s feedback management systems? MK: Yes. It wouldn&rsquo;t be able to fit into something as small as a pea, but if you had any of the broadband high-gain, high-power, behind the ear hearing aids commonly used for children, this can be done. With digital equalization it would be trivial to shape the frequency response in order to compensate for the roll off in the lower frequency region.</p>\r\n<p>MC: Moving to 1988 you had developed the K-AMP&reg; hearing aid (with the invaluable assistance of fellow Canadian Bill Cole of Etymonic Design). What led you to this when there were already many hearing aids available for almost any use? Specifically what led you to design a hearing aid that could reliably transduce inputs of 115 dB SPL- the limit of modern hearing aids microphoneswhen the most intense components of speech was around 90 dB? MK: We invited about eight people to help consult and design various parts of the K-AMP&copy;, including Bill Cole, Norm Matzen and some semi-conductor people. The ability of a hearing aid to handle an input of 115 dB such as many forms of music has always been a design criterion at Etymotic Research, right from the breadboard stage. If it couldn&rsquo;t handle my piano playing or violin playing, it wasn&rsquo;t even considered. Even speech is misunderstood, I believe. The typical (even now) 90 dB maximum input in many hearing aid designs is enough for conversational speech, but not for many social gatherings. I recall Margo Skinner lecturing in Texas that the maximum speech levels were about 80 dB. That night at a Country and Western dance, she was talking across a picnic bench to a colleague and I held a sound level meter to the colleague&rsquo;s ear. It measured peaks of 95 dB. (Mild mannered Margo, indeed!) A 95 dB peak on a SLM corresponds to 105-110 dB instantaneous peak on an oscilloscope. A hearing aid that clips at 90 dB is wildly distorted at 110 dB inputs. A wonderful study by Naidoo and Hawkins in the Journal of the American Academy of Audiology (Monaural/Binaural Preferences: Effect of Hearing Aid Circuit on Speech Intelligibility and Sound Quality&rdquo; 1997;8[3]:188&ndash;202) uncovered the reason many users reported they took off one hearing when they were in high-level noise: they heard better with only one distorting hearing aid! When there was not distortion, they preferred two. MC: If you&rsquo;ll forgive me, we started talking about music levels and ended talking only about speech levels.</p>\r\n<p>MK: You are quite right. Marshall, you yourself have repeatedly reported that many modern hearing aids are totally unacceptable to musicians, and your reports go back 10&ndash;15 years and still continue. Just last month we at Etymotic tested three digital aids at the request of a friend at a hearing aid company. The most recent design distorted the most on simple piano playing. Similarly, we sent some electronic BlastPLG earplugs to members of the National Symphony Orchestra, after I confirmed that they didn&rsquo;t distort on my own loud-aspossible playing. The orchestra musicians liked them but complained that they distorted on loud passages. (Which shouldn&rsquo;t have surprised me: It seems only fair that musicians in a worldclass orchestra can play a violin or trumpet much more loudly than an amateur can!) MC: That is interesting and consistent with my own experience fitting musicians at our Musicians Clinics of Canada here in Toronto, but I was hoping you would talk about what you did in the K-AMP design that changed that. MK: I believe we were the first in the industry to use a balanced-input operational amplifier for the input stage (similar to mixing boards) that could handle 200&ndash;300 mV peaks at the input. That corresponds to 116&ndash;120 dB instantaneous peak into a typical microphone. (By the way, that input cancelled cellphone interference, so when digital cellphones came into use the K-AMP amplifier was already immune. We didn&rsquo;t plan on that, but it was a nice bonus.) But in order to make use of that input capability, it is important not to throw it away by amplifying loud sounds. Since most people need little or no amplification for loud sounds, the basic K-AMP design carried the undistorted reproduction from input to the ear. MC: I would have thought you would also have mentioned that you and your design team did all that with only 300 A of battery drain, so hearing aid batteries could last for weeks. Are you as happy with the Digi-K as you were with the KAMP? MK: I&rsquo;m happier with the modern DigiK in the sense that it allows you to come as close to perfection as possible. In 45 seconds after it is placed in a 16 kHz soundbox, the Digi-K software measures the response, flattens all the microphone, receiver, and tubing peaks within a dB or so, and then introduces the appropriate BTE, ITC, or CIC CORFIG. Whatever goal you set for the frequency response, this approach does it better. MC: I want to return to something that you just touched on regarding microphones. Electret microphones were invented by G.M. Sessler and J.E. West. (Journal of the Acoustical Society of America 1966;40[6]1433). But we don&rsquo;t think of Mead Killion when it comes to electret microphones &ndash; I understand that you were involved in the miniaturization of the electret microphone that makes it useful for modern hearing aids.</p>\r\n<p>MK: Yes, and I am a friend of Jim West and followed his work. The first wideband microphone I helped design at Knowles was a ceramic microphone that had an 8,000 Hz bandwidth. This doubled the bandwidth of many magnetic microphones. We chose ceramic at first because that was a known technology and knew we that we could make a reliable microphone. It had the disadvantage of having a greater sensitivity to vibration. As soon as that was in production we started on the development of a stable miniaturized electret microphone. Usually when I had a design problem I showed it to Elmer Carlson who turned the problem around and clarified it and made it simple. That&rsquo;s why Elmer Carlson&rsquo;s name was usually first on any patent. In this particular case the problem was to get a stable structure for the microphone that would not be temperature and humidity sensitive. Instead of stretching the diaphragm it almost was a free-floating one sitting on a bunch of bumps. That structure allowed the microphone function to be essentially free of temperature and humidity. This was a very stable structure and if you put it in a case that was slightly larger, one could show that the internal noise was lower than that of the human ear. The much smaller microphones that are made now come close: Masking level equivalent to about 5 dB HL, which we have extensively confirmed with our BlastPLG earplug units.</p>\r\n<p>MC: If you open up one of your insert earphones that are used for audiometry and research, you see Elmer Carlson&rsquo;s handiwork staring out at you. He invented the twin tube approach, didn&rsquo;t he? MK: It&rsquo;s nice to have someone remember that innovation, perhaps Elmer&rsquo;s most brilliant. The hearing aid problem he was thinking about at the time was that you can&rsquo;t damp those nasty tubing resonances completely unless you put the damper at the end of the tube, which is the worst possible place to put it in an earmold from the standpoint of earwax (more about that problem below). His hero, Oliver Heaviside, had solved the electrical problem of resonances in telephone lines by realizing that a resistance placed at the end of an electrical transmission line could smooth the frequency response completely if the resistance equalled what he calculated as the &ldquo;characteristic impedance&rdquo; of the line. (Incidentally, Heaviside was kicked out of the British Royal Philosopical Society after demonstrating that those who said he was wrong were dunces. He also patented coaxial cable whose advantages can be viewed with a quick Google or Yahoo search.) MC: That is interesting but what does it have to do with Elmer Carlson and his twin-tube damping method. MK: Sorry, but you are the first one who has shown an interest in this great stuff. Anyway, Elmer knew all of Heaviside&rsquo;s mathematics and also understood they applied to acoustics as well. The characteristic impedance of an acoustic tube is 41/area cgs Ohms. Thus the ubiquitous #13 tubing, which has an I.D. of about 0.2 cm (0.193 cm to be exact), can be readily seen to have an acoustic impedance of 1,400 Ohms. A common damper of 1,500 Ohms is close enough to smooth the response beautifully if placed at the end of the earmold. MC: Mead, you are usually direct. Have you forgotten the original question about twin-tube damping.</p>\r\n<p>MK: Patience, my Canadian friend. I just stated that 1,400 Ohms at the tip of the earmold would smooth the response beautifully. But I also stated earlier that a damper in that location would be exposed to earwax: The hearing aid might sound beautiful for a while and then quit sounding at all! What Elmer realized, in a wild burst of intuition, was that you could add an auxiliary tube, so you have two tubes, the normal sound tube that is open at the (earcanal) end, and a &ldquo;peak cancellation tube&rdquo; blocked at its end. If you used two 1,400 Ohm dampers (in the example of #13 tubing) one damper at the beginning of the sound tube and one at the beginning of the blocked tube, the combination would have a perfectly flat response. MC: What if that damper is right for smoothing the tubing resonances but is the incorrect value for smoothing the receiver response? MK: Wonderful question. Here we see Carlson&rsquo;s total brilliance: Since you can choose any tubing you want (look at the wide variety of tubes used with opencanal hearing aids today), you are free to choose the tubing diameter, and thus the damper value, that gives the best damping and shaping of the receiver response. Pretty neat, huh? MC: How has Etymotic Research exploited Elmer&rsquo;s invention, and didn&rsquo;t you need to obtain a license on his patent. MK: Second question first: We were using Knowles transducers exclusively at the time, and that carried an implied license to such inventions &ndash; which we confirmed, of course. Our first use of the Carlson twin-tube damping was in the ER-1 and ER-2 earphones. The ER-2 is the most fun to describe, because it delivers sound to the ear at the end of 10 inches (254 mm) of tubing, and yet produces an eardrum-pressure response on the average ear (as measured on KEMAR and confirmed with probemicrophone measurements) that is flat within 2 dB from 200 Hz to 12 kHz (and 5 dB from 20 Hz to 16 kHz). It uses a #16 sound tube (1.35 mm I.D.) and thus a 1.35 mm pre-formed stainless steel cancellation tube of exactly the same length wound inside the case. The reader can readily calculate the dampers we use. By the way, it is unlikely that the sound tube will become clogged with earwax because the foam eartip is replaced with each use.</p>\r\n<p>MC: What other uses has the twin tube approach been put to, and how have you been involved in them? MK: The second twin-tube product was our ER-7C probe microphone, which also uses a coiled cancellation tube inside the case. The ER-7C uses a 0.5 mm ID tube with 0.97mm O.D., so it will fit in  the smallest vent holes or around the earmold. In this case, the dampers are so tiny that the manufacturer who makes them calls them &ldquo;no see ums,&rdquo; but this allows us to provide a flat response (with some simple electrical equalization to compensate for the attenuation of sound in small tubes) from 200 Hz to 10 kHz. We continue to provide these units for hearing research and hearing aid research. MC: You really like Carlson&rsquo;s idea! MK: Absolutely. We used basically his approach in the ER-3 insert earphone, which was our first product that anyone wanted. Indeed, we were looking at closing the doors until Nicolet placed a large order for ABR applications. With the ER-3 earphone we needed more power, but not as much fidelity because we only wanted to mimic the TDH-39 audiometric earphones. In that case we found we could produce more output (less loss) by using a &ldquo;lumped element&rdquo; version of the twin tube. Elmer has taught that you could use acoustic mass elements (tubing) and acoustic compliance elements (volume) to give a close approximation to the pure twin tube transmission line. The result looks like sausages (volumes) strung on tubes (masses) inside the ER-3 earphone case. Not as pretty, but highly efficient in smoothing the resonances. By the way, the twin tube approach has been used by progressive hearing aid manufactures as well. MC: Speeding forward to the 1990s, you (and Etymotic Research) had been involved in otoacoustic emissions, dosimetry, blast plugs, hi-fidelity earphones, insert earphones. Is there anything that you haven&rsquo;t been involved in? MK: We had the company evaluated several years ago and the evaluator said  that &ldquo;You are the most difficult company to evaluate I have ever seen. You are involved in almost everything. You are not just consumer products; you are not just diagnostics; you are not just hearing protection.&rdquo; But to answer your question, we don&rsquo;t make ABR units and have no intention to do so. MC: And the most important question of all, in the K-Bass, the K-AMP, and the Digi-K, what does the &ldquo;K&rdquo; stand for? MK: Before I answer that question, I want to state that it was the board of directors who urged me to use my own name whenever possible. It didn&rsquo;t take much encouragement, of course. The answer to all of those is &ldquo;Killion,&rdquo; but in the case of the K-Bass aid Chuck Berlin was largely responsible for making such a hearing aid in the early 1980s, and so that might be considered the KillionBerlin hearing aid.</p>\r\n<p>By Allan H. Gross, MA</p>\r\n<p>Allan Gross completed his undergraduate work in speech pathology and audiology at Kent State University, and received his MA in audiology from Case Western Reserve University. He has worked as a clinician, a medical service corps officer and head of an Occupational Health and Preventive Medicine Directorate for the US Navy, a hearing conservation specialist in the civilian sector, and as a consultant in assistive technology to public school systems. He is presently the manager of 3M Auditory Systems, the licensed manufacturer of the E-A-RTONE 3A and 5A Insert Earphones.</p>\r\n<p>The Telephonics Corporation Model TDH-39 supra-aural earphone was the standard headset for the US Air Force during WWII. Ironically, after the war, it also served our veterans and others, in quite a different way; as the standard audiometer transducer for the then nascent field of audiology. Waning in popularity, but still provided along with some new equipment by audiometer manufacturers today, the supra-aural style earphone in an MX41/AR or similar rubber &ldquo;noise occluding&rdquo; cushion has changed hardly at all since its early contribution both to the war effort itself, and in the subsequent understanding and remediation of the auditory consequences associated with that combat. Unfortunately, the persisting limitations of the supra-aural earphone continue to frustrate hearing health care professionals to this day. The limitations include; poor ambient noise exclusion particularly at the lower frequency range, poor inter-aural separation increasing the need for masking of the non-test ear, a limited bandwidth, inaccurate real-ear frequency response, and a headband force that reduces comfort and may collapse the external auditory canal of some test subjects, resulting in falsely elevated threshold responses.1 In addition, as the nature of audiological procedures requires direct and indirect contact with multiple patients and multiple objects, infection control has become more of a critical issue in health care.2 As such, supraaural cushions need to be cleaned for each patient, or disposable earphone covers must be employed to provide hygienic protection. Finally, the supraaural headband, although adjustable, will not always provide an appropriate fit to insure that the test signal is appropriately directed towards the eardrum without reliance on an awkward accommodation for some patients.</p>\r\n<p>For approximately the same number of years that Moses wandered in the desert of Midian, audiometer manufacturers continued to provide TDH-style supraaural earphones with their audiometers as the only readily available transducer for audiometric testing. A technological corner was turned, however, on July 5, 1984, when US Patent Number 4,677,679; &ldquo;INSERT EARPHONES FOR AUDIOMETRY&rdquo; was filed by Mead C. Killion, PhD. It was undoubtedly just one of many worthy of note inventions for which patents had been filed during that year, including the battery driven golf cart, and the Aerobie&trade; flying ring. This particular development, however, that expanded on the work of the late Elmer V. Carlson and Ross Gardener Jr., and facilitated by the development of wideband subminiature receivers, was the dawn of an evolutionary change in the way audiometric testing would be administered in the US, and across the globe. The &ldquo;Method&rdquo;, &ldquo;Stimuli,&rdquo; or &ldquo;Procedures&rdquo; sections of published audiological research gradually began to  specify not only the audiometer make and model used, but also the earphone.</p>\r\n<p>Initially introduced as the ER-1&reg; and ER-2&reg; Tubephones &ndash; high-fidelity, reference-quality insert earphones for research applications - those versions were followed by a standard audiometric ER-3A&reg; Tubephone version which, primarily by virtue of the way it coupled to the ear, resolved or mitigated most of the vexing limitations of the supra-aural earphone noted above. The ER-3A Insert Earphone was designed specifically to mimic the limited real-ear frequency response of the TDH-39 device so that the two transducers could be used interchangeably.3 In 2001 Killion&rsquo;s company, Etymotic Research, in a co-development project with Aearo Technologies, (now a part of 3M Company, and still the sole licensed manufacturer of the identical but rebranded E-A-RTONE&trade; 3A), introduced the &ldquo;next generation&rdquo; insert earphone &ndash; the E-A-RTONE/ER-5A Insert Earphone. Utilizing the existing foam coupler system of the tubephone insured that the same basic calibration procedures applied, and that all the advantages of the original device would be maintained. The E-A-RTONE 5A Insert Earphone provides the additional benefits of no front tubes to replace, an extended high frequency range, increased output capability, and greater ease of foam eartip insertion. The E-ARTONE 3A Insert Earphone and E-A-RTONE 5A Insert Earphone, as currently produced, are illustrated respectively in Figure 1 and Figure 2. The published research to date investigating the relative performance of supra-aural earphones and insert earphones has confirmed that the problems encountered with supra-aural earphones can be resolved or diminished by switching to an insert earphone. Here&rsquo;s why: reduCtion of BaCKground noise With a properly inserted E-A-RLINK (Figure 3) foam eartip as the coupler, the E-A-RTONE Insert Earphone can be expected to provide 30 to 40 dB of ambient noise attenuation; a reduction sufficient to permit testing to audiometric zero in typical office noise levels, and considerably greater than supra-aurals with or without an added circumarual enclosure.4 The greatest difference is in the frequency range below 1,000 Hz, where the effect is most critical. Table 1 shows the difference in decibels between the ears covered ambient attenuation for supra-aural and insert earphones. Reliable thresholds on normal-hearing listeners (to 0 dB HL) can be obtained under field-testing conditions with insert earphones if the ambient noise levels are known to be below 40 to 45 dBA.5</p>\r\n<p><strong>greater inter-auraL attenuation</strong></p>\r\n<p>Arguably, the most valuable advantage to clinicians is the E-A-RTONE Insert Earphone&rsquo;s high inter-aural attenuation characteristic. Insert earphones significantly reduce testing time and complexity by limiting the situations where clinical masking is necessary, and reducing the masking level required when the potential for crossover does exist. When masking is needed, the lower levels that can be employed with insert earphones will reduce the chance for errors.6 Figure 4 illustrates the interaural attenuation advantage of the insert earphone compared to the TDH-39 (supra-aural) earphone.</p>\r\n<p><strong>eLiMination of CoLLapsed CanaL artifaCt</strong></p>\r\n<p>With an insert earphone&rsquo;s foam eartip properly placed in the earcanal, holding it open rather than collapsing it, the problem of canal collapse artifact is eliminated.7</p>\r\n<p>hearing aid seLeCtion Because an insert earphone is calibrated via a 2-cc coupler, and interacts with the ear much like a hearing aid, both maximum output and 2-cc coupler gain requirements for amplification can be determined in less time and with greater confidence compared to an earphone that is calibrated via a 6-cc coupler.5 iMproved hygiene / Less MaintenanCe / Better suBjeCt fit and CoMfort The disposable foam eartips used with the E-A-RTONE Insert Earphone prevent any cross contamination from one ear or one patient to another. There are no headbands or cushions to adjust, clean, and periodically replace, and most subjects are likely to be more comfortable with a lightweight insert earphone connected to the appropriate size foam eartip in their earcanal than with a supra-aural earphone. For the above and other advantages. including improved test-retest reliability, reduced occlusion effect in bone conduction testing, and stimulus artifact resolution in auditory evoked response evaluations that space limitations rule  out describing in more detail herein, those who test hearing with insert earphones, and those who are tested with them, owe Dr. Killion their greatest esteem and appreciation.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. Killion MC. New Insert Earphones for Audiometry. Hearing Instruments 1984;35:45&ndash;46.</p>\r\n<p>2. Bankaitis AU. Infection Control in the Audiology Clinic: Frequently Asked Questions. Audiology Today 2005;17(5):17&ndash;19.</p>\r\n<p>3. Killion MC. Earphones in audiometry. Journal of the Acoustcal Society of America 1988;83:1688&ndash;89.</p>\r\n<p>4. Berger EH and Killion MC. Comparison of the Noise Attenuation of Three Audiometric Earphones, with Additional Data On Masking Near Threshold. Journal of the Acoustical Society of America 1989;86(4):1392&ndash;403.</p>\r\n<p>5. Clemis JD, Ballad WJ, and Killion MC. Clinical Use of an Insert Earphone. Annals of Otology Rhinology and Laryngology 1986;95(5):520&ndash;24.</p>\r\n<p>6. Killion MC, Wilber LA, and Gudmundsen GI. Insert Earphones for More Interaural Attenuation. Hearing Instruments 1985;36:34&ndash; 36.</p>\r\n<p>7. Killion MC and Villchur E. Comments on &lsquo;Earphones in audiometry (Zwislocki et al., Journal of the Acoustical Society of America 1988;83:1688&ndash;89)&rdquo; Journal of the Acoustical Society of America 1989;85(4):1775&ndash;78.</p>\r\n<p>By Elliott H. Berger, MS</p>\r\n<p>Elliott H. Berger, MS, is a division scientist for 3M&rsquo;s Occupational Health &amp; Environmental Safety Division. For over 35 years, Elliott has studied noise and hearing conservation with an emphasis on hearing protection. He has numerous text book chapters and over 60 published articles in the topic area, and chairs the ANSI working group on hearing protectors. Among his favourite sounds is his terrier, Sophie, munching on a sesame brittle treat.</p>\r\n<p>Throughout the first 40 years or so of hearing protector research following World War II, the developments were all about hearing protection, that is, the more the better. This was natural &ndash; after all wasn&rsquo;t protecting hearing what such devices were intended to do? It wasn&rsquo;t until the early 1980s that authors began to ask whether the frequency dependence of the attenuation characteristic, and its amount, might be affected so as to provide better sounding protection and the &ldquo;appropriate&rdquo; level of protection, too. By that was meant an attenuation characteristic that was relatively uniform across the primary portion of the audible frequency range, and designed for the right value of protection &ndash; as opposed to simply the most attenuation possible. This type of attenuation would avoid the muffled sound typical of passive (i.e., nonelectronic) hearing protection. At about this same time Mead Killion was working with the Chicago Symphony orchestra to address their concerns regarding noise exposures of their musicians. He realized that a promising solution to the exposure issue would be a flat-attenuation hearing protector providing a naturalsounding music spectrum. Fortuitously, Mead&rsquo;s mentor, Elmer Carlson (Figure 1), had already conceived of and described such a hearing protector in the late 1970s. It incorporated acoustic elements into a sound channel through an earplug, but Carlson had never produced or marketed the product. Mead was able to license the Carlson patent1 from his employer, Knowles Electronics, and turned the concept into a commercially viable product in 1988 &ndash; the ER-15 Musicians Earplugs&trade;.</p>\r\n<p>A drawing of the product embodied in a custom earmold, and its equivalent circuit, appear as Figure 2, and a photograph of the earplugs appears as Figure 3. As Killion et al.2 succinctly describe, an acoustic button at the entrance to the earplug incorporates a flexible plastic diaphragm that acts as a compliance (C1) and a sound channel (L1) that provides an acoustic mass to form a Helmholtz resonator between the inertance of the sound channel, and  the combined compliance of the flexible diaphragm and the earcanal volume. The resonance can be tuned to about 2.7 kHz, providing the desired boost to offset the loss of the ear&rsquo;s natural resonance at that frequency which occurs whenever the ear is occluded by an earplug. Another feature of the earplug is that it includes a sound inlet to the button (R1 in Figure 2) that is recessed and near the concha floor. This advantageously utilized the ear&rsquo;s natural high-frequency amplification to further offset the earplug&rsquo;s built-in tendency to block more high-frequency sound than lowfrequency sound. And finally, the R2/L2/C2 side branch corrects for a minor dip in response near 6 kHz to provide the flattest possible attenuation.</p>\r\n<p>The elegance of the Musicians Earplugs was well suited to the original intended audience, symphony musicians, but many others both within and outside the music industry, from bar tenders at loud clubs to NASA astronauts on the International Space Station (Danielson 2011, personal communication) have adopted it as well. Whenever modest attenuation and an earplug that sounds natural is required, i.e., just as though the sounds of the world were slightly attenuated instead of unpleasantly filtered, the Musicians Earplugs are a perfect fit. Another valuable application is for those experiencing tinnitus and hyperacusis who need modest good-sounding attenuation to be able to comfortably hear the world.3 They substantially benefit from the ER15, which provides protection yet lets in enough sound to help mask the tinnitus and make it more tolerable. Conventional earplugs not only distort sound, but can also block so much ambient noise that one perceives that the tinnitus is worsened while the plugs are worn. To make the product more affordable and universally available, Mead&rsquo;s company, Etymotic Research, teamed with the E&bull;A&bull;R&trade; brand of Cabot Safety Corporation (now the E&bull;A&bull;R&trade; brand of 3M Company) in a jointdevelopment effort. That work resulted in a premolded eartip version of the Musicians Earplugs dubbed the ER-20 earplugs, today called the HiFi&trade; earplugs as sold by 3M, and the ETY&bull;Plugs&trade; earplugs as sold in two sizes by Etymotic (Figure 4). The ER20 provides much of the performance of the ER-15 at less than 1/10 price and, thus, makes it available to a larger audience. Figure 5 shows the response curves of the two products compared to the attenuation of well-fitted conventional earplugs. Note how both the ER-15 and the ER-20 provide lower levels of protection and, especially in the case of the ER-15, more uniform levels of protection across frequency. My response, when as an experienced user of hearing protection in the late 1980s I fitted a pair of ER-15 earplugs for the first time, was &ldquo;it sounds like there is nothing in my ear.&rdquo; It took me a moment to confirm that I was actually getting protection since the muffled and distorted characteristic common to other hearing protection of that era was absent.</p>\r\n<p>One of the difficulties of promoting a product like the ER-15/20 is that so much of the hearing protection business is driven by the Noise Reduction Rating (NRR), the Environmental Protection Agency required noise rating that appears on all hearing protection in the U.S. Most buyers want as high an NRR as possible, which the ER-15/20 does not provide since it is not intended for high attenuation. Mead responded to this unfortunate more-is-better model of thinking by following the dictum that any self-respecting fallacy should be voiced in Latin. He coined the phrase Parvum bonum, plus melius, meaning &ldquo;a little is good, more is better,&rdquo; and proceeded to argue strenuously against that notion, both in word (&ldquo;If two aspirin are good for your headache, should you take the entire bottle?&rdquo;) and indeed (by purveying the Etymotic line of flat and moderate attenuation earplugs). As an early adopter of the ER-15 earplugs, I have been personally grateful to Mead for commercializing this invaluable product as it has immeasurably increased my listening enjoyment and auditory safety for over 20 years. Thank you, Mead, for an elegant engineering solution, and the willingness to risk the introduction of, what was at the time, such an unusual product.</p>\r\n<p><strong>References</strong></p>\r\n<p>1 . Carlson EV. Passive Ear Protector. U. S. Patent 4,807,612. 1989.</p>\r\n<p>2. Killion MC, DeVilbiss E, and Stewart J. &ldquo;An Earplug with Uniform 15-dB Attenuation. Hearing Journal 1988;41(5):14&ndash; 17.</p>\r\n<p>3. Berger EH. Life Can Be Loud &ndash; Remember Your Hearing Protection. Tinnitus Today 2003;28(1):20&ndash;22.</p>\r\n<p>By Bill Cole</p>\r\n<p>William A. Cole is the president of Etymonic Design, a manufacturer of the Audioscan and Verifit. Bill has been involved in the hearing aid industry for more than 40 years and has been responsible for many of the standards and technologies now in use.</p>\r\n<p>Somewhere on my desk is a small box awaiting my attention. It was sent to me by an old friend along with a note reading &ldquo;I have been informed that this hearing aid can no longer be repaired. I am hoping that you can help because it works better in noisy situations and at the opera than any of the new digital aids I have tried.&rdquo; In the box was a very old K-AMP&reg; hearing aid and its story begins in 1975. In that year, Mead Killion began work on a 2-year PhD in audiology at Northwester University. His research project was the design and evaluation of high-fidelity hearing aids. Considering that the best hearing aids of the time had very limited bandwidth, a mountainous frequency response and high distortion, this was a very ambitious and challenging project. In the 4 years that followed, Mead was able to demonstrate that it was possible, using available hearing aid microphones and receivers and a wearable amplifier, to make a hearing aid that was judged by listeners with normal hearing to be as good, or better, than expensive studio monitor speakers. Mead had already solved part of the frequency response problem when he and Elmer Carlson invented a miniature electret microphone, suitable for use in hearing aids, with a broad, smooth frequency response (US patent 4151480). Smoothing and broadening the response of available wideband hearing aid receivers required the application of known acoustic principles to the coupling system between the receiver and the ear canal. Applying these principles, Mead demonstrated that it was possible to achieve a variety of smooth, wideband responses in both BTE and ITE configurations, including one ITE with nearly flat insertion response from 50 Hz to 16 kHz. The earlevel assemblies were coupled to low distortion body-worn amplifier packs which Mead designed. The &ldquo;how-to&rdquo; information needed to achieve smooth wide-band response was widely disseminated through publications and lectures and Knowles Electronics made available a damped coupling assembly (BF-1743) to encourage manufacturers to improve the response of their products. In the course of his PhD studies, Mead came to the conclusion that there was a large class of people who had nearnormal hearing for loud sounds but had lost sensitivity for soft sounds &ndash; particularly those in the high frequencies. He postulated that, for these people, a high-fidelity hearing aid would be one that provided unobtrusive (i.e., low distortion) high frequency amplification for soft sounds and do absolutely nothing for loud sounds. Mead disclosed the amplifier circuit for such a hearing aid in US patent 4170720. Aside from skepticism of the need for a high-fidelity hearing aid, there were two significant problems preventing hearing aid manufacturers from building such hearing aids &ndash; fitting in the necessary circuitry and finding a place for the AA battery.</p>\r\n<p>Work to solve the first of these problems was begun by Etymotic Research in 1986. It was a task that frequently pushed the limits of technology and human endurance but never compromised the goals Mead had established. I recall arriving at O&rsquo;Hare at 11:00pm and being invited to join the crew for Mexican food at Etymotic where nobody was thinking of calling it a night. And while marvelling at how fresh Mead was at 2 pm the next day, discovering that he had been power napping on the couch in the listening room. It took 3 years and a team of more than 10 designers to develop the K-AMP microchip and its associated circuit module but by the fall of 1989, Etymotic was able to introduce what truly was a breakthrough in hearing aid technology. The solution to the second problem evolved from Mead&rsquo;s interest in Class D amplifiers dating back to 1963. Because of space limitations, the ITE hearing aids of the time used Class A amplifiers which consume a constant battery current. The current required to produce a given undistorted SPL increases with frequency. A hearing aid battery powering a class A amplifier capable of delivering the undistorted high frequency SPL required by Mead&rsquo;s postulated hearing aid would last about 1 day. The Class B amplifiers of the time were much more efficient but were too large to fit the available space. Class D amplifiers were potentially more efficient than Class B and much smaller but nobody had ever designed one for hearing aids. In 1988, Mead Killion did so, under contract to Knowles Electronics, and was granted US patent 4689819. The amplifier was small enough to fit entirely inside the hearing aid receiver and efficient enough to produce the undistorted output needed for a high-fidelity hearing aid.</p>\r\n<p>After wearing prototype K-AMPs for 3 months, Mead felt something was missing and was convinced by Harry Teder of Telex that the answer was something called &ldquo;Adaptive Compression&rdquo; (a Telex trademark). This patented compression scheme provided a release time that varies with the level and duration of loud sounds &ndash; and it was indeed the missing piece. It was licensed from Telex (patent 5144675 was obtained for its use in wide-dynamic range hearing aids) and it became part of every K-AMP circuit. By 1989, all the elements necessary to build the high-fidelity ITE hearing aids that Mead had envisioned a decade earlier, were available to every hearing aid manufacturer. In the months that followed, with tireless enthusiasm, Mead delivered the K-AMP message to dispensers and the hearing impaired through countless lectures and numerous papers and articles. And demand grew. At its peak, the K-AMP hearing aid accounted for nearly 20% of hearing aids sold in the US and Europe. Why was the K-AMP hearing aid so effective? Its smooth, wideband frequency response ensured that muchneeded audibility was not compromised by limited bandwidth and discomfortcausing peaks. This also ensures that the effects of room reverberation were not exaggerated and (for CIC aids) that important localization cues were not masked by hearing aid peaks. Its low distortion over a wide frequency range for input levels up to 115 dB SPL ensured that the high frequency components of speech and music (often at low levels) were not masked by distortion products. The provision of (usually) high frequency gain for soft sounds and a zero gain (usually) flat response for loud sounds compensated for the loss of outer hair cell function. Also important was a compression threshold curve that was the inverse of the gain curve which meant, when adjusted for a high frequency loss, that frequencies that were not being amplified did not cause the gain to be reduced at frequencies where it was needed. All of these features combined with the adaptive-release time contributed to its legendary performance in noise. But, above all, the K-AMP was effective because Mead refused to make the compromises that others were prepared to live with.</p>\r\n<p>By Charles I. Berlin</p>\r\n<p>Charles I. Berlin, PhD, retired on 9/1/02 as professor of otorhinolaryngology, head and neck surgery, and physiology, and director of the world-renowned Kresge Hearing Research Laboratory at LSU Medical School in New Orleans. He is the recipient of the American Academy of Otolaryngology, Head and Neck Surgery\'s highest award, the Presidential Citation; the recipient of the Honors of the Association as well as the Frank J. Kleffner Award for Lifetime Clinical Achievement from the American Speech Language and Hearing Association; and the recipient of the Lifetime Career Research Award from the American Academy of Audiology. He is currently coordinator of the Auditory Neuropathy Spectrum Disorders Program at All Children\'s Hospital, St. Petersburg, FL and clinical professor of otolaryngology head and neck surgery at the University of South Florida.</p>\r\n<p>When I went to professional meetings, I often sought out a piano in order to stay in practice for my (all too infrequent) paying jazz gigs. At the time I was living in New Orleans and playing at least twice a week, sometimes more often on Bourbon Street and at the Fairmont Hotel. When I found the backstage piano my first night there, and played a few notes on it, I found it to be in tune and looked forward to a long and pleasant practice session over the next few days. What was especially appealing about backstage pianos at hotels was that the sound didn&rsquo;t travel very far past the heavy curtains and one was almost always alone&hellip;.allowing reverie, introspection, risk-taking and mistakes&hellip;lots and lots of mistakes. So there I was hoping to indulge in a reverie and make lots of &ldquo;innovations.&rdquo; I was frankly put out when I went back  stage the next day and found this bald dude with a mustache playing on MY piano, and without permission! But he was pretty good, so I listened a bit and then sort of easily slid into a four hand piano playing mode, where he played the bass and I the treble, and then we switched. The hours just flew by and we had a great time. I told him my name was Chuck, and he said something than sounded to me like &ldquo;Mead&rdquo; and I said to myself &ldquo;That&rsquo;s a drink made of honey, we should play Honeysuckle Rose.&rdquo; And we did. I excused myself to go to a meeting, and he did the same.</p>\r\n<p>Then we both sat in the front row to hear a talk on &hellip;whatever&hellip;which is when we found out we were in the same profession and field. However, it was the piano and jazz that made us fast friends forever. The collaborations on hearing projects were just icing on a delicious cake. (And when Mead married Gail, it was a startling friendship because our spouses bonded as well. So both Mead and Gail are among our best friends and Gail is my special link to the Basics in my life.) Mead was working at Knowles at the time and I learned a lot about his work on wide band hearing aids. Fortuitously we soon thereafter discovered a form of hearing loss where hearing was normal at 10 kHz while it was very poor in the more commonly tested frequencies. How were we going to manage that? Well, some talented people in my lab (Henry Halperin and the late Jack Cullen) hatched an idea to build a frequency shifting aid that moved low frequencies up to high. But what were going to be the tranducers? Killion to the rescue with Knowles B1912 transducers! He made the first  shells and mounted the transducers in them which went out to 16 kHz. A remarkable technical achievement for the 1970s and even today. It was a huge success with these patients and we soon published some germinal, but now mostly ignored papers, on ultra audiometric hearing. Mead, Linda Hood, and I also published a FUN paper on an open ear fitting for LOW frequency losses! It was called the K-Bass aid where the high frequency output of a power aid was muffled by a special ear hook, the open ear allowed the high frequencies through which were heard normally, and there was a comfortable but not overpowering low frequency amplification for the 10 or so patients who were candidates. One of those patients, the only one who rejected the aid, actually had auditory neuropathy/ dys-synchrony which I only discovered long after the paper was published! It should come as no surprise that Mead, Gail, and my wife Harriet and I travel together from time to time. We especially enjoy a magical place called Chautauqua in upstate New York, where the lectures, the music, and the zeitgeist are just perfect for a group of music-andscience-loving eccentrics like us.</p>\r\n<p>By David Preves</p>\r\n<p>David Preves, who is currently a senior staff engineer at Starkey Laboratories, was a consultant at Etymotic Research in 2001-2002. He is a life member of the International Institute of Electrical and Electronic Engineers, Audio Engineering Society and the American Auditory Society, and is chair of the Acoustical Society of America (ASA) accredited working group on hearing aid standards.</p>\r\n<p>I t has been my pleasure to know Mead Killion as a friend, brilliant engineer, and highly talented musician. If there could ever be a modern day renaissance man, it would be Mead. I have often thought how fortunate our hearing health care industry has been to have the interest and attention of such a talented and caring person. When I began working as a consultant at Etymotic Research in the fall of 2001, Mead and several of his engineers had already begun working on the development of a programmable digital hearing aid circuit that would ultimately become known as the Digi-K. The Digi-K high fidelity hearing aid circuit was an extension of Mead&rsquo;s PhD dissertation work at Northwestern1 and his lifelong belief about the need and feasibility of hearing aids having a smoothly-extended high frequency bandwidth. Mead has long held the belief, which is somewhat controversial, that persons with hearing loss can make use of extended high frequency sounds and can distinguish whether they are present or not. Therefore Mead advocated long ago that hearing aids should amplify at frequencies above 10,000 Hz after he demonstrated 30 years ago that hearing aid microphones and receivers could produce frequency responses out to 16kHz.</p>\r\n<p>In the early 1980s, Mead advocated extending hearing aid high frequency response while he worked as an engineer at Industrial Research Products, Inc.&ndash; the research division of Knowles Electronics. Mead promoted, in concert with hearing industry earmold labs (National Association of Earmold Laboratory Manufacturers), a system of stepped earmolds for behind the ear hearing aids as a way of extending their high frequency response. Perhaps some readers will remember how the individual stepped earmold designs were distinguished in this unique system of earmolds &ndash; for example, 8CR,6R12, 16KL. These devices were essentially miniature megaphones for the high frequency output of hearing aids, working in conjunction with a damping screen placed within the earmold tubing or earhook to damp out peaks to provide a wideband, flattened frequency response. (Mead&rsquo;s 1970&rsquo;s dissertation work involved blind comparative listening tests by hundreds of people at various conventions and speaking occasions rating recordings made on KEMAR of hearing aids with these earmolds against recordings made with high fidelity components. The wideband hearing aid was judged superior in sound quality every time.) One of the main difficulties with the stepped earmolds was the damping screen would become clogged with moisture and debris. Ultimately, the demand for these earmolds waned, and they no longer are being manufactured. For the DigiK introduction (AAA, Philadelphia 2002), Etymotic Research prepared an audio CD containing binaural KEMAR recordings that compared the sound quality of various types of music in the open ear against processed music through seven digital   hearing aids and hearing aids having Digi-K and analog K-AMP&reg; circuits. These same recordings were also used in juried listening tests performed by both normal and hearing impaired listeners. The listeners were also asked to assign a dollar value to the sound quality they perceived for each listening trial. Figure 1 shows results obtained for 23 normal hearing listeners at the 2000 Illinois Academy of Audiology meeting. The Digi-K and K-AMP had the highest  fidelity ratings and corresponding dollar value. Figure 2 shows that ratings for the 7 digital and Digi-K hearing aids made by hearing impaired and normal hearing are very similar, with the Digi-K again coming out with the highest rating, close to that obtained with the music played through the open KEMAR ear. Unfortunately, at the time of the DigiK introduction, many of the larger hearing aid manufacturers were already developing their own hearing aid integrated circuits and did not, in general, perceive the need for wideband hearing aids or the DigiK. However, time has ultimately proven out Mead&rsquo;s vision of over 30 years ago: finally, the need for wideband hearing aids has been firmly established, and hearing aid manufacturers are responding with devices extending well into the higher frequencies, well beyond the upper frequency limit achieved previously. For those readers that are interested in more design details, some of the unique concepts that went into developing the Digi-K circuit were ultimately patented in the Etymotic Research US patent 7697705.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. Killion M. Design and Evaluation of High Fidelity Hearing Aids, Northwestern University, PhD dissertation. 1979.</p>\r\n<p>2. Killion M, Preves D, Scicluna R, Niquette P. Hearing Aid Fidelity Ratings: 25-Band Accuracy Scores and Compression Characteristics. IHCON Conference, Lake Tahoe, CA. 2002.</p>\r\n<p>By Patty Niquette, AuD</p>\r\n<p>Patty Niquette has been an audiologist for almost 25 years. She earned a master&rsquo;s degree from the University of Iowa and a doctorate from the Osborne College of Audiology at Salus University. For the past 15 years she has been a research audiologist at Etymotic Research, where she has had the privilege of working with Mead Killion and other talented audiologists, scientists and engineers to develop products to measure, improve and protect hearing.</p>\r\n<p>I n the recent Wired Magazine article &ldquo;The Breakthrough Myth,&rdquo; author Clive Thompson noted, &ldquo;Anything that&rsquo;s going to have an impact over the next decade&hellip;has already been around for 10 years.&rdquo; He further stated that &ldquo;Evolution trumps revolution, and things happen slowly.&rdquo;1 Interestingly, about 10 years before the introduction of the QuickSIN&trade; test, Dr. Mead Killion, in discussing the difficulty hearing aid users have hearing in noise, stated that they had lost ABONSO: the Automatic Brain Operated Noise Suppressor Option. He believed so strongly in this concept that he light-heartedly created an alter-ego, Dr. Abonso. Prior to the evolution of the QuickSIN, there was ABONSO. It all started with ABONSO.</p>\r\n<p>The ABONSO concept is simple: the most powerful, exquisite noise suppressor on the planet is the one that each of us is born with: the human brain. The first time I heard the term ABONSO was in Mead&rsquo;s lecture, &ldquo;The KAMP&trade; Hearing Aid: An Attempt to Present High Fidelity for the Hearing Impaired.&rdquo;2 Mead was discussing what was then, and still is now, the biggest problem reported by hearing aid users: difficulty hearing in noise. In normal hearers, our ABONSO allows us to function in the most difficult listening situation: that in which what we want to hear is speech (&ldquo;target talker&rdquo;) and what we don&rsquo;t want to hear is also speech (&ldquo;background talkers&rdquo;). For example, one minute Joe might be the target talker, while Sue, John and Mary are background talkers; when conversation shifts, Mary might be the target talker and Joe, Sue and John the background talkers. We tune in to the target talker and tune out the background talkers, and when the target and background talkers switch, we seamlessly make the necessary shift and carry on. How is this ability affected by hearing loss? Most sensory hearing loss occurs in the high frequencies and progresses slowly, resulting in a reduction in high frequency speech cues &ndash; those that carry the most meaning in our language. In quiet, the person may still be able to function, but when noise covers up a portion of the remaining audible speech cues, the person with hearing loss has Dr. Abonso difficulty hearing in noise. Historically</p>\r\n<p>hearing aids didn&rsquo;t help much in noise, since they were narrow-band amplifiers that produced too much gain for loud sounds, not enough gain for quiet sounds, and plenty of distortion. Mead contended that by cleaning up hearing aid defects and distortion and providing a clean, audible, wideband signal, the brain could relearn to process the missing speech cues, allowing an individual to reclaim their ABONSO. And Mead&rsquo;s high-fidelity K-AMP hearing aids did just that. Beyond that, Mead contended (and research has since shown), filtering and signal processing don&rsquo;t substantially increase speech intelligibility in noise; that is, no signal processing technology has been shown to be superior to the human brain.3 As time went on and millions of K-AMP hearing aids were sold (mere hundreds by me personally), some of us noticed a curious phenomenon: while some patients no longer struggled in noise, others (with the same or better pure tone audiometric thresholds) still had difficulty. Mead concluded that we needed to look beyond what we were measuring on the pure tone audiogram &ndash; we needed to actually measure the ABONSO. Mead has a remarkable grasp of the scientific literature, and he often points to the wealth of data that already exists in most areas we study. (For example, a quick search of the journal archives of the Acoustical Society of America revealed a citation for speech-in-noise testing dating back to the first issue in 1929.4 ) The only reason to create a new speech-in-noise test would be if an adequate measure didn&rsquo;t already exist. When designing a speech-in-noise test, the choice of speech and background noise materials is a compromise between realism and reproducibility. Monosyllabic words at a uniform intensity level are not representative of real speech, and a constant-level background noise, while easy to control and reproduce, is not typical of the background noise encountered by most people in their everyday lives. Mead thought these factors were essential to incorporate into a speech-in-noise test, and a test of that nature did not already exist.</p>\r\n<p>Etymotic Research&rsquo;s first speech-in-noise test, the SIN Test,5,6 evolved from the research of Mead&rsquo;s doctoral student, Selda Fikret-Pasa. In her doctoral dissertation, Fikret-Pasa (1993) combined a Massachusetts Institute of Technology recording of IEEE sentences (Institute of Electrical and Electronics Engineers, 1969) with a recording of four-talker babble (Auditec of St. Louis 1971) to study the effects of compression ratio on speech intelligibility and quality. These materials were chosen for their natural speech dynamics and realistic simulation of a social gathering. Based on discussions with Fikret-Pasa and the earlier teachings of Tom Tillman, Mead combined the IEEE sentences and Auditec four-talker babble into test blocks. Each test block had five sentences at each of four pre-recorded signal-to-noise ratios (SNRs of 15, 10, 5 and 0 dB) and two presentation levels (70 and 40 dB HL). As a clinician I used the SIN Test on a number of my patients. For the first time I could identify before the hearing aid fitting which patients would likely hear well in noise, and which patients would likely have trouble hearing in noise, even after being fit with wideband, low distortion, high-fidelity hearing aids. I was measuring their baseline ability to hear in noise &ndash; their ABONSO. And my patients loved it; for the first time, they believed they were being tested for the one issue that gave them the most difficulty: understanding speech in noise. Many times they exclaimed, &ldquo;This is exactly what it sounds like to be me, listening in noise with a hearing loss!&rdquo; As constructed, however, the SIN Test was time-consuming and the scoring was cumbersome. This wasn&rsquo;t a problem for Mead, who was known to spend as much as four hours with a single patient in a single visit (and still does, on occasion). However, for the rest of the world, test time and complexity were a deterrent to use of the SIN Test, and it wasn&rsquo;t embraced by the clinical community. Additionally, some subjects couldn&rsquo;t understand enough words, even at the best SNR, to score the test. It was a good tool that needed modification.</p>\r\n<p>Eventually I left clinical work for a position at Etymotic Research, and in the late 1990s we began a series of experiments to develop a clinical speech-in-noise test using the same premise as the SIN Test (realistic speech and background babble, with multiple signal-to-noise ratios) but that was quick and easy to administer and score. The result, the QuickSIN Test7 was comprised of 12 one-minute lists, each having one sentence at each SNR of 25, 20, 15, 10, 5 and 0 dB. The QuickSIN Test measures SNR loss, which is the increased signal-to-noise ratio needed to understand speech in noise, compared to someone with normal auditory function. The SNR loss cannot be predicted from the pure tone audiogram or any other standard audiometric test.8 Like hearing loss, we suggested categories of SNR loss (normal, mild, moderate and severe) to aid in describing the degree of hearing-in-noise difficulty and the amount of SNR improvement needed for the person to function in noise. The new test format and simplified scoring method resulted in a practical test that could be used clinically to quickly and easily quantify a patient&rsquo;s ABONSO and assist professionals in choosing technology (hearing aids, directional microphones, and other signal-to-noise enhancing technologies) and provide information useful for counselling regarding realistic expectations. The QuickSIN&trade; Test proved so useful, in fact, that informal surveys indicated it is the most widely used speech-in-noise test among audiologists and hearing instrument specialists in the United States.9,10 The QuickSIN&hellip;it all began with ABONSO. Where will we be 10 years from now? It&rsquo;s difficult to predict, but the process of evolution is exciting. The QuickSIN is showing promise as a tool to assist clinicians in identifying mild traumatic brain injury (TBI) in our soldiers returning from Iraq and Afghanistan, and work is being done to incorporate speech-in-noise protocols as part of a rehabilitative tool. Perhaps 10 years from now, I&rsquo;ll write another article, &ldquo;It all began with QuickSIN.&rdquo; Stay tuned.</p>\r\n<p>References</p>\r\n<p>1. Thompson C. 2011. The Breakthrough Myth. Wired, 7/26/11; Retrieved June 26, 2011. http://www.wired.com/magazine /2011/07/st_thompson_ breakthrough/.</p>\r\n<p>2. Killion MC. The K-AMP Hearing Aid: An Attempt To Present High Fidelity for the Hearing Impaired. Paper Based On A Presentation at the Mayo Audiology Video Conference. American Journal of Audiology 1993;2(2):52&ndash;74.</p>\r\n<p>3. Killion MC, Niquette PA. Principles of High-Fidelity Hearing Aid Amplification. In Sandlin RE (ed), Textbook of Hearing Aid Amplification: Technical and Clinical Considerations, Third Edition. Kentucky, USA: Cengage (In press).</p>\r\n<p>4. Knudsen VO. The Hearing of Speech in Auditoriums. Journal of the Acoustical Society of America 1929;1(30).</p>\r\n<p>5. Killion MC, Villchur E. Kessler Was Right&mdash;Partly: But SIN Test Shows Some Aids Improve Hearing In Noise. Hearing Journal 1993;46(9):31&ndash;35.</p>\r\n<p>6. Etymotic Research. The SIN Test&trade; (Compact Disk). Elk Grove Village, IL. 1993.</p>\r\n<p>7. Etymotic Research. The QuickSIN&trade; Speech-in-Noise Test (Compact Disk). Elk Grove Village, IL. 2001.</p>\r\n<p>8. Killion MC, Niquette PA. What Can the Pure-Tone Audiogram Tell Us about A Patient&rsquo;s SNR Loss? Hearing Journal 2000;53(3): 46&ndash; 48, 50, 52&ndash;53.</p>\r\n<p>9. Mueller HG. In The Words of Shakespeare: Fitting Test Protocols Are &ldquo;More Honored In The Breach and the Observance.&rdquo; Hearing Journal 2003;56(10):19&ndash;20, 22&ndash; 24, 26.</p>\r\n<p>10. Mueller HG. Three Pre-Tests: What They Do and Why Experts Say You Should Use Them More. Hearing Journal 2010;63(4):17&ndash;18, 20, 22&ndash; 24.</p>\r\n<p>By Ruth Bentler PhD</p>\r\n<p>Ruth Bentler, PhD, is professor and chair in the Department of Communication Sciences and Disorders at the University of Iowa. Her longtime interest in optimizing hearing aid technologies that promote user satisfaction and benefit has driven both her research and her friendships.</p>\r\n<p>I t was a dark and stormy night &hellip; back in 1996, sitting in the Washington, D.C. airport, awaiting a flight to Chicago. A number of audiologists from around the country had converged on the capital city for a &ldquo;Hearing on the Hill&rdquo;; that is, we went to test the hearing of members of Congress in an attempt to bring awareness of both our profession as well as the prevalence of hearing loss in our country. The event was pretty momentous, as we had hoped. At the time, audiology in general, and hearing aids, specifically, were taking pretty hard hits by the FDA and its leader. So, here we sat, two disciples of audiology, Mead Killion and I, rejoicing in our small but positive input to the cause. But it really was a stormy night in D.C., and flights were delayed. We ran out of accoladic words about our profession and its past and future and began to formulate another plan. What if we did a study (well, I would do the study and Mead would fund it) to show the naysayers just how good hearing aids were; that is, how far we had come in terms of advanced technology in the last 100 years. We almost feverishly plotted how we could start with the ear trumpet era at the turn of the 20th century, include the body aid era of the 30s and 40s, onto those crummy peak clippers of the 50s and 60s, then the first programmable multichannel hearing aids of the 80s, and finish with the newest technology of all: the recently released digital hearing aids of the mid-90s. Because Mead would be funding this venture, we threw in the K-AMP&trade; as an analog singlechannel design, with its TILL processing from the 80s.</p>\r\n<p>Flash forward: The study went well. My graduate student, Monica Duve, and I gathered loads of evidence about improvements in bandwidth, distortion, MPO, etc. &ndash; all those hearing aid attributes that significantly improved over the 20th century. What we found relative to our speech-in-noise outcomes created plenty of stir in the field, however. The brand new, high technology, digital processors that had just hit the market did no better in noise than some of the earlier models of hearing aids, including the ear trumpet! Oh, my. As provocative as that finding was, our intent to impress David Kessler (the current FDA czar) had taken an unintended detour. In fact, by the time our well-intentioned findings were published1 there were plenty of critics condemning the &ldquo;ear trumpet&rdquo; study for reasons such as &ldquo;no control group&rdquo; (the unaided ear?), no binaural conditions (we plugged one ear), and failure to fit the hearing aids optimally (all were fit to era or manufacturer specifications), and so on. But Mead was undeterred. In his lifetime he has sought to prove that good high fidelity2 (class D amplifiers) coupled with cochlear-like nonlinear processing3 (K-AMP), with a broad-band response4 were the foundation blocks of hearing aid user acceptance and satisfaction. Our data supported his cause. Most recently, Mead has shown evidence that the success can be further enhanced by easier accessibility and affordability (PSAPs) without compromising the primary tenant of audibility.</p>\r\n<p>While Mead and I might not agree on all things related to hearing aids, we agree on this: Audibility may not be everything, but it is the best place to start. Without audibility, there is no reason to add the bells and whistles of the current market. I would add: Without verification steps, we really don&rsquo;t know the status of that audibility. Mead&rsquo;s recognition of the dead region impact has led to many papers and presentations devoted to understanding how audibility may be compromised &ndash; but not undone &ndash; by that unfortunate state. As a final note, we did another study in my lab a few years later, dubbed the &ldquo;hype&rdquo; study.5 Subjects were fitted with different pairs of hearing aids, deemed to be &ldquo;conventional&rdquo; or digital.&rdquo; The reality (for one group) was that the subjects were wearing the same set of hearing aids. Even though we had optimized the audibility for those subjects, many believed that the ones labelled &ldquo;digital&rdquo; were actually superior. While this non-surprising finding took Mead off into a direction of &ldquo;making them believers&rdquo; in their own success, he was still carrying the same thesis: Audibility is the one sure way to begin the success. The rest of the story is convincing the patient they really can succeed. (Flashback to a Jackson Hole Rendezvous where Preacher Killion was convincing Disciple Fabry he could walk again if he believed strongly enough). That dark and stormy night ended pretty well. Our flight took off about midnight, as the rains moved on. Fortuitously for me, my connection from Chicago to Iowa City was cancelled. Mead took me home with him. What a surprise that was for Gail, his wife and my longtime friend. As a result, I got a few more hours of Mead-time, and truly delighted was I to listen, learn, and laugh a little longer, until my flight finally took me home.</p>\r\n<p>referenCes</p>\r\n<p>1. Bentler RA Duve M. Comparison of Hearing Aids over The 20th Century. Ear and Hearing 2000; 21:625&ndash;39.</p>\r\n<p>2. Killion MC. www.etymotic.com/ publications/erl-0008-1985.pdf The Noise Problem, There\'s Hope. Hearing Instruments 1985;36(11):26.</p>\r\n<p>3. Killion MC. The K-Amp Hearing Aid: An Attempt to Present High Fidelity for Persons with Impaired Hearing. American Journal of Audiology 1993;2:52&ndash;74.</p>\r\n<p>4. Killion MC and Villchur E. www.etymotic.com/publications /erl-0024-1993.pdf Kessler Was Right-Partly: But Sin Test Shows Some Aids Improve Hearing In Noise. The Hearing Journal 1993;46(9):31+.</p>\r\n<p>5. Bentler R, Niebuhr D, Johnson T, and Flamme G. Impact of Digital Labeling on Outcome Measures. Ear &amp; Hearing 2003;24:215&ndash;24.</p>\r\n<p>By Larry Revit, MA</p>\r\n<p>A music recording engineer who acquired a severe hearing loss, Larry Revit is now a consultant providing precision sound engineering services, mostly to researchers in hearing aids and cochlear implants (see www.revitronix.com). He is also a professionally active musician.</p>\r\n<p>This brief article relates some highlights of the knowledge, guidance, experience, and friendship that Mead Killion has shared with me throughout the last 28 years. Not too many folks get to coin new words that become part of the language of one&rsquo;s profession, but Mead Killion can be counted among those very few. Importantly, two, somewhat strangesounding words that he coined, &ldquo;etymotic&rdquo; and &ldquo;CORFIG,&rdquo; have changed our world, for the better. The first of these, &ldquo;etymotic&rdquo; (pronounced &quot;et-im-OH-tik&quot;) signifies the philosophy underlying much of what Mead has contributed to the world. The term is said to mean &ldquo;true to the ear.&rdquo; A pretty good synonym is &ldquo;highfidelity sound.&rdquo; Fittingly, Mead entitled his doctoral dissertation, &ldquo;Design and Evaluation of High-Fidelity Hearing Aids&rdquo;1 &ndash; which demonstrated that the High-Fidelity K-AMP&trade; not only sounded great, but was a viable device which changed the world. In Mead&rsquo;s words, &ldquo;&hellip;the important question for hearing aid research [was] no longer &ldquo;What can a hearing aid be designed to do?&rdquo; but &ldquo;What should a hearing aid be designed to do&hellip;?&rdquo;2 To demonstrate to audiologists and hearing aid engineers what a hearing aid &ldquo;should do,&rdquo; in a manner that is &ldquo;true to the ear,&rdquo; Mead recognized that it was necessary to express what it meant to the wearer to put on a hearing aid, and in language that hearing-aid builders and fitters could easily understand &hellip; CORFIG was born.</p>\r\n<p>With his &ldquo;coupler response for flat insertion gain&rdquo; (or &ldquo;CORFIG&rdquo;),3 Mead provided a means of transforming realear insertion-gain prescriptions into 2 cc-coupler test-box responses. By using CORFIG, a hearing-aid builder or clinician could evaluate prescribed hearing aids, in an &ldquo;etymotic&rdquo; way, from the get-go &ndash; that is, at the factory, or at the fitter&rsquo;s office, before the client put them on the first time. To convert an insertion-gain prescription to a target 2 cc coupler-gain response, one simply must add the CORFIG curve to the prescribed insertion-gain curve. (Of course, your fitting software likely does this automatically &ndash; but only for the average ear, unless real-ear measures are included.) Flipping the coin, one could subtract the CORFIG (or add its inverse, the &ldquo;GIFROC&rdquo;) from the measured coupler-gain response to estimate the real-ear insertion-gain response.4</p>\r\n<p>Of course Mead was one of those who saw the obvious: There was a need for measuring actual hearing-aid responses at or near the eardrum &ndash; with the hearing aid in place! &ndash; leading to the development of the ER-7C probe-tube microphone, whose ultra-flexible, 1-mm outer diameter probe tube set the could be achieved very closely by measuring in the ear from a single sound-source location: directly overhead.</p>\r\n<p>The idea of placing the loudspeaker overhead to achieve a diffuse-field response made sense, because the direction-dependent pinna and concha, are not &ldquo;seen&rdquo; from overhead. So if you placed the loudspeaker for real-ear measurements directly overhead, you would not only be measuring the correct (diffuse-field) real-ear response, but, because of direction independence, head movements during measurements would likely produce less variability than from other loudspeaker locations. I added an idea from my own listening experience from when I was a music recording engineer: High frequencies are heard best when the sound source is both elevated and toward the side &ndash; leading to my hypothesis that the most repeatable measures would come from an &ldquo;up and over&rdquo; location (see &ldquo;45/45&rdquo; in Figure 2). The 45/45 location combined the reduced direction dependence of elevation with an increase in high-frequency signal-tonoise ratio achieved by moving somewhat to the side.</p>\r\n<p>Well, it turns out that the 45/45 location did give the most repeatable insertiongain measures. Too bad that that location is impractical for clinical applications! The 45/0 location came in second for repeatability. The 0/90 location did produce the diffuse-field response for KEMAR but it didn&rsquo;t work well for human subjects because, we speculate, reflections from the shoulders created variability in the repeated measures.6 The worst repeatability came from 0/0, likely because of head-shadow effects with head movements &ndash; although it is important to keep in mind that this  experiment used no control or reference microphone at the ear, which, when active, helps greatly with achieving consistent measures with head movements. In any case, I will always remember Mead\'s gifts of guidance, patience, encouragement, and countless hours with the deepest gratitude and affection.&quot;</p>\r\n<p>The reason I have gone into such detail about my master\'s thesis is to introduce to the reader a new hypothesis: In my thesis study, I believe we should have tried one more loudspeaker location: 0/45. (See the bold &ldquo;X&rdquo; in Figure 2.) That is, placing the loudspeaker in front of the subject, but also elevating it (to reduce concha and head-shadow effects), could likely produce a near-diffuse-field response (high validity), with high repeatability (no shoulder bounce), and would not have the inconvenience of having to move the subject (or loudspeaker) for each ear. I hope someone reading this, who may be interested in taking the validity and reliability of real-ear measures up one more small notch, will decide to make a new study out of testing the 0/45 location &ndash; perhaps as a capstone project or such! I will end this article by saying that the first time I, as a music engineer who had acquired a hearing loss, saw the words &ldquo;high fidelity&rdquo; and &ldquo;hearing aids&rdquo; in the same title,1,2 I knew that Mead was a very special person. I&rsquo;m so glad to have become his lifelong student (once a mentor, always a mentor), some-time coworker, and friend.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. Killion. MC.. Design and Evaluation of High-Fidelity Hearing Aids. Doctoral dissertation. Northwestern University.1979.</p>\r\n<p>2. Killion MC and Tillman TW. Evaluation of High-Fidelity Hearing Aids. Journal of Speech and Hearing Research 1982:25(1):15&ndash;25.</p>\r\n<p>3. Killion MC, and Monser EL. CORFIG: Coupler Response for Flat Insertion Gain. Acoustical Factors Affecting Hearing Aid Performance. GA. Studebaker and I Hochberg, eds. Baltimore: University Park Press. 149&ndash;68, 1980.</p>\r\n<p>4. Killion MC and Revit LJ. CORFIG and GIFROC: Real Ear to Coupler and Back. Acoustical Factors Affecting Hearing Aid Performance. 2nd ed. GA Studebaker and I Hochberg, eds. Boston: Allyn and Bacon. 65&ndash;85. 1993</p>\r\n<p>5. Revit LJ. New Loudspeaker Locations for Improved Reliability in Clinical Measures of the Insertion Gain of Hearing Aids. Master&rsquo;s thesis. Northwestern University. 1987.</p>\r\n<p>6. Killion MC and Revit LJ. Insertion Gain Repeatability Versus Loudspeaker Location: You Want Me To Put My Loudspeaker W H E R E? Ear and Hearing 1987;8(5):68&ndash;73.</p>',NULL,'2022-11-28'),(34,3255,'ajchr','http://www.andrewjohnpublishing.com/','','<p>Pendant 28 ans, les s&eacute;minaires en ou&iuml;e ont &eacute;t&eacute; parmi mes passe-temps favoris. Joanne DeLuzio et moi-m&ecirc;me avons commenc&eacute; &agrave; coordonner cette conf&eacute;rence d&rsquo;une journ&eacute;e en 1986 et nous venons d&rsquo;avoir notre toute derni&egrave;re plut&ocirc;t ce printemps &ndash; le 28ieme s&eacute;minaire annuel en ou&iuml;e. L&rsquo;objectif de ce s&eacute;minaire &eacute;tait de r&eacute;unir ensemble dans une m&ecirc;me salle cliniciens, ing&eacute;nieurs concepteurs des appareils auditifs, et chercheurs et de proposer un conf&eacute;rencier ou des conf&eacute;renciers qui &eacute;tablira le milieu de la discussion. A bien des &eacute;gards, l&rsquo;apprentissage se passait durant les pauses caf&eacute;s et de la personne assise &agrave; c&ocirc;t&eacute;. M&ecirc;me maintenant, avec des opportunit&eacute;s de formation continue comme les CEU en ligne, c&rsquo;est tout &agrave; fait sp&eacute;cial que de rencontrer des gens face &agrave; face, des gens qui peut&ecirc;tre vous n&rsquo;auriez pas rencontr&eacute; autrement. Toutes les recettes ont &eacute;t&eacute; vers&eacute;es sous forme de bourses soit &agrave; the University of Western Ontario (Bourse des s&eacute;minaires en ou&iuml;e) ou &agrave; the Institute of Biomaterials and Biomedical Engineering de l&rsquo;Universit&eacute; de Toronto (La bourse de Poul B. Madsen). Les bourses des s&eacute;minaires en ou&iuml;e ont permis &agrave; une ou un &eacute;tudiant en derni&egrave;re ann&eacute;e de maitrise de fr&eacute;quenter un &eacute;tablissement &ldquo;extraordinaire&rdquo; n&rsquo;importe o&ugrave; en Am&eacute;rique du nord. Sur plusieurs ann&eacute;es, les r&eacute;cipiendaires sont all&eacute;s dans l&rsquo;arctique canadien pour voir comment les &eacute;valuations des appareils auditifs et les suivis sont ex&eacute;cut&eacute;s sur 3000km de distance &agrave; l&rsquo;aide de traineaux &agrave; chiens, et aussi dans des &eacute;tablissements de p&eacute;diatrie de renomm&eacute;e internationale tel que le Boys Town dans le Nebraska. Ce num&eacute;ro de la Revue Canadienne d&rsquo;audition affiche une s&eacute;lection de trois r&eacute;sum&eacute;s de certains conf&eacute;renciers au dernier s&eacute;minaire en ou&iuml;e intitul&eacute; &ldquo; l&rsquo;ou&iuml;e &agrave; travers les &acirc;ges&rdquo; avec des contributions de Dr. Susan Scollie, Dr. Jo DeLuzio, et Marilyn Reed. Comme vous devez certainement le deviner par le domaine de sp&eacute;cialit&eacute; des conf&eacute;renci&egrave;res, le s&eacute;minaire a commenc&eacute; avec des jeunes enfants et a fini avec des personnes du troisi&egrave;me &acirc;ge et leurs exigences uniques en communications.</p>\r\n<p>On trouvera aussi dans ce num&eacute;ro de la Revue Canadienne d&rsquo;audition, une transcription de la section du panel de discussion du quatri&egrave;me s&eacute;minaire en ou&iuml;e entre Harry Levitt et Edgar Villchur qui &eacute;taient les conf&eacute;renciers &agrave; cette r&eacute;union. Harry Levitt est professeur &agrave; la retraite du CUNY &agrave; New York et bien c&eacute;l&egrave;bre pour son travail pionnier sur les appareils auditifs num&eacute;riques. Edgar Villchur a invent&eacute; la compression multi bande et est le p&egrave;re du haut-parleur &agrave; air suspendu. Des num&eacute;ros ant&eacute;c&eacute;dents de la Revue Canadienne d&rsquo;audition ont affich&eacute; des entrevues avec ces deux pionniers dans la rubrique Les fondateurs de Notre Profession. Au congr&egrave;s de l&rsquo;acad&eacute;mie canadienne d&rsquo;audiologie &agrave; Ottawa de 2012, J&rsquo;ai assist&eacute; &agrave; une pr&eacute;sentation admirablement claire et r&eacute;fl&eacute;chie par Andr&eacute; Marcoux (qui &eacute;tait le premier r&eacute;dacteur en chef de la Revue Canadienne d&rsquo;audition). Il a &eacute;voqu&eacute; certaines technologies et approches nouvelles dans les mesures des r&eacute;ponses &eacute;voqu&eacute;es auditives du tronc c&eacute;r&eacute;bral. J&rsquo;ai pens&eacute; que c&rsquo;&eacute;tait tellement clair que m&ecirc;me moi je pouvais comprendre, alors il a &eacute;t&eacute; somm&eacute; de nous &eacute;crire quelque chose. En parlant de clart&eacute;, Dr Jim Jerger a r&eacute;dig&eacute; un merveilleux article pour the International Journal of Audiology (IJA) intitul&eacute; &ldquo;Pourquoi l&rsquo;audiogramme est invers&eacute;.&rdquo; Je l&rsquo;ai vu sous forme d&rsquo;&eacute;bauche d&rsquo;article et je l&rsquo;ai imm&eacute;diatement appel&eacute; (et Ross Roesser, le r&eacute;dacteur en chef de IJA) pour demander la permission de le r&eacute;imprimer. Ils ont bien voulu mais j&rsquo;&eacute;tais le deuxi&egrave;me sur la liste. The Hearing Review &eacute;tait avant moi alors vous l&rsquo;auriez peut-&ecirc;tre d&eacute;j&agrave; vu avant, mais certainement, il vaut bien la peine d&rsquo;&ecirc;tre relu et trois fois. Marlene Begatto et ses coll&egrave;gues &agrave; l&rsquo;Universit&eacute; Western (le nouveau nom de the University of Western Ontario) a r&eacute;dig&eacute; un article enchanteur sur les r&eacute;sultats audiologiques pour les enfants qui portent des appareils auditifs, et &eacute;videmment le titre est explicite. Alberto Behar, qui a r&eacute;cemment re&ccedil;u un prix majeur de l&rsquo;association canadienne de normalisation (voyez le dernier num&eacute;ro de la Revue Canadienne d&rsquo;audition) a co&eacute;crit un article avec un des &eacute;tudiants dipl&ocirc;m&eacute;s de l&rsquo;Universit&eacute; Ryerson de Toronto et y examine les &eacute;couteurs double fonction de protection de l&rsquo;ou&iuml;e et de communication &eacute;lectronique et s&rsquo;ils sont nuisibles pour l&rsquo;ou&iuml;e.</p>\r\n<p>Bien entendu, nous avons nos chroniqueurs r&eacute;guliers, Calvin Staples (From the blogs), Gael Hannan (The Happy HoH), et Dr. Vincent Lin du centre des sciences de sant&eacute; de Sunnybrook et ses coll&egrave;gues qui ont contribu&eacute; sous la banni&egrave;re de la chronique the E in ENT, au sujet des injections de st&eacute;ro&iuml;des par voir orale versus tympanique comme options de traitement pour la perte auditive neurosensorielle soudaine. Pour fermer la boucle, Dr Briam Fligor de Boston a bien voulu r&eacute;diger la chronique Questions Cliniques de ce num&eacute;ro, mais il faudra lire plus en avant pour en savoir plus. Je vous souhaite &agrave; toutes et &agrave; tous une belle saison chaude, utilisez l&rsquo;&eacute;cran solaire, portez un chapeau, et n&rsquo;oubliez pas de vous inscrire &agrave; la prochaine conf&eacute;rence annuelle de l&rsquo;Acad&eacute;mie Canadienne d&rsquo;Audiologie qui aura lieu le mois d&rsquo;octobre prochain &agrave; Terre Neuve et Labrador.</p>\r\n<p>By Calvin Staples, MSc Hearing Instrument Specialist Faculty/Coordinator, Conestoga College CStaples@conestogac.on.ca</p>\r\n<p>As April showers have brought May snow in most of Ontario and throughout many parts of Canada, most of us have just finished up spring conference season. Conferences often provide clinicians the opportunity to view the latest and greatest products from hearing aid manufacturers. The blogs in this series will focus on the new developments in the hearing and hearing aid industry. I frequently visit the blogs at hearinghealthmatters.org as a springboard to further topic investigation, I hope our readers find the topics below insightful and useful clinically. As you will see from the submissions below, numerous achievements have occurred that will help shape our industry into the future. Happy Reading!</p>\r\n<p>Blending electronics and biology, scientists at Princeton University have used readily available 3-D printing tools to create a functioning &ldquo;bionic ear&rdquo; that can detect radio frequencies far beyond the range of normal human capability. In a May 1 news release, John Sullivan of the Office of Engineering Communication at Princeton reported that the primary purpose of the researchers was to develop an effective means of merging electronics with biological tissue. The scientists used 3-D printing of cells and nanoparticles followed by cell culture to combine a small coil antenna with cartilage, creating what they termed a bionic ear. The lead researcher is Michael McAlpine, an assistant professor of mechanical and aerospace engineering at Princeton. He told Sullivan, &ldquo;There are mechanical and thermal challenges with interfacing electronic materials with biological materials. However, our work suggests a new approach &ndash; to build and grow the biology up with the electronics synergistically and in a 3-D interwoven format.&rdquo; The Princeton team has been doing research in cybernetics for several years. This promising field seeks to design bionic organs and devices to enhance human abilities. The bionic ear project was the first effort by McAlpine and colleagues to create a fully functional organ: one that replicates a human ability and then uses embedded electronics to extend it. Writing in the journal Nano Letters, the scientists said that cybernetics, &ldquo;has the potential to generate customized replacement parts for the human body, or even create organs containing capabilities beyond what human biology ordinarily provides.&rdquo; In order to replicate complex threedimensional biological structures, the researchers turned to 3-D printing. A 3- D printer uses computer-assisted design to conceive of objects as arrays of thin slices. It then deposits layers of materials to build up a finished product. One example of this approach is CAMISHA (computer-aided-manufacturing-for-individual-shells-for-hearing -aids), which was invented by Soren Westermann at Widex, and is now used to build 95% of custom hearing aids. According to Princeton, the bionic ear project marked the first time that researchers have demonstrated that 3-D printing is a convenient strategy to interweave tissue with electronics. The researchers used an ordinary 3D printer to combine a matrix of hydrogel and calf cells with silver nanoparticles that form an antenna. The calf cells later develop into cartilage. The initial device developed by McAlpine and colleagues detects radio waves, but the team plans to incorporate other materials that would enable it to hear acoustic sounds. While it will take much more work to develop a bionic ear that could restore or enhance human hearing, McAlpine said that in principle it should be possible to do so. The team that developed the bionic ear consists of six Princeton faculty members, two graduate students from Princeton and Johns Hopkins University, and Ziwen Jiang, a high school student at the Peddie School in Hightstown, NJ. McAlpine said of the precocious teenager, &ldquo;We would not have been able to complete this project without him, particularly in his skill at mastering CAD designs of the bionic ears.&rdquo;</p>\r\n<p>ANAHEIM, CA&ndash;An international public art initiative, a &ldquo;Three Wise Monkeys&rdquo; campaign to encourage regular hearing health checks, and a pocket-sized electronic hearing testing device captured top honors in the Ida Institute&rsquo;s competition, Ideas, Speak up &ndash; Action and Awareness for Hearing Loss. The winning entries were celebrated at a reception held here April 3 at the start of the American Academy of Audiology&rsquo;s annual convention, AudiologyNOW! 2013. The purpose of the international contest was to stimulate ideas with the potential to create public awareness of hearing loss, put hearing loss on the public agenda, and encourage people to take action to address hearing loss. The Ida Institute, a Danish-based independent non-profit foundation funded by the Oticon Foundation, launched the ideas competition at AudiologyNOW! 2012 held in Boston. Over the following months it generated more than 400 submissions from all over the world. three top priZes From these, first prizes were awarded in three categories. The winning entry in the Public Awareness Campaign category was submitted by Curtis Alcott, from the United Kingdom. Entitled &ldquo;Three Monkeys: Eyes Checked. Teeth Checked. Hearing Checked,&rdquo; his idea was to link a simple message to the iconic three wise monkeys (&ldquo;See no evil, hear no evil, speak no evil&rdquo;) to raise awareness of regular hearing health checks. The monkeys encourage making hearing checks part of a health routine that also includes getting one&rsquo;s eyes and teeth checked on a regular basis. The three monkeys image can be used in many media, including print and broadcast advertising, web sites, billboards, bus posters, and cinema trailers</p>\r\n<p>Khalid Islam of Bangladesh invented the winning idea in the Best Event category. He devised &ldquo;Look Who&rsquo;s Hearing,&rdquo; an international public art initiative that would involve &ldquo;fitting&rdquo; hearing aids on statues in major cities around the world. The artist-designed hearing aids could be mounted as sculptures and then auctioned off to support hearing health charities. An Internet campaign would enable people to follow this initiative, track the next statue, and spread awareness. In the Best Gadget category, Kasper Rubin, a Dane, won the blue ribbon for his Hearing Tone Test Card, an inexpensive electronic card that would serve as a practical hearing checker. The pocket-sized card uses simple electronic technology like that used in singing greeting cards. However, instead of making music, the technology is used to test hearing. At the reception in Anaheim where the contest winners were announced, Niels Boserup, chairman of the Oticon Foundation, said, &ldquo;We recognize that to continue the good work of this project and to achieve increased public awareness of hearing loss worldwide will require a strategic, dedicated initiative.&rdquo; He added that the Oticon Foundation &ldquo;will investigate ways to develop and implement the worthy ideas.&rdquo; Lise Lotte Bundesen, managing director of the Ida Institute, said, &ldquo;The Ideas Campaign sparked the creativity and passion of people around the world.&rdquo; ideas Worth hearing The prize-winning ideas were selected by a panel of judges including Brenda Battat, executive director of the Hearing Loss Association of America; Tom Healy, a writer, poet and chairman of the Fulbright Foreign Scholarship Board; Bob Isherwood, former worldwide creative director of Saatchi &amp; Saatchi, the Ideas Agency; Sergei Kochkin, PhD, former executive director of the Better Hearing Institute; and Helle &Oslash;stergaard, executive director of the Crown Princess Mary Foundation. These and some of the other best ideas submitted can be viewed online at Ideas Worth Hearing. The Ideas Catalog is designed to inspire and to help people around the world take action and start raising awareness of hearing loss in their communities.</p>\r\n<p>Most audiologists realize that noiseinduced hearing loss (NIHL) refers to a gradual, cumulative and preventable decline in auditory function that follows repeated exposure to loud noise. It is, of course, the leading cause of preventable hearing loss. It is also estimated that 10% (30 million) of Americans are encountering hazardous levels of noise, that 25% of those working in the construction, mining, agriculture, manufacturing, transportation, and military industries routinely encounter noise levels above 90 dB (A), and that such noise exposure has already generated a sizeable population of workers who meet the Occupational Safety and Health Administration&rsquo;s (OSHA) definition for material impairment of hearing&rdquo; (over 25 dB threshold at 1000, 2000, and 3000 Hz). This number is probably much greater among workers and participants in high noise activities in countries where regulations are not as stringent as those in developed countries. Since workers and those with recreational hearing losses can have significant effects on their employment, social interactions, family interactions, protecting hearing health in the workplace and while having fun has become very important. Programs and regulations for occupational exposure (e.g. maximum allowed daily noise doses) have been designed, but no matter where you live there are virtually no standards for recreational noise, an emerging contributor to noise-induced hearing loss. There are numerous sources of non-occupational noise exposure. Clark and Bohne have compiled a partial list of significant sources of leisure noise, and music figures prominently in their construct. Music, in addition, transcends the recreational setting to pose an occupational risk of NIHL for groups such as music venue workers and music performers, even the audiences&hellip;&hellip; think BaCk Most of us (yes, even audiologists) have &ldquo;been there&rdquo; at one time or another. You are a fan! A BIG FAN LL Cool J, Beyonce, Madonna, maybe even the Stones and your favorite musical artist is in town for a greatest hits concert! You have a babysitter, a designated driver. Look out, you are out on the town! As Rick Nelson said, &ldquo;Sang them all the old songs, thought that is why they came&rdquo; and that IS why they came&hellip;and a super time was had by all! The Next Day: You wake up with horrible tinnitus, probably a hangover as well and wonder why it was so important to get close to the speakers during the rock concert the night before. As the day goes on you begin to feel better, but the tinnitus lingers on reminding you of a major noise exposure the night before. Over the next day or so, the tinnitus will usually subside and we end up OK, but as audiologists we know that there has been some hair cell destruction.Typically, the noise exposure causes levels of toxic chemicals called &ldquo;free radicals&rdquo; inside the hair cell to rise beyond manageable levels, and the cell dies. We also know that if we continue to attend too many of these concerts the exposure to the intense sound levels will ultimately lead to a number of hair cell deaths and, subsequently, a permanent hearing impairment. BUT&hellip;.What if we could reverse the process, make it like we had never been exposed at all&hellip;.a Morning After Pill&hellip;..Now it probably will not do too much for the hangover, but there may be a method to minimized or eliminate the effects of the noise exposure due to taking a pill that actually works.</p>\r\n<p>the Morning after Studies in this area have been ongoing for a number of years. Based upon their studies, researchers at the University of Michigan, Kresge Hearing Research Institute have developed AuraQuell (pill) which is a combination of Vitamins A, C and E, plus magnesium, taken before a person is exposed to loud noises. The funding for the Michigan project was provided by General Motors and the United Auto Workers that led to the 2007 study of the mechanism attributed to induce hearing loss and the pre-clinical research that contributed to the development of AuraQuell. During clinical studies, guinea pigs who had been administered AuraQuell experienced about eighty percent preventative blockage of noiseinduced hearing impairment (&ldquo;The treatment one hour before a five hour exposure to 120 decibel (dB) sound pressure level noise, and continued once daily for five days.&rdquo; Josef M. Lynn, Ph. D., the Lynn and Ruth Townsend Professor of Communication Disorders, Director of the Center for Hearing Disorders at the University of Michigan Department of Otolaryngology&rsquo;s Kresge Hearing Research Institute and co-leader of the research expects AuraQuell could effectively block 50% of noise induced hearing loss in humans. A trademark for AuraQuell was granted in June 2009. Clinical human testing of AuraQuell is being evaluated in four multinational trials: &ldquo;Military trials in Sweden and Spain, an industrial trial in Spain, and trial involving students at the University of Florida who listen to music at high volumes on their iPods and other PDAs.&rdquo; The human clinical trials for AuraQuell maybe in the form of a tablet or snack bar. These trials studies are funded by National Institute of Health (NIH).&rdquo;This is the first NIH &ndash; funded clinical trial involving the prevention of noiseinduced hearing loss.&rdquo; AuraQuell may prove to limit induced hearing loss of military personal exposed to improvised explosive devices (IEDs) and other noises. It appears that AuraQuell is still in clinical field trials, but if these trials are successful, Dr. Joseph Miller, the noise-induced hearing loss prevention concoction could be available within two years.</p>\r\n<p>By Mary Edgar, BKin, David Clinkard, MS, and Vincent lin, MD, FRCSC edgarmary01@hotmail.com</p>\r\n<p>Mary Edgar (left) has a bachelor&rsquo;s degree in kinesiology and has just been accepted into the MSc physiotherapy program at UBC. She has worked as an audiometric technician at the Vernon Health Unit for the past five years. David Clinkard (middle), and Vincent Lin (left) are with the Otolaryngology Department at Sunnybrook Health Sciences Centre, Toronto, Ontario.</p>\r\n<p><strong>Abstract</strong></p>\r\n<p>There is a myriad of treatment options for sudden sensorineural hearing loss. However clinical evidence supporting the efficacy of these treatments are generally limited to case series and a few clinical trials. Due to the paucity of good clinical evidence, the treatment of sudden sensorineural hearing loss continues to challenging for otolaryngologists. Although controversial, corticosteroids are considered the standard of care. A typical treatment regiment is a tapering course of high dose oral corticosteroids. Recently, transtympanic corticosteroids have been administered as salvage therapy, primary therapy or in addition to oral corticosteroid treatments. The role of oral versus transtympanic corticosteroid therapy remains poorly understood.</p>\r\n<p>Sudden sensorineural hearing loss (SSNHL) is a relatively common complaint in audiology and otolaryngology practices. SSNHL is the acute onset of hearing loss of at least 30 dB in at least three different frequencies over a 72-hour period.1 While usually unilateral in origin, bilateral occurance is possible, though rare (1&ndash;2%). The overall incidence of diagnosed ISSNHL ranges from 5 to 20 per 100,000 persons per year, with some estimates as high as 160 per 100,000.2 Given the high spontaneous recovery rates (32&ndash;65%), the actual incidence of ISSNHL may be higher.3 ISSNHL typically occurs between the ages of 50 and 60, with no gender predominance.4,5 Etiology is often unknown, with the majority (85%) of patients having no identifiable cause. However, viral, vascular and immunologic contributions have been suggested as possible etiologies.</p>\r\n<p><strong>Diagnosis and Treatment</strong></p>\r\n<p>Aural fullness and muffled hearing are the most common presenting symptoms of SSNHL and may be mistaken for less serious conditions such as cerumen impaction or nasal congestion leading to eustachian tube dysfunction7 . These can be ruled out with a complete history, physical exam, and audiologic evaluation.2 A rapid diagnosis of SSNHL is vital because a delay in diagnosis may reduce the efficacy of treatments thought to restore hearing.3,4 Given the multifactorial and ultimately unknown nature of ISSNHL multiple therapy options have been proposed. These include steroids, vasodilators, anticoagulants, plasma expanders, vitamins, and hypobaric oxygen.3,5,8 Current standard of care is a tapering dose of systemic steroids, either oral or intravenous. The treatment should be started as soon after diagnosis in order to obtain the best outcome. Prednisone (1 mg/kg/day up to 60 mg max), as a single dose for 10&ndash;14 days is currently recommended by the American Academy of Otolaryngology. Other commonly used steroids include methylprednisolone, prednisolone, and dexamethasone, depending on physician preference. Steroids were first shown to have beneficial effects by Wilson et al., who demonstrated that patients receiving oral steroids experienced a significantly greater return of spontaneous hearing (61%), as compared to those receiving placebo (32%). This is believed to have benefit due to research showing steroids blunt a cellular inflammatory cascade that occurs ISSNHL.4,8,9 The initial use of transtympanic injections of glucosteroids were recommended as salvage therapy if patients do not experience an increase in hearing recovery within 10 days of the initial treatment. However, there is limited research to support dosing regiments for salvage therapy.</p>\r\n<p><strong>Prognosis</strong></p>\r\n<p>The prognosis of ISSNHL is dependent on a variety of risk factors including demographics, duration of hearing loss, severity of hearing loss, speech discrimination scores, age, presence of vertigo, associated symptoms, and audiogram characteristics.11 Of all demographic factors studied, advanced age (&gt;60 years in most studies) has been universally correlated with decreased rates of hearing recovery and lower absolute threshold gains.5 The greatest spontaneous improvement in hearing occurs during the first two weeks and late recovery has been reported but is rare. Treatment with corticosteroids appears to offer the greatest recovery in the first two weeks, with little benefit after four to six weeks.2</p>\r\n<p><strong>Changes to treatMent options</strong></p>\r\n<p>Despite their widespread use, there is little consensus on the effectiveness of oral steroids in ISSNHL. High-dose administration of systemic steroids can raise risks of adverse effects, such as avascular necrosis of the femur head, immune suppression, endocrine problems, osteoporosis, glucose intolerance, or weight gain.3 To avoid these side effects, recent studies have proposed transtympanic treatment be used as the sole initial treatment for ISSNHL, with studies showing this protocol to be non-inferior to conventional oral steroids.4,12 However, there are numerous downsides to this approach; transtympanic steroids can cause patient discomfort, are more expensive, inconvenient to inject and carry a risk of otomycosis.3 Preliminary work has suggested that administration of glucosteroids by perfusion through a round window catheter can deliver a higher concentration of steroid to the inner ear and improve hearing when compared to tympanic membrane injection. This delivery method can avoid the side effects caused by systemic steroid use and avoid tympanum perforation.</p>\r\n<p>Currently, the Sunnybrook approach involves an audiogram to confirm hearing loss, followed by blood work to rule out infectious processes if clinically indicated. If the hearing loss is unilateral, magnetic resonance imaging (MRI) is ordered to rule out retrocochlear causes such as an acoustic schwannoma. If these investigations fail to a reveal cause of hearing loss, then prednisone at 1 mg/kg/day for the first six days and then tapering for eight days, for a 14-day total course is prescribed. Patients are also offered intratympanic dexamethasone injections (1 cc of 10 mg/mL) for at least three daily injections until hearing improvement plateaus. If hearing improvement continues, then the injections continue until audiologic testing reveals no further improvement. One major issue which has still not be fully addressed is the window of opportunity in which either oral or intratympanic corticosteroid treatment will continue to have any effect. Our centre uses the 14&ndash;21 day windowpatients presenting after that period are not typically offered any treatment.</p>\r\n<p><strong>ConCLusion</strong></p>\r\n<p>Although controversial, the use of oral steroids in the initial treatment of ISSNHL has been considered by many to be the gold standard of care. Current research suggests that transtympanic corticosteroid treatment increases concentration in the cochlear fluids. Therefore in the philosophy of maximizing corticosteroid concentration in the inner ear to minimize permanent damage, we advocate a combined oral and intratympanic corticosteroid treatment paradigm in patients diagnosed with SSNHL.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. National Institute of Deafness and Other Communication Disorders (NIDCD). Sudden deafness. 2003. http://www.nidcd.nih.gov/ health/hearing/pages/sudden.aspx. Accessed October 26, 2012.</p>\r\n<p>2. Stachler RJ, Chandrasekhar SS, Archer SM, et al. Clinical practice guideline: sudden hearing loss. Otolaryngol Head and Neck Surg 2012;146(3):S1&ndash;S35.</p>\r\n<p>3. Lim HJ, Kim YT, Choi SJ. Efficacy of 3 different steroid treatments for sudden sensorineural hearing loss: a prospective, randomized trial. Otolaryngol Head and Neck Surg 2013; 148(1):121&ndash;7.</p>\r\n<p>4. Rauch SD. Clinical practice. Idiopathic sudden sensorineural hearing loss. N Engl J Med 2008; 359(8):833&ndash;40. 5. Kuhn M, Heman-Ackah SE, Shaikh JA, et al. Sudden sensorineural hearing loss: a review of diagnosis, treatment, and prognosis. Trends in Amplification 2011;15(3):91&ndash;105.</p>\r\n<p>6. Neely JG, Ortmann AJ. Sudden sensorineural hearing loss and delayed complete spontaneous recovery. J Am Aca Audiol 2012; 23(4):249&ndash;55.</p>\r\n<p>7. Rauch SD, Halpin CF, Antonelii PJ, et al. Oral vs intratympanic corticosteroid therapy for idiopathic sudden sensorineural hearing loss. JAMA 2011;305(20):2071&ndash;79.</p>\r\n<p>8. Conlin AE, Parnes LS. Treatment of sudden sensorineural hearing loss, I: a systematic review. Arch Otolaryngol Head Neck Surg. 2007;133(6):573&ndash;81.</p>\r\n<p>9. Roebuck J, Chang CY. Efficacy of steroid injection on idiopathic sensorineural hearing loss. Otolaryngol Head and Neck Surg 2006;135(2):276&ndash;79.</p>\r\n<p>10. Shemirani NL, Schmidt M, Friedland DR. Sudden sensorineural hearing loss: an evaluation of treatment and management approaches by referring physicians. Otolaryngol Head and Neck Surg 2009;140(1):86&ndash;91.</p>\r\n<p>11. Kara E, Cetik F, Tarkan O, et al. Modified intratympanic treatment for idiopathic sudden sensorineural hearing loss. Eur Arch Otorhinolaryngol 2010;267(5):701&ndash;7.</p>\r\n<p>12. Piccirillo JF. Steroids for idiopathic sudden sensorineural hearing loss. JAMA 2011;305(20):2114&ndash;15.</p>\r\n<p>13. Wang Y, Ren J, Lu Y, et al. Evaluation of intratympanic dexamethasone for treatment of refractory sudden sensorineural hearing loss. J Zhejiang Univ Sci B 2012;13(3):203&ndash;8.</p>\r\n<p>14. Spear SA, Schwartz SR. Intratympanic steroids for sudden sensorineural hearing loss: a systematic review. Otolaryngol Head and Neck Surg 2011;145(4):534&ndash;43.</p>\r\n<p>By Andr&eacute; Marcoux, PhD and Isaac Kurtz, MHSc, PEng amarcoux@uottawa.ca</p>\r\n<p>Andr&eacute; Marcoux, PhD, adjunct professor, Department of Audiology and SLP, University of Ottawa; chief audiologist and president, The Sound Room Hearing Centres; www.thesoundroom.ca. Isaac Kurtz, MHSc, PEng, vice-president of research and technology, Vivosonic Inc.; www.vivosonic.com.</p>\r\n<p>Canada is a leader in the development of auditory brainstem response (ABR) technologies that enhance response detection. In this article, we examine the clinical challenges associated with ABR measurements and uncover advanced technologies developed by Canadian researchers and engineers that offer noise reduction capabilities essential for achieving quality ABR measurements. These advanced technologies are transforming hearing health care around the world.</p>\r\n<p>Most audiologists would agree that noise is the foremost frustration with clinical auditory brainstem response (ABR) measurements. In this context, noise refers to interference from electromagnetic and myogenic sources which make it challenging to recognize and detect the true response in ABR waveforms. Whether employing ABR for neurodiagnostics, for estimating hearing ability, or for screening, noise is a common and persistent issue. As an electrophysiological measurement which requires information be collected &ldquo;far field,&rdquo; at a distance, ABR is extremely susceptible to contamination. With electrodes placed on the patient&rsquo;s scalp, minute responses of 0.05 to 0.5 microvolts are acquired from the auditory nerve and brainstem pathways. These minute responses travel to a recording device to be processed. From the point of data acquisition to processing of the signal, there is ample opportunity for the ABR to be contaminated by physiological artifacts from the patient, and extraneous artifacts and interferences in the environment. When the amplitude of the recorded response shows more than 20 microvolts, it is certain that what is shown is not ABR, but noise.</p>\r\n<p><strong>CoMMon sourCes of noise (interferenCe)</strong></p>\r\n<p>Noise is everywhere. ABR recordings are particularly vulnerable to interference from sources with frequencies of 20 to 30 Hz up to 2500 Hz &ndash; the frequency range of a typical ABR signal. Thus, it is helpful to recognize potential sources of noise and understand how they might be introduced into an ABR waveform.</p>\r\n<p><strong>Physiological Artifacts</strong></p>\r\n<p>There are numerous sources of physiological noise generated voluntarily or involuntarily by the adult or child being assessed. Muscular activity or movement, even from a fragile newborn, can produce significant artifact that interferes with the much smaller ABR. A patient who is relaxed and motionless still has small EMG activity in the area of the electrode sites such as the forehead, mastoids and scalp, as well as EOG arising from the eyes, ECG from the heart, and EEG from the brain. All of these sources lead to unwanted noise in the recordings. It is impossible to eliminate their effects entirely, but it is possible to significantly reduce them through good clinical practice and advanced ABR technologies.</p>\r\n<p><strong>Motion Artifacts</strong></p>\r\n<p>Artifacts due to motion are the result of electrode leads moving during data acquisition. Often this is caused by patient movement or when adjustments to the leads are made.</p>\r\n<p><strong>Recording Environment</strong></p>\r\n<p>Sources of extraneous noises in our environment are typically the most difficult to identify and mitigate. Frequently the presence of electromagnetic noise from nearby equipment, conducted power line noise, and radio frequency interference, all serve to contaminate the ABR recording. Without proper shielding of wires and/or the recording environment, electrode leads are prone to field artifacts. Inadequate grounding invites unwelcome electrical pickup from circuitries in the room and the influence of 50/60 Hz noise and harmonics can appear in the waveform.</p>\r\n<p><strong>ConseQuenCes of (too MuCh) noise</strong></p>\r\n<p>Too much noise in ABR recordings has a number of consequences. Here are the major ones.</p>\r\n<p><strong>Misinterpretation of ABR</strong></p>\r\n<p>Artifact and interference make it difficult to interpret waveforms and can result in reduced accuracy of wave recognition and latency measurement. When estimating hearing ability or hearing loss, specifically at lower stimulus intensity levels, the amplitude of the waveform may be similar to that of the noise making it difficult to interpret. Stapells1 cautions that ABR recordings of insufficient quality may mean that an ABR wave V is identified as &ldquo;present&rdquo; when its amplitude is not significantly greater than the background noise. Or, a common mistake is to indicate a &ldquo;no response&rdquo; when the recording is too noisy and the residual EEG noise is greater than a typical threshold response.</p>\r\n<p><strong>Lengthy Measurement Period</strong></p>\r\n<p>In noisy environments, when conventional averaging of waveforms is used, measurement must continue for excessively long periods of time in order to accurately detect the response. This is problematic when assessing infants, children, or other patients who may be uncooperative. Only partial data may be collected and a follow on appointment must be arranged to complete the assessment adding to costs and inconvenience for all concerned.</p>\r\n<p><strong>Sedation of Infants and Young Children</strong></p>\r\n<p>Sedation or anesthesia is often used to minimize contamination of the ABR recording from myogenic artifacts present when infants and young children are awake and alert. There is an entire body of literature that examines the effects of sedation. For the most part it is safe, yet there remains a certain amount of risk related with its use. &ldquo;Sedated ABR procedures are costly, time-consuming and require constant patient monitoring during the procedure.&rdquo;2 In a recent report by the Pediatric Sedation Research Consortium,3 auditory brainstem response was identified as one of the procedures for which sedation was commonly used. Data from 114,855 pediatric sedations indicated that monitoring guidelines published by the American Academy of Pediatrics (AAP) were followed in only 52% of cases.</p>\r\n<p><strong>Time Spent Reducing Noise</strong></p>\r\n<p>&ldquo;Electrical interference from feeding pumps, monitors, etc. is our #1 problem. Much more time is spent trying to solve electrical interference issues than in actual test time.&rdquo;2 When the source of noise cannot be identified or eliminated, the patient may need to be moved to a less noisy environment, or assessed in a shielded room or Faraday cage.</p>\r\n<p><strong>Cannot Complete Assessment</strong></p>\r\n<p>In some cases, it is simply not possible to reduce noise to acceptable levels to obtain quality recordings. This is a frequent occurrence in environments with high electromagnetic interference, such as the neonatal intensive care unit (NICU) or operating room (OR). Even when potential sources of interference have been removed and non-essential equipment powered off, noise may remain so high that testing must be abandoned.</p>\r\n<p><strong>ConventionaL Means of reduCing noise</strong></p>\r\n<p>How is noise extracted from the response that we are trying to measure? Following good clinical practice, along with built-in noise reduction features of the ABR measurement instrument, it is possible to reduce noise in the ABR. Conventional methods for reducing noise are mentioned here.</p>\r\n<p><strong>Shielding</strong></p>\r\n<p>When noise and interference cannot be mitigated further by moving or powering off equipment in the test environment, shielding is sometimes the only means to ensure adequate immunity. This can be an effective, but costly solution to the problem of extraneous noise.</p>\r\n<p><strong>Natural Sleep and Sedation</strong></p>\r\n<p>Natural sleep and sedation are common approaches used with infants and young children to manage muscular activity. In general, it is preferable to assess an infant in natural sleep over the risks of sedation. Natural sleep often requires that an infant be deprived of sleep before the appointment, and still it may be necessary to wait for the infant to fall asleep before testing can proceed. Particularly in the case of older infants and young children, natural sleep is frequently not an option. Rather than manage the myogenic artifact arising from an active or uncooperative child, many clinics proceed directly to sedation, providing that sedation is not contraindicated and caregivers consent to this procedure. Patient Posture and Positioning To reduce muscular activity and provide support for the neck, adult patients are typically asked to lie supine on a bed, close their eyes, and relax as much as possible. In most cases, this is sufficient to minimize muscular noise. However, when patients are aware that the assessment seeks evidence of a tumour, they are understandably agitated and as a consequence generate undue levels of muscular artifact which is not easily extracted from the signal. Electrode Impedance To obtain cleaner recordings, it is common practice to scrub and exfoliate the skin of the patient with a mild abrasive before applying electrodes to the site. This serves to reduce electrode impedance which can significantly impact EEG quality. &ldquo;The impedance does not affect the ABR itself, but the larger the impedance, the larger the amount of pickup of external electromagnetic interference and of artifacts from movement of the electrode leads.&rdquo;4 A low electrode impedance of 3 or 4 kOhm is often recommended, with impedance difference between electrode pairs not more than 1 kOhm. Acceptable ABR recordings can be obtained with higher impedances providing the impedance difference is balanced and symmetrical. This is needed for common-mode rejection, otherwise there is difficulty obtaining an acceptably low level of EEG noise when recording ABR.</p>\r\n<p>Averaging Signal averaging is possible because ABR is time-locked to the stimulus, with each repeated stimulation eliciting the same response. Noise, on the other hand, is very random and has no regular pattern. By presenting the same stimulation over and over again, and averaging the responses together, the ABR waveform should emerge from the noise. Increasing the number of stimulus presentations, or sweeps, improves waveform morphology. Averaging can be terminated as soon as a clear ABR waveform is visualized. Repeatability of the waveform is required to confirm the presence or absence of a response. If the measurement instrument has two recording buffers, repeatability is easily determined by visually comparing the averaged waveforms in each buffer. Statistical tools can further provide an objective validation. Conventional averaging techniques typically weight all sweeps equally so that sweeps with higher amplitudes (high noise) have the same impact on the waveform morphology as sweeps with lower amplitudes (less noise and closer to an ABR). Note that more advanced &ldquo;weighted&rdquo; averaging techniques, such as Kalman Weighted Averaging, weight sweeps according to noise content so that noisy responses have less of an impact on the waveform morphology. Artifact Rejection When conventional averaging is used, it is typical to set an artifact rejection level of a certain voltage such as 20 microvolts. Sweeps with amplitudes greater than the rejection level are deemed to have too much noise and are not included in the averaging. While this reduces the impact of noisy responses on ABR morphology, too many rejected sweeps can prolong recording time. As sweeps are rejected, more data must be collected for sufficient averaging to occur.</p>\r\n<p>Pause Equipment Signal processing and noise cancellation techniques are usually inadequate to overcome the effects of myogenic artifact such as a baby stirring or a child squirming. When patient movement causes too much noise, it may be more practical to simply pause data acquisition until the movement subsides. advanCed aBr teChnoLogies that reduCe noise Noise in ABR measurements can be significantly reduced through innovative technologies developed by researchers and engineers in Canada. The three technologies described here have been developed by Vivosonic Inc., a leader in technologies that enhance ABR detection. The combination of these technologies effectively minimizes the need to sedate infants and young children for ABR assessment,5 is effective in managing electrical and artifacts in places with high electromagnetic interference such as the NICU6&ndash;8 and OR,2 permit ABR measurement via tele-audiology,9,10 help to identify false indications of noiseinduced hearing loss,11 and provide more accurate ABR under non-ideal conditions compared to conventional methods.6,7,12,13 &ldquo;We were able to get valid passing newborn hearing screenings on infants that were awake and in electrically complex locations (running isolette and being held by a parent/nurse).&rdquo; And,  &ldquo;Accurate recordings were obtained regardless of whether or not the baby was awake, asleep, in a crib or running isolette.&rdquo;7 &ldquo;There is much less, if any, interference from monitors and other OR equipment. Test time is easily cut in half.&rdquo;2</p>\r\n<p>aMpLitrode This patented technology provides two distinct innovations: filtering of the ABR before amplification, along with amplification of the signal directly at the recording electrode site (Figure 1). By prefiltering the signal, the effects of EOG, ECG, motion artifact, and RF are almost completely eliminated. Gain adjustments are no longer needed, and the risk of signal saturation is reduced. Furthermore, by amplifying the signal &ldquo;in situ&rdquo; (at the recording site), sources of noise from the recording environment are reduced. Instead of an unamplified signal travelling along the electrode leads picking up electromagnetic noise and other contamination, the result is the recording of a more robust ABR signal.14 In contrast, the of lack in-situ amplification in conventional systems means that amplification occurs after the signal has had to travel from the electrode, along a cable, all the way to a preamplifier. With the cables acting as an antenna, there is a great deal of opportunity for noise to be introduced from sources present in the recording environment. Line noise and additional wires also contribute to contamination of the signal. Now, when the signal reaches the preamplifier, it is contaminated with all sorts of noise which is subsequently amplified.</p>\r\n<p>The patented Amplitrode eliminates many of the problems related to extraneous noise by prefiltering and amplifying immediately at the site of data acquisition, before the signal has had a chance to pick up undesirable noise. WireLess teChnoLogY Technology that can provide complete wireless communication between the recording platform and the electrodes has valuable benefits. As a batterypowered unit, the VivoLink is immune to line noise. Furthermore, elimination of wires reduces susceptibility to electromagnetic interference in the recording environment. Overall, this means there is less noise to manage which translates to very clean waveforms in very little time. Wireless recording also makes it possible to collect data while a baby is held, strolled, or nursed &ndash; untethered to equipment. In the case of high-risk babies in the NICU, the VivoLink enables babies to be tested inside an incubator while the recording platform remains outside. The incubator may even be closed shut while testing is in  progress, with the recording platform up to 10 metres (30 feet) away. This technology also permits children and adults the freedom to move and be tested in comfort (Figure 2).</p>\r\n<p><strong>Soap adaptive proCessing (an evoLution of kaLMan Weighted averaging)</strong></p>\r\n<p>This is perhaps the most innovative technology for noise reduction in evoked potential responses. SOAP Adaptive Processing is a combination of patented and proprietary technologies that adaptively reduce the myogenic and electromagnetic noise in ABR. It is an evolution of signal processing algorithms that use Kalman Weighted Averaging. Together with the Amplitrode and VivoLink wireless technology, SOAP provides superior response detection under non-ideal conditions and facilitates non-sedated ABR measurement (Figure 3). As with Kalman Weighted Averaging techniques, there is no artifact rejection. Instead, sweeps are included in the recording and assigned a weighting based on its noise content. Groups of sweeps with less noise are assigned a much greater weighting than sweeps with higher amplitude noise. Thus, noisy responses have less of an impact on the waveform morphology. By including all sweeps, and by weighting them according to the noise content, we can actually obtain a much clearer ABR waveform in less time. In addition to averaging, adaptive processing methods are used throughout the measurement. The system recalculates all weightings according to the noise content and the relationship between sweeps (covariance). This very active and unique dynamic weighting system provides much cleaner waveforms in much less time. finaL thoughts Mastering ABR measurement is a worthwhile undertaking in order to provide a comprehensive diagnostic picture of auditory function. Good clinical practice combined with technological advancements can help to overcome frustrations with noise in data acquisition and interpretation, and ultimately aid in obtaining quality ABR measurements.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. Stapells DR. Frequency-Specific ABR and ASSR Threshold Assessment in Young Infants. Phonak Sound Foundations 2010 manuscript (pp. 67-105). An updated version of Frequency-specific threshold assessment in young infants using the transient ABR and the brainstem ASSR. In R.C. Seewald and A.M. Tharpe (eds.), Comprehensive handbook of pediatric audiology (pp.409-448). San Diego: Plural Publishing, Inc.</p>\r\n<p>2. Horsch M. Newborn Hearing Screening: Utilization of Non-Sedated ABR to Assist with Loss to Follow-up. Presentation at AudiologyNOW! 2011, Chicago, IL, April 6-9, 2011.</p>\r\n<p>3. Langhan ML, Mallory M, Hertzog J, Lowrie L, Cravero J for the Pediatric Sedation Research Consortium. Physiological Monitoring Practices During Pediatric Procedural Sedation: A Report from the Pediatric Sedation Research Consortium. Arch Pediatr Adolesc Med. 2012;166(11):990&ndash;98.</p>\r\n<p>4. BC Early Hearing Program (revised by Hatton J, Hyde M, Stapells DR). Audiology Assessment Protocol, Version 4.1, November 2012.</p>\r\n<p>5. Hall JW III, Sauter T. Clinical Experience with New Technology For Recording Un-Sedated ABRs. Poster presentation at AudiologyNOW! 2010, San Diego, CA, April 14-17, 2010.</p>\r\n<p>6. Brown DK, Hunter LL, Baroch K, Eads E. Comparison of Auditory Brainstem Response Systems in the NICU Population. Poster presentation at AudiologyNOW! 2011, Chicago, IL, April 6-9, 2011.</p>\r\n<p>7. Johnson K. Universal Newborn Hearing Screening in the NICU Population Using New Features of the Vivosonic Integrity ABR Unit: Assessing the Correlation Coefficient as a Function of the Number of Sweeps Collected. Proceedings of University of Kansas Intercampus Program in Communicative Disorders. Au.D. Research Day, April 27, 2012.</p>\r\n<p>8. Walker B. Clinical Significance of Advanced ABR Technology for Newborn Hearing Screening Programs. Hearing Review Products, March 2012.</p>\r\n<p>9. McVicar S, Randall K, Wnek S, Bleazard C, Ladner D. Tele-Audiology in Utah: Our Efforts to Reduce Newborn Hearing Screening Loss to Follow-up. AMCHP 2013 Annual Conference, Washington, DC, February 9-12, 2013.</p>\r\n<p>10. See C. and Seeliger E. TeleAudiology: The Key to Serving Rural Populations. EHDI 2012 Conference, St. Louis, MO, March 5-6, 2012.</p>\r\n<p>11. Steinman A. Use of the Vivosonic Integrity V500 System to Identify False Indications of Noise Induced Hearing Loss (unpublished document). Based on an instructional document by Holdstein Y. Definitive auditory evaluation of workers exposed to excessive noise at work. Prepared for Labour Ministry, Israel, 10/12/2009.</p>\r\n<p>12. Meyer D, Moskop J, Winston A, Schupback J. ABR Results in Quiet and Active Subjects. Poster presentation at AudiologyNOW! 2011, Chicago, IL, April 6-9, 2011.</p>\r\n<p>13. Gerhart MJ, Hall JW III, Black AL. Evaluation of the Vivosonic Integrity Device for Auditory Brainstem Response Measurement. Poster presentation at AudiologyNOW! 2010, San Diego, CA, April 14-17, 2010.</p>\r\n<p>14. Kurtz I and Sokolov Y. Reducing the effect of electric and magnetic fields on auditory evoked potentials. Presented at 28th Annual Midwinter Meeting of Association for Research in Otolaryngology, New Orleans, LA, February 19-24, 2005.</p>\r\n<p>By Marlene Bagatto, Sheila Moodie, Christine Brown, April Malandrino, Frances Richer t, Debbie Clench, Doreen Bar tlett, Richard Seewald, and Susan Scollie  bagatto@nca.uwo.ca</p>\r\n<p>Marlene Bagatto (pictured), Sheila Moodie, Richard Seewald, and Susan Scollie are with the Child Amplification Laboratory, Western University, London, Ontario. Christine Brown and Frances Richert are with the Speech &amp; Hearing Clinic, Western University. April Malandrino and Debbie Clench are with theHumber River Regional Hospital, Toronto, Ontario. Doreen Bartlett is with the School of Physical Therapy, Western University. (Adapted from a poster presented at the International Hearing Aid Research Conference, Lake Tahoe, California, August 2012)</p>\r\n<p><strong>BaCkground</strong></p>\r\n<p>The primary goal of Early Hearing Detection and Intervention (EHDI) programs is to provide effective intervention by six months of age to maximize the infant&rsquo;s natural potential to develop language and literacy skills. Intervention with hearing aids is a common choice among families of infants identified as having permanent childhood hearing impairment (PCHI). Audiologists have access to scientifically based strategies and clinical tools to ensure the hearing aids are fitted appropriately to the infant.</p>\r\n<p><strong>Pediatric Outcome EvaLuation</strong></p>\r\n<p>Outcome evaluation is a key component of the pediatric hearing aid fitting process; however, there has been little consensus on best practices for functional outcome measurement in EHDI programs. A lack of well-normed clinical tools that are valid and feasible may have been a barrier to outcome evaluation in children with hearing aids.</p>\r\n<p>The University of Western Ontario Pediatric Audiological Monitoring Protocol Version 1.0 (UWO PedAMP)2 consists of a battery of outcome evaluation tools and related support materials. This protocol aims to support clinical, systematic evaluation of auditory-related outcomes for infants, toddlers, and preschool children with PCHI who wear hearing aids. This includes both clinical process measures and functional outcome measures in a two-stage process by developmental level. The functional outcome measures included in the protocol are the LittlEARS Auditory Questionnaire3 and the Parents&rsquo; Evaluation of Aural/Oral Performance of Children (PEACH).4 The PEACH is used in its rating scale format,4 and applied in the second developmental stage.</p>\r\n<p><strong>Purpose</strong></p>\r\n<p>This study examines how children with aided PCHI perform on the functional outcome measures within the UWO PedAMP. The LittlEARS is a 35-item questionnaire that assesses the auditory development of infants during the first two years of hearing. The PEACH Rating Scale is a 13-item questionnaire that assesses auditory performance in quiet and noisy situations for toddlers and preschool children. Normative values exist for normal hearing children for both questionnaires.5,6 However, few data for children who are followed within an EHDI program are available. This work characterizes LittlEARS and PEACH scores for children with PCHI who (a) are enrolled within an EHDI program; and (b) reflect the general population of children typically followed in a pediatric audiology outpatient clinic.</p>\r\n<p><strong>Method</strong></p>\r\n<p>Data were obtained as part of a longitudinal observational study in which outcomes were logged for all patients at participating sites. Pediatric audiologists at four clinical sites administered the LittlEARS and PEACH to caregivers of infants, toddlers, and preschool children with aided PCHI. The patients were seen during routine clinical care through Ontario&rsquo;s Infant Hearing Program (OIHP) over a period of 18 months. The OIHP follows children from birth to age six years and uses provincial protocols for the provision of hearing aids,1 which include fitting the hearing aids to the Desired Sensation Level (DSL) version 5.0a prescriptive algorithm.7 Audiometric and medical profiles of the children varied, along with follow-up details. partiCipants Table 1 provides the number of participants involved in this study in one of three groups: (1) typically developing; (2) comorbidities; and (3) complex factors. Children with comorbidities were born prematurely and/or had other identified medical issues besides hearing loss. Complex factors were logged to track non-medical issues that may impact overall outcome with intervention (i.e., late identification, late fitting, inconsistent hearing aid use). resuLts: auditorY deveLopMent and auditorY perforManCe Regression analyses were conducted on each group separately to determine the effect of age on the overall PEACH score. For all children who were typically developing, scores varied significantly with age (R2 =0.19; F=5.60, df=25, p&lt;0.05; Figure 1). This is consistent with published data.5 In a second analysis, only typically developing children older than 24 months were included, and the effect of age was not significant (R2 =0.09; F=1.57, df=16, p=0.23; Figure 2). Comparing the curves indicates that there is no significant age effect on overall PEACH scores after 24 months of age. This may support the use of raw (rather than age- corrected) scores for children older than 24 months of age and typical development. Overall PEACH scores for all children in the study ranged from 13.64 to 100% (mean=74.47%; SD=16.87). Descriptive statistics are reported for 17 typically developing children, 16 children with comorbidities and 32 children with complex factors related to hearing aid use (Figure 3). These scores differ markedly from published normative ranges5 for this scale for typically developing children. A multivariate analysis of covariance (MANCOVA) was conducted to determine the impact of degree of hearing loss and complexity (three-level independent variable) on the scores for the PEACH Quiet and Noise subscales. Results indicated that the multivariate effect of degree of hearing loss was significant (F [2,70] = 7.43, p &lt; 0.05, ?2 =0.179) but presence of complexity was not (F [2,70] = 0.37, p &gt; 0.05, ?2 = 0.011). Univariate effects confirmed that children who are typically developing or have complexities did not differ on their PEACH scores for either the Quiet (F [2,73] = 0.39, p &gt; 0.05) or Noise (F[2,73] = 0.53, p &gt;0.05) subscales. However, the degree of hearing loss had a significant impact on PEACH scores for the Quiet (F [1,73] = 9.59, p &lt;0.05) but not the Noise (F [1,73] = 1.03, p &gt;0.05) subscales. Regression analysis of the entire sample revealed a decrease in overall PEACH scores with increasing hearing loss (R2 = 0.07; F = 4.99, df = 72, p = 0.03).</p>\r\n<p><strong>suMMarY and CLiniCaL iMpLiCations</strong></p>\r\n<p>In summary, typically developing children who were identified and fitted early with high quality amplification reach age-appropriate auditory development milestones (LittlEARS) and display typical auditory performance (PEACH). Children with comorbidities and complex factors display different auditory development trajectories on the LittEARS compared to their typically developing peers. PEACH scores for typically developing children in this sample are approaching the score achieved by normal hearing children (90%) by age three years.5 Regression analyses indicated there is no age-related effect on overall PEACH score for children who are typically developing and older than 24 months: this may simplify clinical use of the tool as it obviates age-corrected scoring. Further analysis indicated that the degree of hearing loss impacts scores on the PEACH but complexity does not. This study contributes to a better understanding of functional outcomes for children within an EHDI program using a systematic approach to outcome evaluation.</p>\r\n<p><strong>Acknowledgements</strong></p>\r\n<p>This work was supported by The Canadian Institutes of Health Research (M. Bagatto 220811CGV-204713-174463) and the Ontario Research Fund, Early Researcher Award (S. Scollie).</p>\r\n<p><strong>References</strong></p>\r\n<p>1. Bagatto M, Scollie S, Hyde M, and Seewald R. Protocol for the provision of amplification within the Ontario Infant Hearing Program. Int J Audiol 2010:49:S70&ndash;79.</p>\r\n<p>2. Bagatto M, Moodie ST, Malandrino A, Richert F, Clench D, and Scollie S. The University of Western Ontario Pediatric Audiological Monitoring Protocol (UWO PedAMP), Trend Amplif 2011;15(1):34&ndash;56.</p>\r\n<p>3. Tsiakpini L, Weichbold V, Kuehn-Inacker H, Coninx F, D&rsquo;Haese P, and Almadin S. LittlEARS Auditory Questionnaire, MED-EL, Innsbruck: Austria; 2004.</p>\r\n<p>4. Ching T and Hill M. The Parents&rsquo; Evaluation of Aural/Oral Performance of Children (PEACH) Rating Scale, Australian Hearing, Chatswood, New South Wales, Australia; 2&mdash;5. http://www.outcomes.nal.gov.au/LOCHI %20assessments.html.</p>\r\n<p>5. Ching T and Hill M. The parents&rsquo; evaluation of aural/oral performance of children (PEACH) scale: Normative data, J Am Acad Audiol 2007;18:220&ndash; 235.</p>\r\n<p>6. Weichbold V, Tsiakpini L, Coninx F, and D&rsquo;Haese P. Development of a parent questionnaire for assessment of auditory behaviour of infants up to two years of age, Laryngo-Rhino-Otol 2005;84:328&ndash;34.</p>\r\n<p>7. Scollie S, Seewald R, Cornelisse L, et al. 2005. The Desired Sensation Level multistage input/output algorithm. Trends Amplif 2005;9(4):159&ndash;97.</p>\r\n<p>By Alber to Behar, PEng and Gabe Nespoli, BSc, MA Ryerson University albehar31@gmail.com</p>\r\n<p>Alberto Behar is a professional engineer and certified industrial hygienist. He holds a diploma in acoustics from the Imperial College and has been the recipient of several fellowships, including one from the Fulbright Commission (USA) and the Hugh Nelson Award of Excellence in Industrial Hygiene (OHAO, Canada). He is lecturer at Dalla Lana School of Public Health, University of Toronto and a board certified member of the Institute of Noise Control Engineering. Alberto is a chairman and member of CSA and ANSI committees and working groups and is also the Canadian representative at two ISO Working Groups. Gabe Nespoli is research operations coordinator at Ryerson University and lab manager (SMART Lab) at Ryerson University</p>\r\n<p>Headsets are headphones with an attached microphone that allows the user to communicate. We see them all the time in fast food takeouts (sometimes with one cup only) so that the worker can take your order while walking around. On a noisy shop floor they are used to attenuate background noise while enabling communication with fellow workers or supervisors. Some truck drivers wear headsets to listen to the radio or communicate with the dispatch centre, freeing their hands for driving. They are also used in call centres, airport control towers, and construction sites. We even use them at home when we want to listen to TV without disturbing others, or when trying to block out environmental noise while working or playing on the computer. Different headsets provide different amounts of attenuation for different applications. High attenuation headsets may also act as hearing protectors. When wearing a headset, there are two sources of sound involved: environmental (background) noise and an audio signal (that can be speech or music). The headset&rsquo;s cups attenuate environmental noise, while the signal is routed directly into the ears of the listener through the loudspeakers situated in the  cups. Usually, the user adjusts the signal to a comfortable listening level for speech or music.</p>\r\n<p><strong>Can the use of headsets daMage our ears?</strong></p>\r\n<p>How much does the level of the signal have to be raised above the background noise to ensure comfortable intelligibility? At Ryerson University, 22 students were individually presented with a speech signal (non-related sentences) through a headset. They were asked to adjust the level to be able to understand it properly. Three different types of background noise &ndash; babbling speech, industrial noise and construction noise &ndash; were introduced in a soundtreated room where the tests were performed. Two headsets were used: one with high attenuation and one with low attenuation. For the low attenuation headset (average measured attenuation 0.7 dBA), our results show that the addition of the speech signal increased the sound level by as much as 5 dBA. For example, if the background noise level is 85 dBA, the level inside the headset could be as high as 90 dBA (background noise + speech signal). The high attenuation headset used in our experiment reduced the background noise level by an average of 13.5 dBA. Therefore, a background noise level of 85 dBA would be reduced to 71.5 dBA. Including the speech signal the total sound level inside the headset would be 76.5 dBA (that is, the background noise attenuated by the headset, plus the 5 dBA increase due to speech).</p>\r\n<p>Can the use of headsets daMage our ears? How much does the level of the signal have to be raised above the background noise to ensure comfortable intelligibility? At Ryerson University, 22 students were individually presented with a speech signal (non-related sentences) through a headset. They were asked to adjust the level to be able to understand it properly. Three different types of background noise &ndash; babbling speech, industrial noise and construction noise &ndash; were introduced in a soundtreated room where the tests were performed. Two headsets were used: one with high attenuation and one with low attenuation. For the low attenuation headset (average measured attenuation 0.7 dBA), our results show that the addition of the speech signal increased the sound level by as much as 5 dBA. For example, if the background noise level is 85 dBA, the level inside the headset could be as high as 90 dBA (background noise + speech signal). The high attenuation headset used in our experiment reduced the background noise level by an average of 13.5 dBA. Therefore, a background noise level of 85 dBA would be reduced to 71.5 dBA. Including the speech signal the total sound level inside the headset would be 76.5 dBA (that is, the background noise attenuated by the headset, plus the 5 dBA increase due to speech).</p>\r\n<p>1. In high noise environments, headsets must be of the high attenuation type.</p>\r\n<p>2. The increase in noise exposure due to the signal is on the order of 5 dBA on top of the background noise attenuated by the headset.</p>\r\n<p>3. This increase is highly dependent of the type of noise in the environment (speech, industrial, construction, etc.).</p>\r\n<p>By james jerger, PhD</p>\r\n<p>sciences, and his 1953 book, Speech and Hearing in Communication, 2 was a virtual bible for serious researchers throughout the second half of the 20th century.</p>\r\n<p>I n every new generation of audiology students and otolaryngology residents, at least one or two inquisitive individuals invariably ask why the audiogram is upside-down. Students spend years studying science textbooks in which two-dimensional graphs are virtually always portrayed such that the numbers on the vertical scale increase as they move from the bottom to the top of the page; then they encounter audiograms and wonder why the &ldquo;HL in dB&rdquo; numbers increase in a downward rather than an upward direction. Basically, the audiogram is upside down; the values on the vertical axis become smaller, rather than larger, as they move from the bottom to the top of the graph. How this anomaly came about is the story of an interesting collaboration among three remarkable individuals: Edmund Prince Fowler, Harvey Fletcher, and R.L. Wegel. Edmund Prince Fowler (Figure 1) was an otolaryngologist who practiced in New York City. He received his MD degree from the College of Physicians and Surgeons of Columbia University in 1900, then became a member of the Manhattan Eye, Ear, &amp; Throat Hospital staff and, ultimately, Professor at the College of Physicians &amp; Surgeons. Fowler was one of the giants of otology during the first half of the 20th century. He is perhaps best known to audiologists for his discovery of loudness recruitment, but his investigative nature took him into many other aspects of hearing and hearing loss.</p>\r\n<p>Harvey Fletcher (Figure 2) was a physicist who earned his PhD degree from the University of Chicago in 1911, and then taught physics at Brigham Young University in Utah for 5 years. In 1916, he moved to the New York City area to join the Bell Telephone Laboratories. Fletcher was an early pioneer in the speech and hearing sciences, and his 1953 book, Speech and Hearing in Communication, 2 was a virtual bible for serious researchers throughout the second half of the 20th century. R.L. Wegel (whose photo we were not able to locate) was a physicist who earned his AB degree from Ripon College in 1910. From 1912 to 1913, he worked as a physicist in the laboratory of Thomas A. Edison. In 1914, he joined the Engineering Department of the Western Electric Company in New York City. He worked mainly in the area of telephone transmitters and receivers, but developed an interest in hearing and hearing disorders as a result of his own intractable tinnitus.3 Wegel is perhaps best known to auditory scientists for his collaboration with C.E. Lane on an early study of tone-on-tone masking.4 genesis of the audiograM forM The trio &ndash; Fowler, Fletcher, and Wegel &ndash; came together in the New York City area in the years immediately following World War I. Their common interest was the development and evaluation of the first commercially available audiometer in the USA, the Western Electric Model 1-A, designed jointly by Fletcher and Wegel for the American Telephone and Telegraph Company (AT&amp;T) and employed clinically in the otologic practice of Dr. Fowler.</p>\r\n<p>Throughout World War I, the research resources of AT&amp;T were focused on underwater sound transmission and detection, but when the war ended, interest returned to the basic study of the hearing and speech processes, and, tangentially, hearing loss, all important to telephone communication. AT&amp;T turned, therefore, to its engineering wing, the Western Electric Company, and to its research wing, the Bell Telephone Laboratories, for the development of an instrument to measure hearing loss. R.L. Wegel of Western Electric and Harvey Fletcher of Bell Labs took responsibility for the task. When the 1-A audiometer was ready for clinical evaluation, Wegel and Fletcher found a willing collaborator in Edmund Prince Fowler. (Fowler had previously worked with Fletcher and Alexander Nicholson of Western Electric in the development of a group phonograph audiometer for screening the hearing of schoolchildren.5 )</p>\r\n<p>the saga of the vertiCaL sCaLe It is difficult to imagine from our presentday vantage point the terra incognita in which this trio worked. Prior to the invention of the vacuum tube by Lee De Forest in 1906, there was really no satisfactory way of controlling and calibrating the amplitude of a pure tone. Tuning forks could produce a range of frequencies, but their use in measuring degree of hearing loss was restricted either to a temporal measure (ie, how long could the patient hear the fork in relation to how long the examiner could hear it), or to a distance measure (ie, how far away from the examiner could the patient still hear him).8 Thus, tuning forks interjected a truly mind-boggling number of uncontrolled variables. Use of the intensity dimension &ndash; the faintest intensity at which the patient can just hear the tone &ndash; had never been successfully exploited until the electric audiometer became available to clinicians. (As Alberto Behar9 has emphasized, the exact definition of &ldquo;intensity&rdquo; in physical acoustics is a complex issue; the term is used here mostly in the popular general sense of &ldquo;strength of sound.&rdquo;) Now it was possible via a telephone receiver to produce a pure tone of known sound pressure level, which could be systematically varied to facilitate a threshold search separately for each ear. As the Western Electric 1-A audiometer came into clinical use, our trio of Fowler, Fletcher, and Wegel began to wrestle with the issue of how to standardize the reporting of audiometric thresholds. Fowler and Wegel&rsquo;s first attempt was presented to otologists in 1922 at the 25th annual meeting of the American Laryngological, Rhinological and Otological Society in Washington, DC.10 It was concerned primarily with how to represent thresholds graphically.</p>\r\n<p>There was never a serious issue concerning representation of the frequency scale; the well-established musical scale, in which octave intervals are equally spaced, was readily adopted for the horizontal dimension of the graph. But the vertical dimension, the representation of threshold intensity, underwent a number of iterations. In a 1922 publication, Wegel11 had published a graph of the &ldquo;auditory area&rdquo; &ndash; the area between threshold audibility and the sensation of &ldquo;feeling&rdquo; across the audible frequency range. I have recreated this historic graph in Figure 3. Frequency was represented horizontally at approximately equally spaced octave intervals; intensity was represented vertically on a logarithmic scale of sound pressure level change, ranging from 0.0001 to 10,000 dynes/cm2 . A logarithmic scale of sound intensity was already widely accepted in the 1920s, based on the earlier studies of the great German psychologists, Ernst Weber and Gustave Fechner.8 It was well agreed, among students of audition, that the &ldquo;strength of sensation&rdquo; dimension should be represented logarithmically. From the standpoint of scientists like Fletcher and Wegel, the sound pressure level, expressed in dynes/cm2 , and increasing logarithmically from small numbers at the bottom to large numbers at the top of the graph, was consistent with scientific tradition.</p>\r\n<p>But the story does not end here. Indeed, it has hardly begun. After studying graphs like Figure 3, Fowler noted that when sound intensity was represented logarithmically, in which each successive step represented a pressure change ratio of 10:1, slightly less than 7 such steps separated the threshold of audibility from the threshold of feeling in the midfrequency (1000 to 3000 Hz) region. Fowler described this as the range of &ldquo;sensations&rdquo; characterizing the human auditory system and arbitrarily defined each step as a &ldquo;sensation unit.&rdquo; From here, it was only a short jump to the concept that the hearing loss of a hearing-impaired person could be represented as a loss in sensation units; if the normal sensation range, from justheard to just-felt, was 6.7 sensation units, and the patient&rsquo;s threshold of audibility was 2.1 units above the normal threshold of audibility, then one could say that the patient had a loss in sensation units of 31% (2.1/6.7). In other words, one could convert any patient&rsquo;s threshold of audibility to a &ldquo;percentage loss&rdquo; by this arithmetic maneuver. It was possible to take this one step further, reasoned Fowler, by subtracting the percentage loss from 100 to achieve &ldquo;percent of normal hearing&rdquo;(100% &minus;31% = 69%). Figure 4 is based on Figure 3 of the Fowler and Wegel (1922) paper.10 The filled squares show the hypothetical audiometric contour of a person with a high-frequency hearing loss. This chart, thought Fowler, gave you the numbers you needed to counsel patients. In his own words: &ldquo;This chart gives, perhaps, the most practical and logical answer to the question so often asked by the patient. &lsquo;How much hearing have I left?&rsquo; This can be read for single frequencies from the chart. The physician, as well as the patient, is usually interested in the loss, or amount retained, of sensory capacity.&rdquo; [p 110]10 Interestingly, a similar graphic representation was advanced in 1885 by the German otologist A. Hartmann of Berlin.8 He displayed duration of hearing at each tuning fork frequency as a percentage of normal duration. The percentages on the vertical scale ranged from 100% at the top of the graph to 0% at the bottom.</p>\r\n<p>aLea JaCta est! The die is cast! Julius Caesar uttered this famous phrase to indicate that crossing the Rubicon was an irrevocable act. However, Edmund Prince Fowler could not have known that placing the 100%- of-normal-hearing line at the top of the audiogram form was a similar irrevocable act. Fowler&rsquo;s influence in the otologic community in the decade of the 1920s was so pervasive that no one ventured to challenge it; indeed, his colleagues seemed to applaud the concept. The vertical scale satisfied the notion that the numbers ought to increase from bottom to top of the graph. We can see in Figure 4 that, if Fowler&rsquo;s original concept had been followed, the graph of audiometric results, which came to be called the &ldquo;audiogram,&rdquo; would have followed standard scientific usage; the values on the vertical scale (percent of normal hearing) would, indeed, have moved upward from the lowest to the highest numbers. At this point, the die had been cast. The line that came to be called &ldquo;zero HL in dB&rdquo; was fixed at the top of the graph and would never change thereafter. But Harvey Fletcher, a physicist, not a clinician, clearly did not agree with the percent-loss approach. In a lecture and demonstration given before the American Academy of Ophthalmology and Otolaryngology in Chicago in 1925,13 he made the following argument: &ldquo;In a paper presented before the American Triological Society by Fowler and Wegel (Audiometric Methods and Their Applications, May 1922), a hearing scale was proposed which has been objected to by some otologists because it is dependent on the threshold of feeling as well as the threshold of hearing. On this scale the percent hearing loss is the number of sensation units from the normal to the patient divided by the number of sensation units from the normal to the feeling point for a person of normal hearing. It is undoubtedly the best answer to the practical question as to what is the percent hearing loss, and is very useful in expressing general results. It is particularly useful for describing to the patient his degree of hearing. However, for an accurate expression of the degree of hearing loss, it seems desirable to express results in terms of sensation units rather than percent hearing loss.&rdquo;[p 167]13 In 1923, Fletcher presented audeograms [sic] of patients with typical deafness in which the intensity dimension was</p>\r\n<p>presented in just exactly that fashion. An example is shown in Figure 5. The filled squares reflect the data of the same hypothetical contour shown in Figure 4. Audiologists who deal with the frequency-response data of amplification devices will recognize how much more easily the response of the impaired ear and the response of the hearing aid could have been compared over the past halfcentury if this representation of audiograms had been retained. Clearly, physicist Fletcher was more comfortable with a purely physical scale of sound intensity than with the percentage concept based on the range between &ldquo;just audible&rdquo; and &ldquo;just felt.&rdquo; But when he had convinced Fowler to abandon the &ldquo;percent-of-normalhearing&rdquo; concept, he failed to follow through on the approach illustrated in Figure 5. Instead, he renamed Fowler&rsquo;s vertical scale &ldquo;sensation units&rdquo; in which each unit represented not a percentage change but a 10:1 change in sound pressure, but left the zero line at the top rather than moving it to the bottom of the graph. He simply changed the 100% line at the top of the graph to 0 sensation loss and renumbered so that increasing loss moved downward on the vertical scale. The audiogram was now doomed to be upside-down forever. Implicit in Fowler&rsquo;s original concept of &ldquo;sensation units&rdquo; was the principle that intensity, or hearing loss, was plotted relative to average normal hearing rather than relative to a physical baseline; at each frequency, the straight line at 100% on Figure 4 was simply the threshold of audibility straightened out to eliminate the fact that the sound pressure level corresponding to that 100% level varies with frequency. This concept quickly took hold, leading to the terminology &ldquo;Hearing Loss in Sensation units.&rdquo; By 1926, Fletcher was publishing audiograms in which the vertical scale was &ldquo;Hearing Loss&ndash;Sensation Units.&rdquo; By 1928, Fowler had abandoned his &ldquo;Percent of Normal Hearing&rdquo; measure and now plotted audiograms with intensity progressing downward from 0 to 120, and labeled &ldquo;Sensation Loss.&rdquo; introduCtion of the deCiBeL notation In the original conception of the sensation unit, slightly less than 7 units covered the range from audibility to feeling in the most sensitive portion of the auditory area. Fletcher13 thought this range too small for making meaningful distinctions among different degrees of hearing loss. In the Western Electric 1-A audiometer, he and Wegel redefined hearing loss as: HL = 10 log I/Io = 20 log P/Po , where... I is the patient&rsquo;s threshold power level, Io is the threshold power level of the average normal ear, P is the patient&rsquo;s threshold pressure level, and Po is the pressure level of the average normal ear. They adopted what we now know as the decibel notation, thereby increasing the range on the vertical dimension from slightly less than 7 sensation units to about 120 decibel (dB) units. As a result of Fletcher&rsquo;s influence, over the next decade, &ldquo;sensation units&rdquo; and &ldquo;sensation loss&rdquo; slowly gave way to &ldquo;Loss in Decibels.&rdquo; In a 1943 publication14 by Fowler&rsquo;s son, Edmund Prince Fowler Jr, the vertical scale in one of his figures [Figure 1a, p 393] is clearly labeled &ldquo;Hearing Loss in Decibels.&rdquo;</p>\r\n<p>Some years later, in a move toward terminological purity, Hallowell Davis, at Central Institute for the Deaf in St Louis, pointed out that &ldquo;loss&rdquo; can only be expressed relative to a known previous status of the patient rather than relative to average normal hearing. The term &ldquo;Hearing Level in dB&rdquo; (dB HL) was deemed more appropriate for the vertical scale. This brings us to contemporary usage. And that is the interesting story of how the audiogram came to be upside down. refLeCtions What lessons might we derive from this saga? First, it seems clear that relating a patient&rsquo;s degree of hearing loss to the physical characteristics of amplification devices would have been greatly simplified if Fletcher&rsquo;s scheme for the format of the audiogram (see Figure 5) had ultimately survived. Both sets of data would have been based on the same physical reference at all frequencies rather than the present situation in which one is based on sound pressure levels that vary across the frequency range according to the variation in &ldquo;average normal hearing&rdquo; (the audiogram), while the other is based on the same reference sound pressure level (0.0002 dynes/cm2 or 20 &mu;Pa) at all frequencies (amplification characteristics). Second, Fowler&rsquo;s notion of &ldquo;&hellip;amount of retained sensory capacity&rdquo; as quantified by &ldquo;percent of normal hearing&rdquo; may not have been such a bad idea. It had the virtue that it yielded a number, at each test frequency, easily understandable as a percentage rather than a decibel value. It also had the property that the numbers on the vertical scale increased, rather than decreased, from the bottom to the top of the recording form. Fletcher&rsquo;s discomfort with the threshold of feeling as a point of reference may have stemmed from the perception that &ldquo;feeling&rdquo; must be quite variable across individuals with and without hearing loss. In fact, however, the variability of the threshold of feeling in young adults with normal hearing is less than the variability of the threshold of audibility.16 It has the additional property that it is the same in persons with varying degrees of hearing loss, both conductive and sensorineural, and in persons with total deafness.17,18 Additionally, a measure of loss based on the range of useful hearing at each frequency (range from just audible to felt), rather than the range of all possible sound pressure levels above the audibility threshold, has a certain face validity. The fact that the usable range of hearing varies across the frequency range is a fundamental property of the auditory system but is not evident from the contemporary audiometric display. In any event, two quite sensible ways of recording audiometric threshold data emerged in the early 1920s, Edmund Prince Fowler&rsquo;s scheme, illustrated in Figure 4, and Harvey Fletcher&rsquo;s scheme, illustrated in Figure 5. Either would probably have been better than the present system, and would have preserved scientific tradition relative to the ordinates of graphs.</p>\r\n<p><strong>Acknowledgments</strong></p>\r\n<p>The author is grateful for the many helpful suggestions of Susan Jerger, Michael Stewart, and Richard Wilson. This article originally appeared in the March 2013 edition of The International Journal of Audiology, 1 and is adapted and reprinted here with permission from the publisher. CHR thanks IJA Editor-inchief Ross Roeser and Managing Editor Jackie Clark for their help in the preparation and republishing of this article.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. Jerger J. Why the audiogram is upside-down. Int J Audiol 2013;52:146&ndash;150.</p>\r\n<p>2. Fletcher H. Speech &amp; Hearing in Communication. 2nd ed. New York: Van Nostrand; 1953.</p>\r\n<p>3. Wegel R. A study of tinnitus. Arch Otolaryngol 1931;14:158&ndash;165.</p>\r\n<p>4. Wegel R, Lane C. The auditory masking of one pure tone by another and its probable relation to the dynamics of the inner ear. Phys Rev 1924;23:266&ndash;285.</p>\r\n<p>5. Fagen M. A History of Engineering and Science in the Bell System. Vol II, National Service in War and Peace (1925-1975). Murray Hill, NJ: Bell Telephone Laboratories Inc; 1975.</p>\r\n<p>6. Dean L, Bunch C. The use of the pitch range audiometer in otology. Laryngoscope 1919;29:453.</p>\r\n<p>7. Bunch C. Auditory acuity after removal of the entire right cerebral hemisphere. J Am Med Assn 1928;90:2102.</p>\r\n<p>8. Feldmann H. A History of Audiology. Vol 22: Translations of the Beltone Institute for Hearing Research. Chicago: The Beltone Institute for Hearing Research; 1970.</p>\r\n<p>9. Behar A. Sound intensity and sound level. Canadian Hearing Report 2012;7:26&ndash;27.</p>\r\n<p>10. Fowler E, Wegel R. Audiometric methods and their applications. In: 28th Annual Meeting of the American Laryngological, Rhinological, and Otological Society, Washington, DC, May 4-6, 1922. Omaha, Neb: American Laryngological, Rhinological, and Otological Society [now Triological Society]; 1922:98&ndash;132.</p>\r\n<p>11. Wegel R. Physical examination of hearing and binaural aids for the deaf. Proc Nat Acad Sci 1922;Wash 8:155&ndash;160.</p>\r\n<p>12. Fletcher H. Audiometric measurements and their uses. Transactions of the College of Physicians of Philadelphia 1923;45:489&ndash;501.</p>\r\n<p>13. Fletcher H. New methods and apparatus for testing hearing. Ann Otol, Rhinol &amp; Laryngol 1926;35:165&ndash;180.</p>\r\n<p>14. Fowler E Jr. Audiogram interpretation and the fitting of hearing aids. Proc Royal Soc Med 1943;36:391&ndash;402.</p>\r\n<p>15. Martin M. Decibel&mdash;the new name for the Transmission Unit. The Bell System Technical Journal 1929;8:1&ndash;2.</p>\r\n<p>16. Durrant J, Lovrinic J. Bases of Hearing Science. Baltimore: Williams &amp; Wilkins; 1977.</p>\r\n<p>17. Reger S. The threshold of feeling in the ear in relation to artificial hearing aids. Psych Monographs 1933;44:74&ndash;94.</p>\r\n<p>18. Lierle D, Reger S. Threshold of feeling in the ear in relation to sound pressure. Arch Otolaryngol 1936;23:653&ndash;664.</p>\r\n<p>By Susan Scollie scollie@nca.uwo.ca</p>\r\n<p>Dr. Susan Scollie is an associate professor and faculty scholar at the National Centre for Audiology at Western University. Together with colleagues, she develops and supports the DSL Method for hearing aid fitting in adult and children. Her current research focuses on the evaluation of digital signal processing for hearing aids, and early intervention for children with hearing loss. In her classroom teaching, Dr. Scollie focuses on calibration, pediatric audiology, and advanced procedures in amplification</p>\r\n<p>Many Canadian provinces are now initiating universal newborn hearing screening programs (UNHS), while others have not yet begun. This pattern significantly lags the progress made in the United States, where 100% of states have universal newborn hearing screening programs in place. Why the difference? Over the course of my career, I have witnessed the transformation of this area of our scope of practice, from high-risk registry screening to present day practices. Interactions with colleagues involved in this rapidly changing area has allowed me to observe the impacts of what I feel have been major factors in the near-universal implementation of UNHS south of the border. These include the recommendations of the interdisciplinary Joint Committee on Infant Hearing (JCIH), which recommended UNHS in 1996. This impactful group includes not only those from our profession, but also our colleagues from medicine (especially pediatrics), speaking with one evidencebased voice for the good of the children whom we serve. They have continued to do so, with re-jigging of important UNHS details as recommendation updates in 2007.1 Recommendations, however, do not result in successful UNHS practices on the ground, nor do they ensure that legislative support for programs is achieved. These changes have been largely mediated by the National Centre for Hearing Assessment and Management (NCHAM), which has worked diligently to provide nation-wide clinician training and legislation development for many years, among other initiatives. Remarkably, NCHAM provided proposed bill &ldquo;templates&rdquo; that could be downloaded at no cost, and used as a starting place for discussions with legislators, keeping track on a national map with colours indicating states with versus without legislation. With most of the legwork done, advocates for UNHS could provide a bill to their elected representatives that was 99% complete. This single act is likely responsible for the widespread legislation supporting UNHS in the United States, most recently culminating in The Early Hearing Detection and Intervention Act (EHDI: 2010) which added an EHDI requirement to the Public Health Services Act at the federal level. NCHAM continues their important work, with current efforts aimed at promoting legislation for improved hearing aid coverage in health care plans.</p>\r\n<p>Do we have parallel efforts in Canada? Although we can lean upon standards development (such as ANSI) and evidence from audiology science from south of the border, leaning upon their efforts in health care legislation is less likely to be helpful. Our health care systems are just too different. It&rsquo;s encouraging that we seem to have a recent parallel to JCIH. The Canadian Pediatric Society recently issued a report on Canadian public policy and child and youth health entitled &ldquo;Are We Doing Enough?&rdquo;2 Listed third among eleven key areas for improvement is &ldquo;Newborn hearing screening&rdquo; alongside such mainstream issues as youth smoking,   child and youth mental health, and bicycle helmet legislation. Powerful messages supporting the cost-benefit of early detection of infant hearing loss are provided in this important document, as well as 2011 summary table of the current status of screening programs with recommended next actions. This type of position statement sets the stage for follow up action and lends support to provincial initiatives to initiate legislative support for new programs.</p>\r\n<p>In discussion of these issues, we can and should remember that UNHS does not imply that intervention and follow up services are available or equitable. We have some provinces that provide fully funded, interdisciplinary services that halt in early childhood due to coverage based on age and others that carry on to age 18. We have others that provide government-funded or low-cost hearing aids to all children, and others that rely upon the limited means of families to purchase full-cost hearing aids for thousands of dollars. A national initiative to improve access to equitable health care for infant and childhood hearing impairment could call not only for UNHS, but also equitable and evidencebased intervention services that take cost burdens into consideration. Evidence-based intervention with hearing aids is possibly a more comfortable topic. New evidence and developments in hearing aid fitting techniques for children offer several messages: (1) the electroacoustic &ldquo;success&rdquo; of the fitting seems to matter, with new studies of outcome revealing that children whose hearing aids are grossly underfit have significantly poorer outcomes than do their well-fitted peers; (2) new technologies in hearing aids may have different uses for kids, and new tools for verifying these may be helpful in making clinical selection decisions; (3) monitoring of outcomes in children who use hearing aids has been a major area of change in pediatric practice in recent years. New tools are available. The sections below will review these three areas.</p>\r\n<p><strong>Electroacoustic success and Outcomes</strong></p>\r\n<p>Recent studies in Canada have looked at the nature of fit to prescribed DSL targets for kids on a normal pediatric audiology caseload. This work has been led by the Network of Pediatric Audiologists of Canada.3 The group includes a large number of clinicians from British Columbia, Alberta, Manitoba, Ontario, Quebec, and Nova Scotia. Their documented fit to targets across hundreds of ears is within 5 dB to the limits of the gain of the device. These data have been used to develop a normative range of Speech Intelligibility Index (SII) values for well-fitted hearing aids. In contrast, two recent U.S. studies have examined children whose hearing aid fittings are &ldquo;off the street&rdquo; to see how they fare. Both studies,4,5 found that although many children were fitted well, a subset of children were not. Stiles et al. found that low versus high SII values were predictive of poor word recognition, phoneme repetition, and word learning. These results reinforce the importance of consistent hearing aid practices, with routine electroacoustic verification and use of a validated prescriptive method. The basics still matter. neW teChnoLogies: evidenCe, fitting, and verifiCation Over the past decade, advances in digital signal process have allowed us to have feedback controls (leading to open fitting more often than ever before), noise reduction, and frequency lowering. These three technologies can be considered from a pediatric perspective. First, effective feedback control is of obvious interest for any pediatric fitting, but does it partner well with open fitting for pediatrics? The issue of open fits for kids is trickier than for adults, mainly because of ear canal size and hearing loss magnitude. Kids often pair ears that are too small for vents with losses that are challenging for highly vented (a.k.a. &ldquo;open&rdquo;) fittings. Does this take consideration of venting and open fitting off of our mental radar screens? Recent data from Johnstone et al. may push us a little to put it back on the considerations list, at least for kids with certain types of losses.6 Consistent with older adult data form,7 Johnstone reports better sound localization with open versus closed molds for children, and shares particularly interesting cases of children with unilateral hearing losses. Children who were provided with an open fit in their aided ear were able to localize sound better: is there a sensitive period for spatial hearing development? Recall that the primary cue for horizontal sound localization is low frequency timing difference between ears.8 The best way to preserve and deliver this timing cue is through a large vent, if appropriate for the degree of loss. We can verify the acoustic transparency of open fittings by comparing the open ear response to the occluded ear response with the aid worn but turned off. This can tell us how much vent-transmitted sound is making its way into the ear canal. These protocols for verification have not changed over the years (it&rsquo;s just the classic &ldquo;REOG&rdquo; approach9) &ndash; what&rsquo;s different is that it&rsquo;s now relevant to more of our fittings.</p>\r\n<p>Other enhancements in signal processing include noise reduction and frequency lowering. We are motivated to pursue options for use in noise because children spend a lot of their day in noise.10 We are motivated to pursue options for  frequency lowering for fittings where extended bandwidth can&rsquo;t give us access to the important fricative cues in speech.11 Management of loudness in noisy situations can take the form of simply using less gain in those situations.12 This strategy is implemented in DSL v5 as a DSL-Noise prescription,12 and has been shown effective in maintaining audibility of speech cues while reducing loudness for high-level inputs.13 A variety of other noise-focused signal processors exist, and new verification techniques are available to probe their function effectively (For a review of these, see Smriga, 2004.14). Frequency lowering signal processing is now available in many different forms: we use the term &ldquo;frequency lowering&rdquo; as an umbrella which covers frequency transposition, compression, and translation. Each of these provides a different type of frequency lowering effect. Outcomes research on the use of frequency lowering for children has provided data on efficacy, effectiveness, and candidacy,15 acclimatization,16 sound quality, and changes in brain activity arising from changes in audibility from frequency lowering.17 Case studies reveal the importance of fine tuning to an appropriate setting for each individual, in order to achieve actual benefit in speech sound detection and recognition.18 Obtaining these outcomes in clinical practice is supported by the use of systematic verification and fine tuning protocols.17,18 We can monitor the outcomes for individual children with targeted tests of speech sound detection aimed at bandwidth and/or frequency lowering effects,18,19 as well as more generic outcomes monitoring through caregiver reports or tests of sentence-level speech recognition.20,21 suMMarY The practice area of pediatric audiology is challenging, important, and has experienced dramatic and rapid changes both from the fronts of policy and product. This update article highlights some of these areas, with a discussion of their impacts on change in clinical practice. We have wonderful tools for hearing aid signal processing, verification, and fitting. We need better resources for universally available early detection and cost-effective intervention for permanent childhood hearing loss.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. Joint Committee on Infant Hearing. Year 2007 position statement: Principles and guidelines for early hearing detection and intervention programs. Pediatrics 2007;120:898&ndash;921. doi: 10.1542/peds.2007-2333</p>\r\n<p>2. Canadian Pediatric Society. Are we doing enough? A status report on Canadian public policy and child and youth health. ISSN 1913- 5645. Accessed from: http://www.cps.ca/ advocacy-defense/status-report. 2012.</p>\r\n<p>3. Moodie S, Bagatto M, Miller L, et al. An Integrated Knowledge Translation Experience: Use of the Network of Pediatric Audiologists of Canada to Facilitate the Development of the University of Western Ontario Pediatric Audiological Monitoring Protocol (UWO PedAMP v1.0), Trends in Amplification 2011;15:34&ndash;56.</p>\r\n<p>4. McCreery R, Bentler R, and Roush P. The characteristics of hearing aid fittings in infants and young children. Ear and Hearing 2012; in press.</p>\r\n<p>5. Stiles D, Bentler R, and Mcgregor K. The speech intelligibility index and the pure-tone average as predictors of lexical ability in children fit with hearing aids. Journal of Speech, Language, and Hearing Research, first published online on January 5, 2012 as doi:10.1044/1092- 4388(2011/10-0264); 2012.</p>\r\n<p>6. Johnstone PM, N&aacute;b lek AK, and Robertson VS. Sound localization acuity in children with unilateral hearing loss who wear a hearing aid in the impaired ear. Journal of the American Academy of Audiology 2012;21:522&ndash;34.</p>\r\n<p>7. Noble W, Sinclair S, Byrne D. Improvement in aided sound localization with open earmolds: observations in people with highfrequency hearing loss. Journal of American Academy of Audiology 1998;9:25&ndash;34.</p>\r\n<p>8. Macpherson E and Middlebrooks J. Listener weighting of cues for lateral angle: The duplex theory of sound localization revisited. Journal of the Acoustical Society of America 2002;111(5):2219&ndash;2236.</p>\r\n<p>9. Mueller HG. Probe microphone measurements: 20 years of progress. Trends in Amplification 2001;5(2): 35&ndash;68.</p>\r\n<p>10. Crukley J, Scollie S, and Parsa, V. An exploration of school-age listening landscapes: Implications for pediatric hearing aid fittings. Journal of Educational Audiology 2011;17:23&ndash;35.</p>\r\n<p>11. Stelmachowicz P, Pittman A, Hoover B, et al. The importance of high-frequency audibility in the speech and language development of children with hearing loss. Archives of Otolaryngology -- Head &amp; Neck Surgery 2004;130(5):556&ndash;62.</p>\r\n<p>12. Scollie S, Ching T, Seewald R, et al. Evaluation of the NAL-NL1 and DSL v4.1 prescriptions for children: preference in real world use. International Journal of Audiology 2010;49: S49&ndash;S63.</p>\r\n<p>13. Crukley J, and Scollie S. Children\'s speech recognition and loudness perception with the Desired Sensation Level v5 Quiet and Noise Prescriptions. American Journal of Audiology 2012; Doi: 10.1044/1059-0889(2012/12-002).</p>\r\n<p>14. Smriga DJ. How to measure and demonstrate four key digital hearing aid performance features. Hearing Review 2004;11(11).</p>\r\n<p>15. Glista D and Scollie S. Modified verification approaches for frequency lowering devices. AudiologyOnline 2009; http://www.audiologyonline.com/articles/article_detail.asp? article_id=2301.</p>\r\n<p>16. Glista D, Easwar V, Purcell D, and Scollie S. (2012). A Pilot Study on Cortical Auditory Evoked Potentials (CAEPs) in children: Aided CAEPs change with frequency compression hearing aid technology, International Journal of Otolaryngology 2012; Article ID 982894, doi:10.1155/2012/982894.</p>\r\n<p>17. Glista D, Scollie S, and Sulkers J. Perceptual acclimatization post nonlinear frequency compression hearing aid fitting in older children. Journal of Speech, Language, and Hearing Research 2012; Doi:10.1044/1092- 4388(2012/11-0163).</p>\r\n<p>18. Scollie S and Glista D. (2011). Digital signal processing for access to high frequency sounds: implications for children who use hearing aids. ENT and Audiology News 2011;20(5):83&ndash;87.</p>\r\n<p>19. Glista D and Scollie S. (2012). Development and evaluation of an english language measure of detection of word-final plurality markers: The University of Western Ontario Plurals Test. American Journal of Audiology 2012;21:76&ndash;81.</p>\r\n<p>20. Ng S, Meston C, Scollie S, and Seewald R. Adaptation of the BKB-SIN test for use as a pediatric aided outcome measure. Journal of the American Academy of Audiology 2011;22:375&ndash; 86.</p>\r\n<p>21. Bagatto M. 20Q: Baby steps following verification - outcome evaluation in pediatric hearing aid fitting. AudiologyOnline 2012; http://www.audiologyonline.com/articles/ article_detail.asp?article_id=2414).</p>\r\n<p>By joanne Deluzio, PhD jo.deluzio@utoronto.ca</p>\r\n<p>Joanne DeLuzio PhD, Audiologist, Reg. CASLPO, is adjunct professor with the Department of Speech-Language Pathology at the University of Toronto.</p>\r\n<p>The &ldquo;gold standard&rdquo; for outcomes in the field of childhood hearing loss is language development and academic achievement commensurate with age and cognitive ability. However, achieving age-appropriate levels in these areas will not necessarily ensure that the children have good socialemotional development (i.e., the ability to form close, confident relationships and to experience, regulate, and express emotions within these relationships). Even with good auditory language measures, the social development of many children with hearing loss continues to lag behind their typically hearing peers1,2 Communication training with young children with hearing loss relies primarily on adult-child interactions, as the children are usually involved in therapy with one or more adult service providers. Adult-child interactions are important because language learning occurs during conversations with adults, and the adults serve as language models for the children. During adultchild interactions, adults are typically the initiator and they modify their language and communication to accommodate both the linguistic and social needs of the children. Peer interactions on the other hand are also imperative, and may be the primary context in which young children can practice assertiveness, aggressiveness, and conflict management because there is not the power imbalance that occurs when interacting with adults.3 It is during peer interactions that children have the opportunity to function as equal and autonomous communication partners. It may not be sufficient to place children with hearing loss into integrated classrooms and assume that positive peer interactions will flourish. The typically hearing children may not be responsive to them.1 Given the importance of social skills development and positive peer interactions, assessment of children with hearing loss should include measures of social-emotional maturity and peer interaction skills. As well, the literature has &ldquo;reduction of loneliness&rdquo; as an outcome with children who have chronic illness, and these types of measures may also be beneficial for children with hearing loss.4 Additionally, education for parents needs to include milestones for socialemotional maturity and social skills development in addition to speech and language milestones.</p>\r\n<p>Professionals in the field of childhood hearing loss need to move towards more child-centered outcomes. This means considering outcomes that: are identified by the child, support the child&rsquo;s physical social and psychological development, consider the child&rsquo;s developmental needs, and measure the child&rsquo;s perceptions of the impact of the treatments they are receiving. To that end, measures of pediatric quality of life should be used routinely in the assessment protocol. The pediatric quality of life inventory5 (PedsQL) is one tool that may be applicable. It addresses dimensions of health that are of universal concern to children across age groups and has data on 35,000 healthy children. The platinum standard in the field of childhood hearing loss should be commensurate achievement in all developmental areas including: socialemotional development, communication, language, and academic success. The ultimate goal is for these children to be healthy and well adjusted and to experience positive self-esteem, peer acceptance and the ability to form close relationships throughout their life.</p>\r\n<p><strong>References:</strong></p>\r\n<p>1. DeLuzio J and Girolametto L. (2011). Peer interactions of preschool children with and without hearing loss. Journal of Speech, Language, and Hearing Research 2011;54:1197&ndash;10.</p>\r\n<p>2. Martin D, Bat-Chava Y, Lalwani A, Waltzman SB. Peer relationships of deaf children with cochlear implants: predictors of peer entry and peer interaction success. Journal of Deaf Studies and Deaf Education 2011;16(1):108&ndash; 20.</p>\r\n<p>3. Ladd GW. Children&rsquo;s peer relations and social competence. New Haven, CT: Yale University Press; 2005.</p>\r\n<p>4. Ladd GW, Kochenderfer BJ, and Coleman CC. Friendship quality as a predictor of young children&rsquo;s early school adjustment. Child Development 1996;67:1103&ndash;18.</p>\r\n<p>5. Varni J. The PedsQLTM (Pediatric Quality of Life Inventory). http://www.pedsql.org/; (2008-2013).</p>\r\n<p>Carri johnson, AuD  Canadian Academy of Audiology Chair, Third Par ty Committee</p>\r\n<p>Over the years many of you have sent in questions for the federal health partners. Many of these questions are repeated each year so, I thought I would take this opportunity to clarify a few things. did You knoW&hellip;&hellip; VAC will pay for the manufacturer&rsquo;s invoice cost for earmolds as long as the invoice is submitted with the billing. They will also pay impression fees for replacement molds. For ear molds fit with the hearing aid originally the cost of the impression fee is included in the dispensing fee. As of June 1, 2013, audiologists are no longer required to complete NIHB&rsquo;s Hearing Aid Confirmation Form. We must now only fax the manufacturers invoice with a copy of the Preauthorization Form (referencing their PA number) to their respective Health Canada regional office in order to finalize the approval process DND, NIHB, RCMP, VAC have negotiated 2 year warranties on all hearing aids with all CAEA members. This is the standard warranty for all their clients regardless of what warranties you have negotiated for your private pay clients If your patient is covered by one of the federal health partners and requires an item that is on their grid, a letter can be written to request an exception. These applications should include the medical reasons why this device is required for the clients day to day living. They are considered on a case by case basis. If you have questions about any of the federal health partners please feel free to contact CAA at anytime of the year. We are here to help you and your patients.</p>\r\n<p>By Marilyn Reed, MSc mreed@baycrest.org</p>\r\n<p>Marilyn Reed, MSc, is the practice advisor for audiology at Baycrest, a geriatric care and research center in Toronto, where she has worked since 1997. Marilyn graduated with a master&rsquo;s degree in audiology from the University of Southampton in England in 1976, and has since worked in clinical audiology in a variety of settings, always with a geriatric interest.</p>\r\n<p>Alzheimer&rsquo;s disease, the most common form of dementia, has become the primary public health concern in Canada. It is the leading cause of disability among Canadians over the age of 65, already costs billions of dollars each year, and prevalence is predicted to double worldwide within 20 years.1 Dementia cannot be prevented or cured, and there is an urgent need to find ways to delay the onset and progression of the disease and reduce the associated social and economic costs. Since hearing loss and cognitive impairment are both highly prevalent in older adults, dual impairments are common. However, hearing loss is more prevalent in those with dementia than in matched control.2 The link between agerelated hearing loss and cognitive impairment has been well-established through over 30 years of research, but recent epidemiological findings show that older adults with hearing loss are more likely to develop dementia, and the more severe the hearing loss, the greater the risk.3 Longitudinal studies have also shown a close correlation between central auditory processing (CAP) problems and cognitive impairment, with scores on dichotic speech tests being predictive of the likelihood of cognitive decline.4,5 The specific mechanisms underlying the association between audition and cognition are unknown; theories include the possibility of a common cause, due to age-related pathological changes in the brain, or a causal relationship, with hearing loss being a modifiable risk factor for cognitive decline. Possible causal pathways might involve the additional burden that hearing loss places on declining cognitive resources needed for information processing, or the lack of cognitively stimulating interaction and social isolation resulting from sensory deprivation. Whatever the mechanism, the evidence strongly suggests that hearing loss may contribute to or accelerate the progression of symptoms of cognitive decline in older adults. If management of hearing loss could reduce or delay the progression of dementia, the implications for the cognitive health of older adults and the costs of dementia to public health and society as a whole are huge. Audiologists need to be aware of the role that cognition plays in the communication problems of our clients so that we can begin to apply recent research findings to improve both assessment and management. While it may be obvious which clients have more advanced dementia, milder cognitive impairment is difficult to recognize in only one or two visits, and yet can have a significant impact on the success of our interventions. A &ldquo;snapshot&rdquo; of the cognitive status of randomly selected Baycrest audiology patients over the age  of 68 years revealed that 16 out of 20 failed the Montreal Cognitive Assessment test, indicating that they had at least mild cognitive impairment and suggesting that cognitive screening is warranted. Many authors advise us that this is indeed the case.6&ndash;8 Assessment of cognitive status through observation of behaviour, history taking, screening tools, or speech tests that address working memory and other aspects of auditory processing and cognitive function would be a valuable addition to the audiologic assessment battery. Similarly, assessment of hearing should be part of any assessment of cognitive function, especially since many cognitive tests are verbal and therefore impacted by hearing loss. Audiologists can play an important role in the education of other health care professionals in this area, and provide them with hearing screening tools and referral criteria.</p>\r\n<p>There are currently no established best practice protocols for the audiologic assessment of patients with cognitive impairment. While those of us working with elderly clients have developed our own modifications to test procedures (see Table 1), it would be helpful to develop more standardized test protocols that address the impact of cognitive decline on patients&rsquo; ability to provide information and the most effective ways for us to obtain it. We should also include new tests that provide information about higher auditory and cognitive processing; we need to do more than speech testing in quiet to get information about the entire auditory system that will assist with management decisions. Specialized speech tests can provide much information about functional communication ability, CAP and aspects of cognitive function, and are available in varying degrees of difficulty to suit the ability of the patient. Dichotic tests which target binaural integration skills, dual tasking and memory target both auditory and cognitive processing. The dichotic digit test9 is recommended by many in the literature10 as being the most appropriate and cost-effective for use with the elderly, and is currently under trial in our clinic at Baycrest. How does knowledge of cognitive status change what we do? Baycrest audiologists are currently looking at whether we modify our services based on awareness of our patients&rsquo; cognition, with a view to developing and integrating best practice procedures for those with both hearing loss and cognitive decline. We do know that there is a great need to provide and improve services for this population11,12 for whom amplification in the form of hearing aids provides limited benefit and poses problems for management. Our current, technology focused approach is not very successful for older listeners and needs to be resituated in a broader context of audiologic rehabilitation (AR) because of the important role that training and therapy play in promoting compensatory cognitive function.13 Speech perception difficulties of the elderly result from a complex interaction of sensory and cognitive processes, and arise from peripheral, central and cognitive changes that occur with age. Listening, comprehending and communicating require more general cognitive operations such as attention, memory, and language representation.14 In daily life, listeners constantly take in bottom-up information using their hearing, and combine it with &ldquo;top-down&rdquo; knowledge that&rsquo;s learned and stored in the brain. The more difficult the listening conditions, the more effort we have to make to hear and understand. This increased listening effort puts more demands on cognitive resources needed for other aspects of information processing such as deriving meaning and storing in memory. Cognitive decline makes it harder for older listeners to ignore, inhibit or suppress irrelevant acoustic stimuli like music or competing voices, and attend to the specific voice of interest. Poorer working memory (WM) makes it harder to fill in the gaps in conversation, and the effort of listening and paying attention means that older listeners are less likely to understand and remember what they&rsquo;re hearing, even if they hear it.15 Focusing on the hearing aid as a &ldquo;fix&rdquo; for their communication problems misleads many clients with   age-related hearing loss into having unrealistic expectations and sets them up for failure. No matter how perfect our real-ear aided responses are, the speech signal provided at the periphery will be distorted by damaged central and cognitive processing.8,16 Hearing aids can both help and hinder success with communication; they can reduce listening effort by improving the quality of the signal reaching the auditory cortex through restoring audibility and improving the signal to noise ratio with directional microphones and noise reduction algorithms. However, complex signal processing may not necessarily be beneficial for everyone, as it may introduce distortions in ways that impede or cancel the intended benefits for some individuals. Studies show that those with cognitive impairment and lower WM are more susceptible to distortion from fast amplitude compression (WDRC) and frequency compression/lowering and that HA signal processing should be less aggressive for these patients.16&ndash;18 Binaural aiding may not be the best strategy for some elderly persons for whom higher auditory processing factors such as decreased interhemispheric communication and binaural integration result in reduced ability to use binaural cues.19,20 Aging and cognitive decline also appear to affect hemispheric asymmetry in linguistic processing, so that asymmetry favoring the left hemisphere reverses, resulting in significant right ear advantage in those with cognitive impairment.10 Of course we also have to pay attention to non-acoustic factors related to agerelated cognitive and physical limitations (Table 2).</p>\r\n<p>If our goal is to maximize our patients&rsquo; ability to communicate, we must consider the role of cognitive processing in AR. It is impossible to disentangle sensory loss from cognitive processing in older listeners, and so effective intervention must include both amplification (bottomup) and training (top-down) to improve auditory skills and teach compensatory behavioral strategies. Bottom-up strategies focus on access to a clear signal, while topdown strategies focus on functional communication (see Table 3, based on Ferre, J: Rehabilitation for Auditory Processing Difficulties in Adults, ASHA on-line seminar, 2012). &ldquo;There&rsquo;s more than one way to recognize a word&rdquo;13; through AR techniques, we can teach compensatory behavioral communication strategies to patients and caregivers, to improve top down processing and help to compensate for sensory deficits. Group AR programs not only help older adults become more effective communicators, they also foster their participation and social interaction.22 A group gives an opportunity for repetitive practice of communication repair strategies in a meaningful context while addressing social participation needs. Social interaction is known to promote cognitive health and has been shown to have a protective effect against dementia.5,23,24 The Hard of Hearing Club at Baycrest was designed for seniors with severe hearing loss at risk for social isolation and has successfully addressed both educational and social needs for many of its members over the 13 years that it has been running.25 There is a pressing need for audiologists to understand how cognitive impairment interacts with hearing loss so interventions can be tailored to better suit client needs. Dr. Lin is conducting another research project that will follow older adults over time to see if audiologic interventions will help delay the onset or slow the progression of cognitive decline. At Baycrest, audiologists will be working with psychologists to look at whether fitting HAs and providing AR will have a positive impact for patients with early dementia and their caregivers. If this is indeed the case, the implications are huge, and audiologists could play a critical role in providing solutions to this pressing public health concern.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. Alzheimer&rsquo;s Society of Canada. Rising tide: the impact of dementia on Canadian society. Toronto: Author; 2010.</p>\r\n<p>2. Uhlmann RF, Larson EB, Rees TS, et al. Koepsell. Relationship of hearing impairment to dementia and cognitive dysfunction in older adults. .Journal of the American Medical Association 1989;261:1916&ndash;19.</p>\r\n<p>3. Lin FR. Hearing loss and cognition among older adults in the United States.Journals of Gerontology A: Biological Sciences and Medical Sciences 2011;66:1131&ndash;36.</p>\r\n<p>4. Gates GA, Beiser A, Rees TS, et al. Central auditory dysfunction may precede the onset of clinical dementia in people with probable Alzheimer&rsquo;s disease. Journal of the American Geriatrics Society 2002;50:482&ndash;88.</p>\r\n<p>5. Gates GA, Anderson ML, McCurry SM, et al. Central auditory dysfunction is a harbinger of Alzheimer&rsquo;s dementia. Archives of Otolaryngology-Head and Neck Surgery 2011;137:390&ndash;95.</p>\r\n<p>6. Kricos P. Audiologic management of older adults with hearing loss and compromised cognitive/psychoacoustic auditory processing capabilities. Trends in Amplification 2006;10(1):1&ndash;28.</p>\r\n<p>7. Pichora-Fuller MK. Effects of age on auditory and cognitive processing: implications for hearing aid fitting and audiologic rehabilitation, Trends in Amplification 2006;10(1) 29&ndash;59.</p>\r\n<p>8. Lunner T. Memory systems in relation to hearing aid use. Cognition, Audition and Amplification, AAA Conference, Boston; 2012.</p>\r\n<p>9. Musiek F. Assessment of central auditory dysfunction: The Dichotic Digit Test revisited. Ear and Hearing 1983;4:79&ndash;83.</p>\r\n<p>10. Idrizbegovic E, Hederstierna C, Dahlquist M, et al.Central auditory function in early Alzheimer\'s disease and in mild cognitive impairment.Age and Ageing 2011;40:249&ndash;54.</p>\r\n<p>11. Lin FR, Metter EJ, O&rsquo;Brien RJ, et al. Hearing loss and incident dementia.Archives of Neurology 2011;68:214&ndash;20.</p>\r\n<p>12. Kricos P. Providing hearing rehabilitation to people with dementia presents unique challenges. The Hearing Journal 2009;62(11):39&ndash;43.</p>\r\n<p>13. Pichora-Fuller MK. Perceptual effort and apparent cognitive decline: Implications for audiologic rehabilitation. Seminars in Hearing 2006;27:4.</p>\r\n<p>14. Kiessling J, Pichora-Fuller MK, Gatehouse S, et al. Candidature for and delivery of audiological services: Special needs of older people. International Journal of Audiology 2003;42(Suppl 2):2S92&ndash;101.</p>\r\n<p>15. Pichora-Fuller MK. Audition and cognition: Where the lab meets clinic. ASHA Leader 2008;13(10):14&ndash;17.</p>\r\n<p>16. Humes LE. Modeling and predicting hearingaid outcome. Trends in Amplification 2003;7(2):41&ndash;75.</p>\r\n<p>17. Gatehouse S, Naylor G, and Elberling C. Linear and non-linear hearing aid fittings &ndash; 2. Patterns of candidature. International Journal of Audiology 2006;45:153&ndash;71.</p>\r\n<p>18. Lunner T and Sundewall-Thor&eacute;n E. Interactions between cognition, compression, and listening conditions: Effects on speech-in-noise performance in a two-channel hearing aid. Journal of the American Academy of Audiology 2007;18:604&ndash;17.</p>\r\n<p>19. Walden TC and Walden BE. Unilateral versus bilateral amplification for adults with impaired hearing. Journal of the American Academy of Audiology 2005;16(8):574&ndash;84.</p>\r\n<p>20. Kobler S, Lindblad AC, Olofsson A, and Hagerman B. Successful and unsuccessful users of bilateral amplification: differences and similarities in binaural performance. International Journal of Audiology 2010;49(9):613&ndash;27.</p>\r\n<p>21. Sweetow RW, Sabes JH. The need for and development of an adaptive Listening and Communication Enhancement (LACE) Program. Journal of the American Academy of Audiology 2006;17(8):538&ndash;58.</p>\r\n<p>22. Worrall L and Hickson L. Communication disability in aging: From prevention to intervention. Clifton Park, NY: Delmar Learning; 2003.</p>\r\n<p>23. Fratiglioni L, Paillard-Borg S, Winblad B. An active and socially integrated lifestyle in late life might protect against dementia. Lancet Neurol 2004;3(6):343&ndash;53.</p>\r\n<p>24. Hultsch DF, Hertzog C, Small BJ, and Dixon RA. (1999). Use it or lose it: Engaged lifestyle as a buffer of cognitive decline in aging? Psychology and Aging 1999;14:245&ndash;63.</p>\r\n<p>25. Reed M. The Hard of Hearing Club: A social framework for audiologic rehabilitation for seniors with severe hearing difficulties. In L. Hickson (Ed), Hearing care for adults: The challenge of aging. Phonak: St&auml;fa, Switzerland; 2009</p>\r\n<p>Co-ordinator: Marshall Chasin, AuD., Reg.\r\nCASLPO (far left)\r\nSpeaker: Harry Levitt, PhD, City University of\r\nNew York (middle)\r\nSpeaker: Edgar Villchur, MS Ed., Foundation for\r\nHearing Aid Research (left)</p>\r\n<p>E. Villchur: The consonants are\r\nidentified not only by their spectral\r\nmakeup, but also by their temporal\r\npattern. A [t] starts out with a sharp jump\r\nin amplitude and tapers off. Also, the\r\nconsonant is affected by the vowel\r\nenvironment ? it is preceded or followed\r\nby one sound or another. If interference\r\ndestroys on or two of these cues, the third\r\none may be enough to identify it. One of\r\nthe cues that allows us to understand\r\nspeech is the context or meaning of the\r\nspeech. If I say ?I fell out of the boak,? we\r\nare going to change that [k] to a [t],\r\nbecause it doesn?t make sense otherwise.\r\nBut if I also miss the [b] or the [o], I won?t\r\nhave the additional cue.\r\nH. Levitt: Another example of\r\nredundancy is to stress a syllable. In the\r\nword ?confuse? ? we change the stress\r\npattern and the meaning is changed.\r\nThere are cues that are correlated with\r\nstress, such as the lengthening of the\r\nstressed syllable, the intensity of the\r\nvoiced syllable, and the increasing of the\r\nvoice pitch of the stressed syllable. All of\r\nthese cues depend on the stress, and that\r\nis a redundant situation. If only one of\r\nthose cues is heard, such as may be the\r\ncase with a hearing impaired person,\r\nthen the redundancy is reduced so that\r\nthe meaning may not be apparent.\r\nQuestion: What are your experiences\r\nwith frequency displacing hearing aids\r\nwhich transpose the high frequencies\r\nand impose them on the lower?\r\nE. Villchur: Work by Johanssen, in\r\nSweden, has tried to do this, and indeed\r\nthey came out with a commercial\r\nproduct (under the name of Oticon in the\r\n1970s). There was a modification of this\r\nwhich was published in an IEEE journal\r\nwithin the last decade, where instead of\r\nfolding the entire high frequency band\r\nonto the low frequency band where they\r\nfeared interference effects, he only folded\r\nthe energy above 5000 Hz back down, in\r\neffect only affecting the fricatives. I don?t\r\nknow of any application of this in any\r\nhearing aid.\r\nH. Levitt: There have been a number of\r\nexperimental devices along these lines,\r\nbut I?m not familiar with any one of them\r\nwhich has reached the marketplace other\r\nthan the Johanssen device.\r\nE. Villchur: One problem with these\r\ndevices is that you have to learn a new\r\nlanguage. You have to learn to recognize\r\nnew sounds. The thing I liked about the\r\nsynthetic fricatives, which followed\r\nsurrogate fricatives (Levitt), is that you\r\ndon?t have to learn a new language.\r\nH. Levitt: These transposition devices\r\ncan be broken up into three groups (1)\r\nwhich transposes everything from the\r\nhigh frequencies to lower ones, (which\r\nhave not been particularly successful), (2)\r\nthe phonetic transposition devices which\r\nfirst decides whether it?s a fricative or\r\nanother sound, and only that sound is\r\ntransposed down, (and that reduces the distortion and the transposition only\r\noccurs during fricatives. This has been\r\nmore successful and the model was\r\npublished around 1968), and (3) logic\r\nfrequency transposition which is a device\r\nwhich reduces everything only slightly so\r\nthat speech still sounds like speech. We\r\nget small improvements in intelligibility\r\nparticularly with female and children?s\r\nvoices which have a higher pitched\r\nfrequency spectrum. If you transpose\r\nabout 20% down, you are likely to\r\nimprove intelligibility.\r\nQuestion: Dan Graupe who invented\r\nthe Zeta Blocker chip, has stated that\r\nhe has a system which can reduce\r\nspeech down to an 800 Hz bandwidth\r\nand still be intelligible, because he\r\nwas using a non-linear frequency\r\ntransposition instead of a linear one.\r\nH. Levitt: Non-linear transposition has\r\nbeen tried at MIT and they call it\r\nfrequency warping. To my knowledge\r\nthey have not gotten particularly exciting\r\nresults. But, they also did a feasibility\r\nstudy which was quite interesting. One\r\nof the arguments against radical\r\nfrequency transposition is that the\r\nresulting speech is not recognizable\r\nwithout training. You have to learn a new\r\ncode. There is a fundamental question\r\nwhether you can actually learn the new\r\ncode. The group at MIT created artificial\r\nspeech sounds which were all under\r\n1000 Hz and that were as perceptually\r\ndifferent from each other as possible.\r\nThese were clicks and all sorts of strange\r\nsounds. They trained people to associate\r\nthese sounds with speech sounds. They\r\nwere able to demonstrate that it was\r\npossible to at least train a person to learn\r\nthe consonant set. So in principle, people\r\ncould learn a new code. Nobody has yet\r\ncome up with a machine which does it\r\nautomatically.\r\nE. Villchur: I have no doubt that speech\r\nis intelligible in an 800 Hz band because\r\nunprocessed normal speech cut off above\r\n800 Hz is intelligible. The question is\r\nwhether intelligibility is improved with a\r\nhard of hearing person. When you\r\ncompress the frequencies of speech\r\ndown to 800 Hz, one of the things you\r\ndo is bring the frequency components of\r\nspeech much closer together. When a\r\nperson cuts of at 800 Hz, that person is\r\nlikely to be in the profoundly deaf group\r\nand is likely to suffer from problems in\r\nfrequency resolution. It may be that\r\nbringing those formants together may do\r\nmore harm than bringing the high\r\nfrequency elements down to within the\r\n800 Hz range.\r\nQuestion: When you have a profound\r\nloss which requires a high amount of\r\ngain but at the same time you have\r\nrecruitment, how do you make the\r\ncompromise between the gain and the\r\nsaturation level of the hearing aid?\r\nE. Villchur: The best you can do is to\r\namplify speech to within these limits but\r\nthe first thing you need to do is to make\r\nthese sounds audible by giving extra\r\namplification to the weak sounds to\r\nbring them into the residual dynamic\r\nrange of the subject, without over\r\namplifying the intense sounds. This may\r\nnot be enough but at least this is the first\r\nthing that must be done. If you decide\r\nthat you are going to use some other type\r\nof processing, it?s important not to drop\r\nthat processing which at least made the\r\nsound audible.\r\nQuestion: In all of the examples today,\r\nthe hearing impaired person was\r\ndescribed through the audiogram and\r\nthe intensity dynamic range. Do you\r\nsee any alternatives to describing the\r\nhearing impaired by other means?\r\nE. Villchur: The presentation was based\r\non an assumption which is that the two\r\nmost prevalent distortions which affect\r\nthe hearing impaired are (1) attenuated\r\nfrequency response and (2) recruitment.\r\nIf you make this assumption then data\r\nwill be presented via the amplitude\r\nrange. All that the dual channel\r\ncompressors are, are two little men\r\nturning volume control wheels up or\r\ndown ? nothing more mysterious than\r\nthat. Even if you solve the above\r\nmentioned two major distortions, you\r\ndon?t restore normal hearing, which\r\nimplies that there are other aberrations,\r\nwhich either can or cannot be\r\ncompensated. All I can do is discuss the\r\nones we know about and they are in\r\nterms of amplitude.\r\nQuestion: The kind of dimension that\r\nis missing is the temporal one. There\r\nare experimental data which go back\r\nquite some time which show that even\r\nif two people have identical amplitude\r\naudiograms, one may have very good\r\nspeech understanding and the other,\r\npoor. The studies have tried to\r\ndetermine what other variables can\r\nexplain the differences between these\r\ntwo individuals. Of all the variables\r\nlooked at, temporal resolution was the\r\nmost likely candidate. The one with\r\nbetter temporal resolution also has\r\nbetter speech understanding. This\r\nimplies that we not only need to\r\nmeasure the amplitude/recruitment\r\ncharacteristics of an individual, but we\r\nneed to measure the temporal\r\nresolution characteristics as well. It?s\r\nnot an easy thing to do but it can be\r\ndone, and I think that we should pay\r\nmore attention to it. Hopefully that\r\nwill indicate what methods of signal\r\nprocessing will be required in the\r\ntemporal domain to improve hearing.\r\nE. Villchur: You can?t have temporal\r\nresolution for sounds that you can?t hear.\r\nTherefore, first bring the sound into the\r\ndynamic range of the hearing. It?s a  necessary, but possibly insufficient\r\ncondition for achieving what we want. \r\n</p>\r\n<p>Question: One of the problems with\r\nmulti-band compression is that it\r\nseems to interfere with temporal\r\ncharacteristics. Do you have a\r\ncomment?\r\nE. Villchur: There is no question that\r\ncompression reduces temporal\r\nresolution. It has to. For example, if you\r\nhave two sounds, one following the\r\nother, and the first sound drops off and\r\nthen there?s silence, and then the next\r\nsound starts, the time where the first\r\nsound is dropping off will be changed by\r\nthe compression ? it will be lifted. The\r\nfaint, trailing parts of the first sound will\r\nbe increased by the compression. The\r\ncompression will tend to fill in the gap\r\nbetween the two sounds. What it will do\r\nis to restore the temporal resolution to\r\nthat of a normal listener. The person\r\nbefore compression hears a more\r\nprecipitous drop off because of his\r\nrecruitment, than the normal listener.\r\nBut it may be that in some cases, the hard\r\nof hearing listener cannot take the\r\nrestoration to normal temporal\r\nresolution. It may turn out that he needs\r\nan abnormally good temporal resolution.\r\nBut, only to the extent that a properly\r\nadjusted compression system interferes\r\nwith temporal resolution, and not by\r\nrestoring normal temporal resolution.\r\nQuestion: Some cases of profound\r\nhearing loss do not show any ability\r\nto function on cues that are below 800\r\nHz. I am questioning whether the\r\ntransposition of cues to the low\r\nfrequency band would be effective,\r\nand also whether we are using the\r\nsame definition of profound loss.\r\nE. Villchur: There are some profoundly\r\ndeaf where there is no way to restore\r\nintelligibility. It has been shown that\r\nrestoring some cues which are\r\ninsufficient for intelligibility (accent,\r\nstress), gives them an advantage for lip\r\nreading. In some cases you just have to\r\ngive up.\r\nQuestion: When you map the high\r\nfrequency information into the low\r\nfrequency region, are you not\r\ndestroying the temporal cues by doing\r\nthis? In this case would you not be\r\nbetter to present both low and high\r\nfrequency artificial cues rather than\r\noverloading the low frequency band?\r\nE. Villchur: That has been done by using\r\na vocoder system where a few individual\r\nbars of noise have been modulated to\r\nrepresent speech and from that way of\r\nthinking, I prefer to use my synthetic\r\nfricatives which only interferes at one\r\npoint over a third of an octave at the top\r\nof the residual range, rather than folding\r\nover the entire frequency spectrum. As\r\nfor the vocoder system, it?s amazing how\r\nlittle you need to present before the\r\nsystem becomes intelligible. I have\r\nlistened to a system with only three bars\r\nof noise going up and down and get an\r\noccasional word out of it. By the time you\r\nget to five bars of noise you understand\r\nit fairly well.\r\nQuestion: Would it not be better to\r\npresent the high frequency energy in\r\nthe low frequency band only when it\r\nwas important, and to present the low\r\nfrequency energy in the low frequency\r\nband when that was important?\r\nH. Levitt: That is indeed the philosophy\r\nunderlying the technique of surrogate\r\nfricatives. If you had a voiceless fricative\r\nthe low frequency energy is relatively\r\nunimportant. The only energy that\r\ncounts is the high frequency energy. With\r\nthe exception of these voiceless fricatives,\r\nthe low frequency sounds are more\r\nimportant. That particular form of\r\ntransformation worked quite well.\r\nQuestion: Dr. Levitt mentioned that it\r\nwas important to maintain the phase\r\ncharacteristics of the speech in the\r\ndigital processing system. Would that\r\nbe related to temporal information or\r\nsomething else?\r\nH. Levitt: Basically phase information is\r\ntemporal. There are some conflicting\r\ndata in the literature, which I?ll remind\r\nyou of. A lot of data show that when you\r\ndiscard phase information in speech such\r\nas on the telephone, the speech remains\r\nintelligible and that you can hardly tell\r\nthe difference. That is true for any\r\nmonaural listening system. On the other\r\nhand, there are substantial data which\r\nshow that if you have a binaural listening\r\nsystem, phase information is greatly\r\nimportant. So we have two rather\r\nextreme sets of data ? monaural (phase\r\nunimportant) versus binaural (phase\r\nimportant). When people looked into\r\nnoise reduction for monaural systems,\r\nsince these systems used a single\r\nheadphone, it was thought that phase\r\nwas not important. However, the relative\r\nphase between the speech components\r\nand the noise components turns out to\r\nbe important. The auditory system does\r\nnot discard phase information. Although\r\nexperiments show that phase\r\ninformation is not important for\r\nunderstanding speech, it does not mean\r\nthat the auditory system discards phase\r\ninformation. What experiments do show\r\nis that as part of a noise reduction system,\r\neven monaurally, if phase information is\r\nretained, we get better results.\r\nQuestion: In the two channel system\r\ndiscussed in your talk, where was the\r\ncrossover between the low and the\r\nhigh frequency channels?\r\nE. Villchur: In the tapes that I played, I\r\nused the average compensation  characteristics required by the six\r\nsubjects that I used in my 1973 study,\r\nwhich was 1500 Hz. But the last tape\r\nthat I played through the Resound\r\nhearing aid has an adjustable crossover\r\nbetween 800 Hz to 2000 Hz. Among the\r\nsix subjects there was a variation of no\r\nmore than 1.5:1. The average falls in the\r\narea of 1500 Hz.\r\nQuestion: it appears that the low\r\nfrequency band in a two channel\r\ncompression system requires a\r\ncompression ratio of 2.3 whereas the\r\nhigher frequency band requires a\r\nmuch higher ratio, perhaps even\r\ninfinite. Is this indeed the case and\r\nwhat ratio characteristics would be\r\nrequired to cover the hearing impaired\r\npopulation?\r\nE. Villchur: The compression ratios that\r\nI used were not a matter of guesswork or\r\nmy own hypothesis, but were calculated\r\non the basis of a formula which may not\r\nhave been the correct one. The formula\r\nwas this; I defined the normal dynamic\r\nrange at any frequency as the distance\r\nbetween threshold and the equal\r\nloudness contour pegged to the\r\nmaximum speech level of conversational\r\nspeech. This is on the order of 65?70 dB\r\nacross the spectrum. I then defined the\r\nresidual dynamic range of a hearing\r\nimpaired person as the distance between\r\nhis threshold and the equal loudness\r\ncontour pegged to his preferred listening\r\nlevel of conversational speech. When you\r\ndo that, a typical person with\r\nmoderately-severe to severe impairment,\r\nwhich my six subjects had, is likely to\r\nrequire a compression ratio of 2:1 in the\r\nlow frequency band (which represents\r\nthe ratio of the normal dynamic range\r\nand his residual dynamic range) and a\r\nratio of 3:1 in the high frequency band.\r\nAn infinite compression ratio may still be\r\nintelligible but it accomplishes\r\nsomething new. What I was trying to do\r\nwas to place the speech band in the same\r\nposition between his threshold and the\r\nequal loudness contour, as that for a\r\nnormal hearing person. The average for\r\nthe entire band was about 3:1 (frequency\r\nby frequency), and the subjects did not\r\nlike it. They reported that speech was\r\nstrident. I hypothesized that when the\r\ndynamic range was very severely\r\nreduced, that other things were going on\r\nwhich meant that they couldn?t take the\r\nsound.\r\nQuestion: So can we say that the\r\nhighest ratio we need is 3:1?\r\nE. Villchur: In my experience, below a\r\nprofound or very severe loss, we would\r\nnot need a ratio in excess of 3:1. A\r\nprofoundly deaf person may need a 5:1\r\nratio. When you get to a compression\r\nratio of 5:1, it doesn?t make much\r\ndifference. The result is the same as 10:1\r\nand so on. With a ratio of 5:1, with an\r\ninput increase of 10 dB, the change in\r\noutput will only be 2 dB. If we double\r\nthat to a 10:1 ratio the output change will\r\nonly be 1 dB.\r\nQuestion: With your dual channel\r\nsystem, when you go to a noisy party,\r\nthe response in noise tends to become\r\nflat. This is in contrast to the Zeta\r\nNoise Blocker, or other ASP system\r\nwhich tries to achieve a relative high\r\nfrequency emphasis. Would you\r\ncomment on that?\r\nE. Villchur: In fact, the frequency\r\nresponse which I adjusted it to was up 9\r\ndb at 4000 Hz so it wasn?t flat. I was\r\ntrying to see with my experience with\r\ncompressed sound what would happen\r\nin a real life situation. It was not adjusted\r\nto an optimum setting to my hearing. It\r\nwas purposefully exaggerated. But this\r\nhighlights the last thing I was talking\r\nabout. There are two things that you can\r\ndo about the difficulty that hearing\r\nimpaired people have in a noisy\r\nenvironment. One is to try to optimize\r\nthe conditions which they listen in that\r\nenvironment so that the target signal has\r\na better ratio to the background signal.\r\nThe other thing is to ignore the signal to\r\nratio and to concentrate on the clarity of\r\nthe target signal. By increasing the\r\nnumber of redundancy cues, you make\r\nit possible for the hard of hearing person\r\nto operate better within the noisy\r\nenvironment, and that is what I have\r\nbeen trying to do.\r\nQuestion: Was the recruitment\r\nsimulator used in your experiments\r\ndigital or analog?\r\nE. Villchur: The one that I published\r\nabout was done at MIT and I used their\r\nhybrid system but the one I have at\r\nhome, which is the 16 channel one, built\r\nby Mead Killion about 15 years ago, is\r\nanalog.\r\nQuestion: Given the equipment which\r\nis out there, how does one go about\r\nevaluating level dependent type\r\nhearing aids?\r\nE. Villchur: The first who wrote about\r\nlevel dependent hearing aids is Margo\r\nSkinner and she showed that the optimal\r\nfrequency response of her subjects\r\ndepended on level. The lower the level,\r\nthe more high frequency emphasis she\r\ncould take. In the higher level, the less\r\nhigh frequency emphasis was optimum\r\nfor them or indeed that they would\r\ntolerate. She came to the conclusion that\r\nwhat was needed was a level dependent\r\nfrequency response. I wrote her in\r\nagreement and said that a level\r\ndependent frequency response was the\r\nsame as a frequency dependent\r\namplitude response, which is what you\r\nget from a dual channel compression\r\nhearing aid with different compression\r\nratios for the low and high frequency  bands. I ran a series of curves with my 2\r\nchannel compressor using ratios of 2:1\r\nand 3:1 showing that at low levels it had\r\na contradiction between level dependent\r\nfrequency response and frequency\r\ndependent amplitude response, but that\r\nthey are indeed the same. On the other\r\nhand, a level dependent frequency\r\nresponse can be achieved in another way\r\nwhich Mead Killion is currently working\r\non using a single channel compressor\r\nwhich he feels will be useful for mild to\r\nmoderate deficits. Mead feels that a 2\r\nchannel approach is not needed for these\r\nmore mild losses.\r\nQuestion: The current calibration\r\nmethod for evaluating hearing aids\r\nuses a swept signal across the\r\nfrequency range, but this would not be\r\nuseful for dual channel systems.\r\nH. Levitt: What is needed is a new\r\nstandard which would specify the\r\ncalibration and evaluation of these level\r\ndependent hearing aids. There are several\r\nmethods being proposed. One method is\r\nto use a broadband signal and then\r\nanalyze the resultant spectrum. The\r\nother is to have at least two tones ? one\r\nto get the compressor working and the\r\nother to sweep across the frequency\r\nrange. (Editor?s note: A problem can\r\noccur if the first tone to get the\r\ncompressor working is too low in\r\nfrequency [e.g., 300 Hz], then difference\r\ntones can erroneously enter the\r\nfrequency response).\r\nE. Villchur: The most common is to use\r\na family of curves ? each one at a\r\nsuccessively higher level. Instead of using\r\none frequency response curve you will\r\nuse a series, perhaps spaced every 10 dB\r\nfrom 50 to 80 dB input.\r\nComment: You can?t characterize a nonlinear system with a swept sinusold and\r\nthere is a proposal before the ANSI\r\ncommittee which will allow you to use a\r\ncomplex stimulus and to define the\r\ncharacteristics of that spectrum as speech\r\nspectrum noise. The analysis means will\r\nbe a swept spectral analysis at the output\r\nor a digital technique. There is some\r\nlikelihood that that standard will come\r\nthrough in the next couple of years.\r\nQuestion: In the cochlear implants\r\nmentioned today, what are the factors\r\nthat limit the frequency of\r\nstimulation?\r\nH. Levitt: You first have to characterize\r\nthe implant. There is a single channel\r\nimplant with a single electrode, and there\r\nare two multi-electrode cochlear\r\nimplants. One multi-electrode system is\r\nlike a vocoder where you have several\r\ncontiguous frequency bands and each\r\nband drives a pair of electrodes. The\r\nsecond type has an array of 22 electrodes\r\nand each one electrode plus a round\r\nelectrode is stimulated. You don?t have\r\nmuch frequency resolution with the\r\nsingle channel cochlear implant, and that\r\nimplant is on the way out. The multichannel cochlear implant is the one that\r\nallows for coding of frequency\r\ninformation in various ways. There are\r\ntwo essential types of implants. One type\r\nof cochlear implant is a multi-channel\r\nsystem where there is a correspondence\r\nto different frequency bands. The design\r\nconsiderations are what frequency range\r\nbandwidths are required to encode\r\nspeech. The other type of implant is\r\nwhere you extract the features of speech\r\nsuch as the voice fundamentals and\r\nencode that. This stimulates the\r\nelectrodes in the cochlea. The question is\r\nwhich characteristics of speech ought to\r\nbe encoded.\r\nQuestion: For the benefit of those who\r\ndo not fit hearing aids, could you\r\ncomment on the relative effectiveness\r\nof hearing aids, including some of\r\nthose discussed here.\r\nE. Villchur: Neither Dr. Levitt nor I are\r\nclinicians. The models discussed here\r\nhave not as yet been implemented in\r\ncommercial hearing aids. 3M is just\r\ncoming out. The Resound aid will be out\r\nin the spring of 1989, but I?m not quite\r\nsure.\r\nH. Levitt: Regarding the Zeta Noise\r\nBlocker and similar hearing aids, there is\r\ngenerally not good clinical follow-up, so\r\nwe only have information on those who\r\nare dissatisfied and that is not the best\r\nway to measure the degree of satisfaction.\r\nHowever, even using that crude measure,\r\nand by published return rates, there have\r\nbeen a fair amount of returns of the Zeta\r\nNose Blocker. We should have more\r\nformal success/failure information on\r\nthese systems.\r\nE. Villchur: I would like to say a word\r\nabout the ASP system. One of the two\r\nthat Dr. Levitt described used a\r\ncompressor in the low channel to reduce\r\nthe noise and nothing in the high\r\nfrequency channel. The compressor will\r\nreduce the noise only if the compression\r\nthreshold is engaged by noise which is\r\nintense enough, so this would imply that\r\nit is not a compressor, but actually a\r\ncompressor-limiter. With real\r\ncompressors, weak sounds are not\r\nreduced but are increased in gain. Once\r\nyou look at a compressor as increasing\r\nweak sounds out of the mud, and once\r\nyou look at compressor-limiters as\r\ndecreasing overly intense sounds, it\r\nbecomes important to point out that I\r\nhave been talking about compressors and\r\nnot compressor-limiters. That is, a\r\ncompressor increases gain, not decreases\r\nit. So the Zeta Noise Blocker is more of a\r\ncompressor limiter.</p>',NULL,'2022-11-29'),(35,3253,'ajchr','http://www.andrewjohnpublishing.com/','','<p>Years ago I wrote an article with the title, ?Outside of the audiology room?. I am not sure where I submitted it or if it ever was published, but I was gradually starting to realize (or remember?) that it was what I did outside of normal audiometry that was really audiology, and also that this was really quite important to our clients. I am not sure that the art of audiology is something that can be explicitly taught, but it is something that can be learned. I suspect that it should not be in the university audiology curriculum as a specific course with a specific course number, but it is something that should permeate all of the audiology courses and clinical practicums. Accurate audiometry is certainly important, and this is where the various provincial medicare programs pay for things, but that is only the very beginning. What is sometimes just as important, if not more so, is the interaction that I have with my client? audiology is as important as an art as it is a science. Actually this is precisely what drew me to audiology in the first place. Having completed a degree in theoretical mathematics, I was looking for a field that would allow me to apply the science and also the art ? audiology provided the perfect balance. (Actually speech-language pathology does that as well but I am not smart enough to keep track of the many tests that my speech colleagues need to perform.) All too often, an audiologist does what is ?paid for.? Many of us work in the realm of hearing aids since this is ?what pays the bills.? Hearing tests can be billed through the provincial medical schemes, but the many things that comprise the art of audiology are not ?billable.? It is unfortunate that we live in a market society where the worth of something is defined by its price or the value of a code that can be billed.</p>\r\n<p>This issue of the Canadian Hearing Report has been guest edited by two of my favourite people, Dr. Joanne DeLuzio and Gael Hannan. Joanne DeLuzio has the unique combination of being a clinical audiologist with a PhD in speech-language pathology. She has been teaching applied audiology in the Speech-Language Pathology Program at the University of Toronto since 2000. Her primary area of interest is the importance of social skills development and peer interaction for young children with severe and profound hearing loss. Joanne is an advocate for the removal of barriers for people who are D/deaf and hard of hearing. She has served as vicechair and chair of the board of The Canadian Hearing Society and is currently on the interim board of Hands and Voices. Despite having an odd spelling for her first name, Gael Hannan is a writer, actor, and public speaker who grew up with a progressive hearing loss that is now severe-to-profound. She is a director on the national board of the Canadian Hard of Hearing Association (CHHA) and an advocate whose work includes speechreading instruction, hearing awareness, workshops for youth with hearing loss, and work on hearing access committees. Gael also writes a blog from the consumer?s point of view for HearingHealthMatters.org and is a regular columnist as the Happy HoH for the Canadian Hearing Report. Joanne and Gael have teamed up to remind us all what is really important in the field of audiology ? the interaction between the hearing health care professional and the client. And, they have coordinated an amazing list of authors ranging from Dr. Laya PoostForoosh to Dr. Andre Marcoux. Andre was the first editor-in-chief of the Canadian Hearing Report. They even convinced Dr. Charles Laszlo to write something for them ? actually they probably only needed to ask him once, and he likely jumped at the chance. For those who do not know Charles, he was the guiding force that resulted in the eventual formation of the Canadian Hard of Hearing Association. And, he was the guy who sat beside me at many of the CRTC meetings on hearing aid telephone compatibility in the early 1980s. Thank goodness he was on my side!</p>\r\n<p>I l y a quelques ann&eacute;es, j?ai &eacute;crit un article intitul&eacute;, ?Hors de la chambre d?audiologie?. Je ne suis pas certain o&ugrave; je l?avais soumis ou s?il a jamais &eacute;t&eacute; publi&eacute;, mais petit &agrave; petit, j?ai commenc&eacute; &agrave; r&eacute;aliser (ou me rappeler?) que ce que je faisais en dehors de l?audiom&eacute;trie normale &eacute;tait vraiment de l?audiologie, et que c?&eacute;tait vraiment important pour nos clients. Je ne suis pas certain que l?art de l?audiologie peut &ecirc;tre enseign&eacute; explicitement, mais il peut &ecirc;tre appris. Je doute bien qu?il ne devrait pas &ecirc;tre dans le programme universitaire de l?audiologie comme cours sp&eacute;cifique avec un num&eacute;ro correspondant, mais il devrait infiltrer tous les cours d?audiologie et pratiques cliniques. L?audiom&eacute;trie pr&eacute;cise est certainement importante, et ce que les diff&eacute;rents programmes provinciaux de l?assurance sant&eacute; couvrent, mais c?est seulement le tout d&eacute;but. Ce qui est tout aussi important des fois, si ce n?est plus, est l?interaction que j?ai avec mon clientl?audiologie est tout un art, aussi important que c?est une science. En fait, c?est pr&eacute;cis&eacute;ment ce qui m?a attir&eacute; vers l?audiologie de premier abord. Ayant obtenu un dipl&ocirc;me en math&eacute;matiques th&eacute;oriques, j?&eacute;tais &agrave; la recherche d?un domaine qui me permettrait d?appliquer et la science et l?art?L?audiologie a &eacute;t&eacute; l?&eacute;quilibre parfait. (En fait, l?orthophonie fait pareil mais je ne suis pas assez intelligent pour me tenir au courant de tous les tests que mes coll&egrave;gues orthophonistes ont &agrave; effectuer.) Tout aussi souvent, un audiologiste ex&eacute;cute ce qui ?rembours&eacute;.? Plusieurs d?entre nous exer&ccedil;ons dans le domaine des appareils auditifs &eacute;tant donn&eacute; que c?est ce qui ?couvre nos d&eacute;penses.? Les tests auditifs sont factur&eacute;s &agrave; travers les programmes m&eacute;dicaux provinciaux, mais plusieurs composantes de l?art de l?audiologie ne sont pas ?facturables.? C?est malheureux de vivre dans une soci&eacute;t&eacute; de march&eacute; o&ugrave; la valeur des choses est d&eacute;finie par leurs prix ou la valeur d?un code &agrave; facturer.</p>\r\n<p>Ce num&eacute;ro de La revue canadienne d?audition a comme &eacute;ditrices invit&eacute;es deux de mes personnes favorites, Dr. Joanne DeLuzio et Gael Hannan. Joanne DeLuzio a la combinaison unique d?une audiologiste clinicienne et titulaire d?un doctorat en orthophonie. Elle enseigne l?audiologie appliqu&eacute;e dans le programme de l?orthophonie de l?Universit&eacute; de Toronto depuis l?ann&eacute;e 2000. Son domaine d?int&eacute;r&ecirc;t primaire est l?importance du d&eacute;veloppement des comp&eacute;tences sociales et l?interaction entre paires pour jeunes enfants qui pr&eacute;sentent une perte auditive s&eacute;v&egrave;re et profonde. Joanne milite pour la suppression des barri&egrave;res pour les personnes culturellement sourdes, sourdes et avec perte auditive. Elle a si&eacute;g&eacute; en tant que vice-pr&eacute;sidente et pr&eacute;sidente du conseil d?administration de la soci&eacute;t&eacute; canadienne de l?ou&iuml;e et actuellement si&egrave;ge au conseil int&eacute;rimaire de Hands and Voices. En d&eacute;pit de son pr&eacute;nom &agrave; grammaire inusuelle, Gael Hannan est un auteur, actrice, et oratrice qui a grandi avec une perte auditive progressive qui est maintenant s&eacute;v&egrave;re &agrave; profonde. Elle est directrice au conseil d?administration national de l?association des malentendants canadiens et militante dont le travail inclus la formation en lecture labiale, sensibilisation &agrave; l?ou&iuml;e, ateliers pour les jeunes qui pr&eacute;sentent une perte auditive, et les travaux sur les comit&eacute;s d?acc&egrave;s &agrave; l?audition. Gael a aussi un blog du point de vue du consommateur pour HearingHealthMatters.org et est chroniqueuse r&eacute;guli&egrave;re en tant que the Happy Hoh pour la revue canadienne d?audition. Joanne et Gael font &eacute;quipe pour nous rappeler &agrave; nous tous ce qui est vraiment important dans le domaine de l?audiologie ? l?interaction entre le professionnel des soins de sant&eacute; auditifs et le client. Elles ont coordonn&eacute; une liste extraordinaire d?auteurs allant de Dr Laya Poost-Foroosh au Dr Andr&eacute; Marcoux. Andr&eacute; est le premier &eacute;diteur en chef de la revue canadienne d?audition. Elles ont m&ecirc;me convaincu Dr Charles Laszlo qui a &eacute;crit pour elles? en fait, elles n?ont eu probablement &agrave; lui demander qu?une seule fois, et vraisemblablement, il a saut&eacute; sur l?occasion. Pour ceux et celles qui ne connaissent pas Charles, il est la force qui a abouti &agrave; la formation de l?association des malentendants canadiens. Et, il est le gars qui s?est assis &agrave; mes c&ocirc;t&eacute;s &agrave; plusieurs r&eacute;unions du CRTC au sujet de la compatibilit&eacute; t&eacute;l&eacute;phonique des appareils auditifs au d&eacute;but des ann&eacute;es 80. Dieu merci, il &eacute;tait de mon c&ocirc;t&eacute;!</p>\r\n<p>Joanne DeLuzio (near left), PhD, Audiologist, Reg. CASLPO, is adjunct professor with the Department of Speech-Language Pathology at the University of Toronto. jo.deluzio@utoronto.ca..</p>\r\n<p>Gael Hannan (far left), is a hearing health advocate and a writer on consumer hearing loss issues. gdhannan@rogers.com.</p>\r\n<p>The hearing loss population is booming. Hearing assistive technology has reached unprecedented levels of sophistication and accessibility. Universities and colleges across the country are producing hundreds of educated and skilled hearing health care professionals each year. The number of hearing health clinics and hearing aid retailers is increasing rapidly, and public awareness of hearing loss issues is on the rise. Still, only 20?25% of people who could benefit from hearing aids and aural rehabilitation actually access hearing health care, and those who do often express dissatisfaction with the care they receive. While affordability of hearing aids is acknowledged as a major problem, how hearing health care professionals provide service to their clients is being recognized as an equally important issue. As a consumer with hearing loss (Gael) and a hearing health care professional (Jo), we?ve been interested in this subject for many years. In 2003 we gave a presentation at the Hearing Loss Association of American (HLAA, then SHHH) conference in Atlanta, Georgia. ?Me and My Audie? looked at the importance of the consumer-audiologist partnership. Although the turnout was poor ? we were competing with an ice cream social ? the workshop participants who did attend were thrilled with what they heard. We were convinced (and remain so) that people with acquired hearing loss can reach their optimal level of communication ? that is, living successfully with hearing loss ? if they and their hearing health care professionals engage in a positive, long-term relationship. The concept is simple, but it has been a tough sell. There is a history of mistrust between these two groups. Consumers are not happy with the medical view of hearing loss and the paternalistic perspective of the professional who presumes to know what is best for them. There is widespread suspicion that hearing aids are too often recommended based on monetary gain for the professional, and not on the best fit for the consumer. On the other side of the fence, many hearing health care professionals are defensive. It?s not always easy working with consumers who have unrealistic expectations that are almost impossible to achieve, and who are often angry and in denial about their hearing loss. Many hearing health care professionals feel burnt out. As professionals who have worked hard to perfect their craft, many are tired of being constantly criticized. This is compounded by the fact that, even when they recognize that a client may need more extensive counselling, under the current fee structures, they are not compensated for this service.</p>\r\n<p>So, is it possible to change the existing dynamics to create positive and effective partnerships? Acquired hearing loss has a profound impact on all aspects of a person?s life. When people encounter difficulty with their hearing, they experience a variety of emotions and often do not know where to turn for support. The aural rehabilitative process is complex and often difficult to navigate, especially when the consumer does not know what to expect and/or the professional is not providing it. Technology is changing rapidly and there are copious amounts of information available on the Internet, some of which is misleading. Slick advertisements promise people with acquired hearing loss the latest in invisible hearing aids, perfect hearing in quiet situations, and DVD-quality sound.</p>\r\n<p>Consequently, consumers need a hearing health care professional who will take the time to understand their unique listening needs and help them to sift through a variety of amplification products and other necessary communication strategies. This is not a ?one shot? deal. Acquired hearing loss is for life and so is the need for constructive hearing health care, which ideally includes the cultivation of a long-term relationship between the consumer and the hearing health care professional. This relationship must be based on mutual trust and respect to be successful. Consumers need to understand and be involved in all recommendations and aspects of their care. They need to develop reasonable expectations about how they can achieve the best possible outcomes. Both parties have important roles and share responsibility for creating a clear vision and a clear path to optimal communication. ?Aural Rehab? is not limited to a course of action that a hearing health care professional prescribes. The process really begins with the first suspicion of hearing loss and continues throughout the lifespan. Mark Ross, esteemed audiologist and professor emeritus at the University of Connecticut, has often reported on the 8-week, full-time aural rehabilitation program he attended at the Walter Reed Army Medical Center in 1952. According to Dr. Ross, diagnostic tests and hearing aid fittings were provided, but the program also focused on ?lipreading? and auditory training, as well as memory and cognitive training. He also speaks of the invaluable support the participants in these groups provided for each other. Wearable hearing aids were not well developed at that time but they were nevertheless seen as an integral part of the whole program to improve communication and facilitate living with hearing loss. It is somewhat ironic that 60 years later hearing aids are no longer considered as a program component. They are viewed as an end in themselves, a self-contained treatment for hearing impairment. To be sure, hearing aids are now highly evolved, but we feel that the industry has lost sight of the real goal, and has shifted its focus from people and communication to instrumentation and technology.</p>\r\n<p>In guest editing this issue of Canadian Hearing Report, we are offering the views of both consumers and professionals. We share the belief that there is a need for a new model of hearing care that provides better benefits for both parties, a course of care that presents the big picture of living successfully with hearing loss, an ongoing process that involves professional assessment, mental preparation, technology, and a wide array of communication strategies. Support comes from many sources including family, friends, co-workers, and support groups, but the single most important resource, other than the person themselves, is the trained hearing health care professional. The central theme of the journal is the pivotal role of this relationship. From the very first meeting ? the client with hearing loss and the hearing health care professional whose role is to be of service ? a collaborative partnership must form which will provide powerful benefits to both parties. Both partners have clearly defined roles and they share the responsibility for success. Otherwise, audiologists will continue to struggle with clients who balk at every suggestion, and hard of hearing clients who, if they are not exposed to additional communication strategies beyond their hearing aids, will not develop the best possible skills to successfully manage their communication difficulties. In this journal, you will read about a client-centered model for hearing aid delivery proposed by Poost-Foroosh. We agree with Poost-Foroosh that the impact of hearing loss on a person is highly complex, and cannot be understood without examining that person?s perspective on how they function in environments that are specific and important to them. Her paper offers valuable insights on how clinicians can provide more clientcentred service. Dr. Andr&eacute; Marcoux, professor of audiology at the University of Ottawa, describes his active model for a client-centred practice. Charles Lazlo, a founding member of both the Canadian Hard of Hearing Association and the International Federation of Hard of Hearing People, writes about the pivotal role of technology in his life and why hearing health care professionals need to educate themselves and their clients about integrating technology into their daily activities.</p>\r\n<p>At the time of writing, a joint communiqu&eacute; was released by the Academy of Doctors of Audiology, the American Speech-Language-Hearing Association and the American Academy of Audiology. This ground-breaking statement recognizes the changing face of the hearing health care environment and calls on the hearing health care community to focus on consumer needs in their service delivery. This statement has been publicly applauded by the Hearing Loss Association of America. How these recommendations will be adopted by health care professionals remains to be seen, but it?s our hope that Canadian hearing health care organizations will rise to the challenge, by adopting and promoting similar standards of health care delivery for  Canadians with hearing loss. The ultimate goal of aural rehabilitation is ?optimal communication? for the consumer/client. But what exactly does that mean? (As an aside, we are still searching for a better phrase to describe this concept that does not sound like a brand of hearing aid or yogurt.) Optimal communication will be different for everyone, involving an individual mix of communication tools. It necessitates addressing all of the feelings and emotions associated with hearing loss (e.g., anger, denial, frustration, isolation, stress on relationships, etc.) as well as understanding technology and how it can be used to maximize understanding of speech and overall functioning. Optimal communication for one person might require sound awareness and auditory training or it could mean speechreading training. As well, there are a host of other communication tips (environmental manipulation, preparatory, speaker and listener strategies) that can be used. Assertiveness training, advocacy skills, and obtaining support from others can all be part of someone?s ?optimal communication? package. Ideally the person with hearing loss and the hearing health care professional will implement a variety of technologies and strategies over the years that can be re-evaluated and changed as the person?s hearing and listening needs change, or as technology evolves. We hope you enjoy this issue that offers different perspectives on a service model in which, together, ?me and my audie? can work in partnership to remove barriers to communication and promote living well with hearing loss. Hopefully ? and soon ? this concept will no longer be a tough sell, but the new reality.</p>\r\n<p>Joanne DeLuzio, Audiologiste, Reg. CASLPO, est professeur adjointe au d&eacute;partement d`audiologie &agrave; l?Universit&eacute; de Toronto. jo.deluzio@utoronto.ca.</p>\r\n<p>Gael Hanna est militante pour les droits des personnes avec perte auditive. gdhannan@rogers.com</p>\r\n<p>La population de la perte auditive est en pleine croissance. La technologie d?assistance auditive a atteint des niveaux sans pr&eacute;c&eacute;dents de sophistication et accessibilit&eacute;. Les universit&eacute;s et les coll&egrave;ges &agrave; travers le pays forment et produisent des centaines de professionnels des soins de sant&eacute; auditifs comp&eacute;tents chaque ann&eacute;e. Le nombre de cliniques de sant&eacute; auditive et de d&eacute;taillants d?appareils auditifs augmente rapidement, et la sensibilisation du grand public aux enjeux de la perte auditive est en croissance. Toutefois, seulement 20?25% des personnes qui pourraient b&eacute;n&eacute;ficier de l?utilisation d?appareils auditifs et de r&eacute;&eacute;ducation auditive, ont acc&egrave;s aux soins de sant&eacute; auditifs, et celles qui le font expriment souvent leur insatisfaction des soins qu?elles re&ccedil;oivent. Tandis que l?abordabilit&eacute; des appareils auditifs est reconnu comme probl&egrave;me majeur, la mani&egrave;re avec laquelle les professionnels des soins de sant&eacute; auditifs offre leur service &agrave; leurs clients est un enjeu d?importance &eacute;gale. En tant que consommatrice vivant avec la perte auditive (Gael) et une professionnelle des soins de sant&eacute; auditifs (Jo), le sujet nous int&eacute;ressait depuis bien longtemps. En 2003, nous avons pr&eacute;sent&eacute; &agrave; la conf&eacute;rence de the Hearing Loss Association of American (HLAA, jadis la SHHH) qui s?est tenue &agrave; Atlanta, dans l?&eacute;tat de Georgia. ?Me and My Audie? explorait l?importance du partenariat consommateur-audiologiste. M&ecirc;me si le taux de participation a &eacute;t&eacute; faible ? on pr&eacute;sentait au m&ecirc;me temps qu?une activit&eacute; sociale impliquant de la cr&egrave;me glac&eacute;e? ceux pr&eacute;sents &agrave; l?atelier &eacute;taient fr&eacute;missants par ce qu?ils avaient entendu. Nous &eacute;tions convaincues (et le sommes encore) que les personnes avec une perte auditive acquise peuvent atteindre leur niveau optimal de communication? &eacute;tant de vivre avec succ&egrave;s leur perte auditive? si elles et leurs professionnels de soins de sant&eacute; auditifs s?engagent dans une relation positive au long terme.</p>\r\n<p>Le concept est simple, mais tr&egrave;s dur &agrave; vendre. Les ant&eacute;c&eacute;dents de m&eacute;fiance entre ces deux groups ne facilitent pas la t&acirc;che. Les consommateurs ne sont pas contents de la vision m&eacute;dicale de la perte auditive et la perspective paternaliste des professionnels qui pr&eacute;sument savoir ce qui est mieux pour eux. Une suspicion g&eacute;n&eacute;ralis&eacute;e que les appareils auditifs sont tr&egrave;s souvent recommand&eacute;s pour des profits pour le professionnel, et non pour l?int&eacute;r&ecirc;t du consommateur. De l?autre c&ocirc;t&eacute;, plusieurs professionnels des soins de sant&eacute; auditifs sont sur la d&eacute;fensive. Il n?est pas toujours facile de travailler avec des consommateurs qui ont des attentes chim&eacute;riques qui sont presque impossibles &agrave; r&eacute;aliser, et qui sont souvent en col&egrave;re et en d&eacute;ni de leur perte auditive. Plusieurs professionnels des soins de sant&eacute; auditifs se sentent &eacute;puis&eacute;s. Comme professionnels qui ont travaill&eacute; tr&egrave;s fort &agrave; perfectionner leur art, plusieurs sont fatigu&eacute;s d?&ecirc;tre critiqu&eacute;s tout le temps. Ceci est cumul&eacute; avec le fait que, m&ecirc;me quand ils reconnaissent qu?un client pourrait avoir besoin de counseling intensif, sous la structure de frais appliqu&eacute;e actuellement, ils ne sont pas indemnis&eacute;s pour ce service.</p>\r\n<p>Alors, est-il possible de changer la dynamique existante pour cr&eacute;er des partenariats positifs et efficaces ? La perte auditive acquise a un impact profond sur tous les aspects de la vie d?une personne. Quand les personnes se heurtent aux difficult&eacute;s &agrave; cause de leur ou&iuml;e, elles font l?exp&eacute;rience d?&eacute;motions vari&eacute;es et  souvent ne savent pas o&ugrave; aller trouver le soutien. Le processus de r&eacute;&eacute;ducation auditive est complexe et souvent difficile &agrave; naviguer, sp&eacute;cialement quand le consommateur ne sait pas &agrave; quoi s?attendre et/ou le professionnel ne l?offre pas. La technologie est en changement rapide et de copieuses quantit&eacute;s d?informations sont disponibles sur internet, et certaines sont trompeuses. Les publicit&eacute;s adroites promettent aux gens qui ont une perte auditive acquise le dernier cri des appareils auditifs invisibles, parfaite ou&iuml;e dans des situations tranquilles, avec une qualit&eacute; de son de DVD. Par cons&eacute;quent, les consommateurs ont besoin d?un professionnel des soins de sant&eacute; auditifs qui prendra le temps de comprendre leurs besoins de r&eacute;ception uniques et les aidera &agrave; s&eacute;lectionner parmi la grande vari&eacute;t&eacute; des produits d?amplifications et autres strat&eacute;gies de communications n&eacute;cessaires. Ceci n?est certainement pas une transaction sans r&eacute;currence. La perte auditive acquise est pour la vie et tout aussi le besoin pour des soins de sant&eacute; auditifs constructifs, qui id&eacute;alement incluent la culture d?une relation au long terme entre le consommateur et le professionnel des soins de sant&eacute; auditifs. Cette relation doit se baser sur une confiance et un respect mutuels pour avoir du succ&egrave;s. Les consommateurs ont besoin de comprendre et d?&ecirc;tre impliqu&eacute;s dans toutes les recommandations et aspects de leurs soins. Ils ont besoin de d&eacute;velopper des attentes raisonnables des r&eacute;alisations des meilleurs r&eacute;sultats possibles. Les deux parties ont des r&ocirc;les importants et partagent la responsabilit&eacute; pour la cr&eacute;ation d?une vision et d?une trajectoire claires &agrave; une communication optimale. ?La r&eacute;&eacute;ducation auditive? n?est pas limit&eacute;e &agrave; un plan d?action qu?un professionnel des soins de sant&eacute; auditifs prescrit. Le processus commence r&eacute;ellement avec le premier soup&ccedil;on de perte auditive et continue &agrave; travers la dur&eacute;e de la vie.</p>\r\n<p>Mark Ross, audiologiste respect&eacute; et professeur &eacute;m&eacute;rite &agrave; the University of Connecticut, a souvent rapport&eacute; sur le programme &agrave; temps plein de 8 semaines en r&eacute;&eacute;ducation auditive auquel il a particip&eacute; au the Walter Reed Army Medical Center en 1952. Selon Dr Ross, les tests de diagnostic et l?ajustement des appareils auditifs ont &eacute;t&eacute;s fournis, mais le programme s?est aussi centr&eacute; sur ? la lecture labiale? et l?&eacute;ducation auditive, tout aussi bien que le d&eacute;veloppement des comp&eacute;tences cognitives et de m&eacute;morisation. Il &eacute;voque aussi le soutien inestimable des participants les uns aux autres dans ces groupes. Les appareils auditifs portables n?&eacute;taient pas tr&egrave;s d&eacute;velopp&eacute;s &agrave; l?&eacute;poque pourtant ils &eacute;taient per&ccedil;us comme partie int&eacute;grale du programme complet pour am&eacute;liorer la communication et faciliter la vie avec la perte auditive. Il est plut&ocirc;t ironique que 60 ans apr&egrave;s, les appareils auditifs ne sont plus consid&eacute;r&eacute;s comme composants du programme. Ils sont vus comme une fin en soi, un traitement autonome pour la d&eacute;ficience auditive. C?est s&ucirc;r, les appareils auditifs sont maintenant tr&egrave;s &eacute;volu&eacute;s, mais nous avons le sentiment que l?industrie a perdu de vue les objectifs r&eacute;els, et a d&eacute;plac&eacute; sa concentration sur les personnes et la communication vers l?instrumentation et la technologie. En tant qu?&eacute;ditrices invit&eacute;es de ce num&eacute;ro de la revue canadienne d?audition, nous pr&eacute;sentons les points de vue des consommateurs et professionnels. Nous partageons le m&ecirc;me point de vue que le besoin se fait sentir pour un nouveau mod&egrave;le de soins de sant&eacute; auditifs qui fournit de meilleurs avantages pour les deux parties, un plan de soins qui pr&eacute;sente la grande perspective de vie avec succ&egrave;s sa perte auditive, un processus continu qui implique l?&eacute;valuation professionnelle, la pr&eacute;paration mentale, la technologie, et une large gamme de strat&eacute;gies de communication. Le soutien provient de sources diff&eacute;rentes, la famille, les amis, les coll&egrave;gues de travail et les groupes de soutien, mais la plus importante et unique ressource, autre que la personne en soi, est le professionnel de soins de sant&eacute; auditif qualifi&eacute;. Le th&egrave;me central de cette revue est le r&ocirc;le cl&eacute; de cette relation. D&egrave;s la premi&egrave;re r&eacute;union? le client qui pr&eacute;sente une perte auditive et le professionnel des soins de sant&eacute; auditif dont le r&ocirc;le est de servir? un partenariat de collaboration doit se former et va fournir des avantages puissants aux deux parties. Les deux partenaires ont des r&ocirc;les clairement d&eacute;finis et ils partagent la responsabilit&eacute; de la r&eacute;ussite. Autrement, les audiologistes continueront &agrave; avoir des difficult&eacute;s avec les clients qui flanchent &agrave; chaque suggestion, et les clients malentendants qui, s?ils ne sont pas expos&eacute;s &agrave; des strat&eacute;gies de communication au-del&agrave; des appareils auditifs, ne vont pas d&eacute;velopper les meilleures comp&eacute;tences possibles pour g&eacute;rer avec succ&egrave;s leurs difficult&eacute;s de communication. Dans cette revue, vous aller en savoir plus sur un mod&egrave;le de prestation de service des appareils auditifs centr&eacute; sur le client propos&eacute; par Poost-Foroosh. Nous sommes d?accord avec PoostForoosh que l?impact de la perte auditive sur une personne est tr&egrave;s complexe, et ne peut &ecirc;tre compris sans examiner la perspective de la personne sur son fonctionnement dans des environnements qui sont sp&eacute;cifiques et importants pour elle. Son papier offre un aper&ccedil;u pr&eacute;cieux sur un service centr&eacute; sur le client que les cliniciens peuvent offrir.</p>\r\n<p>Dr Andr&eacute; Marcoux, professeur en audiologie &agrave; l?Universit&eacute; d?Ottawa, d&eacute;crit son mod&egrave;le actif pour un cabinet centr&eacute; sur le client. Charles Lazlo, un membre fondateur de l?association des malentendants canadiens et the International Federation of Hard of Hearing People, fait &eacute;tat du r&ocirc;le cl&eacute; de la technologie dans sa vie et de la n&eacute;cessit&eacute; que les professionnels des soins de sant&eacute; auditifs forment et instruisent leurs clients sur l?int&eacute;gration de la technologie dans leurs activit&eacute;s quotidiennes. Au moment de l?&eacute;laboration de ce papier, un communiqu&eacute; conjoint a &eacute;t&eacute; diffus&eacute; par the Academy of Doctors of Audiology, the American SpeechLanguage-Hearing Association et the American Academy of Audiology. Cette d&eacute;claration in&eacute;dite reconnait le faci&egrave;s changeant de l?environnement des soins de sant&eacute; auditifs et appelle la communaut&eacute; des soins de sant&eacute; auditifs &agrave; se concentrer sur les besoins du consommateur dans leur prestation de service. Cette d&eacute;claration a &eacute;t&eacute; publiquement applaudie par statement recognizes the changing face of the hearing environment and calls on the hearing healthcare community to focus on consumer needs in their service delivery. This statement has been publicly applauded by the Hearing Loss Association of America. Comment seront adopt&eacute;es ces recommandations par les professionnels des soins de sant&eacute; reste &agrave; voir, mais c?est notre souhait que les organisations canadiennes des soins de sant&eacute; auditifs vont se montrer &agrave; la hauteur de la situation en adoptant et en faisant la promotion de normes similaires pour la prestation des services pour les canadiens vivant avec une perte auditive. How these recommendations will be adopted by healthcare professionals remains to be seen, but it?s our hope that Canadian hearing healthcare organizations will rise to the challenge, by adopting and promoting similar standards of healthcare delivery for Canadians with hearing loss. L?objectif ultime de la r&eacute;&eacute;ducation auditive est ?la communication optimale? pour le consommateur/client. Mais &ccedil;a veut dire quoi exactement? (Comme en apart&eacute;, nous sommes toujours &agrave; la recherch&eacute; d?une meilleure phrase pour d&eacute;crire ce concept qui sonne comme une publicit&eacute; pour une marque d?appareil auditif ou yogourt.) La communication optimale est diff&eacute;rente pour tous, elle implique un m&eacute;lange individuel d?outils de communications, elle n&eacute;cessite une r&eacute;ponse &agrave; tous les sentiments et &eacute;motions associ&eacute;s avec la perte auditive (ex., col&egrave;re, d&eacute;ni, frustration, isolement, stress dans les relations, etc.) et aussi une compr&eacute;hension de la technologie et son utilisation pour maximiser la compr&eacute;hension du discours et le fonctionnement en g&eacute;n&eacute;ral. La communication optimale pour une personne pourrait exiger la sensibilisation au son et une &eacute;ducation auditive ou signifier une formation sur la lecture labiale. Aussi, une multitude d?autres atouts de communication (Strat&eacute;gies pour orateur et auditeur, de pr&eacute;paration et de manipulation environnementale) peuvent &ecirc;tre utilis&eacute;es. La formation sur la confiance en soi, les comp&eacute;tentes pour le travail de d&eacute;fense, et l?obtention de soutien d?autres peuvent faire partie du paquet ?communication optimale? d?une personne. Id&eacute;alement, la personne qui pr&eacute;sente une perte auditive et le professionnel des soins de sant&eacute; auditifs vont mettre en ?uvre une vari&eacute;t&eacute; de technologies et strat&eacute;gies &agrave; r&eacute;&eacute;valuer et changer au fur et &agrave; mesure que les besoins en ou&iuml;e et &eacute;coute changent, ou &agrave; mesure que la technologie &eacute;volue.</p>\r\n<p>Nous esp&eacute;rons que vous allez prendre du plaisir &agrave; lire suppl&eacute;ment qui offre des perspectives diff&eacute;rentes en un mod&egrave;le de service dans lequel, ensemble, ?Mon audie et moi? peut fonctionner en partenariat pour supprimer les barri&egrave;res &agrave; la communication et faire la promotion du bien &ecirc;tre avec une perte auditive. Esp&eacute;rons ? et bient&ocirc;t ? que ce concept ne soit pas dur &agrave; vendre, mais plut&ocirc;t la nouvelle r&eacute;alit&eacute;.</p>\r\n<p>steve Aiken President, Canadian Academy of Audiology steve.aiken@dal.ca</p>\r\n<p>As I walked in the door after being away for a week at our conference, my youngest, Isaac, who has just learned to talk, jumped into my arms and shouted ?Dada?! Is there anything better than this? When you stop and think about how important communication is for what it means to be human, it is truly staggering. We are defined by our relationships and our communities; we are social beings to the core. Audiologists play an incredibly important role helping people with this most basic aspect of human existence. Our community has many dedicated members that work hard every day to help people overcome barriers in communication. It?s easy to become lost in the details, to get caught up in the tensions of the moment ? busy waiting rooms, hearing aid fitting problems, diagnostic puzzles and challenges with third-party payers ? but it?s worth stepping back and looking at the big picture. The challenges will always be there, but the challenges associated with untreated hearing loss are worse: educational problems, lost employment opportunities, dementia, and social isolation. That is why our work is so important. In spite of this, audiology is still relatively unknown. Many people don?t know who we are or what we do, and how we fit into the health care system. They know about optometrists and dentists, but not audiologists. Once, after telling someone that I was an audiologist, I was asked ?How can you make money studying ideas?? I probably should have given her my card! People need to know about the importance of visiting an audiologist, of taking care of their hearing, and of seeking treatment for hearing loss and tinnitus. And governments need to know about the importance of our services and the need for adequate funding. Communication is not an optional part of the human experience.</p>',NULL,'2022-11-29'),(36,3252,'ajchr','http://www.andrewjohnpublishing.com/','','<p>I recently received a great honour. I was informed that I was being audited by my provincial government program for prescribing too many binaural hearing aids, and that this was &ldquo;way above the rate of binaural hearing aid prescription by my colleagues.&rdquo; Although this did take a fair amount of paperwork and the pulling of almost 200 files it did give me the opportunity to perform a self-review, and this is always a good thing. In fact, many provincial colleges that regulate the profession of audiology do just this, and I have always found this to be a constructive and often enlightening endeavour. Of the 193 files pulled, indeed the vast majority were for binaural fittings. There were 6 that were &ldquo;suspect&rdquo;in the sense that I really didn&rsquo;t know (and indeed indicated this on the hearing aid evaluation form) whether they would benefit from two hearing aids instead of one. My clinical intuition was &ldquo;let&rsquo;s try it and you always have the option of returning one, or both, at the end of a trial period.&rdquo; We can only predictso much in our clinics. The hearing aid wearerjust needsto wearit outside and experience amplified life forseveral weeks. Several issues ago, in the CanadianHearing Report, Dr. Wayne Staab was gracious enough to give his perspective on the more general question of &ldquo;what percentage of people who need hearing aids, actually get them.&rdquo; His response was based on the concept of &ldquo;hurt.&rdquo; Was a person bothered by their hearing loss and is this not fully predictable from their audiometric measurement? Dr. Staab, and indeed most of the clinicians I know, stated that it was fine to recommend amplification for someone who had near normal audiometric thresholds, if they experienced communication difficulty, especially in adverse listening environments. This discussion can be extended further to the fitting of binaural hearing aids &ndash; I would argue that a binaural fitting is best unless it&rsquo;s not. And the way we know that it&rsquo;s&ldquo;not&rdquo; is because the hearing aid wearer feels that there is no benefit from having the hearing aid(s) after trying it in real life environments.</p>\r\n<p>Audiometry is such a gross and simplistic measure yet we rely on it to such a great extent. With the advent of other tests that purport to assess audiometric function, rather than audiometric sensitivity, we are gaining a new appreciation of how to deal with our hard of hearing clients. For example, otoacoustic emission measures become pathological long before one observes and audiometric pure tone threshold shift. In some sense, by the time that one observes a measureable hearing loss using pure tone threshold testing, a lot of cochlear damage has already occurred. And with long standing cochlear damage we are now seeing more central changes that diminishes an individual&rsquo;s communication ability. So, should our clinical decision to recommend one, two, or no hearing aids be based on audiometric pure tone thresholds &ndash; probably not, but more often than not, regulators have nothing more to go on. It is of course more complex than this. For example, is a fitting of two hearing aids a truly binaural fitting or are there more central processing issues that limit the full benefit of binaural summation, phase integration, and synthesis? It is therefore our responsibility as a profession to update our regulators (who have a difficult enough job as is) with current technology, assessment techniques, and clinical philosophy. Preferred Practice Guidelines (or PPGs) are statements of minimal care. Perhaps it&rsquo;s time to have &ldquo;Optimal Practice Guidelines&rdquo; as well? In thisissue of the CanadianHearing Report we are pleased to present you with an article by Christopher Schweitzer and Christopher McCarron about some interesting phenomena with asymmetrical listenersthat touch on some of these issues. Alberto Behar, in his column Noise about Noise questions the usefulness of audiometric testing, and some of the issues surrounding this. And Calvin Staples in From the Blogs has selected several blog entries from HearingHealthMatters.org about issues surrounding ethics. Peter Stelmacovich, in his column The Deafened Audiologist continues with the theme that more may be better. We shouldn&rsquo;t restrict what we are able to offer our clients and this includes directional microphones, wireless options, and the use of assistive listening devices such as FM systems &ndash; more may be better. For any one client, this may not be the case, but unless they are provided with the opportunity to experience the options that our field can offer, there is no way of predicting who requires what in an apriori fashion. Gael Hannan continues with the Happy HoH and talks about the many things that a hard of hearing person needs to worry about. And in this issue we have a guest columnist for All Things Central &ndash; Irene Hoshko discussed central auditory processing assessment with children in 2012 and where we are now. In Spotlight on Science Lendra Friesen and Samidha Joglekar update us on the Oral vs. Intratympanic Steroid Treatment for Sudden Sensorineural Hearing Loss. From time to time we see clients who wake up with a sudden, unexplained unilateral hearing loss (or even a suddenly deafened client &ndash; both of whom stretch our clinical and counselling experience. This is a nice overview of the current state of affairs and what we should be telling our clients.</p>\r\n<p>J &rsquo;ai r&eacute;cemment re&ccedil;u un grand honneur. On m&rsquo;a inform&eacute; que je faisais l&rsquo;objet d&rsquo;une v&eacute;rification par le programme du gouvernement provincial pour avoir prescris beaucoup d&rsquo;appareils auditifs binauraux, ce qui &eacute;tait &ldquo; bien audel&agrave; du taux des prescriptions des appareils auditifs binauraux de mes coll&egrave;gues.&rdquo; M&ecirc;me si &ccedil;a a pris un temps appr&eacute;ciable et l&rsquo;extraction de presque 200 dossiers, ceci m&rsquo;a donn&eacute; l&rsquo;opportunit&eacute; de proc&eacute;der &agrave; une autor&eacute;vision, ce qui est toujours une bonne chose. En fait, plusieurs coll&egrave;ges provinciaux qui r&egrave;glementent la profession de l&rsquo;audiologie font justement &ccedil;a, ce que j&rsquo;ai toujours trouv&eacute; tr&egrave;s constructif et souvent un effort instructif. Des 193 dossiers tir&eacute;s, &agrave; ne pas en douter, la vaste majorit&eacute; &eacute;taient pour des ajustements binauraux. 6 d&rsquo;entre eux &eacute;taient &ldquo;suspect&rdquo; dans le sens que r&eacute;ellement je ne savais pas (et en fait indiqu&eacute; dans le formulaire d&eacute;valuation de l&rsquo;appareil auditif) si la personne allait b&eacute;n&eacute;ficier de deux appareils auditifs au lieu d&rsquo;un seul. Mon intuition clinique &eacute;tait &ldquo;on va l&rsquo;essayer et vous avez toujours l&rsquo;option de restituer un ou les deux, &agrave; la fin de la p&eacute;riode d&rsquo;essai.&rdquo; Nous ne pouvons pas tout pr&eacute;dire dans nos cabinets. Le porteur de l&rsquo;appareil auditif a juste besoin de le porter &agrave; l&rsquo;ext&eacute;rieur et faire l&rsquo;exp&eacute;rience de la vie amplifi&eacute;e pendant quelques semaines. Dans des num&eacute;ros pr&eacute;c&eacute;dents de la revue canadienne d&rsquo;audition, Dr Wayne Staab nous avaient donn&eacute; sa perspective autour de la question plus g&eacute;n&eacute;rale &ldquo;des personnes qui ont besoin d&rsquo;appareils auditifs, quel pourcentage d&rsquo;entre elles effectivement les obtiennent.&rdquo; Sa r&eacute;ponse &eacute;tait bas&eacute;e sur le concept de &ldquo;pr&eacute;judice.&rdquo; Est-ce que la personne &eacute;tait d&eacute;rang&eacute;e par sa perte auditive et que ceci ne serait pr&eacute;visible si on regarde de pr&egrave;s ses mesures audiom&eacute;triques ? Dr. Staab, et en fait la plupart des cliniciens que je connaisse, ont d&eacute;clar&eacute; que c&rsquo;&eacute;tait normal de recommander l&rsquo;amplification &agrave; quelqu&rsquo;un dont les seuils audiom&eacute;triques &eacute;taient normaux, s&rsquo;il a des difficult&eacute;s de communications, sp&eacute;cialement dans des environnements d&rsquo;&eacute;coute d&eacute;favorables. Cette discussion peut aller plus loin, aux ajustements des appareils auditifs binauraux &ndash; Je plaiderai que l&rsquo;ajustement binaural est meilleur &agrave; moins qu&rsquo;il ne le soit pas. Et on sait qu&rsquo;il ne l&rsquo;est pas parce que le porteur de l&rsquo;appareil auditif sent qu&rsquo;il n&rsquo;y a pas d&rsquo;avantages &agrave; porter des appareils auditifs apr&egrave;s l&rsquo;avoir essay&eacute; dans un environnement de vie r&eacute;elle.</p>\r\n<p>L&rsquo;audiom&eacute;trie est une mesure tellement grossi&egrave;re et simpliste mais on compte beaucoup dessus. Avec l&rsquo;av&egrave;nement d&rsquo;autres tests qui sont suppos&eacute;s &eacute;valuer la fonction audiom&eacute;trique, nous avons plus de m&eacute;rite pour faire face &agrave; nos clients malentendants. Par exemple, les mesures de l&rsquo;&eacute;mission otoacoustique sont pathologiques bien avant qu&rsquo;on puisse les observer et les seuils du son pur audiom&eacute;trique changent. Dans un sens, le temps qu&rsquo;on observe une perte auditive mesur&eacute;e par le son pur, bien des dommages &agrave; la cochl&eacute;e se sont d&eacute;j&agrave; produits. Et avec un dommage continu &agrave; la cochl&eacute;e, nous voyons maintenant plus de changements centraux qui diminuent la capacit&eacute; de communication de la personne. Alors, doit on baser notre d&eacute;cision clinique de recommander un ou deux ou aucun appareils auditifs sur des seuils audiom&eacute;triques de pure son &ndash; probablement non, mais plus souvent que pas, les r&eacute;gulateurs n&rsquo;ont pas autre chose sur quoi se baser. C&rsquo;est bien s&ucirc;r plus compliqu&eacute; que &ccedil;a. Par exemple, est ce que l&rsquo;ajustement de deux appareils auditifs est un vrai ajustement binaural ou y a t il d&rsquo;autres enjeux de traitements plus centraux qui limitent l&rsquo;avantage total de la sommation binaurale, la phase d&rsquo;int&eacute;gration, et la synth&egrave;se ? Il est par cons&eacute;quent notre responsabilit&eacute; comme profession de mettre &agrave; jour nos r&eacute;gulateurs (qui ont un travail assez difficile d&eacute;j&agrave;) avec la technologie actuelle, les techniques d&rsquo;&eacute;valuation et la philosophie clinique. Les lignes directrices pr&eacute;f&eacute;r&eacute;es sont des &eacute;tats de soins minimes. Peut-&ecirc;tre, est-il temps d&rsquo;avoir &ldquo;Des lignes directrices de pratiques optimales&rdquo; aussi ? Dans ce num&eacute;ro de La revue Canadienne d&rsquo;audiologie, nous avons le plaisir de vous pr&eacute;senter un article de Christopher Schweitzer et Christopher McCarron concernant des ph&eacute;nom&egrave;nes assez int&eacute;ressants avec des auditeurs asym&eacute;triques qui touchent &agrave; certains de ces enjeux. Alberto Behar, dans sa colonne Noise about Noise se pose des questions sur l&rsquo;utilit&eacute; des tests audiom&eacute;triques, et certains des enjeux entourant cette question. Et Calvin Staples dans From the Blogs a s&eacute;lectionn&eacute; plusieurs entr&eacute;es sur le blog de HearingHealthMatters.org autour des enjeux &eacute;thiques. Peter Stelmacovich, dans sa colonne The deafened Audiologist continue sur le th&egrave;me que plus peut &ecirc;tre meilleur. Nous ne devrions pas restreindre ce que nous pouvons offrir &agrave; nos clients parmi les microphones directionnels, les options sans fil, et l&rsquo;utilisation des appareils d&rsquo;amplification sonore comme les syst&egrave;mes FM&ndash; plus peut &ecirc;tre mieux. Il se peut que ce ne soit pas le cas pour tout client, mais &agrave; moins qu&rsquo;on leur fournisse l&rsquo;opportunit&eacute; d&rsquo;exp&eacute;rimenter les options que notre domaine peut leur offrir, il n&rsquo;y a aucun moyen de pr&eacute;dire qui exige quoi. Gael Hannan continue avec le Happy HoH et nous parle des multitudes de choses dont une personne malentendante devrait s&rsquo;inqui&eacute;ter. Et dans ce num&eacute;ro, nous avons une chroniqueuse invit&eacute;e pour All Things Central &ndash; Irene Hoshko se penche sur les &eacute;valuations des traitements auditifs centraux chez les enfants en 2012 et o&ugrave; nous en sommes maintenant. Dans Spotlight on Science, Lendra Friesen et Samidha Joglekar nous font une mise &agrave; jour du traitement oral de la perte soudaine d&rsquo;audition neurosensorielle versus les st&eacute;ro&iuml;des intra tympaniques. De temps en temps, nous avons des clients qui se r&eacute;veillent avec une perte auditive unilat&eacute;rale soudaine et inexplicable (ou m&ecirc;me un client avec une surdit&eacute; soudaine) et c&rsquo;est justement ces clients qui &eacute;tirent &agrave; la fois notre exp&eacute;rience clinique et de counseling. C&rsquo;est un beau survol de la situation courante et ce que nous devrions dire &agrave; nos clients. Ce num&eacute;ro de la revue canadienne d&rsquo;audition nous fait r&eacute;fl&eacute;chir sur plusieurs th&eacute;matiques, bien au chaud devant un feu rugissant, ou au moins dans un fauteuil pelucheux. J&rsquo;esp&egrave;re que vous savourez votre automne, et pour ceux d&rsquo;entre vous qui avez assist&eacute; au dernier congr&egrave;s de l&rsquo;acad&eacute;mie canadienne d&rsquo;audiologie &agrave; Ottawa, j&rsquo;esp&egrave;re que vous avez aussi rencontr&eacute; de nouveaux coll&egrave;gues et reconnect&eacute; avec d&rsquo;anciens camarades de classes.</p>\r\n<p>By Calvin Staples, MSc Hearing Instrument Specialist faculty/Coordinator, Conestoga College CStaples@conestogac.on.ca</p>\r\n<p>September is here and for many across the country that means the end of summer and back to school. I teach professional ethics for hearing health care at Conestoga College so I too am back to school. The course outlines the scope of practice and code of conduct for the hearing instrument specialist. I am continually trying to show the students case-based examples with moral and ethical implications. I am sure the argument could be made that every decision we make in our clinical practices has a moral or ethical consequence, as we work in health care. As audiologists, we pride ourselves in being the &ldquo;best hearing health care providers&rdquo; and we are bound to serve our patient population with the highest integrity. And for the most part I think we meet this criteria. I always express to my students that the moment the lines become grey that should be a sign that your decision-making skills have been compromised. Janet Clarke once told me that we should practice like our picture will be on the front-page of the paper. I think there is some real merit in that statement and I decided this blog summary would focus on ethics. I really like these blogs. I hope the readers and you both feel the same. The first one is a real doozie, thanks for the blog Holly! By Holly Hosford-Dunn A few weeks ago, Hearing Economics ventured into Ethical territory &ndash; not a place economists like to visit. Nevertheless, we&rsquo;re back in that quagmire of bad decisions, their effects on practices, and whether they are moral temptations or true ethical dilemmas. The latter surface when there is a clash between two or more moral beliefs, referred to as central values. This post suggests that &ldquo;Big&rdquo; carries ethical, if not moral, weight in health care. CentraLVaLue: size Matters Mayo Clinic agreed last week to pay $1.26 million to the federal government for &ldquo;knowingly billing Medicare, Medicaid, and other government healthcare programs for nonexistent pathology work.&rdquo; Mayo Clinic has long been the Gold Standard of American health care. It&rsquo;s a huge organization that covers all specialties. Should our Gold Standard be tarnished just because it has problems in its billing department? Don&rsquo;t we all? Comment: We&rsquo;veseen banks and companies deemed Too Big to Fail and spared the axe. Now it seems that some health care organizations are Too Big to be Unethical. I&rsquo;m just guessing that if I got caught billing government agencies for nonexistent services and hearing aids, the State of Arizona would yank my license and never give it back (they&rsquo;re like that). Further, the Government would hit me up with fines that were proportionally huge compared to the measly $1mil+ bill handed to Mayo. I would be out of business, unable to make a living professionally, and out of funds. By contrast, it&rsquo;s business as usual at Mayo except for a one-time dip into petty cash. Some wit noted that &ldquo;Corporations are People Too&hellip; They&rsquo;re Just Bigger People.&rdquo; You could add to that: &ldquo;Bigger People Can Assume Bigger Risk.&rdquo; I qualified my projected demise in the previous paragraph by saying &ldquo;if I got caught.&rdquo; Small folks have to think long and hard before doing something immoral like stealing, given the consequences of getting caught. Not so much for Big Mayo, where the odds were good that they wouldn&rsquo;t get caught and the penalties for getting caught were small and fleeting. Mayo took the risk and they&rsquo;re probably still ahead, especially since they don&rsquo;t have to acknowledge blame as part of the payment. This is not an ethical dilemma for Mayo. Not only does this fall in the realm of moral temptation, it falls into a special Big People category I&rsquo;m calling &ldquo;Calculated Moral Temptation.&rdquo;</p>\r\n<p>Interestingly, it&rsquo;s the economic view that is not clear cut in the Mayo case, where the economic cost is much larger than the accounting cost of the $1.26 million penalty. This is where the ethical dilemma lurks. If I go out of business because I succumb to moral temptation, there is no harm to the community, other businesses, or most people with hearing loss. The case is simple. But, if Mayo takes the wrong moral path and goes under, the town of Rochester, MN, goes with it. An entire town loses its economic base, professionals lose their jobs, families are displaced, important research is threatened, severely ill patients&rsquo; lives hang in the balance, and credibility of health care delivery in America suffers. Who wants to be the one who signs off on that order? You&rsquo;d have to go into hiding from The Greater Good who would be out hunting you down. Economics and ethics join up in the philosophy of utilitarianism, espoused by famous 19th century economist and philosopher John Stuart Mill and encapsulated in his statement: Actions areright to the degreethat they tend to promotethe greatest good forthe greatest number. Guess Mayo wins this one, based on the greater good. But their win will probably bring down at least one new government regulation on the rest of us. In that vein, it&rsquo;s worth pointing out that being Big means your actions can be unethical, immoral but NOT illegal. How else to explain Big Finance company MF Global&rsquo;s apparent success in avoiding federal fraud charges for its &ldquo;loss&rdquo; of over a billion dollars in customers&rsquo; monies, on grounds that it was &ldquo;sloppy&rdquo; not &ldquo;criminal.&rdquo; The &ldquo;Big&rdquo; Central Value can be rephrased as &ldquo;It&rsquo;s good to be King.&rdquo; To quote a famous 20th century moral philosopher, &ldquo;Steal a little and they throw you in jail. Steal a lot and they make you king.&rdquo; Bob Dylan There is any number of other ethical dilemmas and moral temptations to consider in hearing health care, especially if you are an audiologist: protection of intellectual property, stealing patients, steering patients, turning away patients, selling hearing aids without providing implied services, deriding colleagues, handling impairments of patients and staff, plagiarism, calculated errors of omission and commission, billing insurances by all the rules &hellip; the list just doesn&rsquo;t stop. But I am stopping now. Philosophy and ethics are hard and confusing because they question decisions made at the margins of behaviour. This blog is in full retreat, moving back next week to the simple world of economics where margins are measureable.</p>\r\n<p>Previously, Hearing Economics described thefts and deceptions in professional settings. Transgressions were bizarre, some absurd, but all actually happened. Most were illegal; all received some form of punishment. The point was that owners and managers are responsible for imposing and enforcing checks and balances in hearing health care environments in order to protect patients, staff, and assets from theft and manipulation. Indeed, checks and balances are important preventive measures put in place to protect people from making bad choices and create a reliable, trusting environment. Which brings us to the topic of today&rsquo;s post: Illegal or not, do situations exist in which stealing or deceptions are ethically defensible in hearing health care environments? I think I&rsquo;m on reasonably firm shifting sand when I say that the Economic view is that all are OK so long as they are not illegal and are done for the good of the firm. Readers are encouraged to send in stories of legal stealing and deception that helped their companies prosper &ndash; I&rsquo;m sure we could all benefit from such information. While we anxiously await examples, it&rsquo;s worth a minute to define terms. Bad behaviour is often described as &ldquo;morally and ethically wrong.&rdquo; But seriously, does anyone reading or writing this post know the difference between moral and ethical? Can something be morally right and ethically wrong, or vice-versa? This area has consumed the life of more than one philosopher, so don&rsquo;t look for an answer in this post. However, I was encouraged to dig a little when I discovered that I could ask the Universe on its brand new Twitter account. I haven&rsquo;t heard back from The Universe &ndash; making me wonder fleetingly if I am just a speck &ndash; but I quickly left that path to seek out more reliable, or at least closer, experts. Somewhat tautologically, it turns out that morals are beliefs and ethics are &ldquo;advanced expressions of morality&rdquo; based on consistent reasoning. You have to wonder how consistent rationalizations are handled.</p>\r\n<p>You&rsquo;re in the moral ballgame if your gut tells you that a proposed act is &ldquo;wrong&rdquo; (e.g., stealing from the business) or &ldquo;right&rdquo; (not stealing). Rushworth M. Killer, deceased ethicist and author of How Good People Make Tough Choices calls these &ldquo;right-wrong&rdquo; decisions moral temptations: clear-cut decisions about behaviours that are widely &ldquo;understood to be wrong&rdquo; and provide excellent career opportunities for televangelists. Dealing with what Dr. Killer calls &ldquo;right-right&rdquo; decisions moves you up to the big leagues of ethical dilemmas, where choices set one central value (not stealing is good) against another (taking money from the wealthy to feed the poor serves the Greater Good) &ldquo;in ways that will never be resolved simply by pretending that one is wrong.&rdquo; So much for rationalizing&hellip; ethics requires honesty in one&rsquo;s thinking How about those transgressions in health care mentioned previously? Were they moral temptations or ethical dilemmas? What is the economic view? Below are a few examples, grouped according to the aforementioned Central Values pitted against the good of the firm.</p>\r\n<p><strong>CentraLVaLue: faMiLy Matters</strong></p>\r\n<p>The poor accountant last week embezzled $16 million, but her motive&ndash; only now revealed &ndash; was pure. She used that money unselfishly to prop up her son&rsquo;s failed ambulance business. The big picture emerges: A mom helping her son, a family business, ambulances saving people&rsquo;s lives, the world a better place. Ethically, how can you blame the woman for repurposing that money to such a worthy cause? A close-knit family business in Long Island employed 11 family members who provided special ed. services to disabled toddlers. In the process, the business is accused of falsifying records and overbilling about $2 million. But hey, the kids got (some) services, the family prospered, and $2 mil is a drop in the bucket in the program&rsquo;s $2 billion budget. &ldquo;Your office manager confesses that she stole money from the office account to buy medicine for her ailing father. Her father has died, and she offers you a check from the insurance proceeds to pay you back. After you cash the check, do you fire her or forgive her?&rdquo; Comment: With notable exceptions (Robin Hood, Soprano family) most of us will see theseexamples as moral temptationsrather than ethical dilemmas. It is wrong to steal. On the other hand, it is not only OK to steal but stealing is a cornerstone of Robin Hood and Tony Soprano ethics &ndash; oneethicsays it&rsquo;s for the Greater Good of the Family of Man, the other&rsquo;sethic says it&rsquo;s for the Good of The Family. Not stealing (or not doing other wrong things) would be an ethical dilemma for those bound by oath to organizations such as these. The economic view is clear cut for the three cases, unless the Sopranos go into health care. Stealing from the firm raises costs, which reduces supply, raises price, and cuts demand. Not good for the business. Not good for consumers. Separate the transgressors from the business and get the stolen funds back, using legal means if necessary. Beyond that, any punishments are the purview of the courts. In general, professions are not well served by instances of moral and/or ethical failure. The ripple effects of such failures tend to reach consumers, who react by complaining. Complaints get the attention of agencies, which in turn react by applying scrutiny to the profession. Life gets really rough when government agencies move from scrutiny to regulations and investigations of the profession and its members. Just ask Tony Soprano, who practically lives with the Feds in his house. He&rsquo;ll tell you: it&rsquo;s a lot easier and far more profitable to police your own organization than have the government step in or, worse, take over.</p>\r\n<p>I n diagnosing central auditory processing dysfunction ([C]APD) the audiologist&rsquo;s focus shifts from sensory end organ to the challenging arena of the auditory brain. (C)APD clinical practice guidelines and position statements are now in development by associations of communication professionals in North America. Educational audiologists recognize the heavy premium placed on the correct interpretation of classroom auditory information before children achieve proficient reading skills. The introduction of electronic multimedia technology to pedagogy requires children to integrate auditory and visual information from disparate sources in real time, accelerating the processing challenge. ASHA defines (C)APD as &ldquo;difficulties in the perceptual processing of auditory information in the CNS and the neurobiologic activity that underlies that processing and gives rise to electrophysiologic auditory potentials.&rdquo;1 The true prevalence rate of (C)APD though uncertain, is estimated at 7%. 2 The goal of (C)APD assessment is to provide insight into, and delineate by deficit profiling, areas of strength and weakness in the operation of multiple auditory processes. This objective is realized by simulating in the test booth, the disadvantageous reception conditions children encounter in their everyday listening environments and by observing when and how the processing breakdown occurs. This knowledge is used to direct a remedial effort. A generation ago, (C)APD in children was diagnosed by excluding other contributory factors. In 2012 the diagnostic process is more rigorous. Yet, as Allen notes, (C)APD test selection remains difficult as no &ldquo;gold standard&rdquo; exists to evaluate the effectiveness of our diagnostic tools. 3 There are many such &ldquo;hot topics&rdquo; in (C)APD assessment and intervention today with only modest consensus established in their treatment by researchers and reflective practitioners. At issue are the following and this list is by no means exhaustive:</p>\r\n<p>1. The selection and number of criterion-referenced tests to include in a comprehensive battery.</p>\r\n<p>2. The diagnostic value of using two test procedures to assess a single auditory process when the deficit suspicion index is high.</p>\r\n<p>3. Optimizing test battery diagnostic power and cost effectiveness by balancing sensitivity, specificity and clinical efficiency while avoiding effects of fatigue, attention and motivation.</p>\r\n<p>4. What criteria to use for failure.</p>\r\n<p>5. Facilitating differential diagnosis by including materials with limited language load.</p>\r\n<p>6. Managing language confounds in assessing speech-sound disorders in multilingual children.&nbsp;</p>\r\n<p>7. Ensuring that selected tests are appropriate for a child&rsquo;s language development level and maturational and chronological age.</p>\r\n<p>8. Treating co-morbid conditions in assessment and in interpreting test results, such as, evaluating the impact of disorders of attention, language, learning, global cognition, memory and motivation.</p>\r\n<p>9. Establishing if supramodal tests (e.g., measuring the visual analog of auditory tests or using instruments specifically designed to evaluate attentional status) contribute to differential diagnosis or if auditory intra/intertest comparisons are sufficient.</p>\r\n<p>10. Determining which formalized conceptual model best diagnoses and categorizes (C)APD deficits and targets therapies: the Buffalo, Bellis/Ferre or Spoken Language Processing Model.</p>\r\n<p>11. Quantifying the value and reliability of an expanding array of</p>\r\n<p>The audiologist carefully reviews results and anecdotal comments from screening instruments and behavioural inventories completed by instructional personnel and parents, such as The Buffalo Model Questionnaire9 ; Children?s Auditory Performance Scale (CHAPS) 10 ; Listening Inventory for Education (LIFE)11 ; Children?s Home Inventory for Listening Difficulties (CHILD)12 ; Screening Instrument for Targeting Educational Risk (SIFTER)13 ; and the Conners? Scales. 14 A detailed case history including pertinent medical, developmental and academic information is gathered. The verbal and nonverbal parent-child interaction patterns in the waiting room are observed. The audiologist converses informally with the child; judges their comfort level in the clinical setting; determines what motivates them and establishes rapport. Peripheral testing evaluates pure tone hearing status complemented with distortion-product otoacoustic emissions (to evaluate efferent function); immittance; acoustic reflex thresholds (to rule out auditory neuropathy spectrum disorder) and speech discrimination in quiet comparing monaural and binaural performance with that obtained at competitive signalto-noise ratios. Numerous signs and behavioural indicators signalling (C)APD high risk status may emerge during test. Other observations suggest medical referral as a hyperacusic child may benefit from a neurological consult. The audiologist assesses the sequential unfolding of diagnostic impressions and uses clinical decision analysis to identify the best auditory diagnostic strategy for (C)APD testing if candidacy is indicated. Using a hypothetico-deductive strategy, 15 a short list of potential (C)APD subtype diagnoses is formed and progressively refined using ongoing clinical test results. Suspect skills requiring measurement are identified and a battery is built around them, strategically selecting from among tests of binaural separation and integration; temporal, frequency and intensity resolution; auditory discrimination under degraded conditions and temporal sequencing.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. American Speech-LanguageHearing Association. (Central) Auditory Processing Disorders (Technical Report). Retrieved from http://www.asha.org/docs/html/ TR2005-00043.html. 2005.</p>\r\n<p>2. Musiek FE, Chermak GD, Weihing J, Zappulla M, and Nagle S. Diagnostic Accuracy of Established Central Auditory Processing Test Batteries in Patients with Documented Brain Lesions. J Am Acad Audiol 2011;22:342&ndash;58.</p>\r\n<p>3. Allen P. (Central) Auditory Processing Disorders in Children.In: Comprehensive Handbook of Pediatric Audiology. Seewald R and Tharpe AM. (Eds.), San Diego, Plural Publishing Inc.; 2011.</p>\r\n<p>4. McLeod S and Goldstein BA. (Eds.) Multilingual Aspects of SpeechSound Disorders in Children. Toronto: Multilingual Matters; 2012.</p>\r\n<p>5. Medwetsky L. Spoken Language Processing: A Convergent Approach to Conceptualizing (Central) Auditory Processing. ASHA Leader 2006;11(8):13&ndash;17.</p>\r\n<p>6. Kelly DA. Parenting the Child with Auditory Processing Disorders: A Dynamic and Challenging Role. In: Auditory Processing Disorders Assessment, Management and Treatment, Geffner D, and RossSwain D, (Eds.) San Diego: Plural Publishing; 2007.</p>\r\n<p>7. Marler JA, Champlin CA, and Gillam RB. Auditory Memory for Backward Masking Signals in Children with Language Impairment. Psychophysiology 2002;39:767&ndash;80.</p>\r\n<p>8. Siekierski BM, Jarratt KP, et al. WISC-III Freedom from Distractibility Index and Measures of Attention in Children. Presented Paper: 111th APA Conference, Toronto, Canada; 2003.</p>\r\n<p>9. Katz J. The Buffalo Model Questionnaire-Revised. Tampa, FL: Educational Audiology Association; 2009.</p>\r\n<p>10. Smoski WJ, Brunt MA, and Tannahill JC. Children&rsquo;s Auditory Performance Scale. Tampa, FL: Educational Audiology Association; 1998.</p>\r\n<p>11. Anderson KL, and Smaldino JJ. Listening Inventories for Education: A classroom measurement tool. Hear J 1999; 52:74&ndash;76.</p>\r\n<p>12. Anderson KL and Smaldino JJ. Children&rsquo;s Home Inventory for Listening Difficulties (CHILD). Educational Audiology Review 2000;17 (3 Suppl.).</p>\r\n<p>13. Anderson KL, and Matkin N. Screening Instrument for Targeting Educational Risk (SIFTER). Tampa, FL: Educational Audiology Association; 1996.</p>\r\n<p>14. Conners C and Wells K. Conners&rsquo; Parents&rsquo;, Teachers&rsquo; and Self- Report Scales. NY: Multi-Health Systems; 2007. 15. Hyde ML, Davidson MJ, and Alberti P. Auditory Test Strategy. In: Diagnostic Audiology, Jacobson JT, and Northern JL (Eds.). Austin, Texas: Pro-Ed; 1991.</p>\r\n<p>Over the years as I have morphed into a &ldquo;hearing health advocate,&rdquo; I have been immersed in positive hearing communication strategies. Thanks to my peers and my hearing health providers, I&rsquo;ve been dunked, dredged, and baked into a confident and assertive advocate for people with hearing loss. However, that&rsquo;s not to say I practice all these strategies at all times. I certainly know what I should be doing, but on occasion, cracks appear in my polished, hand-crafted suit of communicationand-advocacy armour. I still have bad hearing moments and full-on crappy hearing days. It&rsquo;s at these very times that we&rsquo;re supposed to intone the following mantra: Above all, to live successfully with hearing loss, I will keep my sense of humour. But what if you don&rsquo;t have one? What then is a poor, humourless hard of hearing person supposed to do? My sense of humour, although reasonably sound, doesn\'t always rise to the occasion, on demand, especially during a hearing loss moment. While I can tell funny stories about embarrassing hearing faux pas, I can also guarantee they weren&rsquo;t hilarious at the time &ndash; at least not to me, although other people might have had a laugh or two at my verbal non-sequitur. Not only is hearing loss not particularly funny, growing up with it can turn you into a worry-wart, or a complete bundle of nerves. Now that I&rsquo;m older, I worry about new things I had never considered. And, I&rsquo;m not sure that hearing health professionals are fully aware of this aspect of their clients, because most hard of hearing people wouldn&rsquo;t like to talk about this stuff in public. &ldquo;Hearing&rdquo; people worry when they actually hear something go bump in the night. But at least they can figure out how to react, like grabbing a frying pan or whatever to fight off the thing that goes bump. We don&rsquo;t hear bumps in the night &ndash; but we know they must be out there, because other people say they are. So, I start to worry &ndash; what am I not hearing on a given night? What&rsquo;s happening out there in the dark &ndash; a bump, a crash, a yell, a smash? I hear nothing &ndash; and trust me, this can keep you awake, wondering what you&rsquo;re not hearing. The bags under my eyes are not hereditary; they grew on my face out of worry.</p>\r\n<p>What else does a HoH worry about? Oh, just about everything, but here&rsquo;s a partial list. I worry that</p>\r\n<p>&bull; My shake-awake alarm will stop vibrating before I wake up.</p>\r\n<p>&bull; The battery people will go on strike; my hearing aids and assistive devices are all battery operated!</p>\r\n<p>&bull; Next year&rsquo;s flu season will be bad and everyone will wear surgical masks instead of lipstick. Can you imagine the hell this would cause for speech readers like me?</p>\r\n<p>&bull; My hearing aid will feed back when I hug somebody &ndash; so I hug with my neck stuck out at a weird angle.</p>\r\n<p>&bull; When crossing a busy, noisy street, I won&rsquo;t hear the sound of a car about to hit me.</p>\r\n<p>&bull; ALL the captioners quit, and we&rsquo;re left to depend on speech-to-text, voice-recognition software. I know that live captioners aren&rsquo;t perfect, either; in recent TV coverage, the &ldquo;Archbishop of Canterbury&rdquo; and &ldquo;Queen Victoria&rdquo; were captioned as the Arch Bitch of Canterbury and Queen Vicious. But with imperfect software, that&rsquo;s what we would get all the time!</p>\r\n<p>&bull; My husband&rsquo;s lips will lose their ability to move. Or he&rsquo;ll get tired of repeating himself and will get a new wife who CAN hear through walls.</p>\r\n<p>&bull; My grandchildren will have high squeaky voices. Their moms will say, &ldquo;Face Nana when you talk to her, sweet pea, she has a hearing loss,&rdquo; and they will respond, &ldquo;Tough s--t!&rdquo;</p>\r\n<p>&bull; My friends will start going out without me, saying, &ldquo;We didn&rsquo;t invite you to the new restaurant, darling, because we know how much noise bothers you. But we brought you back some of the pat&eacute;.&rdquo; I hate pat&eacute;.</p>\r\n<p>&bull; My ear hole will close up and I won\'t be able to wear a hearing aid.</p>\r\n<p>&bull; After I buy my newest $5000 hearing aids, they&rsquo;ll go on sale at 50% off.</p>\r\n<p>&bull; That new study linking hearing loss to dementia proves to be true! Apparently, for every 10 decibels of hearing loss, the risk of dementia increases by 20%. With my 70 dB loss, I reckon I&rsquo;ve got about 20 minutes before I lose my mind completely.</p>\r\n<p>&bull; I have missed an important, lifechanging opportunity because I didn&rsquo;t hear the phone ring.</p>\r\n<p>&bull; The worst of all &ndash; I worry that I will lose my vision. (This one truly keeps me awake.) These may sound stupid or paranoid to you and I admit I&rsquo;m not really that much of a mess, although I do have my moments. Being cut off from perfect communication is stressful. And when I read that people with hearing loss are prone to depression, anxiety, and social withdrawal &ndash; it&rsquo;s enough to make a hard of hearing person crawl under a rock! So what to do? One option is to dust off the sense of humour (even though it&rsquo;s not scheduled to come back on until tomorrow at 7 am), and get out there and enjoy! Another option is to tell our audiologists about our concerns; they might be able to help because they understand what we&rsquo;re going through. Right?</p>\r\n<p>By Peter Stelmacovich Peter.Stelmacovich@phonak.com</p>\r\n<p>As an audiologist with hearing impairment, I routinely wear both the hat of a clinician and the hat of a patient. This allows me to see hearing loss from both sides of the sound proof booth. Interestingly the knowledge I have obtained from these two perspectives is different yet complimentary. Being an audiologist has taught me much about how the auditory system functions, how to assess auditory function, and how to properly prescribe and fit hearing aids, cochlear implants, and wireless remote microphones such as FM systems. As a hearing impaired person, I have learned firsthand what it is like to live with significant hearing loss. Moreover, I know what it feels like to struggle to communicate, especially in the presence of background noise. We know as audiologists that the two main problems of sensorineural hearing loss are 1. Loss of Audibility 2. Loss of Clarity We manage the loss of audibility quite well as audiologists. If our patients cannot hear well, we provide them with amplification of varying amounts of gain. Today&rsquo;s hearing aids intelligently provide different amounts of amplification as a function of frequency as well as the original intensity of the signal. Scene analysis in hearing aids optimize gain and frequency response for different environments. As the hearing loss increases we provide increasing amounts of amplification. Should this not restore audibility we now have non-linear frequency compression techniques available to restore audibility of high frequency consonants. Finally if this is not sufficient, we can refer our patients for cochlear implantation. We all know that loss of clarity means that when there are other noises present, people with hearing impairment will have a very hard time communicating. Just like amplification, we need to provide our patients with greater signal to noise ratios as the hearing loss increases. The two tools we have at our disposal for improving the signal to noise ratio are directional microphones and wireless remote microphones, with FM systems being the most common example of the latter. Directional microphones provide about a 4 to 5 dB SNR improvement. This amount of improvement is sufficient for adults with mild to moderate degrees of hearing loss. But once we get to a moderate-severe degree of hearing loss (around 60 dB HL), the directional microphone won&rsquo;t be enough. And this is where we start to fail to meet the needs of our patients. So who should get a directional microphone? In my opinion, every person with a hearing loss, regardless of degree of loss would benefit. Yes there are times when omni-directional microphones are better so we need to provide options for manual switching or an intelligent hearing aid that knows when to appropriately switch based in the environment. But people with moderate-severe, severe, and profound hearing loss must have an FM system if they wish to communicate in noise. FM systems provide about a 15&ndash;20 dB SNR improvement which is what people with significant hearing loss will need to communicate in noise. Yet what percentage of these patients actually have an FM system? It is far too low. Perhaps this is area in which I differ most from my normal hearing colleagues. I know firsthand how hard it is to communicate in a noisy environments like a restaurant, bar, cafe, or car. I cannot imagine functioning without my FM system. As such, I will make sure I offer this technology to all patients with moderate-severe losses or greater.</p>\r\n<p>I recognize the reasons why more patients do not use remote wireless microphones are varied. But after over 20 years&rsquo; experience as an audiologist and 48 years experience of living with hearing loss, I remain convinced that the number one reason most adults do not use this technology is because the technology was never presented to the patient I get frustrated with my audiology colleagues for failing to introduce this technology. Similarly, I get frustrated by my fellow people with hearing loss for rejecting technology that will be of such benefit to their lives. So here are my pleas:</p>\r\n<p><strong>To audioLogists and hearing instruMent PraCtitioners</strong></p>\r\n<p>1. For adult patients, please ensure that you select a hearing instrument that can use an wireless microphone system such as an FM system, even if you do not think they need it right away. The FM system can be used with direct audio input, a telecoil, or in some cases a streamer. Make sure the patient knows how to get to the correct program in their hearing device that can use an FM system. Activate the telecoil at least. I know you also need to keep things simple, but try not to limit the patient&rsquo;s options too.</p>\r\n<p>2. Please introduce the concept of an FM system at least to patients with moderate-severe losses or greater. At this degree of hearing loss, only an FM system can provide them with the required signal-to-noise ratio needed to understand speech in a noisy environment.</p>\r\n<p>3. For pediatric patients, please double check to make sure the FM + M program has been activated. Too often I trouble shoot FM problems in schools, and find this as the cause.</p>\r\n<p><strong>To People with hearing Loss</strong></p>\r\n<p>1. Please don&rsquo;t always go with the smallest possible hearing aid, especially if you have more than a moderate loss of hearing. You likely won&rsquo;t be able to use an FM system and that seriously limits your listening options. But, the hearing aids that can use an FM system are still quite small! And, FM systems are small now too.</p>\r\n<p>2. Please understand that the hearing aid is but one device that will help you hear better. You can hear better in noise if you add another device such as an FM system.</p>\r\n<p>3. Please don&rsquo;t say the problem is that everyone else mumbles. It&rsquo;s not true &hellip;you need help. Your audiologist would be delighted to get you all the help you need. It is crucial as hearing health care professionals we address both the problems of audibility and the problems of hearing in noise. If all we do is restore audibility, we are only doing half our job. Peter Stelmacovich has a regular blog entitled Deafened But Not Silent: How to live life to the max with hearing loss</p>\r\n<p>By lendra friesen PhD, and Samidha Joglekar,MClSc (C),Audiologist, Reg.CASlPO  Cochlear Implant Research Program, Sunnybrook Health Sciences Centre</p>\r\n<p>Sudden sensorineural hearing loss (SSNHL) is a common affliction that promptly poses a threat to the quality of life of those patients who experience it. SSNHL refersto a unilateralsensorineural hearing loss of 30 dB or greater over at least three contiguous audiometric frequencies with onset and development over 72 hours. 1&ndash;3 SSNHL is a complaint that is commonly encountered in audiologic and otolaryngologic clinical practice and thus, it is necessary that the clinical audiologist be aware of the possible etiologies, characteristics, and treatment options for this condition. Current epidemiological data related to SSNHL estimates an incidence of between 5 and 20 cases per 100,000 people per year. 2 The true incidence may be higher than these estimates, as individuals who recover quickly and spontaneously do not often seek medical attention. 2 While individuals of all ages may be affected, the peak incidence of SSNHL is between the fifth and sixth decade of life with equal incidence in men and women. 2,4,5 In their review article entitled Sudden Sensorineural Hearing Loss: A Review of Diagnosis, Treatment, and Prognosis, Kuhn and colleagues provide a thorough literature review, along with a comprehensive table, of identifiable causes of SSNHL organized into the following main categories: (1) autoimmune, (2) infectious that includes Lyme disease, mumps, and toxo-plasmosis, a treatable parasitic infection commonly contracted due to contact with cat feces or the ingestion of undercooked meat, (3) functional, that includes malingering and conversion disorder, (4) metabolic that includes diabetes and hypothyroidism, and (5) neoplastic that includes vestibular schwannoma and cerebellopontine angle tumour. 6 The most common bacterial infections to cause SSNHL in the U.S. are Lyme disease and syphilis. 6 Besides mumps, which is the leading viral cause, other viruses implicated in the etiology of SSNHL include herpes simplex, varicella zoster, entero virus, and influenza. 6,7 Vascular pathologiesthat decrease blood supply to the cochlea and reduce intra-cochlear oxygen levels are also a possible cause. 6 Approximately 5% of patients who initially present with SSNHL are ultimately diagnosed with some other otologic disorder as the condition manifests over time. In some cases the final diagnosis is Meni&egrave;re&rsquo;s disease, but it may also be fluctuating hearing loss, otosclerosis, or progressive SNHL. 2,6,7 Despite an overwhelming amount of research in the area, controversy remains with regard to the etiology and appropriate care of patients with this condition, mostly because recommendations vary greatly between publications. 2,4,7 The prognosis of SSNHL depends heavily on identifiable etiology, disease process and duration, specific impact on cochlear structures, and possible treatment options given these other factors. 6 However, the majority of patients with SSNHL have no identifiable cause for their hearing loss and thusthese hearing losses are classified as &ldquo;idiopathic.&rdquo;4,6 While many of the known causes of SSNHL cause permanent hearing loss due to cochlear and hair cell damage, it has been documented that 45 to 65% of patients with idiopathic SSNHL may regain some pre-loss hearing thresholds without therapy. 2,6,8,9 However, prognosis also depends heavily on a variety of risk factors including age at onset of hearing loss, duration of deafness, the presence of associated symptoms (such as vertigo and/or tinnitus), audiogram characteristics, and the time between onset of the hearing loss and treatment from a physician.</p>\r\n<p>According to a recent study by Rauch et al., the current standard of treatment for idiopathic SSNHL is a tapering course of oral corticosteroids (either prednisone or methylprednisone). 2 Over the last 15 years, intratympanic corticosteroid treatment by direct injection into the middle ear has gained wide popularity. 2 A theoretical advantage, documented in guinea pig studies, is an increased drug concentration at the target organ. 10 Another potential benefit of intratympanic steroid treatment over oral steroid treatment is reduced systemic steroid exposure. 2 Rauch et al., conducted a multi-centre, randomized trial in order to investigate the effectiveness of oral prednisone compared to intratympanic methylprednisone for principal treatment of idiopathic SSNHL. 2 The study took place over almost five years and across 16 academic community-based otolaryngology practices. Participants were followed for six months and received doses of either oral prednisone or intratympanic methylprednisone over 14 days. 2 Overall, their findings showed that the efficacy of both treatments was comparable. The mean PTA at 2 months was 56.0 for the oral-steroid group and 57.6 dB for the intratympanic group and recovery of hearing at 2 months was 2 dB greater for oral-steroid treatment compared to intratympanic treatment. 2 The investigators concluded that from the standpoint of comfort, cost, and convenience, oral steroids are better than intratympanic steroid treatment. However, there were no significant differencesfound between either method in terms of therapeutic impact on SSNHL and hearing loss recovery. 2 Although most cases of SSNHL are idiopathic, a number of treatable conditions can underlie SSNHL and thus a medical referral should be made immediately in suspect cases so that efforts can be directed towards establishing a medical diagnosis and, most importantly, ruling out an identifiable underlying cause of the hearing loss. 4,6,7 Patients who experience SSNHL should be cautiously counselled regarding prognosis, as hearing recovery depends on a multitude of factors. 6,7 Standard pure tone audiometry provides the criteria for diagnosis of SSNHL and also has prognostic value, as many patients undergo a series of audiograms to documentrecovery, monitortreatment, guide aural rehabilitation, screen for relapse, and to rule out hearing lossin the contralateral ear. 2 Although many cases of SSNHL spontaneously improve without treatment, the current evidence-based standard of care is directed therapy against identifiable causes of SSNHL, and a ten day to two-week course of either oral or intratympanic corticosteroid therapy for idiopathic SSNHL.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. Merchant SN, Durand ML, Adams JC. Sudden deafness: is it viral? J OtoRhinoLaryngol Relat Spec 2008;70(1):52&ndash;60.</p>\r\n<p>2. Rauch SD, Halpin CF, Antonelli PJ, et al. Oral vs Intratympanic Corticosteroid Therapy forIdiopathic Sensorineural Hearing Loss A Randomized Trial. JAMA 2011;305:2071&ndash;79.</p>\r\n<p>3. Wilson WR, Byl FM, and Laird N. The efficacy of steroids in the treatment of idiopathic sudden hearing loss. a double-blind clinical study. Acta Oto-Laryngol 1980;106:772&ndash;76.</p>\r\n<p>4. Chau JK, Lin JR, Atashband S, et al. Systematic review of the evidence for the etiology of adult sudden sensorineural hearing loss. Laryngoscope 2010;120:1011&ndash;21.</p>\r\n<p>5. Chen CY, Halpin C, Rauch SD. Oral steroid treatment of sudden sensorineural hearing loss: a ten year retrospective analysis. Otol Neurotol 2003;24(5):728&ndash;33</p>\r\n<p>6. Kuhn, M, Heman-Ackah SE., Shaikh, JA, Roehm P. Sudden sensorineural hearing loss: a review of diagnosis, treatment, and prognosis. Trend Amp 2011;15 (3):91&ndash;105.</p>\r\n<p>7. Byl FM, Jr. Sudden hearing loss: eight years\' experience and suggested prognostic table. Laryngoscope 1984;94(5 pt 1):647&ndash;61.</p>\r\n<p>8. Banerjee A, Parnes LS. Intratympanic corticosteroidsforsudden idiopathic sensorineural hearing loss. Otol Neurotol 2005;26(5):878&ndash;81.</p>\r\n<p>9. Chandrashekar SS. Intratympanic dexamethasone for sudden sensorineural hearing loss: clinical and laboratory evaluation. Otol Neurotol 2001;22(1):18&ndash;23</p>\r\n<p>10. Parnes, LS, Sun AH, Freeman DJ. Corticosteroid pharmacokinetics in the inner ear fluids: an animalstudy followed by clinical application. Laryngoscope 1999;109(7 pt 2):1&ndash; 17.</p>\r\n<p>Reviewed by Neil S. Hockley, MSc,Aud(C) nh@bernafon.ch</p>\r\n<p>When I was finishing up my thesis for my MSc in the mid 1990s, Dr. K. K. Charan, one of the pillars of the School of Communication Sciences and Disorders Program at McGill University, had at that time recently retired (I met Dr. Charan by chance, a few years after I graduated, in a clinic where I very nervously tested his hearing. He remarked to me part way during this test that I should not try to use any masking that day because even Ira Hirsch from the CID could not mask his hearing loss properly.) and he had left behind a pile of unwanted books in his former office. I was a student who wanted to expand his audiological library inexpensively and so I accepted the administrator&rsquo;s invitation, one hot Montreal summer&rsquo;s day, to have a look through his books. I was given permission to take what I wanted and spent a couple of hours in this dark office picking up and putting down many books from Dr. Charan&rsquo;s private library. I ended up with a small pile of books that included an autographed copy of Experiments on Tone Perception by Reinier Plomp from 1966 (including a very worn free vinyl demo disk), and a first edition of Diana Deutsch&rsquo;s 1982 book The Psychology of Music. Along with a few books on musical instrument acoustics, there was also the book that I am going to write about in this short review: The Acoustical Factors Affecting Hearing Aid Performance edited by Gerald A. Studebaker and Irving Hochberg. If we jump forwards a few years to the present (2012), this 32 year-old book has ended up being the most likely to disappear from my bookshelf for extended periods of time, and in the next few paragraphs I hope to explain to you why this is the case.</p>\r\n<p>The Acoustical Factors Affecting Hearing Aid Performance is a compilation of presented papers and discussions from a conference that was held in New York City from June 14&ndash;16, 1978. It was published in 1980 as part of a series of books entitled Perspectives in Audiology by University Park Press out of Baltimore MD, edited by Lyle Lloyd. The list of contributors to this volume reads much like a &ldquo;who&rsquo;s who&rdquo; of researchers on acoustics and audiology working during the 1970s, some of whom are still very active today. Researchers such as Jozef Zwislocki, Robyn Cox, Norman Erber, Mead Killion, Harry Levitt, Margo Skinner, and Edgar Villchur were involved. The book covers many topics and so it is divided into a number of sections. The first section is entitled &ldquo;Acoustical Effects of the Environment&rdquo; with chapters on room acoustics and reverberation to name but two. The second section moves on to present some basic acoustics in a section entitled &ldquo;The External Ear, the Earmold, and the Earphone.&rdquo; The third section is entitled &ldquo;Modeling Techniques&rdquo; and introduces a topic that is very important today in the discussion of real ear measurement and hearing instrument fitting software. The fourth section &ldquo;Frequency Response Selection Techniques&rdquo; examines techniques for selecting hearing instruments with regards to gain and frequency response, and includes discussions on master hearing aids. Tacked on to the end of this section is a chapter with some summaries of the conference discussions, where some interesting insights are made that resonate still within the realm of hearing instrument research. This list of topics is not dated and could have been written yesterday; perhaps this explains why this book is a corner stone within the hearing instrument literature and one of Marshall Chasin&rsquo;s favourite books. I will now go on to describe some of the chapters in the book within each of these sections that I found especially interesting.</p>\r\n<p>aCoustiCaL effeCts of the enVironMent This section contains 5 chapters. The highlight of this section, in my opinion, is Chapter 2 entitled &ldquo;Effects of room acoustics on speech perception through hearing aids by normal-hearing and hearing-impaired listeners&rdquo; by Anna Nabelek. (Dr. Nabelek&rsquo;s recent work has been on the development of the Acceptable Noise Level (ANL) Test that is a very powerful clinical tool to guide the fitting and ultimately the rehabilitation needed when prescribing hearing aids.) Nabelek begins by describing the sounds that we perceive as a mixture of three components: 1. The original or direct sound; 2. The early reflections occurring shortly after the direct sound; and 3. The later more diffuse reflections. The two groups of reflected sounds (2 and 3 above) produce different perceptual effects. The earlier reflections &ldquo;colour&rdquo; the sound; in contrast, the later reflections are responsible for the prolongation of sounds, which is more commonly called reverberation. Nabelek goes on to describe the effects on speech intelligibility. For example, if the direct sound is quite soft then the early reflections will improve intelligibility (with no reverberation). While reviewing a number of studies, Nabelek states that reverberation generally reduces speech intelligibility but this has many factors including room size, distance from the source, type and amount of masking, monaural versus binaural listening, individual factors, and whether or not the listener is wearing hearing aids. In general though, wearing binaural hearing aids in moderately reverberant rooms is not that different than in anechoic conditions. Reverberation is a complex phenomenon which can make perceiving speech quite difficult and it is still a challenge for today&rsquo;s hearing instruments.</p>\r\n<p>the externaL ear,the earMoLd,and the earPhone This, the largest section of the book is comprised of 6 chapters. The highlight of this section describes some very important work completed in Canada, included in Chapter 6: &ldquo;The Acoustics of the External Ear,&rdquo; written by Edgar A.G. Shaw. Edgar Shaw worked at the NRC research laboratories in Ottawa beginning in the early 1950s after emigrating from the United Kingdom. He did a lot of work which generated many patents and publications on topics such as probe microphones and headphones. He even served as president of the Acoustical Society of America in the 1970s, 1 and devised a number of experiments to measure the acoustics of the external ear canal using probe microphones. 2,3 Any probe microphone measurements made today can be traced to Shaw&rsquo;s pioneering work. As clinical audiologists, we take probe microphone measurements for granted. Edgar Shaw&rsquo;s work was incredibly detailed and required the utmost precision and patience to collect the data. In Chapter 6, he summarizes the acoustical transformation of SPL in the free field to the tympanic membrane. He began with presenting the external ear from two points of view, firstly as an efficient sound collector especially above 2 kHz, and secondly as a filter of complex and uncertain characteristics. Shaw stated that it is hardly surprising that the external ear is &ldquo;an acoustical factor affecting hearing aid performance&rdquo; and that we need to be conscious of its effects as we fit hearing instruments. Shaw goes on to describe the elements of the external auditory system starting with the concha, then the external ear canal, and finally the tympanic membrane. This brief chapter summarizes a huge amount of work mostly performed by Shaw himself. The details about the acoustical effects of the different anatomical parts of the external ear are really fascinating, and are something that we as clinicians deal with every day. At the end of this chapter, Shaw says the following with regards to improving the S/N ratio: &hellip;we can imagine a hearing aid in which relevant parameters, such as frequency response and the directionality, are adjusted, perhaps from moment to moment in an adaptive fashion, to maximize the information content of the sound that reaches the seriously impaired inner ear (page 124). 34 years after this was presented at the New York conference, this goal is still being pursued by hearing instrument manufacturers worldwide.</p>\r\n<p>ModeLing teChniques The modeling of the hearing instruments and the associated acoustic transforms are an important aspect of today&rsquo;s hearing instrument technology. Models of the acoustic performance of hearing instruments are essential in order to have software control over the hearing instrument. In this section of the book, there are two chapters on modeling. My favourite of the two is Chapter 13 by David P. Egolf and is entitled &ldquo;Techniques for Modeling the Hearing Aid Receiver and Associated Tubing.&rdquo; If you look at all the parts of a hearing instrument that can affect the sound, each of these parts can be described mathematically. Mathematical descriptions of the microphone, receiver, acoustic coupling methods, etc. can be made and linked together to provide an accurate picture of the hearing instrument behaviour when it is worn on the ear. Egolf is specifically looking at the receiver and the tubing effects, and describes the effects mathematically. Egolf then goes on to describe how a computer model can be compared with probe-tube measurements within a real ear. One example is that of tubing length. Basically, the longer the tubing is, the lower in frequency the first resonance peak. The tubing length is beyond the control of the hearing instrument software but can potentially be measured with probe microphone equipment. Mathematical modelling techniques play an important role in hearing instrument and software design, in order to obtain an accurate picture of all of the variables involved in the path from the free field to the tympanic membrane. Cross calculations within these mathematical models are an essential method to verify that the transformations have been correctly implemented. Clear definitions are needed when acoustical transformations are employed so that clinicians, researchers, and developers can know that they are talking about the same thing. Modelling is an incredibly important part of hearing instrument design. frequenCy resPonse seLeCtionteChniques The final section of this book is concerned with frequency response selection techniques. There are four chapters dedicated to this topic, along with a final discussion chapter on a variety of subjects pertaining to the four sections of this book. I did not find the chapters in this section to be as relevant to today&rsquo;s hearing instruments as the previous chapters due to the fact that hearing instrument selection techniques have changed greatly since the time of the New York conference. Clinically, non-linear fitting rationales designed for complex compression algorithms such as NAL NL24 and DSL m[i/o]5 in addition to the many proprietary fitting rationales, are applied across the hearing instrument industry today. However, I found the last discussion chapter, Chapter 18, to be very interesting. It consisted of very detailed minutes of the discussions that occurred after the presentations of the topics (summarized as the chapters in this book) along with the speaker&rsquo;s name. The summary of each discussion gave me the impression of being a &ldquo;fly on the wall&rdquo; at this historical event. Some of the comments concerning acoustic feedback, for example, are not relevant today with the use of phase cancellation feedback systems. Some other comments mentioned, such as those on flexibility of the acoustical coupling to affect the overall amplification and frequency response of the hearing instrument, could however have been brought up just yesterday. I have read conference proceedings in the past, but none of them have been as interesting as the discussions documented in this book. strengths andweaknesses of this Book This book has many strengths. The material is both interesting and easy to read. The individual chapters are very concise. There are many diagrams and graphs to make the material more easily understood. This book really has no weaknesses, other than the fact that it has been out of print for a number of years. why does this Book stiLL disaPPear froM My BooksheLf? With any book review there is often a statement about who should buy this book. The trouble is that The Acoustical Factors Affecting Hearing Aid Performance is now long out of print, and is probably quite difficult to track down. If, however, you ever find one in your favourite used book store (or online supplier), I recommend that you buy it. It would be well worth owning a copy. Perhaps it too will disappear frequently from your bookshelf like mine. This book is useful for students, researchers, and developers who need to immerse themselves in the acoustics of hearing instrument fittings. It could be useful in understanding some fundamental concepts and it could be of historical interest. I find this book to be a treasure trove of information and it has given me a sense of appreciation for the complexity of the acoustical knowledge needed to amplify signals to alleviate the negative consequences of hearing loss. History teaches us a lot, and this book does indeed accomplish this.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. Stinson M and Daigle G. Edgar Albert George Shaw 1921-2009. Retrieved from: www.rsc.ca/ documents/ShawEdgarElectedin 197519212009.pdf. 2009.</p>\r\n<p>2. Shaw EAG. Earcanal Pressure Generated By a Free Sound Field. Journal of the Acoustical Society of America 1966;39(3):465&ndash;70.</p>\r\n<p>3. Shaw EAG. Transformation of Sound Pressure Level from the Free Field to the Eardrum In The Horizontal Plane. Journal of the Acoustical Society of America 1974;56(6):1848&ndash;61.</p>\r\n<p>4. Keidser G, Dillon H, Flax M, Ching T, Brewer S. The NAL-NL2 prescription procedure. Audiology Research 2011;1:e24.</p>\r\n<p>5. Scollie S, Seewald R, Cornelisse L, et al. The Desired Sensation Level Multistage Input/Output Algorithm Trends in Amplfication 2005;9(4):159&ndash;97.</p>\r\n<p>By Alberto Behar, PEng, CIH behar@sympatico.ca</p>\r\n<p>Well, well, well! I see eyebrows lifted in surprise. What a question to be asked! Everyone who has something to do with hearing conservation will answer is: &ldquo;Yes, of course!&rdquo; Isn&rsquo;t it the first test to be performed to examine the state of the hearing system? Naturally, there are many other tests that aim at different aspects of hearing. There is the audiologic test battery, as well as the otologic test battery, the vestibular battery, and so on. But, the pillar of any examination is the modest audiometric test. So, here, we have the answer to our question, but, also, we may very well define the audiometry as a part of a health check and as such related to any other test in the health maintenance field. what aBout the testers? Do audiometric technicians have to be qualified? Isn&rsquo;t it sufficient with reading the manual provided by the manufacturer, since, in summary a screening audiometer has only two controls: signal&rsquo;s sound level and frequency? (Yes, of course, there is also the &ldquo;left&rdquo; and &ldquo;right&rdquo; ear). Even more, when using a computerized audiometer, just the &ldquo;on&rdquo; button will do the trick. Does it mean that anyone off the street can perform industrial audiometric screening. The answer here is a resounding no! There are other things than moving the dials of the audiometer. To start with, there is the everyday&rsquo;s biological test of the audiometer. Then, there is a need for periodic electroacoustical calibration as well as a quiet room to carry out the test. When the person to be tested comes in, the objectives and procedures have to be explained. Following are the instructions on what to do and how to respond to the signals. Finally, once the test is over, there is the going over the results and explaining their meaning to the subject. Not to forget the discussion on the wearing of hearing protectors if used in the workplace. In some sense, the audiometry is only an excuse to begin the education of the worker &ndash; it is an important excuse, but only the beginning.</p>\r\n<p>do testers need to Be trained? And what about the testers: do they have to be trained? No doubt they should be knowledgeable on noise, the hearing mechanism, noise effects on the exposed individuals (auditory and non auditory), occupational hearing loss and hearing protection and protectors. Finally, they should know about the reasons for, and limitations of air conduction pure tone audiometry. do testers need to Be Certified? Now we are getting to a very sensitive issue: certification: does it has to be done, who should do it, need for recertification, etc. Let&rsquo;s start from the first question: do they have to be certified. Certification, in general, is a way of confirming that the person has the necessary knowledge to perform. We can discuss the extension of the word &ldquo;necessary,&rdquo; but the bottom line is that when somebody applies for the position, he should be able to show that he has the knowledge to perform it properly. That is, the meaning of the certification. Details on the training program, its duration and content can be discussed, as well as the qualification of the training institution. The same applies to the re-certification. What shouldn&rsquo;t admit discussion is the need for certification. what is the situation in ontario? Here we are getting to a sore point. The Province of Ontario contains probably the largest workers&rsquo; population in any Canadian province. Here, there are thousands of industrial establishments where hearing tests are performed (using own or retained testers). However, there are no requirements for audiometric testers, nor there are  training facilities nor there are courses (exception should be made with respect to teaching institutions and Universities, where such a training is a part of graduate and undergraduate courses.) on that subject. Several years ago, the Canadian Hearing Society used to offer a one week &ndash; 20 hour course that was discontinued. The old Ontario Hydro (OH) used to have a training course as well as a re-certification course for its nurses that were performing audiometric tests to the noise exposed OH workers. That was a part of the hearing conservation program that included an audiometric review team comprised by the chief medical officer, the head nurse and a member from the occupational hygiene unit. isn&rsquo;t it tiMe to do soMething? And who should do it? Is this something to be done by the Ministry of Labour, the Ministry of Health or some other institution? At this point, we are trying to raise the question and seek some answers. It&rsquo;s a very interesting issue when you consider that the ministry responsible for the effects of occupational noise exposure (Health) has little to do with the prevention of occupational noise exposure (Labour).</p>\r\n<p>By laura Prigge,AuD, Sherrie Weller, and lynn Weatherby</p>\r\n<p>Laura Prigge, AuD, is Application Specialist at GSI; lcp@grason-stadler.com Sherrie Weller is Application Specialist at GSI; srw@grason-stadler.com Lynn Weatherby is Senior Product Manager at GSI; www.grason-stadler.com</p>\r\n<p><strong>Abstract</strong></p>\r\n<p>CE-Chirp is a new broadband stimulus available for the evaluation of auditory brainstem response. The new CE-Chirp optimizes the stimulus so that the energy from the stimulus reaches all regions of the cochlea at approximately the same time. This change in the stimulus presentation offsets the mechanics of the cochlea&rsquo;s traveling wave and results in an auditory brainstem response waveform that is significantly increased in amplitude. The ABR generated by a CE-Chirp has been demonstrated to be as much as two times more robust than the corresponding click ABR in normal hearing subjects. CE-Chirp Octave Bands are additional stimuli that are available for frequency specific threshold estimation. Using the same principle as the CE-Chirp, the CE-Chirp Octave Bands elicit optimal waveforms for frequency specific evaluations.</p>\r\n<p>For over 30 years, threshold estimation in very young or difficult to test patients has been accomplished with auditory brainstem response (ABR). The ABR is an onset response; a large number of neurons must fire at the same time to elicit the response. To ensure this synchronous firing, a short duration stimulus is used. The two most common short duration stimuli are the click and the tone-pip. The traditional click stimulus is a 100 &micro;s electrical pulse that has a frequency range of approximately 100&ndash; 10,000 Hz. The broad-band nature of the click provides stimulation of a large portion of the cochlea, which causes a large number of neurons to fire simultaneously. The resulting AEP provides information on the neural synchrony of the auditory pathway. The tone pip (also called tone burst) stimulus assists in the evaluation of frequency specific performance of the auditory system. The frequency-specific stimulus is achieved by presenting a sine wave for a brief duration. The tone pip stimulusis based on the number of cycles presented. Typically, the rise and fall times of the stimuli are 2 cycles and the plateau is either 1 or 0 cycles. With this approach, the duration of the stimulus varies with frequency, but the energy content of stimulus is consistent for each frequency. The ABR response to click and tone pip stimuli is highly efficient and results in a clear, repeatable waveform; however, the ABR is limited by the cochlea&rsquo;s travelling wave. It takestime for a stimulusto travel from the high to low frequency regions of the cochlea. Lower stimulus frequenciesresult in longer response time or longer latencies. When the traditional click stimulus is separated into the different frequency components, the response time of the lower frequencies occurs later than the higher frequencies. This limits the contribution of the lower frequenciesto the overall ABR (Figure 1).</p>\r\n<p>soLVingthetraVeLLingwaVe deLay The goal of overcoming the travelling wave delay in ABR is not a new concept. In the late 1990s, the stacked ABR was introduced as a method of enhancing Wave V to assist in identifying small acoustic tumours.1 It was theorized that the contribution of the lower frequency activity in the cochlea due to the traveling wave was inhibiting early identification of tumours, especially when the tumours affected the lower frequency region of the auditory nerve. Through a series of filtering and masking, the neural responsesto click stimuli were isolated and &ldquo;stacked&rdquo; on top of each other to generate a picture of the entire cochlea&rsquo;s contribution to the measurement of ABR. Benefits of the stacked ABR included early identification of small acoustic tumours and larger Wave V. The stacked ABR, however, requires repeated tracings and postacquisition manipulation to the ABR measurement adding significant time to testing. There have been a number of early studies to overcome the travelling delay in the cochlea, but the first comprehensive description was made by Dau et al. 2 More recently, a new approach</p>\r\n<p>to improve ABR recordings has been introduced by Claus Elberling and others. 3&ndash;5 The CE-Chirp is a new broadband stimulus designed to enhance Wave V of the ABR through adjustment of the stimulus frequency composition. This adjustment counteracts the temporal dispersion of the travelling wave inherent in the cochlea by presenting lower frequency energy before higher frequency energy (Figure 2), resulting in an increased Wave V amplitude (Figure 3). The CE-Chirp frequency adjustment maintains the same frequency content of the click (Figure 4). The frequency timing, however, maximizes the response of the cochlea, increasing the synchronous neural firings of the auditory pathway. The increased neural firings to the CE-Chirp stimulus have been demonstrated to result in ABR amplitudes that are 1.5 to 2 times greater than ABR amplitudes to click stimuli in normal hearing subjects (Figure 5). For frequency-specific threshold estimation, the tone-pip or tone burst has traditionally been the most effective stimulus. CE-Chirp Octave Bands are now available for frequency specific threshold estimation. Designed along the same principle as the broadband CEChirp, CE-Chirp Octave Band stimuli (Figure 6) elicit optimal waveforms for frequency specific evaluation. CE-Chirp Octave Bands are derived from the CE-Chirp stimulus; therefore, the latencies of the responses will reflect the timing of the frequencies of the CEChirp. Lower frequency CE-Chirp Octave Band stimuli occur earlier in time than higher frequencies (Figure 7). Therefore, the ABR latencies of the lower frequency CE-Chirp Octave Band stimuli will occur earlier than the higher frequency CE-Chirp Octave Band stimuli. It is important to note that research indicates that for threshold estimation, the absolute latency is not as critical as an identifiable, repeatable response. iMPLeMentation of Ce-ChirP totheaBr eVaLuation CE-Chirp stimuli are ideal stimuli for electrophysiological threshold estimation. Threshold estimation can be difficult to achieve in a single appointment with challenging patients such as infants and young children. The CE-Chirp and the CE-Chirp Octave Band stimuli have been demonstrated to generate a repeatable and reliable Wave V response that is larger in amplitude than the Wave V elicited by traditional click and tone-pip stimuli. The robust responses are often generated with fewer averages which shorten the time of the evaluation. Additionally, the use of CE-Chirp Octave Band stimuli provides robust and fast frequency-specific threshold estimation for a more thorough evaluation. Although clinical studies are not yet available for neurophysiologic diagnostic evaluation, threshold estimation is an immediate and effective use for the CEChirp stimuli.</p>\r\n<p><strong>CaLiBrationand norMatiVe data for Ce-ChirP stiMuLi</strong></p>\r\n<p>The International Organization for Standardization (ISO) has recently defined the measurement and calibration of short duration stimuli relative to the effect that temporal integration has on hearing thresholds through the ISO 389- 6 standard. 6 ISO 389-6 provides the  reference threshold hearing values for traditional click and tone burst signals while IEC 60645-3 defines how to calibrate click stimuli and the tone burst stimuli. Provided that the click and the CE-Chirp are stored in the test equipment with same amplitude spectrum the internal calibration setting of the click also will apply to the CEChirp. The calibration of the CE-Chirp Octave Band stimuli reference values are provided by PTB (PhysikalishTechnische Bundesanstalt, Brauschweig, Germany). As is always recommended for AEP norms, normative data should be collected for the new CE-Chirp stimuli in each clinical environment to ensure appropriate interpretation. When utilizing the CE-Chirp and CE-Chirp Octave Band Stimuli, a protocol similar to the following information outlined in Table 1 is recommended.</p>\r\n<p><strong>Summary</strong></p>\r\n<p>CE-Chirp and CE-Chirp Octave Band stimuli are exciting new additions to the ABR protocol. Available in commercial systems such as the GSI Audera, these new stimuli can help to increase the  clinician&rsquo;s confidence and reduce test time for threshold estimation testing. Continued research and publications on the CE-Chirp are likely to enhance the Auditory Evoked Potential clinical applications in the near future.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. Don M, Kwong B, Tanaka C, Brackmann D, Nelson R. The Stacked ABR: A Sensitive and Specific Screening Tool for Detecting Small Acoustic Tumors. Audiol Neurotol 2005;10:274&ndash;290 (DOI: 10.1159/000086001).</p>\r\n<p>2. Dau T, Wagner O, Mellert V, and Kollmeier B. Auditory Brainstem Responses with Optimized Chirp Signals Compensating Basilar Membrane Dispersion. J Acoust Soc Am 2000;107:1530&ndash;40.</p>\r\n<p>3. Elberling C, and Don M. Auditory Brainstem Responses to a Chirp Stimulus Designed from DerivedBand Latencies In Normal-Hearing Subjects. J Acoust Soc Am 2008;124, 3022&ndash;37.</p>\r\n<p>4. Elberling C, Call&oslash; J, and Don M. Evaluating Auditory Brainstem Responses to Different Chirp Stimuli at Three Levels of Stimulation. J Acoust Soc Am 2010;128:215&ndash;23.</p>\r\n<p>5. Elberling C, and Don M. A Direct Approach for the Design of Chirp Stimuli Used for the Recording of Auditory Brainstem Responses. J. Acoust Soc Am 2010;128:2955&ndash;64.</p>\r\n<p>6. International Standards Organization. 389-6. Acoustics - Reference Zero for the Calibration of Audiometric Equipment - Part 6: Reference Threshold of Hearing for Test Signals of Short Duration. Geneva, Switzerland: Author; 2007</p>\r\n<p>By H. Christopher Schweitzer, PhD and Christopher McCarron,AuD</p>\r\n<p>Christopher Schweitzer (far left) is senior audiologist and corporate chairman at the Family Hearing Centers of Colorado. Christopher McCarron, AuD, is a rehabilitative audiology specialist at the Family Hearing Centers of Colorado.</p>\r\n<p>One of the first activitiesin the typical audiological assessment is to argue with nature. The right ear gets separated and isolated acoustically from the left. The test proceeds, the individual ear audiometric results are recorded, and quite possibly, even the best clinician gives little thought to the underlying surprises that may lurk below the threshold pattern of the then dissected hearing system. In asymmetrical cochlear pathology the surprises may be especially noteworthy. For such asymmetrical clients, with thresholds of one ear significantly worse (e.g., 35 dB or more) than the other, it may not occur to many audiologists to examine the inter-ear differences at common listening levels. However, despite the fact that most common listening experiences are organized around &ldquo;comfortable&rdquo; listening levels for broadband signals (rather than pure tones at threshold levels), there is much that can be learned from simple tests of supra-threshold balancing. Having studied nearly 30 such patients, we provide a few examples and commentary. Simple lateralization tasks were conducted for 29 asymmetrical subjects using a one of two standard clinical audiometers (GSI-16 and Fonix FA-10) calibrated with TDH 39P headphones. The subjects were asked to assist, by verbal report, in adjusting the relative presentation in 5 dB, 2.5 dB, and sometimes 1 dB steps. The characteristic findings represented by two cases for those with known or presumed cochlear impairments are given here. The first example is for a 49-year-old female with a congenital, severe sensorineural impairment of the left ear with audiometric thresholds is shown in Figure 1. Note that the plotting on the audiometrics is on a logarithmic scale, so they appear slightly unconventional to standard audiograms, but all values are dB HL standard notations. No masked thresholds were detected at 2 kHz and above. The right ear is essentially normal. The masked air conduction thresholds for the Left as shown are obviously severe. It is evident that she has a threshold difference for her left/right hearing threshold levels for frequencies 250, 500, 750, 1 k, and 1.5 kHz of about 60 dB. This subject has worn a hearing aid in the bad ear for over 25 years. Hence, it can be assumed that the impaired side was accustomed to sensory stimulation, a point of some relevance. History, reflex testing, and other differential diagnostic findings strongly support a cochlear site of lesion, of undetermined congenital cause.</p>\r\n<p>A unique element shown on this audiogram (and in Figure 5) is a measured portrayal of the inter-ear levels required to achieve a &ldquo;center of the head&rdquo; perceptual experience at comfortably loud sensation levels. To obtain these measures a relatively simple protocol was introduced1 using standard audiometric headphones. The listener was asked to  report the location of the perceived sound using a reference chart shown in Figure 2. Selected signals were manually adjusted to each ear independently by the examiner until the target (center of head) was achieved. With presentation levels to the better ear set to a &ldquo;comfortable&rdquo; setting, interactive adjustments were made to the poor ear level in a bracketing approach until a center-point position of the interrupted (pulsed) tone signals wasreported. Three determinations of the levels, with incremental changes as small as 2.5 dB, were done for each stimulus to provide confidence in the measured levels. The initial signals were pulsed tone frequencies of 250, 500, and 750 Hz for this subject.It was not difficult for the listener to reach the desired &ldquo;center of the head&rdquo; level relatively quickly and without variation on the three repeated determinations for each signal. The recorded tonal measures are shown as red/blue bars for this subject in Figure 1. It can be seen that the differences at the  two ears converged to substantially reduced values of less than 7.5 dB, in some cases less than 5 dB! A steep pattern of &ldquo;loudness catch-up&rdquo; is observed through an assumed combination of possible unmasked cross over and binaural processing. The pattern is somewhat similar to the steep growth of loudness associated with classical sensori-neural hearing loss patterns as compared to normal hearing patterns. This familiar pattern, and the basis for many amplification assumptions, is shown as a reminder in Figure 3. At any rate, it should be immediately observed from Figure 1 that theinter-ear differences greatly constrict at supra-threshold presentation levels &ndash; levels closer to normal listening conditions. Moreover, the pattern, when studied at several presentation levels, for this listener looks like that of Figure 4. An additional method by which speech and music was introduced to collect observations on non-sinusoidal signals was introduce on several of the subjects, including for the subject portrayed in Figure 1. The procedure for these measures follows later in this article. A second audiometric example is shown in Figure 5. This was a male, age 52, with essentially normal hearing on the left ear and severe loss on the right ear subsequent to a vaccine reaction at age 50.</p>\r\n<p>Some initial spontaneous threshold recovery was observed in the impaired ear for this subject in the first several months post-onset. The stabilized thresholds in the severe range are shown in Figure 5 along with inter-ear difference measure results. This subject had tried amplification sporadically with limited success on the impaired right ear. Distortion of external sounds, and of his own voice, dominated his auditory experience, even with very mild gain values. Currently, he reports help with localization and hearing in quiet with amplification levelsfar lessthan standard prescription gain proposals. 9 The balancing tasks were more difficult for this subject due to substantial distortion in the otopathologic ear. He was, however, able to achieve repeatable results shown in Figure 5, including for music. Once again in Figure 5 we have plotted difference levels for selected signal at which balance sensations were achieved. The results were again striking examples of the previously mentioned &ldquo;catching up&rdquo; behaviour for the several frequencies tested. It was clear for this subject, also, that a significantly smaller amount of difference for presentation levels to the two ears was required to achieve a sense of &ldquo;center of the head&rdquo; lateralization experience for tones, speech, and music at comfortable listening levels(CLL) than implied by the threshold audiogram. An experience of binaural auditory perception was clearly achieved, both surprising and curiously amusing the subject. Similar findings were observed for the other participants in these clinical observational studies if cochlear site of lesion was presumed. Clearly the patterns speak to the high value that Nature assignsto the principle of Balance, (with regard to audition, rather than to vestibular function), even when injury and medical mishaps conspire to disrupt it. To re-iterate, differences of 50 and 60 dB at threshold were in some cases condensed to 5 dB or less at comfortable sensation levels. It is noteworthy that, in several instances subjects reported that the auditory &ldquo;image&rdquo; jumped rapidly from right to left, requiring a few moments to engage the adjustments so as to locate the sound within the head. This usually occurred when a long and substantial &ldquo;ear dominance&rdquo; made the introduction of sound to the more severe ear particularly unusual. Another interesting report from several subjects with long-term severe deficits wasthe experience of a &ldquo;phantom&rdquo; image to the bad side perceived briefly when all stimulation was moved back to the better side. Audiograms and notes for two such subjects are shown in Figure 6, and  Figure 7 attempts to illustrate the perceptual &ldquo;cross-over&rdquo; with an unlikely, but admittedly uncertain, amount of acoustic cross-over given the presentation conditions. It appears that the higher neurological features of the auditory pathway, cortical activity and synaptic pattern tracks associated with these perceptual tasks makes the task complex and sometimes ambiguous for the listener. Established neural pathways may require &ldquo;new registrations&rdquo; when stimuli are moved and mixed in the manner described here. Sensitive brain imaging and/or mapping techniques are almost certainly needed for more comprehensive answers. Generally our observations have consistently shown a systematic reduction of the difference to achieve balance as a function of sensation level. In other words, as presentation levels were increased to the better ear, the amount of difference to the injured ear was further reduced as suggested in Figure 5. It is well-established that large individual differences exist in loudness growth patterns among listeners with sensorineural hearing loss. 4,5 Inter-ear differences, as in cases of asymmetrical hearing sensitivities, present numerous additional uncertainties related to balanced auditory perception. As mentioned above, some of the measured findings for these subjects may be related to classical &ldquo;cross over&rdquo; stimulation since classical masking was not introduced for the surpra-threshold measures. However, since the better ear was also receiving simultaneous stimulation of the same signal, it is difficult to sort the interactive aspect. It is also reasonable to speculate that some post-cochlear processes through the brainstem and mid-brain nodal centers may have contributed to the net experience of de-lateralized perception. The report of several listeners of the &ldquo;phantom image&rdquo; in the nonstimulated ear seems consistent with such a conjecture. Conceivably, such post-cochlear pathways may have been the dominant effect, but the clinical research reported here did not have the measurement sensitivity or rigor to inquire deeply into the neurophysiological mechanisms. Although most studies of binaural loudness summation7,8 make use of symmetrical hearing loss subjects, this finding, of an interaction with sensation level, is consistent with studies of binaural loudnesssummation patterns as a function of level. It further emphasizes the uncertain relation between threshold audiometry and the typical goal of amplification &ndash; the delivery of normal speech acoustics to a &ldquo;comfortably clear level&rdquo; (CCL), especially when inter-ear differences are present. non-CLiniCaL sounds For many of the subjects we extended these studies to the related question of whether binaural perception of signals for unilateral or asymmetrical sensorineural impairments can still produce &lsquo;center of the head&rsquo; lateralization, or stereophonic listening experiences &ndash; at preferred listening levels? In other words, do acoustically dichotic signals (not diotic) of stereo music presented via headphones converge to an enjoyable auditory experience if and when the levels at the two ears can be independently adjusted for ears of dissimilar audiometric sensitivity (threshold)? This was addressed by use of a proprietary In Balance control made by Able Planet, Inc. The listener/subject was able to adjust the Left/Right levels of signals delivered from an MP3 player into a set of consumer audio headphones. The In Balance control uses linear tapering to adjust inter-ear differences by up to 24 dB. The music and some recorded speech data shown in Figures 1 and 5 were obtained by having the subjects listen to a musical passage played into a set of Able Planet NC-200 headphones and adjust the In Balance control. The subjects first adjusted the basic volume for a passage of Bonnie Rait&rsquo;s &ldquo;Something to Talk About&rdquo; played at a comfortably clear level (CCL). The 15 subjects in this part of the study indicated the passage (and level) was enjoyable. They adjusted the balance control to reposition the sound until a middle of the head position was achieved. This was usually accomplished in a few seconds after overadjusting briefly to the worse ear, before converging on the best position. The control was then &lsquo;locked&rsquo; into position with the secure toggle switch.</p>\r\n<p>By splitting the signal to a matched set of headphone&rsquo;s the sound pressure level difference between the individual ear outputs were obtained on a standard sound level meter in A-weighted slow mode secured into a coupler. When the subject reported a position at (or near) the target of Number 15 (Figure 2) position on the head chart, the balance control was locked and a pink noise signal was played through the MP3 device. Measured pink noise output differences in dB SPL (sound pressure level) for the two earphones were recorded asinter-ear level differences(see Figure 8). For the first subject described above those differences ranged from 2.5 dB to 7.5 dB, depending on the level at the better ear as shown in the Figure 1 details. Figure 9 addsfurther descriptive detail of the adjustment protocol. suMMary Asymmetrical hearing loss patterns with differences of 35 dB or greater are understood to present diagnostic challenges of masking in order to isolate the more severe ear. They also introduce considerable uncertainty as to inter-ear differences at supra-threshold levels. In cochlear-based asymmetries there is the strong likelihood that differences between ear responses at threshold, especially in the case where one ear is essentially normal, will show considerable &lsquo;catching up&rsquo; at supra-lateralization of bilaterally presented sound stimuli such as in the use of headphones for entertainment. Typical listening levels for such purposes are, of course, considerably more intensive than barely audible (threshold) levels. We have described some clinical research that attempts to join audiometrics with commonplace listening experience. The availability of a reliable balance control may notably improve the stereo listening enjoyment of unilaterally impaired, or asymmetrical listeners without much required offset.</p>\r\n<p>Not surprisingly individual differences for the subjects we have observed in this audiometric category were noteworthy. The issues that confound unilateral and  asymmetrical sensori-neural hearing loss were operating to make each subject unique in his or her auditory history and inter-ear dissimilarities. Nevertheless, the robust and fundamental binaural processing of signals, even from ears of unequal sensitivities and stimulation histories could be readily observed for all three subjects. The clinical tradition for hearing assessment is to first separate the two naturally communicating acoustical sensors (ears), and then to measure them independently. Perhaps it is characteristic of the discovery process that sometimes a great deal can be learned about complex systems, such as hearing, from modest changes in protocol and the serendipitous presentation of a few individuals with non-standard hearing patterns. These findings are instructive at several levels of discourse. These carefully obtained, but admittedly not rigorously researched, observations of a relatively small group of listeners with asymmetrical hearing patterns suggest numerous &lsquo;surprises&rsquo; await the inquisitive and engaged clinician. It is noteworthy that many subjects indicated that being able to re-position the listening experience towards a center of the head position was a desirable feature. In several instances it produced an unprecedented and enjoyable auditory sensation. The corresponding audiologic findings on these listeners&rsquo; binaural balancing experience under controlled conditions are of interest of themselves. The present findings, while obviously varied among the members of the smallsample size, are patterns uniquely pertaining to sensorineural type of impairment, presumably reflecting cochlear damage of varying durations. This assumption was supported by tests on two additional asymmetrical subjects with entirely conductive sites of lesion. Their experience was completely different. In both cases it appeared that balanced performance might possibly only occur if the large threshold differences were essentially maintained and carried up to the supra-threshold listening levels. This was both impractical and outside the interest of the present investigation. While the various differences between the subjects argues against averaging these findings it was tempting to simply compare the Average Threshold difference between \'good\' and \'bad\' ears with the Average Balanced level difference. Those numbers are: 49.2 dB Threshold versus 7.4 dB for supratheshold Balance values across all the various signal types and sensation levels. Clearly, something similar to the speculative pattern of Figure 4 was at work. Clinicians are encouraged to consider the potential for significant differences that may occur &lsquo;between the ears&rsquo; atsupra-threshold listening levelsin these types of patients.</p>\r\n<p><strong>Acknowledgements</strong></p>\r\n<p>Variations of Figures 1&ndash;5, and 8 and 9 appeared in the Schweitzer and Smith article in Hearing Review (16:4). The authors are grateful to the publishers of HR for permission for their use in this publication. Some data collection support was gratefully received from Able Planet, Inc.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. Schweitzer C and Smith D. Meeting in the Middle with Unequal Ears. Hear Rev 2010;16(4):19&ndash;26.</p>\r\n<p>2. Florentine M. SoftnessImperception: Defining a Puzzling Problem. Hearing Health 2004;20(1):31&ndash;34.</p>\r\n<p>3. Florentine M. Page 10: It&rsquo;s Not Recruitment &ndash; Gasp! It&rsquo;s Softness Imperception. Hear J 2003;56(3):10&ndash;15.</p>\r\n<p>4. Marozeau J and Florentine M. Loudness Growth in Individual Listeners With Hearing Losses: A Review. J Acous Soc Am 2007; Express Letters DOI 10.1121:August.</p>\r\n<p>5. Buus S and Florentine M. Growth of Loudness in Listeners with Cochlear Hearing Losses: Recruitment Reconsidered. J Assoc Res Otolaryng 2001;5:120&ndash;39.</p>\r\n<p>6. Buus S, Mus?ch H, and Florentine M. On Loudness at Threshold. J Acoust Soc Am 1998;104:399&ndash;410.</p>\r\n<p>7. Epstein M and Florentine M. Binaural Loudness Summation for Speech and Tones Presented via Earphones and Loudspeakers. Ear and Hearing 2009;30(2):234&ndash;37.</p>\r\n<p>8. Hawkins D, Prosek R, Walden B, and Montgomery A. Binaural Loudness Summation in the Hearing Impaired. J Speech Hear Res 1987;30:37&ndash;43.</p>\r\n<p>9. Schweitzer C and Wakefield E. Gentle Amplification Treatment for Severe Unilateral Cochlear Injury. Paper Presented at ASHA Convention. New Orleans; 2009.</p>',NULL,'2022-11-29'),(37,3251,'','','','<p>By Kim L. Tillery</p>\r\n<p>What a special moment it was to ask some pointed questions to Jack Katz. As always,\r\nhe shared some professional and personal views that are inspiring and insightful.\r\n- Kim Tillery</p>\r\n<p>hoW did You get into the\r\nfieLd of audioLogY?\r\nMiss Carlin was a wonderful English\r\nteacher at Erasmus Hall High School in\r\nBrooklyn. One day she told us that she\r\nhad many years of experience\r\ncounselling students and that we\r\nshould write an essay about ourselves\r\nand from that she would give us some\r\nsuggestions for what we might study for\r\nthe future. I wrote that I was lazy, but\r\nliked people and didn?t like to do the\r\nsame thing over and over again. I am\r\nnot sure what else I wrote, but on my\r\npaper at the top was written, ?Speech\r\nCorrection.? I had no clue what that\r\nmeant so I asked my older brother and\r\nhe didn?t either, but he said that his\r\nfriend?s girlfriend was going into that\r\nfield. So I called her and liked what I\r\nheard but was still not very clear what\r\nit was. When I got to Brooklyn College\r\nand said that I was thinking of majoring\r\nin speech therapy they told me that I\r\ncouldn?t because my speech was not\r\ngood enough. I had to take three classes\r\nto improve my speech so I went to the\r\nSpeech and Hearing Clinic and there I\r\nlearned more and more about the field.\r\nIn those days we trained in both speech\r\nand hearing so in grad school (when\r\npolitics threatened my continuation in\r\nspeech) I simply switched to audiology\r\nin which I was doing quite well.\r\nthe ssW test is 50 Years oLd ?\r\nhoW did it Begin?\r\nI already had an MS in audiology and\r\nspeech but I still had to take practicum\r\nin the PhD program. The audiologist at\r\nMercy Hospital of Pittsburgh told me\r\nthat she was going on vacation and\r\nwould I like to replace her for a month.\r\nI jumped at the chance because Irma\r\nand I just had our first child. One day\r\none of the young ENTs asked me if I\r\nwas aware of the work they were doing\r\nin Germany to identify brain tumours\r\nusing hearing tests. I could not believe\r\nwhat I was hearing because we were\r\ntaught that you cannot assess the\r\nauditory system above the level of the\r\nVIII N because there is too much\r\ndecussation. I said I did not know\r\nabout it and he said that he would bring\r\nin the article. The next day he showed\r\nme a two-paragraph description of the\r\nwork of Joseph Matzker, an ENT\r\ndoctor, who divided a word into a highfrequency band to the one ear and\r\nlow-frequency band to the other ear. If\r\nthe person could combine the bands\r\ncentrally they could get the word, but\r\nthose with temporal lobe tumours\r\ncould not. I was fascinated because\r\naudiology had only gotten to the level\r\nof the VIII N at that time. But the last\r\nline was a downer. It said unfortunately\r\nthe test did not work if the person had\r\na hearing loss. Out of my mouth I heard\r\nmyself say ?Why don?t they use\r\nspondees?? When I realized what I had\r\nsaid, I exclaimed, ?You know that?s a\r\ngood idea. Would you like to work on\r\nthat with me?? He said, ?No, no you go\r\nahead.? That night I had the midnight\r\nand 2 AM feedings for my infant son\r\nwho was recovering from surgery and\r\nhad to be fed every two hours through\r\nthe day and night. As I was feeding him\r\nI started to get excited about the ideas\r\npopping into my head. I could not do\r\nwhat Matzker had done because I had\r\nno equipment so I thought of having\r\none spondee to one ear and another one\r\nto the other ear. Then I thought, ?Wow,\r\nwhat if they were staggered so the\r\nsecond and third monosyllables would\r\nbe competing in time in opposite ears?\r\nThat would give us all sorts of\r\ncomparisons. When my son was fed I\r\nstarted writing feverishly. I thought it\r\nwould look more scientific than\r\nMatzker?s approach if we counterbalanced items starting in the right and\r\nthen the left ear. Then I thought to have\r\nthe first word and the last word to form\r\nthe third spondee. In that way if a\r\nperson missed one competing word</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>',NULL,'2022-11-29'),(38,3249,'ajchr','http://www.andrewjohnpublishing.com/','','<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e001.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e002.png\" alt=\"image\" /></p>\r\n<h4>Let us hear from you!</h4>\r\n<p>Andrew John Publishing Inc. is proud to bring you Canadian Hearing Report (CHR), the only   Canadian magazine of its kind to bring together working practitioners and members of the   industry. In CHR, we have created a forum for the sharing of ideas, knowledge, news, and events.</p>\r\n<p>In the inaugural issue of this format, we bring you an article by Rachelle   Zral, an audiologist and seasoned Yukoner who lives and practises in   Whitehorse. We also meet Johan Hammarstr&ouml;m, a twenty-eight-year-old,   hearing-impaired pilot from Sweden who is preparing to fly around the   world in a single-engine plane. He hopes to raise awareness of hearing   impairment and the modern technology available to help those affected   reduce the impact of their disability.</p>\r\n<p>On the technology front, Ross Harwell,   audiology manager at Oticon Canada,   introduces us to datalogging, an innovative   new tool to improve hearing aid fittings.   And Dr. Ian Bruce from McMaster   University in Hamilton, Ontario, takes us   behind the scenes of the research he and   his team are doing in hearing loss and   optimal amplification.</p>\r\n<p>In addition, we keep you up to date with   news from the industry and upcoming   events, such as the 4th Widex Congress of   Paediatric Audiology being held in Ottawa   this May.</p>\r\n<p>But Canadian Hearing Report cannot exist   without your input. This magazine is for   you&mdash;the practitioners and the industry   that supports them. We need you to let us   know about interesting stories, research,   news, and products.</p>\r\n<p>To audiologists and hearing instrument   practitioners: Do you have an inspiring   story you would like to share with your   colleagues? Do you know someone who is   exceptional in the profession? Are you   someone who works in an interesting setting,   or on a dedicated team that garners   impressive results?</p>\r\n<p>To members of the industry: Has a member   of your team really made a difference?   Is your company participating in or sponsoring   events to improve quality of life for   the hearing-impaired community? What   new products would you like to share   with the readers?</p>\r\n<p>We are also interested in sharing insight   into such general issues as third-party   financing, running a family business, community   awareness, improvements/challenges   in screening, remote practice/treatment,   noise in workplace/everyday life,   and changes in funding and how they   affect both clients and practitioners.</p>\r\n<p>Please contact us with your news, stories,   and insights, and help us to make   Canadian Hearing Report an interesting   and informative tool for our readers. You   can contact me directly with your ideas and   comments at suemharrison@aol.com.</p>\r\n<p><strong>Sound Off</strong></p>\r\n<p><strong>Like what you read? Feel inspired to share an idea?</strong></p>\r\n<p>We welcome your input. Please send your letters and comments, via e-mail, to suemharrison@aol.com, subject: Letter to the Editor.</p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e003.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e004.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e005.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e006.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e007.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e008.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e009.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e010.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e011.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e012.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e013.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e014.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e015.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e016.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e017.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e018.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e019.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e020.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e021.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e022.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e023.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e024.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e025.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e026.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-1-2-1-e027.png\" alt=\"image\" /></p>',NULL,'2022-11-29'),(39,3248,'ajchr','http://www.andrewjohnpublishing.com/','','<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e001.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e002.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e003.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e004.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e005.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e006.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e007.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e008.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e009.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e010.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e011.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e012.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e013.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e014.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e015.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e016.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e017.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e018.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e019.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e020.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e021.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e022.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e023.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e024.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e025.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e026.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e027.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e028.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e029.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e030.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e031.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-1-e032.png\" alt=\"image\" /></p>',NULL,'2022-11-29'),(40,3247,'ajchr','http://www.andrewjohnpublishing.com/','','<p>Very few of us learn anything about the financial aspects of running a business while we are in school. Perhaps the educational institutions don&rsquo;t feel that it is their job &ndash; after all, there is so much technical and clinical information to learn, along with the requirements of the various regulatory bodies that needs to be conveyed to the student. With this in mind, if I were designing an audiology educational program at a university, I would probably not have anything about finances either. Yet, many a clinic has had difficulty establishing itself simply because of cost overruns and lack of awareness of the elements of a balance sheet. This issue of the Canadian Hearing Report focuses on this issue as well as some of the financial trends in this industry.</p>\r\n<p>The industry is changing, but is this a new thing? I believe that industry watchers of the 1970s would have said the same things about industry trends. Amazingly though, there are very few differences in our industry between the 1970s and today. In the 1970s, large retail networks were owned by hearing aid manufacturers; the same can be said of today. In the 1970s, hearing aids were often sold door to door, bypassing the hearing health care professional; the same can be said today with Internet sales. While most jurisdictions have laws limiting hearing aid sales through the Internet, it is really only a matter of marketing. Personal Sound Amplification Products (PSAP) is the phrase used for devices that are offered as a &ldquo;one size fits all&rdquo; approach for personal hearing. Nowhere does it mention anything about hearing loss. PSAPs can help you hear people in the next room or help you hear the crackling of leaves while hunting in a forest. The latest incarnation of this is from United Health Care, but I suspect that this will be the first of many. The same product, if sold by a hearing aid manufacturer would be subject to the limitations of Internet sales, yet it is the &ldquo;same product.&rdquo; However, door to door salesmen of the 1970s went the way of the dinosaur because gradually professional services and assessment became more widely available. It was the lack of professionals in the 1970s and earlier that fostered this behaviour. Will the Internet sales approach blow over? Probably not, but then again, we can do what we did in the 1980s and onwards &ndash; enhance professional services with proper  assessment, counselling, and follow-up.</p>\r\n<p>And this brings me to &ldquo;bundling.&rdquo; Bundling of our services and the products being dispensed has some advantages: &ldquo;one bottom-line dollar value for everything&rdquo; included (devices, fitting, any follow-up, batteries, &hellip;). The downside is that there is &ldquo;one bottom-line dollar value for everything.&rdquo; What if someone purchases a hearing aid&hellip; sorry,&hellip; I meant a PSAP from the Internet and wants to pay extra to have it set up by an audiologist. Some will say no, but others may be more amenable to providing the services. Unbundling the package means that an exact price can be established to program, adjust, and do follow-up for these people. Just something to think about. Actually, quite a bit to think about! Turning our attention back to finances, when I was still quite young, for a bed time story, my father would always tell me four things &ndash; the law of 72; don&rsquo;t go short if you can&rsquo;t afford to lose your money; remember the benefits of compound interest; and borrow to invest. These were great bedtime stories and I use each of these four rules in everyday life. They are common sense and give structure to the seemingly amorphous field of finances. The theme of this issue is the intersection between finances and audiology. This issue has several articles &ndash; two of which have been previously reprinted in the Canadian Hearing Report. When the authors (Traynor and Glaser) graciously agreed to have them reprinted they wondered if they needed updating, but after examination they found that the articles had material that was timeless. Ian Po and Prashant Patel are from the financial sector and have written a beautifully clear and concise overview of estate planning issues and how best to protect your investment for your later years and how to make sure that your children all drive Porches (hybrid ones of course)&hellip; I&rsquo;m sure that the articles in this issue will stimulate some interesting discussion. We do have a Letters to the Editor section, and as always, we welcome your comments.</p>\r\n<p>Rares parmi nous sont ceux qui avons appris les aspects financiers d&rsquo;administrer une affaire au cours de nos &eacute;tudes. Peut-&ecirc;tre les institutions d&rsquo;&eacute;ducation estiment que ce n&rsquo;&eacute;tait pas leur responsabilit&eacute;, la priorit&eacute; est donn&eacute;e aux informations techniques et cliniques &agrave; apprendre, aux exigences des divers corps de r&egrave;glementation qui doivent toutes &ecirc;tre achemin&eacute;es &agrave; l&rsquo;&eacute;tudiant. Maintenant, si je suis en train de concevoir un programme de formation en audiologie &agrave; l&rsquo;universit&eacute;, je n&rsquo;aurai probablement rien sur les finances non plus. Mais plusieurs cliniques ont eu de la difficult&eacute; &agrave; s&rsquo;&eacute;tablir simplement pour des raisons de d&eacute;passements de couts et par manque de connaissance des &eacute;l&eacute;ments d&rsquo;un bilan. Ce num&eacute;ro de la revue canadienne d&rsquo;audition est centr&eacute; sur cet enjeu et aussi autour de quelques tendances financi&egrave;res dans cette industrie. Cette industrie est en changement, mais est-ce nouveau? Je crois que les observateurs de l&rsquo;industrie des ann&eacute;es 70 auraient dit la m&ecirc;me chose sur les tendances de l&rsquo;industrie. Tout aussi extraordinaire, notre industrie aujourd&rsquo;hui est peu diff&eacute;rente de celle des ann&eacute;es 70. Dans les ann&eacute;es 70, les grands r&eacute;seaux de d&eacute;taillants &eacute;taient la propri&eacute;t&eacute; des fabricants des appareils auditifs; on peut dire la m&ecirc;me chose pour aujourd`hui. Durant les ann&eacute;es 70, les appareils auditifs &eacute;taient souvent vendus porte &agrave; porte, contournant les professionnels des soins de sant&eacute; auditifs; pareil aujourd`hui avec les ventes sur internet. Tandis que la plupart des juridictions ont des lois limitant la vente des appareils auditifs sur internet, c&rsquo;est vraiment seulement une question de marketing. Les produits personnels d&rsquo;amplification des sons est la phrase utilis&eacute;e pour les outils qui sont offerts sous forme uniformis&eacute;e pour les appareils auditifs. Nulle part n&rsquo;est-il mention de la perte auditive. Les produits personnels d&rsquo;amplification des sons peuvent vous aider &agrave; entendre les conversations dans la salle d&rsquo;&agrave;-c&ocirc;t&eacute; ou &agrave; entendre les craquements des branches pendant que vous chassez en for&ecirc;t. La derni&egrave;re incarnation de ceci nous vient des United Health Care, mais je soup&ccedil;onne que ce sera le d&eacute;but de plusieurs. Le m&ecirc;me produit, si vendu par un fabricant des appareils auditifs serait sujet aux limitations des ventes sur internet, et c&rsquo;est le &ldquo; m&ecirc;me produit.&rdquo;</p>\r\n<p>Toutefois, le vendeur porte &agrave; porte des ann&eacute;es 70 a effectu&eacute; la marche des dinosaures car graduellement, les services et &eacute;valuations professionnels sont devenus largement disponibles. C`est le manque de professionnels dans les ann&eacute;es 70 et avant qui a nourrit ce comportement. Est-ce que l&rsquo;approche vente sur internet va exploser? Probablement non, mais alors encore, on peut faire ce que nous avons fait dans les ann&eacute;es 80 et plus tard, rehausser les services professionnels avec une &eacute;valuation ad&eacute;quate, du counseling et le suivi. Ce qui m&rsquo;am&egrave;ne au &ldquo; groupage&rdquo;. Le groupage de nos services et des produits offerts a certains avantages: &ldquo;un b&eacute;n&eacute;fice net en dollars pour tout&rdquo; y compris (appareils, ajustements, tout suivi, batteries,&hellip;). Le risque est &ldquo; tout a un b&eacute;n&eacute;fice net en dollars.&rdquo; Et si quelqu&rsquo;un ach&egrave;te un appareil auditif &hellip;d&eacute;sol&eacute;,&hellip;je voulais dire un produit personnel d&rsquo;amplification des sons sur internet et veuille payer un extra pour que &ccedil;a soit mont&eacute; par un audiologiste. Certains diront non, mais autres peuvent &ecirc;tre plus aptes &agrave; fournir les services. D&eacute;grouper le paquet veut dire qu`un prix exact peut &ecirc;tre &eacute;tabli pour programmer, ajuster et faire des suivis pour ces gens. Mati&egrave;re &agrave; r&eacute;flexion. En fait, beaucoup de r&eacute;flexion! Revenons aux finances, quand j&rsquo;&eacute;tais plus jeune, pour histoire de chevet, mon p&egrave;re me disait toujours 4 choses, La r&egrave;gle de 72; ne vend pas &agrave; d&eacute;couvert si tu ne peux pas te permettre de perdre ton argent; rappelle-toi les avantages des int&eacute;r&ecirc;ts compos&eacute;s; et emprunte pour investir. Ce sont de superbes histoires de chevet et j&rsquo;utilise chacune de ces quatres r&egrave;gles au quotidien. Elles sont le bon sens et donne une structure au domaine apparemment amorphe des finances. Le th&egrave;me de ce num&eacute;ro est l&rsquo;intersection entre les finances et l&rsquo;audiologie. Ce num&eacute;ro a plusieurs articles, dont deux qui ont &eacute;t&eacute; d&eacute;j&agrave; r&eacute;imprim&eacute;s dans la revue canadienne d&rsquo;audition. Quand les auteurs (Traynor and Glaser) ont bien voulu nous permettre la r&eacute;impression des articles, ils ont pens&eacute; qu&rsquo;ils avaient peut-&ecirc;tre besoin d&rsquo;une mise &agrave; jour, mais apr&egrave;s examen, ils ont d&eacute;cid&eacute; que les articles ont du mat&eacute;riel qui est &agrave; l&rsquo;&eacute;preuve du temps. Ian Po et Prashant Patel du secteur des services financiers ont r&eacute;dig&eacute; une vue d&rsquo;ensemble, bien claire et concise sur les enjeux de la planification successorale et les fa&ccedil;ons de mieux prot&eacute;ger votre investissement pour les ann&eacute;es &agrave; venir et de s&rsquo;assurer que tous vos enfants conduisent des porches (des hybrides bien s&ucirc;r)&hellip; Je suis s&ucirc;r que les articles de ce num&eacute;ro vont stimuler certaines discussions int&eacute;ressantes. Nous avons la section Lettres &agrave; l&rsquo;&eacute;diteur, et comme toujours, vos commentaires sont les bienvenus.</p>\r\n<p>By Fred Cohen</p>\r\n<p>Chai Feldblum was one of the original lawyers involved in drafting and negotiating the ADA. In a recent article she and two colleagues express their grave disappointment with the judicial limits imposed on the ADA.1 Professor Feldblum provides some compelling examples of real-life impacts flowing from the Supreme Court&rsquo;s ruling on mitigating measures. The analogical relevance to http://hearinghealthmatters.org/lawand hearing/2011/hearing-aids-police-ada/ our NYC police should be apparent.</p>\r\n<p>&bull; Stephen Orr, a pharmacist in Nebraska, was fired from his job at Wal-Mart because he needed to take a half-hour uninterrupted lunch break to manage his diabetes. When Mr. Orr challenged his firing under the ADA, Wal-Mart argued that since Mr. Orr did so well managing his diabetes with insulin and diet, he was not &ldquo;disabled&rdquo; under the ADA. The courts agreed. Although WalMart considered Mr. Orr &ldquo;too disabled&rdquo; to work for Wal-Mart, he was not disabled &ldquo;enough&rdquo; to challenge his firing under the ADA.</p>\r\n<p>&bull; James Todd, a shelf-stocking clerk at a sporting goods store in Texas, was fired from his job a few months after experiencing a seizure at work. Mr. Todd challenged his firing under the ADA, but the district court (i.e., trial court) never reached the question of whether Mr. Todd had been fired because of his epilepsy. Instead, the court concluded that since Mr. Todd&rsquo;s epilepsy was otherwise wellmanaged with anti-seizure medication, he was not disabled &ldquo;enough&rdquo; to challenge his firing under the ADA.</p>\r\n<p>&bull; Allen Epstein, the CEO of an insurance brokerage firm, was demoted from his job after being hospitalized because of heart disease. He was later fired shortly after telling his employer he had diabetes. Mr. Epstein brought a claim under the ADA, alleging that his employer had discriminated against him because of disability. The court held that because his heart disease and diabetes were well-managed with medication, he was not disabled &ldquo;enough&rdquo; to challenge his firing under the ADA.</p>\r\n<p>&bull; Michael Schriner, a salesperson who developed major depression and PTSD after discovering that his minor children had been abused, was fired from his job for failing to attend a training session. Believing he was fired because of his depression and PTSD, Mr. Schriner brought a claim under the ADA. The court never addressed whether his disability was the reason he was fired. Instead, that court concluded that because Mr. Schriner did so well managing his condition with medication, he was not disabled &ldquo;enough&rdquo; to be protected by the ADA.</p>\r\n<p>&bull; Michael McMullin, a career law enforcement officer from Wyoming, was fired from his job as a court security officer because an examining physician determined that his clinical depression and use of medication disqualified him from his job. When Mr. McMullin challenged his firing under the ADA, his employer argued that Mr. McMullin was not &ldquo;disabled&rdquo; under the ADA because he had successfully managed his condition with medication for over 15 years.</p>\r\n<p>The court agreed. Even though Mr. McMullin&rsquo;s employer had fired him because of his use of medication, the court ruled that he was not disabled &ldquo;enough&rdquo; to challenge the discrimination under the ADA. According to the court, &ldquo;[t]his is one of the rare, but not unheard of, cases in which many of the plaintiff&rsquo;s claims are favoured by equity, but foreclosed by the law.&rdquo;</p>\r\n<p>&bull; Ruth Eckhaus, a railroad employee who uses a hearing aid, was fired by her employer who told her that he &ldquo;could not hire someone with a hearing aid because [the employer] had no way of knowing if she would remember to bring her hearing aid to work.&rdquo; Ms. Eckhaus brought a claim under the ADA, alleging that she was discriminated against based on her hearing impairment. The court concluded that since her hearing aid helped correct her hearing impairment, Ms. Eckhaus was not disabled &ldquo;enough&rdquo; to challenge discrimination based on that impairment.2 Should Congress accept this as the governing law today? Since these are not constitutionally-based rulings, Congress is free to change the language of ADA to reflect its intent and, in effect, reverse both the Supreme Court and the lower federal court&rsquo;s interpretation of ADA.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. Feldblum CR, Barry K, and Benfer E. The ADA Amendments Act of 2008, 13 Texas J. on Civil Liberties and Civil Rights 218-23. 2008.</p>\r\n<p>2. Eckhaus v. Consolidated Rail Corp. 2003 WL 23205042 (D.N.J. Dec. 24, 2003). The rationale in Ms. Eckhaus&rsquo; case is even more far-fetched than that advanced by the NYCPD.</p>\r\n<p>By James M. Kates, GN ReSound A/S and University of Colorado, Depar tment of Speech Language and Hearing Sciences, Boulder, CO, USA</p>\r\n<p>Ed Villchur died on 17 October 2011. The obituary in the New York Times spent many paragraphs on his achievements in loud-speaker design and the success of the audio company he founded, Acoustic Research (AR). Also mentioned, but given much less attention, was his work in developing multi-channel dynamic-range compression for hearing aids. I didn&rsquo;t know Ed (Eddie to his close friends) very well, but he had an important influence on my life just the same. One of my first jobs was at AR. By the time I joined AR in the mid 70s, Ed had sold the company to Teledyne and had retired to upstate New York. AR was still a force in audio equipment, however, with a product line that included loudspeakers, the AR turntable, and a stereo receiver. My first assignment at AR was to redesign the turntable. The turntable used an ingenious inverted pendulum design, invented by Ed. The tonearm and platter were mounted to a T-shaped bar which was suspended from the deck by three springs. The relative positions of the tonearm and platter were fixed by the T-bar, and the whole assembly was isolated from external vibrations by the springs. The old advertisements for the turntable showed someone hitting its deck with a hammer, and the system was very well isolated from such vertical shocks. But imagine placing the turntable in a stereo equipment cabinet along one wall of the room. If you walk in the middle of the room your footfalls will cause the middle of the floor to sag, and the turntable will experience both vertical and horizontal displacements. So my challenge was to engineer resistance to horizontal displacements that matched the resistance to vertical displacements that Ed had designed. But the digital revolution had already begun, and the redesigned turntable was never put into production.</p>\r\n<p>The early success of AR was based on the acoustic suspension loudspeaker. Ed Villchur is credited with inventing the concept of acoustic suspension,1 although the idea is clearly described in an earlier patent issued to another important acoustics innovator, Harry F. Olson.2 Ed&rsquo;s patent, however, provides a clear explanation of the physics involved and provides all of the relevant equations. In an acoustic suspension design, the loudspeaker is mounted in a small sealed box. The loudspeaker cone is displaced by an electrical current applied to the voice coil, and the restoring force is provided by the change in pressure of the air trapped in the box. Before acoustic suspension, many loudspeakers were mounted in open cabinets; good low-frequency response required a large box and the mechanical spring used for the restoring force on the loudspeaker displacement could introduce a large amount of nonlinear distortion. The basic approach to loudspeaker design when I was at AR was very  similar to that developed by Ed. The drivers (woofer, dome midrange, and soft dome tweeter) were all based on Ed&rsquo;s original designs, improved over time. The loudspeakers in production were all based on the acoustic suspension principle. Design involved measurements of the loudspeaker response in an anechoic chamber and in a listening room, with the objective of providing a flat on-axis frequency response. I worked on the crossover for the AR-9 (the original loudspeaker &ndash; the model designation was later reused for a different loudspeaker). I also developed a computer system for the digital measurement of loudspeaker response &ndash; work that I felt was very much in the spirit of Ed&rsquo;s curiosity and innovation. I left the audio industry to work more directly in digital signal processing, and I then developed an interest in hearing aids. Of course, Ed Villchur got there ahead of me. His 1973 paper has influenced the course of the entire hearing-aid industry.3 That paper is the first that I am aware of to describe multi-channel dynamic-range compression. The technology used in his compression system was, of course, analog, based on modified audio compressors. He implemented syllabic compression, with an attack time less than 1 ms and a release time less than 20 ms. The results in the paper show substantial improvements in speech intelligibility for the compressed signal, although the unprocessed control condition was an amplified flat or highpass filtered frequency response rather than one shaped to match the listener&rsquo;s hearing loss.</p>\r\n<p>Ed also had the clever idea of turning the compression system around to provide a simulation of hearing loss4,5 for normal-hearing listeners. Instead of compressing the signal to compensate for recruitment in the impaired ear, he expanded the signal to introduce the equivalent of recruitment for a normal ear. He also looked at simulating the loss of frequency resolution in the impaired ear by using a noise vocoder, in which bands of noise are modulated by the speech envelope within each frequency band. The loss of frequency resolution was simulated by increasing the width of the noise bands so that the modulated signal bands overlapped by greater amounts than normal.5 Over the years, I ran into Ed at technical conferences. We would generally end up discussing dynamicrange compression. I tried several times to introduce recent research results that challenged the effectiveness of syllabic compression, but Ed was adamant that his syllabic compression system was the best. Ed Villchur brought intelligence, creativity, and energy to everything he did. He changed the course of two industries, audio and hearing aids, and had a direct influence on my career and that of everyone involved in engineering better sound systems.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. Villchur EM. Sound translating devices. U.S. Patent 2,775,309. Issued December 25, 1956.</p>\r\n<p>2. Olson HF. Loudspeaker diaphragm support comprising plural compliant members. U.S. Patent 2,490,466. Issued December 6, 1949.</p>\r\n<p>3. Villchur EM. Signal processing to improve speech perception in perceptive deafness. Journal of the Acoustical Society of America 1973;53:1646&ndash;57.</p>\r\n<p>4. Villchur E. Simulation of the effect of recruitment on loudness relationships in speech. Journal of the Acoustical Society of America 1974;56: 1601&ndash;11.</p>\r\n<p>5. Villchur E. Signal processing models to simulate the effect of sensory distortions on speech perception by the deaf. Journal of the Acoustical Society of America 1977; 62:665&ndash;74.</p>\r\n<p>By Brenda Battat</p>\r\n<p>The UnitedHealthcare hi HealthInnovations announcement of its direct hearing services to consumers has caused quite a stir. The audiology professional organizations and the hearing aid specialist organizations and some hearing aid companies have already staked out positions against it reiterating that the only approach to effective hearing health care is through an audiologist or hearing aid specialist. Certainly best practices set forth by the entire key hearing aid dispensing industry promote selection, fitting verification and validation via real ear measurement as the gold standard of care. HLAA likewise has always encouraged consumers to work closely with a hearing health care professional they trust as the best way to become a successful hearing aid user. But let?s take a step back and ask ourselves if this traditional approach is reaching most people who could benefit from hearing aids? We all know the answer is no. With 75 percent of people who could benefit from hearing aids not taking steps to treat their hearing loss we are failing a large percentage of people who could improve their quality of life, remain independent into old age and stay on the job without retiring early. Theapproach is new and untried. A lot hinges on the accuracy of the test they plan to use to triage the best candidates for open-fit amplification, how easily people adjust to using the devices and whether or not first-time users can be successful hearing aid users without face-to-face care. Is it going to work? Only time will tell. But let?s give it a chance and not sabotage it from the outset so that consumers can be the ultimate judges. What consumers need are more options ? more ways to enter the system to treat their hearing loss that suits their style of managing their health and will get them to do something about their hearing loss sooner. United?s entry point is the selfadministered hearing screening that triages those who can and cannot be fitted without face-to-face care. They further expand options by making the purchase feasible.</p>\r\n<p>There are already self administered tests that we know consumers are using in the privacy of their homes to confirm what they suspect ? that they have a hearing loss. But the next step to follow up with a more thorough hearing evaluation is often skipped or, if pursued, is stymied when they learn what a pair of hearing aids is going to cost them. Best intentions are shot down. The number one inquiry into the HLAA office is how to afford hearing aids. UnitedHealthcare is making it feasible for consumers to go all the way and actually get aids for free or at reasonable co-pays or cost. HLAA?s concern is consumer protection. If the market is to be opened up then it should be done in a responsible way. From what we know about UnitedHealthcare?s plan there are positive aspects: providing primary care physicians with hearing screening tools; their robust hearing health care network of ENTs, audiologists and hearing aid dispensers; the large pool of 10 million UnitedHealthcare subscribers that translate to many people with hearing loss that can be helped; their intent to collaborate with the hearing health care providers outside of their system to refer those who need face-to-face care; and the captioned support videos and materials to guide new hearing aid users during the 45-day trial period on their website. The program has been designed as a responsible alternative that in no way replaces the existing system but has the potential to reach those who wouldn?t otherwise do anything or could not afford to do anything to treat their hearing loss. I think we should give it a chance and applaud UnitedHealthcare for identifying a pressing health need among America?s seniors and being bold enough to tackle it. Brenda Battat is executive director of the Hearing Loss Association of America</p>\r\n<p><strong>By Alan Moore,</strong> Earmold and Accessories Operations Manager, Bernafon Canada Ltd</p>\r\n<p>October 4th, 2011 was a sad day for many in the hearing aid industry. Kenneth H. Dahlberg passed away at the age of 94.</p>\r\n<p>He was born in St Paul Minnesota and grew up on a farm in Wisconsin. After completing high school, he worked in the hotel business. He started out as a dish washer and worked his way up to food and beverage manger. After being drafted into the army, with the intention of being a cook, he joined the USAAF as a cadet. One of his instructors was Barry Goldwater who eventually became a senator. He had quite an illustrious military career which included being shot down three times and spending three months in a prisoner of war camp, and being awarded the Distinguished Service Cross. When he returned from the war, he took a job at a hearing aid company called Telex. In 1948, he started Dahlberg Electronics manufacturing, among other things, a line of hearing aids called Miracle Ear. In the early 50s, Dahlberg was credited with the first use of the newly developed transistors in a consumer product. The company also developed and patented paging patient monitoring devices and pillow speakers for private listening for hospitalized patients. In 1978, he started a Canadian division called Dahlberg Sciences, and hired an eager sales man to run the new Canadian division. The offer of employment was written on the back of the menu from the restaurant where we had dinner. Dahlberg Sciences became the first company to manufacture custom hearing aids in Canada. He was definitely a colourful boss to work for. Any time someone would ask him how many people worked for him, his favourite retort was &ldquo;about half of them.&rdquo; He also had a warm side which wasn&rsquo;t always evident, when the Canadian sales manger showed up at a conference and was pregnant at the time with her first child, he took her aside and told her &ldquo;make sure that your family comes before the job. &ldquo;He was a true salesman at heart. &ldquo;A sale is not a good sale until the invoice is paid and an order is not an order until the ink is dry.&rdquo;</p>\r\n<p>Probably the event that brought the most attention to Ken was Watergate. It was his political contribution that ended up in the hands of the burglars that lead to the full investigation that eventually exposed the entire scandal. Ken was never charged with any wrongdoing, as he was unaware of any illegal activities surrounding the contribution. He once told me in Phoenix how practical he was to buy a station wagon as it could haul things around. When it was time to go to dinner he asked me to join him in his new station wagon. We got to the parking lot to find his brand new very deluxe Mercedes diesel station wagon, which he was a little upset with and too impatient to wait for the Glow plugs to warm up making it hard to start. He once ordered a new Porsche twoseater convertible during a visit at the Porsche factory and had it shipped to Minneapolis because it was the new corporate colour. Unfortunately it was a standard shift, and I don&rsquo;t believe it ever got past second gear. Ken was an early member in an organization called YPO which stood for Young Presidents organization. This was a networking group to discuss issues and solutions to the everyday problems encountered in business and how fellow members dealt with these as well as a social club. The hard and fast rule of YPO was that at the age of 50, members &ldquo;graduated.&rdquo; Several of the graduates, decided that they would like to continue with the same concept so the CEO club was formed. When asked what the new club did in comparison to YPO, Ken&rsquo;s answer was &ldquo;we do exactly the same things; it just takes us much longer to do them&rdquo;. In 2010, Ken was living with his wife Betty, in Carefree Arizona and still had his own plane. He had a pilot to do all takeoffs and landings, but still enjoyed taking over in the sky from the right hand seat.</p>\r\n<p>At the outset of the Watergate scandal, Richard Nixon asked &ldquo;who the hell is Ken Dahlberg?&rdquo; Had he asked anyone in the hearing aid industry they would have been told he was a pioneer, a super salesman, and certainly a colourful character.</p>\r\n<p><strong>By Calvin Staples, MSc</strong></p>\r\n<p>As I sit here at 6:30am in the dark with no sign of sunlight I start to wonder about the future of hearing health care. The darkness makes it impossible to see too far into the distance. I imagine this is similar to those who are trying to predict the future of our industry. We continue to hear that our industry is essentially immune to the growing global recession concerns and that the growing number of baby boomers will rely on our services for the next 20&ndash;30 years; but none of this is certain. The recent changes in policy, major financial players, and the potential new drugs to alter the impact or management of hearing loss will keep us all guessing about the future. The following blogs from hearinghealthmatters.org will highlight the changing financial landscape of hearing healthcare.</p>\r\n<p><strong>Life in the fast Lane: unraveLing hearusa, part 1</strong></p>\r\n<p>&ldquo;The Company&rsquo;s strategy includes immediate public differentiation from all existing hearing centers.&rdquo;1</p>\r\n<p>Thus began one man&rsquo;s corporate vision to revolutionize hearing care in the US and Canada, and also make a bunch of money. Based on current headlines, it seems the vision has been achieved. The corporation &ndash; currently known as HearUSA for a few more months at least &ndash; has very publicly differentiated itself from anything else ever seen in the field of hearing health care. If one ascribes to the adage that there is no such thing as bad publicity, then HearUSA has hit it out of the park. Adding to the lustre, the corporation in its various guises has managed to make tons of money every year of its existence while never showing a positive profit.2 And so begins this post, the first in a series that may drag on for some time as we muddle through the beginnings, middle, and possible end of the HearUSA vision. Had the corporation failed to distinguish itself so thoroughly, there would be minimal interest in its decline, restructuring, or likely demise. Instead, the story of HearUSA is a fascinating cautionary tale of money, intrigue, backroom dealing, international finance, cronyism, bad marriages, divorces, sugar daddies, contested settlements, and yeah, there&rsquo;s probably sex too (but we&rsquo;re not covering that angle unless we get a really interesting comment that&rsquo;s printable). Traditionally, the business of hearing healthcare has conducted itself in a fairly courtly and discrete manner. It&rsquo;s been a gentleman&rsquo;s game for players who hold their cards close. Not so these past months with HearUSA and Siemens. You can almost see HearUSA swaggering into the saloon, throwing money around, raising a ruckus, and ending up in a main street shootout with its main supplier and banker. As one blogger commented: The hardball tactics are unusual in the hearing-aid industry where conflicts are more often resolved out of the public eye.3 In a nutshell, HearUSA couldn&rsquo;t meet its debt payment to Siemens last December. Siemens called the loan, which prompted a slew of legal petitions and counter-petitions between the companies throughout the spring. HearUSA found a temporary safe haven in bankruptcy, negotiated a big loan from a rival suitor (William Demant Holding), and sent out scary notices to its employees and network affiliates. At the moment, HearUSA is spending the summer grooming itself to be auctioned off to the highest bidder, an effort that includes talking about its rosy future with AARP in &ldquo;45 states and counting.&rdquo;4 As previous writings in this section indicate, I am not a fan of poorly managed companies that fail in their fiduciary duty to their stockholders, or in their societal duty to other stakeholders, such as employees and customers.5 Having got that off my chest, I will make an effort to report in an unbiased manner on all that I&rsquo;ve been able to unearth on the times and travails of Hear USA. Most of it is in the public record, some is from inside sources that prefer anonymity. This post wraps up the first in a series by introducing the future bride and groom in the doomed marriage that produced HearUSA:</p>\r\n<p>1. HEARx was founded by Paul Brown, MD in 1986 in Florida. Dr Brown&rsquo;s vision was to improve the hearing profession by achieving   &ldquo;professional&rdquo; branding via hospital accreditation, with the financial goal of capturing large insurers to cover hearing services and products. The model called for starting offices from scratch and using a central office to ensure quality control.</p>\r\n<p>2. Helix Hearing Care was founded in 1996 in Canada and quickly became the chief competitor to Sonus. The MO for both was to acquire existing offices via a &ldquo;sales liquidating debt&rdquo; approach in which office acquisitions were assigned sales thresholds to recapture expenditures for the office purchases. The business model was to carry a lot of debt but offset it by showing a lot of equity on the books. If opposites attract, Helix and HEARx appeared to be made for each other. Stay tuned for future posts that go into these companies in more detail, then look at the HearUSA merger and bring us up to modern times.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. HEARx Marketing Plan, internal document, about 1986. http://hearinghealthmatters.org/ hearingeconomics/2011/life-in-thefast-lane-unraveling-hearusa-part-1</p>\r\n<p>2. Yes, there is such a thing as negative profit and it seems likely that HearUSA posted negative profits on an annual basis. http://hearinghealthmatters.org/ hearingeconomics/2011/life-in-thefast-lane-unraveling-hearusa-part-1</p>\r\n<p>3. http://hearingmojo.com/hearusalashes-back-at-siemens-with-alawsuit.http://hearinghealth matters.org/hearingeconomics /2011/life-in-the-fast-laneunraveling-hearusa-part-1</p>\r\n<p>4. http://journals.lww.com/thehearing journal/Fulltext/2011/07000/HearUSA_rolls_out_AARP_Hearing_ Care_Program_to_45.7.aspx http://hearinghealthmatters.org/ hearingeconomics/2011/life-in-thefast-lane-unraveling-hearusa-part-1</p>\r\n<p>5. http://hearinghealthmatters.org/ hearingeconomics/2011/who-yagonna-serve-shareholders-orstakeholders http://hearinghealthmatters.org/ hearingeconomics/2011/life-in-thefast-lane-unraveling-hearusa-part-1 http://webmail.nas.net/Redirect/ hearinghealthmatters.org/ hearingeconomics/2011/life-in-thefast-lane-unraveling-hearusa-part-1</p>\r\n<p>Back in April, we reported on possible insider trading in the hearing aid industry and promised some educational discussion of fiduciary duty and the stakeholder paradox in a followup post.2 It&rsquo;s not stuff we get in graduate school, but it&rsquo;s a good idea to at least know the terms now that many dispensers and audiologists are employed by multi-national corporations that trade in hearing aids and the rest of us sell the products of those corporations. The following is a primer on terms, followed by a brief discussion of the stakeholder paradox.</p>\r\n<p>1. Illegal insider trading occurs when someone big inside a publicly traded company buys or sells his/her shares in the company&rsquo;s stock, based on &ldquo;material nonpublic information.&rdquo; &ldquo;Big&rdquo; means anyone who is a large shareholder (&gt;10% of the stock), board member, in top management, or a key employee. Another kind of insider trading has to do with outright theft of company information (&ldquo;misappropriation&rdquo;) by an employee who then trades in any stock&ndash;not just the company&rsquo;s&ndash;in hopes of profiting. Insider trading is illegal in the US and some other countries because the insiders violate their fiduciary duty to the company&rsquo;s shareholders by taking advantage of non-public information to try to make personal profits. For instance, the CEO of Little Hearing Aids knows the company is going to be purchased next week by Big Hearing Aids. The CEO buys a lot of Little Hearing Aid stock before the acquisition is announced. After the announcement, the stock of Little Hearing Aids soars and he makes a tidy profit at the expense of the company&rsquo;s shareholders.</p>\r\n<p>2. A fiduciary duty is the legal and ethical commitment the company has to its investors to act in their best interest when it comes to handling money and property. Note that &ldquo;property&rdquo; includes information. It&rsquo;s a bit like the physician&rsquo;s Hippocratic oath to &ldquo;do no harm&rdquo; to patients, but more stringent: &ldquo;do everything you can to benefit the shareholders financially.&rdquo;</p>\r\n<p>It&rsquo;s easy to understand fiduciary duty from our own small business experiences: say Little Hearing Aids takes on a partner who agrees to put all professional efforts toward building the company. But, you come in on Saturday and find the new partner selling hearing aids out the back door and pocketing the revenues. That partner is self-dealing and not observing his/her fiduciary duty to Little Hearing Aids. Solution: get rid of the partner and pursue legal action if Little Hearing Aids has been materially harmed. The same goes for big corporations and their shareholders, as the current situation at Sonova illustrates.</p>\r\n<p>3. All terms above hinge on what&rsquo;s called the economic theory of the firm. The idea is that companies owe a special fiduciary relationship to shareholders, without regard to the effects on others. All company activities must be aimed at benefiting the shareholders, so long as the activities are legal. Truly, it is a dog-eat-dog world according to this theory, but at least your dogs are on your side and friendly, unlike the insider trading dogs, who are on your side but want to bite you.</p>\r\n<p>4. Economists never seem to agree, so naturally there is a flip side to consider: what about the &ldquo;stakeholders&rdquo; who are not shareholders such as suppliers, employees, patients, and next-door neighbors? What about societal needs in general? This is the stakeholder paradox. 3 Corporate decisions that take stakeholder needs (say for instance, the patients of a practice) into account are likely to violate the special fiduciary relationship owed to shareholders to maximize profitability. It may be the right and moral thing to do &ndash; especially if you are an audiologist adhering to ethical practice guidelines &ndash; but it is also &ldquo;illegitimate&rdquo; and perhaps legally indefensible for a corporate point of view. Paradox indeed! Here&rsquo;s a hypothetical example: Big Hearing Aid Co. has a duty to its stockholders to achieve stated corporate financial goals, one of which is to increase profitability. R&amp;D advances enable Big Hearing Aid Co. to produce instruments for a fraction of former production costs. Simultaneously, society&rsquo;s view of US hearing health care expands to include good hearing as an individual right. Here is the paradox: Big Hearing Aid Co. can decide to pass on the savings by selling its products for less. If it goes that direction, it can maintain its former profit margins but forego increased profitability. This approach satisfies the company&rsquo;s patients and friends (stakeholders) by making hearing healthcare more affordable to more in society, but it fails to satisfy the fiduciary duty of the company to its shareholders to increase profitability. The approach is morally right, but illegitimate. Alternatively, Big Hearing Aids, Co. can take a price premium increase on its breakthrough in hearing aid technology, thus satisfying its shareholders but ignoring the hearing needs of all but a few wellheeled consumers. This approach demon-strates no regard for societal needs. It is legitimate, but morally wrong or at least subject to intense societal scrutiny</p>\r\n<p>In enlightened circles, the Stakeholder Paradox can be solved by using a dual management approach that acknowledges a special, but &ldquo;partial,&rdquo; fiduciary relationship owed to shareholders according to corporate law. At the same time, management also acknowledges certain impartial moral obligations to society in its decision making, insofar as societal economic and general well being are affected by the company&rsquo;s pursuit of stated goals. Applying this approach to our example, Big Hearing Aids Co. pursues higher profits to satisfy shareholders while investing some of the profits in provision of hearing aids to those in society without access to hearing health care. As one of many solutions, this approach also enables what is known as &ldquo;consonance&rdquo; in individual managers&rsquo; personal and corporate ethics &ndash; that is, the manager or audiologist can fit his/her mother-in-law with hearing aids at the company discount rate without facing the ethical dilemma that his/her employer is denying aids at reduced cost to other people&rsquo;s mothers-in-law. (Just out of curiosity &ndash; has this ethical dilemma ever dawned on any of you out there that have fit a family member with hearing aids? I have to admit that it didn&rsquo;t dawn on me, nor does it particularly bother me. I probably need more enlightenment.)</p>\r\n<p><strong>References</strong></p>\r\n<p>1. http://www.professorbainbridge.com/professorbainbridgecom/2010/04/is-insidertrading-bad-if-so-why.html http://hearinghealthmatters.org/ hearingeconomics/2011/who-yagonna-serve-shareholders-orstakeholders</p>\r\n<p>2. http://hearinghealthmatters.org/ hearingeconomics/2011/hearingaid-insider-trading-big-time-or-bush-league/&quot; http://hearinghealthmatters.org/ hearingeconomics/2011/hearingaid-insider-trading-big-time-orbush-league/ http://hearinghealthmatters.org/ hearingeconomics/2011/who-yagonna-serve-shareholders-orstakeholders</p>\r\n<p>3. Goodpaster, KE. Business ethics and stakeholder analysis. Business Ethics Quarterly. 1991. http://hearinghealthmatters.org/ hearingeconomics/2011/who-yagonna-serve-shareholders-orstakeholders http://webmail.nas.net/Redirect/ hearinghealthmatters.org/ hearingeconomics/2011/who-yagonna-serve-shareholders-orstakeholders</p>\r\n<p>This past week has been a struggle &ndash; in my office, at home, and in the news. Along with all of these events I learned that United HealthCare and Best Buy are going direct to consumers and my favourite great innovator, Steve Jobs passed away. There is so much information from the first events that they will consume a few weeks of blogs. When I first heard about UHC and Best Buy I was hurt and angry. I started in this career to go on a journey with people to help with communication and relationships. I do get frustrated when some in the industry or start ups make it all about a product. The product in these marketing ideas, in my opinion, makes it all about the end result. I have always made it my philosophy to make the hearing device part of the journey. The journey includes friends, family, tools, counseling and better developing relationships. I do not agree that an end product can accomplish this. This thought brought me to Steve Jobs. He wanted his products to be more of an experience, not just a machine. There has been numerous links to his past speeches and ideas in the past week that I have reread. In reading his quotes about living and how he saw life I became inspired all over again. I was reading many other HYPERLINK &quot;http://pixelbits.wordpress.com/2011/1 0/05/the-power-of-vulnerabilitythankyoustevejobs/&quot; blogs and one that caught my attention was by Mona Nomura, in which she talked about how Steve helped her grow through being vulnerable. I often feel vulnerable when trying something new whether it is a marketing strategy or new product, but most of the time the payoff is worth it. Steve Jobs liked to borrow a quote from Wayne Gretzky: &ldquo;A good hockey player plays where the puck is. A great hockey player plays where the puck is going to be.&rdquo; I need to look at the future and work at figuring out how to make my own offices better. The introduction from UHC and Best Buy will only affect me in a negative way if I let it. Alternatively, I can use the adages of Steve Jobs to focus my practice toward success in a time of technological challenges. If I lose business from to UHC or Best Buy, I cannot blame those companies. I can use that threat to force myself to look at where my practice is vulnerable: is my practice failing to educate consumers as to the importance of quality service? Do we need to reinforce the importance of patient-practice relationships that grow out of successful hearing healthcare services? We have had these things come up before. I was in private practice when Songbird came and then went direct retail. We must always work on keeping ourselves strong. Yes sometimes the chances we take make us vulnerable, but we must learn and grow through these changes. Next week my thoughts on how the instruments from UHC and BB are being marketed and sold.</p>\r\n<p>By Greg Noel</p>\r\n<p>After graduating from Dalhousie, Greg moved back to Newfoundland and Labrador and began work as a clinical audiologist in Gander. Greg completed a neuroaudiology fellowship with Dr. Musiek in 1995. In 2000, Greg moved to Nova Scotia to become director of audiology for Nova Scotia Hearing and Speech Centres and adjunct professor at the School of Human Communication Disorders, Dalhousie University, Halifax.</p>\r\n<p>Auditory processing can be described as the complex processing of acoustical information that occurs beyond the peripheral hearing mechanism. Professional guidelines suggest that, if there are concerns, an audiologist test for the disorder on children 7 years of age or older. Auditory processing disorders (APDs) span a range of ages and can affect children, younger adults, and older adults. While the exact causes of APDs are not known, Musiek et al. suggest that APDs can be developmental, acquired, or neuro-logical.1 APDs can arise from disorders such as head trauma, stroke, multiple sclerosis, tumours, and epilepsy, to name but a few. It is therefore the audiologists&rsquo; mandate to describe the hearing difficulties encountered by their clients and to provide a rehabilitative pathway. This begins with comprehensive audio-logical testing for both the peripheral and central auditory pathways. The availability of and payment for audiological services are, for the most part, determined by provincial health departments. As a result, audiological services vary from province to province and, not surprisingly, payment for specialty audiological services, such as auditory processing testing, also varies. Thus, whether clients receive certain services can depend upon where they live and whether they are willing to pay for these services. An informal survey of professionals across the country revealed that some audiologists do offer APD testing (i.e., behavioural and evoked potential testing), and these evaluations are covered by the provincial health care model. However, there are regions in which audiologists do not provide this service; families in these regions are thus forced to seek out audiologists in other geographical areas and pay a fee for this service, ranging from $200 to $500. This fee usually covers the case history taking, the performance of peripheral and APD testing, and the production of a written report. A few audiologists also offer to visit with other professionals, the school, and the family as needed. Travel and lodgings are extra costs that the families must bear. I could not find any information about payment for audiology rehabilitation within the private sector. Some private-practice speech-language pathologists (SLPs) and university programs offering human comm-unication degrees offer rehabilitation for APDs, but fees are not listed and this service is largely research based. Chermak et al. suggest that the training of audiologists in this field has improved over recent years but that we must continue to do more.</p>\r\n<p>It would appear that it while APDs are receiving much attention in research arenas, families have difficulty finding professionals who offer clinical testing and services. To complicate matters further, audiologists struggle to offer these services due to their already-demanding caseloads, limited access to continuing education funding, difficulty obtaining test materials and normative data, and a lack of agreement about the definition of APD. It is no wonder that finding an audiologist with such a specialty is increasingly a challenge. A recent survey supported by both the Canadian Association of Speech-Language Pathologists and Audiologists (CASLPA) and the Canadian Academy of Audiology (CAA) on APDs revealed that Canadian audiologists and SLPs require direction on how to screen, diagnose, and manage  APDs. As of the writing of this article, documents are being developed by our national associations. Audiologists need to embrace the call for APD testing within our profession; if we do not take ownership of this arena, other health care professionals will accept the task.</p>\r\n<p>Typically, when we hear of APDs, we think of children. Most often, audiological testing for APDs is generated within in the educational setting as APDs have been shown to impact children&rsquo;s ability to learn. Interestingly, the majority of audiologists who offer this service are employed by health organizations; a few are in private practice. This uneven distribution of resources places a burden on the health care sector &ndash; the resources really should be allocated through the provincial departments of education. While a small percentage of children may have an APD resulting from neurological disorders (a rare occurrence), many more likely have an APD due to developmental issues.3 For the most part, pediatric APD evaluations are brought about because of concern by a parent, teacher, or SLP for a child&rsquo;s hearing. Educational-based audiological assessments should be handled within the mandate of the provincial departments of education. Audiologists working within the health care system need to consider screening and testing for APDs. Adult clients often report difficulties hearing due to a host of reasons, some impacting the peripheral mechanism, others impacting the central auditory system. Collaboration with the medical community is a necessity in such cases. However, physicians do not have the time or training to perform APD testing, whereas audiologists are uniquely qualified to provide auditory processing evaluations. Advanced audiological testing provides functional hearing outcomes that may supply answers for the clients&rsquo; hearing-related issues that other structural tests cannot provide.4 Aging clients and veterans returning from  conflicts overseas also require care from audiologists who have experience with advanced testing protocols and treatment options.</p>\r\n<p>future trends</p>\r\n<p>While today&rsquo;s Canadian audiologists graduate with a better understanding of the entire audiology system and how to assess its complex processes, there still is much work to be done:</p>\r\n<p>&bull; Audiologists need to offer comprehensive evaluations, including testing of the central hearing mechanisms. Recent research suggests that adding two tests that take only minutes to administer can help differentiate those clients in need of further testing from those who do not.</p>\r\n<p>&bull; There is a need to develop an infrastructure to support and foster educational audiology within Canada. Providing a professional home for educational audiologists could improve collaboration and support for children with APDs.</p>\r\n<p>&bull; Support and guidance should be provided by our national associations about appropriate billing guidelines for testing and rehabilitation within APDs.</p>\r\n<p>&bull; National associations should increase the documentation of APDs for professionals and public on their websites.</p>\r\n<p>&bull; A public relations campaign is needed by our national associations about the importance of hearing. We hear with our ears and brains. Audiologists are uniquely qualified professionals to provide APD services.</p>\r\n<p>&bull; Increased collaboration should occur with our SLP colleagues and other health care professionals working with clients with stroke, epilepsy, multiple sclerosis, etc. Audiologists need to embrace and cultivate the diagnostic nature of our profession and keep pace with the current and ever-expanding knowledge about the complex process that is hearing. The audiogram is really just a starting point &ndash; not the destination! Forgoing the comprehensive audiological evaluation and treatment of our clients is a cost our profession cannot afford.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. Musiek FE, Gollegly KM, and LE Ross. Profiles of types of central auditory processing disorders in children with learning disabilities. Journal of Childhood Communications Disorders 1985;9(1):43&ndash;63.</p>\r\n<p>2. Chermak GD, Silva ME, Nye J, et al. An update on professional education and clinical practices in central auditory processing. JAAA 2007;18(5):428&ndash;52.</p>\r\n<p>3. Musiek FE, Chermak GE, Weihing J et al.. Diagnostic accuracy of established central auditory processing test batteries in patients with documented brain lesions. JAAA 2011;22:342&ndash;58.</p>\r\n<p>4. Musiek FE, Baran JA, Shinn J. Assessment and remediation of an auditory processing disorder associated with head trauma. JAAA 2004;15(2):117&ndash;1132.</p>\r\n<p>5. Gates GA, Anderson ML, McCurry SM. Central auditory dysfunction as a harbinger of Alzheimer dementia. Archives of Otolaryngology Head and Neck Surgery 2011;137(4):390&ndash;95.</p>\r\n<p>6. Musiek FE and Chermak GD, (2009). Diagnosis of (central) auditory processing disorder in traumatic brain injury: psychophysical and electrophysiological approaches. ASHA Leader 2009. Available at: http://www.asha.org/publications/ leader/2009/091124/CAPD.htm.</p>\r\n<p>By Gael Hannan</p>\r\n<p>I am not an economist or accountant, but it doesn?t take a degree to figure out that hearing loss has cost me and my family a mighty chunk of change through the years. Without a thorough economic impact study, it?s difficult to attach a figure to the true cost of hearing loss on individuals. It?s a moving target involving many variables ? income of self and family, personality, upbringing, type and degree of hearing loss, home province, and willingness to embrace hearing loss and adopt technology. The dictum that no two snowflakes are identical can be applied to those of us who have hearing loss. On paper, my audiogram may look the same as that of a dental technician in Petawawa, but how she and I function, the impact of our shared audiological profile, including the financial one, may be completely different. But both of us are affected, deeply.. For fun, I did a quick exercise to tally the out-of-pocket costs of my own severe-toprofound hearing loss, for which I use ITCs, over the past two to three years. As I added it up, however, two things arose ? the hair on the back of my neck and the bile in my throat. But wait! There?s more! The above figure doesn?t take into account the time and effort ? the in-kind costs, if you will ? that are associated with having hearing loss. If time is money, let?s attach a cost of $1 to every 1 minute of time spent, by me, on activities related to my personal hearing loss. Whoa, who knew? And this little exercise does not take into account the time and effort that my family, friends, clients and colleagues expend in order to communicate effectively with me. I consider myself a high-functioning, well-adjusted person with hearing loss, and I?m fortunate to have the means to pay for my hearing loss. Communicating is important to me; I demand quality technology and I?m willing to spend the necessary time to ensure optimal communication. But what is the cost, the true impact, on someone who struggles emotionally with their hearing loss? The price of hearing aids and other technology are dealbreakers for many people who have families, who have low income or who live on fixed pensions. If a senior with hearing loss decides against buying a hearing aid even though he needs one ? what devastating cost does this impose on his personal safety, human engagement, and emotional well-being?</p>\r\n<p>We need to work together ? governments, industry, and consumers ?to help reduce the financial and emotional burden on Canadians with hearing loss. Let?s do a Canadian study on the economic impact of hearing loss. Let?s revise the restrictive wording on the Disability Tax Credit to make it accessible to those who need it, and clearer to the hearing health professionals who must sign the forms. Let?s make hearing aids and assistive technology more affordable. Let?s make aural rehabilitation a standard component of hearing health care. If we don?t, the cost of poorly managed national hearing loss will rise to the point where it is incalculable. Hearing loss is one of the country?s most common disabilities, yet one that is still largely ignored by our governments. Its financial wallop is not limited to individuals; there is a powerful ripple effect pending because the number of Canadians with hearing loss is rising, fast. And most of them cannot afford it.</p>\r\n<p>By Marshall Chasin, AuD</p>\r\n<p>From time to time, I receive telephone calls and e-mails from the parents of children with hearing loss asking about which musical instrument their children should play. Actually I receive this type of communication almost weekly! Let?s assume that the child has a ?typical? bilateral high frequency hearing loss commonly found with many forms of congenital and acquired hearing loss. The choice then is a musical instrument that has most, if not all, of its sound energy below 1000 Hz. This is roughly half way between the middle of the piano keyboard and the piano?s top note. Many children (and adults) with hearing loss generally have better hearing in this region so it makes sense to build on what they have. Music, like speech, is made up of sound energy that is spread over a large pitch range. However some instruments inherently squish more sound closer together to make the sound more dense and presumably easier to hear and play. These additional sounds are called harmonics and are not random. When I play a note on the piano or violin, the first harmonic is exactly an octave above the note being played. For example, I can play middle C on the piano and it is made up of middle C but also another C that is 8 white notes above it, and then the G above that. It sounds complicated, but that?s what makes music sound like music.</p>\r\n<p>Instruments that squish a whole bunch of harmonics close together are piano, guitar, all stringed instruments, oboe, and saxophone, to name but a few. For those who like science, these are called half wavelength resonator instruments. Unfortunately even if you do not like science, they are still called half wavelength resonators! There are other instruments that create additional harmonic energy that is spaced much further apart. For example, if I played middle C on a trumpet, the first bit of additional harmonic energy would be the G an octave and a half higher. The C which is only an octave above middle C wouldn?t even be there. These instruments that miss every other harmonic (so that the music is not as densely packed) are called quarter wavelength resonator instruments and examples include the trumpet and clarinet.</p>\r\n<p>The clarinet is a rather odd instrument ? it is a quarter wavelength</p>\r\n<p>instrument for the lower pitched notes, but a half wavelength instrument for the higher pitched notes. This means that where there is a greater hearing loss, the clarinet can help make up for it by having more closely packed harmonics yielding more musical cues. If a trumpet and a violin both play middle C then the trumpet essentially generates only 1/2 to 1/3 of the harmonic energy that the violin does. Or stated a different way, the one half wavelength resonator violin would generate up to three times the harmonic cues which are more tightly packed into the hard of hearing child?s near normal auditory range.</p>\r\n<p>By Lendra Friesen, PhD</p>\r\n<p>I would suggest you read the interesting article by Ou and colleagues on screening for drugs that cause hearing loss using the zebrafish model.1 Although hearing loss is a rising problem, there are no current drugs to cure this impairment. Methods to find drugs for treating hearing loss at the cell and molecular level have largely focused on the hair cells in the cochlea. While in many animals such as birds, reptiles, and frogs, hair cells can regenerate, in the mammalian inner ear, this doesn?t occur. Current research has focused on either stimulating regeneration of mammalian hair cells or preventing existing hair cells from dying. The zebrafish offers several advantages that make it a powerful animal model for studying hair cells in general, as well as for performing drug screens and genetic screens for molecular mechanisms that can protect hair cells. The zebrafish, has hair cells on the outside of its body in a sensory system called the lateral line. This system is used for detecting small differences in water currents on different parts of the body. The hair cells are organized into small groups called neuromasts. Physiologically, their behaviour is very similar to that of inner ear hair cells with depolarization occurring in response to deflection of stereocilia towards a single kinocilium. At the electron microscopic level, the intracellular structure of the lateral line hair cell is also very similar to that of inner ear hair cells, particularly those of the vestibular epithelium.</p>\r\n<p>The utility of the zebrafish for studying hair cells comes from: (1) a single mating of adult zebrafish can produce hundreds of offspring, (2) hair cells of the lateral line selectively pick up several fluorescent vital dyes, (3) at five days post-fertilization, the zebrafish body is clear, enabling in vivo imaging of fluorescently labelled hair cells, and (4) zebrafish mutagenesis protocols, or the process by which changes and alterations in their chromosomes occur are well established. In a screening protocol, a five days postfertilization zebrafish is labelled with a fluorescent dye for 30 minutes, which selectively labels hair cell nuclei. One fish is then placed into each well of a 96- well plate. Owing to their small size, as many as two or three zebrafish larvae can be placed in each well if necessary. Fish can then be exposed to a series of drugs depending on the exact screening protocol. For protective drug screening in the Ou et al. laboratory, fish are first treated to label the lateral line hair cells, then exposed to libraries of potential protective drugs, followed by treatment with known ototoxic drugs such as aminoglycosides or cisplatin. The 96- well plate is then examined with fluorescent microscopy to image hair cells of the lateral line in the fish in each well to evaluate whether hair cells have been protected from exposure to the ototoxic drug; this would be considered a &ldquo;hit.&rdquo; Typically, a single plate with 80 potential protectants requires 30 minutes for evaluation. All hits from the initial screen are then confirmed with repeat testing followed by thorough quantitative studies.</p>\r\n<p>Using this drug screening protocol, a small molecule library of more than 10,000 compounds was screened for small molecules that inhibited neomycin-induced hair cell death.From this library, two small molecules were identified as protective (named PROTO1 and PROTO-2). Additional testing showed that both drugs demonstrated dose-dependent pro-tection against neomycin and were protective against a wide range of neomycin doses. The protective effects were then confirmed in organotypic mouse utricle cultures, demonstrating that these drugs found to have protective effects in the fish had similar effects in mammalian tissue; however, it may be years before safety testing and enough about their pharmacokinetics (concentration-time relationship) is known to obtain FDA approval.</p>\r\n<p>Several libraries of FDA-approved drugs have been developed that are composed of compounds that have already b screened, using the same rapid screening protocol described above.5 One of these drugs, Tacrine, is now being tested in vivo mammalian trials and, if successful, might be a candidate for use in humans. It is important to note that all findings in zebrafish must be confirmed in mammalian tissue. There are differences of fluids in the lateral line, and the hair cell apices and stereocilia extend out into the surrounding water. There are no inner and outer hair cells within a neuromast. Furthermore, hair cells of the lateral line regenerate, with new hair cells detected within 24 hours of hair cell injury.6 In conclusion, the zebrafish lateral line provides a powerful preparation to identify genes, drugs and drug candidates that have potential for protecting hearing, and which can then be evaluated more thoroughly in other animal models. This tool can be applied to drugs that are currently in therapeutic use and at an early stage of testing for drugs under development and improve the safety of care for patients.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. Ou HC, Santos F, Raible D, et al. Drug screening for hearing loss: Using the zebrafish lateral line to screen for drugs that prevent and cause hearing loss. Drug Discovery Today 2010;15(7/8):265&ndash;71.</p>\r\n<p>2. Williams JA and Holder N. (2000) Cell turnover in neuromasts of zebrafish larvae. Hearing Research 2000;143:171&ndash;81.</p>\r\n<p>3. Owens KN, Cunningham DE, MacDonald G, et al. Ultrastructural analysis of aminoglycoside-induced hair cell death in the zebrafish lateral line reveals an early mitochondrial response. Journal of Comparative Neurology 2007;502:522&ndash;43.</p>\r\n<p>4. Owens KN, Santos F, Roberts B, et al. (2008) Identification of genetic and chemical modulators of zebrafish mechanosensory hair cell death. PLoS Genet 2008;4:el000020.</p>\r\n<p>5. Ou HC, Cunningham LL, Francis SP, et al. Identification of FDAapproved drugs and bioactives that protect hair cells in the zebrafish (Danio rerio) lateral line and mouse (Mus musculus) utricle. Journal of the Assocication of Research in Otolaryngology 2009;10:191&ndash;203.</p>\r\n<p>6. Ma EY, Rubel E, Raible DW. Notch signalling regulates the extent of hair cell regeneration in the zebrafish lateral line. Journal of Neuroscience 2008;28:2261&ndash;73.</p>\r\n<p>By Ian Po and Prashant Patel</p>\r\n<p>Ian Po (pictured) and Prashant Patel are both with RBC Dominion Securities. Ian Po can be reached at: ian.po@rbc.com.</p>\r\n<p>ANew Year is upon us and many of us are going through the annual ritual of setting New Year&rsquo;s resolutions. Improving health is usually high on many people&rsquo;s lists &ndash; lose weight, exercise, and eat healthier. However, in addition to improving your physical health, resolve to make 2012 your healthiest financial year ever for your business and your personal finances. This article will provide you with a list of five business and personal financial strategies to consider for 2012 with your professional advisors to help minimize tax secure your retirement income, and efficiently transfer wealth to the next generation. 1. revieW and update Your investMent asset aLLoCation The continued market volatility has potentially taken your asset allocation off-track. Now is a good time to review the asset allocation of your investments (cash, fixed income and equities) as well as their currency and geographic split (Canada, U.S., international). Is your asset allocation appropriate based on your risk tolerance, and your financial and retirement goals? Studies have shown that asset allocation is a key factor in determining your investment performance and variability of returns. Speak to a qualified investment advisor about getting a risk tolerance and asset allocation analysis to see where you stand today and if any changes need to be made. In addition to reviewing your asset allocation, consider the tax efficiency of your investments. Remember the saying, &ldquo;It&rsquo;s not what you make. It&rsquo;s what you keep.&rdquo; To maximize your after-tax returns, here are some general investments guidelines that you may want to incorporate into your overall asset allocation strategy:</p>\r\n<p>&bull; Emphasize interest-bearing investments in your RSP/RIF;</p>\r\n<p>&bull; Hold capital gain and Canadian dividend paying investments primarily outside your RRSP/RRIF to take advantage of their preferential tax treatment;</p>\r\n<p>&bull; Incorporate whole life or universal life insurance into your overall financial plan to take advantage of earning tax-free investment income while also protecting your family in the event of your death;</p>\r\n<p>&bull; Contribute to your Tax-Free Savings Account (TFSA) and earn tax-free income and capital gains. Since the TFSA is flexible and can be used for many different purposes, the asset allocation decision for your TFSA will really depend on your goal for the TFSA (e.g., short-term savings, supplement to retirement savings, speculative, etc.).</p>\r\n<p><strong>2. faMiLY inCoMe spLitting</strong></p>\r\n<p>You can split income and save taxes by paying reasonable salaries for work performed in your business by lowerincome family members. If your family is not involved in your business, then you can still income split with them by paying them dividends from your corporation to adult family members. However, in order to receive dividends the adult family member must be a shareholder of the business either directly or as a beneficiary of a family trust that owns the shares of the business. By restructuring the ownership of the business today, you can still maintain control, but now you have set up your affairs to save taxes by paying dividends to lower-income adult family members and potentially multiplying the $750,000 capital gains exemption if you are able to sell the shares of your business in the future.</p>\r\n<p>If you have a personal investment portfolio (outside RSPs) then ensure you are maximizing TFSAs for all adult family members. You can also shift investment income (interest, dividends and capital gains) that would normally be taxed in your name at high tax rates to a low-income spouse or low income children (of any age) by loaning them cash at the current CRA prescribed rate of 1%. Charging the prescribed rate is required to avoid income attribution. In this case, all investment income earned over 1% can be taxed in the hands of the low income family members (possibly all tax-free). If you have minor children then establishing a family trust will be required. The taxfree income earned by the minor child through the trust can then be used to help fund expenses for them that otherwise would be paid with after-tax dollars such as private school fees, lessons, gifts, etc. This is an opportune time to set up a prescribed rate income splitting loan with a low income spouse or minor children since the 1% loan rate is a historic low and once the loan is established, the 1% rate is locked in indefinitely regardless of future CRA interest rate increases. The following example compares investing $500,000 of excess personal cash in your own name versus making a prescribed rate loan to a family trust with two minor children as beneficiaries. A 6% return is assumed.</p>\r\n<p>The annual tax savings will vary depending on the amount of the loan and the annual investment return. The above example ignores the tax deductibility of any investment management fees as well as trust tax return and other costs of setting up and maintaining a family trust. You can call back the $500,000 loan capital anytime and collapse the family trust.</p>\r\n<p>3. individuaL pension pLan As an alternative to RSPs, incorporated business owners can set up an Individual Pension Plan (IPP) to maximize retirement savings in a taxdeferred plan. IPPs offer the business owner an ability to accumulate retirement savings through their own defined benefit pension plan. IPP contributions (made by your company) are higher than RSP limits for business owner over age 40. In some case, large initial past service IPP contributions can be made by the company for business owners that have been earning T4 income from their corporation for many years.</p>\r\n<p>A couple other interesting features of the IPP not offered by RSPs are that</p>\r\n<p>&bull; all IPP expenses including investment fees are fully taxdeductible; and</p>\r\n<p>&bull; the investment growth rate for IPP assets is 7.5%; so if the IPP earns less than 7.5% then the company can top up the IPP with further taxdeductible contributions to bring the plan back up to &ldquo;tracking&rdquo; 7.5% per year.</p>\r\n<p>lower corporate tax rates it may be better to not pay a salary (hence not contribute to an RSP or an IPP and not earn CPP benefits). As a result, they argue it&rsquo;s better to pay the corporate tax today on monies that otherwise would be put into an IPP or RSP, invest funds in the corporation (taxable account) and pay dividends in retirement for income. That is still up for debate and all depends on the assumptions used to crunch the numbers. However, an IPP offers a creditor protected pool of retirement capital that has a predictable 7.5% growth rate (tax-deferred) and this structured IPP program can provide some peace of mind and retirement income diversification to the business owner.</p>\r\n<p>You should ensure that you have adequate life insurance and disability insurance so your family has adequate income to meet their expenses if you died or became disabled. Consult a licensed insurance specialist and financial planner to determine the appropriate amounts. But what if you are at a stage in your life where you have accumulated large savings or your children are not financial dependant on you so your need of life insurance to meet survivor income needs is less? In this case, you still may want to consider life insurance for other tax and estate planning benefits such as tax-exempt investing, to fund taxes at death, to provide legacies to children or charities, or the ability for your estate to withdraw cash from your corporation tax free. That is, if you have business profits in excess of your lifestyle expenses, there is a tax deferral benefit of leaving the profits in a corporation since active business corporate tax rates are lower than top personal tax rates. For example, the first $500,000 of active business profits are taxed at 15.5% and the excess is taxed at 28.5% (decreasing over next few years). Excess profits retained in the company could then be moved up tax-free to a holding company for creditor protection. That is the good. The bad is that investment income earned in the holding company is taxed at a flat corporate investment tax rate which is slightly higher than the top personal tax rates. Furthermore, there could be a large tax bill upon death related to the deemed disposition or wind up of the holding company shares. These facts result in a more compelling argument to reallocate some of the surplus corporate investments (particularly lower yielding fixed income investments) that may not be needed for lifestyle expenses into corporate owned tax-exempt life insurance. The results are tax-sheltered growth, a taxfree death benefit paid into the company and an ability to distribute the insurance proceeds from the company to the estate tax-free via the Capital Dividend Account. This latter feature is a significant tax benefit of corporate owned life insurance. The following table illustrates net aftertax estate values if $50,000 is deposited for the next 10 years into corporate investments earning 6.0% in a balanced portfolio compared to the same $50,000 being deposited for the next 10 years to a $1MM joint last to die life insurance policy (both spouse&rsquo;s are age 56) where the investment account within the policy earns 2.5% per year. The illustration assumes a dividend tax rate of 32.6% on the corporate assets at death; however it may be possible to reduce this tax at death to a lower capital gains rate.</p>\r\n<p>As the table indicates reallocating $50,000 over 10 years from the corporation to the life insurance policy results in a much higher estate value after tax ever year and even after 35 years. The annual rate of return required in the corporation to break even to the life insurance scenario is about 4.3% after tax for 35 years or 8.0% pre-tax on an interest equivalent basis. So the insurance asset provides an excellent long term guaranteed return for a portion of one&rsquo;s surplus  corporate assets. Clients should consult with a licensed insurance specialist for further information and advice on taxexempt life insurance.</p>\r\n<p>Although it is not pleasant to think about it, it is important to ask yourself, &ldquo;What would happen to my family and my business if I had died or became disabled yesterday?&rdquo; Developing a contingency plan to ensure that your family and business are taken care of under worst case scenarios is an important and fundamental step in your financial planning. One important piece of your contingency plan is your will. Many Canadians do not have a will and for some of those that have prepared a will, it is out of date and not consistent with your estate transfer objectives. The following are some key pointers when it comes to your estate plan.</p>\r\n<p>&bull; Don&rsquo;t leave preparing your will and power of attorney (POA) until the last minute, such as when you are going away on holiday or for surgery. It is important to do the planning when a person has the requisite capacity to do so.</p>\r\n<p>&bull; Regularly review your will and POA, particularly when you have gone through a major life event.</p>\r\n<p>&bull; Make sure the ownership of your investments and beneficiary designations are consistent with your estate plan.</p>\r\n<p>&bull; Consider family dynamics when implementing your estate plan. That is, it may not be wise to appoint children who do not get along as co-executors or cotrustees. Try to design a plan that will reduce the potential for conflict among family members.</p>\r\n<p>&bull; Although probate is an important consideration, a person can compromise their wishes or unduly complicate their planning in an effort to save this relatively modest tax.</p>\r\n<p>&bull; People fail to appreciate the importance of POAs, or mistakenly believe that it is included as part of the will. In reality, they are different documents.</p>\r\n<p>&bull; People do not consider the implications of appointing an executor who lives in another country, which can create problems as simple as whether this person can afford the time to travel to settle your estate.</p>\r\n<p>&bull; Consider the tax and control benefits of testamentary trusts as opposed to direct bequests.</p>\r\n<p>Proper will and estate planning entails more than just preparing a will. A lawyer will review a person&rsquo;s financial situation, their ownership of and value of assets, and thoroughly discuss possible income tax and estate administration tax issues to ensure your expectations will be met. You should seek formal tax and legal advice to ensure that all the T&rsquo;s are crossed and I&rsquo;s are dotted when employing any of the above strategies.</p>\r\n<p>By Rober t M. Traynor EdD, MBA and Rober t G. Glaser, PhD</p>\r\n<p>Robert M. Traynor is CEO/Audiologist with Audiology Associates, Inc., Johnstown, Colorado</p>\r\n<p>Robert G. Glaser is CEO/Audiologist with Audiology Associates of Dayton, Inc., Dayton, Ohio</p>\r\n<p>For most audiologists the patient is foremost as we provide hearing care services. Successful practitioners know that when their practice is centred on their patient&rsquo;s welfare, success will usually follow. Probably the greatest responsibility of the patient-centric practitioner is to be in business next year when the patient needs things that are warranty items, or other services that may be of benefit to them. There are many stories of highly successful patient-centric practices that did not survive for one reason or another caused by difficulties on the business management of the practice, not patient care. Generally, educational programs that prepare audiologists for the clinical world do not adequately prepare clinicians for survival within the business community as there is much information that must be assimilated in the clinical treatment of our patients, thus, minimal or no time to prepare perspective clinicians in business management. When entering into private practice, audiologists must realize that they become part of the cold hard business world and survival depends upon making a profit. Although suppliers, creditors, employees, and others care about the patients we serve, the business of audiology is like any other business requiring much attention and monitoring to succeed. Thus, to be a good manager, clinicians must have the capability to digest information about the financial performance of the practice and develop the background to translate that information into decisions that move the practice toward profitability. Although it is not necessary to obtain an MBA to know how to run your practice or an audiology profit center within a hospital, educational, or other institutional setting, courses in accounting and finance are substantially beneficial and readily available at most local community colleges. These courses offer the practitioner greater insight into the management their practice and give them the power to interpret the relevant business variables. The following discussion is an attempt to orient clinicians to the basics of the Balance Sheet, Income Statement and, probably most important, the Statement of Cash Flows.</p>\r\n<p><strong>FinanciaL Statements</strong></p>\r\n<p>Most of us use the services of an accountant to prepare reports and assist us in the interpretation of the information they contain. Traynor suggests that practitioners should have knowledge of the vocabulary and</p>\r\n<p>language of accounting to effectively communicate with the accounting (and bookkeeping) professionals who manage their practice and protect their assets.1 Although it is the bookkeepers that enter the day-to-day data, it is the accountant that prepares reports that assist practitioners in making evidence-based decisions regarding the success or failure of daily operations, conducting a specific clinical procedure, or a new market offering. These reports are fundamental to understanding the reasons for positive or negative changes in the bottom-line performance of the practice. Such accounting reports are prepared according to internationally accepted accounting rules called the Generally Accepted Accounting Principles (GAAP), a universal method of valuing profit and measuring assets and liabilities. Although they vary slightly from one country to another, GAAP rules are used to conduct accounting in all businesses. GAAP describes how transactions for costs, profit, inventory, sales, and other business specifics are recorded and facilitates the comparison of one business to another since businesses all use these same procedures for accounting. While the role of an accountant in the practice will vary from one practice to another, the professional assistance of these practitioners is essential to success. There are two primary objectives of every business, including audiology practices; profitability and solvency. Unless a practice can produce satisfactory earnings and pay its obligations in a timely manner, all other objectives will never be realized because the practice will not survive. Financial statements that reflect a practice&rsquo;s solvency (the Balance Sheet), its profitability (the Income Statement) and a view of its financial health (the Statement of Cash Flows) provide the practitioner substantive information upon which to make well informed decisions about the operations of the practice. These financial statements are so important that bankers and other lenders depend on them to support their decisions to grant credit opportunities. Bankers and lenders know that financial statements are the basis of the calculations for business ratios that offer important, informative metrics about activity, liquidity, and leverage (debt) of the practice.</p>\r\n<p><strong>BaLanCe sheet</strong></p>\r\n<p>The Balance Sheet contains the elemental fiscal components of the practice; information about assets, liabilities and owner&rsquo;s equity. It presents a snapshot of the financial condition of the practice at a specific moment in time, usually at the close of an accounting period such as the end of the month, quarter, or year.2 Businesstown.com indicates that the purpose of the balance sheet is to quickly review view the financial strength and capabilities of the business as well as answer important questions such as3 :</p>\r\n<p>&bull; Is the business in a position to expand?</p>\r\n<p>&bull; Can the business easily withstand the normal financial ebbs and flows of revenues and expenses?</p>\r\n<p>&bull; Or should the business take immediate steps to strengthen cash reserves? The balance sheet gets its name from the fact that the two sides of the statement must numerically balance, as presented in the classic formula presented below:</p>\r\n<p>Assets = (Liabilities + Owner&rsquo;s Equity) + (Revenue &ndash; Expenses)</p>\r\n<p>Assets are recorded on left side of the Balance Sheet and Liabilities and Owner&rsquo;s (stockholders) Equity are recorded on the right side of the Balance Sheet, as presented in Table 1. On many balance sheets, Total Assets are set to equal 100%, with all other assets listed as a percentage of the total assets. On the right side of the Balance Sheet, Total Liabilities and Equity may also set equal to 100%. Entries of all liabilities and owner&rsquo;s (stockholders) equity accounts are represented as the appropriate percent of the Total Liabilities and Owner&rsquo;s (stockholders) Equity. The Balance Sheet must contain all of the practice&rsquo;s financial accounts and should be generated at least once a month. Monthly review of the balance sheet provides a comprehensive overview of the practice&rsquo;s overall financial position at that specific point in time. Assets listed on the Balance Sheet are items of value that represent the financial resources of the practice. Accounts listed on the Balance Sheet are placed in order of their relative degree of liquidity (ease of convertibility to cash) therefore; Cash is always listed first since it does not require an action or an agent to convert cash into cash. Accounts Receivable is listed second since it represents Cash but must be &ldquo;converted&rdquo; into cash by collection. Assets are commonly differentiated into two classes; Current Assets and Fixed or Long-term Assets (see Table 1). Current Assets are shortlived and are expected to be converted into cash or to be used up in the operations of the practice within a short period of time, usually within a fiscal year. Current Assets include cash, accounts receivable, product inventory (hearing instrument and assistive listening device inventory, batteries, etc.) and prepaid expenses, such as insurance. Next are the Long-term or Fixed Assets that will not be turned into cash within the practice&rsquo;s fiscal year. Examples of Long-term or Fixed Assets may include (but are not limited to) audiometric and other equipment used in the practice, office equipment and computers, purchased vehicles, purchased buildings, leasehold or tenant improvements, telephone systems. These assets are found in the balance sheet (Table 1) listed as &ldquo;Property, Plant and Equipment&rdquo; or as &ldquo;Fixed Assets.&rdquo; To best conceptualize Long-term or Fixed Assets, consider that most fixed assets are purchased over time and must be in place over a long period of time to foster the day-to-day clinical and business operations of the practice. As equipment ages, it is said to depreciate. This depreciation of the equipment is an expense and can be claimed as a tax deduction. The accountant for the practice will evaluate the appropriate method for calculation and the extent of deductions available for every fixed asset listed on the balance sheet.</p>\r\n<p>Liabilities include all obligations the practice has acquired through daily operations of the practice. Liabilities include Accounts Payable (ex. hearing instrument and ALD acquisition costs), Accrued Business Expenses, Interest Owed on Loans, and other obligations incurred from daily operations. Owner&rsquo;s or shareholder&rsquo;s equity includes financial investment by the owner or shareholders and the earned profits that are retained in the business. Current liabilities are listed as amounts owed to lenders and suppliers and are usually separated by those that are due in the short term and long term. As with the asset categories, current liabilities are delineated into subcategories such as short term debt, accounts payable and accrued liabilities. These are referred to as current liabilities since they are due to be paid in a short period of time, usually within the fiscal year. A separate category is retained for long term debt, such as bank or other loans payable over a much longer period, usually longer than the fiscal year. All current and long term liability amounts are then totalled collectively to reflect the total liability of the practice (see Table 1). Owner&rsquo;s (shareholder) Equity represents funds that were initially invested by the owner as well as the profit that was earned and retained in the practice. If the practice were to liquidate, the owners (stockholders) would be an expense requiring payment, thus it is listed on the liability side of the balance sheet as a financial obligation that must be repaid at some point in time.</p>\r\n<p><strong>Income Statement</strong></p>\r\n<p>The Income Statement is sometimes called a profit and loss statement or &ldquo;P and L&rdquo; statements and depicts the status of overall profit within the business. McNamara indicates that income statements simply include how much money has been earned (revenue), subtracts how much money has been spent (expenses) that results in how much money has been made (profits) or lost (deficits).4 Basically, the statement includes total sales minus total expenses. It presents the nature of the practice&rsquo;s overall profit and loss over a specified period of time. Therefore, the Income Statement gives a practitioner a sense for how efficiently the business is operating. In accounting, the practice&rsquo;s profitability is measured by comparing the revenues generated in a given period with the expenses incurred to produce those revenues. The difference between the revenue generated and the expenses created during the generation of the revenue is the profit (or loss) of the practice. In an audiology practice, revenues are defined as the inflow of revenue from providing patient care or the dispensing of products. Expenses can be considered the sacrifices made or the costs incurred to produce these revenues. If revenues exceed expenses, net earnings result while if expenses exceed net revenue, a loss is recorded.</p>\r\n<p>As with other financial statements, the Income Statement, presented in Table 2, may be prepared for any financial reporting period and is used to track revenues and expenses for the evaluation of the operating performance of the practice. Businesstown.com suggests that managers can use income statements to find areas of the practice that are over budget or under budget and identify those areas that cause unexpected expenditures.5 Additionally, the Income Statement tracks the increase or decrease in product returns; cost of goods sold as a percentage of sales and presents some indication of the extent of the practices&rsquo; income tax liability. Since it is very important to format an Income Statement appropriate to the type of business being conducted, the structure of income statements may vary from one business or practice to another. In audiology the format may depend upon the mix of business conducted in diagnostics, hearing products, and rehabilitative services. Net Sales on the Income Statement consist of sales figures representing the actual revenue generated by the business. Marshall states that the Net Sales entry on the Income Statement represents the total amount of all sales less product returns and sales discounts.6 Directly below the Net Sales in Table 2, is the Cost of Goods Sold (COGS). COGS are costs directly associated with making and/or acquiring the products that are sold by the practice. These costs include the acquisition of products, such as hearing aids or assistive devices provided by outside suppliers. If hearing instruments are repaired or manufactured by the practice, COGS could also be materials, parts, and internal expenses related to the manufacturing or repair process, such as faceplates, shells, microphones, receivers, and components. Net Profit, sometimes called Gross Profit, is derived by subtracting the Cost of Goods Sold from Net Sales. This Net Profit, however, does not include any operating, interest, or income tax expenses. Just below the Net Profit entry in Table 2 is a category for Selling and General Administrative Expenses. This subcategory is described by Tracy and Marshall as a broad &ldquo;catchall&rdquo; category for all expenses except those reported elsewhere in the Income Statement.6,7 Examples of Selling and General Administrative Expenses that may be recorded here are legal expenses, the owner&rsquo;s salary, advertising, travel and entertainment, and other similar costs. The actual income from operations, sometimes called Earnings before Interest and Taxes (EBIT) and is the result of deducting the Selling and General Administrative Expenses from the Net Profit. The Earnings before Interest and Taxes (EBIT) is the net revenue generated by the practice but there are still interest expenses and taxes that must be recorded. At this point, the Interest Expense is deducted and then the tax amounts are subtracted to arrive at the Net Income (or Loss).</p>\r\n<p><strong>stateMent of Cash</strong></p>\r\n<p>fLoWs Successful practitioners know that profit and cash flow can be two totally different things, but they are intimately related. A practice can be highly profitable yet on the verge of bankruptcy if the profits are sequestered, for example in the Accounts Receivable &ndash; high profit, low cash flow. This situation results in limited cash to pay the practitioner, employees, taxes, and/or to service the accounts payable. Conversely, if there is substantial cash inflow to a practice but excessive overhead costs that are strangling profitability, financial difficulties will ensue &ndash; low profit, high cash flow. This is a situation where in the practice owner has overextended available resources with ill-conceived equipment purchases, exceptional leasehold costs, or extraneous staff salaries and other questionable business decisions.</p>\r\n<p>The Statement of Cash Flows reflects the cash position of the practice as well as the sources and uses of cash in the practice during a specified business cycle. It presents how cash flows in and out of the practice. While, monthly cash flow statements are useful, quarterly cash statements of cash flow are essential to provide a look at trends that might be developing in the overall cash flow picture of the business. To illustrate how cash flows in and out of the practice, Marshall indicates that the Statement of Cash Flows is used to identify the sources and uses of cash over time and can be compared to the current period for analysis.6 In Table 3, the Statement of Cash Flows is divided into three general sections, Cash Flow from Operating Activities, Cash Flow From Investment Activities and Cash Flow From Financing Activities. The Operating Activity section begins with the Net Income (taken from the Income Statement, Table 2) and includes all transactions and events that are normally entered to determine the operating income. These entries include cash receipts from selling goods or providing services, as well as income earned as interest and dividends, if the practice has investments. Cash Flow from Operating Activities also includes additions or deductions of items that affect cash such as depreciation, increase (or decrease) in accounts receivable, merchandise inventory and liabilities, resulting in the Net Cash used by Operating Activities. The Net Amount of Cash Provided (or used) by practice operating activities is the key figure on a Statement of Cash Flows. The Operations Section is of the most interest since it presents the specific areas of the practice where cash was consumed by the running of the practice. The second section of a Statement of Cash Flows reviews Income generated from investing activities. This section includes transactions and events involving the purchase and sale of equipment, securities, land, buildings, and other assets not generally held in the practice for resale. This area of the statement also covers the making and collecting of loans, if the practice internally finances products and services these loans to consumers internally. Investing Activities are not classified as operating activities since they have an indirect relationship to the central, ongoing operation of the practice. Transactions within the third section record Cash Flows from Financing Activities and deals with the flow of cash between the practice, the owners (stockholders), and creditors as well as the cash proceeds from issuing capital stock or bonds if applicable. For example, if there was a need to transfer profit from the practice to the owners or from the owners (or creditors) into the practice, it would be reflected in the Cash Flows from Financing Activities section. Careful review of the Statement of Cash Flows can offer valuable information to the practitioner as to where the cash generated actually goes and presents an invaluable opportunity to make adjustments in practice operations for management purposes. epiLogue Although these statements are extremely useful, Freeman indicates that these data are a record of practice performance. Until the data is calculated into the various ratios that unlock the valuable information within the Balance Sheet, Income Statement, and the Statement of Cash Flows the totals are just numbers.8 The real information in these statements are the calculations that determine the practice&rsquo;s liquidity, activity and leverage (debt) ratio simple calculations. Although calculations can be conducted on all of the statements, the ratios of primary importance are conducted on the balance sheet and income statement data. These financial accounting ratios can give the practitioner information as to if there are enough funds to pay the bills, how long it takes to turn the accounts receivable, or inventory and even give information as to the debt of the practice. The next part of this series will discuss the calculation of some important ratios that can influence the management of the practice as they are tracked from month to month, quarter to quarter, and year to year.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. Traynor RM. Fiscal Monitoring: Cash Flow Analysis: In: RG Glaser and RM Traynor, eds. Strategic Practice Management. San Diego, CA: Plural Publishing. pp. 74. 2008</p>\r\n<p>2. Brealey R, Myers S, and Marcus A. Fundamentals of Corporate Finance. McGraw-Hill: New York. 2002.</p>\r\n<p>3. Businesstown. 2003. The Balance Sheet. Business Town . Com. Retrieved March 25, 2005. Available at: http://www.businesstown.com/accounting/basicsheets.asp.</p>\r\n<p>4. McNamara C. Profit and Loss Statements. Authenticity Consulting, LLC. 2007. Retrieved April 7, 2007. Available at: http://www.managementhelp.org/ finance/fp_fnce/fp_fnce.htm #anchor561785.</p>\r\n<p>5. Businesstown. The Income Statement. Business Town . Com. 2003. Retrieved March 25, 2005. Available at: http://www.businesstown.com/accounting/basicsheets.asp.</p>\r\n<p>6. Marshall DH. Accounting: What the Numbers Mean?, 6th Edition. New York: McGraw-Hill; 238&ndash;47. 2004.</p>\r\n<p>7. Tracy J. 2001. Accounting for Dummies, 2nd Edition. Hoboken, NJ: Wiley Publishing.</p>\r\n<p>8. Freeman B, Barimo J, and Fox G. 2000. Financial Management of Audiology Practices and Clinics. In: Hosford-Dunn H, Roeser R, and Valente M, eds. Audiology Practice Management. Thieme: New York, pp. 351&ndash;62.</p>\r\n<p>By Rober t M. Traynor EdD, MBA and Rober t G. Glaser, PhD</p>\r\n<p>Freeman et al describe two forms of financial analysis ratio comparisons, cross sectional and a time series analysis.1 A cross sectional analysis, refers to the comparison of the practice&rsquo;s performance to that of an industry standard for similar practices in size, scope and geographical area. Though probably more appropriate recent years, is still difficult to determine an industry standard as there are not good data reported by private audiology practices as to their performance. Since performance comparisons between practices or to an industry standard are difficult to conduct, it is the time series analysis that becomes the most important. The time series comparison looks at the practice performance to itself, or over periods of time, usually month to month or year to year. Data, such as financial statements are compared from one period to another to determine if the practice&rsquo;s performance is better or worse. These time-series comparisons of financial statements and the data they contain are essential to making informed, data based management decisions about the practice and its operations. Where is the data? Financial statements are full of numbers that, by themselves, simply present how the practice performed at a particular point in time and do not have too much significance in isolation. Since the financial statements alone do not provide information on the efficiency or profitability of the practice, they require analysis and a time series comparison to generate real information. When these numbers in the current statements are compared to financial statements conducted at other times (monthly or yearly) they come alive with informative data that paints a true picture of how success or failure has developed. Financial statements with the correct calculations and comparisons can reveal a wealth of information to the stockholders (or the practice owner) about earnings over time, soaring or stagnated sales, and even the practice&rsquo;s capability to pay back a loan to the bank. Within the same practice comparing financial statement totals to others taken at the some point in time is very helpful, for example, comparing the first quarter 2004 with the first quarter or 2005 or the whole year of 2004 with 2005, or last year at this time to this year at this time. Marshall et al. indicate that these calculations assist in the determination of a practice&rsquo;s financial position and the result of their operations by reporting on liquidity, activity, and debt and profitability analysis of income statements.2 It is the calculation of various ratios for balance sheets and income statements that facilitate the comparison of one practice with another, no matter what the size of the operation. Although there are many of these and a wise practice manager should consult with their accountant as to those that are the most beneficial for the practice, these relatively simple measures can be calculated and tracked. The data can then be transferred to a spreadsheet and reviewed over time to demonstrate the health of practice, for obtaining loans or supplier credit, reviewing success and failure for management decisions, to set budgets, or simply general information.</p>\r\n<p>the CaLCuLations Financial statements provide information regarding the capability of the practice to meet obligations to suppliers, employee salaries, product returns, loans, leases, and other expenses. Managers use liquidity, activity, and leverage ratios to analyze the balance sheet to demonstrate the strengths and weaknesses of the practice. Liquidity ratios are used to measure the short-term ability of practice to generate cash to pay currently maturing obligations while activity ratios measure how effectively the organization is using its assets, analyzing how quickly some assets can be turned into cash. Debt or leverage ratios reflect the long term solvency or overall liquidity of the practice and are of interest to the investors and/or the bankers that have loaned money</p>\r\n<p>LiquiditY ratios A common liquidity ratio is the Current Ratio (CR). The CR is sometimes called a Working Capital Ratio as it is a calculation of how many times the practice&rsquo;s current assets cover its current liabilities and specifically looks at if the practice has sufficient resources to meet current liabilities. Put another way, the Current Ratio asks the questions, can the practice pay its bills or not? The Current Ratio is figured on the Balance Sheet as follows:</p>\r\n<p>If the result of a CR calculation is less than 1, the practice will not be able to meet its current liabilities and if the CR is 2 or more, the practice can pay its bills and have money left over. Usually bankers and practice managers like to see this ratio at least between 1 and 2. Since the CR calculation includes prepaid expenses (such as insurance, etc.) and the inventory, in some situations it may offer a cloudy view of the real picture. Particularly these days when audiology practices may have a stock of open fit or RITE hearing instruments, many audiology practices now have some inventory. Thus, a very common modification of the CR is the Quick Ratio (QR), commonly known as the Acid Test Ratio (ATR). The ATR evaluates the practice&rsquo;s liquidity without considering the inventory and prepaid expenses and, in doing so, often presents a more accurate indication of the liquidity of an audiology practice. The ATR is figured from the information on the balance sheet as follows: As with the CR, Acid Test Ratio values less than 1 demonstrate that the practice has serious difficulty meeting everyday expenses. Just as plans are made to meet personal obligations in tough times, wise practice managers keep an emergency fund in the case that business drops off or ceases. These can be from natural disasters, major construction projects proximal to the clinic, or simply a downturn in the economy. In accounting, emergency funds are called Defensive Assets (DA) or those assets that can be turned into cash within three months or less, such as cash (savings), marketable securities, or accounts receivable. A calculation that determines the amount of Defensive Assets (RA) necessary to ward off disaster is the Defensive Interval Measure (DIM). To figure the DIM, it is first necessary to know the Projected Daily Operating Expenses (PDOE) or how much it costs to keep the practice open each day. To find the PDOE, simply look at the income statement and determine the cost of goods sold in a year (listed as the selling and administrative expenses) in a year and other ordinary cash expenses for the year then divide by 365:</p>\r\n<p>It is a good policy for all patients to pay when products and/or services are delivered and most practices have a sign to that effect in the waiting room, collecting as much revenue as possible on the date of delivery. Reality is, however, that insurance companies pay slowly; sometimes 60-120 days after the services are rendered and may often not even pay the first time the claim is submitted. Some patients need time to pay for goods and services require credit to facilitate the sales of hearing aids, batteries, and other goods or services. Although credit given to patients is another topic, the receivable account should be closely monitored to determine how much is due to the practice and how long, on the average, it takes to collect for these credit sales. The Accounts Receivable Turnover Ratio (ART) looks at how many times the receivable account is turned into cash each year. To obtain the ART ratio it is necessary to first find the average amount that is due the practice from the receivable account at any one time or the Average Accounts Receivable (AAR) balance. This is obtained by adding the accounts receivable balance at the end of last year and balance of the accounts receivable at the end of the current year and dividing it by 2:</p>\r\n<p>Once known, the ART present the manager with how long it takes, on the average, to collect the amounts that in the accounts receivable, thus, the higher the ratio the better. For example, if the ART ratio is = 5.3, the practice turns over the accounts receivable 5.3 times per year or every 2.26 months. To obtain more detail, the calculation of the number of days it takes to turn the accounts receivable can be obtained by simply dividing the average accounts receivable into 365.</p>\r\n<p>As indicated earlier, audiology practices are now stocking more inventory than ever before and it is beneficial to understand how fast the inventory sold so that stock can be ordered routinely. The Inventory Turnover Ratio (ITR) is the calculation that measures how fast the inventory is sold, or &ldquo;turned.&rdquo; To arrive at the ITR it is necessary to obtain the average value of the inventory in the practice. The Average Inventory (AI) is found by reviewing the balance sheet and taking the beginning inventory for the year and the ending inventory of the</p>\r\n<p><strong>Summary</strong></p>\r\n<p>Although ratios can be very helpful in the evaluation of a practice, Glaser and Traynor offer some cautions on the use of ratio analysis.3 They indicate that the best information about a company&rsquo;s health is determined from comparison and analysis of a group of ratios, not a single ratio and that these comparisons need to be made from like times of the year to arrive at accurate data on the practice&rsquo;s performance. Additionally, they also indicate that these ratios may be distorted somewhat due to the reimbursement policies of insurance companies. This has been a basic orientation to the use of ratio analysis to evaluate the audiology practice. There are many other ratios that can unlock specific performance information that are not presented in this discussion. The development of a set ratio assessment calculations to track various components of your particular practice should be developed with the help of a certified public accountant or other trained business professional. Once set up these calculations can be tracked over time using a spreadsheet to facilitate a basis for decisions based actual practice performance.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. Freeman B, Barimo J, Fox G. Financial Management of Audiology Practices and Clinics. In: HosfordDunn H, Roeser R, and Valente M, eds. Audiology Practice Management, Thieme: New York. 2000. 351&ndash;62.</p>\r\n<p>2. Marshall DH. Accounting: What the Numbers Mean, 6th Edition. New York: McGraw-Hill. 2004. 238&ndash;47.</p>\r\n<p>3. Glaser RG and Traynor RM. Strategic Practice Management. San Diego, CA: Plural Publishing. 2008.</p>',NULL,'2022-11-30'),(41,3245,'ajchr','http://www.andrewjohnpublishing.com/','','<p>Years ago I wrote an article with the title, ?Outside of the audiology room?. I am not sure where I submitted it or if it ever was published, but I was gradually starting to realize (or remember?) that it was what I did outside of normal audiometry that was really audiology, and also that this was really quite important to our clients. I am not sure that the art of audiology is something that can be explicitly taught, but it is something that can be learned. I suspect that it should not be in the university audiology curriculum as a specific course with a specific course number, but it is something that should permeate all of the audiology courses and clinical practicums. Accurate audiometry is certainly important, and this is where the various provincial medicare programs pay for things, but that is only the very beginning. What is sometimes just as important, if not more so, is the interaction that I have with my client? audiology is as important as an art as it is a science. Actually this is precisely what drew me to audiology in the first place. Having completed a degree in theoretical mathematics, I was looking for a field that would allow me to apply the science and also the art ? audiology provided the perfect balance. (Actually speech-language pathology does that as well but I am not smart enough to keep track of the many tests that my speech colleagues need to perform.) All too often, an audiologist does what is ?paid for.? Many of us work in the realm of hearing aids since this is ?what pays the bills.? Hearing tests can be billed through the provincial medical schemes, but the many things that comprise the art of audiology are not ?billable.? It is unfortunate that we live in a market society where the worth of something is defined by its price or the value of a code that can be billed.</p>\r\n<p>This issue of the Canadian Hearing Report has been guest edited by two of my favourite people, Dr. Joanne DeLuzio and Gael Hannan. Joanne DeLuzio has the unique combination of being a clinical audiologist with a PhD in speech-language pathology. She has been teaching applied audiology in the Speech-Language Pathology Program at the University of Toronto since 2000. Her primary area of interest is the importance of social skills development and peer interaction for young children with severe and profound hearing loss. Joanne is an advocate for the removal of barriers for people who are D/deaf and hard of hearing. She has served as vicechair and chair of the board of The Canadian Hearing Society and is currently on the interim board of Hands and Voices. Despite having an odd spelling for her first name, Gael Hannan is a writer, actor, and public speaker who grew up with a progressive hearing loss that is now severe-to-profound. She is a director on the national board of the Canadian Hard of Hearing Association (CHHA) and an advocate whose work includes speechreading instruction, hearing awareness, workshops for youth with hearing loss, and work on hearing access committees. Gael also writes a blog from the consumer?s point of view for HearingHealthMatters.org and is a regular columnist as the Happy HoH for the Canadian Hearing Report. Joanne and Gael have teamed up to remind us all what is really important in the field of audiology ? the interaction between the hearing health care professional and the client. And, they have coordinated an amazing list of authors ranging from Dr. Laya PoostForoosh to Dr. Andre Marcoux. Andre was the first editor-in-chief of the Canadian Hearing Report. They even convinced Dr. Charles Laszlo to write something for them ? actually they probably only needed to ask him once, and he likely jumped at the chance. For those who do not know Charles, he was the guiding force that resulted in the eventual formation of the Canadian Hard of Hearing Association. And, he was the guy who sat beside me at many of the CRTC meetings on hearing aid telephone compatibility in the early 1980s. Thank goodness he was on my side!</p>\r\n<p>I l y a quelques ann&eacute;es, j?ai &eacute;crit un article intitul&eacute;, ?Hors de la chambre d?audiologie?. Je ne suis pas certain o&ugrave; je l?avais soumis ou s?il a jamais &eacute;t&eacute; publi&eacute;, mais petit &agrave; petit, j?ai commenc&eacute; &agrave; r&eacute;aliser (ou me rappeler?) que ce que je faisais en dehors de l?audiom&eacute;trie normale &eacute;tait vraiment de l?audiologie, et que c?&eacute;tait vraiment important pour nos clients. Je ne suis pas certain que l?art de l?audiologie peut &ecirc;tre enseign&eacute; explicitement, mais il peut &ecirc;tre appris. Je doute bien qu?il ne devrait pas &ecirc;tre dans le programme universitaire de l?audiologie comme cours sp&eacute;cifique avec un num&eacute;ro correspondant, mais il devrait infiltrer tous les cours d?audiologie et pratiques cliniques. L?audiom&eacute;trie pr&eacute;cise est certainement importante, et ce que les diff&eacute;rents programmes provinciaux de l?assurance sant&eacute; couvrent, mais c?est seulement le tout d&eacute;but. Ce qui est tout aussi important des fois, si ce n?est plus, est l?interaction que j?ai avec mon clientl?audiologie est tout un art, aussi important que c?est une science. En fait, c?est pr&eacute;cis&eacute;ment ce qui m?a attir&eacute; vers l?audiologie de premier abord. Ayant obtenu un dipl&ocirc;me en math&eacute;matiques th&eacute;oriques, j?&eacute;tais &agrave; la recherche d?un domaine qui me permettrait d?appliquer et la science et l?art?L?audiologie a &eacute;t&eacute; l?&eacute;quilibre parfait. (En fait, l?orthophonie fait pareil mais je ne suis pas assez intelligent pour me tenir au courant de tous les tests que mes coll&egrave;gues orthophonistes ont &agrave; effectuer.) Tout aussi souvent, un audiologiste ex&eacute;cute ce qui ?rembours&eacute;.? Plusieurs d?entre nous exer&ccedil;ons dans le domaine des appareils auditifs &eacute;tant donn&eacute; que c?est ce qui ?couvre nos d&eacute;penses.? Les tests auditifs sont factur&eacute;s &agrave; travers les programmes m&eacute;dicaux provinciaux, mais plusieurs composantes de l?art de l?audiologie ne sont pas ?facturables.? C?est malheureux de vivre dans une soci&eacute;t&eacute; de march&eacute; o&ugrave; la valeur des choses est d&eacute;finie par leurs prix ou la valeur d?un code &agrave; facturer.</p>\r\n<p>Ce num&eacute;ro de La revue canadienne d?audition a comme &eacute;ditrices invit&eacute;es deux de mes personnes favorites, Dr. Joanne DeLuzio et Gael Hannan. Joanne DeLuzio a la combinaison unique d?une audiologiste clinicienne et titulaire d?un doctorat en orthophonie. Elle enseigne l?audiologie appliqu&eacute;e dans le programme de l?orthophonie de l?Universit&eacute; de Toronto depuis l?ann&eacute;e 2000. Son domaine d?int&eacute;r&ecirc;t primaire est l?importance du d&eacute;veloppement des comp&eacute;tences sociales et l?interaction entre paires pour jeunes enfants qui pr&eacute;sentent une perte auditive s&eacute;v&egrave;re et profonde. Joanne milite pour la suppression des barri&egrave;res pour les personnes culturellement sourdes, sourdes et avec perte auditive. Elle a si&eacute;g&eacute; en tant que vice-pr&eacute;sidente et pr&eacute;sidente du conseil d?administration de la soci&eacute;t&eacute; canadienne de l?ou&iuml;e et actuellement si&egrave;ge au conseil int&eacute;rimaire de Hands and Voices. En d&eacute;pit de son pr&eacute;nom &agrave; grammaire inusuelle, Gael Hannan est un auteur, actrice, et oratrice qui a grandi avec une perte auditive progressive qui est maintenant s&eacute;v&egrave;re &agrave; profonde. Elle est directrice au conseil d?administration national de l?association des malentendants canadiens et militante dont le travail inclus la formation en lecture labiale, sensibilisation &agrave; l?ou&iuml;e, ateliers pour les jeunes qui pr&eacute;sentent une perte auditive, et les travaux sur les comit&eacute;s d?acc&egrave;s &agrave; l?audition. Gael a aussi un blog du point de vue du consommateur pour HearingHealthMatters.org et est chroniqueuse r&eacute;guli&egrave;re en tant que the Happy Hoh pour la revue canadienne d?audition. Joanne et Gael font &eacute;quipe pour nous rappeler &agrave; nous tous ce qui est vraiment important dans le domaine de l?audiologie ? l?interaction entre le professionnel des soins de sant&eacute; auditifs et le client. Elles ont coordonn&eacute; une liste extraordinaire d?auteurs allant de Dr Laya Poost-Foroosh au Dr Andr&eacute; Marcoux. Andr&eacute; est le premier &eacute;diteur en chef de la revue canadienne d?audition. Elles ont m&ecirc;me convaincu Dr Charles Laszlo qui a &eacute;crit pour elles? en fait, elles n?ont eu probablement &agrave; lui demander qu?une seule fois, et vraisemblablement, il a saut&eacute; sur l?occasion. Pour ceux et celles qui ne connaissent pas Charles, il est la force qui a abouti &agrave; la formation de l?association des malentendants canadiens. Et, il est le gars qui s?est assis &agrave; mes c&ocirc;t&eacute;s &agrave; plusieurs r&eacute;unions du CRTC au sujet de la compatibilit&eacute; t&eacute;l&eacute;phonique des appareils auditifs au d&eacute;but des ann&eacute;es 80. Dieu merci, il &eacute;tait de mon c&ocirc;t&eacute;!</p>\r\n<p>Joanne DeLuzio (near left), PhD, Audiologist, Reg. CASLPO, is adjunct professor with the Department of Speech-Language Pathology at the University of Toronto. jo.deluzio@utoronto.ca..</p>\r\n<p>Gael Hannan (far left), is a hearing health advocate and a writer on consumer hearing loss issues. gdhannan@rogers.com.</p>\r\n<p>The hearing loss population is booming. Hearing assistive technology has reached unprecedented levels of sophistication and accessibility. Universities and colleges across the country are producing hundreds of educated and skilled hearing health care professionals each year. The number of hearing health clinics and hearing aid retailers is increasing rapidly, and public awareness of hearing loss issues is on the rise. Still, only 20?25% of people who could benefit from hearing aids and aural rehabilitation actually access hearing health care, and those who do often express dissatisfaction with the care they receive. While affordability of hearing aids is acknowledged as a major problem, how hearing health care professionals provide service to their clients is being recognized as an equally important issue. As a consumer with hearing loss (Gael) and a hearing health care professional (Jo), we?ve been interested in this subject for many years. In 2003 we gave a presentation at the Hearing Loss Association of American (HLAA, then SHHH) conference in Atlanta, Georgia. ?Me and My Audie? looked at the importance of the consumer-audiologist partnership. Although the turnout was poor ? we were competing with an ice cream social ? the workshop participants who did attend were thrilled with what they heard. We were convinced (and remain so) that people with acquired hearing loss can reach their optimal level of communication ? that is, living successfully with hearing loss ? if they and their hearing health care professionals engage in a positive, long-term relationship. The concept is simple, but it has been a tough sell. There is a history of mistrust between these two groups. Consumers are not happy with the medical view of hearing loss and the paternalistic perspective of the professional who presumes to know what is best for them. There is widespread suspicion that hearing aids are too often recommended based on monetary gain for the professional, and not on the best fit for the consumer. On the other side of the fence, many hearing health care professionals are defensive. It?s not always easy working with consumers who have unrealistic expectations that are almost impossible to achieve, and who are often angry and in denial about their hearing loss. Many hearing health care professionals feel burnt out. As professionals who have worked hard to perfect their craft, many are tired of being constantly criticized. This is compounded by the fact that, even when they recognize that a client may need more extensive counselling, under the current fee structures, they are not compensated for this service.</p>\r\n<p>So, is it possible to change the existing dynamics to create positive and effective partnerships? Acquired hearing loss has a profound impact on all aspects of a person?s life. When people encounter difficulty with their hearing, they experience a variety of emotions and often do not know where to turn for support. The aural rehabilitative process is complex and often difficult to navigate, especially when the consumer does not know what to expect and/or the professional is not providing it. Technology is changing rapidly and there are copious amounts of information available on the Internet, some of which is misleading. Slick advertisements promise people with acquired hearing loss the latest in invisible hearing aids, perfect hearing in quiet situations, and DVD-quality sound.</p>\r\n<p>Consequently, consumers need a hearing health care professional who will take the time to understand their unique listening needs and help them to sift through a variety of amplification products and other necessary communication strategies. This is not a ?one shot? deal. Acquired hearing loss is for life and so is the need for constructive hearing health care, which ideally includes the cultivation of a long-term relationship between the consumer and the hearing health care professional. This relationship must be based on mutual trust and respect to be successful. Consumers need to understand and be involved in all recommendations and aspects of their care. They need to develop reasonable expectations about how they can achieve the best possible outcomes. Both parties have important roles and share responsibility for creating a clear vision and a clear path to optimal communication. ?Aural Rehab? is not limited to a course of action that a hearing health care professional prescribes. The process really begins with the first suspicion of hearing loss and continues throughout the lifespan. Mark Ross, esteemed audiologist and professor emeritus at the University of Connecticut, has often reported on the 8-week, full-time aural rehabilitation program he attended at the Walter Reed Army Medical Center in 1952. According to Dr. Ross, diagnostic tests and hearing aid fittings were provided, but the program also focused on ?lipreading? and auditory training, as well as memory and cognitive training. He also speaks of the invaluable support the participants in these groups provided for each other. Wearable hearing aids were not well developed at that time but they were nevertheless seen as an integral part of the whole program to improve communication and facilitate living with hearing loss. It is somewhat ironic that 60 years later hearing aids are no longer considered as a program component. They are viewed as an end in themselves, a self-contained treatment for hearing impairment. To be sure, hearing aids are now highly evolved, but we feel that the industry has lost sight of the real goal, and has shifted its focus from people and communication to instrumentation and technology.</p>\r\n<p>In guest editing this issue of Canadian Hearing Report, we are offering the views of both consumers and professionals. We share the belief that there is a need for a new model of hearing care that provides better benefits for both parties, a course of care that presents the big picture of living successfully with hearing loss, an ongoing process that involves professional assessment, mental preparation, technology, and a wide array of communication strategies. Support comes from many sources including family, friends, co-workers, and support groups, but the single most important resource, other than the person themselves, is the trained hearing health care professional. The central theme of the journal is the pivotal role of this relationship. From the very first meeting ? the client with hearing loss and the hearing health care professional whose role is to be of service ? a collaborative partnership must form which will provide powerful benefits to both parties. Both partners have clearly defined roles and they share the responsibility for success. Otherwise, audiologists will continue to struggle with clients who balk at every suggestion, and hard of hearing clients who, if they are not exposed to additional communication strategies beyond their hearing aids, will not develop the best possible skills to successfully manage their communication difficulties. In this journal, you will read about a client-centered model for hearing aid delivery proposed by Poost-Foroosh. We agree with Poost-Foroosh that the impact of hearing loss on a person is highly complex, and cannot be understood without examining that person?s perspective on how they function in environments that are specific and important to them. Her paper offers valuable insights on how clinicians can provide more clientcentred service. Dr. Andr&eacute; Marcoux, professor of audiology at the University of Ottawa, describes his active model for a client-centred practice. Charles Lazlo, a founding member of both the Canadian Hard of Hearing Association and the International Federation of Hard of Hearing People, writes about the pivotal role of technology in his life and why hearing health care professionals need to educate themselves and their clients about integrating technology into their daily activities.</p>\r\n<p>At the time of writing, a joint communiqu&eacute; was released by the Academy of Doctors of Audiology, the American Speech-Language-Hearing Association and the American Academy of Audiology. This ground-breaking statement recognizes the changing face of the hearing health care environment and calls on the hearing health care community to focus on consumer needs in their service delivery. This statement has been publicly applauded by the Hearing Loss Association of America. How these recommendations will be adopted by health care professionals remains to be seen, but it?s our hope that Canadian hearing health care organizations will rise to the challenge, by adopting and promoting similar standards of health care delivery for  Canadians with hearing loss. The ultimate goal of aural rehabilitation is ?optimal communication? for the consumer/client. But what exactly does that mean? (As an aside, we are still searching for a better phrase to describe this concept that does not sound like a brand of hearing aid or yogurt.) Optimal communication will be different for everyone, involving an individual mix of communication tools. It necessitates addressing all of the feelings and emotions associated with hearing loss (e.g., anger, denial, frustration, isolation, stress on relationships, etc.) as well as understanding technology and how it can be used to maximize understanding of speech and overall functioning. Optimal communication for one person might require sound awareness and auditory training or it could mean speechreading training. As well, there are a host of other communication tips (environmental manipulation, preparatory, speaker and listener strategies) that can be used. Assertiveness training, advocacy skills, and obtaining support from others can all be part of someone?s ?optimal communication? package. Ideally the person with hearing loss and the hearing health care professional will implement a variety of technologies and strategies over the years that can be re-evaluated and changed as the person?s hearing and listening needs change, or as technology evolves. We hope you enjoy this issue that offers different perspectives on a service model in which, together, ?me and my audie? can work in partnership to remove barriers to communication and promote living well with hearing loss. Hopefully ? and soon ? this concept will no longer be a tough sell, but the new reality.</p>\r\n<p>Joanne DeLuzio, Audiologiste, Reg. CASLPO, est professeur adjointe au d&eacute;partement d`audiologie &agrave; l?Universit&eacute; de Toronto. jo.deluzio@utoronto.ca.</p>\r\n<p>Gael Hanna est militante pour les droits des personnes avec perte auditive. gdhannan@rogers.com</p>\r\n<p>La population de la perte auditive est en pleine croissance. La technologie d?assistance auditive a atteint des niveaux sans pr&eacute;c&eacute;dents de sophistication et accessibilit&eacute;. Les universit&eacute;s et les coll&egrave;ges &agrave; travers le pays forment et produisent des centaines de professionnels des soins de sant&eacute; auditifs comp&eacute;tents chaque ann&eacute;e. Le nombre de cliniques de sant&eacute; auditive et de d&eacute;taillants d?appareils auditifs augmente rapidement, et la sensibilisation du grand public aux enjeux de la perte auditive est en croissance. Toutefois, seulement 20?25% des personnes qui pourraient b&eacute;n&eacute;ficier de l?utilisation d?appareils auditifs et de r&eacute;&eacute;ducation auditive, ont acc&egrave;s aux soins de sant&eacute; auditifs, et celles qui le font expriment souvent leur insatisfaction des soins qu?elles re&ccedil;oivent. Tandis que l?abordabilit&eacute; des appareils auditifs est reconnu comme probl&egrave;me majeur, la mani&egrave;re avec laquelle les professionnels des soins de sant&eacute; auditifs offre leur service &agrave; leurs clients est un enjeu d?importance &eacute;gale. En tant que consommatrice vivant avec la perte auditive (Gael) et une professionnelle des soins de sant&eacute; auditifs (Jo), le sujet nous int&eacute;ressait depuis bien longtemps. En 2003, nous avons pr&eacute;sent&eacute; &agrave; la conf&eacute;rence de the Hearing Loss Association of American (HLAA, jadis la SHHH) qui s?est tenue &agrave; Atlanta, dans l?&eacute;tat de Georgia. ?Me and My Audie? explorait l?importance du partenariat consommateur-audiologiste. M&ecirc;me si le taux de participation a &eacute;t&eacute; faible ? on pr&eacute;sentait au m&ecirc;me temps qu?une activit&eacute; sociale impliquant de la cr&egrave;me glac&eacute;e? ceux pr&eacute;sents &agrave; l?atelier &eacute;taient fr&eacute;missants par ce qu?ils avaient entendu. Nous &eacute;tions convaincues (et le sommes encore) que les personnes avec une perte auditive acquise peuvent atteindre leur niveau optimal de communication? &eacute;tant de vivre avec succ&egrave;s leur perte auditive? si elles et leurs professionnels de soins de sant&eacute; auditifs s?engagent dans une relation positive au long terme.</p>\r\n<p>Le concept est simple, mais tr&egrave;s dur &agrave; vendre. Les ant&eacute;c&eacute;dents de m&eacute;fiance entre ces deux groups ne facilitent pas la t&acirc;che. Les consommateurs ne sont pas contents de la vision m&eacute;dicale de la perte auditive et la perspective paternaliste des professionnels qui pr&eacute;sument savoir ce qui est mieux pour eux. Une suspicion g&eacute;n&eacute;ralis&eacute;e que les appareils auditifs sont tr&egrave;s souvent recommand&eacute;s pour des profits pour le professionnel, et non pour l?int&eacute;r&ecirc;t du consommateur. De l?autre c&ocirc;t&eacute;, plusieurs professionnels des soins de sant&eacute; auditifs sont sur la d&eacute;fensive. Il n?est pas toujours facile de travailler avec des consommateurs qui ont des attentes chim&eacute;riques qui sont presque impossibles &agrave; r&eacute;aliser, et qui sont souvent en col&egrave;re et en d&eacute;ni de leur perte auditive. Plusieurs professionnels des soins de sant&eacute; auditifs se sentent &eacute;puis&eacute;s. Comme professionnels qui ont travaill&eacute; tr&egrave;s fort &agrave; perfectionner leur art, plusieurs sont fatigu&eacute;s d?&ecirc;tre critiqu&eacute;s tout le temps. Ceci est cumul&eacute; avec le fait que, m&ecirc;me quand ils reconnaissent qu?un client pourrait avoir besoin de counseling intensif, sous la structure de frais appliqu&eacute;e actuellement, ils ne sont pas indemnis&eacute;s pour ce service.</p>\r\n<p>Alors, est-il possible de changer la dynamique existante pour cr&eacute;er des partenariats positifs et efficaces ? La perte auditive acquise a un impact profond sur tous les aspects de la vie d?une personne. Quand les personnes se heurtent aux difficult&eacute;s &agrave; cause de leur ou&iuml;e, elles font l?exp&eacute;rience d?&eacute;motions vari&eacute;es et  souvent ne savent pas o&ugrave; aller trouver le soutien. Le processus de r&eacute;&eacute;ducation auditive est complexe et souvent difficile &agrave; naviguer, sp&eacute;cialement quand le consommateur ne sait pas &agrave; quoi s?attendre et/ou le professionnel ne l?offre pas. La technologie est en changement rapide et de copieuses quantit&eacute;s d?informations sont disponibles sur internet, et certaines sont trompeuses. Les publicit&eacute;s adroites promettent aux gens qui ont une perte auditive acquise le dernier cri des appareils auditifs invisibles, parfaite ou&iuml;e dans des situations tranquilles, avec une qualit&eacute; de son de DVD. Par cons&eacute;quent, les consommateurs ont besoin d?un professionnel des soins de sant&eacute; auditifs qui prendra le temps de comprendre leurs besoins de r&eacute;ception uniques et les aidera &agrave; s&eacute;lectionner parmi la grande vari&eacute;t&eacute; des produits d?amplifications et autres strat&eacute;gies de communications n&eacute;cessaires. Ceci n?est certainement pas une transaction sans r&eacute;currence. La perte auditive acquise est pour la vie et tout aussi le besoin pour des soins de sant&eacute; auditifs constructifs, qui id&eacute;alement incluent la culture d?une relation au long terme entre le consommateur et le professionnel des soins de sant&eacute; auditifs. Cette relation doit se baser sur une confiance et un respect mutuels pour avoir du succ&egrave;s. Les consommateurs ont besoin de comprendre et d?&ecirc;tre impliqu&eacute;s dans toutes les recommandations et aspects de leurs soins. Ils ont besoin de d&eacute;velopper des attentes raisonnables des r&eacute;alisations des meilleurs r&eacute;sultats possibles. Les deux parties ont des r&ocirc;les importants et partagent la responsabilit&eacute; pour la cr&eacute;ation d?une vision et d?une trajectoire claires &agrave; une communication optimale. ?La r&eacute;&eacute;ducation auditive? n?est pas limit&eacute;e &agrave; un plan d?action qu?un professionnel des soins de sant&eacute; auditifs prescrit. Le processus commence r&eacute;ellement avec le premier soup&ccedil;on de perte auditive et continue &agrave; travers la dur&eacute;e de la vie.</p>\r\n<p>Mark Ross, audiologiste respect&eacute; et professeur &eacute;m&eacute;rite &agrave; the University of Connecticut, a souvent rapport&eacute; sur le programme &agrave; temps plein de 8 semaines en r&eacute;&eacute;ducation auditive auquel il a particip&eacute; au the Walter Reed Army Medical Center en 1952. Selon Dr Ross, les tests de diagnostic et l?ajustement des appareils auditifs ont &eacute;t&eacute;s fournis, mais le programme s?est aussi centr&eacute; sur ? la lecture labiale? et l?&eacute;ducation auditive, tout aussi bien que le d&eacute;veloppement des comp&eacute;tences cognitives et de m&eacute;morisation. Il &eacute;voque aussi le soutien inestimable des participants les uns aux autres dans ces groupes. Les appareils auditifs portables n?&eacute;taient pas tr&egrave;s d&eacute;velopp&eacute;s &agrave; l?&eacute;poque pourtant ils &eacute;taient per&ccedil;us comme partie int&eacute;grale du programme complet pour am&eacute;liorer la communication et faciliter la vie avec la perte auditive. Il est plut&ocirc;t ironique que 60 ans apr&egrave;s, les appareils auditifs ne sont plus consid&eacute;r&eacute;s comme composants du programme. Ils sont vus comme une fin en soi, un traitement autonome pour la d&eacute;ficience auditive. C?est s&ucirc;r, les appareils auditifs sont maintenant tr&egrave;s &eacute;volu&eacute;s, mais nous avons le sentiment que l?industrie a perdu de vue les objectifs r&eacute;els, et a d&eacute;plac&eacute; sa concentration sur les personnes et la communication vers l?instrumentation et la technologie. En tant qu?&eacute;ditrices invit&eacute;es de ce num&eacute;ro de la revue canadienne d?audition, nous pr&eacute;sentons les points de vue des consommateurs et professionnels. Nous partageons le m&ecirc;me point de vue que le besoin se fait sentir pour un nouveau mod&egrave;le de soins de sant&eacute; auditifs qui fournit de meilleurs avantages pour les deux parties, un plan de soins qui pr&eacute;sente la grande perspective de vie avec succ&egrave;s sa perte auditive, un processus continu qui implique l?&eacute;valuation professionnelle, la pr&eacute;paration mentale, la technologie, et une large gamme de strat&eacute;gies de communication. Le soutien provient de sources diff&eacute;rentes, la famille, les amis, les coll&egrave;gues de travail et les groupes de soutien, mais la plus importante et unique ressource, autre que la personne en soi, est le professionnel de soins de sant&eacute; auditif qualifi&eacute;. Le th&egrave;me central de cette revue est le r&ocirc;le cl&eacute; de cette relation. D&egrave;s la premi&egrave;re r&eacute;union? le client qui pr&eacute;sente une perte auditive et le professionnel des soins de sant&eacute; auditif dont le r&ocirc;le est de servir? un partenariat de collaboration doit se former et va fournir des avantages puissants aux deux parties. Les deux partenaires ont des r&ocirc;les clairement d&eacute;finis et ils partagent la responsabilit&eacute; de la r&eacute;ussite. Autrement, les audiologistes continueront &agrave; avoir des difficult&eacute;s avec les clients qui flanchent &agrave; chaque suggestion, et les clients malentendants qui, s?ils ne sont pas expos&eacute;s &agrave; des strat&eacute;gies de communication au-del&agrave; des appareils auditifs, ne vont pas d&eacute;velopper les meilleures comp&eacute;tences possibles pour g&eacute;rer avec succ&egrave;s leurs difficult&eacute;s de communication. Dans cette revue, vous aller en savoir plus sur un mod&egrave;le de prestation de service des appareils auditifs centr&eacute; sur le client propos&eacute; par Poost-Foroosh. Nous sommes d?accord avec PoostForoosh que l?impact de la perte auditive sur une personne est tr&egrave;s complexe, et ne peut &ecirc;tre compris sans examiner la perspective de la personne sur son fonctionnement dans des environnements qui sont sp&eacute;cifiques et importants pour elle. Son papier offre un aper&ccedil;u pr&eacute;cieux sur un service centr&eacute; sur le client que les cliniciens peuvent offrir.</p>\r\n<p>Dr Andr&eacute; Marcoux, professeur en audiologie &agrave; l?Universit&eacute; d?Ottawa, d&eacute;crit son mod&egrave;le actif pour un cabinet centr&eacute; sur le client. Charles Lazlo, un membre fondateur de l?association des malentendants canadiens et the International Federation of Hard of Hearing People, fait &eacute;tat du r&ocirc;le cl&eacute; de la technologie dans sa vie et de la n&eacute;cessit&eacute; que les professionnels des soins de sant&eacute; auditifs forment et instruisent leurs clients sur l?int&eacute;gration de la technologie dans leurs activit&eacute;s quotidiennes. Au moment de l?&eacute;laboration de ce papier, un communiqu&eacute; conjoint a &eacute;t&eacute; diffus&eacute; par the Academy of Doctors of Audiology, the American SpeechLanguage-Hearing Association et the American Academy of Audiology. Cette d&eacute;claration in&eacute;dite reconnait le faci&egrave;s changeant de l?environnement des soins de sant&eacute; auditifs et appelle la communaut&eacute; des soins de sant&eacute; auditifs &agrave; se concentrer sur les besoins du consommateur dans leur prestation de service. Cette d&eacute;claration a &eacute;t&eacute; publiquement applaudie par statement recognizes the changing face of the hearing environment and calls on the hearing healthcare community to focus on consumer needs in their service delivery. This statement has been publicly applauded by the Hearing Loss Association of America. Comment seront adopt&eacute;es ces recommandations par les professionnels des soins de sant&eacute; reste &agrave; voir, mais c?est notre souhait que les organisations canadiennes des soins de sant&eacute; auditifs vont se montrer &agrave; la hauteur de la situation en adoptant et en faisant la promotion de normes similaires pour la prestation des services pour les canadiens vivant avec une perte auditive. How these recommendations will be adopted by healthcare professionals remains to be seen, but it?s our hope that Canadian hearing healthcare organizations will rise to the challenge, by adopting and promoting similar standards of healthcare delivery for Canadians with hearing loss. L?objectif ultime de la r&eacute;&eacute;ducation auditive est ?la communication optimale? pour le consommateur/client. Mais &ccedil;a veut dire quoi exactement? (Comme en apart&eacute;, nous sommes toujours &agrave; la recherch&eacute; d?une meilleure phrase pour d&eacute;crire ce concept qui sonne comme une publicit&eacute; pour une marque d?appareil auditif ou yogourt.) La communication optimale est diff&eacute;rente pour tous, elle implique un m&eacute;lange individuel d?outils de communications, elle n&eacute;cessite une r&eacute;ponse &agrave; tous les sentiments et &eacute;motions associ&eacute;s avec la perte auditive (ex., col&egrave;re, d&eacute;ni, frustration, isolement, stress dans les relations, etc.) et aussi une compr&eacute;hension de la technologie et son utilisation pour maximiser la compr&eacute;hension du discours et le fonctionnement en g&eacute;n&eacute;ral. La communication optimale pour une personne pourrait exiger la sensibilisation au son et une &eacute;ducation auditive ou signifier une formation sur la lecture labiale. Aussi, une multitude d?autres atouts de communication (Strat&eacute;gies pour orateur et auditeur, de pr&eacute;paration et de manipulation environnementale) peuvent &ecirc;tre utilis&eacute;es. La formation sur la confiance en soi, les comp&eacute;tentes pour le travail de d&eacute;fense, et l?obtention de soutien d?autres peuvent faire partie du paquet ?communication optimale? d?une personne. Id&eacute;alement, la personne qui pr&eacute;sente une perte auditive et le professionnel des soins de sant&eacute; auditifs vont mettre en ?uvre une vari&eacute;t&eacute; de technologies et strat&eacute;gies &agrave; r&eacute;&eacute;valuer et changer au fur et &agrave; mesure que les besoins en ou&iuml;e et &eacute;coute changent, ou &agrave; mesure que la technologie &eacute;volue.</p>\r\n<p>Nous esp&eacute;rons que vous allez prendre du plaisir &agrave; lire suppl&eacute;ment qui offre des perspectives diff&eacute;rentes en un mod&egrave;le de service dans lequel, ensemble, ?Mon audie et moi? peut fonctionner en partenariat pour supprimer les barri&egrave;res &agrave; la communication et faire la promotion du bien &ecirc;tre avec une perte auditive. Esp&eacute;rons ? et bient&ocirc;t ? que ce concept ne soit pas dur &agrave; vendre, mais plut&ocirc;t la nouvelle r&eacute;alit&eacute;.</p>\r\n<p>steve Aiken President, Canadian Academy of Audiology steve.aiken@dal.ca</p>\r\n<p>As I walked in the door after being away for a week at our conference, my youngest, Isaac, who has just learned to talk, jumped into my arms and shouted ?Dada?! Is there anything better than this? When you stop and think about how important communication is for what it means to be human, it is truly staggering. We are defined by our relationships and our communities; we are social beings to the core. Audiologists play an incredibly important role helping people with this most basic aspect of human existence. Our community has many dedicated members that work hard every day to help people overcome barriers in communication. It?s easy to become lost in the details, to get caught up in the tensions of the moment ? busy waiting rooms, hearing aid fitting problems, diagnostic puzzles and challenges with third-party payers ? but it?s worth stepping back and looking at the big picture. The challenges will always be there, but the challenges associated with untreated hearing loss are worse: educational problems, lost employment opportunities, dementia, and social isolation. That is why our work is so important. In spite of this, audiology is still relatively unknown. Many people don?t know who we are or what we do, and how we fit into the health care system. They know about optometrists and dentists, but not audiologists. Once, after telling someone that I was an audiologist, I was asked ?How can you make money studying ideas?? I probably should have given her my card! People need to know about the importance of visiting an audiologist, of taking care of their hearing, and of seeking treatment for hearing loss and tinnitus. And governments need to know about the importance of our services and the need for adequate funding. Communication is not an optional part of the human experience.</p>',NULL,'2022-11-30'),(42,3234,'ajchr','http://www.andrewjohnpublishing.com/','','<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-1-1-g001.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-1-1-g002.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-1-1-g003.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-1-1-g004.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-1-1-g005.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" 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INSERT INTO `fulltext_content` VALUES (43,3244,'ajchr','http://www.andrewjohnpublishing.com/','','<p>As Charles Dickens wrote in The Tale of Two Cities in the 19th century, &ldquo;These are the best of columns; these are the worst of columns &hellip; well, actually he never wrote that, but if he would have read the columns in this issue of the Canadian Hearing Report I am sure that he would have been impressed and would have re-titled his famous book A Tale of a Whole Bunch of Great Columns. Not quite as catchy but at least nobody gets beheaded during the French revolution.</p>\r\n<p>In this issue we see the introduction of some new columns, in addition to some oldies. Gael Hannan is a consumer advocate for people living with hearing loss. She works with hearing-related organizations to raise awareness of hearing loss issues, and has delivered her signature presentations EarRage! and Unheard Voices to audiences across North America and New Zealand. Gael is currently a director on the national board of the Canadian Hard of Hearing Association (CHHA). Her column, &ldquo;From the Consumer&rdquo; says it all and Gael starts with a resounding call for cooperation between the consumer and the hearing health care professional. Another new column, &ldquo;All Things Central&rdquo; is about all things central, at least as far as central auditory processing disorders are concerned. The column is written by Dr. Kim Tillery, PhD. She is a professor in and chairperson of the Department of Communication Disorders and Sciences at the State University of New York at Fredonia and also has a private practice in diagnosing and treating individuals with (C)APD. Kim has presented over 90 workshops and presentations at national, international and regional conferences, and has authored and co-authored several book chapters and journal articles on (C)APD. And why stop there? Calvin Staples is well known for his work on the analysis and inherent variability of first fit algorithms for hearing aids. He is currently an instructor at Conestoga College in Kitchener and is also a world-class long distance runner. Calvin has agreed to select several blog entries for every issue of the Canadian Hearing Report from www.hearinghealthmatters.org. A group of well-known audiologists and other hearing health care professionals have formed this blog. Calvin will be selecting some of the more interesting entries and these will be reprinted with permission in our old fashioned print publication &ndash; how&rsquo;s that for retro? And speaking of retro, it&rsquo;s time to dust off our old books. A semiregular column (and with your input, perhaps a regular one) called &ldquo;From the Dusty Bookshelves&rdquo; makes its debuts in this issue. Recently Dr. Richard Seewald gave me the honour of having a first kick at the can for acquiring his old books when he was recently cleaning out his office at the University of Western Ontario. I&rsquo;ve been spending far too much time reading some really amazing publications from the 1940s, 1950s and 1960s &ndash; many of which are now out of print. I thought it appropriate to review one of these old books. Quite frankly, if we don&rsquo;t then who will and they will be lost to oblivion. For this issue of From the Dusty Bookshelves, I have done a review of Forty Germinal Papers in Human Hearing edited by J. Donald Harris, in 1969. Dr. Harris published this and the now discontinued Journal of Auditory Research, in his basement. I would like to issue a call for any of our readers to also review an old, possibly out of print text or monograph they may have on their bookshelves for future incarnations of this column. This issue of the Canadian Hearing Report also has a peer reviewed article entitled &ldquo;Can Acceptable Noise Levels Be Predicted from a Noise Tolerance Questionnaire?&rdquo; All articles submitted to CHR have the option of being peer reviewed or not and this decision is clearly indicated. The process of peer review can be difficult but the benefits can be substantial resulting in a better overall publication. Another excellent article reviews an interesting new innovation that appears to be storming the industry, &ldquo;A new Approach to Protection&rdquo; &ndash; well, at least for the manufacturers. The nano-coating of hearing aid circuitry to minimize moisture contamination may be a long-awaited solution to this annoying repair rate problem. Switching gears, a number of academic clinical coordinators from around the country have put together an excellent piece on supervision and student placement in private practice settings. With private practice being the number one employer of new audiologists this is a welcome and fascinating article. One of the authors was actually a supervisor of mine way back in 1980 when private practice was just a gleam in people&rsquo;s eyes. And finally, Karen Winter recounts her trip to Germany. Karen has Usher&rsquo;s syndrome but her limited vision and hearing certainly hasn&rsquo;t slowed her down. This trip and those like it are designed to be accessible and with a few alterations, have offered some intrepid world travellers the chance to travel in safety. Whenever I hear about a venue, vehicle, or a trip being made accessible, my first reaction is &ldquo;why didn&rsquo;t I think about that?&rdquo; Sometimes we all need to be reminded that equity does not mean equality. I wish everyone a safe and pleasant summer season &hellip; and wear a hat.</p>\r\n<p>Comme Charles Dickens l&rsquo;a &eacute;crit dans Le conte de deux cit&eacute;s au 19&egrave;me si&egrave;cle, &ldquo;Ce sont les meilleures colonnes; ce sont les pires colonnes &hellip; bon, il ne l&rsquo;a vraiment jamais &eacute;crit, mais s&rsquo;il devait lire les colonnes de ce num&eacute;ro de la Revue Canadienne d&rsquo;audition, je suis convaincu qu&rsquo;il serait impressionn&eacute; et aurait titr&eacute; son c&eacute;l&egrave;bre livre Le conte d&rsquo;un nombre de colonnes formidables. Pas aussi accrocheur mais au moins personne ne passe par la guillotine durant la r&eacute;volution fran&ccedil;aise.</p>\r\n<p>Dans ce num&eacute;ro, nous verrons l&rsquo;introduction de nouvelles colonnes, en plus des anciennes. Gael Hannan est une d&eacute;fenseuse des consommateurs vivant avec une perte auditive. Elle travaille avec des organisations li&eacute;es &agrave; l&rsquo;audition pour sensibiliser aux enjeux de la perte auditive, et a livr&eacute; ses pr&eacute;sentations de marque Rage &agrave; l&rsquo;oreille et Voix non entendues pour des audiences &agrave; travers l&rsquo;Am&eacute;rique du nord et la nouvelles Z&eacute;lande. Gael si&eacute;ge actuellement au conseil d&rsquo;administration de l&rsquo;association des malentendants canadiens. Sa colonne &ldquo;Du consommateur &rdquo; en dit long et commence par un appel haut et fort pour une coop&eacute;ration entre le consommateur et les professionnels des soins de sant&eacute; auditifs. Une autre nouvelle colonne, &ldquo;All Things Central&rdquo; touche &agrave; tout ce qui est central, du moins au sujet des d&eacute;ficits des processus auditifs. La colonne est du Dr Kim Tillery. Elle est professeur et directrice du d&eacute;partement des sciences et des troubles de communication &agrave; the State University de New York &agrave; Fredonia et exerce en cabinet priv&eacute;, sa sp&eacute;cialit&eacute; est le diagnostic et le traitement des personnes qui souffrent des d&eacute;ficits des processus auditifs. Kim a r&eacute;dig&eacute; et co r&eacute;dig&eacute; plusieurs chapitres de livres et articles de journaux traitant des d&eacute;ficits des processus auditifs. Elle a pr&eacute;sent&eacute; plus de 90 ateliers et pr&eacute;sentations &agrave; des conf&eacute;rences nationales, internationales et r&eacute;gionales au sujet des d&eacute;ficits des processus auditifs centraux. Et pourquoi en rester la ? Calvin Staples est bien r&eacute;put&eacute; pour son travail d&rsquo;analyse des appareils auditifs et des variabilit&eacute;s inh&eacute;rentes des premiers algorithmes adaptes. Il travaille actuellement comme instructeur au College Conestoga &agrave; Kitchener et il est aussi un coureur de distance de renomm&eacute;e mondiale. Calvin a accept&eacute; de s&eacute;lectionner plusieurs soumissions de blog pour chaque num&eacute;ro de la Revue Canadienne d&rsquo;audition provenant du www.hearinghealthmatters.org. Un groupe compos&eacute; d&rsquo;audiologistes de renom et autres professionnels des soins de sant&eacute; auditifs sont &agrave; l&rsquo;origine de ce blog. Calvin va s&eacute;lectionner quelques unes des soumissions int&eacute;ressantes et celles ci vont &ecirc;tre reproduites avec permission dans notre publication &agrave; impression &agrave; l&rsquo;ancienne &ndash; Plus retro que ca ? En parlant de retro, il est temps de d&eacute;poussi&eacute;rer nos livres anciens. Une colonne semi r&eacute;guli&egrave;re (et avec votre participation, peut-&ecirc;tre une participation r&eacute;guli&egrave;re) sous le nom de &ldquo;Des &eacute;tag&egrave;res poussi&eacute;reuses &rdquo; fait son apparition dans ce num&eacute;ro. R&eacute;cemment, Dr. Richard Seewald m&rsquo;a fait l&rsquo;honneur de me laisser me servir le premier en me portant acqu&eacute;reur de ses livres anciens quand il a nettoy&eacute; son bureau &agrave; the University of Western Ontario. J&rsquo;ai pass&eacute; beaucoup trop de temps &agrave; lire ces publications extraordinaires des ann&eacute;es 40, 50 et 60 &ndash; dont certaines qui sont aujourd&rsquo;hui &eacute;puis&eacute;es. J&rsquo;ai pens&eacute; qu&rsquo;il serait ad&eacute;quat de revisiter un de ces livres anciens. Franchement, si nous ne le faisons pas, qui le ferait et ils tomberaient dans l&rsquo;oubli. Pour ce num&eacute;ro des &eacute;tag&egrave;res poussi&eacute;reuses, j&rsquo;ai revisit&eacute; Forty Germinal Papers in Human Hearing de J. Donald, en 1969. Dr. Harris a publi&eacute; ceci et le Journal of Auditory Research qui a cess&eacute; de para&icirc;tre depuis, dans sa cave. Je voudrais lancer un appel &agrave; tous nos lecteurs pour qu&rsquo;ils revisitent des textes anciens ou monographies qui peut-&ecirc;tre ont cess&eacute; de para&icirc;tre, qu&rsquo;ils peuvent avoir dans leurs biblioth&egrave;ques pour des futures apparitions dans cette colonne. Ce num&eacute;ro de la Revue Canadienne d&rsquo;audition contient aussi un article &eacute;valu&eacute; par les paires dont le titre est &ldquo;Peut-on pr&eacute;voir des niveaux acceptables de bruit &agrave; partir du questionnaire de tol&eacute;rance au bruit ? &rdquo; Tous les articles soumis &agrave; la Revue Canadienne d&rsquo;audition ont l&rsquo;option d&rsquo;&ecirc;tre &eacute;valu&eacute;s par les paires ou pas et cette d&eacute;cision est clairement indiqu&eacute;e. Le processus d&rsquo;&eacute;valuation par les paires peut&ecirc;tre difficile mais les avantages peuvent &ecirc;tre importants r&eacute;sultant en une publication meilleure. Un autre excellent article &eacute;value une nouvelle innovation int&eacute;ressante qui semble avoir l&rsquo;effet d&rsquo;une temp&ecirc;te qui secoue l&rsquo;industrie, &ldquo;Une nouvelle approche &agrave; la protection&rdquo; &ndash; bon, au moins pour les fabricants. Le nano rev&ecirc;tement du circuit des appareils auditifs pour minimiser la contamination par l&rsquo;humidit&eacute; pourrait &ecirc;tre la solution tant attendue au probl&egrave;me contrariant de la fr&eacute;quence des r&eacute;parations.</p>\r\n<p>Changeons de registre, des coordinateurs cliniciens en milieu universitaires &agrave; travers le pays ont cr&eacute;&eacute; un excellent travail sur la supervision et le placement des &eacute;tudiants en cabinet priv&eacute;. Les cabinets priv&eacute;s &eacute;tant les premiers employeurs des nouveaux audiologistes, cet article fascinant est le bienvenu. Un des auteurs en fait &eacute;tait mon superviseur en 1980 quand l&rsquo;exercice en cabinet priv&eacute; &eacute;tait juste un r&ecirc;ve pour le publique. Et finalement, Karen Winter retrace son voyage en Allemagne. Karen souffre du syndrome d&rsquo;Usher mais sa vision et son ou&iuml;e limit&eacute;es ne l&rsquo;ont certainement pas ralentie. Ce voyage et d&rsquo;autres du m&ecirc;me genre sont con&ccedil;us pour qu&rsquo;ils soient accessibles et avec quelques modifications, ils ont offert &agrave; certains voyageurs intr&eacute;pides du monde l&rsquo;occasion de voyager en s&eacute;curit&eacute;. A chaque fois que qu&rsquo;on me parle d&rsquo;un endroit, v&eacute;hicule ou voyage rendu accessible, ma premi&egrave;re r&eacute;action est &ldquo;pourquoi n&rsquo;y ai je pas pens&eacute; ? &rdquo;. Des fois, nous avons tous besoin qu&rsquo;on nous rappelle qu&rsquo;&eacute;quit&eacute; ne veut pas forcement dire &eacute;galit&eacute;. Je vous souhaite une saison d&rsquo;&eacute;t&eacute; plaisante et s&eacute;curitaire&hellip; et portez un chapeau.</p>\r\n<p>Dear Dr. Marshall Chasin and Dr. Joanne DeLuzio,</p>\r\n<p>I would like to offer my sincere thanks for your generous support of my oneweek Northern Initiative clinical placement opportunity in Attawapiskat, Ontario through your Seminars in Audition Scholarship. The week I spent in Attawapiskat was truly an amazing experience. During that time my supervisor and I performed hearing screenings on 60 children and 10 adults in the community. The majority of the testing was performed at the local school, though we were also able to expand the Northern Initiative program to the hospital this year. While there we were able to set up our equipment and test some of the local elders of the community who are currently residing in long-term care. The Northern Initiative placement gave me with the opportunity to provide audiological services to an extremely remote and underserviced area in Northern Ontario. Through this placement I gained invaluable experience and understanding of First Nations culture and of the adaptability required in this field when testing in non-clinical conditions. Again I would like to extend my sincere thanks for your generous support of this endeavour. It was truly a rewarding and life-altering experience for which I am deeply grateful to have been a part of.</p>\r\n<p>AudiologyOnline, the leading online resource for audiology and the hearing profession, today announced that Gus Mueller, PhD., has joined the site as contributing editor. In this role, Dr. Mueller will manage a new monthly feature on AudiologyOnline entitled &ldquo;20Q with Gus Mueller&rdquo; that will examine the latest topics in audiology and hearing science with other leading experts in the field. In addition to providing professionals up-to-the-minute practical information in a variety of areas, 20Q with Gus Mueller will also be available as a text CE activity for AudiologyOnline CEU Total Access members. Dr. Mueller will also lend his expertise to enhancing the AudiologyOnline eLearning live and recorded course offerings, particularly in the area of hearing instrument technology and best practices for selection, fitting, verification and achieving successful outcomes with amplification. AudiologyOnline President Paul Dybala stated, &ldquo;Dr. Mueller is one of the foremost leading experts on hearing instruments, as well as a gifted presenter and author. As a contributing editor at AudiologyOnline, his expertise at navigating the complex world of evidenced-based research for our everyday use in the clinic and with our patients is going to benefit AudiologyOnline readers around the world. We&rsquo;re very excited to be working with him in this capacity.&rdquo; Dr. Mueller is professor of audiology, Vanderbilt University, and has a private consulting practice nestled between the tundra and reality in Bismarck, ND. He also has faculty appointments at the University of Northern Colorado and Rush University. Dr. Mueller is a founder of the American Academy of Audiology, a Fellow of the ASHA and is the hearing aids series editor for Plural Publishing. He also is one of the earGuys at earTunes.com. Dr. Mueller is an internationally known workshop lecturer, and has published nearly 200 articles and book chapters on diagnostic audiology and hearing aid applications. He is the senior author of the books Communication Disorders in Aging, Probe Microphone Measurements, and the co-author of the The Audiologists&rsquo; Desk Reference, Volumes I and II.</p>\r\n<p>Gary Malkowski, special advisor to the president, public affairs, at the Canadian Hearing Society (CHS), was bestowed the honorary degree of doctor of humane letters by Gallaudet University on May 13, 2011. &ldquo;Gary Malkowski is proof that a deaf person can achieve great things if he or she is granted adequate communication access,&rdquo; said Gallaudet President T. Alan Hurwitz. &ldquo;Especially for young deaf men and women, his record as an elected parliamentarian and devoted advocate for the rights of deaf and hard of hearing people is a source of great pride and inspiration.&rdquo; In making the announcement, Gallaudet President Hurwitz cited Malkowski&rsquo;s extensive work on issues of critical importance to the Deaf community, his devoted services in advancing student rights and his work in rehabilitation. After completing his education at Gallaudet in 1984, Malkowski returned to Canada to work as a vocational rehabilitation counsellor with CHS, which since 1940 has provided services, products and information to culturally Deaf, oral deaf, deafened, and hard of hearing people. Malkowski is tireless in the fight for accessible and equitable education for Deaf and hard of hearing students; his leadership in the Deaf Ontario Now Deaf education move-ment lead to American Sign Language and la langue des signes qu&eacute;b&eacute;coise being rec-ognized as languages of instruction in schools for Deaf students. In a departure from serving the community from positions in the Associations of the Deaf and in CHS, Malkowski became the first elected Deaf Member of Ontario&rsquo;s Provincial Parliament. Serving as parliamentary assistant and on many standing committees, he introduced a private member&rsquo;s bill that led to the introduction and implementation of what is now the Accessibility for Ontarians with Disabilities Act (AODA). Supreme court rulings and decisions in support of accessibility rights of Deaf and hard of hearing Canadians are in large part due to the efforts of Malkowski. In his current position at CHS &ndash; special advisor to the president, public affairs &ndash; Malkowski continues to work for the educational and vocational rights of deaf and hard of hearing people. His awards for service include the Queen&rsquo;s Golden Jubilee Medal in recognition of his community service, the Ontario Liberal Government Community Action Award, and the  Ontario Federation of Community Mental Health and Addiction Program&rsquo;s Outstanding Contribution to Mental Health Communities Award. As a further honour from Gallaudet University, Malkowski was invited to deliver what was an incredibly passionate and inspirational keynote address at the university&rsquo;s May 13th commencement. In his address, Malkowski thanked the communities for their support of a body of work that &ldquo;couldn&rsquo;t have been achieved without the communities whose rights we have fought together to defend.&rdquo; Malkowski said, &ldquo;I have had the opportunity and privilege to have been a part of making great strides in breaking down and removing communication barriers faced by culturally Deaf, oral deaf, deafened and hard of hearing individuals, children and their families.&rdquo; He congratulated Gallaudet University for the investment it makes in its students, many of whom have become public office holders &ndash; elected politicians and senior managers at all level of government &ndash; medical doctors, chiropractors, audiologists, speechlanguage pathologists, and leaders in senior management including Dr. Alan Hurwitz, Gallaudet University, Gerry Buckley, National Technical Institute for the Deaf, Benjamin Soukup, Communication Services for the Deaf, and Chris Kenopic, The Canadian Hearing Society &ndash; all Presidents and CEOs.</p>\r\n<p>Malkowski continued in his keynote to say that &ldquo;Gallaudet University is truly a home, and is an engine for higher education that continues to be an integral tool in the building of thousands of bridges between Deaf and hard of hearing people who use signed languages and our general societies, including institutions of all levels of government.&rdquo; &ldquo;I am honoured to work alongside a tireless individual driven by his personal passion, exceptional pro-fessionalism, and integrity,&rdquo; says CHS President and CEO Chris Kenopic. &ldquo;We are proud to have such a key person at CHS whose groundbreaking accomp-lishments continue to promote equity for people who are culturally Deaf, oral deaf, deafened and hard of hearing.&rdquo;</p>\r\n<p>I n 2007, the journal Social Work published a nationwide study looking at the private practice career intentions of social work students in the United States.1 These intentions were examined and contrasted in relation to the extent which graduate students were being prepared for private practice. In what the authors called a &ldquo;striking disconnect,&rdquo; results indicated that, although a majority of students planned on eventually working there, programs were not providing significant content related to the private practice social work setting. Fewer than half the programs contained private practice content of any sort in the curriculums; only one-fourth of the surveyed programs agreed that private practice field placements were accepted at their schools. The current scene for audiology students in Canada is quite different. There are five programs in audiology that currently offer clinical audiology training. These include the University of British Columbia (UBC), the University of Western Ontario (UWO), Universite d&rsquo;Ottawa, Universite de Montreal, and Dalhousie University. All Canadian audiology programs depend significantly on collaboration with private practice audiologists for placements &ndash; to one degree or another. There are a number of reasons for this. First, the scope of private practice audiology is not limited to a particular population or area of practice. It is now possible for students to work in privately run clinics where infant hearing screening, auditory processing assessment, and tinnitus counselling (to name a few examples) are routinely conducted. Second, although the scope of private practice has expanded in recent years, the sector continues to provide considerable expertise in the traditional areas of amplification and aural rehabilitation. Simply put, students need and want experience with hearing aids and private practice audiologists are in a great position to deliver this. Third, it is likely that graduating students will, at some point in their careers, work in a private practice setting. A comparison of membership surveys from the Canadian Association of Speech-Language Pathologists and Audiologists (CASLPA) revealed an increase in private-practice audiologists between 2002 and 2008.2 The 2005 CASLPA survey showed that 40% of respondents worked in this sector.3 Finally, there are many private practice audiologists who want to be involved. These are dedicated, engaged, and skilled clinicians. It is not uncommon for programs to be approached by these audiologists who want to &ldquo;give back&rdquo; and get involved in training the next generation. This pool of expertise is a huge resource and university coordinators naturally want their students to benefit from this. This leads to the question raised by the article in Social Work: if professionals are inevitably to work in a particular setting, wouldn&rsquo;t it be best for all involved (i.e., for the students, for the profession, and for the community at large) if they were provided with guidance, training, and mentorship regarding this environment while they are students? As enrolments rise, clinical coordinators responsible for arranging practicum placements (for all the health professions) are experiencing increasing pressure to find suitable placements for students. Consequently it is important that private practice audiologists offer their support and stewardship by carefully considering placement requests.</p>\r\n<p>In order to gain some perspective on what it was like to host students in private practice, the Academic Coordinators of Clinical Education (Audiology) contacted a small group of private-practice clinicians who had experience with clinical education. Results provided some valuable insights about hosting students in this setting. We&rsquo;d like to share some of these impressions. Nicuta Gairns, AuD, from the Wild Rose Audiology Clinic in Edmonton stated that it was rewarding to see how a student develops clinical skills by the end of the practicum. She also described her clinical educator role as a &ldquo;perpetual&rdquo; learning experience: &ldquo;A student always brings in new ideas or research information.&rdquo; Audiologist Jason Schmiedge of Expert Hearing Solutions in Saskatoon agrees. He feels like he is &ldquo;paying back the profession [when he] helps students gain good learning experiences.&rdquo; Interestingly, he reported that patients responded well to working with students: they liked the fact that his site was helping future clinicians. Mark Hansen, AuD, owner of Sound Hearing Clinic in Vancouver pointed out that taking a student does require more time with each client and that some clients do prefer to work with their regular audiologist. In the end, however, he agreed that &ldquo;most clients react favourably to working with a student.&rdquo; Dr. Hansen sees the act of hosting students as a way to pursue &ldquo;continued education&rdquo; himself. He still remembers with gratitude the audiologist who &ldquo;was generous enough to provide [him] with an externship&rdquo; and therefore wants to do the same for the upcoming generation. After 29 years in the field, Regina Salomon, MSc, RAUD, RHIP, of Elite Hearing in White Rock, BC continues to be very enthusiastic about her job. She correctly indentifies this combination of experience and enthusiasm as a positive dynamic for students. She described students who are &ldquo;usually very keen on learning as much as they can&rdquo; and she loves to teach things that &ldquo;they do not find in the books.&rdquo; But were there any negatives to report? Amazingly, several respondents had absolutely nothing negative to say about hosting students. &ldquo;I&rsquo;ve never had a negative experience,&rdquo; stated Dr. Gairns. Jason Schmiedge reported that he has worked with &ldquo;&hellip;six students over the years and each experience has been positive.&rdquo; Dr. Hansen did mention that the process involves taking more time with each client. Regina Salomon agreed with this point: &ldquo;I usually try to explain things as they are progressing, so it does slow me down a bit.&rdquo; This would understandably be an important concern to all involved. It would not serve anyone&rsquo;s interests if the issue of cost-benefit related to the presence of students were not carefully considered prior to participating. A study published in 2003 in the Journal of Allied Health examined the effects of student clinical education experiences on clinical instructor productivity in the profession of physiotherapy.4 The hypothesis was that teams that included students would be more productive than those without. Results showed &ldquo;increased productivity on all three measures&rdquo; that were studied. In the end, the data supported the notion that, for physiotherapy clinical education at least, students were associated with greater productivity for clinicians. This is not to say that the same situation would, or should, apply for audiology practicum placements. However, it  would also be misleading to not directly address the issue. Hosting students does involve an investment of goodwill, energy, enthusiasm, time and, therefore, resources. But it can also provide tangible opportunities. This would particularly be the case once a student is established at a given site, working at a greater level of independence, and a enjoying a trusting rapport with his or her supervisor. Extra time and effort up front often creates space later on. One of our respondents commented that hosting students helped with patient workload and &ldquo;allowed us to work on other tasks later on in the placements.&rdquo; This is the honest, forthright, and knowing statement of a seasoned clinical educator. Students require mentorship to gain independence and critical thinking skills: they can&rsquo;t achieve this when their supervisor hovers over them 100% of the time. At the end of the day, it is important to remember that all private-practice respondents in this subjective exercise were enthusiastic about participating in clinical education. All recommended that other private practice clinicians consider the practicum process. All respondents described receiving adequate support from the university programs. Dr. Hansen, for example, complimented UBC&rsquo;s practicum handbook and online support materials. With a few caveats, patient/client reaction to the presence of students was positive. Private practice audiologists described the rewards of &ldquo;giving back&rdquo; to the profession and that, although being a clinical educator requires a certain type of expertise, hosting students was also, in fact, a learning experience. So if you&rsquo;ve ever wondered about the possibility of mentoring a student, wonder no more! All clinical coordinators at the various university programs would be grateful for your support. Any questions or requests for more information are welcome. Their students would thank you as well.</p>\r\n<p><strong>REFERENCES</strong></p>\r\n<p>1. Green RG, Baskind FR, Mustian BE, et al. Professional education and private practice: is there a disconnect? Social Work 2007;52(2)151&ndash;9.</p>\r\n<p>2. The Canadian Association of Speech-Language Pathologists and Audiologist. Member survey: Report of findings. Ottawa: Author. 2005.</p>\r\n<p>3. The Canadian Association of Speech-Language Pathologists and Audiologists. 2008 membership study survey report. Ottawa: Author. August, 2008. 4. Dillon LS, Tomaka JW, Chriss CE, et al. The effect of student clinical experiences on clinician productivity. Journal of Allied Health 2003;32(4):261&ndash;5.</p>\r\n<p>By Calvin Staples, MSc</p>\r\n<p>Recently, I have been asked to select a number of blogs from HearingHealthMatters.org and submit them to Canadian Hearing Report. My first selections all focus on the business of hearing and hearing aids in the new industry we are presented with today. The hot topic today at annual conferences, board meetings, and at the water cooler is often the changing landscape of our industry. In the past several years, a large number of retail outlets have surfaced all across Canada. In the world of hearing health care, this is not a new phenomenon; Australia, United States, and Europe have all experienced the retail movement within our industry. However, a large number of successful privately owned and operated clinics still exist in Canada and more are opening on a regular basis. I cannot provide an argument or even a suggestion as to what I think the outcomes or impact is on the changing landscape of hearing health care, but I thought the following blogs would generate some discussion, provide some insight, and create a platform for additional input to CHR. Happy reading!</p>\r\n<p>By David H. Kirkwood</p>\r\n<p>OTTAWA &ndash; When it comes to providing its citizens with health care coverage, Canada has generally gone far beyond the United States. For example, its publicly funded health system ensures that all Canadians have access to free medical care. However, universal newborn hearing screening (UNHS), which the US introduced more than a decade ago, does not yet exist in most of its northern neighbour&rsquo;s provinces. However, that may change. On May 9, the Canadian Paediatric Society released a position statement stressing the importance of UNHS. Currently only Ontario and British Columbia screen all newborns for hearing loss. Quebec approved funding of such a program in 2009, but it has not been implemented In Canada&rsquo;s other seven provinces and in its northern territories, babies are generally tested only if they fall into highrisk categories, such as being born prematurely or having a serious infection.</p>\r\n<p>Hema Patel, MD, lead author of the Paediatric Society&rsquo;s statement, stressed the importance of UNHS. She said, &ldquo;This is critical and we&rsquo;re sadly behind the times. There&rsquo;s no excuse for Canada&rsquo;s dismal record in this area.&rdquo; She added that not only most other Western nations, but even some undeveloped nations, such as Nigeria, have UNHS programs. Patel, a staff pediatrician at Montreal Children&rsquo;s Hospital, noted that a baby born in a province with universal screening &ldquo;has the opportunity to have an early diagnosis, an early intervention, and to reach their full potential cognitively with language and communication.&rdquo; In other provinces, babies with hearing loss are typically diagnosed much later, after already experiencing developmental delay. As a result, said Patel, &ldquo;They&rsquo;re going to have different outcomes &ndash; lifelong.&rdquo; Rex Banks, chief audiologist at the Canadian Hearing Society, said that his group is also strongly supportive of universal screening.</p>\r\n<p>All you audiologists out there, I&rsquo;ll bet you don&rsquo;t know just how good you have it. After all, you have the &ldquo;least stressful job of 2011.&rdquo; Who says? None other than Victoria Brienzi, who listed the 10 least stressful jobs in her post (www.careercast.com/jobs-rated/10-leaststressful-jobs-2011), for CareerCast, a career counselling company. Here&rsquo;s how Ms. Brienzi characterized your easy profession: &ldquo;An audiologist diagnoses and treats hearing problems by attempting to discover the range, nature, and degree of hearing function. The job is not typically physically demanding or stressful, but it does require a keen attention to detail and focused concentration.&rdquo; Actually, when you think about it, that description also applies pretty well to hearing instrument specialists. So I guess you have it pretty soft too. What else makes the life of an audiologist so stressless, even more so than that of dieticians, speech pathologists, and philosophers, other professions on CareerCast&rsquo;s top ten list? Well, maybe it&rsquo;s that $63,144 average annual income. It sure gives audiologists peace of mind knowing that they can raise their children in comfort and pay for their college education &ndash; at least if they have a spouse in a more lucrative profession. True, in some ways hearing care providers do face less stress than some workers. Unlike soldiers or coal miners, or surgeons, they don&rsquo;t run the risk of dying or killing someone on the job. And, there aren&rsquo;t millions of dollars riding on an audiologist&rsquo;s every decision. Also, demand for hearing care seems to be increasing faster than the supply, so job opportunities are better than in many fields. But still, even by the unscientific, subjective standards of these top ten lists that are so popular on the web, this roster of &ldquo;least stressful jobs&rdquo; seems especially meaningless.</p>\r\n<p>What Audiologists Say I&rsquo;ve been covering the hearing industry long enough to know that practitioners face plenty of stress. But instead of making that case for them, let me quote from a few of the people who responded (anonymously) to the CareerCast article. One audiologist wrote, &ldquo;It will never be &ldquo;not stressful&rdquo; to tell a parent of a child with cancer that the chemotherapy has caused hearing loss (as if this family has not been through enough).&rdquo; &ldquo;Not physically demanding?&rdquo; thundered another. &ldquo;Ever done an Epley on a 400- pound man who is freaking out on the table? Plus I&rsquo;d love to see the &lsquo;little stress&rsquo; on someone&rsquo;s face after they&rsquo;ve spent the last 20 minutes instructing and reinstructing someone on how to put a battery in the hearing aid only to have them insert it upside down.&rdquo; Many audiologists questioned, to put it mildly, the author&rsquo;s expertise. One asked, &ldquo;How in the world could you people decide this was the least stressful job? Have you ever told parents that their baby will wear hearing aids the rest of their life? Or tried to convince old people who think they hear fine that they need to spend thousands on hearing aids that they don&rsquo;t want? What a joke this article is.&rdquo; Interestingly, while most respondents disputed the claim that their job wasn&rsquo;t stressful, many of them also extolled the virtues of audiology. For example, one complained about spending the day &ldquo;trying to convince people that they need something (a hearing aid, which they do) when they don&rsquo;t want it.&rdquo; But then he or she added, it&rsquo;s a &ldquo;very rewarding career, but hardly low-stress.&rdquo;</p>\r\n<p>A Different Twist Amid all the outrage, one comment stood out. For one thing, it wasn&rsquo;t anonymous. It was signed by Dr. Patti Kricos, president of the American Academy of Audiology.&rdquo; Secondly, she welcomed the article as a great recruiting tool for her profession. She wrote: &ldquo;CareerCast folks, you are right on target! Audiology is an amazing profession in so many ways! It is a rewarding career track, one that requires scientific background and an interest in technology, as well as compassion and interpersonal skills. With the huge number of Baby Boomers coming of age, there will be an even better market for audiology jobs. &ldquo;As president of the American Academy of Audiology and an audiologist for the past 38 years, I strongly encourage high school and undergraduate students to come on board to a wonderful, fulfilling profession.&rdquo; Well said!</p>\r\n<p>When I am chatting with my ad reps from the different local papers the same theme comes from each of them. How people are pulling back from their marketing and advertising budgets. The things that work take time and need a strong foundation, not a quick fix. Building your referral base of existing patients (or consumers where ever your preference is!) and from professionals such as family physicians, and networking colleagues. One area that really has been hit is real estate. One of the strongest companies here in Tucson, is Long Realty, they have 30% of the market share in Southern Arizona. For the past three years they have cut their newspaper, TV, radio, and other print ads down significantly. Where they have relied heavily to set them apart is education. Not only are the realtors encouraged to take continuing education, but what they send out to the public is geared to educate the public as well. Do we think of educating as marketing? We could pick a topic a month and educate different sectors of our referral base. We can send out e-mails to our patients once a month or every quarter. But educating instead of &ldquo;selling&rdquo; may pay off better in the long run. If you can use as many different mediums to educate then maybe your office will be the one in mind when someone needs to have their hearing checked or are FINALLY ready to make that purchase!</p>\r\n<p>Electronic Hearing Aids At the turn of the 19th century, hearing aids underwent a technological revolution by emulating telephone technology. The first electronic hearing aids used carbon microphones that modulated electrical current in response to sound pressure variations. The main advantages they provided were increased amplification intensity, wider frequency response of amplification, and portability.1 These instruments did not require the user to sit or wear a beard &ndash; they were body worn and could be concealed. The first patent for an electronic hearing aid envisioned an instrument with a body-worn transmitter posing as a badge on the chest. Later devices hid in barrettes, headbands, earrings, and other camouflage connections to body worn instruments. Hearing Aids Become a Business Batteries and electronic components created a market for wearable amplification among people with hearing loss. Hearing aid design, which had previously been a craft or even art, changed into a manufacturing assembly process. Hearing aid manufacturing companies (e.g., Sonotone) appeared and pursued economic profit by seeking new technologies to create new products that were smaller, lighter, more powerful, and more efficient. Vacuum tubes were a major technical advance. The first wearable vacuum tube hearing aid came on the market in 1936. Beltone Hearing Aids was established several years later (1940) and quickly became one of the five largest firms in the industry (35 total firms),2 and one of the most innovative. It introduced the first all-in-one hearing aid in 1944, which combined batteries and transmitter into a single unit. Beltone began a relentless march to expand the market and drive sales nationally which continues even today. In 1943, Beltone set up an exclusive dispenser network that was modeled on the insurance business. It was a franchise model in which franchisees received sales training and marketing support from Beltone in return for which they sold the company&rsquo;s products exclusively.3 Other factors in the 1940s influenced the emerging hearing aid industry. Advanced munitions technologies introduced in WWII created a population of trauma victims with ear and hearing damage. Those soldiers were evaluated and treated in a new specialty ward at Walter Reed Hospital, which was staffed by an odd mix of hearing scientists and speech therapists. That alliance created a new specialty (audiology) and a new armamentarium of electronic equipment to assess and treat hearing loss. As the dimensions of hearing loss were mapped with more precision, the demand for &ldquo;selective&rdquo; hearing aid amplification emerged. Manufacturers responded by diversifying and improving their product lines.</p>\r\n<p>WWII technological innovation benefited the hearing aid industry in its efforts to expand and upgrade. In 1947, the US government released the first printed electronic circuits to private industry. Five years later, transistor circuits were developed that once again revolutionized hearing aids. In the space of one year, from 1952&ndash;1953, almost all hearing aids switched from vacuum tubes to transistors, which miniaturized them to the point that they became ear-level instruments rather than body-worn. Concealment became easier when hearing aids were incorporated into the stems of eye glasses. By 1959, 65% of all hearing aid sales were eye glass type.4 Hearing aids were big business by the 1950s. Total US hearing aid sales reached $22.1 million in 1952, a 37% rise from 1948. By 1959, Dahlberg&rsquo;s Miracle-Ear subsidiary had $100 million in annual revenues and was sold to Motorola, Inc.5 In that same year, Beltone had 187 independent distributors under exclusive contract, along with 50 sub-dealer outlets.</p>\r\n<p>References</p>\r\n<p>1. On-Line Hearing Aid Museum. Carbon Hearing Aids: General Information. Stewartstown, PA: Author. Available at: http://www.hearingaidmuseum.com /gallery/General_Info/GenInfo Carbon/info/generalinfo-carbon.htm</p>\r\n<p>2. Federal Trade Commission Decisions: In the Matter of Beltone Hearing Aid Company. 1956. Available at: http://www.ftc.gov/os/ decisions/docs/Vol%2052/ftcdvol52(JULY-JUNE1956)PAGES830- 933.pdf.</p>\r\n<p>3. On-Line Hearing Aid Museum. History of Various Hearing Aid Manufacturers &ndash; General Information. Stewartstown: PA. Available at: http://www.hearingaidmuseum.com /gallery/General_Info/HACompanies /generalinfo-HACompanies.htm.</p>\r\n<p>4. Valente M, Hosford-Dunn H, Roeser R(eds). Audiology: Treatment (2nd Ed). New York: Thieme, 2007.</p>\r\n<p>5. Wikipedia. Miracle Ear. Available at: http://en.wikipedia.org/wiki/ Miracle-Ear.</p>\r\n<p>By Kim L. Tillery, PhD, CCC-A</p>\r\n<p>Dr. Kim L.Tillery, professor and chairperson of the Department of Communication Disorders and Sciences at the State University of New York at Fredonia also has a private practice in diagnosing and treating individuals with (C)APD. She has been honoured to present 90 workshops or presentations at national, international, and regional conferences, and authored and co-authored several chapters and journal articles on (C)APD.</p>\r\n<p>Do you have clients who complain of &ldquo;mishearing&rdquo; a spoken word? Do they indicate that the wording of &ldquo;Cinderella and the Handsome Prince&rdquo; was heard as &ldquo;Cinderella and the Pransome Hince&rdquo; or &ldquo;sadly&rdquo; was perceived as &ldquo;&lsquo;steadily?&rdquo; Of course &ldquo;mishearing&rdquo; may happen once in awhile to any of us due to inattention, selective listening, or a peripheral hearing loss. However, if these mishearing moments occur several times in a day and remain to be the primary complaint of an individual, then an auditory processing disorder may be the cause.</p>\r\n<p>We are often asked what exactly is a central auditory processing disorder (CAPD)? A common definition often used is: CAPD is not how we hear, but what we do with what we hear.1 In 1994 the American Speech-Language Hearing Association (ASHA) held a consensus meeting to establish a definition and proper practices in diagnosing and treating CAPD. We were provided with an extensive definition of CAPD2 that was upheld, a decade later, in a technical report.3 Central auditory processes were deemed accountable for common behaviours associated with auditory localization, lateralization, discrimination, and pattern recognition when nonverbal or verbal stimuli are used. There was a consensus that temporal aspects (e.g., masking, integration and order) may be compromised and the individual will show weakness when competing or degrading acoustic signals are used. The noted deficiencies may result from dysfunction of the above central auditory processes or they may be a result of a more widespread issue associated with attention or neural timing that affects one&rsquo;s performance across cognition, auditory and linguistic modalities. Usually those with CAPD have normal hearing, but their responses are similar to those associated with a peripheral hearing loss. It is confusing to teachers, family members, and the individual with CAPD as to why there may be delays in responding to directions or questions. We don&rsquo;t worry when there is a delay from the TV reporter who is talking to a reporter in Africa. We acknowledge that distance may cause the technology to have a slow response on occasion. What about the person standing next to you who stares blankly as if the message was not heard? Well, there may be a short distance from your mouth to the temporal lobes of the listener, but there are thousands of neurons working to catch that message. If there is a disruption in the central auditory nervous system, then we may see a delay or other struggles in the response to the auditory message. And the struggles associated with a CAPD are preconscious. The individual usually is unaware of his or her prolonged delays, frequent need for repetition of questions or directions, quiet rehearsals, omission of initial sounds or information, or need for high concentration to accurately process the spoken message. These qualitative struggles are easily recognized during daily activities, in test taking situations, and assist the clinician as to what type of auditory processing disorder (APD) the individual may exhibit. Did you notice the switch from CAPD to APD? Actually, according to the ASHA3 we should use the acronym (C)APD. The inclusion of the (C ) reminds us that there is a &ldquo;central&rdquo; part to our auditory nervous system and that all that appears to be peripheral could indeed be central.</p>\r\n<p><strong>REFERENCES</strong></p>\r\n<p>1. Katz, J. Classification of Auditory Processing Disorders. In Katz J, Stecker N, and Henderson D. (Eds.). Central Auditory Processing: A Transdisciplinary View. Chicago: Mosby Yearbook, 1992.</p>\r\n<p>2. American Speech-Language and Hearing Association (ASHA) Task Force on Central Auditory Processing Consensus Development. Central Auditory Processing: Current Status of Research and Implications for Clinical Practice. American Journal of Audiology 1996;5:41&ndash;54.</p>\r\n<p>3. American Speech-Language and Hearing Association (ASHA). (Central) Auditory Processing Disorders. A technical report. Rockville, MD: Author, 2005.</p>\r\n<p>What a dream job &ndash; being asked to produce a consumer column in the journal for hearing professionals. I admit my first thought was something like &ndash; whoo-hoo, payback time! An opportunity to stuff all those years of tortuous hearing tests, frustrating discussions, and expensive hearing aids into the cannon and blast it! But on second thought, I no longer feel that way towards hearing health professionals. My former emotions have long-since morphed into a healthy admiration for audiologists, manufacturers of assistive technology, and frankly anyone who dedicates their work to improving the quality of my life. The change didn&rsquo;t come easily. Some years ago, trying to adjust to new, stateof-the-art CIC hearing aids, I was well into a frustrated and teary rant against a poor fit, breaking battery cages and wax guards that kept falling into my ear, when my husband cut me off with, &ldquo;Gael, they&rsquo;re not doing this just to irk you. Have more respect for technology and science!&rdquo; That gentle admonishment stopped me in my tracks and brought home how far hearing science had come since age three when the pediatric ENT told my parents that hearing aids would never help me. My husband&rsquo;s reality check was one of those life-changing moments that ultimately spurred me to a life of hearing loss advocacy. Since then, through meeting and working with consumers and professionals from all corners of the hearing arena, I&rsquo;ve come to believe in a few guiding principles for living successfully living with hearing loss:</p>\r\n<p>&bull; We must be honest. (Yes, I do have hearing loss)</p>\r\n<p>&bull; We must be knowledgeable. (What do I need to know about my hearing loss? Who can help me?)</p>\r\n<p>&bull; We must be proactive and use all available communication tools and strategies, to the best of our ability.</p>\r\n<p>&bull; We must communicate our needs to others.</p>\r\n<p>In order to live by these principles, people with hearing loss need support from many sources, including peer support from hard of hearing people, but most specifically from our hearing care professionals. If we have even the tiniest motivation to break through the barriers and achieve successful communication, we must look at hearing professionals as our allies. Although this might seem like a nobrainer to you, it represents a seismic shift in consumer attitude, especially from those of us who are long-time hearing aid users. Like most people with hearing loss, my annual hearing check-up was not a red letter day. Getting the same news year after year was depressing: Your hearing has dropped. No, it won&rsquo;t get any better so don&rsquo;t expect a cure. It&rsquo;s time for new hearing aids. Yup, they&rsquo;re still ugly. Doubled in price, too. But now, thanks to an explosion in hearing technology and access to information, the old stigma is drifting away, and a new consumer population is evolving, one that has a better grasp of the complexities of managing hearing loss. As a result, we expect today&rsquo;s hearing professionals to be well-trained experts in diagnostics, technology, psychology and communication strategies. We depend on you to provide quality hearing aids, answer our difficult questions and search out solutions to our communication needs. You are also expected to face us when you talk to us. And, frankly, we don&rsquo;t feel all this is too much to ask. In fact, we ask for one more thing, especially for new hearing aid users &ndash; the provision of aural rehabilitation programs that ensure we incorporate these necessary communication strategies into our everyday lives. A few years ago, audiologist Joanne DeLuzio and I developed Me &amp; My Audie: The Important Partnership of Consumer and Hearing Health Professional, a presentation aimed at both consumers and audiologists. Its premise is that aural rehab is not limited to a course of action prescribed by a hearing care professional. Instead it begins with the first personal suspicion of a hearing loss, which starts a communication journey that will be most successful when supported by a solid consumer-professional relationship.</p>\r\n<p>As an individual hard of hearing person and as a member of several consumer hearing loss organizations, I celebrate this partnership and look forward to sharing our perspective in coming issues of the Canadian Hearing Report.</p>\r\n<p>By Sheila T.F. Moodie, MCl Sc National Centre for Audiology, Faculty of Health Sciences, University of Western Ontario, London, Ontario, Canada</p>\r\n<p>&ldquo;There is a current trend to develop test protocols that are &ldquo;evidence based.&rdquo; But, before we develop any new fitting guidelines, maybe we should first try to understand why there is so little adherence to the ones we already have&rdquo;</p>\r\n<p>To address Dr. Mueller&rsquo;s challenge to better understand why there may be little adherence by hearing health care professionals to currently available clinical practice guidelines (CPGs), we need to examine not only the guidelines (development, content, recommendations, etc.), but we also need to examine if and how these guidelines are being implemented into clinical practice. The most fundamental limitation of CPGs is that they are often not implemented or adhered to in practice. That is, they often do not change practice behaviour. Analyses of the barriers to practice change indicate that obstacles to change arise at many different levels: at the level of the guideline, the individual practitioner, the organization, the wider practice environment; and at the level of the patient.2&ndash;6 WHAT IS IMPLEMENTATION? Critical components for moving knowledge into clinical practice include: adapting the knowledge to the local context in which it will be used; assessing the barriers and facilitators to knowledge use; ensuring appropriate implementation interventions (e.g., training, tailored targeted protocols) are in place during an implementation stage; the knowledge use monitoring stage; the evaluation stage and the stage at which strategies are implemented to sustain knowledge use.6&ndash;11 The interested reader is directed to the text Knowledge Translation in Health Care: Moving from Evidence to Practice11 for additional information about knowledge translation. Within the knowledge to action process, the term implementation refers to the uptake of research knowledge and/or other evidence-based practice (EBP) protocols into clinical practice through a specified set of activities (for example, the specific steps involved in application of a CPG) with the objective of improving the quality and effectiveness of health care.7,12&ndash;14 WHAT IS IMPLEMENTATION RESEARCH? Implementation research is the scientific study of methods to promote the systematic uptake of research findings and other evidence-based practices and protocols into routine clinical practice and health care policy context. It includes the study of influences on healthcare professionals and organizational behaviour.15&ndash;17 At its core, implementation research is about studying change; change in practice behaviour and maintaining change in organizations.</p>\r\n<p><strong>ENGINEERING CHANGE TO FACILITATE UPTAKE AND IMPLEMENTATION OF EVIDENCE</strong></p>\r\n<p>According to much of the recently published implementation research, implementation interventions are likely to be more effective if they target causal determinants of behavior.14,18&ndash;23 The challenge at this point in the very young field of implementation science and research is developing systematic methods that incorporate an understanding of the nature of the behaviour to be changed and an appropriate system for characterizing intervention and their components that build on this understanding.</p>\r\n<p>THE BEHAVIOUR CHANGE WHEEL Recently a proposed new framework for changing behaviour has been published.23 The framework starts with the question: &ldquo;What conditions internal to individuals and in their social and physical environment need to be in place for a specified behavioural target to be achieved?&rdquo;23 At the centre of this framework is a &ldquo;behaviour system&rdquo; composed of three essential conditions: capability, opportunity, and motivation (it is being referred to as the COM-B system). Figure 1, from Michie et al., 2011 illustrates the COM-B system. The system acknowledges and appreciates that individual, group and organizational factors can have equal impact on, and control behaviour. Capability is defined as &ldquo;the individual&rsquo;s psychological and physical capacity to engage in the activity concerned.&rdquo; Capability includes knowledge and skills. Implementation is a social, dynamic and iterative process, consequently opportunity is an important component to the COM-B system. Opportunity is defined as &ldquo;all the factors that lie outside the individual that make the behaviour possible or prompt it.&rdquo; Finally, Motivation is defined as &ldquo;all those brain processes (including habits, emotional responding and analytic decision-making) that energize and direct behaviour.&rdquo; There is interaction among the components of the COM-B system. Capability and opportunity can influence motivation and executing a behaviour can modify capability, opportunity and motivation.</p>\r\n<p>Each of the COM-B system components can be further divided into categories that could be targeted to cause a behaviour change. As explained by Michie et al.23 capability can be divided into physical and psychological (reasoning, comprehension, etc). Opportunity can be divided into physical (environmental/contextual) and social opportunity (for example, the way concepts are developed to shape how we thing about things). Finally, motivation is divided into reflective processes (selfevaluation, for example) and automatic processes (impulses, emotions, etc.). The developers of the COM-B system recognized during development that targeting behaviour change must occur at the individual, group, organizational and policy-maker levels. This led to the development of the behaviour change wheel (BCW). The BCW is composed of the COM-B system and its associated subdivisions at the hub, encircled by behaviour change intervention functions and then by policy categories. Figure 2, adapted from Michie et al.23 illustrates the behaviour change wheel. One primary advantage to having the potential intervention and policy categories visually present in the wheel is that it assists with a systematic analysis and selection of interventions and policies that might be most effective in changing particular target behaviours.</p>\r\n<p>The findings from audiology research and the development of best practice protocols and guidelines cannot positively impact the patients in our care unless healthcare systems, organizations, and professionals adopt them in practice. Therefore, this article has as its objective to put the &ldquo;spotlight&rdquo; on several exciting new areas in health care research that could be used by researchers, policy makers and practitioners to answer Dr. Mueller&rsquo;s query and to guide future translation of knowledge into clinical practice in audiology. Knowledge translation frameworks such as the knowledge-toaction process provide an evidence-based approach for understanding how to move knowledge into clinical practice. The behaviour change wheel facilitates understanding of behavioural interventions that could be utilized to improve and sustain implementation. Implementation research provides a scientific methodology for the evaluation of the influences of behaviour (individual, organizational and policy) on healthcare practice and policy. We can use knowledge translation and implementation research frameworks to develop some potential research questions to start to address guideline adherence issues in audiology.</p>\r\n<p>What barriers are present within the clinical contexts in which audiologists work that affect adherence to CPGs? What implementation interventions have been used to move CPGs into clinical practice? Which ones have been successful? What conditions internal to audiologists and in their social and physical environment need to be in place for a specified behavioural target (appropriate and consistent use of a CPG for example) to be achieved? What policies might be in place that improve audiologists adherence to CPGs? Of course, asking these questions prior to, or during the guideline development process may lead to improved adherence.</p>\r\n<p><strong>CLOSING THOUGHTS ABOUT THE BEHAVIOUR CHANGE WHEEL</strong></p>\r\n<p>A close examination of the behaviour change wheel shown in Figure 2 should lead the reader to see that this might be an excellent framework to use in clinical practice to develop behaviour change interventions for individuals who wear hearing aids.</p>\r\n<p><strong>DISCLOSURE</strong></p>\r\n<p>This work was supported with funding by the Canadian Institutes of Health Research [Sheila Moodie: 200710CGD188113-171346]. This work has also been supported by The Masonic Foundation of Ontario, Help-2-Hear Project.</p>\r\n<p><strong>ACKNOWLEDGEMENT</strong></p>\r\n<p>With great appreciation to Dr. Susan Michie who reviewed this article for accuracy relative to the Behaviour Change Wheel prior to publication</p>\r\n<p><strong>REFERENCES</strong></p>\r\n<p>1. Mueller HG. In the Words Of Shakespeare: Fitting Test Protocols Are &ldquo;More Honored in the Breach than in the Observance.&rdquo; The Hearing Journal 2003;56(10):19&ndash; 26.</p>\r\n<p>2. Greenhalgh T, Robert G, Macfarlane F, Bate P, and Kyriakidou O. Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations. Milbank Quarterly 2004;82(4):581&ndash;629.</p>\r\n<p>3 Grol R and Grimshaw J. From Best Evidence to Best Practice: Effective Implementation of Change in Patients&rsquo; Care. Lancet 2003;362:1225&ndash;30.</p>\r\n<p>4. Grol RPTM, Bosch MC, Hulscher MEJL, et al. Planning and Studying Improvement In Patient Care: The Use of Theoretical Perspectives. Milbank Quarterly 2007;85(1):93&ndash; 138.</p>\r\n<p>5 L&eacute;gar&eacute;, F. Assessing Barriers and Facilitators to Knowledge Use. In S Straus, J. Tetroe, and I.D. Graham (Eds.), Knowledge Translation in Health Care: Moving from Evidence to Practice. Hoboken, N.J.: Blackwell Publishing Ltd, 2009.</p>\r\n<p>6. Rycroft-Malone, J. The PARIHS Framework: A Framework for Guiding the Implementation of Evidence-Based Practice. Journal of Nursing Care Quality 2004;19(4):297&ndash;304.</p>\r\n<p>&nbsp;7. Graham ID, Logan J, Harrison MB, et al. Lost in Knowledge Translation: Time for a Map? Journal of Continuing Education in the Health Professions 2006;26(1):13&ndash;24.</p>\r\n<p>8. McCormack B, Kitson A, Harvey G, et al. Getting Evidence into Practice: The Meaning of Context. Journal of Advanced Nursing 2002;38(1):94&ndash;104.</p>\r\n<p>9. Rycroft-Malone J, Kitson A, Harvey G, et al. Ingredients for Change: Revisiting a Conceptual Framework. Quality and Safety in Health Care 2002;11:174&ndash;80.</p>\r\n<p>10. Rycroft-Malone J, Harvey G, Seers K, et al. An Exploration of the Factors that Influence the Implementation of Evidence Into Practice. Journal of Clinical Nursing 2004;19:913&ndash;24.</p>\r\n<p>11. Straus SE, Tetroe J, and Graham, I. D. (Eds.). Knowledge Translation in Health Care: Moving from Evidence to Practice. Hoboken, N.J.: Blackwell Publishing Ltd; 2009</p>\r\n<p>12 Fixsen D, Naoom SF, Blase KA, et al. Implementation Research: A Synthesis of the Literature. Tampa, FL: University of South Florida, Louis de la Parte Florida Mental Health Institute, The National Implementation Research Network (FMHI Publication #231); 2005.</p>\r\n<p>13. Durlak JA, and DuPre EP. Implementation Matters: A Review of Research on the Influence of Implementation on Program Outcomes and the Factors. American Journal of Community Psychology 2008;41, 327&ndash;350.</p>\r\n<p>14. Eccles M, Armstrong D, Baker R, et al. An Implementation Research Agenda. Implementation Science 2009;4(18), doi:10.1186/1748- 5908-4-18.</p>\r\n<p>15. Eccles MP and Mittman BS. Editorial: Welcome to Implementation Science. Implementation Science 2006;1(1). doi. 10.1186/1748- 5908-1-1.</p>\r\n<p>16. Foy R, Eccles M, and Grimshaw J. Why does primary care need more implementation research? Family Practice 2001;18:353&ndash;55.</p>\r\n<p>17. Implementation Science (n.d.). In Implementation Science online. Retrieved from http://www.implementationscience.com/.</p>\r\n<p>18. Walker A, Grimshaw J, Johnston M, et al. PRIME - PRocess Modelling in ImpleMEntation Research: Selecting a Theoretical Basis for Interventions to Change Clinical Practice. BMC Health Services Research 2003;3(1):22.</p>\r\n<p>19. Eccles M, Grimshaw J, Walker A, et al. Changing the Behavior of Healthcare Professionals: The Use of Theory in Promoting the Uptake of Research Findings. Journal of Clinical Epidemiology 2005;58:107&ndash;12.</p>\r\n<p>20. Hutchinson A and Estabrooks CA. Cognitive psychology theories of change. In S. Straus, J. Tetroe, &amp; I. D. Graham (Eds.), Knowledge Translation in Health Care: Moving from Evidence to Practice. Hoboken, NJ: Blackwell Publishing Ltd; 2009.</p>\r\n<p>21. Michie S, Fixsen D, Grimshaw J, and Eccles, M. (2009) Specifying and Reporting Complex Behaviour Change Interventions: The Need for a Scientific Method. Implementation Science 2009;4(40), doi:10.1186/1748- 5908-4-40.</p>\r\n<p>22. Michie S, Johnston M, Francis J, Hardeman W, and Eccles M. (2008) From Theory to Intervention: Mapping Theoretically Derived Behavioural Determinants to Behaviour Change Techniques. Applied Psychology 2008;57(4), 660-680, doi: 10.1111/j.1464- 0597.2008.00341.x.</p>\r\n<p>23. Michie S, van Stralen MM, and West, R. (2011). The Behaviour Change Wheel: a New Method for Characterizing and Designing Behaviour Change Interventions. Implementation Science 2011;6(42). doi: 10.1186/1748- 5908-6-42.</p>\r\n<p>I recently came into possession of a gem of a book published in 1969. It is called Forty Germinal Papers in Human Hearing edited by J. Donald Harris, and for those of us over the age of 50, we remember him as a the brainchild of The Journal of Auditory Research, which published from 1969 to 1987. The Journal of Auditory Research served as the publisher for this collection but the 40 articles are from a wide range of sources and publications. Upon opening the cover of the book I was accosted by the acrid smell of an old book that hasn&rsquo;t been opened in decades which brings back fond memories of browsing the library stacks late at night in an attempt to delay doing a math problem set or other equally distasteful endeavour. From Dr. Harris&rsquo;s preface: &ldquo;It is customary on occasions such as this to define the diners for whom the feast is spread&hellip;. One is he who loves to lie in a hammock in his orchard of a summer afternoon, a glass of switchel in one hand and a good book on psychoacoustics in the other&hellip;. One reads not only to inform, to memorize tables and figures and principles, but also to relish with the experimenter his viewpoints on a problem, his hopes, his trials and frustrations, his surprises, failures, and perhaps even his triumphs&rdquo;. (p. v). This column will hopefully be the first in a long string of remembrances from books of the past. I would like to urge you to run to your bookshelves, pick out the oldest, dustiest audiology book that is out of print, or long forgotten, and write a similar review for our readers.</p>\r\n<p>This book is divided into 9 sections: 1. Absolute Intensive Threshold; 2. Masking, Critical Ratio, and Critical Bandwidth; 3. Frequency Selectivity; 4. Differential Intensive Threshold; 5. Psychological Attributes of Sound; 6. Loudness, Its Definition and Relation to Frequency; 7. Psychological Scaling; 8. Adaptation, Sensitization, and Fatigue Processes; and 9. Binaural Hearing. Many of the articles reviewed either were required reading or were referred to in our first course in psychoacoustics and it&rsquo;s a pleasure to have the original source material together in one publication. Only an overview of the first section will be given which is historical in nature. I will &ldquo;gloss over&rdquo; the content of subsequent sections and our memories can fill in the rest. Section One contains excerpts on the &ldquo;Minimal audible pressure and minimum audible field&rdquo; by L.J. Sivian and S.D. White (JASA, 1933) who were contemporaries of Fletcher and Munson (who also published in 1933). This is followed by &ldquo;The Limits of LowFrequency Hearing&rdquo; by Glen Wever and C.W. Bray (Journal of Psychology, 1937). This was the seminal paper that discussed the resonance volley theory of sound. The next paper began the voyage into the perception of brief tones- &ldquo;Acoustical quanta and the theory of hearing&rdquo; (Nature, 1947). In the 1930s and 1940s, anything with the word &ldquo;quanta&rdquo; in the title was almost guaranteed publication because of the excitement and success of the Quantum Theory. This shouldn&rsquo;t detract from the importance of the paper since it spawned the field of brief tone audiometry. This is followed by a seminal (by only 4-page long) paper on temporal integration entitled &ldquo;The threshold of audition for short periods of stimulation&rdquo; by J.W. Hughes (in Proceedings of the Royal Society (London), 1946). And finally this section is rounded out by a paper entitled &ldquo;A determination of the normal threshold of hearing and its relation to the standardization of audiometers&rdquo;, (Journal of Laryngology and Otology, 1952). As can be seen from the publication date, this article took umbrage with the ISO 1951 standard and led, in part to the ASA 1964 standard (a precursor to the ANSI 1969 standard). Subsequent sections are a listing of everything that we need to have at our fingertips to properly discuss psychoacoustics, explain it in lay terms to our patients, and even serve as a topic over a beer. All too often we only have access to other people&rsquo;s summaries, and unless we have an up actually said in 1940 with his article on Auditory Patterns. The same can be said about Zwicker, Flottorp, and Stevens&rsquo; article on the Critical bandwidth in loudness summation. Moving forward to loudness and intensity we move forward to 1933 to re-examine the Fletcher/Munson curves with commentary 20 years later by D.W. Robinson and R.S. Dadson (in the British Journal of Applied Physics). D.W. Robinson is perhaps best known to us from his ground breaking work on noise exposure in large populations. The importance of temporal cues in binaural hearing (E.M. von Hornbostel and M. Wertheimer, 1920 translated by J. Donald Harris) and temporal cues (M. Upton, 1936) have been well studied since but were all based on these two publications. And while we are talking about binaural affects, we finish with an excellent study of binaural beats and their frequency limits by J.C.R. Licklider, J.C. Webster, and J.M. Hedlum in JASA in 1950. This book will undoubtedly occupy some of my mid-summer reading, but unlike J. Donald Harris&rsquo;s liking of a switchel, I&rsquo;ll stick with something a little more mundane.</p>\r\n<p>From August 2&ndash;8, 2010, I participated in the European Rehabilitation Cultural Week of the Deafblind. The holiday was held in the university town of Tubingen, Germany, with its medieval town centre and castle. It is a very nice place. The participants were from Canada, Russia, Finland, Hungary, Denmark, Sweden, Norway, Belgium, Germany, and Switzerland. There were a total of 130 participants, including the guides. (Each participant had his/her own guide.) Many of the people had Usher&rsquo;s type 1 and type 2. Usher&rsquo;s type 1 is complete deaf/blindness from birth. Usher&rsquo;s type 2 is acquired in young adulthood. In addition, there were some persons who were deaf, but their vision was not impaired. I was the only participant from North America. I have Usher&rsquo;s type 2. The onset of my hearing loss started in my late teens and my vision loss started in my mid-twenties. The deterioration of my vision is due to a retinal eye disease called retinitispigmentosa (RP), which is progressive and leads to blindness. RP causes a loss of approximately 10% of vision each year. There is no treatment for this genetic disease. The participant&rsquo;s guides&rsquo; holiday fees were paid for by the governments of Sweden, Denmark and Finland. The Deaf and Blind Association in Hungary paid for the fee of the participant&rsquo;s guides. Hungary&rsquo;s Deaf and Blind Association receives funding from the European Union. The fee for the participant&rsquo;s guide is 450 Euros, which is approximately $550.00 Canadian, and the fee is the same for the participant. The people, who did not receive subsidies, paid 900 Euros, plus transportation costs.</p>\r\n<p>The holiday was wonderful. Each day there were two choices of activities. The activities included a visit to a bread museum in the city of Ulm, where participants baked bread in the museum&rsquo;s kitchen; the museum&rsquo;s guide explained the socio-economic impact of bread on European society; a visit to a Porsche Car Museum near Stuttgart; a tour of a 14th century museum farmhouse in the Black Forest which I especially enjoyed; a tour of the Costume Museum in the Black Forest  (there are interesting costume festivals in the Black Forest towns to-day, that grew out of medieval superstitions); a visit to a castle in Tubingen, a hike in the valley to a very old monastery that is a restaurant to-day, and serves good beer, and many other cultural and fun activities. I have very good memories from the people I met and the holiday activities. I feel that most of the participants had the same experience of really enjoying the holiday. I enjoyed the company of the participants a great deal. I spent time with the participants from Belgium, Finland, Sweden, and Denmark. The Swedes and Danes were a lively bunch. Peter, who is from Belgium, made a strong impression on all of us. He is completely deaf and blind, and he is in his 30s. Peter has attended the university in the Flanders region of Belgium, and he has studied physiotherapy. In the future, he plans to return to his studies at the university for an additional two years. Peter indicated that if he is unable to find employment as a physiotherapist, he hopes to work as a massage therapist. His guide interpreted what Peter explained to us via Lorm, which is a language the deafblind persons use. Lorm is a hand manual language and involves forming sentences by touching the fingers to represent the letters of the alphabet. Lorm, or hand manual, is the communication method used by completely deafblind persons. Peter indicated that he goes to both of the public schools for young children and the universities in Belgium, and he gives a presentation about life as a deafblind person. He is athletic; he swims, he likes to ride on a tandem bike, and he goes kayaking in Belgium&rsquo;s waterways. Peter also travels within Europe. When asked why he isn&rsquo;t married, Peter responded that he likes his job as a bachelor. His various remarks brought a lot of laughter to the dinner table. He has a full life. Then there was the man from Sweden, named Ingmar. Ingmar is deaf, and he has very restricted vision. He is in his 60s. Ingmar likes to take photos; his passion is his train set, and he travels a lot and has even been to China. Ingmar indicated that he receives a lot of social support from the Swedish government. At the end of the holiday, Ingmar and his two Swedish guides had plans to travel by train to a city in Germany where there is a train museum. I think Ingmar also indicated there was a program in this city for train enthusiasts. Ingmar planned to visit there for three days with his guides before he returned to Sweden. My guide, Signe, and I especially liked to spend time with Gaetan and his wife, Petra, who are from Flanders. Gaetan has Usher&rsquo;s type 2, and his condition is similar to my own. Gaetan works in a government office, and he travels whenever he can. He plays soccer, and he leads a support group for people who have Usher&rsquo;s. He was great company.</p>\r\n<p>Usher&rsquo;s syndrome is a terrible condition. There are very few people in life who experience losing both of their vision and hearing, and I feel lucky that I had the experience of meeting a lot of people who have managed to transcend the huge burden that Usher&rsquo;s has given them. Their example makes it possible for me to continue to find ways to make my own life the best that I can. In August 2011, Finland will host the ERCW holiday. In 2012, the ERCW holiday will be held in Denmark. It seems that a sizeable number of Europeans who are deafblind, have the opportunity to participate in a holiday rich in culture each year in a different European country. The access is made possible due to generous subsidies from the government, and in some cases, from the Catholic diocese church. (The holiday is secular.) The support of the government and other sources of funding to facilitate the wonderful holiday for the deafblind is a testament of the value that is placed on the participants.</p>\r\n<p>By Karrie Recker, AuD, CCC-A, FAAA, Martin F. McKinney, PhD, and Brent Edwards, PhD</p>\r\n<p>Karrie Recker, (left) is a research audiologist at Starkey Laboratories. She joined the company in 2000. Over the years Dr. Recker has been involved in a variety of research projects ranging from basic hearing science studies to algorithm testing to mechanical design verification. In 2005, she received her doctoral degree in audiology from the University of Florida. Martin F. McKinney, (middle) holds a BS degree in electrical engineering from Tufts University, an AM degree in electroacoustic music from Dartmouth College and a PhD in speech and hearing sciences from Massachusetts Institute of Technology. Dr. McKinney currently works as a senior DSP research engineer at Starkey Laboratories, Eden Prairie, MN. Brent Edwards,(right) completed his PhD. in electrical engineering at the University of Michigan in 1992, and subsequently a postdoctoral fellowship in psychology at the University of Minnesota. Dr. Edwards has worked in industry since 1995. In 2004, Dr. Edwards joined Starkey Laboratories, where he is currently vice-president of research.</p>\r\n<p><strong>ABSTRACT</strong></p>\r\n<p>The Acceptable Noise Level (ANL) test is a measure of the amount of background noise that a person is willing to tolerate. In recent years it has gained interest among researchers and hearing care professionals because of its ability to predict, with 85% accuracy, who will be successful with hearing aids. This statistic is not only useful for counselling purposes, but it implies that if one could understand why different people are able to tolerate different amounts of background noise, then one could gain insight into what makes a patient successful (or unsuccessful) with hearing aids. This knowledge could be used to target hearing-aid solutions to the individual to improve her prognosis with hearing aids. However, several studies have been unsuccessful at correlating ANLs with audiological factors other than hearing-aid success. This article reviews some of the ANL literature, speculates on the potential future applications of the ANL test and reports the results of a questionnaire that was administered to 139 participants to gain insight into the potential mechanisms underlying individuals&rsquo; ANLs.</p>\r\n<p>The Acceptable Noise Level (ANL) test is a measure of the amount of background noise that a person is willing to tolerate.1 In recent years it has gained interest among researchers and hearing-care professionals because of its ability to predict, with 85% accuracy, who will be successful with hearing aids.2 This statistic is not only useful for counselling purposes, but it implies that if one could understand why different people are able to tolerate different amounts of background noise, then one could gain insight into what makes a patient successful (or unsuccessful) with hearing aids. This knowledge could be used to target hearing-aid solutions for an individual to improve her prognosis with hearing aids. However, several studies have been unsuccessful at correlating ANLs with audiological factors other than hearing-aid success. This article reviews some of the ANL literature, speculates on the potential future applications of the ANL test and reports the results of a questionnaire that we administered to gain insight into why different individuals are willing to tolerate different amounts of background noise. Performing the ANL test is relatively quick and simple. First, running speech is presented to a listener over headphones or via sound field. Often the Arizona Travelogue is used as the speech stimulus (Cosmos, Inc.). This passage consists of continuous discourse by a male talker discussing his travels in Arizona. Using an adaptive procedure, the listener is first instructed to adjust the level of the speech to a level that is &ldquo;too loud&rdquo; then &ldquo;too soft&rdquo; then &ldquo;most comfortable to you.&rdquo; Next, background noise is added, usually multi-talker babble, and the listener is instructed to adjust its level, first to a level that is &ldquo;too loud to understand the speech&rdquo; then to a level that is &ldquo;soft enough for the speech to be very clear&rdquo; and finally to the highest level that she is &ldquo;willing to put up with&rdquo; while following the speech. The difference between the listener&rsquo;s most comfortable listening level (MCL) and her maximum tolerated background noise level (BNL) is her ANL. The test takes about 2&ndash;3 minutes to administer. A lower ANL score reflects a higher tolerance for background noise. According to Nabelek et al.,2 there are three different ANL categories &ndash; low, mid, and high. Individuals who have &ldquo;low&rdquo; ANLs (less than 7 dB) are generally successful hearing-aid wearers, whereas individuals who have &ldquo;high&rdquo; ANLs (greater than 13 dB) are generally unsuccessful hearing-aid wearers. People with &ldquo;mid&rdquo; ANLs (7 to 13 dB) may or may not be successful with hearing aids. Nabelek et al. showed that most hearing-impaired people had ANLs between 0 and 25 dB; the most frequently-occurring ANLs were around 10&ndash;11 dB. ANLs do not appear to be related to an individual&rsquo;s age1,2 gender2,3 hearing sensitivity1,2 or preference for the existence of background sound.4 At present, it is ambiguous whether ANLs are related to an individual&rsquo;s speech understanding abilities &ndash; some researchers5,6 suggest that ANLs and speech intelligibility are uncorrelated while other researchers7 suggest that people with better speech intelligibility skills also have lower ANLs. Similarly, studies examining aided and unaided ANLs have produced conflicting results, with Nabelek et al.6 showing that ANLs are the same regardless of the test condition and Ahlstrom et al.7 showing that aided ANLs are lower than unaided ANLs. In addition to these findings, both directional microphones and noise reduction technology have been shown to improve (lower) listeners&rsquo; ANLs by about 2.5&ndash;4 dB over the aided condition without these features active.8&ndash;10 These results are exciting because they suggest that hearing-aid features and hearing-aid signal processing allow people to tolerate higher levels of background noise, which may in turn improve listeners&rsquo; success rates with hearing aids. Moreover, if we could understand the cues that individuals are using to determine their tolerance of background noise, this information could offer insight into who is most likely to benefit from these technologies. Because the ANL instructions request that listeners be able to follow the primary talker, it is possible that some individuals adjust the level of the background noise based on a speechintelligibility criterion. If this is true, then we suspect that these individuals will be more likely to benefit from directionality, or other SNR-enhancing technology, than listeners who base their ANLs on some other criteria. However, the ANL instructions do not require listeners to adjust the level of the background noise until a certain speech intelligibility criterion is reached. Because listeners are simply asked how much background noise they are &ldquo;willing to put up with&rdquo; while following the speech, they may be basing their decision on some other criterion such as how loud or how annoying the background noise is. If someone were basing her ANL on the loudness of the background noise, then she may be more likely to benefit from hearing-aid features that reduced the loudness of the noise, such as noise reduction.</p>\r\n<p>Although each manufacturer&rsquo;s noise-</p>\r\n<p>reduction algorithm will function differently depending on the environment, generally, the smaller the temporal fluctuations are in a signal, the more likely the noise-reduction algorithm is to classify a signal as &ldquo;noise&rdquo; and reduce the gain of the hearing aid. Specifically with the ANL test, the background &ldquo;noise&rdquo; is 8-talker babble. With this many talkers, the temporal fluctuations in the signal are substantially less than what is observed with a single talker, and so the noise reduction algorithm may recognize it as noise and reduce the gain of the hearing aid. In real-world environments, such as restaurants or bars, there may be many more than 8 talkers, and much higher levels of reverberation than occur in a sound booth. Both of these factors will reduce the temporal fluctuations in the signal and increase the likelihood that a noise-reduction algorithm will classify &ldquo;babble&rdquo; as noise. Other factors that will affect whether a noise reduction algorithm activates include the overall level of the environment and an estimate of the SNR. Finally, once &ldquo;noise&rdquo; is detected, the time constants of the algorithm will determine whether the overall gain of the hearing aid is decreased or whether the gain is only decreased between the pauses of speech. This latter type of noise reduction technology may be especially useful for listeners who are basing their ANLs on loudness, because it will preserve the loudness of the speech signal while reducing the loudness of the &ldquo;noise&rdquo; between the pauses of speech. Listeners who base their ANLs on listening effort may also be good candidates for noise-reduction technology, because it has also been shown to reduce listening effort and free up cognitive resources for other tasks.11 Determining whether the cue underlying a listener&rsquo;s ANL is predictive of her success with different hearing-aid features is of interest because historically it has been very difficult to predict who would benefit from various features, as a listener&rsquo;s performance in the laboratory may not correlate well with her real-world benefit.12&ndash;15 For example, in a double-blind study involving 94 hearing-aid wearers who were fitted for one month with directional technology and one month with omnidirectional technology, Gnewikow et al.14 found that participants performed significantly better on all of the laboratory (speechin-noise) tests with the directional settings than with the omnidirectional settings; however, similar ratings were obtained for the two microphone settings on almost all of the subjective measures of benefit (the Profile of Hearing Aid Benefit (PHAB) and the Satisfaction with Amplification in Daily Life (SADL) questionnaires). The authors concluded that, &ldquo;self-perceived directional benefit is either limited in magnitude, not readily measured using general outcome measures, or both.&rdquo;14 If the cues that listeners are using to determine their ANLs are predictive of hearing-aid feature benefit, then knowledge of individuals&rsquo; ANLs, and the cues that they are using to determine their ANLs, could be used to better counsel patients and to customize hearing solutions for them. Knowledge of this information could also benefit hearing-aid manufacturers, as it would allow them to predict when, where and for whom certain hearing-aid features would provide benefit. Ideally, this would result in a better first fit, less finetuning adjustments, and happier, more satisfied, hearing-aid wearers. As an initial step in determining the cues that listeners are using to determine their ANLs, we created a questionnaire to determine how listeners view their performance in noisy situations compared to quiet ones. METHODS As a first step in determining what cues listeners may be using to select their ANLs, we compared individuals&rsquo; ANLs to their responses to a custom questionnaire (Appendix). The questionnaire investigated the perceived negative impact that background noise has on speech intelligibility, stress levels and concentration levels. Additionally, it asked participants about their own perceived tolerance for background noise and whether or not they typically avoid situations known to have high levels of background noise. Finally, hearing-aid wearers were asked to describe their hearing-aid use following the categories defined by Nabelek et al.2 : (a) I wear my hearing aids whenever I need them, (b) I only wear my hearing aids occasionally, and (c) I do not wear my hearing aids.</p>\r\n<p>The goals of this questionnaire and the ANL testing were threefold. First we wanted to determine whether participants&rsquo; responses to these questions could provide insight into why some people are more tolerant of background noise than others. This information could help explain why some people are more successful hearing-aid wearers than others, and it could help guide future ANL research. Second, we wanted to determine whether a short questionnaire is sufficiently accurate at predicting individuals&rsquo; ANLs that it could be used as an alternative method of predicting hearing-aid success. If so, the questionnaire could replace the ANL test, thereby eliminating the need for electronic equipment to produce and verify the levels of the test signals. Also, if the patient were to complete the questionnaire prior to her visit with the audiologist, the audiologist could save  2&ndash;3 minutes of time that would otherwise be required to perform the ANL test. Third, we wanted to replicate the Nabelek et al.2 study to determine whether ANLs are predictive of hearingaid success for our test population. In all, 86 normal-hearing and 53 hearing-impaired individuals participated in this study. Normal-hearing participants were Starkey employees who had volunteered to participate in research. Hearing-impaired participants were members of our research database; most had bilateral, mild-to-moderately severe sensorineural hearing loss (Figure 1). Forty-three of these participants were full-time hearing-aid wearers. All had digital hearing aids that were built between the years of 2000 and 2010 (median year built = 2007). All individuals signed a consent form before participating. For each of the questions on the questionnaire, participants were asked to consider their performance in a &ldquo;noisy&rdquo; situation compared to a quiet one. A quiet situation was chosen as a reference so that participants would focus on the increased difficulty of the task caused by the background noise. Participants were asked to consider the &ldquo;noisy&rdquo; situation as being the equivalent to a crowded restaurant or bar. This reference was chosen because the type of background noise that one encounters in this situation is likely to be fairly similar to the multi-talker babble that was used during the ANL testing. Using the standard ANL stimuli (the Arizona Travelogue (Cosmos, Inc.) and 8-talker babble), the ANL test was performed five times during a single session for each of the participants. The first iteration was practice; the remaining 4 iterations were averaged to obtain the listener&rsquo;s ANL. All participants were tested unaided. For the questionnaire, each question used a 4 or a 5-point scale.</p>\r\n<p><strong>RESULTS/DISCUSSION</strong></p>\r\n<p><strong>ANL Distribution</strong> Figure 2 shows the distribution of ANLs for the normal-hearing and hearingimpaired groups. Normal-hearing participants had a mean ANL of 5.1 dB, with a range of &minus;4.4 to 21.6 dB, and hearing-impaired participants had a mean ANL of 7.3 dB, with a range of &minus;4.1 dB to 27.5 dB. A Mann Whitney Rank Sum test showed that ANLs were significantly lower for the normalhearing group compared to the hearing-impaired group (p &lt; .05). For both groups, the mean ANLs were lower than the average ANLs of 10&ndash;11 dB reported by Nabelek et al.2 The only potential explanation that we have for this is cultural differences. A majority of the normal-hearing people who participated in this study worked for a hearing-aid manufacturer. Many of these individuals have had past experiences that have led them to have a special interest in hearing or sound (e.g., personal experience with hearing loss, experience participating in psychoacoustic experiments, advanced musical training or audio engineering experience), and these experiences may have caused them to relate to sound differently than a random sampling of the population. Additionally, as previously stated, many of the hearingimpaired individuals were full-time hearing-aid wearers. Nabelek et al.2 has shown that there is a moderate correlation between ANLs and amount of hearing-aid use, and so the fact that many of our hearing-impaired participants were full-time hearing-aid wearers may have biased our results toward lower ANLs. Questionnaire Results For analysis purposes, each multiplechoice response on the questionnaire was assigned a number 1&ndash;5. Low numbers indicate that background noise had minimal perceived negative impact on the listener&rsquo;s performance on that task and high numbers indicate that background noise had a large perceived negative impact on the listener&rsquo;s performance on that task. What Factors Affect Listeners&rsquo; ANLs? To determine which question or combination of questions was best able to predict listeners&rsquo; ANLs, a regression analysis was completed to investigate the relationship between an individual&rsquo;s ANL and her survey response scores. For both normal-hearing and hearingimpaired participants, results showed that concentration levels, perceived speech understanding abilities and tolerance for background noise were the primary factors influencing listeners&rsquo; ANLs. Combining these three factors resulted in only slightly better predictive performance than using the single best factor. For the normal-hearing participants, the top three factors gave a coefficient of determination (R&sup2;) of .1627 (F4,81 = 5.3, p &lt; .005) whereas the single best factor &ndash; individuals&rsquo; perceptions of their own noise tolerance &ndash; gave an R&sup2; of .1207 (F2,83 = 11.5, p &lt; .001). For the hearing-impaired participants, the three top factors gave an R&sup2; of .1861 (F4,48 = 3.7, p &lt; .05) whereas the best single factor &ndash; perceived speech understanding abilities &ndash; gave an R&sup2; of .1410 (F2,50 = 8.4, p &lt; .01).</p>\r\n<p>The low correlations between these variables and participants&rsquo; ANLs suggest that none of these factors is singularly driving listeners&rsquo; ANLs. Potentially, this could mean that different individuals are using different cues to determine their ANLs or that cues other than the ones that were investigated in this study are driving listeners&rsquo; ANLs. Alternatively, it is possible that the questionnaire format did not sufficiently capture the variables of interest. Can ANL Group Membership Be Predicted? Because the ANL category to which an individual belongs should be predictive of her success with hearing aids, we wanted to determine whether we could predict individuals&rsquo; ANL categories based on their responses to questions 1&ndash; 6 of the questionnaire. To investigate this, we performed a quadratic discriminant analysis (QDA). This analysis tried to predict the ANL group (low/mid/high) to which an individual belonged based on her responses to the questions. The results of this analysis showed that the questions had poor predictive ability. At best the ANL category to which an individual belonged could be accurately predicted 54% of the time for normal-hearing participants and 49% of the time for hearing-impaired participants; chance performance was 33%. In general, there was too much overlap in participants&rsquo; responses to the questions to accurately categorize them into the different ANL groups. Can Success with Hearing Aids Be Predicted Based on Participants&rsquo; Responses on the Questionnaire? To determine whether any of the questions 1&ndash;6 on the questionnaire could be used to accurately predict success with hearing aids, we examined the responses of the 43 hearingimpaired participants in this study who reported owning hearing aids. Of these 43 people, 36 (84%) would be considered successful hearing-aid wearers according to Nabelek et al.&rsquo;s2 classification scheme, meaning they reported wearing their hearing aids whenever they needed them (question 8). Only 7 people (16%) would be considered &ldquo;unsuccessful&rdquo; hearing-aid wearers, meaning they only occasionally (5) or never (2) wore their hearing aids. Due to the small sample sizes, it was not possible to draw definitive conclusions regarding the ability of these questions to predict success with hearing aids. However, preliminary data showed that the mean participant responses on each of the questions were fairly similar  across the different hearing-aid use groups, suggesting that participants&rsquo; responses on this questionnaire are unlikely to be predictive of hearing-aid success (Figure 3).</p>\r\n<p><strong>Do ANLs Predict Success with Hearing Aids?</strong></p>\r\n<p>According to Nabelek et al.2 , people with low ANLs are likely to be successful with hearing aids, whereas people with high ANLs are likely to be unsuccessful with hearing aids. To determine whether this same trend occurred for our participants, we compared hearing-aid wearers&rsquo; ANL groups to their responses to question 8 on the questionnaire (which classified them into successful and unsuccessful hearing-aid wearers, as discussed above). We found that 85% of our participants with low ANLs (17 of 20), 83% of our participants with mid ANLs (15 of 18) and 80% of our participants with high ANLs (4 of 5) would be considered successful hearing-aid wearers. These percentages are much higher than the 36% of individuals that Nabelek et al. suggested would be successful hearing-aid wearers. Additionally, they do not show the same strong trend for hearing-aid success to decrease with increasing ANL score. Again, differences between our results and those reported by Nabelek et al. may be due to biases in the way in which our participants were recruited. CONCLUSION Historically it has been very difficult to predict who would be successful with hearing aids. Research by Nabelek et al.2 has offered hope that hearing-aid success may be predicted with a high degree of accuracy using a simple test investigating the amount of background noise that listeners are willing to accept while listening to running speech. The current questionnaire was administered to gain insight into the potential cues that listeners may be using to determine their ANLs, which may offer an explanation as to why some individuals are successful with hearing aids while others are not. The results of our study showed the following:</p>\r\n<p>&bull; The distribution of ANLs for our participants was much lower than what has been reported in the literature.2 This would suggest that most of our participants should be successful with hearing aids. In fact, 84% of the hearing-aid wearers in this study would be considered successful hearing-aid wearers based on Nabelek et al.&rsquo;s definition of hearing-aid success. It is possible that our participant selection method may have biased the findings of the current study toward lower ANLs and therefore more successful hearing-aid wearers.</p>\r\n<p>&bull; For the normal-hearing and the hearing-impaired groups, there were mild, but significant, correlations between participants&rsquo; ANLs and their responses to questions on concentration levels, perceived speech understanding abilities and tolerance for background noise. While these results suggest that these variables may play a role in listeners&rsquo; ANLs, the low correlations suggest that none of these factors is singularly driving listeners&rsquo; ANLs.</p>\r\n<p>&bull; The results of the questionnaire did not accurately predict the ANL category to which an individual belonged nor did they accurately predict whether or not someone was successful with hearing aids.</p>\r\n<p>&bull; For our population, ANLs were not predictive of hearing-aid success. The results of this study suggest several areas in which additional research is necessary. First, existing research should be replicated to address the discrepancies between our results and those of other researchers to confirm that the observed differences in ANL distribution and hearing-aid success are, in fact, due to population differences and not some other variable. Second, future research should focus on determining the cues that individuals are using to select their ANLs. In particular, it may be useful to investigate the potential roles that concentration and speech intelligibility have on ANLs, given that significant correlations were observed between both of these variables and listeners&rsquo; ANLs. Finally, research is necessary to determine whether the cues that individuals are using to determine their ANLs are in fact related to user benefit with various hearing-aid features. The results of these studies could have far-reaching implications for the treatment and rehabilitation of those with hearing loss.</p>\r\n<p><strong>REFERENCES</strong></p>\r\n<p>1. Nabelek AK, et al. Toleration of background noises: relationship with patterns of hearing aid use by elderly persons. J Speech Hear Res 1991;34(3):679&ndash;85.</p>\r\n<p>2. Nabelek AK, et al. Acceptable noise level as a predictor of hearing aid use. J Am Acad Audiol 2006;17(9):626&ndash;39.</p>\r\n<p>3. Rogers DS, et al. The influence of listener&rsquo;s gender on the acceptance of background noise. J Am Acad Audiol 2003;14(7):372&ndash;82; quiz 401.</p>\r\n<p>4. Freyaldenhoven MC, et al. Acceptable noise level: reliability measures and comparison to preference for background sounds. J Am Acad Audiol 2006;17(9):640&ndash;8.</p>\r\n<p>5. Crowley HJ and Nabelek IV Estimation of client-assessed hearing aid performance based upon unaided variables. J Speech Hear Res 1996;39(1):19&ndash;27.</p>\r\n<p>6. Nabelek AK, et al. Comparison of speech perception in background noise with acceptance of background noise in aided and unaided conditions. J Speech Lang Hear Res 2004;47(5):1001&ndash;11.</p>\r\n<p>7. Ahlstrom JB, et al. Spatial benefit of bilateral hearing AIDS. Ear Hear 2009;30(2):203&ndash;18.</p>\r\n<p>8. Freyaldenhoven MC, et al. Acceptable noise level as a measure of directional hearing aid benefit. J Am Acad Audiol 2005;16(4):228&ndash;36.</p>\r\n<p>9. Mueller HG, et al. The effects of digital noise reduction on the acceptance of background noise. Trends Amplif 2006;10(2):83&ndash;93.</p>\r\n<p>10. Peeters H, et al. Subjective and objective evaluation of noise management algorithms. J Am Acad Audiol 2009;20(2):89&ndash;98.</p>\r\n<p>11. Sarampalis A, et al. Objective measures of listening effort: effects of background noise and noise reduction. J Speech Lang Hear Res 2009;52(5):1230&ndash;40.</p>\r\n<p>12. Ricketts T and Mueller HG Predicting directional hearing aid benefit for individual listeners. J Am Acad Audiol 2000;11(10):561&ndash; 9; quiz 75.</p>\r\n<p>13. Bentler RA Effectiveness of directional microphones and noise reduction schemes in hearing aids: a systematic review of the evidence. J Am Acad Audiol 2005;16(7):473&ndash; 84.</p>\r\n<p>14. Gnewikow D, et al. Real-world benefit from directional microphone hearing aids. J Rehabil Res Dev 2009;46(5):603&ndash;18.</p>\r\n<p>15. Cord MT, et al. Relationship between laboratory measures of directional advantage and everyday success with directional microphone hearing aids. J Am Acad Audiol 2004;15(5):353&ndash;64.</p>\r\n<p>By Stephen Coulson, PhD, Chief Technical Officer P2i.</p>\r\n<p>Stephen invented the P2i technology while carrying out his PhD at Durham University on &ldquo;Liquid repellent surfaces.&rdquo; He was consequently employed by the MoD to set up a plasma capability and further scale-up the patented technology for industrial applications. In 2001, Stephen moved into project managing the UK Nuclear Biological and Chemical clothing program, but continued to exploit the plasma technology for a range of commercial applications. Stephen was the founding member of P2i when it was formed in January 2004 and has more than a decade&rsquo;s experience in advanced material sciences and plasma processing</p>\r\n<p>Modern hearing instruments are increasingly miniature, sophisticated and fragile, and difficult to protect from moisture damage. Aridion, P2i&rsquo;s liquid repellent nano-coating for electronics, aims to transform standards of reliability by overcoming the limitations of traditional approaches.</p>\r\n<p>According to Hearing Industries Association data, the proportion of behind-the-ear (BTE) models sold increased to 64% in 2009 from 57% in 2008, comprising almost 1.7million units in total, reaching their highest-ever market share of 66% in the fourth quarter of 2009. But closer scrutiny of the figures also reveals that 40% of the BTEs sold in 2009 were the latest, smallest, most discreet devices, and almost three quarters of those were receiver-in-canal (RIC) BTEs. These figures reflect the growing aspiration, especially among younger users, for a hearing instrument that can be worn unobtrusively, and for more extended periods of time as an integral part of an active lifestyle. However, as designs become smaller and more delicate, they are also increasingly difficult to protect. Hazards faced by hearing instruments are principally liquids, such as sweat, water, and humidity. For example, in the January 2010 issue of Hearing Review, the &ldquo;Field Study on the Effect of Relative Humidity on Hearing Aid Receivers&rdquo; highlighted the very strong correlation between receiver problems and relative humidity between 60 and 90%. Because RIC/BTE devices are delicate and contain expensive digital electronics, repair costs (to manufacturers via warranty failure, or users via accidental damage) are potentially very high, especially given the current trend towards wearing binaural devices (one for each ear). What is needed is a means of protecting the delicate components of hearing aids against the effect of aqueous and oleous (e.g., cerumen) contaminants.</p>\r\n<p><strong>OLD TECHNOLOGIES HAVE REACHED THEIR LIMIT</strong></p>\r\n<p>Old ways of protecting the delicate electronics in hearing instruments have involved the use of spray or dip applied coatings, but three limitations in particular undermine this approach.</p>\r\n<p>1. Coatings are applied to individual components of the outer casing. After assembly, not all of the instrument will be protected equally.</p>\r\n<p>2. Spray and dip coatings are not durable and rub off over time.</p>\r\n<p>3. Spray and dip coatings can be too thick to protect fine-tolerance acoustic components without affecting their performance.</p>\r\n<p>Aridion, technology by P2i, overcomes these limitations in a new and very different way. Plasmas have long been known for their use in modifying the surface properties of materials. Aridion uses a special ionized gas (plasma), created in a vacuum chamber, to apply a pinhole-free protective polymer layer over the entire surface of a finished, fullyconstructed hearing instrument. This layer is nanoscopically thin, but lowers the surface energy significantly so that when liquids come into contact with it, they form beads and simply roll off.</p>\r\n<p>The way Aridion treats finished articles, and readily penetrates their complex structures, is a radical improvement on traditional coatings. This is because the patented technology works at a pressure that allows full penetration of the complex device, while the energized gas allows durable attachment to the plastics, metals and rubbers from which the product is constructed. This results in total device protection at the nano scale. It&rsquo;s also important to note that Aridion technology is solvent-free and uses only tiny quantities of protective monomer, resulting in minimal waste and no adverse impact on the environment.</p>\r\n<p><strong>NO NEED TO SWEAT OVER RELIABILITY</strong></p>\r\n<p>Reduced corrosion has been demonstrated by P2i in the industry standard sweat test. This common industry test exposes a hearing instrument placed on a prosthetic ear to continual drops of a sweat solution for several days. Following this, the amount of corrosion is determined visually and various diagnostic tests are run. Before/after images show that no visible corrosion occurs in the Aridion&trade; protected device after the sweat test; visible corrosion is apparent, however, in the uncoated sample. In tests with multiple samples, 100% of the Aridion protected products pass while 80% of the uncoated products fail. This leads to an extended product lifecycle, consumer confidence that the instrument is working correctly and both reduced return rates and warranty costs. It&rsquo;s also very important to ensure that hearing aids with Aridion can be worn next to the skin and function correctly, for an extended period of time. P2i has carried out a number of different biocompatibility tests and subject tests, where the nano-coating is placed in contact with human skin for a prolonged time period. For example, P2i commissioned a &ldquo;repeat insult&rdquo; patch test of 50 human subjects to evaluate skin irritation or sensitization, using cotton and polyester processed with P2i&rsquo;s liquid repellent nano-coating technology. The results showed Aridion to be non-irritating and non-allergenic. Further tests by the device manufacturers have confirmed that these medical instruments can be worn next to skin.</p>\r\n<p><strong>FIT AND FORGET</strong></p>\r\n<p>Because the Aridion nano-coating establishes permanent molecular bonds with the surface substrate, it is much more durable and robust than traditional approaches. P2i&rsquo;s tests show that Aridion is five times more durable than traditional coatings, possessing superior abrasion resistance properties to other surface coatings used in the industry. For example, in a test that simulates the effect of day-to-day abrasive wear of the hearing aid housing, samples protected with Aridion maintained an effective degree of water repellence over 600 abrasion cycles, whereas uncoated samples lost their effectiveness after just 100 cycles. One reason for this is that the strong molecular bonding of the nanocoating means it doesn&rsquo;t leach away. It&rsquo;s also the case that older technologies can only be applied to the plastic housing, and so don&rsquo;t protect the delicate electronics within the device. Importantly for increasingly miniature devices, the Aridion coating does not affect the performance of acoustic components in the same way as traditional approaches. It is one thousand times thinner than a human hair, making it acoustically transparent and imperceptible to users.</p>\r\n<p><strong>PERFORMANCE &hellip; WITH PRACTICALITY?</strong></p>\r\n<p>The proven protective qualities of Aridion are now providing unbeatable protection against corrosion damage for more than three million hearing aid users worldwide. Licensed by three of the largest hearing aid manufacturers, Aridion is transforming conventional levels of reliability by substantially reducing warranty failure and repair costs and ultimately increasing user confidence.</p>\r\n<p><strong>CONCLUSIONS</strong></p>\r\n<p>When complete hearing instruments are treated using the Aridion process, they achieve much stronger resistance to liquids than would be possible by assembling components individually treated using alternative techniques. The resulting improved product reliability is likely to decrease the number of repairs required per unit, saving money, time and frustration for manufacturers, dispensers and end users alike. With three of the world&rsquo;s major hearing aid manufacturers now having adopted Aridion as part of their technology portfolios, and three million devices now protected using the technique, the benefits of Aridion are now moving further into the mainstream. The challenge is now to keep spreading the benefits of Aridion to wider and more diverse audiences, for example smaller manufacturers and even dispensers. This may be particularly relevant in areas of the world where Aridion protection is most needed, but may be less straightforward to deliver &ndash; for example in regions of South America and South Asia with high humidity and a less affluent client&egrave;le. At P2i we&rsquo;re hoping we&rsquo;ve begun to address that need with the launch of the Aridion 8 machine, which opens up the possibility of for cost-effective and efficient processing at lower product volumes.</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>\r\n<p>xxx</p>',NULL,'2022-11-30'),(44,3235,'ajchr','http://www.andrewjohnpublishing.com/','','<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g001.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g002.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g003.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g004.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g005.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g006.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g007.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g008.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g009.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0010.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0011.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0012.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0013.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0014.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0015.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0016.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0017.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0018.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0019.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0020.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0021.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0022.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0023.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0024.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0025.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0026.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0027.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0028.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0029.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0030.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0031.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0032.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0033.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0034.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0035.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0036.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0037.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0038.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0039.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0040.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0041.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0042.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0043.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0044.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0043.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0044.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0045.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0046.png\" alt=\"image\" /></p>\r\n	<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-2-1-g0047.png\" alt=\"image\" /></p>',NULL,'2022-11-30'),(45,3243,'','','','<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-6-2-1-g001.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-6-2-1-g002.png\" alt=\"image\" /></p>\r\n<p>&ldquo;Smoking will stunt your growth&rdquo;; &ldquo;Smoking will cause hair loss&rdquo;; &ldquo;Smoking will make you go blind&rdquo;&hellip; well, maybe this last one was about something else, but these and other common warnings of smoking were often heard when we were younger and were usually uttered by our parents. Now it seems that audiologists and others in the hearing health care professions have taken up the call warning against smoking. Evidence is in that smoking can be a major factor in hearing loss and perhaps we should be warning the youth of today about smoking, in the same breath as when we warn them about the potential of hearing loss from recreational music. &ldquo;Smoking and Hearing Loss&rdquo; is a short summary article that can be freely copied from this issue of the Canadian Hearing Report and provided to your clients. Summary reports such as this, and similar ones published by the American Medical Association give the impression that this is an open and closed case. It is true that the long-term effects of smoking can have dramatic implications for your health and even lifespan. It is, however, a more grey area regarding the short-term aspects of how smoking and hearing loss may be related. For example, Dengerik in the 1980s showed that a little bit of smoking was actually protective against hearing loss, as long as the worker had good cardiovascular function. And it&rsquo;s really all about good cardiovascular function, so keep doing those wind sprints, push-ups, and stair climbing exercises, &hellip; and don&rsquo;t smoke!</p>\r\n<p>We continue to have input from students at the various Canadian universities. In this issue there are two article abstracts: The influence of early exposure to frequency-transposed speech on word recognition during infancy; and Systematic review of interventions for hearing loss in children. Both articles are clearly related and both offer good clinical information for the busy audiologist in practice. It&rsquo;s nice to have students do our work for us, on occasion! Tiffany Johnson gives an interesting insight into the relationship between behavioural thresholds and otoacoustic emissions. One would suspect that the relationship have an inherent high degree of variability &ndash; after all, one is a measure of acuity, and the other of function. There should be a correlation, but can one be predictive of the other? And what about the time course? Does one measure degrade prior to the other and if so, is this always the case? So, you are now ready for your first job as an audiologist. Or, you are considering a change to a different type of audiology facility. What are the strengths and weaknesses of each type of job environment? What are the benefits of working in a not-for-profit venue? How about having many colleagues around to bounce ideas off of? Or perhaps a solo private practice situation would fill the bill. In this issue we have an overview of all of these possibilities as discussed by some experienced audiologists who have been there, and now are sharing their perspectives with the rest of us.</p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-6-2-1-g003.png\" alt=\"image\" /></p>\r\n<p>&ldquo;Le tabagisme met en p&eacute;ril votre croissance&rdquo;; &ldquo;Fumer fait perdre les cheveux &rdquo;; &ldquo;Fumer vous rendra aveugle&rdquo;&hellip; Peut-&ecirc;tre cette derni&egrave;re phrase a trait &agrave; quelque chose d\'autre, mais ces avertissements et autres du genre contre le tabagisme sont souvent entendus dans notre jeunesse et souvent r&eacute;p&eacute;t&eacute;s pas nos parents. Maintenant, il semble que les audiologistes et autres professionnels des soins de sant&eacute; auditive ont pris le relai de l\'appel avertisseur contre le tabagisme. Les preuves sont que le tabagisme peut &ecirc;tre un facteur majeur dans la perte auditive et peut-&ecirc;tre devrions nous avertir les jeunes d\'aujourd\'hui contre le tabagisme, dans le m&ecirc;me &eacute;lan quand on les avertit contre la perte potentielle de l\'ou&iuml;e caus&eacute;e par la musique r&eacute;cr&eacute;ative. Vous pouvez librement copier l\'article &ldquo;Tabagisme et perte auditive&rdquo; de ce num&eacute;ro de la Revue Canadienne d\'audition et le fournir &agrave; vos clients. Les rapports sommaires comme celui-ci, et d\'autres similaires publi&eacute;s par the American Medical Association, donnent l\'impression que c\'est un dossier ouvert et clos. Il est vrai que les effets du tabagisme sur le long terme peuvent avoir des implications dramatiques sur votre sant&eacute; et m&ecirc;me pour la dur&eacute;e de votre vie. Cependant, la relation au court terme entre le tabagisme et la perte auditive est une zone plus grise. Par exemple, Dengerik dans les ann&eacute;es 80 a montr&eacute; qu\'un peu de tabagisme prot&egrave;ge contre la perte auditive, tant que le travailleur ait une bonne fonction cardiovasculaire. Tout est vraiment fonction d\'une bonne fonction cardiovasculaire, alors continuez ces sprints courts, tractions, et exercices d\'escaliers, ... et ne fumez pas! La collaboration des &eacute;tudiants des diff&eacute;rentes universit&eacute;s canadiennes continue. Nous avons deux articles dans ce num&eacute;ro: L\' influence de l\'exposition pr&eacute;coce au langage transpos&eacute; par la fr&eacute;quence sur la reconnaissance des mots durant l\'enfance; et les r&eacute;visions syst&eacute;matiques des interventions pour la perte auditive chez les enfants. Les deux articles sont clairement li&eacute;s et les deux offrent une bonne information clinique pour l\'audiologiste occup&eacute; dans son cabinet. C\' est gentil d\' avoir les &eacute;tudiants qui font notre travail pour nous, occasionnellement!</p>\r\n<p>Tiffany Johnson donne une perspective int&eacute;ressante de la relation entre les seuils de comportement et les &eacute;missions oto-acoustiques. On penserait que la relation a un grand degr&eacute; de variabilit&eacute; inh&eacute;rente &ndash; apr&egrave;s tout, une est une mesure d\'acuit&eacute;, et l\'autre de la fonction. Il devrait y avoir une corr&eacute;lation, mais une peutelle pr&eacute;dire l\'autre? et la chronologie? Une mesure se d&eacute;grade-t-elle avant l\'autre et si c\'est le cas, est ce toujours le cas ? . Donc, vous &ecirc;tes pr&ecirc;t(e) maintenant pour votre premier emploi comme audiologiste. Ou, vous &ecirc;tes en train de r&eacute;fl&eacute;chir &agrave; changer et aller dans une branche diff&eacute;rente d\'audiologie. Quels sont les points forts et faibles de chaque type d\'environnement de travail? Quels sont les avantages &agrave; travailler dans un secteur &agrave; but non lucratif? Que diriez vous de tous ces coll&egrave;gues autour de vous avec toutes leurs id&eacute;es? Ou peut-&ecirc;tre une consultation en cabinet priv&eacute; pour payer les charges. Un aper&ccedil;u g&eacute;n&eacute;ral de toutes ces possibilit&eacute;s racont&eacute;es par des audiologistes exp&eacute;riment&eacute;s qui sont pass&eacute;s par la, et qui partagent maintenant leurs perspectives avec nous.</p>\r\n<p>My name is Tony Laviola and I&rsquo;m a professional bass player. I have been playing all kinds of music for almost half a century. Over the past 20 years I have been aware of the slow and steady decline of my hearing, so about 10 years ago I was fitted with my first pair of in-the-canal hearing aids. I rejected them because of the poor sound quality, the occlusion effect and they made my ear canals sweat. About two years ago speech became harder to understand and I could tell people around me were getting tired of repeating themselves. Over this course of time I have been fitted with some &ldquo;top of the line&rdquo; hearing aid models with totally unacceptable results for music so I started looking around and found that they now had these open fit aids. I was intrigued but the last 14 months have proved to be a source of a kind of frustration I have never experienced before. Having only received the hearing aids days before, I was excited to play my first gig until I got there. It turned out to be a small upscale restaurant where the din from the diners was often equal to the SPL of our three-piece jazz trio. As it turned out this was the worst possible environment for musicians with hearing aids. Not only did the sound level overwhelm the capacity of my hearing aids to sort out individual conversation so that I could only count on my ability to read lips to understand what tune the piano player 10 feet away from me was calling next but the sound processing made the pitches quiver with a quick Buffy St. Marie type vibrato. I had to look at my hand position on my acoustic bass to make sure I was close to the note! This is not easy when you&rsquo;re reading charts and I doubt I&rsquo;ll get a call back for that gig.</p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-6-2-1-g004.png\" alt=\"image\" /></p>\r\n<p>As a consumer, I started reading everything I could find on hearing aids and people&rsquo;s experiences and reviews of these devices. Being a musician I am familiar with what compression and anti feedback technology can do, but how they do it so poorly in the new digital hearing aids is a mystery. In the end I had to do and end run around the hearing aid industry in Canada and actually went to the USA to get them because they are not sold here in Ontario. When I finally got the Digi-K hearing aids, I couldn&rsquo;t believe I finally found something that worked so much better than anything else I&rsquo;d tried and it was less than half the price of the other hearing aids available in Canada, even without the provincial support programs. Finally I had hearing aids that I could wear at rehearsals and small gigs so I could understand what was going on. Next to natural hearing these are the best, most comfortable aids yet. I am still trying to get a pair with the original analogue K-AMP circuit from 1988 and with a sympathetic and helpful audiological ear, I now have a line on obtaining these hearing aids from just south of the Canadian border. As long as industry and governments regulate the industry for the good of the industry and not for the good of the hard of hearing consumer they will continue to provide a disservice to the people they say they want to help. My heartfelt gratitude to Drs. Mead Killion and Marshall Chasin for the work they&rsquo;ve done for all hearing impaired people and especially musicians.</p>\r\n<p>The Canadian Hearing Society is hosting its unique fundraising event, CHS Quest, on Sunday, May 29, 2011 in two cities: Toronto and Oshawa. CHS Quest is a smartphone-based scavenger hunt, where teams of four people solve video clues delivered in spoken, written and sign language to find their way to a series of QuestStops scattered across the city. At each QuestStop, teams must perform a fun, challenging task. Think Amazing Race without the international travel! CHS Quest is a pledge-based event, raising much-needed funds to support the 17 programs and services offered by CHS. Since 1940 CHS has been on a quest to break down barriers to communication faced by people with hearing loss. This fundraiser helps CHS to continue that all-important quest. Here&rsquo;s what people had to say about last year&rsquo;s inaugural CHS Quest: &ldquo;Had a great day with family and friends&rdquo; &ldquo;Excellent &hellip;it incorporated some sign language into the event which was fun to learn&rdquo; &ldquo;Led me to parts of the city I didn&rsquo;t know were there&rdquo; There are lots of ways to get involved: (1) Form a team and come out and join the fun; (2) Sponsor someone; and (3) Volunteer. The Honorary Chair is Andrew Younghusband, TV host of Canada&rsquo;s Worst Driver and Canada&rsquo;s Worst Handyman: &ldquo;I am proud to be this year&rsquo;s honorary chair of CHS Quest, an event like no other. It&rsquo;s a chance to meet new people, to compete and win some fantastic prizes, and most important, it&rsquo;s a fun way to raise funds in support of The Canadian Hearing Society.&rdquo;</p>\r\n<p>This year&rsquo;s Lead Sponsor of CHS Quest 2011 is Siemens. Partner sponsors include Wind Mobile and Compass Creative Media. To find out more about CHS Quest 2011, check out chs.ca/quest.</p>\r\n<p><strong>MICHAEL TEASE TO LEAD UNITRON&rsquo;S GLOBAL OPERATIONS</strong></p>\r\n<p>Unitron, a global provider of world-class hearing innovations, announced today the appointment of Michael Tease to the position of president and CEO. Mr. Tease will lead Unitron&rsquo;s global operations from the company&rsquo;s headquarters location in Kitchener, Ontario, Canada. &ldquo;As a core brand of the Sonova Group, Unitron is an important growth driver in our global business strategy. Michael Tease brings to Unitron a significant track record for performance, a depth of leadership expertise, and a passion for the customer that will allow us to further build and extend Unitron&rsquo;s brand reputation around the globe,&rdquo; says Valentin Chapero, CEO, Sonova Group. &ldquo;I am incredibly excited about the opportunity to lead a world class organization such as Unitron. The hearing healthcare industry is poised for significant growth and expansion, and I believe Unitron has the right mix of people, products, and customer partnerships to achieve longlasting brand leadership, and to make a true difference in people&rsquo;s lives,&rdquo; says Michael Tease.</p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-6-2-1-g005.png\" alt=\"image\" /></p>\r\n<p>By Marshall Chasin, AuD, MSc, Aud(C), Reg. CASLPO</p>\r\n<p>The first well-controlled study was published in 1998 by the Journal of the American Medical Association and cited some compelling statistics. The study included 3,753 people aged 48&ndash;92 and there appeared to be a clear trend that increased hearing loss was proportional to the number of cigarettes smoked each day. Specifically, 25.9% of smokers in the 48 to 59 age group were suffering from hearing loss, but it was only 16.1% among non-smokers. Also, 22.7% of exsmokers were suffering from hearing loss. This was also found in the older age groups.1 As can be imagined, research in this area can be quite difficult. Smokers may not provide exact information of the number of cigarettes smoked, and &ldquo;ex-smokers&rdquo; may not truly be &ldquo;ex-smokers.&rdquo; One of the uncontrolled factors may be whether these smokers also had good cardiovascular function. It turns out that one major factor is how much oxygen reaches the inner ear. All cells require oxygen in order to function. Conceivably a heavy smoker that also has excellent cardiovascular function may have minimal hearing loss from smoking. Another study performed in 2004 published in the Archives of Otolaryngology, Head and Neck Surgery at the University of Wisconsin at Madison found no relationship between smoking and hearing loss. In this study, cardiovascular function was controlled for.2 Having said this however, most people that smoke also have poor cardiovascular function, so the 1998 study is probably correct in their conclusions. Alternatively, one may argue that if you smoke, you should also take steps to maintain your cardiovascular system. To further complicate matters, it turns out that factors of smoking, aging, and working in a noisy environment, together act &ldquo;synergistically&rdquo; to create a hearing loss that is greater than any one of these factors alone.</p>\r\n<p>However, cardiovascular integrity and noise exposure history are not the only factors affecting whether smoking causes hearing loss. In 2008, an audiologist at the Western Michigan University, Dr. Bharti Katbamna published an overview of those factors that can interact with smoking to create hearing loss as well as some possible mechanisms of how that may happen.3 There appear to be three different mechanisms of how smoking may affect the cochlea. The first of these mechanisms has to do with how much oxygen is available in the cochlea. Nicotine and carbon monoxide from cigarette smoking may deplete the available oxygen levels thereby increasing the susceptibility of the various structures in the cochlea to damage (from noise and the aging process). The second mechanism may be related to nicotine interfering with the neurotransmitter substances in the auditory nerve thereby altering the hearing transmission mechanism. The third potential mechanism derives from studies on adolescent youths. The structures of the auditory nerve that takes neurological energy from the cochlea to the auditory centres of the brain are not well developed until late adolescence. It is possible that nicotine, along with other potentially toxic chemicals, may alter or prevent the various neurological pathways from developing properly. Whatever the mechanisms, clients should be counselled against smoking for a myriad of reasons, but especially if they are young, and have poor cardiovascular function.</p>\r\n<p><strong>REFERENCES</strong></p>\r\n<p>1. Cruickshanks KJ, Klein R, Klein BEK, et al. Cigarette Smoking and Hearing Loss - The Epidemiology of Hearing Loss Study. JAMA 1998;279(21):1715&ndash;19.</p>\r\n<p>2. Nondahl DM, Cruickshanks KJ, Dalton DS, et al. Serum Cotinine Level and Incident Hearing Loss: A Case-Control Study. Arch Otolaryngol Head Neck Surg 2004;130:1260&ndash;64.</p>\r\n<p>3. Katbamna B. Effects of Smoking on the Auditory System. San Antonio, TX. Audiologyonline. 2008. Accessed Nov. 2010. http://www.audiologyonline.com/ articles/article_detail.asp?article _id=2137.</p>\r\n<p>By Lendra Friesen, PhD</p>\r\n<p>Most cochlear implant (CI) users have excellent speech understanding in quiet; however, in noisy environments or, when listening to music, their perception rapidly deteriorates. Current CI devices provide up to 22 channels of information delivered directly to the auditory nerve. However, it has been demonstrated that most CI users are only obtaining information from 4&ndash;8 channels. Some of the reasons for this limitation are thought to include the broad current spreads from the stimulated electrodes and the resulting overlapping populations of activated neurons which might limit CI users&rsquo; access to all of the frequency or spectral information transmitted by the device. These channel interactions ultimately limit CI performance in noise, particularly dynamic noise.1,2 Recently, studies examining methods of reducing channel interaction and increasing the number of spectral channels have been conducted.3,4 Results from these studies might help to design CI signal processing strategies that provide more information in complex listening environments.</p>\r\n<p>The cochlea is arranged in a tonotopic manner with incoming high frequency sounds causing activity at the cochlear base and low frequency sounds at the apex. This pattern of activity is preserved up to the cortex. For someone having a CI, incoming sound is processed and converted to electrical signals. An external processor controls an internal receiver/stimulator that generates electrical signals and sends these to the electrode array implanted in the cochlea. Each electrode on the electrode array is assigned a frequency band of information, in a tonotopic manner, which it delivers to the nearby auditory nerve endings. This information is often termed a channel of information.</p>\r\n<p>Current steering with virtual channels has been proposed to increase the number of frequency or spectral channels of information beyond the actual physical number of electrodes. Virtual channels are created by simultaneously stimulating two adjacent electrodes. The peak of excitation is &ldquo;steered&rdquo; or shifted between the component electrodes by varying the amount of current delivered to the apical and basal electrodes. This shifting can evoke an intermediate pitch percept.5,6 For example, Donaldson et al. observed from two to nine place pitch steps in-between electrodes.5 Current steering is commercially implemented using monopolar stimulation where there is one active intra-cochlear electrode and one return electrode in the receiver/stimulator and current flows between the two electrodes. Because the active and return electrodes are widely spaced, current spreads over a wider area, stimulating a larger neuronal population and perhaps limiting sensitivity to spectral detail. Reducing current spread and neural interactions might allow CI users to  access more of the spectral cues provided by the device (whether via virtual or physical channels).</p>\r\n<p>Current focusing or tripolar stimulation has been proposed to reduce current spread. Here, current is delivered to an active electrode, and an equal amount of current is simultaneously delivered to the two adjacent flanking electrodes. Because the current loop is entirely intracochlear with tripolar stimulation, current spread is reduced. However, it is sometimes difficult to achieve sufficient loudness. To address the limitations of current steering and current focusing, Landsberger and Srinivasan proposed using quadrupolar virtual channels to combine current steering and current focusing.3 Theoretically, quadrupolar virtual channels would use current steering to transmit more spectral channels beyond the number of implanted electrodes and use current focusing to reduce channel interactions, thereby providing better functional spectral resolution. Quadrupolar virtual channel stimulation consists of four simultaneously stimulated intra-cochlear electrodes: two center &ldquo;steering&rdquo; electrodes between which the current is divided and two outer &ldquo;focusing&rdquo; electrodes which act as a ground. In this study, they compared virtual channel discrimination between monopolar virtual channel and quadrupolar virtual channel stimulation modes in CI users. Results showed significantly better virtual channel discrimination with quadrupolar virtual channel stimulation than with monopolar virtual channel stimulation, suggesting less current spread with quadrupolar stimulation, although this was not directly measured.</p>\r\n<p>In another study, Svrinivasan and colleagues measured current spread by comparing psychophysical forwardmasked excitation patterns between monopolar virtual channel and quadrupolar virtual channel stimuli in CI users, at equally loud comfortable listening levels.4 They found a sharper peak in the excitation pattern and a reduced spread of masking for quadrupolar virtual channel stimuli. Results from the forward masking study were compared with the 2009 study measuring virtual channel discrimination ability and showed a weak relationship between spread of excitation and virtual channel discriminability. The results from these studies suggest that CI signal processing strategies that use both current steering and current focusing might improve CI users&rsquo; functional spectral resolution by transmitting more channels and reducing channel interactions.</p>\r\n<p><strong>REFERENCES</strong></p>\r\n<p>1. Fu QJ, Shannon RV, and Wang X. Effects of Noise and Spectral Resolution on Vowel and Consonant Recognition: Acoustic and Electric Hearing. J Acoust Soc Am 1998;104(6):3586&ndash;96.</p>\r\n<p>2. Fu QJ and Nogaki G. Noise Susceptibility of Cochlear Implant Users: The Role of Spectral Resolution and Smearing. J Assoc Res Otolaryngol 2005;6(1):19&ndash;27.</p>\r\n<p>3. Landsberger DM and Srinivasan AG. Virtual Channel Discrimination Is Improved By Current Focusing In Cochlear Implant Recipients. Hear Res 2009;254(1-2):34&ndash;41.</p>\r\n<p>4. Srinivasan AG, Landsberger DM, and Shannon RV. Current Focusing Sharpens Local Peaks of Excitation in Cochlear Implant Stimulation. Hear Res 270(1&ndash;2):89&ndash;100.</p>\r\n<p>5. Donaldson GS, Kreft HA, and Litvak L. Place-Pitch Discrimination of Single- Versus Dual-Electrode Stimuli By Cochlear Implant Users (L). J Acoust Soc Am 2005;118(2):623&ndash;6.</p>\r\n<p>6. Firszt J.B., et al., Current steering creates additional pitch percepts in adult cochlear implant recipients. Otol Neurotol 2007;28(5):629&ndash;36.</p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-6-2-1-g006.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-6-2-1-g007.png\" alt=\"image\" /></p>\r\n<p><strong>THERAPEUTIC AREA</strong></p>\r\n<p>This book provides a comprehensive text for the specialty of pediatric audiology</p>\r\n<p><strong>FORMAT</strong></p>\r\n<p>This handbook contains 41 chapters that are organized into eight sections: I. Typical Auditory Development, II. Etiology and Medical Considerations, III. Auditory Disorders, IV. Early Identification of Hearing Loss, V. Approaches to Assessment, VI. Hearing Technologies, VII. Management Considerations and VIII. Family and Educational Considerations. The 70 contributors to this book are considered leaders in the field of pediatric audiology.</p>\r\n<p><strong>AUDIENCE</strong></p>\r\n<p>The Comprehensive Handbook of Pediatric Audiology text is intended for use by students in graduate education programs in audiology. Because of the comprehensive nature of the text it will also be immensely useful to practicing audiologists and audiologist-researchers interested in pediatric audiology. Other health care providers (otolaryngologists, geneticists, speechlanguage pathologists, early interventionists, auditory-verbal therapists, etc.) who work with children with hearing loss and their families are also likely to find this book beneficial. Finally, the chapters focused on principles and methods of population hearing screening in early hearing detection and intervention (EHDI) programs (Chapter 16) and descriptive epidemiology of childhood hearing impairment (Chapter 5) will also prove useful to policy-makers and program evaluators.</p>\r\n<p><strong>CONTENT</strong></p>\r\n<p>Section I, Typical Auditory Development, offers four chapters on embryology of the ear, development of the auditory system from periphery to cortex, infant speech perception and auditory development in children with normal hearing. Section II, Etiology and Medical Considerations, provides important epidemiological information relative to worldwide childhood hearing impairment, the genetics of childhood hearing loss, and offers the perspectives of both a pediatrician and otologist regarding medical considerations for infants and children with hearing loss. Section III, Auditory Disorders, is composed of seven chapters focusing on: conductive; unilateral; minimal/mild; and moderate to profound hearing loss. Section III also provides information on auditory neuropathy/dys-synchrony type hearing loss and (central) auditory processing disorders in children. The final chapter in this section focuses on false and exaggerated hearing loss in children. Section IV, Early Identification of Hearing Loss, offers two chapters. The first challenges the reader to critically examine principles and methods of population screening in EHDI programs and to consider areas for improvement. The second chapter provides an evidence-based review of factors that should be considered in the design, implementation and evaluation of screening programs for young children. Section V, Approaches to Assessment, provides chapters that cover relevant areas for best practice protocols for assessment of children with hearing loss. Chapters include middle ear measurement; otoacoustic emissions, frequency-specific ABR and ASSR threshold assessment, electrophysiologic assessment with auditory middle and late responses, and behavioural audiometry with infants and children. The final chapter in this section provides an overview of a systems approach to assessment and management of children with hearing loss that is culturally sensitive and family-centered. Section VI of the Comprehensive Handbook of Pediatric Audiology focuses on Hearing Technologies including: approaches to the fitting of amplification, FM systems, cochlear implants, bone-anchored hearing aids, and hearing instrument orientation for children and their families. Section VII, Management Considerations, has eight chapters which focus on audiological assessment, (re)habilitation, language learning and educational management to minimize barriers to communication for children with hearing loss and their families. The section begins with a history of management of hearing loss in children. The remaining chapters provide information about management of the listening environment and methods to facilitate early communication development, guidelines/protocols for delivering audiological services to families with toddlers and preschoolers, and managing the relationship of hearing loss to the listening and learning needs of schoolaged children. Later chapters in this section focus on thorough management/monitoring plans for children with unilateral and minimal/mild bilateral hearing loss, children with cochlear implants and children with ANSD. Chapter 36 in Section VII provides modifications/ adaptations that should be considered for assessment of hearing loss in children with multiple modality involvement. The final section of this comprehensive handbook, Section VIII, Family and Educational Considerations, provides the reader with the most recent information regarding familycentered practice, family support and informational counselling and provides information about the role of the pediatric audiologist as an advocate and professional collaborator in the educational setting. Chapter 40 in this section looks at how far we have come as pediatric audiologists in delivering quality services to young children with hearing loss and their families, and acknowledges where our EHDI programs still fall short. It concludes by providing information about ongoing initiatives aimed at closing gaps that still exist in delivering services to children with hearing loss and their families</p>\r\n<p><strong>USABILITY</strong></p>\r\n<p>This concise and comprehensive text book provides detailed information on the practice of pediatric audiology. The division of the book into eight sections results in easy navigation to particular topics of interest. The chapters are wellwritten and provide both basic science and research background, always linking the science to relevant clinical practice information. Each chapter has a significant number of pertinent and up-to-date references. Text, figures, tables, pictures, and appendices are of good size and impeccable print quality. Many chapters provide checklists, protocols, and/or handouts that will be useful for pediatric audiologists in clinical practice. Proceeds of the book are dedicated to a student scholarship fund at Vanderbilt University, TN, in memory of Dr. Judith Gravel who envisioned the need for such a book in pediatric audiology</p>\r\n<p><strong>HIGHLIGHTS</strong></p>\r\n<p>The Comprehensive Handbook of Pediatric Audiology provides reading material for most courses focused on pediatric audiology offered in today&rsquo;s graduate audiology programs. It will save many students from having to buy multiple text books and save audiology faculty members from having to search for relevant, up-to-date, well-written readings and lecture materials in the area of pediatric audiology. Audiologists in practice will find the text provides a wide range of clinically relevant information that will augment their knowledge and skills and improve the quality of services they are able to provide to children with hearing loss and their families. The chapters on epidemiology (Chapter 5), frequencyspecific ABR and ASSR assessment (Chapter 20), cochlear implants for children (Chapters 27 and 35), boneanchored hearing aids (Chapter 28), and auditory neuropathy spectrum disorder (Chapters 13 and 37) fill many gaps that exist in current pediatric audiology text books.</p>\r\n<p><strong>LIMITATIONS</strong></p>\r\n<p>There are minimal limitations to this text. Future editions of the text may benefit from inclusion of a chapter on vestibular evaluation of infants and children and on management of the child with progressive hearing loss. There is some redundancy in chapters, however, with 70 contributors and 41 chapters this is largely unavoidable, and the editors have managed to keep it at an acceptable level.</p>\r\n<p><strong>REVIEWER&rsquo;S SUMMARY</strong></p>\r\n<p>The Comprehensive Handbook of Pediatric Audiology is a valuable and necessary reference for the library of pediatric audiologists, students, and other professionals interested in EHDI programs, hearing loss in children and the impact on families. The inclusion of a diverse range of information in a single text book makes it a &ldquo;must-have&rdquo; and sets the bar high for future text books in audiology. It will facilitate the training, and continued development of, highly qualified professionals in pediatric audiology. It is truly an exemplary reflection of what Dr. Gravel would want it to be: scholarly, scientific, clinically applicable and useful for teaching. Judy would be proud.</p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-6-2-1-g008.png\" alt=\"image\" /></p>\r\n<p><strong>FINANCIAL DISCLOSURE</strong></p>\r\n<p>None reported.</p>\r\n<p><strong>ABSTRACT</strong></p>\r\n<p>This research project was undertaken to provide an update of a systematic review of interventions for hearing loss in children, previously commissioned by Health Canada.1 The review sought to evaluate the existing research pertaining to the effectiveness of interventions for children with permanent congenital hearing loss who received at least one of the following four interventions: oral communication, sign language, auditoryverbal therapy, or total communication. The updated study included articles from January 2001 through July 2008 inclusively. Consistent with predetermined eligibility criteria, all articles which reported communication outcomes on children with permanent hearing loss were included in this review. A total of 124 articles (and 23 dissertations) were retained. For this project, the 124 studies were analyzed and separated into direct and indirect evaluations of effectiveness of the four interventions. Data abstraction was conducted using synthesis tables to sort the studies according to (1) study population, (2) hearing loss, (3) intervention program, (4) co-interventions, and (5) family variables. A meta-analysis of the results was not possible due to the small number of studies which directly evaluated intervention effectiveness and the heterogeneity of the studies. Therefore a qualitative analysis was conducted. A variety of outcomes were documented, however, information pertaining to the subjects (e.g., age of intervention) and the intervention programs (length, intensity) was frequently not reported. The overwhelming majority of studies focused on children with cochlear implants. However, in most cases, the goal of these studies was to evaluate the effectiveness of cochlear implantation rather than one of the four intervention programs. In general, these studies reported that participants using oral communication methods were more comparable to their hearing age-mates than participants using other communication methods. Objective comparisons of the effectiveness of each intervention program could not be made due to lack of information on the program and the participants.</p>\r\n<p><strong>REFERENCE</strong></p>\r\n<p>1. Schachter HM, Clifford TJ, Fitzpatrick E, et al. Systematic Review of Interventions for Hearing Loss in Children. Ottawa: Health Canada. Contract # 030SS.HT091- 01001. November 2000.</p>\r\n<p>By Rex Banks, MA, CCC-A, Reg. CASLPO Director of Hearing Health Care The Canadian Hearing Society</p>\r\n<p><strong>NON-PROFIT AUDIOLOGY PAYS HIGH DIVIDENDS IN JOB SATISFACTION</strong></p>\r\n<p>Week one on the job at my first audiology position right out of grad school, the office manager for the ENT physician that I worked for dropped a large bag of &ldquo;slightly used&rdquo; hearing aids (fresh from the local funeral parlor I might add) onto my desk. This ENT doctor served on the board of the local, non-profit Deaf Services Centre and for years had donated the services of his audiologists to what was called &ldquo;The Hearing Aid Bank.&rdquo; My first act as a newbie audiologist towards serving the greater good was to determine which of these hearing aids were working and could be given to people in rural Kentucky who couldn&rsquo;t afford to buy a new hearing aid of their own. That was over 20 years ago and looking back, I realize that this altruistic ENT physician planted the first seeds of desire for nonprofit work into my heart.</p>\r\n<p>I embraced everything about The Hearing Aid Bank for the next couple of years before pulling up stakes and moving to South Florida. My next position was in a private practice setting that had a connection to Deaf Services and once again, I found myself sifting through donated hearing aids and finding new homes for them. I went on to work at a hospital and then finally, seven years into my career, I landed an audiology position at a charity called United Hearing and Deaf Services (now League for the Hard of Hearing Florida). I&rsquo;ll never forget the executive director telling me &ldquo;Rex, you can be whatever kind of audiologist you want to be in non-profit, but it&rsquo;s really up to you to make it happen.&rdquo; That was the day that I had an awakening, that as an audiologist, I could and should be doing much more than just pushing buttons and watching for hand signals for when people heard the beep &ndash; I could make a difference and non-profit was where I was going to do it. I spent the next six years of my life doing challenging, rich, and fulfilling projects that are nothing less than par for the course in non-profit work.</p>\r\n<p>It was the mid 90s and the HIV/AIDS  epidemic was in full force in South Florida. I started noticing an increasing amount of people on my caseload who were HIV+ and exhibiting hearing loss. Although many of these individuals were working, they couldn&rsquo;t afford to buy hearing aids and weren&rsquo;t eligible for Medicaid. I developed a relationship with a local HIV/AIDS organization to bring awareness to the issue and through our partnership, we raised money to make sure those with HIV/AIDS had access to hearing aids and other devices at no charge. I also worked closely with The United Way and obtained grants for a whole range of important and diverse issues including providing free hearing aids, repairs, and ALDs to low socioeconomic populations; ensuring that local hard-of-hearing support groups had access to real-time captioning; and providing speech language therapy for children with hearing loss long after their insurance companies stopped paying the bills. Running speech-reading groups, certifying people for hearing dogs, meeting with school social workers for deaf and hard-of-hearing kids &ndash; all in a day&rsquo;s work for the nonprofit charity based audiologist. Fate brought me to Canada in the summer of 2001. Upon my arrival to Toronto, I knew I wanted to continue my work in the non-profit sector and was hired as a staff audiologist at The Canadian Hearing Society (CHS) where my focus was on aural rehabilitation programs. My eyes were wide with excitement as I started to learn about all the wonderful things that were happening at CHS. The audiologists that had come before me had built a strong clinical environment based on compassionate values. Innovative ideas from running a week-long hearing awareness focused Elder Hostel to extensive development of materials around noise pollution to the most comprehensive aural rehab programming I had even seen, were all signs of committed, professionally like-minded audiologists who were clearly interested in making a difference on the hearing health care landscape. Rewarding opportunities like participating in health fairs, helping launch the Healthy Hearing component for The Special Olympics, providing school screenings to First Nations Cree children in Moosonee, and running a support group for people with acoustic neuromas are all things that were encouraged and supported for audiologists to pursue at The Canadian Hearing Society</p>\r\n<p>Audiologists are usually familiar and comfortable with referring to and working with other medical professionals. In a non-profit environment, you also gain an understanding and appreciation for the importance and contribution of those with social service backgrounds. For instance, at CHS, audiologists may provide care in synchrony with employment counsellors, mental health clinicians, home-based social workers, and sign language interpreters with everyone working towards the same goal of improving the consumer&rsquo;s quality of life. Non-profit settings generally approach hearing loss from a holistic perspective, treating the entire person and exploring how far reaching hearing loss is and its impact on a person&rsquo;s life on multiple levels. Exposure to the unique sensitivities of various consumer groups including culturally Deaf, oral deaf, deafened, and hard-of-hearing people enhances the audiologists&rsquo; overall perspective and scope of understanding of communication and the challenges that each group faces. Yes, you do need to sell hearing aids in non-profit as well. It&rsquo;s a reality of being an audiologist for most of us. There is, however, a great sense of satisfaction in knowing that the proceeds are reinvested directly back into the charitable programs and activities offered by the organization. It won&rsquo;t come as any surprise that in a non-profit environment we have to be good stewards of our financial resources and we take nothing for granted. Time and thought and resources have to be used as efficiently and effectively as possible. As challenging as that can sometimes be, there is nothing more rewarding in a non-profit environment than the stories of remarkable people who have overcome enormous challenges and barriers. It is from those consumers that we as audiologists can learn the most. By using these newfound insights and stories, we can help others achieve the same level of strength and success in their lives in coping and managing their hearing loss.</p>\r\n<p>For audiology students who are about to transition from the classroom to the real world, I would definitely recommend taking a look at the non-profit sector as a potential career path. It&rsquo;s challenging, enlightening and rewarding &ndash; what more could you ask for?</p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-6-2-1-g009.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-6-2-1-g0010.png\" alt=\"image\" /></p>\r\n<p>By Tani Nixon, MCI.Sc, Reg. CASLPO</p>\r\n<p>In 1975 the number of private practice audiologists in Ontario could be counted on one hand. The number of audiologists dispensing hearing aids was also relatively small. Fifteen years later, audiologists realized that waiting for government-funded practices to open was not serving the public and that hearing aids were not always a priority. Slowly private practice has now grown to represent more than 50% of the various work settings for audiologists practicing in Ontario. It&rsquo;s easy to identify the benefits of working for yourself. First of all, you make all your own decisions rather than comply with someone else&rsquo;s idea of how your practice should be run. &bull; You get to arrange your own schedule, determine how long appointments should be, set your hours to be convenient for your own life, and take vacations whenever it is convenient for you. (You can also decide to spend longer with some clients you KNOW require more time). &bull; You can choose to go to workshops you feel are appropriate for your practice. &bull; You can set up a location close to your home (or to your gym!) &bull; You can expand the practice as you see fit. (You can decide to work more when your practice is busy and less when it&rsquo;s not so busy) &bull; You can choose your own office management system and/or design your own setup for things like call backs, appointment length, nonstandard hours etc. &bull; You can hire your own staff, pick people you get along with and approve their holidays etc., for the needs of the business. You can even hire your own kids to help with things such as university expenses, and ensure your kids will have a job even in difficult times. &bull; You can join a buying group if you choose, and after several years, you can anticipate higher income levels than a typical employee.</p>\r\n<p>Perhaps the biggest advantage to private ownership is the freedom to organize your life and your work to suit your own personal needs and beliefs. Sounds good? Okay, let&rsquo;s have a look at some of the potential problems with working in a private practice. Having no other audiologist to talk to everyday can be lonely. It can be fun working in an audiology department with a group of audiologists. In private practice it&rsquo;s important to make time to talk to colleagues and to recognize that some will see you as the competition when previously they might have been your friends. You are responsible for it all. You need to be a mature and responsible person who knows how to handle some tough situations with a calm and reasonable approach. Personally, I did not start private practice until I had worked as an employee for many years &ndash; including management. Experience and management training help enormously and make you aware of the obligations to and expectations of staff. You need to have an understanding of staff supervision as you are bound to have at least a secretary who will have needs of his or her own. You need to understand labour laws and your responsibilities as an employer. If you have only one or two employees, their loss due to illness (or leaving) will have a much larger impact than in an organization with many staff. You will need to give some consideration to temporary help, if you can find it. You are going to be fully responsible for managing all financial aspects of your business and so you need a reasonable understanding of business management and/or a great bookkeeper. Training in this aspect of your practice is very important and you can expect to spend a minimum of 10% of time on management functions. Some knowledge of business accounting will also help you to follow what your accountant is trying to tell you.</p>\r\n<p>When starting a business you will need to develop a business plan for your bank. This plan will also help you to know if you are achieving your financial goals. A lawyer and an accountant can set up a corporation and do taxes annually. Look carefully at malpractice and liability insurance as these expenses will be much higher than for an employed individual. It is more difficult to organize a benefit package or a pension plan although an accountant may help with these problems. There is often no one to help make the tough decisions. Do I need to spend $15,000 on new equipment? Am I doing too much? Can I afford to cut back? Can I stop doing ABR&rsquo;s and still get referrals  from local physicians for hearing aids? If I increase the cost of tests for seniors how will if affect my business? Do I need to move to a mall? These questions are ever present in the mind of a business person, as they should be. Independent audiologists need to constantly survey what is happening in our profession to be sure to remain current. I have always found pricing to be tricky. Should you charge more or less than your competitors? And managing cash flow is a constant issue. It is important to understand billing procedures fully as you are the only one who will be looking to find problems. Collections are never fun. You will need to purchase equipment that you may not be familiar with, including phones, fax machines, photocopiers etc. Periodically you need to negotiate terms with manufacturers, and you will benefit from learning all about advertising, including what works in your community and for your patient profile.</p>\r\n<p>Written policies and procedures are useful so that they are clear for new staff members and for students. It is important to stay abreast of your college&rsquo;s rules and regulations as well as laws that may affect your practice. And in a relatively small town you need to smile at everyone because that fellow coming along the street is bound to be the cousin of the sister of the uncle of the brother of the fellow that you just saw this morning. Still thinking about private practice? Starting a business is a way of stimulating some brain cells that may not be used often. Certainly I can promise that you will never be bored in private practice. And if you&rsquo;re lucky, some day the practice can be sold and form part of your retirement funding.</p>\r\n<p>By Eloise Thurier, MCl.Sc, Reg. CASLPO</p>\r\n<p>I have held two placements as a hospitalbased audiologist. The first was at St. Joseph s Hospital in Thunder Bay, Ontario (two years) and since 1982 I ve been at Mount Sinai Hospital. These two work settings were like night and day. In the first I worked as a sole-charge and was &ldquo;Director of Audiology&rdquo; and in the second I have always been part of a team. There are so many things to consider when you think about whether a hospital is the right choice for you. The field of audiology has evolved considerably since I graduated. I was, and still am attracted to working in a setting with plenty of variety, and Mount Sinai continues to provide challenging opportunities for professional growth. Not only do we have a busy diagnostic clinic and hearing aid dispensary, we also do teaching, and have a research division as well. I am not personally involved with it, but the department also provides services for the Infant Hearing Program. We are also fortunate to have a number of &ldquo;old-timers&rdquo; providing a wealth of experience for the newer members of the team. On a &ldquo;normal&rdquo; day, I may be scheduled to work in the outpatient ENT clinic cranking out audiograms where patients are booked in 20 minute slots. This may be for an hour, or an all day job. Other slots are &ldquo;Hearing Consultation,&rdquo; Hearing Aid Fitting, ABR, and ENG, all scheduled as one hour visits. Some days I am assigned to staff a two hour hearing aid dispensary &ldquo;Walk-in Clinic&rdquo; where patients come to have urgent hearing aid problems diagnosed. Occasionally, I am scheduled to teach a &ldquo;Hearing Information Class&rdquo; to patients who are currently not hearing aid users but would like to understand more about their hearing loss and hearing aid options. Periodically I teach medical students or ENT residents from the University of Toronto Department of Otolaryngoloy and I also take a student from UWO for a two month externship every spring/summer.</p>\r\n<p>We have weekly clinical meetings to review ENG cases, dispensary issues, or administrative updates. It is a constant whirlwind and can be stressful. For each patient encounter, there will be a certain amount of paperwork generated, and sometimes it is hard to keep up with all of it. Mount Sinai has a busy ENT clinic and much of what our department does is driven by the demands of the ENT service. We strive to balance the ENT needs with other important activities. It can be an advantage to have the ENT staff nearby, for example when an unforeseen problem arises from taking an ear impression.</p>\r\n<p>Working in a hospital means there are many protocols and procedures beyond what CASLPO guidelines stipulate governing how you work with patients. The hospital itself has a Policy and Procedure Manual and we also have a departmental manual which are fundamental for providing consistent quality of care/service to patients with safety and security in mind. A hospital, like any corporation or business has a hierarchy and a budget, with admininstration and bureacracy, deadlines to meet, etc. We are continuously competing for space, resources, and money with other departments. Our level of funding depends on government, so we are tuned to the political and economic forecasts. For budget purposes, there are mandatory statistics that are gathered and reported to the Ministry of Health.</p>\r\n<p>As the knowledge base for heath care is upgraded and as health challenges arise, the hospital is there to work with the challenges. In 2003, we had the SARS crisis, and before that, the spread of AIDS. We now face concerns dealing with resistance to antibiotics and an possible global flu epidemic. Our administration has a big job to fulfill being on the lookout for these events, which may not always be foreseeable, and then trying to disemminate the correct information to the staff and public. I am not sure what the experience of other hospital based audiologists might be, but I feel privileged to work at Mount Sinai Hospital. We have a good administration and our group makes a good team.</p>\r\n<p>By Kate Dekok, MCl.Sc Aud(C), Reg. CASLPO Chief Audiologist, ListenUP! Canada</p>\r\n<p>It has been an exciting 13 years. Thirteen years into an audiology career that I could have never have imagined. Thirteen years of twists and turns that has brought me to work for the largest employer of audiologists in Ontario. Thirteen years of opportunities to develop my career; from working in a private practice, to an educational setting, to starting up my own audiology private practice, to partnering with ListenUP! Canada which was the most unexpected, and yet most rewarding change of all. The transition from business owner to working in a multi-practice setting was a relatively easy one for me as I was already utilizing the expertise of other professionals such as bookkeeper, accountant and lawyer. Sure, there was stress that went along with handing over the reigns of my business to someone else. However it was relieved over time as I came to appreciate all the additional support that came along with this new partnership &ndash;from more professional and effective marketing to handing over the less attractive tasks of accounting, receivables and payables, payroll and professional support. My clients were pleased with the added value and perks that came along with the ListenUP! products and services, while still enjoying that personalized care that they had come to expect from me. So it was a win-win &ndash; my clients were happy and it was exactly what I needed at that stage in my career.</p>\r\n<p>Partnering with ListenUP! Canada allowed me to maintain the professional autonomy I was used to in my clinical work and the sale of my business provided the financial freedom I craved. But most important, it provided an ideal solution that allowed me to achieve an incredible life/work balance that wasn&rsquo;t possible as a single owner/operator of a business. As well, with a larger and growing organization I have been able to extend the scope of my experience and career from clinician, to clinic manager, regional manager, and now to chief audiologist. Through these different roles, I have been presented with a multitude of opportunities that are unique to a multi-practice operation including mentoring other hearing health care professionals, participating in a variety of marketing initiatives, providing input on internal processes and management of both professional and support staff; and all under the umbrella of one company.</p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-6-2-1-g0011.png\" alt=\"image\" /></p>\r\n<p>In addition to multiple career and learning opportunities, partnering with ListenUP! Canada was a wonderful opportunity to become part of a larger community of like minded hearing healthcare professionals who share common goals, problems and interests.</p>\r\n<p>I now have an incredible network of over 100 peers and we enjoy sufficient scale to develop best practices from many inputs, have our own conferences, and throw a great annual conference and party with our own awards and prizes/trips &ndash; it is much less isolated than running my own business. It is also a privilege to be a part of something that has engaged the public so well, and is successful, growing and at the forefront of change in the industry. When considering working within a large organization, I think there are three core questions you need to ask yourself. First: &ldquo;Where or how will I fit in at a multi-practice organization?&rdquo; One of the biggest advantages of a multi-location venue is the variety of opportunities, both geographically and professionally available. For example, at ListenUP! Canada, our focus is the provision of rehabilitative audiology services, primarily to adults. However, our size provides flexibility and multiple opportunities: we have locations that see a mix of children and adults, some clinicians do an extensive amount of testing for ENTs, some locations are rural and others urban, some locations are situated in medical centres while others are more retail or store front. All clinicians are not alike; they have different attributes, interests and preferences. In a multi-practice organization you are more likely to find a role that is just right for you &ndash; and one that has multiple career options in the future if that&rsquo;s what you want. The second question is: &ldquo;How can a large organization support me professionally?&rdquo; The scale of a larger company provides the flexibility and structure to enhance and develop your skills and credentials. With designated professional development time, internal conferences and vendor training sessions customized to our needs, an internal certification program that in some cases goes beyond what you learned in school (i.e., mostly practical things that are essential for dispensing audiologists to know), the private sector, and ongoing training and development programs on core areas of competency to enhance your skills as a clinician, you will enjoy an enriched clinical environment. There are also extensive opportunities to share experiences and learn from a large variety of professionals, some with over 20 or 30 years of experience. Large organizations are simply better equipped to support their own staff through ongoing professional development investments and activities &ndash; and they are both willing and able to do so.</p>\r\n<p>The third question you need to ask yourself is: &ldquo;Is a multi-practice organization right for me?&rdquo; I have already related many advantages available in a multi-practice organization; however, there is no question that large organizations, such as ListenUP! Canada may not be the right fit for all clinicians. For example, we are a quickly growing and evolving company which can bring with it ongoing challenges. One thing that does not change around here is that we are in a constant mode of change! We experiment, try new products and vendors, look for ways to constantly improve the value that our clients receive, and explore various clinical and development strategies. There is a constant focus on how or what can we do to be better. Change is not always a good thing but it is necessary for the growth that we have seen from two locations seven years ago to now over 80 locations. What worked for a company with two locations, will not work where we are at today. We strive to provide not only an exceptional hearing health care experience for our clients, but also to provide a rich and fulfilling work experience for our staff. To accomplish this, change is a key ingredient and it requires our staff to work in a very dynamic environment. While some clinicians excel in this environment, others may find it too challenging. In addition to the changing environment, some people just fit better at ListenUP! For example: &bull; Many of our most successful clinicians have outstanding interpersonal and social skills such as a naturally outgoing personality, and poise and confidence in dealing with the public. These are often innate attributes that cannot be learned. How are your social skills? &bull; Some clinicians have a desire to progress into management roles and others do not &ndash; both fit well with us. What does your vision for a career look like? &bull; Some clinicians are comfortable with predetermined and set standards for protocols and practices which is important for success in a large organization. How do you feel about that? &bull; Being a team player is also critical for success here. The ability to work cooperatively in a collegial setting. Are you better off working on your own or with others? The good news is that everyone fits well somewhere.</p>\r\n<p>In summary, working in a multi-practice organization offers audiologists &minus; both new grads and experienced clinicians &ndash; an incredible array of flexibility, growth opportunities and options. From clinical work and business development to mentoring and training, a multi-practice setting provides unparalleled career advancement opportunities or even  more importantly, a place to practice your profession without the headaches and significant risks of running your own business. Which twists and turns will your career take? Perhaps the next turn of fate will bring you to a multi-practice organization where you too could grow in a variety of ways and utilize the broad ranging support available to practice audiology. Where will I be 13 years from now? That, I cannot answer. However, I do know for certain that right now, working at ListenUP! Canada, I am as challenged, happy and excited about my career as I was when I started 13 years ago.</p>\r\n<p><strong>ABSTRACT</strong></p>\r\n<p>During the last year, new hearing aids have been developed that incorporate a processing feature which may prove effective for cases of severe and profound loss that affect the structures related to the coding of high-frequency information. Frequency transposition holds the possibility of providing high-frequency speech cues to an auditory system with a deficient cochlear high-frequency partition. Frequency transposition is the extraction of information from frequency regions of the speech spectrum that corresponds to the dysfunctional high-frequency regions of the cochlea and the transposition of this information to a frequency region where function is more adequate. Frequency transposition studies with adult listeners have shown increased identification of highfrequency speech items, including syllables containing high frequency consonants. A few case studies have also shown a similar benefit with young children. Therefore, it can be hypothesized that transposed speech may also facilitate overall speech recognition in infants and children with severe levels of loss. However, it remains to be determined whether this will promote the language development. A child with high-frequency severe hearing loss may more easily develop language with transposed speech versus non-transposed speech simply because of the significant increase in available acoustic cues which become audible with frequency transposition. Although a logical argument exists for employing frequency transposition, it remains an empirical question whether the frequency transposition feature of hearing aids would enhance language development in infants and children with severe and profound high-frequency hearing loss.</p>\r\n<p>Tiffany A. Johnson, PhD. CCC-A, is an assistant professor at the University of Kansas SpeechLanguage-Hearing: Sciences and Disorders Dole, Human Development Center in Lawrence, KS. She can be contacted by e-mail at tiffany-johnson@ku.edu.</p>\r\n<p><strong>ABSTRACT </strong></p>\r\n<p>Otoacoustic emissions are used in a variety of research applications, but their clinical application primarily has been limited to the identification of the presence or absence of hearing loss. Here, we describe the relationship between distortion product otoacoustic emissions (DPOAE) responses and behavioural thresholds for a range of approaches to relating the two measures. The data reviewed here suggest that there is a relationship between DPOAE levels and behavioural thresholds. They also suggest that DPOAE thresholds show a moderately strong relationship with behavioural thresholds. Although these relationships are characterized by variability, DPOAEs can be used to provide some information regarding the degree of hearing loss, in addition to their more common application where they are used to screen for hearing loss.</p>\r\n<p><strong>OUTER HAIR CELLS, OTOACOUSTIC EMISSIONS, AND BEHAVIOURAL THRESHOLDS</strong></p>\r\n<p>In a normal, healthy cochlea sound is processed in a highly nonlinear manner such that the output of the cochlea may not be directly proportional to the input. The cochlear outer hair cells (OHC) are thought to be the source of this nonlinearity.1 One important characteristic of OHCs is that they are motile and, therefore, move in response to sound stimulation.2 The motile action of the OHCs serves to amplify the displacement of the basilar membrane for low sound levels and this action is responsible, in large part, for our ability to hear soft sounds. The motility and nonlinear behaviour of the OHCs also results in the production of otoacoustic emissions (OAEs). OAEs are soft sounds that are produced within the cochlea but can be recorded in the ear canal. OAEs are widely used in both clinical and research applications because they provide a noninvasive probe of cochlear function and can be used to predict the status of the cochlea.</p>\r\n<p>The most widespread use of OAEs is as a tool to screen for the presence or absence of hearing loss, typically in infants and young children. In this application, OAE level or signal-to-noise ratio (SNR) is used to make predictions regarding whether an ear is likely to have either normal or impaired hearing. In the event that a possible hearing loss is identified, no predictions are made regarding the  degree of hearing loss. However, the reason OAEs have been successful in screening applications is because there is a relationship between OHC function and both OAE level and behaviouralthreshold level. If OHCs are damaged, OAE level is reduced and behavioural threshold increases. It is, therefore, reasonable to expect that there may be a relationship between OAE level and behavioural threshold that would allow behavioural threshold prediction from OAE responses. There have been reports of success in predicting behavioural threshold from transient-evoked OAE responses3 ; however, because the majority of the work in this area has been with distortion product OAEs (DPOAEs), we will focus on the results obtained with DPOAEs. DPOAEs are produced in response to two pure-tones with slightly different frequencies (&fnof;1, &fnof;2; &fnof;2&gt;&fnof;1). As a consequence of the nonlinear behaviour of the cochlea, stimulation with two tones results in the generation of distortion products at many different frequencies. In humans, the largest component occurs at 2&fnof;1-&fnof;2 and, therefore, this is the component that is typically measured when recording DPOAEs. It should be noted, however, that the nonlinear process that produces the DPOAE arises primarily from locations near the &fnof;2 characteristic place. Therefore, the DPOAE response (measured at the 2&fnof;1-&fnof;2 frequency) is used to make predictions regarding the status of the cochlea near &fnof;2. DPOAE LEVELS AND BEHAVIOURAL THRESHOLDS Several reports have been published suggesting there is a relationship between DPOAE level and behavioural threshold.3&ndash;7 Dorn et al. described the relationship between DPOAE level and behavioural threshold for ears with thresholds falling in the normal-hearing range (i.e., thresholds between &ndash; 5 and 20 dB HL).4 The level of &fnof;1 (L1) was fixed at 65 dB SPL and the level of &fnof;2 (L2) was fixed at 55 dB SPL. For these ears, there was a systematic decrease in DPOAE level as behavioural threshold increased from &minus;5 to 20 dB HL. The mean DPOAE level for ears with behavioural thresholds of &minus;5 dB HL was approximately 5 dB SPL while the mean DPOAE level for ears with behavioural thresholds of 20 dB HL was approximately &minus;2.5 dB SPL, a decrease of 7.5 dB relative to ears with the best thresholds.</p>\r\n<p>Gorga et al. report data that extend this relationship to behavioural thresholds between -5 and 55 dB HL.6 These data are reproduced here in Figure 1. Here, audiometric (behavioural) threshold (dB HL) is plotted as a function of DPOAE level (dB SPL) for &fnof;2 frequencies ranging from 750 to 8000 Hz (as indicated within each panel). For each &fnof;2 frequency, L1 and L2 were set at 65 and 55 dB SPL, respectively. Within each panel, the dark, solid line represents the median DPOAE level and the shaded regions represent the interquartile range. These data suggest that there is a relationship between DPOAE level and  behavioural thresholds ranging from &minus;5 to 55 dB HL such that ears with poorer thresholds produce DPOAEs with lower levels than ears with better thresholds. The data in Figure 1 also illustrate that this relationship is characterized by variability as indicated by the width of the interquartile range. It should be noted that these data do not extend beyond behavioural thresholds of 55 dB HL. Complete loss of OHC function would not be expected to produce hearing losses exceeding 50 to 60 dB; therefore, it is unlikely that DPOAE level would relate to behavioural thresholds when the hearing loss exceeds 50 to 60 dB HL. Although the data in Figure 1 are variable, data such as these suggest that some information regarding behavioural threshold may be gained by examining DPOAE level.</p>\r\n<p><strong>DPOAE THRESHOLDS AND BEHAVIOURAL THRESHOLDS</strong></p>\r\n<p>Given the apparent relationship between DPOAE levels and behavioural threshold, it is reasonable to evaluate the relationship between thresholds predicted from DPOAE responses and behavioural thresholds. There have been two different approaches to predicting thresholds from DPOAE responses. The first approach involves recording DPOAE responses for decreasing L2 levels until the response falls into the noise floor, i.e., until the SNR falls below some criterion level. We will refer to this approach as the SNR approach. The second approach involves recording DPOAE input-output (I/O) functions for a range of L2 levels and then fitting the I/O function with a regression equation that is used to predict behavioural threshold. We will refer to this as the I/O approach. We will consider the results obtained with the SNR approach first. Of the two approaches to determining DPOAE thresholds, the SNR approach is simpler to implement because the only requirement is to decrease L2 until the DPOAE response is no longer distinguishable from the noise, which is often defined as the point at which the SNR falls below 3 dB. The L2 at which this occurs becomes the DPOAE threshold. Several studies have explored the relationship between the SNR-based DPOAE thresholds and behavioural thresholds.3,8&ndash;10 Across these studies, correlation coefficients ranged from 0.52 to 0.91. The strongest correlations are for &fnof;2 &rsquo;s between 1.5 and 6 kHz, where correlations exceed 0.75 in most reports. These data suggest that there is a linear relationship between SNR-based DPOAE thresholds and behavioural thresholds, although there is variability in the relationship.</p>\r\n<p>Boege and Janssen developed a technique for predicting behavioural threshold from the DPOAE I/O function.11 In this approach, DPOAE levels were recorded for a range of L2s, with L2 not exceeding 65 dB SPL. If at least 3 L2s produced DPOAEs with a 6-dB SNR or greater, the DPOAE levels (measured in dB SPL) were converted to pressure values (&micro;Pa). The resulting data were then fit with a linear-regression equation. For those I/O functions where the regression line was judged to be a good fit (based on evaluation of r2 , slope, and standard error values), the regression equation was solved for the L2 where the DPOAE level equalled 0 &micro;Pa. This L2 was defined as the DPOAE threshold, which was then correlated with behavioural threshold.</p>\r\n<p>Using this I/O approach, Boege and Janssen reported a correlation of 0.65 between behavioural thresholds and DPOAE thresholds, although they did not explore the extent to which this relationship varied across frequency.11 Using a similar I/O approach to the one described by Boege and Janssen, Gorga et al. explored the relationship between DPOAE thresholds and behavioural thresholds as a function of frequency.12 A summary of their data is reproduced in Figure 2. Here, behavioural threshold (dB HL) is plotted as a function of DPOAE threshold (dB SPL), with each panel representing a different frequency. The solid line within each panel is the best-fit line. Correlation coefficients ranged from 0.49 at 750 Hz to 0.85 at 4000 Hz. For low frequencies between 500 and 750 Hz, the correlations were &le; 0.57, whereas the correlations were &ge; 0.66 for frequencies above 750 Hz and were &ge; 0.74 for frequencies above 1500 Hz. These data suggest that there is a relationship between DPOAE thresholds and behavioural thresholds for mid-tohigh frequencies, although, as was the case for the SNR approach, the relationship is characterized by variability</p>\r\n<p>In addition to describing the relationship between DPOAE and behavioural thresholds, Gorga et al. also explored the characteristics of the ears not meeting the inclusion criteria for estimating DPOAE threshold from the I/O function.12 Of those ears not producing three points on the I/O function with a 6 dB or higher SNR, the majority had hearing loss. For example, at 750 Hz 78% of ears not meeting the SNR criterion had thresholds &ge; 30 dB HL and at 4000 Hz 100% of the ears not meeting this criterion had thresholds &ge; 30 dB HL. In contrast, the majority of ears not meeting the criteria for goodness of regression fit (i.e., r2 , slope, and standard error values) had thresholds &le; 30 dB HL These results suggest that some information regarding auditory status is available even for ears where a DPOAE threshold could not be estimated from the I/O function. The data described above suggest that there is a relationship between DPOAE thresholds and behavioural thresholds using both the SNR approach and the I/O approach to estimating DPOAE threshold. Is there any advantage to using one approach as compared to the other? Johnson et al. explored the relationship between DPOAE thresholds and behavioural thresholds when both approaches were used to predict behavioural thresholds in the same group of subjects.9 Figures 3 and 4 plot the results reported by Johnson et al. that describe the relationship between DPOAE thresholds and behavioural thresholds for the two approaches. Results for the SNR approach are plotted in Figure 3, with results for the I/O approach plotted in Figure 4. In both   figures, each panel represents data for a different frequency between 707 and 8000 Hz. The solid line in each panel is the best-fit line whose equation is shown as an inset in each panel. As can be seen in Figures 3 and 4, there is a relationship between DPOAE threshold and behavioural threshold for both approaches. Correlation coefficients were similar for the two approaches, ranging from 0.59 to 0.87 with correlations &ge; 0.67 for frequencies above 1000 Hz (with most cases exceeding 0.70). There was no consistent pattern of correlations favouring one approach as compared to the other. These data suggest that both approaches result in a similar linear relationship between DPOAE thresholds and behavioural thresholds. Although the data plotted in Figures 3 and 4 suggest a similarity between the SNR and I/O approaches, Johnson et al. explored other aspects of the comparison that might be important in clinical implementations.9 This included examining the number of ears for which a DPOAE threshold could be estimated. For the I/O approach, a DPOAE threshold could be estimated in 36 to 54% of ears, depending the frequency at which the prediction is made. In contrast, for the SNR approach, DPOAE thresholds could be predicted in 57 to 94% of ears for the same range of frequencies. The number of ears for which a DPOAE threshold could be estimated using the SNR approach exceeded the I/O approach by nearly 30 to 50% for most frequencies. However, it appears that the wider applicability of the SNR approach comes at the expense of the accuracy of the prediction. The standard errors for the I/O approach ranged from 7.29 to 19.61 dB and were less than approximately 12 dB for the frequencies 707 to 4000 Hz. In contrast, the standard errors for the SNR approach were between 11.64 and 21.59 dB, and exceeded 13 dB for all frequencies above 707 Hz. At every frequency, standard errors for the I/O approach were between 2 and 6 dB less than those observed for the SNR approach.</p>\r\n<p><strong>SUMMARY</strong></p>\r\n<p>The data reviewed here suggest that there is a relationship between DPOAE levels and behavioural thresholds, as might be expected based on the contribution of OHC function to both DPOAE responses and behavioural threshold levels. They also suggest that there is a moderately strong linear relationship between DPOAE thresholds (using either the SNR or the I/O approach) and behavioural thresholds. While the correlations between DPOAE thresholds and behavioural thresholds are similar for the SNR and I/O approaches, the I/O approach can be applied to fewer ears but yields a more accurate prediction than the SNR approach. Although there is variability in the relationship, the data reviewed here suggest that information regarding behavioural threshold can be obtained from recording DPOAE thresholds.</p>\r\n<p><strong>REFERENCES</strong></p>\r\n<p>1. Kim DO. Active and Nonlinear Cochlear Biomechanics and The Role of the Outer-Hair-Cell Subsystem in the Mammalian Auditory System. Hear Res 1986;22:105&ndash;114.</p>\r\n<p>2. Brownell W. Observations on a Motile Response in Isolated Outer Hair Cells. In: Webster WR, Aitken L, eds. Mechanisms of Hearing. Clayton, Australia: Monash University Press; 1983:5&ndash;10.</p>\r\n<p>3. Martin, GK, Ohlms, LA, Franklin, DJ, et al. Distortion Product Emissions in Humans III. Influence of Sensorineural Hearing Loss. Ann Otol Rhinol Laryngol 1990;99:30&ndash; 42.</p>\r\n<p>4. Stover L and Norton SJ. The Effects of Aging on Otoacoustic Emissions. J Acoust Soc Am 1993;94:2670&ndash;81.</p>\r\n<p>5. Dorn PA, Piskorski P, Keefe DH, et al. On the Existence of An Age/Threshold/Frequency Interaction in Distortion Product Otoacoustic Emissions. J Acoust Soc Am 1998;104:964&ndash;71.</p>\r\n<p>6. Gorga MP, Neely ST, Johnson TA, et al. Distortion-Product Otoacoustic Emissions in Relation to Hearing Loss. In: Robinette MS, Glattke TJ, eds. Otoacoustic emissions : Clinical applications (3rd Edition). New York: Thieme; 2007:197&ndash;225.</p>\r\n<p>7. Sisto R, Chelotti S, Moriconi L, et al. Otoacoustic Emission Sensitivity to Low Levels of Noise-Induced Hearing Loss. J Acoust Soc Am 2007;122:387&ndash;401.</p>\r\n<p>8. Dorn, PA, Konrad-Martin D, Neely ST, et al. Distortion Product Otoacoustic Emission Input/Output Functions In Normal-Hearing and Hearing-Impaired Human Ears. J Acoust Soc Am 2001;110:3119&ndash;31.</p>\r\n<p>9. Johnson TA, Neely ST, Kopun JG, et al. Clinical Test Performance of Distortion Product Otoacoustic Emissions Using New Stimulus Conditions. Ear Hear 2010;31(1):73&ndash;83.</p>\r\n<p>10. Johnson TA, Neely ST, Kopun JG, et al. Distortion Product Otoacoustic Emissions: Cochlear-Source Contributions and Clinical Test Performance. J Acoust Soc Am 2007;122:3539&ndash;53.</p>\r\n<p>11. Boege P, Janssen T. Pure-Tone Threshold Estimation from Extrapolated Distortion Product Otoacoustic Emission I/O-Functions In Normal and Cochlear Hearing Loss Ears. J Acoust Soc Am 2002;111:1810&ndash;18.</p>\r\n<p>12. Gorga MP, Neely ST, Dorn PA, et al. Further Efforts to Predict Pure-Tone Thresholds from Distortion Product Otoacoustic Emission Input/Output Functions. J Acoust Soc Am 2003;113:3275&ndash;84.</p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-6-2-1-g0012.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-6-2-1-g0013.png\" alt=\"image\" /></p>',NULL,'2022-11-30'),(46,3236,'ajchr','http://www.andrewjohnpublishing.com/','','<p>Treize ans plus tard, je demeure inspir&eacute;e par les audiologistes du Canada. C&rsquo;est un groupe d&eacute;vou&eacute; dont les membres travaillent ensemble et individuellement &agrave; am&eacute;liorer la qualit&eacute; des soins de sant&eacute; auditifs et le secteur de l&rsquo;audiolo-coveries to advance the fields of hearing science and audiology. The individuals who work together to bring audiological services, supplies, and training to those in developing countries who might otherwise live in silence. The corporations who promote audiology and hearing health care around the world every day. These are the people who will inspire the next generation of audiologist, but only if they hear about them. So how do we ensure that their songs are sung to the masses?</p>\r\n<p>The Canadian Academy of Audiology presents annual awards to audiologists and those in related fields who have made a significant contribution to the profession. What we need from you is nominations. Help us to publicly recognize the good work that we do as a profession. There are five awards for which you can nominate someone. The following awards are available:</p>\r\n<p>&bull; The Moneca Price Humanitarian Award</p>\r\n<p>&bull; Paul Kuttner Pioneer Award</p>\r\n<p>&bull; Jean Kienapple Award for Clinical Excellence</p>\r\n<p>&bull; Richard Seewald Career Award</p>\r\n<p>&bull; Honours of the Academy</p>\r\n<p>(see the CAA website, www.canadianaudiology. ca, for more details on these awards) The call for nominations went out earlier this year and the response was fabulous. Each year, these awards a given to individuals whose peers have centered them out as being exceptional. These awards are presented at the President&rsquo;s Luncheon and I hope that you will be there to help us honour these outstanding award winners. I also hope that our winners this year will inspire you to nominate someone you know who has made a significant contribution to audiology. Help us let the world know what audiologists can do.</p>\r\n<p>gie &agrave; travers le pays et dans le monde. Nous les connaissons tous.Le clinicien qui aussi offre son aide au camp de th&eacute;&acirc;tre d&rsquo;&eacute;t&eacute; pourenfants malentendants ou sourds. Le professeur qui incite ses &eacute;tudiants&agrave; se d&eacute;fier, &agrave; aller &agrave; la recherche de nouvelles d&eacute;couvertespour faire avancer les secteurs de la science de l&rsquo;ou&iuml;e et de l&rsquo;audiologie.Les personnes qui travaillent ensemble pour faciliter l&rsquo;acc&egrave;saux services audiologiques, l&rsquo;approvisionnement et la formation deceux dans les pays en voie de d&eacute;veloppement qui autrement viventdans le silence. Les entreprises qui, chaque jour, font la promotionde l&rsquo;audiologie et des soins de sant&eacute; audiologiques &agrave; travers lemonde. Ce sont ces personnes qui vont inspirer la prochaineg&eacute;n&eacute;ration d&rsquo;audiologistes, mais seulement s&rsquo;ils savent qu&rsquo;elles existent.Comment donc pouvons-nous nous assurer que leurs chansonssont chant&eacute;es aux masses? L&rsquo;Acad&eacute;mie Canadienned&rsquo;Audiologie pr&eacute;sente des prix annuels aux audiologistes et &agrave;d&rsquo;autres travaillant dans des secteurs affili&eacute;s, qui ont eu une contributionsignificative &agrave; la profession. Nous avons besoin de vosmises en candidature. Aidez nous &agrave; reconnaitre publiquement lebon travail que nous faisons comme profession. Il y&rsquo;a cinq prixauxquels vous pouvez proposer un laur&eacute;at. Voici les prixdisponibles:</p>\r\n<p>&bull; Prix Moneca Price pour activit&eacute;s humanitaires</p>\r\n<p>&bull; Prix du pionnier Paul Kuttner</p>\r\n<p>&bull; Prix Jean Kienapple pour l&rsquo;excellence clinique</p>\r\n<p>&bull; Prix professionnel Richard Seewald</p>\r\n<p>&bull; Honneur de l&rsquo;Acad&eacute;mie</p>\r\n<p>(Pour plus de d&eacute;tails sur ces prix, veuillez visiter le site web del&rsquo;ACA, <a href=\"http://www.canadianaudiology.ca)\">www.canadianaudiology.ca)</a></p>\r\n<p>L&rsquo;appel pour les mises en candidature a &eacute;t&eacute; lanc&eacute; plus t&ocirc;t cetteann&eacute;e et la r&eacute;ponse a &eacute;t&eacute; fantastique. Chaque ann&eacute;e, ces prix sontremis &agrave; des personnes dont les coll&egrave;gues ont vant&eacute; l&rsquo;exceptionnalit&eacute;.Ces prix sont remis au Diner du Pr&eacute;sident et j&rsquo;esp&egrave;re que vousserez pr&eacute;sents pour nous aider &agrave; honorer ces r&eacute;cipiendaires exceptionnels.Je souhaite aussi que les laur&eacute;ats de cette ann&eacute;e vousinspirerons &agrave; mettre en candidature quelqu&rsquo;un que vous connaissezet qui a eu une contribution significative &agrave; l&rsquo;audiologie. Aidez nous&agrave; faire savoir au monde ce que les audiologistes peuvent accomplir.</p>\r\n<p>Dr. Richard C. Seewald retired onJune 30, 2009 from the Schoolof Communication Sciences andDisorders and the National Centrefor Audiology in the Faculty ofHealth Sciences at the University ofWestern Ontario (UWO). His wellearnedretirement came 40 yearsafter he earned his baccalaureatedegree in speech pathology andaudiology from Ithaca College in1969. During his 40 year career as aworld-renowned audiologist, mostnoted for his meticulous work ondeveloping and advancing theDesired Sensation Level (DSL)Method used by audiologists toselect and to fit hearing aids fortheir pediatric clients, Richardshowed unfailing devotion to theprofession of audiology and toinfants and young children withhearing loss.</p>\r\n<p>Richard&rsquo;s career in audiology began in earnest after he was awarded hismaster&rsquo;s degree in audiology in 1974from the University of Minnesota. Inthe mid-1970s, he moved to Canadato work as a clinical audiologist in theNova Scotia Hearing and SpeechClinic in Halifax. An unexpectedrubella outbreak in Nova Scotian childrenand their ensuring hearing problemsgalvanized Richard&rsquo;s resolve to devote his career to paediatric audiology.In order to best meet the needs ofchildren with hearing loss and to satisfyhis desire to learn how to helpthem more effectively, Richard completedhis doctoral degree in 1981 inaudiology under the sage guidance ofProfessor Mark Ross at the Universityof Connecticut at Storrs. After a briefstint as an assistant professor in theDepartment of Speech Pathology andAudiology at Ithaca College, Richardreturned to Nova Scotia in the early1980s to take up a faculty position inthe School of Human CommunicationDisorders at Dalhousie University atHalifax. During his time at Dalhousieas an assistant professor, Richard publisheda report on the use of computersand mathematical formulas toguide audiologists in the selection andfitting of hearing aids to infants andchildren with hearing loss.</p>\r\n<p>In 1986, Richard and his wife Carol moved from DalhousieUniversity to the University ofWestern Ontario at London Ontariowhere Richard took up a faculty positionin the Department ofCommunicative Disorders. Richard&rsquo;sresearch career blossomed over the 23years he spent at Western. His scholarlywork on a software-based hearingaid selection and fitting proceduresurged with the development of theDSL Method and its evolving, moresophisticated versions. The DSL softwareprovides audiologists with easyaccess to evidence-based calculationsso their young clients with hearingloss will have the best access to soundthrough their hearing aids in order todevelop speech and language skills.This was a pioneering translation oflaboratory research directly to theclinic. It is this type of knowledgetransfer activity on which Richardworked throughout his career andwhich he will continue to pursue duringhis retirement.</p>\r\n<p>Richard worked diligently, methodicallyand collaboratively for manyyears refining the DSL Method. Hisscholarly work attracted the attentionof multiple industrial and peerreviewedfunding agencies that helpedsupport his research. Moreover,Richard recruited multi-talented graduatestudents and research associatesto his laboratory, with each addingnew dimensions and perspectives tohis foundational work in pediatricaudiology and to the DSL Method inparticular. During his time at theUniversity of Western Ontario,Richard acted as wise and respectedmentor to dozens of research audiologystudents, learned teacher to buddingclinical and research audiologists,and trusted colleague to fellow faculty.He was instrumental in the earlydevelopment and advancement of theHearing Health Care Research Unit atthe UWO that later evolved into the internationally acclaimed NationalCentre for Audiology. Richard alsochampioned the development andimplementation of the Ontario InfantHearing Program (IHP), a service thatscreens the hearing of every infantborn in Ontario and has resulted inthe earlier detection of and appropriateremediation for infants and childrenwith hearing impairment. TheIHP has been the model program ofchoice used in many countries theworld over to screen and to assess thehearing of infants and children and toprovide appropriately-fitted hearingaids to those infants with hearing lossusing the DSL Method. His role asconsultant to the IHP has been instrumentalto its continuing successes.</p>\r\n<p>Richard&rsquo;s seminal research and academicwork was noticed andacknowledged by university officials,research foundations, and clinical andresearch colleagues. Starting in 2002,Richard held the Canadian Institutesof Health Research Canada ResearchChair in Childhood Hearing. The federallyfunded chair position providedprotected time and resources for hisfocused research. He was awardedprofessor status in 1997 which wasthen advanced to the prestigious levelof distinguished university professorin 2008, a title bestowed on only aselect three or four outstanding facultyat the UWO each year. Richard&rsquo;snumerous research awards include,but are not limited to, the RichardSeewald Annual Award for ChildhoodHearing, named in his honour by theHear the World Foundation. In addition,he received the Career Awardfrom the Canadian Academy ofAudiology, the Lifetime AchievementAward from the Canadian Associationof Speech-Language Pathologists andAudiologists, the International Awardin Hearing from the AmericanAcademy of Audiology, and an honorarydoctorate of laws, honoris causafrom Dalhousie University.</p>\r\n<p>A review of Richard&rsquo;s career accomplishmentsshows that he achieved thestatus of &ldquo;giant&rdquo; in pediatric audiology.In addition to being an accomplishedscientist, he also demonstratedtremendous artistic talent and creativity,especially in his photographic artswhich adorn the walls in many buildingsat the UWO. It is clear that he isfinely attuned to exquisite sensorystimulation &ndash; both auditory and visual.Those of us working in the area ofhuman communication disorders, particularlyin the profession of audiologyand the discipline of hearing science,are indebted to Richard for his soundresearch, his uncompromising collegiality,and his humble leadership.Moreover, we acknowledge and thankRichard for being a leading, internationalfigure whose highly creative andoriginal work will continue to influenceresearchers, clinicians, colleagues,policy makers, families, andthose with hearing loss throughoutthe world for decades to come.</p>\r\n<p>Dr. Andr&eacute; Marcoux,professor of audiologyat the University ofOttawa has beenappointed to head theCanadian Hard ofHearing Association&rsquo;s(CHHA) new NationalAdvisory Committee onScience, Health andIndustry. In a recentannouncement, CaroleWillans, the national president of CHHA, stated that&ldquo;its role is to provide the CHHA National Board ofDirectors with advice on relevant and current issuesand initiatives related to science, health, and industry.&rdquo;</p>\r\n<p>This is Dr. Marcoux&rsquo;s first experience with this consumer-based group and it promises to be quite fruitful.Dr. Marcoux stated that he has urged CHHA over a numberof years to become more vocal on issues relating toscience and this appointment will help for this to occur.When one thinks of organizations such as CHHA, onethinks about accessibility, and this new scientific thrustspearheaded by Dr. Marcoux will add a much neededscientific component for providing access for the hard ofhearing.</p>\r\n<p>Dr. Marcoux stated that CHHA is an excellent organizationwith which to become involved. He states that &ldquo;itis well organized and provides no direct service otherthan support and education to its members. As such itwill be well positioned to influence decision makers in awide range of industries and governments.&rdquo;</p>\r\n<p>Congratulations to Marshall Chasin andMojgan Owliaey (co-recipient Beno&icirc;t Jutras),who each received a grant of $2,500.</p>\r\n<p>Of the many differences between languages, subject-object-verb (SOV) languages such as Koreanhave post-positions which tend to have lowerintensity than English (or SVO) prepositions.Marshall Chasin&rsquo;s research will test the hypothesisthat compression circuitry should be set to yieldmore gain for low level inputs for Korean than forEnglish.</p>\r\n<p>Mojgan Owliaey along with Beno&icirc;t Jutras willfocus their research on auditory processing. Theresearch questions they will investigate are the following:How do children with an APD benefit fromhearing in noise training, in terms of neurophysiologyand auditory behaviours? Does therapy impacton the social participation of children with an APD?CASLPA would like to thank AON for their generoussponsorship and support of clinical researchin Canada.</p>\r\n<p>More information is available at:</p>\r\n<p>http://www.caslpa.ca/english/profession/clinical_research_grants_winners.asp</p>\r\n<p><strong>FOR PATIENTS AND PROFESSIONALS: SPONSORED BY</strong><strong>THE DEPARTMENT OF OTOLARYNGOLOGY &ndash; HEAD AND</strong><strong>NECK SURGERY, DEPARTMENT OF COMMUNICATION</strong><strong>SCIENCES,THE UNIVERSITY OF IOWA</strong></p>\r\n<p>This conference is intended for otologists, audiologists,psychologists, and nurses who provide clinical managementservices for patients with tinnitus. The conference willalso provide information to patients who have tinnitus, theirfamily and friends, but it will NOT include individual diagnosisand treatment. The purpose of this conference is to providea review of current evaluation and management strategiesfor the treatment of tinnitus. Upon completion of theprogram, the participant will be able to discuss the managementof tinnitus and the tinnitus patient.</p>\r\n<p>The guest of honour is Paul Van De Heyning, MD &ndash; ElectricalStimulation of the Cochlea and the Auditory Cortex for theTreatment of Tinnitus</p>\r\n<p>For more information please visit: www.uihealthcare.com/depts/med/otolaryngology/conferences/TinnitusBrochure2009.pdf</p>\r\n<p>The Board of Directors of theCanadian Academy of Audiology(CAA) announced Tate MarketingInc. has been appointed its newagency of record. The GTA-basedshop was shortlisted with six otheragencies during a nationwide reviewprocess that began in early June.Carri Johnson, CAA President, wasexuberant. &ldquo;Tate provided CAA with atop of the line plan of what theywould want to achieve over the courseof the next 3 years, and was the onlyagency that suggested showing andtesting its creative concepts at theCAA Conference October 28&ndash;31 inToronto. Tate was very in tune with allthe activities and projects the CAA hasbeen involved in the past, and exhibiteda confidence that they would beable to execute a national brandingprogram for CAA.&rdquo;</p>\r\n<p>&ldquo;From my perspective as an audiologist,CAA needs to do more to let thepublic know what we do&rdquo; says RonaldChoquette, Chair of the CAA PR &amp;Visibility Committee. &ldquo;With Tate&rsquo;sexperienced and creative help, aproactive marketing plan and creativematerials will be developed to promoteour profession&rdquo;.</p>\r\n<p>Tate Marketing already has plansunderway, but details have not yetbeen released.</p>\r\n<p>The shift to digital technology hasbrought about many importantdesign innovations which wouldhave been difficult or impossible toachieve with analog circuitry.Features such as adaptive noisereduction, feedback cancellation andadaptive directional microphonesare all common place today due todigital technology.</p>\r\n<p>While digital hearing aids performthe same functions as analog ones,there are some fundamental differencesin their characteristics that thepracticing audiologist should be awareof when fitting such devices. This arti- cle describes three of the most readilyobserved differences between digitaland analog hearing aid performance.These include: audio bandwidth,input dynamic range, and time delay.</p>\r\n<p><strong>Digital Amplifiers</strong></p>\r\n<p>Every digital hearing aid contains anintegrated circuit known as a digitalamplifier, or digital signal processor(DSP). A DSP is a high-speed computerthat manipulates the audio signalsin a hearing aid numerically. In orderto perform its function, the DSP relieson the conversion of signals from theirreal-world, analog format to digital format for processing. This function isperformed by the analog-to-digitalconverter (ADC) and the reverse bythe digital-to-analog converter (DAC).The analog-to-digital conversionprocess requires that continuous-timeanalog signals be sampled at discretetime intervals and converted into astream of numerical values, or samples.This process is illustrated inFigure 1.</p>\r\n<p>It is the conversion between analogand digital signal domains that leadsto most of the differences betweenanalog and digital hearing aids. This isdescribed in more detail below.</p>\r\n<p><strong>AUDIO BANDWIDTH</strong></p>\r\n<p>To ensure an accurate digital-signalrepresentation, the rate at which theanalog signal is sampled (the samplingfrequency) must be at least twice ashigh as the highest frequency componentin the audio signal. This is a fundamentallimitation of digital signal</p>\r\n<p>processing. Failure to obey this limitationresults in an unrecoverable signaldistortion known as aliasing.</p>\r\n<p>To avoid aliasing, the incoming signalis filtered to restrict its bandwidthto less than half of the sampling frequency.This filtering process resultsin a sharper high-frequency cutoff fora digital hearing aid as compared toan analog hearing aid. This is illustratedin Figure 2. The green curve representsthe frequency spectrum of themicrophone signal. The orange curverepresents the filtered signal that ispresented to the ADC. For minimal aliasing distortion, the filtering processremoves all the signal energy abovehalf the sample frequency (Fs/2).Of course, the audio bandwidth ofa DSP can be extended by simplyincreasing the sampling frequency.RYAN |</p>\r\n<p>Unfortunately, a higher sampling frequencyrequires a faster DSP to handlethe increased rate of audio samplesand to allow for advanced features. Afaster DSP, in turn, consumes morebattery power which is undesirable in a hearing aid. As a result, there is atrade-off between signal bandwidthand battery current. Often, designersof digital hearing aids will reduce theaudio signal bandwidth to the minimumrequired for processing speechsignals in order to minimize batteryconsumption. This can lead to poorperformance for music, since thebandwidth of music signals can easilyexceed that of speech.</p>\r\n<p><strong>INPUT LIMITING LEVEL AND</strong><strong>DYNAMIC RANGE</strong></p>\r\n<p>In addition to the time samplingdescribed above, analog-to-digitalconversion also requires amplitudesampling. The continuous-time analogwaveform, sampled at discrete timeintervals, is converted into a series ofnumbers by the analog-to-digital converter.The accuracy of the amplitudesampling is governed by the precisionof some sensitive analog circuitry inthe front end of the DSP.</p>\r\n<p>Increasing the dynamic range ofthe conversion process requires higherprecision analog circuitry. Typically,however, this requires an increase inthe power consumption which is disproportionateto the increase indynamic range. As a result, thedynamic range of a hearing aid ADCis usually limited to roughly 80 dB.This was a major limitation of earlydigital instruments since the dynamicrange of the best analog instrumentswas greater than 90 dB.</p>\r\n<p>Input range is increased by providinga programmable-gain amplifier infront of the ADC. This allows theADC performance to be tuned for specificsituations by adjusting the fixedgain of the preamplifier. For instance,the ADC can be adjusted for quiet(Q), normal (N) and loud (L) situationsby adjusting its input range asshown in Figure 3. This methodallows an 80 dB ADC to cover the same dynamic range as a 95 dBmicrophone.</p>\r\n<p>Of course, the numerical precisionof the subsequent DSP also affects thesystem dynamic range. To understandwhy, consider that a DSP manipulatesaudio signals through digital computationsusing the binary number format.</p>\r\n<p>In the binary system, numericalprecision is measured in binary digits,or bits. A well-known rule of thumb isthat each bit of numerical precisionrepresents approximately 6 dB ofdynamic range. Thus, a 16-bit digitalword, as used in the CD audio format,results in a dynamic range of approximately96 dB.</p>\r\n<p>When two numbers are multipliedwithin a DSP, the product containstwice the number of bits compared tothe multiplicands. Since the numberof bits cannot grow beyond the DSP&rsquo;snative word length, the product precisionmust be reduced through rounding.</p>\r\n<p>The rounding process introducesa small error in the signal representationthat is manifested as a noiseadded to the audio signal. For repeatedoperations on the same signal,rounding error accumulates increasingthe noise by the same amount eachtime. For each doubling of the numberof rounding operations, the noiseincreases by 3 dB reducing dynamicrange by the same amount.</p>\r\n<p>If one were to apply a 16-bit DSPto the output of an analog-to-digitalconverter with a 96 dB dynamicrange, the dynamic range of the systemwould be reduced by 6 dB afteronly four rounding operations.Restricting the DSP to only fourrounding operations would not allowvery complicated algorithms to beapplied to the signal.</p>\r\n<p>Consequently, modern hearing-aidDSPs offers native word sizes in excessof 16 bits. A 20-bit DSP, for example,results in a dynamic range of 120 dB.</p>\r\n<p>This means that over 200 additionalrounding operations can be applied tothe audio signal while maintaining thesame quantization noise. This is sufficientto support many of the signalprocessing algorithms in hearing aidstoday.</p>\r\n<p><strong>TIME DELAY</strong></p>\r\n<p>Time delay in a digital hearing aidarises due to both the analog-to-digitalconversion processes (ADC and DAC)and the signal-processing algorithms.This type of delay is not present inanalog hearing aids and it representsone of the more noticeable differencesbetween analog and digital instruments.</p>\r\n<p>Most of the analog-to-digital converter\r\n  delay arises due to the aggressive\r\n  low-pass filtering that must be\r\n  applied to the analog signal in order\r\n  to restrict its bandwidth for digital\r\n  sampling (as shown in Figure 2). In a\r\n  typical high-quality audio converter,\r\n  time delays of several milliseconds can\r\n  arise, owing to the nature of the filtering\r\n  used. Such delays must be minimized\r\n  for a digital hearing aid since\r\n  conversion delays reduce the amount\r\n  of time left to implement signal-processing\r\nfeatures.</p>\r\n<p>\r\n  Signal-processing delays are influenced\r\n  by two factors: the filter bank\r\n  that decomposes the audio signal into\r\n  its constituent frequency components,\r\n  and the need to reduce computations\r\nto minimize power consumption.</p>\r\n<p>\r\n  The filter bank algorithm forms the\r\n  core of many advanced audio features,\r\n  such as adaptive noise reduction. For\r\n  maximum effectiveness, such algorithms\r\n  can require a narrowband filter\r\n  bank. Unfortunately, there is a fundamental\r\n  relationship between filterbank\r\n  frequency resolution and time\r\n  delay. A filter bank with many, narrow-\r\n  band filters necessarily incurs a\r\n  longer time delay than one with fewer,\r\nwide-band filters.</p>\r\n<p>As mentioned above, DSP power\r\n  consumption is directly related to the\r\n  number of computations required for\r\n  each audio sample. More complex signal-\r\n  processing algorithms typically\r\n  require more computations per sample\r\n  leading to increased power consumption.\r\n  To overcome this, hearingaid\r\n  engineers can spread the computations\r\n  over a wider time interval but\r\n  this can also result in longer time\r\ndelays.</p>\r\n<p>\r\n  Evolution in integrated-circuit technology\r\n  is helping to reduce hearingaid\r\ntime delays.</p>\r\n<p>\r\n  With each new technology generation,\r\n  transistor feature size and power\r\n  consumption shrink by half. This\r\n  means that more transistors can fit\r\n  within the same silicon area and\r\n  power budget. More transistors mean\r\n  higher DSP computation rates, allowing\r\n  more complex system designs and\r\nlower time delay.</p>\r\n<p>\r\n  While early digital instruments\r\n  exhibited time delays in excess of 10\r\n  ms, time delays on the order of 4&ndash;6\r\n  ms are now the norm, even though\r\n  algorithm complexity has actually\r\nincreased.</p>\r\n<h4>Summary</h4>\r\n<p>\r\n  The adoption of digital technology has\r\n  resulted in a major change in hearinginstrument\r\n  design. Compared to their\r\n  analog counterparts, digital hearing\r\n  aids possess a sharper high-frequency\r\n  cutoff, exhibit longer time delay, and\r\n  may have a reduced dynamic range.\r\n  With each successive generation of\r\n  digital circuit technology, transistor\r\n  feature size and power consumption\r\n  will continue to shrink. With more\r\n  transistors available for the same size\r\n  and power budget, engineers can consider\r\n  more complex design options.\r\n  This will lead to continued innovation\r\n  of new hearing-aid features and to\r\n  continued improvements in the system\r\nspecifications described above.</p>\r\n<p>If you are like most audiologists,\r\n  our knowledge of genetics and\r\n  how they may affect certain pathological\r\n  processes in the cochlea is\r\n  limited. The most that I know about\r\n  genetics (having last studied it 30\r\n  years ago) is how to tell a boy chromosome\r\n  from a girl chromosome &hellip;\r\n  you pull down its genes&hellip;\r\n  In this study the authors note that\r\n  noise induced hearing loss (NIHL) is a\r\n  complex disorders and is related to\r\n  both environmental and genetic factors.\r\n  They also point out that people\r\n  have different susceptibilities two people\r\n  who were both exposed for 30\r\n  years at 100 dBA may have as much\r\n  as an 85 dB HL loss and as little as a\r\n  35 dB loss. The authors attribute, at\r\n  least part of this difference, to genetic\r\nfactors.</p>\r\n<p>\r\n  The authors admit that &ldquo;little is\r\n  known about the genetic factors that\r\n  influence NIHL&rdquo; but by using animal\r\n  models and, more recently, association\r\n  studies on candidate genes, more specific\r\n  information can be obtained.\r\n  The authors talk about three main\r\n  areas where genes may play an important\r\n  role in NIHL. These include the\r\nfollowing:</p>\r\n<p>\r\n  1. Oxidative Stress: Because of the\r\n  cochlear metabolism, reactive oxygen\r\n  species (ROS) are naturally produced\r\n  when oxygen is metabolized\r\n  ings are only preliminary.\r\n  3. Heat Shock Proteins: These proteins\r\n  are found in all cells in both normal\r\n  and pathological conditions. They\r\n  are responsible for intracellular\r\n  transport. High levels of these proteins\r\n  can be found whenever there\r\n  is a stressful condition such as heat,\r\n  virus, toxicity, or higher levels of\r\n  noise such as NIHL. Higher levels\r\n  can be ototoxic to the cochlea. For\r\n  moderately high levels of noise, the\r\n  heat shock proteins are actually\r\n  protective but become toxic at\r\n  higher levels. In a study of 70\r\n  Chinese automotive workers, the\r\n  HSP70 gene was analyzed and\r\n  found to play a role for increased\r\n  susceptibility to NIHL. This was\r\n  confirmed in subsequent studies of\r\nSwedish and Polish workers.</p>\r\n<p>\r\n  The authors conclude with a discussion\r\n  of the possible therapies for\r\n  prevention that are based on these\r\n  three areas that appears to be implicated\r\n  in differing susceptibilities for\r\n  NIHL. Among these proposed therapies\r\n  that would use current and future\r\n  technologies are the use of growth\r\n  hormones, and stem-cell based therapies.\r\n  Again the authors caution about\r\n  making and final conclusions based\r\n  on genetic studies as most of the\r\n  research is both preliminary and the\r\n  subjects involved may be affected by\r\n  uncontrolled environmental toxins\r\nsuch as smoking.</p>\r\n<p>\r\n  to water. In cases of NIHL, ROS are\r\n  produced in greater quantity and\r\n  unless mitigated by antioxidant\r\n  enzymes, can cause damage to\r\n  DNA, proteins, and membranes. An\r\n  association study of 58 workers\r\n  indicated that the gene GSTM1 was\r\n  implicated in those workers who\r\n  had lower susceptibility to NIHL.\r\n  However, caution should be exercised\r\n  since the power of the test\r\n  was low. In another study of 94\r\n  workers, the genes PON1, PON2,\r\n  and SOD2 also showed significant\r\n  association with NIHL; however,\r\n  the authors again caution about\r\n  definitive conclusions due to a\r\n  small sample size and possible confounding\r\n  factors such as smoking\r\nthat could not be controlled for.</p>\r\n<p>\r\n  2. K-recycling pathways: These refer\r\n  to genes that potentially disrupt the\r\n  normal K+ ion pathways when high\r\n  noise levels are present. K+ is quite\r\n  important for a healthy cochlear\r\n  metabolism as evidenced by the\r\n  large number of both syndromic\r\n  and non-syndromic hearing losses\r\n  resulting from genes that alter the\r\n  K-recycling pathways in the\r\n  cochlea. Of interest is the gene\r\n  KCNE1 where the p.85N allele was\r\n  only detected in those workers who\r\n  were susceptible to NIHL. This\r\n  variant of the KCHE1 gene caused\r\n  K+ channels to open more rapidly\r\n  than normal and also the normalized\r\n  current was higher. The\r\nauthors do caution that these find- ings are only preliminary.</p>\r\n<p>\r\n  3. Heat Shock Proteins: These proteins\r\n  are found in all cells in both normal\r\n  and pathological conditions. They\r\n  are responsible for intracellular\r\n  transport. High levels of these proteins\r\n  can be found whenever there\r\n  is a stressful condition such as heat,\r\n  virus, toxicity, or higher levels of\r\n  noise such as NIHL. Higher levels\r\n  can be ototoxic to the cochlea. For\r\n  moderately high levels of noise, the\r\n  heat shock proteins are actually\r\n  protective but become toxic at\r\n  higher levels. In a study of 70\r\n  Chinese automotive workers, the\r\n  HSP70 gene was analyzed and\r\n  found to play a role for increased\r\n  susceptibility to NIHL. This was\r\n  confirmed in subsequent studies of\r\n  Swedish and Polish workers.</p>\r\n<p>\r\n  The authors conclude with a discussion\r\n  of the possible therapies for\r\n  prevention that are based on these\r\n  three areas that appears to be implicated\r\n  in differing susceptibilities for\r\n  NIHL. Among these proposed therapies\r\n  that would use current and future\r\n  technologies are the use of growth\r\n  hormones, and stem-cell based therapies.\r\n  Again the authors caution about\r\n  making and final conclusions based\r\n  on genetic studies as most of the\r\n  research is both preliminary and the\r\n  subjects involved may be affected by\r\n  uncontrolled environmental toxins\r\n  such as smoking.</p>\r\n<p><strong>Academy</strong>: Good Morning, Don.\r\n  Thanks for your time today.\r\n  Henderson: Hi, Doug. My pleasure.\r\n  It&rsquo;s always nice to chat with a UB\r\nalum.</p>\r\n<p>\r\n  <strong>Academy</strong>: Don, you&rsquo;ve done some\r\n  extraordinary work regarding pharmacologic\r\n  mechanisms as they relate to\r\n  hearing protection and noise-induced\r\n  hearing loss. How did you get\r\ninvolved?</p>\r\n<p>\r\n  <strong>Henderson</strong>: This area is relatively\r\n  new, and I became interested in protecting\r\n  the ear from noise-induced\r\n  hearing loss because of a number of\r\n  basic science findings. For example,\r\n  we have recently learned that highlevel\r\n  noise exposure creates a level of\r\n  oxidative stress within the cells of the\r\ncochlea.</p>\r\n<p>\r\n  <strong>Academy</strong>: And in this context, oxidative\r\n  stress refers to the situation in\r\n  which the cochlea is generating large\r\nnumbers of free radicals?</p>\r\n<p>\r\n  <strong>Henderson</strong>: Exactly, and these are\r\n  greater numbers of free radicals than\r\n  can be neutralized via the natural protective\r\n  action of cochlear antioxidants.\r\n  I should mention that antioxidants are\r\n  found in all tissues of the human\r\n  body. Free radicals are oxygen or\r\n  nitrogen molecules with un-paired, or\r\n  free electrons. And simply, these molecules\r\n  attack the nucleus or the mitochondria\r\n  or the cell membranes of\r\nsurrounding, and the cochlear damage leads to the resultant noise-induced\r\nhearing loss. In fact, the primary site\r\nfrom which the free radicals emerge\r\nare the mitochondria of the outer hair\r\ncells. We think this is true because the\r\nouter hair cells consume a lot of energy.\r\nAcademy: I believe you mean the\r\nouter hair cells consume a lot of energy\r\nin their role as the cochlear amplifier?\r\nHenderson: Yes, that&rsquo;s correct. The\r\nouter hair cells use a lot of energy and\r\na lot of oxygen.</p>\r\n<p>\r\n  <strong>Academy</strong>: And so even though noiseinduced\r\n  hearing loss looks like a\r\n  &ldquo;mechanical event,&rdquo; it may actually be\r\n  a chemical event or perhaps a chemical\r\n  event that results from an initial\r\n  mechanical insult?</p>\r\n<p>\r\n  <strong>Henderson</strong>: Exactly. And if this is\r\n  true, then we think there is an excellent\r\n  likelihood that we can intervene\r\n  in the process through chemical measures.\r\n  Academy: And just to be clear&hellip;some\r\n  pharmacological solutions have been\r\n  shown to work in animals, and some\r\n  of the proposed solutions are available\r\n  in pharmacies and health food stores,\r\n  but there have not yet been large-scale\r\n  randomized tests of humans to prove\r\n  that pharmacological intervention and\r\n  preventative measures work in\r\n  humans.</p>\r\n<p>\r\n  And therefore, I want to be sure to say\r\n  that in no way are you suggesting that\r\n  chemical and pharmaceutical solutions and alternatives are to be used\r\n  instead of normal hearing protection\r\n  protocols, but indeed, the probable\r\n  outcome of the research is that pharmacological\r\n  agents may be advisable\r\n  in addition to standard and historic\r\n  hearing protection protocols.\r\n  Henderson: Yes, that&rsquo;s the direction\r\n  we&rsquo;re going.</p>\r\n<p>\r\n  <strong>Academy</strong>: Okay, and so as the outer\r\n  hair cells are damaged by a mechanical\r\n  process, such as loud noise exposure,\r\n  and the mitochondria give off\r\n  free radicals that is a chemical process,\r\n  the cells start to die off.</p>\r\n<p>\r\n  <strong>Henderson</strong>: Yes, and there are two\r\n  cell death processes: necrosis and\r\n  apoptosis. This is very important\r\n  because apoptosis is a highly regulated\r\n  event within a cell. The cell gets a trigger\r\n  that indicates time is up, time to\r\n  die, the proteins begin to break down,\r\n  and the cell implodes. The components\r\n  are carried off via the waste disposal\r\n  system of the cochlea. However,\r\n  maybe we can alter the outcome and\r\n  prevent the cell death by blocking the\r\n  trigger for apoptosis.</p>\r\n<p>\r\n  <strong>Academy</strong>: And then, what&rsquo;s the best\r\n  relative description of necrosis?\r\n  Henderson: I think of necrosis more\r\n  as passive cell death. The cell membrane\r\n  is damaged and as calcium\r\n  moves in and water moves in, the cellular\r\n  contents slip out. The cell gets\r\n  larger and finally ruptures and the cell\r\n  contents can actually pollute the local\r\n  area, and that local pollution can further\r\n  damage neighboring cells with\r\n  the reaction of trace amount of iron and oxygen radicals creating hydroxyl\r\n  radicals, which are very toxic.\r\n  Academy: Okay. And there are two\r\n  broad classifications of drugs being\r\n  developed to be used in these endeavors,\r\n  right?</p>\r\n<p>\r\n  <strong>Henderson</strong>: Yes. There are drugs that\r\n  act as boosters to the normal antioxidant\r\n  defense system of the cochlea,\r\n  and there are drugs that prevent apoptosis.\r\n  The larger category at this time\r\n  is the antioxidant drugs, such as Nacetyl-\r\n  L-cysteine (&ldquo;L-NAC&rdquo;), Dmethionine\r\n  and both promote glutathione\r\n  (also called GSH). GSH is a\r\n  naturally occurring antioxidant, and it\r\n  protects cells from free radical damage,\r\n  and so these drugs promote glutathione\r\n  synthesis. However, it&rsquo;s difficult\r\n  to give GSH orally because much\r\n  of their activity is absorbed in the\r\n  stomach and intestines, and so very\r\n  little makes it to the target organ. So,\r\n  one goal is to make the building\r\n  blocks of glutathione more easily\r\n  accessible and available for the cells\r\n  to prevent free radicals from damaging\r\n  cells and to prevent the apoptosis\r\n  trigger.</p>\r\n<p>\r\n  <strong>Academy</strong>: And if I recall, the U.S.\r\n  Navy was looking at L-NAC years\r\n  ago?</p>\r\n<p>\r\n  <strong>Henderson</strong>: Yes. That&rsquo;s right. But the\r\n  study was not as well controlled as\r\n  would have liked.</p>\r\n<p>\r\n  <strong>Academy</strong>: Yes, well, of course one\r\n  cannot take a group of humans,\r\n  expose some to this, some to that, and\r\n  then compare and see where less\r\n  damage was done!</p>\r\n<p>\r\n  <strong>Henderson</strong>: Exactly. And the experiments\r\n  made some assumptions about\r\n  all subjects receiving equivalent noise\r\n  exposures, but in the end, it was very\r\n  hard to sort out. Some of the Navy\r\n  personnel wore hearing protection\r\n  (which was a reasonable idea!) and\r\n  some didn&rsquo;t, and so it&rsquo;s very difficult to make a control and experimental\r\n  group and to really document the outcomes.\r\n  Academy: And so maybe the only\r\n  way is a shotgun style study, looking\r\n  at very large groups and long-term\r\n  trends over decades?</p>\r\n<p>\r\n  <strong>Henderson</strong>: Right, or maybe study\r\n  musicians who experience TTS in\r\n  their day-to-day music routines. Or\r\n  maybe we would study people in\r\n  noisy industrial situations. One might\r\n  assume if we prevent some musicians\r\n  or workers from experiencing TTS, we\r\n  can safely assume they won&rsquo;t be developing\r\n  PTS. And so there are a number\r\n  of studies that can be done that may\r\n  allow us to draw some fairly solid\r\n  conclusions, but variability is difficult\r\n  to overcome, and safety is of paramount\r\n  concern.</p>\r\n<p>\r\n  <strong>Academy</strong>: But regarding animal studies,\r\n  we can make some very strong\r\n  statements.</p>\r\n<p>\r\n  <strong>Henderson</strong>: Exactly. There is no question\r\n  that in animal studies, these\r\n  drugs prevent noise-induced hearing\r\n  loss. But again, in animal lab situations,\r\n  we control everything; we test\r\n  their hearing and we know the results,\r\n  we know exactly the sounds they&rsquo;re\r\n  exposed to in loudness and duration,\r\n  we know the strength of the drugs\r\n  administered, and we can measure the\r\n  outcome.</p>\r\n<p>\r\n  <strong>Academy</strong>: So it appears the science is\r\n  very solid, but the human applicability\r\n  is as of yet to be defined.</p>\r\n<p>\r\n  <strong>Henderson</strong>: Yes. But to me, there really\r\n  is no doubt. These approaches\r\n  work for animals, and the animals\r\n  used have auditory system and biochemistry\r\n  similar to humans. I&rsquo;m confident\r\n  with more experiments in\r\n  humans, that it&rsquo;ll be clear that the\r\n  pharmacological contribution is\r\n  worthwhile, beneficial, and protective.</p>\r\n<p>\r\n  <strong>Academy</strong>: Don, have you had personal\r\n  human experience with these drugs?</p>\r\n<p>\r\n  <strong>Henderson</strong>: Well, I have a friend who\r\n  is a music professor and conductor.\r\n  She was having difficulty with TTS,\r\n  tinnitus, and hyperacusis after practicing\r\n  with an orchestra in a very reverberant\r\n  room. I suggested she might\r\n  try a combination of L-NAC and\r\n  acetyl-L-carnitine (ALCAR), nutraceuticals\r\n  we have studies with chinchillas.\r\n  She purchased them from a health\r\n  food store and after two weeks, she\r\n  was relieved of her symptoms. Of\r\n  course that&rsquo;s not to say that would\r\n  happen for anyone else, but it worked\r\n  for her, and so to me, that&rsquo;s very\r\n  encouraging.</p>\r\n<p>\r\n  <strong>Academy</strong>: Amazing. And so far we&rsquo;ve\r\n  actually only addressed free radicals\r\n  and antioxidants, but there&rsquo;s also a lot\r\n  being done with regard to Src\r\n  inhibitors and blocking apoptosis\r\n  when cells physically lose their connections\r\n  with neighboring cells.</p>\r\n<p>\r\n  <strong>Henderson</strong>: Exactly, and drugs that\r\n  block apoptosis are very promising\r\n  with regard to preventing noiseinduced\r\n  hearing loss. But we can chat\r\n  about that another time.</p>\r\n<p>\r\n  <strong>Academy</strong>: Don, this is fascinating.\r\n  Thanks so much for your time and\r\n  knowledge.</p>\r\n<p>\r\n  <strong>Henderson</strong>: My pleasure, Doug. These industrially designed couplers,\r\n  including the Zwislocki,\r\n  IEC-711 and 2-cc versions, vary in\r\n  their overall ability to reproduce the\r\n  response of the ear canal to various\r\n  acoustic inputs. While the 2-cc coupler\r\n  may not mimic the ear canal\r\n  response as well as some analogous\r\n  versions, it is nonetheless the most\r\n  commonly used in North America.\r\n  While measuring performance in a\r\n  2-cc coupler shows manufacturers\r\n  and clinicians whether the hearing\r\n  aid and many of its integrated features\r\n  are functioning within specifications,\r\n  they may not provide an\r\n  accurate picture of performance for\r\n  a given patient. Even if a standard\r\n  coupler could be manufactured to\r\n  exactly reproduce the influences that\r\n  the ear canal has on acoustic input,\r\n  this coupler would, at best, only\r\n  mimic the ear canal of the population\r\n  average. There are many reports\r\n  in the literature which depict the variability in ear canal properties\r\n  across the adult population and the\r\n  variability they allow when transforming\r\n  acoustic inputs from hearing\r\n  aids or other transducers.1&ndash;3 The\r\n  Real-Ear-to-Coupler Difference\r\n  (RECD) accurately provides a measure\r\n  to depict the difference of how\r\n  acoustic input is transformed\r\n  between a 2-cc coupler and the\r\n  human ear canal in relation to an\r\n  insert earphone or hearing aid.\r\n  Saunders and Morgan4 compared the\r\n  average RECD on 1,814 adult ears\r\n  and observed a significant inter-subject\r\n  variability as large as 35 dB at\r\n  some frequencies, demonstrating\r\n  that the use of a standard coupler or average ear canal estimate could\r\n  provide misleading information\r\n  regarding the level of hearing aid\r\n  output being provided to a specific\r\n  patient. Most variability in the\r\n  RECD is encountered across different\r\n  age groups such as when comparing children younger than two\r\n  years of age with older individuals.5\r\n  Previous research has shown that,\r\n  for the same input level, the smaller\r\n  ear canal of a child will cause a\r\n  greater eardrum Sound Pressure\r\n  Level (SPL) value due to its larger\r\n  acoustical impedance and that the\r\n  difference between children&rsquo;s RECD\r\n  and those of adults will diminish as\r\n  the child becomes older. The maturation\r\n  of the ear canal is significant\r\n  during the first two years of life and\r\n  then occurs more gradually until\r\n  approximately five years of age, at\r\n  which point the RECD will have\r\n  likely reached maturity.5,6 In general,\r\n  while there is important age-related\r\n  variability in the RECD, there have\r\n  also been reports of large amounts\r\n  of variability within age categories\r\n  for both children6 and adults.4 It has\r\n  been suggested by both these groups\r\n  of authors that a greater level of\r\n  accuracy can be brought to the hearing\r\n  aid fitting when the clinician can\r\n  verify the performance beyond the\r\n  2-cc coupler, or an age-specific estimate,\r\n  and consider the ear canal\r\n  characteristics of the particular\r\n  patient to which the hearing aid is\r\n  being provided by measuring that\r\n  patient&rsquo;s RECD.</p>\r\n<p>The measurement of the RECD for\r\n  pediatric and adult recipients of hearing\r\n  aids also becomes important when\r\n  conductive or mixed hearing loss is\r\n  diagnosed. Certain middle ear pathologies\r\n  have been shown to modify\r\nthe ear canal and eardrum impedance thereby influencing acoustic input\r\ninto the ear canal. Differences as much\r\nas 35 dB SPL (but most often around\r\n10 to 15 dB) can be measured in the\r\near canal of a patient with abnormal\r\nmiddle ear function in comparison to\r\none with an asymptomatic middle\r\near.7 More specifically, if a pathological\r\ncondition reduces the ear&rsquo;s impedance,\r\nsuch as a tympanic membrane perforation\r\nor the presence of a tympanostomy\r\ntube (both of which create the\r\neffect of an increased ear canal volume),\r\nthe sound pressure level measured\r\nwill be smaller than that of a\r\nnormal ear. The opposite effect is also\r\npossible, where pathologies such as\r\notosclerosis will increase the middle\r\near&rsquo;s impedance, resulting in a greater\r\nSPL measurement at the eardrum.</p>\r\n<p>During the past decades, prescriptive\r\n  rationales such as the Desired\r\n  Sensation Level (DSL) method and\r\n  National Acoustics Laboratories (NAL)\r\n  have been developed to ensure that an\r\n  optimal amount of hearing aid output\r\n  and gain can be prescribed for specific\r\n  levels of hearing loss and subsequently\r\n  verified with in situ measurements.\r\n  Formulae were developed to generate\r\n  prescriptive amplification targets\r\n  which reflect the amount of amplification\r\n  required to account for a specific\r\n  level of hearing loss in order to provide\r\n  audibility for a defined spectrum\r\n  of sound levels and/or intelligibility of\r\n  the speech spectrum at various input\r\n  levels. These formulae consider that\r\n  while hearing aid output is measured\r\n  in decibels of Sound Pressure Level\r\n  (dB SPL), hearing loss is measured\r\n  using a normalized decibel scale of\r\n  hearing level (dB HL) where the zero\r\n  value depicts normal hearing levels in\r\n  a group of young adults with average\r\n  outer ear characteristics and where\r\n  elevated values can be neatly categorized\r\n  in degrees of hearing loss.\r\nObviously, the comparison between hearing aid performance and prescriptive\r\ngain targets only becomes possible\r\nonce a common measurement scale is\r\nadopted.</p>\r\n<p>\r\n  Because dB HL values are always\r\n  referenced to the hearing ability of the\r\n  young adult population with a set of\r\n  defined average outer ear characteristics,\r\n  it does not appear sensible to use\r\n  this scale and measure hearing aid\r\n  performance of children or most\r\n  adults (with outer ear characteristics\r\n  which most often will differ from the\r\n  norm). On the other hand, for the\r\n  purposes of computing amplification\r\n  targets, hearing level, expressed in dB\r\n  HL, can effectively be transposed onto\r\n  a dB SPL scale by adding the\r\n  Reference Equivalent Threshold\r\n  Sound Pressure Level (RETSPL) which\r\n  was originally subtracted to normalize\r\n  threshold data for the general population\r\n  using a specific transducer. The\r\n  caveat of expressing measurements in\r\n  dB SPL is that a reference point must\r\n  be inferred. The selection of the\r\n  eardrum as a reference point to document\r\n  hearing loss in dB SPL is an\r\n  important point. Apart from obvious\r\n  anatomical anomalies of the outer ear,\r\n  milder variations in shape and size of\r\n  the ear canal have never been considered\r\n  to represent a deficit, although\r\n  these variations may cause some\r\n  minor decreases (or increases) in the\r\n  amount of sound which is made available\r\n  to the cochlea. Certainly this is\r\n  the case for infants, who naturally\r\n  have smaller outer ears than adults\r\n  and although these immature structures\r\n  may funnel less sound in the\r\n  area of 2,700 Hz from the free-field\r\n  (the resonance frequency of mature\r\n  outer ears), we would never consider\r\n  these individuals to have a hearing\r\n  loss in this frequency region.</p>\r\n<p>\r\n  Therefore, the fact that SPL is referenced\r\n  at the eardrum is important,\r\n  such that the influence of the outer\r\n  ear is effectively controlled when\r\n  determining the actual auditory deficit in hearing sensitivity caused by more\r\n  central structures for the purposes of\r\n  providing accurate levels of amplification\r\n  to compensate. Measuring\r\n  eardrum dB SPL directly at the\r\n  eardrum would be the most accurate\r\n  method for determining thresholds in\r\n  dB SPL, but the difficulties in ensuring\r\n  a constant position of the probe during\r\n  this measurement,8 as well as\r\n  issues related to noise of the probe\r\n  microphone and the test environment\r\n  may limit the measurement of sound\r\n  corresponding to very low hearing\r\n  thresholds. As a solution, the measurement\r\n  of an RECD and its subsequent\r\n  summation with the patient&rsquo;s\r\n  coupler-referenced threshold (dB HL +\r\n  RETSPL) has been validated as an\r\n  accurate and effective means of\r\n  obtaining eardrum-level dB SLP\r\n  thresholds.9 Therefore, not only are in\r\n  situ measurements, such as those\r\n  required for the RECD, important in\r\n  eliminating inaccuracies of hearing aid\r\n  performance measures caused by\r\n  using a 2-cc coupler or an age-specific\r\n  estimate, but they are an important\r\n  step in determining the patient&rsquo;s hearing\r\n  loss in dB SPL at the eardrum: a\r\n  reference point which can more accurately\r\n  depict genuine levels of underlying\r\n  deficit for which an accurate and\r\n  appropriate prescription of gain can\r\n  be provided. It is also important to\r\n  note that the RECD will only be used\r\n  to transform HL values into SPL when\r\n  insert earphones were used to measure\r\n  hearing thresholds. Because other\r\n  transducers permit different portions\r\n  of the outer ear to influence sound\r\n  during psychoacoustic measurements\r\n  with REDD, as with RECD, transformations\r\n  aren&rsquo;t required. Different\r\n  acoustic transforms will be required to\r\n  obtain SPL values,10 all of which are\r\n  impractical to measure individually\r\n  for a patient in the clinical setting.\r\n  Furthermore, because the RECD is\r\n  later used in the computation of pre- scriptive targets to determine the\r\n  influence of the ear canal on hearing\r\n  aid output, it makes sense to also use\r\n  insert earphones, thereby limiting\r\n  error of the entire target computation\r\n  by using a single acoustic transform.\r\n  To summarize, the RECD is considered\r\n  at two important points during\r\n  the hearing aid fitting procedure; in\r\n  determining how the ear canal will\r\n  influence the threshold measurement\r\n  using insert earphones, thereby permitting\r\n  the transformation of thresholds\r\n  and loudness discomfort values\r\n  from dB HL to eardrum-level dB SPL,\r\n  and secondly in determining an\r\n  appropriate hearing aid amplification\r\n  target by considering how the ear\r\n  canal will influence output. Whether\r\n  the RECD is actually measured in the\r\n  ear of the older child or adult is a\r\n  decision which currently remains at\r\n  the discretion of the clinician.\r\n  Infants and very young children\r\n  may be those who currently benefit\r\n  from the most accurate fitting and verification\r\n  strategy as a result of intervening\r\n  with such young individuals\r\n  insofar as they are prone to moving\r\n  and vocalizing during direct real-ear\r\n  measurements. These two behaviours\r\n  are often difficult to control and are\r\n  counterproductive to obtaining a valid\r\n  Real-Ear Aided Response. It is for this\r\n  reason that clinicians often opt for\r\n  using average acoustic transforms to\r\n  estimate the REAR. However, accepting\r\n  the arguments detailed above that\r\n  individual real-ear measurements are\r\n  necessary for accurate pediatric hearing\r\n  aid fittings, the clinician must\r\n  adopt a real-ear technique for these\r\n  patients despite the inherent difficulties\r\n  in application. Moodie et al.,\r\n  devised a technique which could\r\n  effectively predict, or simulate the Real\r\n  Ear Aided Response from a couplerassisted\r\n  verification technique in conjunction\r\n  with the child&rsquo;s individual\r\n  RECD.11 This technique was sub sequently validated as an efficient means\r\n  to predict the REAR9&ndash;12 in individuals\r\n  who are not able to passively participate\r\n  in the direct measurement of the\r\n  REAR, and is commonly used in pediatric\r\n  clinics.</p>\r\n<p>\r\n  Older children and adults, however,\r\n  will easily remain still and silent\r\n  during real-ear measurements following\r\n  such instructions. As such, there is\r\n  no behaviour-related reason to choose\r\n  a time-efficient estimation of the\r\n  REAR since direct measurements can\r\n  be easily obtained. Consequently, the\r\n  RECD is not measured for the patient\r\n  and RECD estimates are used to compute\r\n  SPL thresholds at the eardrum\r\n  and an accurate REAR target. This\r\n  technique sits well with most clinicians\r\n  as there is an erroneous notion\r\n  that the ear canal of the older child\r\n  and adult has a volume, length and\r\n  shape that is fairly standard in the\r\n  general population.4 Not surprisingly,\r\n  documents such as Guidelines for the\r\n  Audiologic Management of Adult\r\n  Hearing Impairment13 state that a variety\r\n  of verification procedures, including\r\n  the real-ear or coupler-assisted\r\n  REAR and the REIG can be utilized\r\n  with an adult population. Clinically,\r\n  the REAR may be, and often is, measured\r\n  as soon as the patient is able to\r\n  provide a sustained level of passive\r\n  participation during the verification\r\n  process. This may occur in children as\r\n  young as 2 years of age, and will certainly\r\n  be available in older children\r\n  and adults. As is normally the case,\r\n  the REAR will be compared to its predicted\r\n  targets, and the hearing aid\r\n  may be adjusted until a good match\r\n  can be observed between the response\r\n  and target. The end result is that it is\r\n  common practice for the REAR or the\r\n  REIG to be the only real-ear measurements\r\n  performed with the adult population.</p>\r\n<p>\r\n  However, one may question what\r\n  would happen when a clinician assumes normal ear canal dimensions\r\n  for his patient and decides, by default,\r\n  to permit the computation of real-ear\r\n  targets to be generated with an agespecific\r\n  RECD estimate, and subsequently\r\n  measure the REAR to match\r\n  the prescriptive targets. First, what\r\n  level of error can be reflected within\r\n  targets if the patient&rsquo;s own RECD was\r\n  not measured? Secondly, what would\r\n  be the outcome of attempting to\r\n  match these erroneous targets with an\r\n  REAR? The hypothesis of this study is\r\n  that a verification approach which\r\n  relies solely on the direct measurement\r\n  of the REAR may negatively\r\n  influence the computation of prescriptive\r\n  targets in the event where the\r\n  RECD is not measured for older children\r\n  and adults with ear canal dimensions\r\n  that differ from the norm.</p>\r\n<p>\r\n  Furthermore, attempting to match\r\n  these targets will result in adjustments\r\n  that may be counterproductive to providing\r\n  appropriate amplification to\r\n  these individuals.</p>\r\n<p>\r\n  The objective of the present paper\r\n  is twofold; (1) to confirm that measurement\r\n  of the RECD is an appropriate\r\n  means of obtaining accurate amplification\r\n  targets for individuals of all\r\n  ages as concluded by Saunders and\r\n  Morgan4 and (2) to further provide\r\n  evidence that the usefulness of the\r\n  RECD extends beyond providing coupler-\r\n  assisted means of obtaining the\r\n  REAR as a substitute of direct conventional\r\n  sound field verification for children,\r\n  and that a direct sound field\r\n  REAR should not be directly obtained\r\n  in adults unless an individual RECD\r\n  has been measured to more accurately\r\n  define the real-ear targets. Case studies\r\n  will be presented in order to show\r\n  that some adults could benefit from a\r\n  more precise hearing aid fitting when\r\n  a REAR is obtained following the prior\r\n  measurement of the patient&rsquo;s RECD.</p>\r\n<p>\r\n  Two case studies are offered to substantiate\r\n  these points, one from a 25-year-old female and the other from a\r\n  5-year-old boy.</p>\r\n<p>\r\n  <strong>Case 1: 25-Year-Old Female</strong></p>\r\n<p>\r\n  Otoscopy did not reveal any indication\r\n  that this patient had an ear canal\r\n  that differed from clinical norms and\r\n  thus required special consideration for\r\n  the purposes of amplification. There\r\n  were also no concerns regarding a\r\n  conductive or mixed component to\r\n  her loss of hearing. Tympanometry\r\n  values were all within normal limits\r\n  for adults: a physical volume of 1.2 cc\r\n  with static acoustic admittance of 0.4\r\n  mmho and normal middle-ear pressure.\r\n  She was fitted with Widex Inteo-\r\n  9 hearing aids with standard custom\r\n  ear moulds. The average RECD values\r\n  were selected in the programming\r\n  software. As a matter of routine, the\r\n  RECD would not have been measured\r\n  for this patient and rather, a direct\r\n  sound-field REAR would have been\r\n  obtained to closely match the hearing\r\n  aid output to the DSL targets. Table 1\r\n  provides details of the hearing loss,\r\n  real-ear targets and real-ear responses\r\n  (REAR) for the patient&rsquo;s left ear following\r\n  two scenarios: the first where the\r\n  average adult RECD values were used\r\n  to calculate targets and the second,\r\n  where the patient&rsquo;s individual RECD,\r\n  using the foam tip of the insert ear-phone transducer, was measured.\r\n  Real-ear targets as well as the average\r\n  RECD values were generated using the\r\n  Desired Sensation Level 5.1 (DSL) calculation\r\n  for adults.</p>\r\n<p>\r\n  The first notable difference for this\r\n  patient is the extent to which her\r\n  RECD (line 3) differs from the average\r\n  (line 2). The reason for this difference\r\n  is not immediately clear and may be\r\n  caused by a combination of factors\r\n  which are known to influence the\r\n  RECD, such as ear canal length and\r\n  occluded volume, middle ear impedance\r\n  and coupling of the RECD transducer\r\n  to the patient&rsquo;s ear and probetube\r\n  microphone. However, none of\r\n  these factors were obviously abnormal\r\n  during otoscopy or immittance tests.\r\n  Furthermore, every precaution was\r\n  taken during the RECD procedure to\r\n  minimize low-frequency leakage due\r\n  to an under expansion or an insufficient\r\n  depth of the transducer foam tip\r\n  or a high-frequency loss due to an\r\n  insufficient microphone depth in the\r\n  ear canal.8,14 One could hypothesize\r\n  that the overall larger RECD across\r\n  frequencies may stem from the\r\n  patient&rsquo;s smaller occluded ear canal\r\n  while the predominance of the RECD\r\n  difference in the mid-frequencies may\r\n  stem from a slight rigidity of the middle\r\n  ear possibly combined with a slight reduction in SPL in the low and\r\n  high frequencies due to coupling of\r\n  the transducer and probe-tube microphone\r\n  to the patient&rsquo;s ear. The variability\r\n  of this RECD measurement\r\n  clearly confirms the need to individually\r\n  measure this acoustic transform\r\n  on each patient.</p>\r\n<p>\r\n  The result of the larger RECD is\r\n  different thresholds when referenced\r\n  at the eardrum. What this implies is\r\n  that this patient has a hearing ability\r\n  (line 5) that is markedly different from\r\n  a person presenting the same audiogram\r\n  but with an average RECD (line\r\n  4). This can be explained by the fact\r\n  that audiometers are calibrated to\r\n  ensure that the audiometric zero (0 dB\r\n  HL) is representative of normal hearing\r\n  in a large group of young listeners,\r\n  and who consequently would have\r\n  dimensions of the ear canal that are\r\n  on average representative of the average\r\n  RECD value for adults. When the\r\n  ear canal dimensions, and hence the\r\n  RECD, are different from the average\r\n  value, the audiometric zero is offset\r\n  and is no longer accurate or helpful in\r\n  defining the hearing ability of the\r\n  patient. This 25-year old patient possesses\r\n  a hearing loss which is worse\r\n  than that depicted by her audiogram,\r\n  and as such, her audiometric results\r\n  will underestimate the deficits caused\r\n  by auditory structures which lie\r\n  beyond the ear canal. (For a comprehensive\r\n  review of these notions, the\r\n  reader is encouraged to refer to\r\n  Marcoux and Hansen,15 and Marcoux\r\n  and Durieux-Smith.16 This patient\r\n  would therefore require REAR targets\r\n  (lines 7, 10) which are greater than\r\n  the average patient with a similar\r\n  audiogram (lines 6, 9) to meet her\r\n  need for audibility. What becomes\r\n  clear is that unless the individual\r\n  RECD of this patient was measured,\r\n  the REAR targets provided by DSL or\r\n  any other fitting software would have\r\n  been too low.</p>\r\n<p>The smaller ear canal of this patient\r\n  will influence the REAR measurement.\r\n  Notice how very different the REAR\r\n  values for a 55 dB (line 8) and 70 dB\r\n  input (line 11) are from the targets\r\n  that would be available to the clinician\r\n  who had chosen to use the average\r\n  RECD values (lines 6, 9). As a\r\n  result the clinician would note that\r\n  the REAR is much too high and\r\n  would conclude that the hearing aid\r\n  was not programmed correctly and\r\n  would proceed to reducing the gain of\r\n  the instrument, leading to an underamplification\r\n  of this patient&rsquo;s hearing\r\n  loss. In the mid-frequency, area, an\r\n  under-amplification of close to 6 dB in\r\n  gain would be produced by attempting\r\n  to match the erroneous REAR targets\r\n  which did not consider the\r\n  patient&rsquo;s own RECD. Fortunately, most\r\n  adults are able to provide subjective\r\n  feedback when their hearing aids are\r\n  not providing sufficient amplification\r\n  and, in this case, the patient may have\r\n  noted the under-amplification and\r\nrequested a boost in gain.</p>\r\n<p>\r\n<strong>Case 2: 5-Year-Old Boy</strong></p>\r\n<p>\r\n  Let us now consider another example,\r\n  that of a child, who may be able to\r\n  refrain from talking or moving during\r\n  the measurement of the REAR but\r\n  who will likely not possess the vocabulary\r\n  required to express his dissatisfaction\r\n  with the performance of his\r\n  hearing aid in the event it is not working\r\n  optimally. This child was fitted\r\n  with Phonak Perseo 211 dAZ FM\r\n  hearing aids and standard ear molds.\r\n  The hearing aids were programmed\r\n  using the DSL-child fitting rationale\r\n  and average RECD values were selected\r\nin the programming software.</p>\r\n<p>\r\n  Again, let us assume that a clinician\r\n  will carry out a comprehensive on-ear\r\n  REAR procedure and where the RECD\r\n  was not measured. Table 2 provides\r\n  details of the hearing loss, real-ear targets\r\nand real-ear responses for the child&rsquo;s left ear using two scenarios: the\r\nfirst where the average RECD values\r\nfor a 60-month-old patient would\r\nhave been used to calculate targets\r\nand the second, where the patient&rsquo;s\r\nindividual RECD was measured using\r\nthe foam tip of the insert earphone\r\ntransducer. Targets as well as the average\r\nRECD were generated using the\r\nDSL 5.1 version for children.</p>\r\n<p>\r\n  There were also no concerns\r\n  regarding a conductive or mixed component\r\n  to the hearing loss of this\r\n  child. Otoscopy was normal and tympanometry\r\n  values were all within normal\r\n  limits for adults: a physical volume\r\n  of 0.6 cc with static acoustic\r\n  admittance of 0.5 mmho at -20 daPa\r\n  pressure.</p>\r\n<p>\r\n  This patient&rsquo;s RECD (line 3) does\r\n  differ slightly from the population\r\n  estimate used for 5-year old children\r\n  (line 2). The result of this difference\r\n  will lead to different thresholds when\r\n  referenced at the eardrum. This\r\n  implies that this patient has a hearing\r\n  ability (line 5) that is markedly different\r\n  from a person presenting the same\r\n  audiogram but with an average RECD\r\n  (line 2). This can be explained by the\r\n  fact that audiometers are calibrated to\r\n  ensure that the audiometric zero (0 dB\r\n  HL) is representative of normal hearing\r\n  in a large group of young adult listeners,\r\n  and who consequently would have dimensions of the ear canal that\r\n  are on average representative of the\r\n  average RECD value for adults.\r\n  Routinely for children, the use of\r\n  insert earphones and the measurement\r\n  of an RECD are encouraged as\r\n  the audiometric zero is offset but is\r\n  seldom used in defining the hearing\r\n  ability of the child. As such, this\r\n  young boy not only possesses a hearing\r\n  loss that is worse that an adult\r\n  with the same audiogram but is worse\r\n  than other 5-year olds with this same\r\n  audiogram. This is likely due to a\r\n  slightly smaller occluded ear canal\r\n  which, when coupled to the insert\r\n  earphone, provided an increase in SPL\r\n  and allows for slightly better audiometric\r\n  results. As such, our patient\r\n  would require REAR targets (lines 7,\r\n  10) which are greater than the average\r\n  5-year-old child with a similar audiogram\r\n  (lines 6, 9) to meet his need for\r\n  audibility. What becomes clear is that\r\n  unless the individual RECD of this\r\n  patient was measured, the REAR targets\r\n  provided by DSL or any other fitting\r\n  software would have been too low.</p>\r\n<p>\r\n  The smaller occluded ear canal of\r\n  this patient will influence the REAR\r\n  measurement. Notice how very different\r\n  the REAR values for a 55 dB (line\r\n  8) and 70 dB input (line 11) are from\r\n  the targets that would be available to\r\n  the clinician who had chosen to use\r\n  the average RECD values (lines 6, 9).</p>\r\n<p>As a result the clinician would note\r\n  that the REAR is much too high,\r\n  would conclude that the hearing aid\r\n  was not programmed correctly and\r\n  would proceed to reducing the gain of\r\n  the instrument, leading to an underamplification\r\n  for this patient&rsquo;s hearing\r\n  loss. The output targets are lower than\r\n  necessary and an attempt to match the\r\n  inadvertently higher REAR with these\r\n  targets will result in a significant\r\n  under-amplification, which at certain\r\n  frequencies will be as great as 5 dB in\r\nthe mid-frequencies for 55 dB inputs.</p>\r\n<p>\r\n  In the case of this hearing-impaired\r\n  child, this may be a serious cause for\r\n  concern as language development may\r\n  be impacted. While this child possesses\r\n  expressive skills that are considered\r\n  age-appropriate, there continues to be\r\n  difficulty in describing satisfaction or\r\n  dissatisfaction with the hearing aid fitting.\r\n  As has often been reported in the\r\n  literature, children are quite dependant\r\n  on the audiologist&rsquo;s fitting skills\r\n  for their continued language development\r\n  as children are unlikely/unable\r\n  to subjectively report inaccuracies in\r\nthe fitting.</p>\r\n<h4>\r\n  Discussion</h4>\r\n<p>\r\n  When we consider that the hearing\r\n  threshold is the sole basis of a hearing\r\n  aid output calculation and that so\r\n  many complex signal processing features\r\n  hinge on this initial calculation,\r\n  it seems counter-productive to fail to\r\n  obtain the most accurate starting\r\n  point, the real-ear targets, and then\r\n  later to rely on patient feedback to\r\n  achieve the optimal performance of\r\n  the hearing aid. Furthermore, many\r\n  adults may have little patience for\r\n  hearing aids that are not working to\r\n  their satisfaction and may subsequently\r\n  reject or return them. Most would\r\n  argue that successful fittings are often\r\n  dependant on achieving the most\r\naccurate fitting from the outset.</p>\r\n<p>\r\n  The two case studies presented in this article highlight a few pitfalls of\r\n  current practices with older children\r\n  and adults. Notice how for both case\r\n  studies, the measured REAR values for\r\n  a 55 dB (line 8) and 70 dB input (line\r\n  11) resemble the REAR targets for\r\n  these patients when the acoustic\r\n  transform (i.e., RECD) had been\r\n  measured (lines 7, 10). In essence, a\r\n  problem only arises when the RECD\r\n  used to generate SPL thresholds and\r\n  the corresponding real-ear response\r\n  depicts average-estimated ear canal\r\n  properties rather than those of the\r\n  patients, which could otherwise have\r\n  been measured. The error introduced\r\n  to the calculation of real-ear targets\r\n  will increase as differences between\r\n  average-estimated and actual values\r\n  increase. This error becomes most\r\n  problematic and counter-productive\r\n  when matching the real-ear aided\r\n  response (i.e., using the patient&rsquo;s own\r\n  ear canal properties or RECD) with\r\n  real-ear aided targets which have been\r\n  influenced by the inclusion of an\r\n  RECD depicting average/estimated ear\r\n  canal properties. As such, matching\r\n  the real-ear response of a hearing aid\r\n  to targets that do not consider the\r\n  same real-ear properties as those used\r\n  during audiometry should not be considered\r\n  as good clinical practice.</p>\r\n<p>\r\n  Using the case studies of this article,\r\n  one could easily determine that the\r\n  REAR obtained from these patients\r\n  would be much closer to the ideal\r\n  response (lines 7 and 10) without\r\n  matching the REAR to target obtained\r\n  using an average RECD. However, by\r\n  no means should verification be foregone.\r\n  Unfortunately a lack of verification\r\n  has been shown to provide hearing\r\n  aid output that is markedly different\r\n  from the intended values shown\r\n  on the computer software, even when\r\n  software may ascribe to reaching targets\r\n  recommended by prescriptive\r\n  approaches such as DSL and NAL.17\r\n  While verification of hearing aid output\r\n  is a necessity, guidelines are necessary\r\n  to strengthen the validity of the\r\n  static verification process.</p>\r\n<p>\r\n  Real-ear measurement guidelines\r\n  should be revised to (1) eliminate the\r\n  preconceived notion that any real-ear\r\n  measurement will suffice for optimally\r\n  fitting a hearing aid to a specific configuration\r\n  of hearing loss, (2) encourage\r\n  the measurement of the RECD in\r\n  older children and adults in order to\r\n  compute more accurate amplification\r\n  targets, and (3) discourage the use of\r\n  the REAR in older children and adults\r\n  unless the measurement of an RECD\r\n  was previously performed. Specific\r\n  suggestions should include the following:\r\n  (1) the measurement of a couplerassisted\r\n  (i.e., simulated) REAR following\r\n  the measurement of the patient&rsquo;s\r\n  RECD, or (2) the measurement of a\r\n  direct sound-field REAR in the event\r\n  the patient&rsquo;s RECD has been measured\r\n  prior to the computation of real-ear\r\n  amplification targets. These guidelines\r\n  should apply for patients of all ages.\r\n  As such the measurement of the\r\n  RECD would no longer be recommended\r\nsolely for the pediatric population.</p>\r\n<p>\r\n  <strong>INSERTION GAIN</strong></p>\r\n<p>\r\n  Although Real-Ear Insertion Gain\r\n  (REIG) measurements are becoming\r\n  less frequently utilized, one may question\r\n  whether insertion gain measurements\r\n  may be useful to optimally fit\r\n  hearing aids. Most prescriptive gain\r\n  software will provide REIG targets.\r\n  Practically, insertion gain measurements\r\n  are not suggested for infants\r\n  and young children as a patient must\r\n  hold completely still during both the\r\n  unaided (i.e., REUR) and aided (i.e.,\r\n  REAR) portions of the measurement.\r\n  Furthermore, even in cases where an\r\n  age-appropriate REUR estimate can be\r\n  used, the REIG target calculation\r\n  requires two acoustic transforms: the\r\n  REUR and the RECD to calculate the aided component of the insertion gain\r\n  calculation. The use of multiple\r\n  acoustic transforms, whether estimated\r\n  or measured, can potentially\r\n  increase the amount of error contained\r\n  within target and measured values.\r\n  As most adults are able to sit still\r\n  during real-ear measurements, insertion\r\n  gain measurements can be easily\r\n  obtained. However, as with all real-ear\r\n  output or gain measures, the clinician\r\n  must ensure that the acoustic transforms\r\n  of the patient&rsquo;s external ear (i.e.,\r\n  the REUR and the RECD in the case\r\n  of insertion gain) are the same as\r\n  those used to compute real-ear targets.\r\n  Seldom has the present author witnessed\r\n  clinicians measuring the REUR\r\n  and the RECD to generate insertion\r\n  gain targets as there is a general misconception\r\n  that all adult ear canals are\r\n  identical. In general terms, real-ear\r\n  insertion gain techniques will be erroneous\r\n  in a manner proportional to the\r\n  difference between the patient&rsquo;s REUR\r\n  and RECD and the estimated values\r\n  used for the computation of real-ear\r\n  targets.</p>\r\n<h4>\r\n  Conclusion</h4>\r\n<p>\r\n  As a closing argument, one may question\r\n  whether systematically measuring\r\n  the older child&rsquo;s or adult&rsquo;s RECD will\r\n  have a significant influence on benefit\r\n  and satisfaction of fittings. Obviously,\r\n  evidence would be helpful in determining\r\n  whether this is the case. One\r\n  could argue that measurement of the\r\n  RECD is only important for infants\r\n  and young children who require the\r\n  utmost precision from verification\r\n  techniques due to the fact that they\r\n  are unable to provide feedback leading\r\n  to modifications of hearing aid\r\n  output, compounded by their\r\n  dependence on optimal amplification\r\n  to develop language. Furthermore, it\r\n  is obvious that corrections in output,\r\n  based on the RECD, often occur in\r\n  1 dB steps in comparison to the 5 dB audiometric step. When considering\r\n  that a patient may provide a threshold\r\n  that is inadvertently 5 dB higher that\r\n  its true value, it is difficult to fathom\r\n  how the RECD can be as helpful to\r\n  the patient when providing audiometric\r\n  responses conducted with 5 dB\r\n  step sizes.</p>\r\n<p>\r\n  However, verification measures are\r\n  here to stay in order to ensure that a\r\n  hearing aid&rsquo;s programmed output can\r\n  actually be provided by the instrument.\r\n  Although some may initially\r\n  think that the RECD measurement\r\n  appears unnecessary in older children\r\n  and adults because of the ability of\r\n  these patients to provide feedback\r\n  which can result in drastic changes of\r\n  hearing aid output from those prescribed\r\n  by real-ear targets, they would\r\n  think again if static verification measures\r\n  are performed. An intuitive and\r\n  effective verification approach which\r\n  is based on prescriptive output targets\r\n  should involve the individual measurement\r\n  of the RECD for all age\r\n  groups. While prescriptive targets do\r\n  not depict how the hearing aid will\r\n  perform in real-world environments,\r\n  they do provide a starting point which\r\n  has been validated in the literature as\r\n  providing benefit to hearing-impaired\r\n  patients.18 Although modifications are\r\n  often brought to the output characteristics\r\n  of hearing aids to address the\r\n  real-life performance of hearing aids,\r\n  the static target remains an anchorpoint\r\n  which can provide context for\r\n  these modifications.</p>\r\n<p>\r\n  The purpose of this paper is not so\r\n  much to justify the use of real-ear\r\n  measures as it is to direct the clinician\r\n  as to their proper use. Clinicians\r\n  should therefore accept that if real-ear\r\n  static verification techniques are being\r\n  used to enhance clinical practices,\r\n  then they should be performed optimally.\r\n  As such, clinicians should consider\r\n  measuring the older patient&rsquo;s\r\n  RECD prior to performing a couplerassisted or direct REAR.\r\n  It should also be noted that,\r\n  instead of finding cases with remarkably\r\n  abnormal RECDs, such as those\r\n  with obvious differences in outer ear\r\n  dimensions or mixed hearing losses, a\r\n  more ubiquitous, nondescript selection\r\n  was considered for this article in\r\n  order to highlight the fact that average\r\n  RECDs are not as constant in older\r\n  children and adults as some may\r\n  imagine. As such, manufacturers\r\n  should be encouraged to develop\r\n  equipment which could increase the\r\n  ease with which acoustic transforms,\r\n  such as the RECD, are measured during\r\n  hearing aid fittings, or even during\r\n  audiometry. Innovation in this area\r\n  could help convince professionals of\r\n  their added value to clinical practice\r\n  without the burden of additional\r\n  training, manipulation and clinical\r\n  testing time.</p>\r\n<h4>References</h4>\r\n<p>\r\n  1. Gauthier EA, Rapisardi DA. A Threshold is a\r\n  Threshold is a Threshold &hellip;Or is It? Hearing\r\nInstruments 1992;43:26.</p>\r\n<p>\r\n  2. Valente M, Potts LG,Valente M. et al. Inter-\r\n  Subject Variability of Real-Ear Sound\r\n  Pressure Level: Conventional and Insert\r\n  Earphones. Journal of the American\r\nAcademy of Audiology 1994;5:390&ndash;98.</p>\r\n<p>\r\n  3. Voss SE, Hermann BS. How Does the Sound\r\n  Pressure Generated By Circumaural, Supra-\r\n  Aural, and Insert Earphones Differ for Adult\r\n  and Infant Ears? Ear and Hearing\r\n2005;26:636&ndash;50.</p>\r\n<p>\r\n  4. Saunders GH, Morgan DE. Impact on\r\n  Hearing Aid Targets of Measuring Thresholds\r\n  in Db HL versus Db SPL. International\r\nJournal of Audiology 2003;42:319&ndash;26.</p>\r\n<p>\r\n  5. Feigin JA, Kopun JG, Stelmachowicz PG,\r\n  Gorga MP. Probe Tube Microphone\r\n  Measures of Ear-Canal Sound Pressure\r\n  Levels In Infants and Children. Ear and\r\nHearing 1989;10:254&ndash;58.</p>\r\n<p>\r\n  6. Bagatto MP, Scollie SD, Seewald RC, et al.\r\n  Real-Ear-to-Coupler Difference Predictions\r\n  as a Function of Two Coupling Procedures.\r\n  Journal of the American Academy of\r\nAudiology 2002;13:407?15.</p>\r\n<p>\r\n  7. Voss SE, Rosowski JJ, Merchand SN, et al.\r\n  Middle Ear Pathology Can Affect the Sound\r\n  Pressure Generated by Audiologic\r\n  Earphones. Ear and Hearing\r\n2000;21:265&ndash;74.</p>\r\n<p>8. Dirks D, Ahlstrom J, Eisenberg L.\r\n  Comparison of Probe Insertion Methods on\r\n  Estimates of Ear Canal SPL. Journal of the\r\n  American Academy of Audiology\r\n1996;7:31&ndash;38.</p>\r\n<p>\r\n  9. Seewald RC, Moodie KS, Sinclair ST, Scollie\r\n  SD. Predictive Validity of a Procedure for\r\n  Pediatric Hearing Instrument Fitting.\r\n  American Journal of Audiology\r\n1999;8:143&ndash;52.</p>\r\n<p>\r\n  10. Revit L.The Circle of Decibels: Relating the\r\n  Hearing Test, to the Hearing Instrument, to\r\n  Real Ear Response.The Hearing Review\r\n1007;4(11):35&ndash;38.</p>\r\n<p>\r\n  11 Bagatto M, Moodie S, Scollie S, et al. Clinical\r\n  Protocols for Hearing Instrument Fitting in\r\n  the Desired Sensation Level Method.Trends\r\nIn Amplification 2005;9:199?226.</p>\r\n<p>\r\n  12. Munro KJ, Hatton N. Customized Acoustic\r\n  Transform Functions and their Accuracy at\r\n  Predicting Real-Ear Hearing Aid\r\n  Performance. Ear and Hearing\r\n2000;21:59?69.</p>\r\n<p>\r\n  13. American Academy of Audiology Task Force.\r\n  Guidelines for the Audiologic Management\r\n  of Adult Hearing Impairment. Reston,VA:\r\nAuthor, 2003.</p>\r\n<p>\r\n  14. Bagatto MP. Optimizing your RECD\r\n  Measurements,The Hearing Journal\r\n2001;54(9):32&ndash;36.</p>\r\n<p>\r\n  15. Marcoux A, Hansen H. Ensuring Accuracy of\r\n  the Pediatric Hearing Aid Fitting.Trends in\r\nAmplification 2003;7:11&ndash;27.</p>\r\n<p>16. Marcoux AM, Durieux-Smith A.\r\n  Consid&eacute;rations Cliniques Et\r\n  Psycholinguistiques Sur L&rsquo;&eacute;valuation Et\r\n  L&rsquo;appareillage De L&rsquo;enfant Malentendant. In:\r\n  B. Ars (Ed.), Langage et l&rsquo;Homme, E.M.E.,\r\nBrussels, 59&ndash;137, 2005.</p>\r\n<p>\r\n  17. Aarts NL, Caffee CS. Manufacturer\r\n  Predicted and Measured REAR Values in\r\n  Adult Hearing Aid Fitting: Accuracy and\r\n  Clinical Usefulness. International Journal of\r\nAudiology 2005;44(5):293&ndash;301.</p>\r\n<p>\r\n  18. Hornsby BW, Mueller HG. User Preference\r\n  and Reliability of Bilateral Hearing Aid Gain\r\n  Adjustments. Journal of the American\r\nAcademy of Audiology 2008;19,158&ndash;70. </p>\r\n<p>There are several fitting formulas\r\n  with which to adjust a hearing\r\n  instrument for optimal performance\r\n  in quiet. The best known, and most\r\n  widely accepted, are DSL v51,2 and\r\n  NAL-NL1.3 Combining the benefits\r\n  of accepted fitting formulas with the\r\n  flexibility and sound quality of current\r\n  multichannel digital instruments,\r\n  ensures that almost all fittings\r\n  can yield excellent performance\r\n  in quiet without much difficulty.\r\n4</p>\r\n<p>\r\n  <strong>The Dilemma of Listening in\r\nNoise</strong></p>\r\n<p>\r\n  Determining desired audibility for listening\r\n  is noise is much more challenging.\r\n  There are many unknown factors\r\n  at the time of the fitting. For example,\r\n  there are no defined methods for\r\n  adjusting adaptive parameters such as\r\n  speech enhancement, noise reduction,\r\n  and microphone strategy; features that\r\n  significantly impact noisy or reverberant\r\nenvironments. As such, clinicians are forced to make theoretical\r\nassumptions regarding the impact of\r\nseveral parameters in multiple listening\r\nsituations. Furthermore, what\r\ncounts as desirable listening for one\r\nperson may represent unacceptable\r\nnoise for another.</p>\r\n<p>\r\n  In a quiet listening situation, it is\r\n  reasonable to assume that an individual&rsquo;s\r\n  primary amplification goal is to\r\n  improve the perception of speech.\r\n  However, the hearing instrument\r\n  wearer&rsquo;s goals in more challenging\r\n  environments will vary across a continuum,\r\n  from speech perception to\r\n  comfort or sound quality, depending\r\n  on the nature of the situation and the\r\n  person&rsquo;s reason for being there. Figure\r\n  1 shows the listening goals for two\r\n  individuals across five common listening\r\n  situations. In a general sense the\r\n  importance of speech understanding\r\n  increases from the left panel (public\r\n  transit) to the right panel (doctor&rsquo;s\r\n  office). Within each panel the two\r\n  people demonstrate a range of prefer- ences on the comfort/clarity continuum,\r\n  also called speech audibility that\r\n  varies by listening situation and individual.\r\n  For example, both people prefer\r\n  very high clarity when speaking to\r\n  their family doctor, for obvious reasons.\r\n  They also prefer a similar balance\r\n  of comfort and clarity while at\r\n  the shopping mall. However, though\r\n  they may have very similar audiograms\r\n  and sit in the same bus or jazz\r\n  club on a regular basis, their preferences\r\n  on the comfort/clarity scale are\r\n  completely different in those environments.\r\n  For example, while riding the bus\r\n  the wearers&rsquo; goals will surely include\r\n  awareness of alerting signals for safety.\r\n  Yet one individual may not require\r\n  speech clarity, especially if clarity\r\n  reduces comfort or sound quality.</p>\r\n<p>\r\n  Meanwhile the other person rides the\r\n  bus with a spouse or colleague on\r\n  exactly the same busy street. This person\r\n  may readily accept diminished\r\n  comfort in exchange for improved\r\n  speech clarity. Furthermore, while one\r\n  person goes to a jazz club exclusively\r\n  to enjoy the music, another prefers\r\n  the music only as a backdrop to conversing\r\n  with friends. Once again their\r\n  goals diverge considerable in the same\r\n  environment based on their intent.</p>\r\n<p>\r\n  Despite these differences, at the initial\r\n  fitting, when asked in which situations\r\n  they would like to hear better,\r\n  both might respond, &ldquo;At the jazz\r\n  club.&rdquo; This will doubtlessly lead the\r\n  clinician to set both of their hearing instruments in the exact same way.\r\n  Figure 1 shows how preferences for\r\n  comfort and clarity can vary across\r\n  individuals in any given situation. The\r\n  second individual (dark blue dot) has\r\n  a much higher need for clarity in the\r\n  jazz club than the first individual\r\n  (light blue dot) because he is more\r\n  interested in social interaction than in\r\n  primarily listening to the music. Even\r\n  though the two individuals represented\r\n  in this diagram frequent the same\r\n  listening situations, and may have\r\n  similar hearing losses, their goals in\r\n  many cases are quite different.\r\n  A User Control Solution\r\n  An alternative to the standard clinical\r\n  approach described above is based on\r\n  an adjustable user control for multiple\r\n  adaptive features. The approach\r\n  begins with an initial fitting where the\r\n  clinician presets the instruments in\r\n  the office for the wearer&rsquo;s desired listening\r\n  environments. While some\r\n  minor fine-tuning is often desirable, a\r\n  high level of precision is not required\r\n  at this stage. Instead a user adjustment\r\n  is provided that allows the wearer to\r\n  control the strength of the features\r\n  that will yield the most demonstrable\r\n  impact in difficult listening situations.</p>\r\n<p>\r\n  User control has always been limited\r\n  to volume control or the ability\r\n  to make broad program changes\r\n  according to settings the fitter thinks\r\n  might be best for a particular listening\r\n  environment. Automatic programs are also available but the\r\n  parameters within these programs\r\n  require certain assumptions on the\r\n  part of the fitter; assumptions which\r\n  may not always meet the needs of the\r\n  wearer. In contrast, it is highly effective\r\n  to empower users to manipulate\r\n  those features which impact hearing\r\n  instrument output, but have no\r\n  clearly associated prescription. For\r\n  example, when the wearer experiences\r\n  a difficult listening situation,\r\n  they can control a group of parameters\r\n  including: microphones, speech\r\n  enhancement, noise reduction, and\r\n  overall gain. Using one simple control,\r\n  the wearer can simultaneously\r\n  optimize all four parameters to meet\r\n  their desired goal in any listening\r\n  environment. Thus the wearer has\r\n  the opportunity to rapidly converge\r\n  on an optimized fitting in any listening\r\n  environment as efficaciously as\r\n  possible, increasing satisfaction and\r\n  performance, while minimizing problems\r\n  and complaints, even before the\r\n  follow-up visit.</p>\r\n<p>\r\n  Here is an example of how such a\r\n  user control can work. The example\r\n  is based on the smartFocus&trade; control\r\n  and it provides a range of adjustment\r\n  from comfort to clarity. When adjusting\r\n  towards comfort, the goal is not\r\n  to maximize speech intelligibility or\r\n  improve understanding, but rather to\r\n  increase the overall listening comfort\r\n  without losing environmental awareness.\r\n  The parameter settings at the\r\n  comfort end of the continuum are\r\n  optimized specifically to meet these\r\n  goals.</p>\r\n<p>\r\n  Conversely, when adjusting toward\r\n  clarity, all of the parameters have been\r\n  optimized to enhance the perception\r\n  of speech, particularly in noisy environments.\r\n  Both comfort and clarity can be\r\n  adjusted as follows (Figure 2&ndash;4 and\r\n  Table 1).</p>\r\n<p>\r\n  Although the noise canceller is\r\n  engaged whether the control is adjusted\r\n  toward comfort or clarity, its\r\n  impact is different in each direction.\r\n  When adjusted towards the direction\r\n  of comfort, the noise canceller is more\r\n  aggressive, reducing noise by up to 10\r\n  dB/band at its maximum. The relatively\r\n  greater aggressiveness along this\r\n  end of the control is designed to meet\r\n  the listening goal of comfort in noise.\r\n  However, when adjusted towards the\r\n  direction of clarity, the impact of the\r\n  noise canceller is limited to 6 dB/\r\n  band. The noise canceller is less\r\n  aggressive at the clarity end of the\r\n  continuum than at the comfort end because its purpose is to improve the\r\n  clarity of speech signals in this area. If\r\n  the noise canceller works too aggressively\r\n  in combination with speech\r\n  enhancement it can actually deteriorate\r\n  clarity. This is one benefit of preconfiguring\r\n  the relative combination\r\n  of these multiple parameters along the\r\n  control. It helps ensure that parameters\r\n  will be set to achieve desired goals\r\n  without causing artifacts\r\n  Another effect that most hearing\r\n  instrument wearers associate with\r\n  comfort is a slight gain reduction.</p>\r\n<p>\r\n  Thus a variable broadband gain reduction\r\n  of up to 5 dB is also applied as\r\n  the control is adjusted from neutral to\r\n  comfort.</p>\r\n<p>\r\n  The combined effect on the gain\r\n  model of all parameters under adjustment\r\n  is shown below in Figure 6.</p>\r\n<p>\r\n  <strong>More Control Without\r\n  Increased Hassle</strong></p>\r\n<p>\r\n  There is the risk that constant adjustment\r\n  of a user control in different listening\r\n  situations will rapidly become\r\n  intrusive. Therefore, other components\r\n  of the hearing system can be\r\n  utilized to help the wearer converge\r\n  on their desired smartFocus setting\r\n  with minimal adjustment. It should\r\n  then automatically return to the new\r\n  settings whenever the wearer is in the\r\n  same listening environment. There are\r\n  two components of the hearing system\r\n  which make this possible.</p>\r\n<p>\r\n  <strong>AUTOPRO4</strong></p>\r\n<p>\r\n  This is an automatic program, which\r\n  includes the following destinations:\r\n  speech only, speech in noise, noise\r\n  only, and music. The smartFocus control\r\n  can be adjusted to a different\r\n  position for each of these destinations.\r\n  As the instrument cycles from\r\n  HAYES |\r\n  Figure 2. Microphones Figure 3. Speech Enhancement Figure 4. Noise Canceller\r\n  Figure 5.</p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-3-1-g001.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-3-1-g002.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-3-1-g003.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-3-1-g004.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-3-1-g005.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-3-1-g006.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-3-1-g007.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-3-1-g008.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-3-1-g009.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-3-1-g0010.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-3-1-g0011.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-3-1-g0012.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-3-1-g0013.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-3-1-g0014.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-3-1-g0015.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-3-1-g0016.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-3-1-g0017.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-3-1-g0018.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-3-1-g0019.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-3-1-g0020.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-3-1-g0021.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-3-1-g0022.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-3-1-g0023.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-3-1-g0024.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" 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src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-3-e030.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-3-e031.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-3-e032.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-3-e033.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-3-e034.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-3-e035.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-3-e036.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-3-e037.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-3-e038.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-3-e039.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-3-e040.png\" alt=\"image\" /></p>',NULL,'2022-11-30'),(49,3231,'ajchr','http://www.andrewjohnpublishing.com/','','<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e001.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e002.png\" alt=\"image\" /></p>\r\n<h4>Commitment,Nostalgia, and Other Belongings</h4>\r\n<p>The mosaic of hearing health care and certainly of audiology\r\n  is quite simply a force to be reckoned with. With regulators,\r\n  associations, lobby groups, stakeholders, ministries,\r\n  political parties, nothing short of professional martyrdom\r\n  would be required to join all of these groups. Thankfully many\r\n  audiologists have decided to give a portion back to a profession\r\n  that has treated them well and has subsequently been quoted as\r\n  one of most rewarding health professions to be sought after by\r\n  students. This brings me to an important point: who better to\r\n  promote a profession and advocate for a profession that its own\r\n  professionals. However, as children are not born with a sense of\r\n  commitment to, well, much of anything, neither do audiologists\r\n  enter into the profession with a sense of commitment and\r\n  responsibility unless they are provided with the proper knowledge\r\n  and tools to do so. During a recent meeting with several\r\n  colleagues from universities across Canada, it was refreshing to\r\n  hear that audiology programs were either already involved with,\r\n  or in the process of creating significant mandatory professional\r\n  practice components within their curricula to emphasize the\r\n  role of audiologists in their professional, social, and political\r\n  contexts. The future certainly looks bright as, along with other\r\n  necessary realignments to our profession, we can be assured that\r\n  young audiologists will be actively committed to their profession Since the beginning of 2008, CHR has been profiling university programs in Canada. The audiology program at the University\r\n  of British Columbia was profiled in our last issue (Vol 3. No1)\r\n  and this issue will provide details on the program at the\r\n  University of Ottawa. While this information is an excellent\r\n  overview of what is happening in our university programs, we\r\n  indirectly wish that you read these profiles throughout the year\r\n  and hope that you develop a sense of nostalgia and increase\r\n  your level of involvement with these programs. Contrary to\r\n  other disciplines, the ivory towers of the audiology programs\r\n  typically have large gates with neon welcome signs, realizing\r\n  that the relationship with clinical audiologists is an important\r\n  component which needs to be encouraged and nurtured.</p>\r\n<p>As well, we invite you to keep reading CHR as we have another\r\n  profile in &ldquo;Founders of our Profession.&rdquo; We have received many\r\n  compliments on this segment and intend to ensure our professional\r\n  legacy by profiling some of the greatest minds in both\r\n  Canadian and international audiological research.</p>\r\n<p>Our original research article this issue, from Erin Schafer and\r\n  Jace Wolfe, provides an interesting perspective on acceptable\r\n  noise levels in adults with cochlear implants. Speaking of noise,\r\n  we also include Alberto Behar&rsquo;s contribution on the topic of\r\n  noise protection devices.</p>\r\n<p>We sincerely hope you will enjoy this latest issue of CHR.\r\n  Happy reading!</p>\r\nSincerely,\r\nAndr&eacute; Marcoux, Ph.D.\r\nEditor-in-Chief\r\n<h4>Engagement,nostalgie et autres appartenances.</h4>\r\n<p>L&rsquo;&eacute;ventail des intervenants dans le domaine des soins\r\n  auditifs, et certainement dans le domaine de l&rsquo;audiologie,\r\n  constitue une force sur laquelle il faut compter.\r\n  Compte tenu de l&rsquo;existence d&rsquo;autorit&eacute;s de r&eacute;glementation,\r\n  d&rsquo;associations, de groupes d&rsquo;int&eacute;r&ecirc;t, de parties int&eacute;ress&eacute;es, de\r\n  minist&egrave;res et des partis politiques, rien de moins qu&rsquo;un &laquo;\r\n  martyr professionnel &raquo; serait exig&eacute; pour g&eacute;rer tous ces intervenants.</p>\r\n<p>Heureusement, nombre d&rsquo;audiologistes ont d&eacute;cid&eacute; de rendre service &agrave; une profession\r\n  qui les a bien trait&eacute;s et qui a &eacute;t&eacute; class&eacute;e par la suite parmi les professions\r\n  les plus enrichissantes du domaine de la sant&eacute; qui sont recherch&eacute;es par les &eacute;tudiants.\r\n  J&rsquo;en arrive &agrave; un point important; qui est mieux plac&eacute; pour promouvoir et\r\n  d&eacute;fendre une profession que les professionnels qui la pratiquent. Toutefois, tout\r\n  comme les enfants ne naissent pas avec un sens de l&rsquo;engagement &agrave; l&rsquo;&eacute;gard de\r\n  quoique ce soit, les audiologistes n&rsquo;entre pas dans le domaine avec un sens de\r\n  l&rsquo;engagement et des responsabilit&eacute;s &agrave; moins que ne leur soient fournis les connaissances\r\n  et les outils ad&eacute;quats pour le faire. Au cours d&rsquo;une rencontre r&eacute;cente\r\n  avec plusieurs coll&egrave;gues d&rsquo;universit&eacute;s canadiennes, il a &eacute;t&eacute; agr&eacute;able d&rsquo;apprendre\r\n  que les programmes d&rsquo;audiologie participaient d&eacute;j&agrave; au processus de cr&eacute;ation de\r\n  composantes de pratique professionnelle obligatoires et importantes dans leur\r\n  curriculum afin de mettre l&rsquo;accent sur le r&ocirc;le des audiologistes dans les contextes\r\n  professionnels, sociaux et politiques. L&rsquo;avenir est prometteur puisque que les\r\n  ajustements n&eacute;cessaires seront apport&eacute;s &agrave; notre profession et qu&rsquo;en plus, nous\r\n  pouvons &ecirc;tre certains que de jeunes audiologistes participeront activement &agrave;\r\n  leur domaine de profession.</p>\r\n<p>Depuis le d&eacute;but de 2008, la RCA examine les programmes universitaires offerts\r\n  au Canada. Notre dernier num&eacute;ro (vol. 3, n&deg;1) comptait un article sur le programme\r\n  d&rsquo;audiologie de l&rsquo;Universit&eacute; de la Colombie-Britannique et pr&eacute;sentait\r\n  des d&eacute;tails sur le programme de l&rsquo;Universit&eacute; d&rsquo;Ottawa. Cette information constitue\r\n  une excellente mise &agrave; jour sur nos programmes universitaires, et nous\r\n  esp&eacute;rons que lorsque vous lirez ces articles tout au long de l&rsquo;ann&eacute;e, que vous\r\n  d&eacute;velopperez un sentiment de nostalgie et que vous augmenterez votre niveau\r\n  d&rsquo;engagement &agrave; l&rsquo;&eacute;gard de ces programmes. Contrairement &agrave; d&rsquo;autres disciplines,\r\n  les tours d&rsquo;ivoires des programmes d&rsquo;audiologie ont g&eacute;n&eacute;ralement de grandes\r\n  portes avec des enseignes de bienvenue au n&eacute;on puisque les universit&eacute;s reconnaissent\r\n  que la relation avec les audiologistes cliniciens est une composante\r\n  importante qui doit &ecirc;tre encourag&eacute;e et entretenue.</p>\r\n<p>Pour en savoir plus sur les fondateurs de notre profession, nous vous invitons &agrave;\r\n  continuer &agrave; lire la RCA. Nous avons re&ccedil;u de nombreux compliments relatifs &agrave;\r\n  ces chroniques et nous avons l&rsquo;intention d&rsquo;assurer notre h&eacute;ritage professionnel\r\n  en dressant le profil de certains des plus grands acteurs canadiens et internationaux\r\n  dans le domaine de la recherche en audiologie.</p>\r\n<p>Notre article de recherche sp&eacute;cial du mois, pr&eacute;par&eacute; par Erin Shafer et Jace Wolfe,\r\n  offre une perspective int&eacute;ressante sur les niveaux de bruit acceptables chez les\r\n  adultes dot&eacute;s d&rsquo;implants cochl&eacute;aires. Parlant de bruit, nous pr&eacute;sentons &eacute;galement\r\n  un article d&rsquo;Alberto Behar sur les dispositifs de protection contre le bruit.</p>\r\n<p>Nous esp&eacute;rons sinc&egrave;rement que vous appr&eacute;cierez ce plus r&eacute;cent num&eacute;ro de la\r\n  RCA. Bonne lecture!</p>\r\n<p>Je vous prie de recevoir, chers coll&egrave;gues, mes salutations distingu&eacute;es.</p>\r\n<p>Andr&eacute; Marcoux, Ph.D.\r\n  &Eacute;diteur en chef</p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e003.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e004.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e005.png\" alt=\"image\" /></p>\r\n<p>The notion of an association that is the voice of\r\n  the profession of audiology in Canada was the\r\n  seed that began the Canadian Academy of\r\n  Audiology It grew from a strong interest in seeing\r\n  an association that was by audiologists and for audiologists.\r\n  The profession has grown over the past\r\n  decade, both in terms of numbers and in terms of\r\n  recognition. Where once we needed the support of\r\n  the greater numbers of our speech-language pathology\r\n  colleagues, we now garner enough recognition\r\n  to begin to stand on our own and to speak with our\r\n  own voice. Without the history of collaboration and\r\n  cooperation of the profession of speech-language\r\n  pathology however, we would have been unable to\r\n  reach this point. Although our roots are tied to that integration of\r\n  professions, we are growing out of that need.</p>\r\n<p>The Canadian Academy of Audiology began as a conference-driven\r\n  association, providing an excellent forum for audiologists to gain\r\n  access to continuing education and to cutting edge research in our\r\n  own country. While we continue to develop our conference, the CAA\r\n  now has many tangible and intangible benefits to membership\r\n  beyond the conference. We are slowly becoming THE voice for audiology\r\n  in Canada, and in reaching that goal we are offering value to\r\n  our members. However, there is a long way to go in order to have\r\n  the structure necessary to reach that goal. That is what this year\r\n  holds for us. That is, a change in administration and infrastructure\r\n  that will allow us to support the growth of the association in a\r\n  responsible manner.</p>\r\n<p>In reflection of the history and growth of the CAA, a movement in\r\n  Ontario may see the birth of a provincial association of audiologists,\r\n  for audiologists. Some time ago, the CAA was approached by a group\r\n  of audiologists in Ontario, expressing a need in the province for such\r\n  an association. Audiologists in the province of Ontario had long been\r\n  well represented by the Ontario Association of Speech Language\r\n  Pathologists and Audiologists (OSLA). However, interest by OSLA\r\n  members in an audiology organization for Ontario, one that is not\r\n  tied to speech-language pathologists, created the impetus for OSLA\r\n  and CAA to work collaboratively to investigate a model that would\r\n  work. A survey of Ontario audiologists indicated an interest in a distinct\r\n  provincial audiology association. OSLA and the CAA then began\r\n  initial discussions to evaluate this concept.</p>\r\n<p>The board of directors of the CAA have long recognized the potential\r\n  disconnect of a national association to the needs of members in each\r\n  province. Discussion around formal linkages to provincial associations\r\n  has long been on the agenda. It is in the interest of the profession\r\n  for a national association to have structured communication\r\n  channels to provincial associations so that both parties can respond\r\n  appropriately to the needs of members. This structure would lead to\r\n  improved advocacy and the avoidance of duplication of efforts. The\r\n  potential for a provincial &ldquo;Academy of Audiology&rdquo; with ties to the\r\n  national academy exists with the Ontario situation.</p>\r\n<p>However, the development of such a body must be entered into with\r\n  great care. A professional association carries with it responsibility to\r\n  members, both financial and legally. In order for any association to\r\n  survive and to serve all members effectively there needs to be an\r\n  administrative infrastructure in place capable of supporting the\r\n  endeavour. If all of the necessary pieces are not in place prior to the\r\n  formation of an association and the enlisting of members, the proba-la naissance de l&rsquo;acad&eacute;mie canadienne d&rsquo;audiologie. Elle s&rsquo;est d&eacute;velopp&eacute;e gr&acirc;ce &agrave; l&rsquo;int&eacute;r&ecirc;t pour plusieurs de voir la\r\n  r&eacute;alisation d&rsquo;une association form&eacute;e PAR des audiologistes\r\n  et POUR des audiologistes. Cette profession s&rsquo;est consid&eacute;rablement\r\n  d&eacute;velopp&eacute;e pendant les dix derni&egrave;res ann&eacute;es,\r\n  autant en chiffre qu&rsquo;en reconnaissance. Autrefois, le soutient\r\n  de nos coll&egrave;gues les orthophonistes nous &eacute;tait n&eacute;cessaire,\r\n  car ceux-ci &eacute;taient sup&eacute;rieurs en nombre, mais\r\n  aujourd&rsquo;hui nous poss&eacute;dons la reconnaissance dont nous\r\n  avons besoin pour faire entendre notre propre voix.\r\n  Toutefois, sans la collaboration et la coop&eacute;ration de la\r\n  profession de l&rsquo;orthophonie, nous n&rsquo;aurions pu atteindre\r\n  ce point. Bien que nos racines soient li&eacute;es &agrave; l&rsquo;int&eacute;gration\r\n  de ces professions, nous sommes en train de grandir\r\n  s&eacute;par&eacute;ment.</p>\r\n<p>L&rsquo;Acad&eacute;mie Canadienne d&rsquo;Audiologie (ACA) a connu ses d&eacute;buts en\r\n  offrant uniquement une conf&eacute;rence &agrave; la hauteur des attentes des audiologistes\r\n  canadiens, fournissant d&rsquo;excellents forums aux audiologistes\r\n  en leur donnant acc&egrave;s &agrave; une &eacute;ducation continue et &agrave; la recherche effectu&eacute;e\r\n  dans notre propre pays. Aujourd&rsquo;hui, l&rsquo;ACA dispose de nombreux\r\n  efectifs et b&eacute;n&eacute;fices tangibles et non tangibles pour ses membres. Peu &agrave;\r\n  peu, nous sommes en train de devenir la voix de l&rsquo;audiologie au\r\n  Canada et, en atteignant cet objectif, nous offrons une valeur sure &agrave;\r\n  nos membres. Toutefois, nous avons du chemin &agrave; faire avant d&rsquo;obtenir\r\n  la structure n&eacute;cessaire &agrave; l&rsquo;atteinte de cet objectif. C&rsquo;est justement sur\r\n  cela que nous allons travaill&eacute;s pendant cette ann&eacute;e. Une modification\r\n  dans l&rsquo;administration et l&rsquo;infrastructure qui nous permettra de supporter\r\n  la croissance de l&rsquo;association de mani&egrave;re responsable.</p>\r\n<p>En refl&eacute;tant sur l&rsquo;histoire et la croissance de l&rsquo;ACA, nous percevons la\r\n  possibilit&eacute; qu&rsquo;un mouvement en Ontario voie l&rsquo;apparition d&rsquo;une association\r\n  provinciale d&rsquo;audiologistes, pour les audiologistes. Dans le pass&eacute;,\r\n  l&rsquo;ACA fut approch&eacute; par un groupe d&rsquo;audiologistes de l&rsquo;Ontario exprimant\r\n  un besoin pour une telle association dans notre province. Les\r\n  audiologistes de la province de l&rsquo;Ontario ont longtemps &eacute;t&eacute; repr&eacute;sent&eacute;s\r\n  par le Ontario Association of Speech Language Pathologists and\r\n  Audiologists (OSLA). Toutefois, un int&eacute;r&ecirc;t des membres audiologistes\r\n  d&rsquo;OSLA de fonctionner sans l&rsquo;influence des membres orthophonistes a\r\n  men&eacute; cette association, en coop&eacute;ration avec l&rsquo;ACA, &agrave; trouver un mod&egrave;le\r\n  de collaboration qui pourrait mieux r&eacute;pondre aux besoins des\r\n  audiologistes. Un sondage fait aupr&egrave;s d&rsquo;audiologistes ontariens d&eacute;montre\r\n  un int&eacute;r&ecirc;t pour une association provinciale d&rsquo;audiologie distincte.\r\n  L&rsquo;OSLA et l&rsquo;ACA ont alors commenc&eacute;s &agrave; discuter et &agrave; faire l&rsquo;&eacute;valuation\r\n  d&rsquo;un tel concept.</p>\r\n<p>En refl&eacute;tant sur l&rsquo;histoire et la croissance de l&rsquo;ACA, nous percevons la\r\n  possibilit&eacute; qu&rsquo;un mouvement en Ontario voie l&rsquo;apparition d&rsquo;une association\r\n  provinciale d&rsquo;audiologistes, pour les audiologistes. Dans le pass&eacute;,\r\n  l&rsquo;ACA fut approch&eacute; par un groupe d&rsquo;audiologistes de l&rsquo;Ontario exprimant\r\n  un besoin pour une telle association dans notre province. Les\r\n  audiologistes de la province de l&rsquo;Ontario ont longtemps &eacute;t&eacute; repr&eacute;sent&eacute;s\r\n  par le Ontario Association of Speech Language Pathologists and\r\n  Audiologists (OSLA). Toutefois, un int&eacute;r&ecirc;t des membres audiologistes\r\n  d&rsquo;OSLA de fonctionner sans l&rsquo;influence des membres orthophonistes a\r\n  men&eacute; cette association, en coop&eacute;ration avec l&rsquo;ACA, &agrave; trouver un mod&egrave;le\r\n  de collaboration qui pourrait mieux r&eacute;pondre aux besoins des\r\n  audiologistes. Un sondage fait aupr&egrave;s d&rsquo;audiologistes ontariens d&eacute;montre\r\n  un int&eacute;r&ecirc;t pour une association provinciale d&rsquo;audiologie distincte.\r\n  L&rsquo;OSLA et l&rsquo;ACA ont alors commenc&eacute;s &agrave; discuter et &agrave; faire l&rsquo;&eacute;valuation\r\n  d&rsquo;un tel concept.</p>\r\n<p>Toutefois, le d&eacute;veloppement d&rsquo;un tel projet doit &ecirc;tre fait avec grand\r\n  soin. Une association professionnelle est responsable, de fa&ccedil;on l&eacute;gale bility of failure is high. The CAA is not prepared to have such an\r\n  opportunity come to failure and we wish to carefully consider all\r\n  aspects of this trust and partnership prior to its inception. The\r\n  trust and reputation that the CAA has with its members cannot be\r\n  placed in jeopardy at this or any juncture.</p>\r\n<p>The board of directors of the CAA is wholly supportive of the formation\r\n  of an Ontario Academy of Audiology, indeed of any and\r\n  all provincial audiology associations with ties to the national academy.\r\n  We intend to continue discussions with the OSLA executive\r\n  and the committee that they have established to initiate this move.\r\n  It is the strong hope of both parties that the end result will be a\r\n  model for audiologists in all provinces and a movement towards\r\n  further growth of the profession. Rest assured, however, that we\r\n  are taking careful steps toward this goal, with every effort to\r\n  ensure that the trust of our members is not harmed in any way. I\r\n  ask that members continue to watch with interest and continue to\r\n  send us questions and comments regarding the CAA. And, as\r\n  always, I welcome those who wish to help nurture a worthy\r\n  cause, to volunteer time to serve the profession as we grow.</p>\r\n<p>William Campbell, MClSc,\r\n  Audiologist\r\n  President</p>\r\n<p>La notion d&rsquo;une association pouvant &ecirc;tre la voix de la\r\n  profession d&rsquo;audiologie au Canada est responsable de et financi&egrave;re, de ses membres. Il est important qu&rsquo;une association puisse servir tous ses membres de fa&ccedil;on efficace et, pour faire ainsi, il est n&eacute;cessaire\r\n  d&rsquo;avoir une infrastructure administrative en mesure de supporter un\r\n  tel projet. Si nous n&rsquo;avons pas tous les &eacute;l&eacute;ments n&eacute;cessaires en place avant\r\n  la formation d&rsquo;une association et l&rsquo;enr&ocirc;lement des membres, les probabilit&eacute;s\r\n  de faillites sont &eacute;lev&eacute;es. L&rsquo;ACA n&rsquo;est pas pr&eacute;par&eacute;e pour voir une telle\r\n  opportunit&eacute; faire faillite et nous d&eacute;sirons consid&eacute;rer tr&egrave;s prudemment tous\r\n  les aspects du projet avant d&rsquo;en faire la cr&eacute;ation. La r&eacute;putation et la confiance\r\n  en l&rsquo;ACA par ses membres ne peut &ecirc;tre plac&eacute;e en danger.</p>\r\n<p>Le conseil d&rsquo;administration de l&rsquo;ACA supporte enti&egrave;rement la formation\r\n  d&rsquo;une acad&eacute;mie d&rsquo;audiologie en Ontario, et de toutes et n&rsquo;importe quelle\r\n  association d&rsquo;audiologie provinciale en liens avec l&rsquo;acad&eacute;mie nationale.\r\n  Nous avons l&rsquo;intention de continuer nos discussions avec l&rsquo;ex&eacute;cutif d&rsquo;OSLA\r\n  et le comit&eacute; qui a &eacute;t&eacute; &eacute;tabli afin d&rsquo;initi&eacute; ce mouvement. Nous esp&eacute;rons que\r\n  le r&eacute;sultat final pourra servir de mod&egrave;le pour les audiologistes de toutes les\r\n  provinces et que cela contribuera &agrave; faire cro&icirc;tre notre profession encore\r\n  plus. Soyez assur&eacute;s que nous demeurons prudents dans nos d&eacute;marches\r\n  vers l&rsquo;atteinte de cet objectif et que nous veillons &agrave; ce que la confiance de\r\n  nos membres ne soit bless&eacute;e en aucune fa&ccedil;on. Je vous prie de continuer &agrave;\r\n  nous envoyer des questions au sujet de l&rsquo;ACA. Et, comme d&rsquo;habitude, j&rsquo;encourage\r\n  ceux qui le d&eacute;sirent de contribuer leur temps afin de servir cette\r\n  profession en pleine croissance.\r\n  William Campbell, MClSc,\r\n  Audiologiste\r\n  Pr&eacute;sident</p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e006.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e007.png\" alt=\"image\" /></p>\r\n<h4>Richard Seewald receives\r\n  Distinguished University\r\n  Professor Award</h4>\r\n<p>We know that you will all join us in congratulating our\r\n  colleague and friend Dr. Richard Seewald (University of\r\n  Western Ontario Department of Communication Sciences and\r\n  Disorders) who is being honoured with a 2008 Distinguished\r\n  University Professor Award. The Distinguished University\r\n  Professor Award is UWO&rsquo;s highest recognition for a faculty\r\n  member. This award is presented in honour of sustained excellence\r\n  in teaching, research and service\r\n  during an outstanding scholarly\r\n  career at The University of Western\r\n  Ontario.</p>\r\n<p>Richard joined the University of\r\n  Western Ontario in 1986. Since that\r\n  time he has received numerous international\r\n  awards including: Honours of\r\n  the Association Distinction (CASLPA;\r\n  1996); Career Award Distinction\r\n  (CAA; 2001); Tier 1 Chair in\r\n  Childhood Hearing Loss (Canada\r\n  Research Chairs Program; 2002); Fellow Distinction (ASHA;\r\n  2003); The International Award in Hearing Distinction (AAA;\r\n  2007). He has also recently been recognized with an award named\r\n  in his honour by the Hear the World Foundation (The Richard\r\n  Seewald Annual Award for Childhood Hearing; www.hear-theworld.\r\n  com). Well done Richard!</p>\r\n<p>The National Centre for Audiology\r\n  University of Western Ontario</p>\r\n<h4>Bill Cole of Audioscan\r\n  presented with Lifetime\r\n  Achievement Award.</h4>\r\n<p>On April 2nd during the\r\n  Audiology NOW! conference in\r\n  Charlotte, North Carolina, Bill Cole,\r\n  (above left), was presented with the\r\n  Lifetime Achievement Award by\r\n  NASED for his work in hearing aid\r\n  circuit development, hearing aid\r\n  testing standards, test box and real\r\n  ear measurement systems, and as\r\n  one of the founding partners of\r\n  Audioscan/Etymonic Design.</p>\r\n<h4>Inter-organizational\r\n  Collaboration</h4>\r\n<p>On April 20, 2008, the Canadian Academy of Audiology\r\n  (CAA) along with representatives of the provincial/territorial\r\n  associations for audiologists and speech-language\r\n  pathologists, the Canadian Alliance of Regulators (CAR),\r\n  the Canadian Council of University Programs in\r\n  Communicative Sciences and Disorders (CCUP-CSD), and\r\n  the Canadian Association of Speech-Language Pathologists\r\n  and Audiologists (CASLPA) met for the second time as part\r\n  of an inter-organizational group to discuss issues surrounding\r\n  audiology and speech-language pathology in Canada.\r\n  This year&rsquo;s meeting, like last year&rsquo;s, resulted in a great deal\r\n  of mutually beneficial information being exchanged and\r\n  many concrete action items were established. Some of the\r\n  topics discussed included the following.</p>\r\n<p>&bull; <strong>Human Resources:</strong> What positions are needed to service\r\n  the public? What are the areas that need improvement (geographical\r\n  areas, areas of specialty, multi-cultural considerations)?\r\n  What can we do to improve the state of audiology\r\n  and speech-language pathology in Canada?</p>\r\n<p>&bull; <strong>Mandates, Roles and Terminology:</strong> Defining roles of\r\n  educators, regulators and associations to eliminate redundancy\r\n  and confusion.</p>\r\n<p>&bull; <strong>Clinical Education: </strong>What changes are happening in our\r\n  universities to help prepare graduates for a career in audiology\r\n  or speech-language pathology (program changes and\r\n  funding changes)?</p>\r\n<p>&bull;<strong> Establishing essential competencies models</strong> for audiology\r\n  and speech-language pathology.</p>\r\n<p>&bull; <strong>Identifying opportunities for collaboration.</strong></p>\r\n<p>&bull; <strong>Public relations and education activities</strong> across the\r\n  country.</p>\r\n<p>Perhaps the biggest outcome of this meeting was the establishment\r\n  of a steering committee to determine the roles, responsibilities\r\n  and common initiatives of the various groups involved.\r\n  This yet to be named committee will be composed of representatives\r\n  from the three key stakeholder groups; the educators\r\n  (represented by CCUP-CSD), the regulators (represented by\r\n  CAR) and the associations (represented by CASLPA and CAA).\r\n  The goal of this group is to determine the most appropriate\r\n  course of action to promote and support the professions of\r\n  audiology and speech-language pathology in Canada. This\r\n  steering committee is the first step in developing an efficient\r\n  Canadian system with clearly segmented units for audiology\r\n  and speech-language pathology.</p>\r\n<p>The CAA&rsquo;s role on this committee will be to advocate for audiology\r\n  at this table and ensure that the profession is served in\r\n  the most efficient means possible. The CAA has a few items to\r\n  bring to this committee, and as the work of committee progresses\r\n  we will be looking to you, our membership, for input\r\n  and we hope that you will lend your voice to these important\r\n  initiatives.</p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e008.png\" alt=\"image\" /></p>\r\n<h4>Celebrate Our Profession &ndash;\r\n  Nominate a Colleague for a\r\n  CAA Award</h4>\r\n<p>Last year at the CAA&rsquo;s 10th Anniversary\r\n  Conference, Rex Banks, on behalf of\r\n  the Canadian Hearing Society (CHS) and\r\n  the CAA announced the introduction of\r\n  the MONECA PRICE HUMANITARIAN\r\n  AWARD. Established in 2007 by the CHS\r\n  and CAA, the Moneca Price\r\n  Humanitarian Award will be presented to\r\n  an audiologist in recognition of extraordinary\r\n  humanitarian and community service,\r\n  above and beyond the requirements of\r\n  employment. In a particularly poignant\r\n  moment at the 10th Anniversary\r\n  Celebration Gala, Moneca&rsquo;s husband,\r\n  Dave, addressed the guests, speaking\r\n  about Moneca and thanking the CAA and\r\n  CHS for dedicating this award on her\r\n  behalf.</p>\r\n<p>As you may or may not be aware, CAA has\r\n  an awards committee which oversees the\r\n  distribution of all CAA awards annually. This\r\n  program supports the recognition of those\r\n  people who have made significant contributions\r\n  to our profession. The introduction of\r\n  Moneca Price Humanitarian Award brings\r\n  the CAA&rsquo;s total number of awards to seven.</p>\r\n<p>Following is a list of the Awards that are\r\n  offered annually along with the Moneca\r\n  Price Humanitarian Award:</p>\r\n<h4>HONOURS OF THE\r\n  ACADEMY</h4>\r\n<p>Given in recognition of outstanding\r\n  contribution to audiology or a related\r\n  field; such as the development of a significant\r\n  clinical program, test procedure or\r\n  protocol, an outstanding research project,\r\n  teaching or mentoring, excellence in management\r\n  of an audiology or related program,\r\n  contribution to the field through\r\n  advocacy, or outstanding public relations\r\n  efforts.</p>\r\n<p>Laurie Usher from British Columbia was awarded Honours of the Academy at the\r\n  2006 Conference by Past President Anne\r\n  Caulfield, who had been awarded the prize\r\n  before her.</p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e009.png\" alt=\"image\" /></p>\r\n<p>At the 2007 CAA conference, Richard\r\n  Seewald presented Honours of the Academy\r\n  to Krista Riko and Martyn Hyde for their\r\n  outstanding contribution to audiology and\r\n  related fields over the past 30 years.</p>\r\n<h4>PRESIDENT&rsquo;S AWARD</h4>\r\n<p>Given in recognition of outstanding\r\n  contribution to the development of\r\n  the academy, the recipient is nominated\r\n  by the president of the CAA, with the\r\n  unanimous consent of the board of\r\n  directors.</p>\r\n<p>Past winners of this award include Glen\r\n  Sutherland (2006) and Kathy Pichora-\r\n  Fuller (2007).</p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e010.png\" alt=\"image\" /></p>\r\n<h4>PAUL KUTTNER PIONEER\r\n  AWARD</h4>\r\n<p>Paul Kuttner was the &quot;Paul Bunyon&quot; of the\r\n  profession and one of Canada\'s first audiologists.\r\n  The Paul Kuttner Award is presented to\r\n  a pioneer in audiology in Canada, who has\r\n  &ldquo;boldly gone where no one has gone before&rdquo;\r\n  and been the &ldquo;first&rdquo; to embark on a new program\r\n  or procedure which has impacted\r\n  audiology service delivery in Canada.</p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e011.png\" alt=\"image\" /></p>\r\n<p><strong>STUDENT AWARD</strong></p>\r\n<p>The Student Award is presented to an\r\n  outstanding audiology graduate student\r\n  in Canada for academic or clinical excellence,\r\n  outstanding research, or community\r\n  service. Each Canadian program may nominate\r\n  one student to be considered. The student\r\n  award winner will be provided a plaque\r\n  or certificate, transportation costs to a maximum\r\n  of $500, and complimentary conference\r\n  registration to the CAA conference in\r\n  order to receive their award.</p>\r\n<p><strong>JEAN KIENAPPLE AWARD\r\n  FOR CLINICAL EXCELLENCE</strong></p>\r\n<p>Jean Kienapple, who lived and worked in\r\n  Nova Scotia, was one of Canada&rsquo;s more noteworthy\r\n  audiologists. The Jean Kienapple\r\n  Award is given in recognition of clinicians\r\n  who deliver outstanding clinical services on\r\n  an ongoing basis, as recognized by peers and\r\n  clients.</p>\r\n<p><strong>RICHARD SEEWALD CAREER\r\n  AWARD</strong></p>\r\n<p>Richard Seewald, whose name is synonymous\r\n  with the word &ldquo;audiology&rdquo; is a professor\r\n  at the University of Western\r\n  Ontario. His contributions to our field are\r\n  legendary. The Richard Seewald Career\r\n  Award is given in recognition of an outstanding\r\n  career in clinical practice and/or\r\n  teaching and mentoring young people.</p>\r\n<p>The candidate must have made significant\r\n  contributions to the practice and/or teaching\r\n  of audiology or a related field and\r\n  have had a long-term professional career.</p>\r\n<p><strong> CELEBRATE OUR\r\n  PROFESSION AND\r\n  NOMINATE A COLLEAGUE\r\n  FOR AN AWARD!</strong></p>\r\n<p>We have awards to give! What we\r\n  don&rsquo;t have are that many nominees\r\n  for these awards. Surely, you can think of\r\n  some deserving recipient who meets the\r\n  criteria for one of these awards? In anticipation\r\n  of this year&rsquo;s CAA conference in\r\n  Halifax, Nova Scotia, please give consideration\r\n  to nominating a deserving person for\r\n  one of these awards.</p>\r\n<p><strong>Nomination Procedure</strong></p>\r\n<p>Nominations may be submitted by any\r\n  member of the association and must be seconded\r\n  also by a member (with the exception\r\n  of the Student Award which must be submitted\r\n  by the head of the training program and\r\n  the President&rsquo;s Award which is submitted by\r\n  the president). Nominees must be CAA\r\n  members to be considered for the President&rsquo;s\r\n  Award or the Jean Kienapple Clinical Award.\r\n  You do not have to be a CAA member to be\r\n  considered for other categories.</p>\r\n<p>Nominations must include the nominees\r\n  name, organization, and contact information\r\n  and the names and signatures of two nominators.Nominations must include a letter\r\n  indicating the reason for nomination with\r\n  sufficient detail on the nominee&rsquo;s training,\r\n  background, experience, and outstanding\r\n  aspects of their professional career to allow\r\n  the Awards Committee to evaluate the nomination.\r\n  For the Jean Kienapple Award, nominations\r\n  should include testimonials from\r\n  clients or other individuals impacted by the\r\n  nominee.</p>\r\n<p>All submissions are due by August 1st and\r\n  will be forwarded to the Awards Committee\r\n  for consideration.</p>\r\n<p><strong>Granting Procedure</strong></p>\r\n<p>Awards deemed appropriate will be presented\r\n  at the CAA Annual Conference.</p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e012.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e013.png\" alt=\"image\" /></p>\r\n<h4>Publicity Ideas for\r\n  National Audiology Week</h4>\r\n<p><strong>October 20 to 26, 2008</strong></p>\r\n<p>Effective publicity for National\r\n  Audiology Week events is essential\r\n  in order to gain community awareness\r\n  and participation. The following\r\n  is a list of ideas that may be\r\n  used to increase the reach and\r\n  impact of important messages.</p>\r\n<p>Media</p>\r\n<p>&bull; Appearing on local radio programs</p>\r\n<p>&bull; Appearing on local access television programs</p>\r\n<p>&bull; Getting the local television station to do a\r\n  story on National Audiology Week</p>\r\n<p>&nbsp;</p>\r\n<p>&bull; Inviting media to shadow an audiologist\r\n  for a day</p>\r\n<p>&bull; Publishing newspaper articles, Letter to\r\n  the Editor, and advertisements</p>\r\n<p>&bull; Placing special inserts in local newspapers</p>\r\n<p>&bull; Running radio public service announcements</p>\r\n<p>&bull; Organize a television or radio interview\r\n  with an adult in your community living\r\n  with a hearing problem</p>\r\n<p>&bull; Set-up a call-in radio show with an audiologist\r\n  to let the public &ldquo;talk to the\r\n  experts.&rdquo;</p>\r\n<p><strong>Partnering with Organizations</strong></p>\r\n<p>&bull; Events cosponsored with organizations\r\n  and companies to promote good hearing health, etc.\r\n  &bull; Mall events, such as displays</p>\r\n<p>&bull; University events (schools of audiology),\r\n  education and communication can help\r\n  plan campus-wide events; students may\r\n  be able to get university credit for volunteering\r\n  to help with hearing health promotion\r\n  activities; faculty may give generously\r\n  of their time; (plan this early)</p>\r\n<p>&bull; Hold a career presentation at a local high\r\n  school, college, or university to introduce\r\n  our professions to students</p>\r\n<p>&bull; Display National Audiology Week posters\r\n  on bulletin boards throughout your community\r\n  &ndash; at work, local schools, shopping\r\n  centres, community centres, or churches,\r\n  etc.</p>\r\n<p>&bull; Offer an information session to members\r\n  of the community who wish to find out\r\n  more about audiology and hearing</p>\r\n<p>&bull; Provide National Audiology Week colouring/\r\n  activity sheets to be put in your waiting\r\n  room, doctors&rsquo; offices, etc.</p>\r\n<p>&bull; Supply your local pharmacies/grocery\r\n  stores with audiology and hearing literature\r\n  and ask them to include it in the bag\r\n  with each customer&rsquo;s purchase</p>\r\n<p>&bull; Hold an open house or health fair where\r\n  co-workers, clients, community members,\r\n  and the general public are invited to visit\r\n  your facilities</p>\r\n<p>&bull; Offer hearing screenings and demonstrate\r\n  equipment such as FM amplification systems,\r\n  assistive listening devices, etc.</p>\r\n<p>&bull; Participation of local legislators; for example,\r\n  health screenings of legislators at municipal, provincial, and federal levels</p>\r\n<p>&bull; Church bulletin inserts</p>\r\n<p>&bull; Create a speakers bureau consisting of\r\n  audiologist (offer to give workshops to\r\n  local businesses, schools)</p>\r\n<p>&bull; Display a National Audiology Week poster\r\n  in the lobby of your hospital</p>\r\n<p>&bull; Do a presentation about audiology and\r\n  hearing at the Chamber of Commerce\r\n  Luncheon, social clubs, etc.</p>\r\n<p><strong>Other Ideas</strong></p>\r\n<p>&bull; Restaurant table tents</p>\r\n<p>&bull; Banner</p>\r\n<p>&bull; Fridge magnets</p>\r\n<p>&bull; Luncheon and breakfast placemats</p>\r\n<p>&bull; Proclamation</p>\r\n<p>&bull; Create sticker or stamp announcing the\r\n  National Audiology week to put on outgoing\r\n  mail</p>\r\n<p><strong>National Audiology Week\r\n  Promotional Materials May Be\r\n  Distributed to:</strong></p>\r\n<p>Local businesses, Local malls, Local restaurants,\r\n  Health clubs, Schools, Libraries, Local\r\n  grocery stores, Laundromats, Movie theaters,\r\n  Daycare, centers, Youth centers, Banks, Hair\r\n  salons, Hospitals, Medical, optometrist, and\r\n  dental offices, Senior citizen homes, Public\r\n  health departments, and health organizations\r\n  and clubs (Red Cross, Lions Clubs, etc.).</p>\r\n<h4>Id&eacute;es publicitaires pour la Semaine\r\n  nationale de l&rsquo;audiologie</h4>\r\n<p><strong>20 au 26 octobre 2008</strong></p>\r\n<p>Pour sensibiliser la communaut&eacute; et\r\n  obtenir sa participation, il faut une\r\n  publicit&eacute; efficace des activit&eacute;s\r\n  pr&eacute;vues au cours de la Semaine\r\n  nationale de l&rsquo;audiologie. La liste\r\n  suivante comprend des options\r\n  pouvant &ecirc;tre utilis&eacute;es pour augmenter\r\n  la port&eacute;e et l&rsquo;impact des\r\n  messages importants.</p>\r\n<p><strong>M&eacute;dias</strong></p>\r\n<p>&bull; Passer &agrave; la radio locale</p>\r\n<p>&bull; Passer &agrave; la t&eacute;l&eacute;vision locale</p>\r\n<p>&bull; Demander &agrave; la cha&icirc;ne de t&eacute;l&eacute;vision locale\r\n  de faire un reportage sur la Semaine nationale de l&rsquo;audiologie</p>\r\n<p>&bull; Inviter les m&eacute;dias &agrave; observer le travail\r\n  d&rsquo;un audiologiste pendant une journ&eacute;e</p>\r\n<p>&bull; Faire para&icirc;tre des articles dans les journaux,\r\n  une lettre au r&eacute;dacteur en chef et\r\n  des annonces publicitaires</p>\r\n<p>&bull; Ins&eacute;rer des encarts sp&eacute;ciaux dans les journaux\r\n  locaux</p>\r\n<p>&bull; Faire diffuser des messages d&rsquo;int&eacute;r&ecirc;t public\r\n  &agrave; la radio</p>\r\n<p>&bull; Organiser une entrevue &agrave; la t&eacute;l&eacute;vision ou &agrave;\r\n  la radio avec un adulte de votre communaut&eacute;\r\n  aux prises avec un probl&egrave;me auditif</p>\r\n<p>&bull; Organiser une &eacute;mission de radio t&eacute;l&eacute;phonique\r\n  avec un audiologiste pour que\r\n  le public puisse parler aux &laquo; experts &raquo;</p>\r\n<p><strong>Partenariat avec des organismes</strong></p>\r\n<p>&bull; Activit&eacute;s de promotion de la sant&eacute; auditive,\r\n  etc. coparrain&eacute;es avec des organismes\r\n  et entreprises</p>\r\n<p>&bull; Activit&eacute;s dans les centres commerciaux,\r\n  telles expositions</p>\r\n<p>&bull; Activit&eacute;s dans les universit&eacute;s (&eacute;coles d&rsquo;audiologie)\r\n  &ndash; les services d&rsquo;&eacute;ducation et de\r\n  communications peuvent aider &agrave; planifier\r\n  des activit&eacute;s sur le campus; les &eacute;tudiants\r\n  peuvent obtenir des cr&eacute;dits universitaires\r\n  en participant volontairement aux activit&eacute;s\r\n  faisant la promotion de l&rsquo;audition; les\r\n  membres de la facult&eacute; peuvent donner\r\n  g&eacute;n&eacute;reusement de leur temps (commencer\r\n  t&ocirc;t la planification)</p>\r\n<p>&bull; Faire un expos&eacute; d&rsquo;initiation aux carri&egrave;res &agrave;\r\n  une &eacute;cole secondaire, au coll&egrave;ge ou &agrave; l&rsquo;universit&eacute;\r\n  de votre r&eacute;gion pour faire conna&icirc;tre\r\n  la profession aux &eacute;l&egrave;ves et &eacute;tudiants</p>\r\n<p>&bull; Mettre des affiches de la Semaine\r\n  nationale de l&rsquo;audiologie sur les tableaux\r\n  d&rsquo;affichage dans votre communaut&eacute; &ndash; au\r\n  travail, dans les &eacute;coles, centres commerciaux,\r\n  centres communautaires, &eacute;glises, etc.</p>\r\n<p>&bull; Offrir une s&eacute;ance d&rsquo;information aux membres\r\n  de la communaut&eacute; qui d&eacute;sirent en\r\n  savoir davantage sur l&rsquo;audiologie et l&rsquo;audition</p>\r\n<p>&bull; Placer des feuilles &agrave; colorier et des feuilles\r\n  d&rsquo;activit&eacute;s sur la Semaine nationale de\r\n  l&rsquo;audiologie dans votre salle d&rsquo;attente, les\r\n  cabinets de m&eacute;decin, etc.</p>\r\n<p>&bull; Donner de la documentation sur l&rsquo;audiologie\r\n  et l&rsquo;audition aux pharmacies et\r\n  &eacute;piceries de votre r&eacute;gion et leur demander\r\n  de la mettre dans le sac d&rsquo;&eacute;picerie de\r\n  chaque client</p>\r\n<p>&bull; Tenir une journ&eacute;e portes ouvertes ou une\r\n  foire sur la sant&eacute; et inviter vos coll&egrave;gues\r\n  de travail, membres de la communaut&eacute; et\r\n  le grand public &agrave; visiter vos installations,\r\n  etc.</p>\r\n<p>&bull; Organiser une activit&eacute; de d&eacute;pistage auditif\r\n  et faire une d&eacute;monstration de\r\n  l&rsquo;&eacute;quipement comme syst&egrave;me de diffusion\r\n  MF, dispositifs techniques pour malentendants,\r\n  etc.</p>\r\n<p>&bull; Faire appel &agrave; la participation des &eacute;lus\r\n  municipaux, provinciaux et f&eacute;d&eacute;raux, en\r\n  leur faisant subir un d&eacute;pistage auditif par\r\n  exemple</p>\r\n<p>&bull; Mettre des encarts dans les bulletins\r\n  paroissiaux</p>\r\n<p>&bull; Cr&eacute;er un service de conf&eacute;renciers form&eacute;\r\n  d&rsquo;audiologistes (offrir de donner des ateliers\r\n  aux entreprises, &eacute;coles locales)</p>\r\n<p>&bull; Mettre une affiche de la Semaine nationale\r\n  de l&rsquo;audiologie dans le hall d&rsquo;entr&eacute;e de\r\n  votre h&ocirc;pital</p>\r\n<p>&bull; Faire un expos&eacute; sur l&rsquo;audiologie &agrave; un\r\n  d&icirc;ner de la chambre de commerce locale,\r\n  aux clubs sociaux, etc.</p>\r\n<p><strong> Autres id&eacute;es</strong></p>\r\n<p>&bull; Cartes-chevalets dans les restaurants</p>\r\n<p>&bull; Banni&egrave;re</p>\r\n<p>&bull; Aimants de r&eacute;frig&eacute;rateur</p>\r\n<p>&bull; Napperons pour d&icirc;ner et d&eacute;jeuner</p>\r\n<p>&bull; Proclamation</p>\r\n<p>&bull; Cr&eacute;ation d&rsquo;auto-collants ou d&rsquo;un timbre\r\n  annon&ccedil;ant la Semaine nationale de l&rsquo;audiologie\r\n  pour le courrier &agrave; exp&eacute;dier</p>\r\n<p><strong>Le mat&eacute;riel promotionnel de la\r\n  Semaine nationale de l&rsquo;audiologie\r\n  peut &ecirc;tre distribu&eacute; comme suit </strong>:</p>\r\n<p>Entreprises locales, Centres commerciaux\r\n  locaux, Restaurants locaux, Clubs de sant&eacute;,\r\n  &Eacute;coles, Biblioth&egrave;ques, &Eacute;piceries locales,\r\n  Buanderies, Cin&eacute;mas, Garderies, Centres de\r\n  jeunes, Banques, Salon de coiffure,\r\n  H&ocirc;pitauxs, Cabinets de m&eacute;decin, d&rsquo;optom&eacute;triste\r\n  et de dentiste, Foyers pour personnes\r\n  &acirc;g&eacute;es, Services de sant&eacute; publique,\r\n  Organismes de sant&eacute; et clubs sociaux (Croix-\r\n  Rouge, clubs des Lions, etc.)</p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e014.png\" alt=\"image\" /></p>\r\n<h4>Industry Insider</h4>\r\n<h4>BERNAFON INTRODUCES\r\n  MOVE</h4>\r\n<p>At AudiologyNOW! in Charlotte,\r\n  N.C. (April 3&ndash;5, 2008), the Swiss hearing\r\n  system manufacturer Bernafon proudly\r\n  presents the most complete and comprehensive\r\n  product portfolio ever. MOVE, a new\r\n  upper mid-range hearing system family is\r\n  introduced as a world premiere. Bernafon&rsquo;s\r\n  receiver-in-the-ear technology, brite, is made\r\n  even more flexible with additional micromold\r\n  styles.</p>\r\n<p>At this year&rsquo;s convention, Bernafon introduced\r\n  MOVE, an upper mid-range hearing\r\n  system family that offers advanced adaptive\r\n  functionality based on the patient&rsquo;s individual\r\n  lifestyle. The automatic program offers\r\n  the choice of nine different signal processing\r\n  modes based on adaptivity to changing environments\r\n  with emphasis on speech or comfort.\r\n  A new copy program function as well as\r\n  freely configurable programs makes MOVE\r\n  flexible, easy and fast to fit. The large range\r\n  of BTEs includes a micro BTE with a T-coil\r\n  and an optional standard earhook. All BTEs\r\n  are suitable for open fittings with the modular\r\n  thin tube system SPIRA flex. The micro\r\n  BTEs are available in 10 attractive housing\r\n  colors which will MOVE patients to take the\r\n  first step to better hearing.</p>\r\n<p><strong>www.bernafon.com</strong></p>\r\n<h4> WIDEX SUPPORTS DEAF\r\n  SPORTS</h4>\r\n<p>Widex is sponsoring two annual\r\n  awards for the best male and the best\r\n  female athlete in deaf sports respectively. The\r\n  awards &ndash; &rdquo;Widex Sportsman of the Year&rdquo; and\r\n  &rdquo;Widex Sportswoman of the Year&rdquo; &ndash; are part\r\n  of Widex&rsquo; support for the International\r\n  Committee of Sports for the Deaf (ICSD),\r\n  which also stages the Deaflympics.</p>\r\n<p><strong>2007 Winners</strong></p>\r\n<p>The 2007 Widex Sportsman of the Year\r\n  award was won by the 40-year-old badminton\r\n  player Rajeev Bagga from India, who\r\n  has not lost a singles match since 1989.</p>\r\n<p>The 2007 Widex Sportswoman of the Year\r\n  was the swimmer Natalia Deeva from\r\n  Belarus, who at the latest world deaf championship\r\n  broke three world records on the\r\n  same day.</p>\r\n<p><strong>Many Years of Support</strong></p>\r\n<p>Widex has been supporting deaf sports for\r\n  many years. In addition to the above-mentioned\r\n  awards, they also grant a special\r\n  &ldquo;Widex Fair Play Prize&rdquo; in connection with\r\n  the Summer Deaflympics, which will take\r\n  place in Taipei in 2009.</p>\r\n<p><strong>www.widex.com</strong></p>\r\n<p><strong> SIEMENS HEARING\r\n  INSTRUMENTS TURNS UP\r\n  THE VOLUME WITH NEW\r\n  NATIONAL ADVERTISING\r\n  CAMPAIGN</strong></p>\r\n<p>Campaign Touts CENTRA&rsquo;s\r\n  SoundSmoothing Technology,\r\n  Shown in Laboratory Tests to\r\n  Reduce Non-Speech Transient\r\n  Sounds</p>\r\n<p><strong>Piscataway, N.J., February 25, 2008</strong> &ndash;\r\n  Siemens Hearing Instruments, Inc. a leading\r\n  manufacturer of hearing instruments in the\r\n  United States, today announced the launch\r\n  of a new national advertising campaign for\r\n  its CENTRA&trade; line.</p>\r\n<p>Central to the campaign is the promotion of\r\n  CENTRA&rsquo;s SoundSmoothing&trade;, the world?s\r\n  first transient noise suppression technology,\r\n  which is available on every CENTRA instrument.\r\n  In a recent study conducted at the\r\n  National Acoustic Laboratories, the noisereduction\r\n  algorithm used in</p>\r\n<p>SoundSmoothing to reduce non-speech transient\r\n  sounds was shown to offer benefits to\r\n  the hearing aid wearer in terms of comfort,\r\n  with no noticeable effect on localization or\r\n  intelligibility.</p>\r\n<p>&ldquo;Siemens CENTRA line with\r\n  SoundSmoothing is one of the most comprehensive\r\n  product portfolios on the market -\r\n  addressing wearers&rsquo; audiological and lifestyle needs &ndash; and this national campaign allows\r\n  us to show off those attributes,&rdquo; said Dr.\r\n  Thomas Powers, vice president of Audiology\r\n  and Professional Relations at Siemens\r\n  Hearing Instruments, Inc.</p>\r\n<p><strong>www.siemens-hearing.ca</strong></p>\r\n<p><strong>EX&Eacute;LIA MICRO OFFERS THE\r\n  FULL LIFE EXPERIENCE\r\n  &ndash;MORE THAN YOU\r\n  WOULD EVER EXPECT\r\n  FROM A MICRO!</strong></p>\r\n<p><strong>St&auml;fa, Switzerland, 2nd April 2008 </strong>&ndash;</p>\r\n<p>Phonak expands the new paradigm in hearing\r\n  excellence with the introduction of the\r\n  Ex&eacute;lia micro. Ex&eacute;lia, a unique combination\r\n  of cutting-edge technology, audiological\r\n  expertise and wireless connectivity, delivers\r\n  unprecedented hearing performance and\r\n  user interaction together with easy access to\r\n  modern communication and entertainment\r\n  systems.</p>\r\n<p>The Ex&eacute;lia micro is the most advanced,\r\n  highly featured microStyle hearing instrument.\r\n  At the heart of the Ex&eacute;lia system is\r\n  CORE (Communication Optimized Realaudio\r\n  Engine) technology which allows\r\n  Ex&eacute;lia micro to address communication\r\n  challenges in three principal areas:</p>\r\n<p><strong>Best Hearing Performance</strong></p>\r\n<p>The Ex&eacute;lia micro superior hearing performance\r\n  is based on SoundFlow, a revolutionary\r\n  automatic system that seamlessly creates an\r\n  infinite number of situation-specific programs.</p>\r\n<p><strong> Full Control over System</strong></p>\r\n<p><strong>Functionality</strong></p>\r\n<p>Although seamless automatic hearing performance\r\n  is paramount; users occasionally\r\n  require manual control. The optional\r\n  myPilot command center provides intuitive\r\n  control of hearing instrument functions and\r\n  sophisticated network status information.</p>\r\n<p><strong> Easy and Complete Connectivity to\r\n  the Digital World</strong></p>\r\n<p>Technology surrounds us, and modern\r\n  lifestyles require access to a multitude of\r\n  devices and gadgets. iCom is a highly inno vative wireless communication interface\r\n  through which any Bluetooth enabled device\r\n  is accessible with stereo audio quality.</p>\r\n<p><strong>www.phonak.com</strong></p>\r\n<p><strong>VIVOSONIC INC.\r\n  APPOINTS MR. SERGE\r\n  AMAR AS VICE PRESIDENT,\r\n  WORLDWIDE SALES</strong></p>\r\n<p><strong>Toronto, Ontario, Canada,April 8,\r\n  2008</strong> &ndash; Vivosonic Inc., the Toronto-based\r\n  developer and manufacturer of the world&rsquo;s\r\n  only non-sedated ABR technology, is pleased\r\n  to announce the appointment of Mr. Serge\r\n  Amar as vice president, Worldwide Sales.\r\n  Mr. Amar is responsible for the further\r\n  development of the Vivosonic Integrity&trade;\r\n  sales platform throughout the globe, working\r\n  closely with specialty equipment distributors,\r\n  institutions, and private practices.Serge brings nearly 20 years of international\r\n  experience in the medical device industry,\r\n  heading worldwide sales and market development\r\n  teams for several technology-based\r\n  companies.</p>\r\n<p>&ldquo;Serge has a wealth of industry experience\r\n  and demonstrated success in managing and\r\n  growing a global sales organization&rdquo; said Dr.\r\n  Yuri Sokolov, president and CEO of\r\n  Vivosonic.</p>\r\n<p>&ldquo;Vivosonic is an innovator with a superior\r\n  solution portfolio and a strong track record.&rdquo;\r\n  said Mr. Amar. &ldquo;I am excited to join the\r\n  company and look forward to working with\r\n  Vivosonic&rsquo;s exceptional team to deliver outstanding\r\n  results.&rdquo;</p>\r\n<p><strong> NEXT&bull; REDEFINES THE\r\n  ADVANCED THROUGH\r\n  ESSENTIAL CATEGORIES</strong></p>\r\n<p><strong>Everything You Need to Succeed\r\n  April 2, 2008</strong> &ndash; Kitchener, Ontario,\r\n  Canada &ndash; Unitron Hearing announced\r\n  today the introduction of its new Next&bull;\r\n  series comprised of four outstanding product\r\n  lines: Next 16, Next 8, Next 4, and Next E, each with a unique set of purpose-driven\r\n  features for client needs. Next is developed\r\n  on the world&rsquo;s most advanced digital sound\r\n  processing platform resulting in a better\r\n  sounding hearing instrument. Each Next\r\n  product line raises the bar for performance\r\n  and features in the advanced through essential\r\n  categories, with flagship technologies\r\n  included across the series.</p>\r\n<p><strong> World&rsquo;s Leading Breakthrough\r\n  Feedback Management</strong> Next features the world&rsquo;s most advanced\r\n  feedback management technology across all\r\n  four product lines which detects and suppresses\r\n  multiple feedback peaks faster, while\r\n  maintaining superior sound. The breakthrough\r\n  feedback technology provides more\r\n  useable gain, an expanded fitting range,\r\n  more open styles, and larger venting for\r\n  more natural sound. The advanced feedback\r\n  technology means more custom product styles than ever before, including a new\r\n  Power CIC and full shell power directional,\r\n  along with client-pleasing innovations.\r\n  &ldquo;Unitron Hearing has a long-standing commitment\r\n  of developing industry-leading\r\n  technologies across all product categories,&rdquo;\r\n  explains Cameron Hay, president and CEO,\r\n  Unitron Hearing. &ldquo;Unitron Hearing&rsquo;s\r\n  Element&bull; series continues to set the benchmark\r\n  for features and performance in the\r\n  advanced to essential categories. Now, we\r\n  have raised the bar to the Next&bull; level in\r\n  terms of breadth of offering, features and\r\n  performance expectations across all form factors\r\n  and price points. Quite simply, Unitron\r\n  Hearing now has the most advanced, comprehensive\r\n  hearing instrument portfolio in\r\n  the industry.&rdquo;</p>\r\n<p>The Next series of products will be available\r\n  in May 2008. Please contact your localrepresentative\r\n  for availability in your market.</p>\r\n<p><strong> www.unitronhearing.ca</strong></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e015.png\" alt=\"image\" /></p>\r\n<h4>Hearing Protection Devices:\r\n  A Double Noise Reduction Rating?</h4>\r\n<p>Question: Why do we measure the attenuation\r\n  of a hearing protector device (HPD)?\r\n  Answer: To calculate the noise level of the\r\n  protected ear (i.e., the effective level the ear\r\n  is exposed to once the HPD is in place). For\r\n  all practical purposes, if we know the noise\r\n  level a person is exposed to and if this level\r\n  exceeds a certain jurisdiction&rsquo;s limit of best\r\n  practice, we would like to protect that person\r\n  by providing him with a HPD that will\r\n  reduce the level to below the limit.</p>\r\n<p>That is what the Noise Reduction Rating or\r\n  NRR was supposed to do and, for a long\r\n  time, we were satisfied using it. The NRR\r\n  was obtained by calculations, using results\r\n  from attenuation measurements performed\r\n  in a laboratory setting, using trained subjects\r\n  and following the procedures in the ANSI\r\n  S.19-1974 Standard.1 It did offer a very easy\r\n  method for the calculation: measure the\r\n  noise level in dBC, subtract the NRR of the\r\n  HPD and you get the sound level of the protected\r\n  ear in dBA. If you couldn&rsquo;t measure\r\n  the noise in dBC, but in dBA, you had simply\r\n  to add 7 dB to the above mentioned difference.</p>\r\n<p>For example, if the ambient noise level was\r\n  100 dBC, and if the acceptable limit was\r\n  85dBA, then you would have to look for a\r\n  HPD with an NRR of 100 &ndash; 85 = 15 dB or\r\n  greater. And if you measured your noise in\r\n  dBA and it was 98, then the NRR will be\r\n  98 &ndash; 85+7 = 20 dB.</p>\r\n<p>Unfortunately, numerous studies had shown\r\n  that the results were overly optimistic and\r\n  did not match the real-life situations at all.\r\n  That was the reason for the Occupational\r\n  Safety and Health Administration (OSHA) to recommend a de-rating of 50% of the NRR.\r\n  The National Institute for Occupational\r\n  Safety and Health (NIOSH) recommended a\r\n  selective de-rating of 25% for muffs, 50% for\r\n  formable earplugs and 70% from all other\r\n  plugs. Further studies have shown that there\r\n  is no firm ground for recommending any derating\r\n  schemes.2</p>\r\n<p>The problem was not really the NRR measurement\r\n  per se, but the way measurements\r\n  of the attenuation were performed. This is\r\n  the reason why, as a result of multiple studies,\r\n  a new method (&ldquo;B&rdquo;) was developed and\r\n  included in the current ANSI standard.3 It\r\n  requires &ldquo;na&iuml;ve&rdquo; subjects that have no previous\r\n  experience in using HPDs. Also, they do\r\n  not get assistance from the technician in\r\n  charge of the test. The subjects have to fit\r\n  the HPDs following the instructions on the\r\n  package. This situation is much more in line\r\n  with the way users behave and so, the\r\n  results of the measurements are closer to\r\n  those obtained in real-life situations.\r\n  However, even having a reliable method for\r\n  the measurement, there was still the need for\r\n  guidance on how to use the results of the\r\n  measurement.</p>\r\n<p>Here is what is new in that respect:\r\n  ANSI has just issued a new standard, the\r\n  ANSI S12.68-2007.4 Produced by the\r\n  Working Group 11 of the Accredited\r\n  Standard Committee S12 (Noise), this is the\r\n  first ANSI Standard that provides a method\r\n  for the calculation of the noise level of the\r\n  protected ear.</p>\r\n<p>The really revolutionary concept in this standard\r\n  is the introduction of a double rating\r\n  for the same HPD indicating two levels of\r\n  attenuation that can be obtained by different\r\n  groups of users.</p>\r\n<p>It is a well-known fact that different individuals\r\n  obtain different attenuation using the\r\n  same HPD. This is due mainly to the quality\r\n  of the fit they can achieve: better fit results\r\n  in an improved seal between the HPD and\r\n  the ear of the user and consequently in a\r\n  higher attenuation. The fit is a combined\r\n  effect of several causes such as an easier donning\r\n  process and the training and motivation of the user: it has been proven that real-life\r\n  attenuation is higher in workplaces with an\r\n  effective hearing conservation program. On\r\n  the other hand, in places where HPDs are\r\n  just handed out without proper training and\r\n  motivation the observed attenuations are significantly\r\n  lower.</p>\r\n<p>One draw-back of the today&rsquo;s NRR (obtained\r\n  either using Method &ldquo;A&rdquo; or &ldquo;B&rdquo;) is that it\r\n  does not show explicitly the variation of the\r\n  attenuation among the individual users.*\r\n  That is when the idea of using a dual rating\r\n  came into place. According to the ANSI\r\n  S12.68-2007 standard, the attenuation and\r\n  standard deviation data from measurements\r\n  performed using either Method &ldquo;A&rdquo; or &ldquo;B&rdquo;\r\n  are used to calculate the so called Noise\r\n  Level Reduction Statistics (NRS) &ndash; a measurement\r\n  that is similar to the NRR.</p>\r\n<p>There are two NRSs: NRSA and NRSG. They\r\n  are obtained using two different calculation\r\n  procedures (analytical and graphical) one\r\n  more complex than the other, but they yield\r\n  similar results. The user does not have to\r\n  calculate them: this is done by the manufacturer\r\n  who will have them written on the\r\n  package (in the same way as the NRR is\r\n  written now).</p>\r\n<p>Each of the NRSs can be calculated for a\r\n  different percentage of the protected population,\r\n  and this percentage appears as a subscript\r\n  of the NRS. As an example, the NRS\r\n  calculated for the 20th percentile of the population**\r\n  using the analytical method is\r\n  indicated as NRSA,20. This is the attenuation\r\n  that will be achieved or exceeded by </p>\r\n<p>*This is not exactly true: the standard deviation\r\n  among the results is used for the calculation of\r\n  the NRR.The larger the variation, smaller is the\r\n  NRR. However, by only knowing the NRR one\r\n  does not know separately the attenuation and\r\n  the standard deviation.</p>\r\n<p>**Indicates that 20% of the population will\r\n  achieve or exceed the NRSA,20 value.\r\n  NRSA,80, will be met or exceeded by 80% of\r\n  the protected population.</p>\r\n<p>highly motivated and trained individuals.\r\n  On the other hand, the NRS calculated for\r\n  the 80th percentile of the population using\r\n  the graphic method is indicated as NRSG,80.\r\n  This will be the protection achieved or\r\n  exceeded by most users. The 20th percentile\r\n  value will always be higher than the 80th\r\n  percentile one.</p>\r\n<p>Other advantages of the &ldquo;two-numbers\r\n  approach&rdquo; are that:</p>\r\n<p>a. It indicates the range of attenuation to be\r\n  obtained by different users.</p>\r\n<p>b. It diverts the attention of the buyer from\r\n  the tendency to purchase the HPD with\r\n  the highest NRS value.</p>\r\n<p>c. It uses the ambient noise level measured\r\n  in dBA for the calculation of the noise\r\n  level of the protected ear.</p>\r\n<p>d. It draws attention to the possibility of over\r\n  protection (the danger of too much protection\r\n  that may them uncomfortable and\r\n  hampers the ability to hear danger or\r\n  warning signal).</p>\r\n<p><strong>Use of the Noise Level Reduction\r\n  Statistics</strong></p>\r\n<p>The effective A-weighted sound pressure\r\n  level L&rsquo;Ax of the protected ear (for protection\r\n  performance x percent) is computed as:</p>\r\n<p>L&rsquo;Ax = LA &ndash; NRSAx,</p>\r\n<p>Where LA is the time-weighted average noise\r\n  level (in dBA) the person is exposed to.\r\n  As an example, if LA at a given location is\r\n  95dBA and the values of the HPD are\r\n  NRSA80 = 19 dB and NRSA20 = 27, then\r\n  L&rsquo;A80 = 95 &ndash; 19 = 76 dBA &ndash; the effective\r\n  A-weighted level most users will not exceed\r\n  and L&rsquo;A20 = 95 &ndash; 27 = 68 dBA &ndash; the effective A-weighted level a few motivated proficient\r\n  users will not exceed.</p>\r\n<p>The EPA plans to reconsider its hearing protector\r\n  device-labeling rule probably this year.\r\n  So, starting in 2009, there may already be\r\n  HPDs with two values of NRS on their packaging.</p>\r\n<p><strong>Impact of the Double Rating in\r\n  Canada</strong></p>\r\n<p>The Canadian standard that deals with hearing\r\n  protectors is the CSA Z94.2-02.5 The\r\n  standard specifies that the measurement of\r\n  the attenuation should be done following the\r\n  ANSI standard S12.6-1997 (R2002) referred\r\n  to above. It also specifies three different ways\r\n  for the selection of the HPDs, using the\r\n  results of the attenuation measurements.\r\n  They are:</p>\r\n<p><strong>a. Classes A, B, and C.</strong> Its use is recommended\r\n  for LEX, 8 hr of &lt; 105 dBA, =\r\n  &lt;95 dBA and = &lt;90 dBA respectively.\r\n  Basically, the user has to measure the\r\n  LEX, 8 hr in the workplace and then\r\n  choose the HPD on the basis of its Class,\r\n  that is indicated by the manufacturer.</p>\r\n<p><strong>b. SNR(SF84) Grades 1 through 4.</strong> The\r\n  name stands for Single Number Rating,\r\n  Subject Fit 84th Percentile. Its use is recommended\r\n  for L LEX, 8 hr of &lt;105 dBA,\r\n  = &lt;100 dBA, = &lt;95 dBA and = &lt;90 dBA\r\n  for the Grades 1. 2, 3, and 4 respectively.</p>\r\n<p><strong>c. Octave Band Computation</strong>. This is a\r\n  straightforward calculation, subtracting\r\n  the attenuation values from the octave\r\n  band values of the ambient noise level.</p>\r\n<p>The above classifications methods didn&rsquo;t gain\r\n  much popularity for two reasons:</p>\r\n<p>1. Because the only information available to\r\n  users remained the NRR, since its use is compulsory in the USA &ndash; the country\r\n  with the largest market, and</p>\r\n<p>2. Because potential users are more familiar\r\n  with the NRR.</p>\r\n<p>If and when EPA institutes the dual rating\r\n  NRS system, manufacturers will have to label\r\n  their products accordingly. Canadian users\r\n  will have to be informed about the meaning\r\n  and the usage of this system, since only the\r\n  NRS values will be available to them.</p>\r\n<p>At that time (or even before) it will be advisable\r\n  that the Canadian standard CSA Z94.2\r\n  be revised accordingly and the new classification\r\n  be included in the text. Another\r\n  avenue will be the adoption of the ANSI\r\n  S12.68-2007, something that may simplify\r\n  the entire process. In any event, parts of CSA\r\n  Z94.2 should be updated and kept, since it\r\n  contains important information regarding\r\n  the care and use of the protectors.</p>\r\n<h4> References</h4>\r\n<p>1. ANSI. 1974. Method for the Measurement of\r\n  Real-Ear Protection of Hearing Protectors and\r\n  Physical Attenuation of Earmuffs. American\r\n  National Standards Institute S3.19 &ndash; 1974 (ASA\r\n  STD 1-1975): New York, NY.</p>\r\n<p>2. Frank J, et al. Four Earplugs in Search of a Rating\r\n  System. Ear and Hearing 2000; 21(3):218&ndash;26.</p>\r\n<p>3. ANSI. 1997-2002. Methods for Measuring the\r\n  Real-Ear Attenuation of Hearing Protectors.\r\n  American National Standards Institute S12.6-\r\n  1997(R2002): New York, NY.</p>\r\n<p>4. ANSI. 2007. Methods of Estimating Effective Aweighted\r\n  Sound Pressure Levels when Hearing\r\n  Protectors are Worn. American National\r\n  Standards Institute S12.68-2007: New York, NY.</p>\r\n<p>5. CSA. 2007. Hearing Protection Devices &ndash;\r\n  Performance, Selection, Care and Use. Canadian\r\n  Standards Association Z94.2-02 (R2007):\r\n  Toronto, ON.</p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e016.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e017.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e018.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e019.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e020.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e021.png\" alt=\"image\" /></p\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e022.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e023.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e024.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e025.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e026.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e027.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e028.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e029.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e030.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e031.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e032.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e033.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-2-e034.png\" alt=\"image\" /></p>',NULL,'2022-11-30'),(50,3230,'ajchr','http://www.andrewjohnpublishing.com/','','<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-1-e001.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-1-e002.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-1-e003.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-1-e004.png\" alt=\"image\" 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src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-1-e023.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-1-e024.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-1-e025.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-1-e026.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-1-e027.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-3-1-e028.png\" alt=\"image\" /></p>',NULL,'2022-11-30'),(51,3229,'ajchr','http://www.andrewjohnpublishing.com/','','<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-4-e001.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-4-e002.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-4-e003.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-4-e004.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-4-e005.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" 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src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-4-e030.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-4-e031.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-4-e032.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-4-e033.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-4-e034.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-4-e035.png\" alt=\"image\" /></p>\r\n<p><img class=\"img-responsive\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-2-4-e036.png\" alt=\"image\" /></p>',NULL,'2022-11-30'),(52,3254,'ajchr','http://www.andrewjohnpublishing.com/','','<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-1-1-g001.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-1-1-g002.png\" alt=\"image\" /></p>\r\n<p>By the time you open this issue of the Canadian Hearing Report, Christmas will be long passed and the snow will still probably be on the ground. And, unfortunately, we will all be carrying about 5 kg of unwanted bulge. So don&rsquo;t forget to get out to exercise, or at least shovel the snow. It&rsquo;s not only good for our waistline but also for our hearing. Increased pulmonary blood flow and an improved cardiac system has been related to improved hearing as we age. Presbycusis was once considered to be inevitable but research (Alessio and Hutchinson, Canadian Hearing Report 2010;5(6):20&ndash; 29) demonstrate that 80-year-old couch potatoes have statistically poorer hearing than 80 year olds who are physically fit. Like many areas of audiology, there is a significant degree of variability in this area of study, and variability is one of several themes that run through this issue.</p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-1-1-g003.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-1-1-g004.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-1-1-g005.png\" alt=\"image\" /></p>\r\n<p>Spotlight on Science is a regular column which is shared by Dr. Sheila Moody at Western University (previously called the University of Western Ontario), and Lendra Friesen and Samidha Joglekar at the Sunnybrook Health Sciences Centre &ndash; each sharing alternating duties. This will be Lendra&rsquo;s and Samidha&rsquo;s last column (but Lendra will be back guest editing an issue of the Canadian Hearing Report later this year), and we wish both Lendra and Samidha all the best. To try to fill their shoes, Dr. Steve Aiken of Dalhousie University will be sharing writing responsibilities with Sheila Moody. Steve is currently the president of the Canadian Academy of Audiology and has the rare combination of working in a clinical environment, in industry with a hearing aid manufacturer, and in an academic setting so I suspect that his Spotlight on Science column will be broadly based. This issue\'s Spotlight on Science column touches on the often annoying feature of the variability of a neural response for those implanted with cochlear implants. Why does one person do well and another person may have a more limited response? Neural variability and some of its indicators are covered in this column. Variability touches on all aspects of audiology and in some areas only about half of the clinical or evoked response variability can be explained. And speaking of variability in human populations, the topic that always comes to mind is the study of noise and how it affects our auditory system. When one thinks of the research on noise, you can&rsquo;t help but come across the name of Dr. Don Henderson.</p>\r\n<p>Actually, Don Henderson will be honoured at this year&rsquo;s American Academy of Audiology (2013) in Anaheim, California, for a lifetime of work in research in audiology&hellip; Well not to brag, but the State University of New York at Buffalo and the Canadian Hearing Report, have both beat them to the punch. On Aril 20, 2012 the Department of Communicative Disorders and Science and the Center for Hearing and Deafness hosted a one-day seminar in honour of Don Henderson&rsquo;s life&rsquo;s work. A little known fact is that Don was born is Hamilton, Ontario, and even less known is that he played one year for the British Columbia Lions in the Canadian Football League. The greater known facts include reams of publications and book chapters in virtually all aspects of our field, concentrating on the effects of noise on our auditory system. In this issue of the Canadian Hearing Report we have amassed an impressive list of articles by Don&rsquo;s colleagues and students who attended this one day conference last April. I won&rsquo;t say anything more about Don at this point because we already have a wonderful introduction to Don and his life&rsquo;s work co-written by Dr. Dick Salvi (recently promoted to distinguished professor status at SUNY at Buffalo) and by Carol Altman (who actually is one of the driving forces behind the department). There are seven articles in total, some of which have been written by people who have presented at the Canadian Academy of Audiology &ndash; remember Dr. Eric Bielefeld at our most recent meeting in Ottawa? I hope you all are having a pleasant winter season and haven&rsquo;t put on too many of those annoying, hearing-loss affecting, kilograms.</p>\r\n<p>Au moment o&ugrave; vous allez ouvrir ce num&eacute;ro de la Revue Canadienne d&rsquo;audition, no&euml;l serait loin derri&egrave;re nous et la neige probablement toujours au sol. Malheureusement, nous porterons tous pr&egrave;s de 5 Kg de surpoids non voulu. Alors n&rsquo;oubliez pas de sortir pour faire de l&rsquo;exercice, ou au moins pelleter la neige. Ce n&rsquo;est pas seulement bon pour notre tour de taille mais aussi pour notre ou&iuml;e. Une augmentation du d&eacute;bit sanguin pulmonaire et un syst&egrave;me cardiaque am&eacute;lior&eacute; ont &eacute;t&eacute; li&eacute;s &agrave; une ou&iuml;e am&eacute;lior&eacute;e pendant le processus de vieillissement. La presbyacousie a &eacute;t&eacute; une fois consid&eacute;r&eacute;e in&eacute;vitable mais la recherche (Alessio and Hutchinson, Revue canadienne d&rsquo;audition 2010;5 (6):20&ndash;29) d&eacute;montre qu&rsquo;une personne s&eacute;dentaire de 80 ans a statistiquement une ou&iuml;e de qualit&eacute; inf&eacute;rieure &agrave; celle d&rsquo;une personne de 80 ans qui fait de l&rsquo;exercice. Similaire &agrave; beaucoup de domaine de l&rsquo;audiologie, on trouve un certain degr&eacute; de variation dans ce domaine d&rsquo;&eacute;tude, et la variation est un des plusieurs th&egrave;mes de ce num&eacute;ro. Spotlight on Sciene est une chronique r&eacute;guli&egrave;re qui est partag&eacute;e par Dr. Sheila Moody de l&rsquo;universit&eacute; Western (de son nom pr&eacute;c&eacute;dent the University of Western Ontario), et Lendra Friesen et Samidha Joglekar du Sunnybrook Health Sciences Centre &ndash; chacune partageant des taches alternantes. C&rsquo;est la derni&egrave;re chronique de Lendra et Samidha (mais Lendra va &ecirc;tre de retour en tant que r&eacute;dactrice invit&eacute;e de La Revue Canadienne d&rsquo;audition plus tard cette ann&eacute;e), et nous souhaitons le meilleur &agrave; Lendra et Samidha. Pour essayer d&rsquo;acc&eacute;der &agrave; leur niveau, Dr. Steve Aiken de Dalhousie University va partager les responsabilit&eacute;s de r&eacute;daction avec Sheila Moody. Steve est actuellement le pr&eacute;sident de l&rsquo;acad&eacute;mie canadienne d&rsquo;audiologie et a la combinaison rare de travailler dans un environnement clinique, dans l&rsquo;industrie avec un fabricant d&rsquo;appareils auditifs, et dans un environnement acad&eacute;mique, alors je me doute bien que sa chronique spotlight on sciences aura une base assez large.</p>\r\n<p>Ce num&eacute;ro de Spotlight on sciences touche la caract&eacute;ristique souvent contrariante de la variabilit&eacute; de la r&eacute;ponse neurale pour ceux et celles qui ont un implant cochl&eacute;aire. Pourquoi certains affichent de bons r&eacute;sultats et d&rsquo;autres ont une r&eacute;ponse plus limit&eacute;e ? La variation neurale et certains de ses indicateurs sont trait&eacute;s dans cette chronique. La variation touche tous les aspects de l&rsquo;audiologie et dans certains domaines, &agrave; peu pr&egrave;s seulement la moiti&eacute; de la variation de la r&eacute;ponse clinique ou &eacute;voqu&eacute;e peut &ecirc;tre expliqu&eacute;e. En parlant de variation chez les &ecirc;tres humains, le sujet qui surgit toujours est l&rsquo;&eacute;tude du bruit et son effet sur le syst&egrave;me auditif. Quand on pense &agrave; la recherche sur le bruit, on ne peut ne pas croiser le nom du Dr. Don Henderson. &hellip; En fait, un hommage sera rendu &agrave; Don Henderson &agrave; la American Academy of Audiology de cette ann&eacute;e (2013) &agrave; Anaheim, en Californie, pour le travail de toute une vie en recherche en audiologie &hellip; Bon, sans &ecirc;tre pr&eacute;tentieux, mais the State University of New York &agrave; Buffalo et la Revue Canadienne d&rsquo;audition, les a coiff&eacute; au Poteau. Le 20 avril 2012, le d&eacute;partement des sciences des troubles de communication et le centre pour l&rsquo;ou&iuml;e et la surdit&eacute; a organis&eacute; un s&eacute;minaire d&rsquo;une journ&eacute;e pour honorer le travail de toute une vie de Don Henderson. On ne le sait pas assez mais Don est n&eacute; &agrave; Hamilton, en Ontario, et ce qu&rsquo;on sait moins encore est qu&rsquo;il a jou&eacute; pour une ann&eacute;e pour les Lions de la Colombie britannique dans la ligue canadienne de Football. On est plus au courant de la multitude de ses publications et chapitres de livres pratiquement au sujet de tous les aspects de notre domaine, avec une concentration sur les effets du bruit sur notre syst&egrave;me auditif. Dans ce num&eacute;ro de la Revue Canadienne d&rsquo;audition, nous avons amass&eacute; une liste impressionnante d&rsquo;articles de coll&egrave;gues et &eacute;tudiants de Don qui ont particip&eacute; &agrave; cette journ&eacute;e unique de conf&eacute;rence au mois d&rsquo;avril dernier.</p>\r\n<p>Je n&rsquo;en dirai pas plus sur Don parce que cet &eacute;ditorial sera suivi par une superbe introduction &agrave; Don et son travail de toute une vie co-&eacute;crit par Dr. Dick Salvi (r&eacute;cemment promu au statut de professeur distingu&eacute; au SUNY &agrave; Buffalo) et par Carol Altman (qui est une des forces dirigeant le d&eacute;partement). En somme, sept articles, dont certains ont &eacute;t&eacute; r&eacute;dig&eacute;s par des personnes qui ont pr&eacute;sent&eacute; &agrave; l&rsquo;acad&eacute;mie canadienne d&rsquo;audiologie&ndash; vous rappelez vous du Dr.Eric Bielefeld &agrave; notre derni&egrave;re r&eacute;union &agrave; Ottawa? J&rsquo;esp&egrave;re que vous passez tous et toutes une bonne saison d&rsquo;hiver et que vous n&rsquo;avez pas pris beaucoup de ces kilogrammes tellement irritants affectant la perte auditive.</p>\r\n<p>By David H. Kirkwood</p>\r\n<p>Reprinted with permission from HearingHealthMatters.org</p>\r\n<p>People who know me probably wonder why I would ask such a tendentious question. After all, my father, who was born and raised in Ontario, remained a Canadian for most of my childhood years. And, except for my mother and brother, all my Kirkwood relatives still live on the northern side of the border. I also have fond memories of family visits to Toronto, Montreal, and the Gasp&eacute; Peninsula. Professionally, I&rsquo;ve also had great experiences with Canada and its people. As an editor, I have observed consistently that manuscripts submitted by Canadian audiologists and hearing instrument specialists are especially well written. I don&rsquo;t know if that&rsquo;s true of Canadians across the board or just among those who go into the hearing care field. In any case, I appreciate it. I should also note that two of our blog&rsquo;s outstanding editors are from Ontario &ndash; Marshall Chasin and Gael Hannan.</p>\r\n<p><strong>A Healthcare Issue</strong></p>\r\n<p>So, what&rsquo;s my beef with the world&rsquo;s second largest nation? Well, it has to do with healthcare. No, I&rsquo;m not talking about its vaunted publicly funded health care system, which, despite its detractors in the U.S., even conservative Canadians have grown to cherish during the nearly 30 years it has been in effect. Canada also has a pretty good record of taking care of citizens with hearing loss. In several provinces, the government covers at least part of the cost of hearing aids for adults as well as children.</p>\r\n<p>The country also does an excellent job of educating hearing instrument specialists. It has several two-year program for that purpose, putting it well ahead of the U.S. in that respect. That&rsquo;s why it is so shocking that of the ten Canadian provinces, only Ontario and British Columbia require universal newborn hearing screening (UNHS). Quebec is on its way. It passed a law mandating UNHS, but it is not scheduled to be fully implemented until the end of 2013. Other provinces tend to test only babies at high risk of hearing loss, such as preemies and those suffering serious infections like meningitis. Contrast that within the U.S., where the UNHS movement took off in the 1990s. Now, 95% of babies born here are screened.</p>\r\n<p><strong>The Case Is CLear</strong></p>\r\n<p>One reason that universal newborn screening is such a no-brainer is its cost effectiveness. True, when you add up the hundreds of screenings, at about $35 a pop, that it takes to identify a single newborn with hearing loss, the price may seem high. But then consider the value of early identification and intervention. It is well established that the earlier a child&rsquo;s disability is addressed, the more likely that child is to learn as well as his or her normalhearing classmates and to become a successful, productive adult. Children whose hearing loss is discovered and treated at age 1 or 2 or older are likely to need special education that will cost society far more than the cost of detecting and addressing it early. What&rsquo;s worse is that these children will be far less likely to achieve their full potential. Their lost opportunities are a tragedy both for the children and their families and for society as a whole.</p>\r\n<p>A lot of Canadians are working hard to introduce UNHS in every province and territory of the country. The Canadian Association of Speech-Language Pathologists and Audiologists has adopted position papers to that effect, most recently in 2010. And last January, CASLPA recommended that the national budget provide for universal access to newborn hearing screening throughout Canada. In 2011, the Canadian Paediatric Society issued a statement calling on all provinces to implement universal newborn hearing screening. One of the leading champions for UNHS in Canada is Hema Patel, MD. A staff pediatrician at Montreal Children?s Hospital, she is lead author of the Paediatric Society?s position statement. In an Interview with the Globe &amp; Mail, Patel said, ?Virtually every developed country has a screening program. It?s shameful that Canada doesn?t.? She also pointed out to a Montreal CTV affiliate that each day a child unnecessarily lives in silence can result in permanent and possibly irreparable loss of development. She explained, ?Hearing is actually not about the ears. Hearing is about the brain and the longer that the child is deprived of that auditory input and the sound that is all around us, the more that it shuts down that development.?</p>\r\n<p>The Canadian Hearing Society, which provides services to people with hearing loss, also supports universal newborn hearing screening. According to the Calgary Herald, advocates for UNHS in Alberta are petitioning their province to get with the program. Twice before, the government in Edmonton has considered and rejected the idea. But this time, there seems to be growing support for this eminently sensible health policy. It is shocking that in a country that is generally so progressive universal newborn hearing screening is more the exception than the rule. It is high time that Canadians who share our blog?s credo that Hearing Health Matters take steps to remedy one of the few things about Canada that need fixing.</p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-1-1-g006.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-1-1-g007.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-1-1-g008.png\" alt=\"image\" /></p>\r\n<p>Elliott H. Berger, MS, division scientist for 3M?s Occupational Health &amp; Environmental Safety Division, will be presented with the National Hearing Conservation Association Lifetime Achievement Award in St. Petersburg, FL, in February, 2013. This prestigious award represents the highest honour bestowed by the NHCA and is intended to recognize a lifetime of extraordinary accomplishment in the field of hearing loss prevention and in service to NHCA. The NHCA honours Elliott Berger for his significant and lasting contributions to hearing conservation and to NHCA as evidenced by his extensive body of quality work. For over 35 years, Berger has been a driving force in hearing loss prevention research and training, personal hearing protection product development, and the establishment of national and international standards and regulations. Through his role at 3M (previously E-A-R and Aearo Technologies), Berger has helped direct the industry?s approach to the prevention of hearing loss due to occupational and environmental noise. Berger is perhaps most widely known as a respected author and editor of hearing-conservation-related books, book chapters, peer-reviewed papers and articles, and through hundreds of national and international presentations. As chair of the ANSI Working Group on hearing protectors, Berger has laboured tirelessly since 1985 to establish relevant standards that support hearing conservation efforts. He is a past president of NHCA and currently serves as NHCA?s historian.</p>\r\n<p>Berger?s acceptance of the Lifetime Achievement Award will take place at an awards luncheon during the NHCA?s 38th Annual Conference to be held February 21-23, 2013 in St. Petersburg, Florida. Many of Berger?s colleagues and associates will be on hand to honour and recognize this prestigious achievement. For more information about the NHCA Conference, The Art of Hearing Conservation, go to http://www.hearingconservation.org.</p>\r\n<p>The C&eacute;gep of La Pocati&egrave;re has just proceeded with the hiring of Mr. Daniel Bois, audiologist. With a master?s degree in audiology, Mr. Bois has nearly 20 years? experience in private practice and in hospitals. He was a lecturer at the University of Montreal, has published articles, and has lectured extensively on hearing problems and hearing aid technology in North America. He was also recently seen on the T.V. shows Une pillule, une petite granule (T&eacute;l&eacute;-Qu&eacute;bec) and Famille 2.0 (Canal V). Mr. Bois will teach the new Audioprosthesis Program which will receive its first intake of students in the fall semester of 2013. He officially took office on December 3, 2012 and will be primarily responsible for the coordination and the implementation of the new curriculum, devising the course layout and setting up the required installations including the premises and equipment required. The C&eacute;gep of La Pocati&egrave;re will invest almost $700,000 acquiring the proper equipment for this new program. The C&eacute;gep of La Pocati&egrave;re thus becomes only the second institution in Quebec, and the fifth in Canada, to offer the Diploma of Collegial Studies (DEC) in Audioprosthesis. Managing director of the C&eacute;gep, Mr. Claude Harvey said ?The announcement in June by Minister of Education, Recreation and Sports (MELS) Mich&egrave;le Courchesne, was the crowning moment of two years hard work and at the same time proved that our college was able to offer this training in optimal conditions. This news was greeted with much enthusiasm from our college community since it will allow a regional college to train young people in a profession that will hopefully incite them to settle into our region later. There will be an increase in demand for this technology given the ageing of the population.?</p>\r\n<p>Some study programs already offered at the C&eacute;gep of La Pocati&egrave;re such as Physical Technology, Nursing and Special Care Education have affinities with the technological, medical and patient-centered approaches to audio-prosthesis. It is to be noted that due to the shortage of labour in this sector, the job market is very favourable and is in constant progression and that working conditions are also very appealing.</p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-1-1-g009.png\" alt=\"image\" /></p>\r\n<p>I f you are a parent, what did you worry about when expecting your child, especially the first child? Probably the standard issues: will all the regular bits be in good working order, will it be healthy, and please let it look like my side of the family? One thing most parents don?t think about is that their baby might be born deaf. And why would they? Chances are, no one told them to add hearing loss to their worry-list. And, as approximately only three in 1000 babies are born with some degree of hearing loss, the odds are favourable that the child would come into this world with typical hearing. I didn?t worry about it either. I swear to heaven, even with my own hearing loss that wasn?t diagnosed until age two and a half, I don?t recall thinking about it during pregnancy. Perhaps it was because hearing loss didn?t ?run in the family,? and at the time I didn?t know that congenital hearing loss has many causes. A more likely reason was that I was finally having a wonderful, viable pregnancy, and in the greater scheme of things, hearing loss just didn?t seem to matter. What I did worry about, however, was how I was going to hear the baby? I was concerned that my hearing might put my child in danger. What if I didn?t hear him cry, or burp, or call for me? What if he became lost and I couldn?t find him? All those things actually did occur at some point and to varying minor degrees, in Joel?s childhood. But one day, as I blubbered about my some hearing-related baby mishap, my husband gave me a most wonderful gift ? the reassurance that parenting is 50% luck, regardless of hearing ability.</p>\r\n<p>Recently, my now 17-year-old son roared into the room (teenage boys are incapable of simply entering) with a bunch of his baby pictures, saying: ?Let?s look at them together, Mum.? In the pile was one I?d almost forgotten ? a sleeping four month-old having an auditory brainstem response (ABR) hearing test. Because of my severe congenital loss, Joel?s pediatrician considered him high risk and he had three hearing tests in his first year of life, which was 1995, a few years before Universal Newborn Hearing Screening was introduced in Ontario. For the ABR test that measures the brainstem?s response to sound, the baby must be asleep so he had to arrive at the hospital. (The fact that I, the mom, was already brutally sleep-deprived was not considered good enough.) This meant keeping the baby up late, getting him up early and not feeding him his breakfast. Up to that point, it was stressful but we got through it. Then came the drive to SickKids hospital. Have you ever tried to keep a drowsy baby awake? As my husband drove the car as fast as legally possible, I jiggled and wiggled Joel in an attempt to irritate him into wakefulness. When he started to slip away into sleepy-land, I started singing, loudly and badly, but his eyes rolled up in his head and he was gone. He perked up at the hospital, but when little electrodes were placed on his head, he conked out again. And that?s when it hit me. What if my baby had my hearing loss? There had been no signs in his early months, but seeing him asleep with thingies stuck to his head, the possibility that he might have similar life-long hearing challenges shocked me into tears. But this screening, and subsequent tests confirmed he did not have hearing loss, and we were grateful.</p>\r\n<p>If Joel had been born with hearing loss, I know that like other parents who receive the diagnosis, we would have been upset. But the good news is that interventions would have given Joel the best shot at optimal communication, for effective language. If the loss had been severe or profound ? and if I knew then what I know and believe now ? we would have raised him to communicate in both spoken and signed languages. Through the years, I?ve watched closely for signs of hearing loss and had him tested again at age 10. So far, his hearing is ?fine? although I have a new worry ? noise damage. Raised by a hard of hearing advocate, my son should, you might think, understand the consequences of unsafe listening practices. When he was younger, he could make the angels (and his parents) weep with the beauty of his classical guitar playing, but now he?s happier screeching out chords on an electric guitar and a wicked amplifier. He recently came home from a club party with ringing ears that lasted for two days. It scared the heck out of him ? which I was glad to see, hoping it would spur him to wear earplugs in the future. But for now, I?m grateful for the newborn hearing screening available for today?s babies ? that is, the ones born in Ontario, BC, and some Atlantic provinces. But what about all the other Canadian babies who don?t benefit from this one simple test, unless they are considered high risk? As hearing health professionals and consumer advocates, we need to ramp up our advocacy to federal and provincial bodies for a national UNHS strategy that is implemented in every province and territory. When an infant?s hearing is screened, he or she has just taken an important first step to a good life of language and communication. Don?t all our babies deserve that?</p>\r\n<p>The Federal Healthcare Partnership (FHP) consists of Veterans\' Affairs Canada, the Department of National Defense (DND), the Non-insured Health Benefits Branch of Health Canada (NIHB), and the Royal Canadian Mounted Police (RCMP). Representatives from the CAA meet, together with other audiology professional organizations, with the FHP twice annually ?to maintain open channels of communication with our Third Party Payers to ensure effective, efficient and beneficial hearing healthcare services are being provided to our mutual clients. Minutes of the meeting held in October 2012 in Ottawa are available at http://www.canadianaudiology.ca/assets/ docs/CAA_October_2012_FHP_Meeting _Notes.pdf</p>\r\n<p>By Kim L. Tillery, PhD, CCC-A kltillery@gmail.com</p>\r\n<p>Dr. Kim L. Tillery, professor and chairperson of the Department of Communication Disorders and Sciences at the State University of New York at Fredonia also has a private practice in diagnosing and treating individuals with (C)APD. She has been honoured to present 90 workshops or presentations at national, international, and regional conferences, and authored and co-authored several chapters and journal articles on (C)APD.</p>\r\n<p>While there are questionnaires and screening tests that are used routinely in clinics and schools there are some points to keep in mind. One point is that a questionnaire is only as good as who is answering the questions. A story comes to mind ? of a psychologist who administers a well-recognized questionnaire to rate attention behaviours. While the psychologist?s comprehensive evaluation revealed a significant attention disorder, the teacher?s ratings were found within normal ranges on the attention questionnaire. The psychologist telephoned the teacher to discuss the rating scores and was surprised to hear that the teacher ?does not believe in attention disorders.? A second point is that if we need to control for fatigue, noise, and attention during the administration of the APD test battery, then the same precautions need to be applied when screening measures are being administered. These tests should be administered in a quiet room, and in the morning to enhance reliable test results. False positive test results can be related to the test conditions. There is an advertisement in the ASHA Leader marketing AP screening tools for ages 3 to 59. Thanks to Robert Keith we have new versions of the SCAN: one for adults/adolescents and one for children. The original SCAN (1986) test was considered a screening measure. The newest versions contain three screening measures and several diagnostic tests to be given if the individual fails the screening measure or if there is a referral for a diagnostic evaluation. The screening tool for very young ages is the Auditory Skills Assessment (ASA) (Geffner &amp; Goldman, 2010) measuring discrimination ability in noise, proper understanding of nonsense words, blending phonemes, recognizing rhymes and ability to sequence nonverbal (music) sounds. A third choice is the Differential Screening Test for Processing (DSTP) (Richards and Ferre, 2006) which is the only test available that screens at various levels of auditory and language to identify areas for further evaluation.</p>\r\n<p>This is one of my favourite books on my bookshelf and indeed was quite dusty. I looked at it often from afar and that seemed sufficient to remind me of what was in there and to remind myself of some important technologies and design approaches that permeated the 1980s. Dusting off the front cover, the first paragraph of the Preface gives the rationale for the ?Vanderbilt Report?: This monograph reports the proceedings of ?A Working Conference on Amplification for the Hearing Impaired: Research Needs? held at the Bill Wilkerson Hearing and Speech Center of Vanderbilt University in Nashville, Tennessee on June 7 through 10, 1981. The impetus for the meeting was the belief that progress on how best to design and apply amplification systems for the hearing impaired has been impeded by insufficient communication between researchers working on matters related to different aspects of the problem?.? Actually, what was not said was even more important? There was a belief that progress? has been impeded by insufficient communication between manufacturers, researchers, and front line clinicians. And I must say that this is indeed the case today. In the 1970s and 1980s manufacturers were scrambling to glean information on how to build a better hearing aid and the front-line clinician was the rock star of the era. If a clinical or research audiologist showed up at a hearing aid manufacturer?s facility, everything stopped and the audiologist was bombarded with questions and perspectives on how best to help the hard of hearing clients. In contrast, today it?s the other way around. Many manufacturers have well-funded facilities and employ world class researchers that provide in-house solutions to hearing aid design problems. I can see strengths to both approaches, but for obvious reasons I recall a fondness for the early 1980s! The ?Vanderbilt Report? as it colloquially became known, brought together those researchers at the time who were at the top of their game. All aspects of the design and the fitting of hearing aids were addressed including new and updated models of normal and pathological auditory systems. Section I is entitled ?Basic Research ? Sound Perception by the Hearing Impaired?. There are articles on the psychoacoustics of elementary sound, spectral and temporal resolution by the hearing impaired, Spectral considerations in the speech discrimination ability of the hearing impaired, and temporal distortions in noise. The authors involved B. Scharf, M. Florentine, L. Humes, H. Levitt, and A. Nabelek. D. Dirks and S. Gelfand also contributed with well thought out comments on some of these topics./p&gt;</p>\r\n<p>The next section was a product of its time and technology. Section II is entitled ?Basic Research-Electroacoustic Considerations for Hearing Aid Performance.? The articles were about research problems in coupler and in situ measurements, and functional gain correlates of electroacoustic performance data. The author list included E. Burnett, D. Preves, R. Cox. Reading this section  provides us with an amazing insight into the issues and audiological hurdles of the early 1980s. Section III deals with ?Engineering Applications ? Special Problems.? Topics include acoustic feedback control, telephone coupling, transducer and earmold effects, signal and speech processing, the evaluation of compression processing, and a new topic- recent research on multi-band compression. Again, the author list is impressive ? S. Lybarger, D. Egolf, M. Killion, E. Libby, J. Lim, R. Schafer, L. Braida, N. Durlach, and E. Villchur. Some of the material in this section is dated but it?s nice to see the original thoughts of some of the founders and early thinkers of this field. Acoustic feedback control was limited to simple phase shifting by an all pass filter that was non-linear with respect to phase- a far cry from today?s use of phase control, notching filtering, and gain reduction, sometimes all available in one hearing aid product. E. Villchur is known as the father of modern day compression, and although his article is from 1981, it?s well worth re-reading even today. (See also Founders of our Profession interview with Eddie Villchur in the Canadian Hearing Report 2008:3[1]:19?20.)</p>\r\n<p>The final section (IV) is about the Delivery of Services and this discussion is as valid today as it was 30 years ago. Issues discussed were about hearing aid selection, a basis for selection amplification characteristics, validation of the selection measures and measures of hearing aid fitting success, factors affecting hearing aid use, and my personal favourite, a chapter by Mark Ross on Communication Access. Although Dr. Ross&rsquo;s article was written more than 30 years ago, it is still apropos to today&rsquo;s time. (See also Founders of our Profession interview with Mark Ross in the Canadian Hearing Report 2009;4(1):28&ndash;30.) Other authors read like the list of rock stars that they wereG. Studebaker, L. Beck, M. Skinner, D. Pasco, J. Miller, G. Popelka, G. McCandless, D. Byrne, B. Walden, E. Owens, M. Osberger, M. Collins, M. Ross, and D. Konkle. Finally Fred Bess and Wayne Olsen wrapped it up in the final section V &ldquo;Research Needs.&rdquo; Many of these issues and topics have still not been resolved today, but we are on our way. The Vanderbilt Report is a conglomeration of the state of the art 30 years ago. Reading through the yellowed pages will provide the reader with insight of where we have been, and even more importantly, where we are going.</p>\r\n<p>The Moneca Price Humanitarian award is presented to an audiologist in recognition of extraordinary humanitarian and community service, above and beyond the requirements of employment. The award is to honour the late Moneca Price, who took on significant leadership roles in both the Canadian Academy of Audiology (CAA) and the College of Audiologists and Speech Language Pathologists of Ontario (CASLPO). This year&rsquo;s winner, Gilbert Li, provides free audiology services in underprivileged regions in the Yunnan Province of China. Prior to each visit, Gilbert invests substantial personal time in soliciting donated or refurbished hearing aids and equipment in preparation for his humanitarian work. The organization he volunteers with is called EMAS (Education, Medical Aid and Service). His team has seen over 300 people and dispensed 207 hearing aids &ndash; free of charge. The $500 award he received at the 2012 CAA conference in Ottawa was put towards furthering his work on another trip to China in November.</p>\r\n<p>By Lendra Friesen PhD, and Samidha Joglekar, MClSc (C), Audiologist, Reg. CASLPO Cochlear Implant Research Program, Sunnybrook Health Sciences Centre</p>\r\n<p>One of the greatest challenges in hearing science research is the task of examining and understanding what produces patient variability in performance. We have all faced clinical situations in which we apply strategies that we expect will optimize patient experience and benefit, using methods that have worked with other patients in the past, only to find that these strategies are not optimal for the patient in question. It is then up to us, as audiologists and researchers, to consider the complex variables that make two patients who are similar in hearing loss type and configuration, duration of hearing impairment, and age, so different in their overall experience with a cochlear implant (CI) or a hearing aid. Research with auditory evoked potentials can allow us to investigate the auditory system at a deeper level and detect changes in the brain that may precede or follow certain behavioural outcomes in patients with hearing loss.1 A growing area of interest is the exploration of auditory neural survival and correlates of patient performance.2 Variability in objective performance and perceived benefit is very common among CI users and can be perplexing for the clinical audiologist. A current area of study related to this issue focuses on investigating both auditory nerve survival and neural population size using electrically evoked compound action potentials (ECAP).3 To review, the output of the cochlea is a series of action potentials (APs) that are conducted along the thousands of neurons that form the auditory nerve.1,2 The ECAP is an auditory evoked potential that is electrically elicited from surviving auditory neurons and measured from an intra-cochlear (CI) electrode stimulated with biphasic pulses.1,3 It is characterized by a single negative peak (N1) that is followed by a less prominent positive potential (P2).1 Presently, various CI manufacturers have built-in systems and provide software to measure ECAPs using intra-cochlear electrodes for both stimulation and recording.1,3,4 A major goal of this research is to make it relevant within a clinical framework, with the ambition of developing better cochlear implant fitting methods for the clinical audiologist.2,3 However, this a long-term goal that depends greatly on our understanding of the complex changes that occur throughout the auditory system as a result of hearing impairment, the aging process, and neuroplasticity, all of which are key factors that generate high variability in patients&rsquo; perceived, as well as measurable, benefit.</p>\r\n<p>Recent studies in this area of CI research have looked at the ECAP recovery function in relation to rate of stimulation and loudness perception. In brief, to measure the ECAP recovery function two pulses are used and the neural response to the second pulse is measured as a function of the inter-pulse interval.3 Refractoriness in the neural fibres arises from the first pulse (the masker) and leads to a masking of the ECAP evoked by the second pulse (the probe).3,6 The masker-probe interval is varied and the ECAP amplitude is measured at each interval in order to plot the recovery function.3 It is important to remember that the ECAP, as well as the recovery function, are the collective response of numerous neurons.1,3 Thus, if a given neuron exhibits refractoriness after firing, the capacity of the whole nerve to be excited might not be diminished if there are many other neurons in the region that are not in a refractory state and therefore ready to fire.</p>\r\n<p>An interesting study by Botros and  Psarros (2010) examined ECAP recovery functions with the hypothesis that ECAP recovery is heavily influenced both by neural survival as well as the size of the neural population that can be recruited to respond to a pulse-train stimulus. The popular understanding of the recovery function has been that faster recovery indicates a more efficient response to the individual pulses within a sequence.3 However, psychophysical data have not supported this view and, in fact, the opposite has been observed; faster recovery has been found to lead to poorer psychophysical thresholds.3 The researchers attempted to investigate this counterintuitive finding by postulating that the size of the neural population available to respond would heavily influence the refractoriness and operating status of the whole nerve. As it is not possible to count neural populations in human subjects, their study relied on a computational model of the cat auditory nerve and human ECAP measurements. Their findings demonstrated that slower ECAP recovery was related to better temporal synchrony with increasing stimulation rate.3 Based on these findings they propose that the size of the neural population, in addition to neural survival, influences the whole nerve refractoriness: large neural populations operate near threshold and are more susceptible to masking, leading to slower ECAP recovery; however, they maintain temporal responsiveness through greater numbers of nonrefractory neurons.3,6 It is known that auditory nerve degeneration advances with duration of hearing impairment and another major finding of this study was that longer durations of hearing loss were associated with faster ECAP recovery</p>\r\n<p>Overall, studies such as the one described highlight the complexity of the auditory system and the changes that occur in the brain when auditory input changes due to hearing loss. Studies that allow us to investigate brain-related changes are our gateway into discovering the underlying causes of patient variability, and ultimately in the long term, can help us provide the best clinical care for our patients.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. Abbas P and Brown C. Electrocochleography. In Katz J, Medwetsky L, Burkard R, and Hood L, Handbook of Clinical Audiology, Sixth Edition. Baltimore, MD: Lippincott Williams &amp; Wilkins; 2009.</p>\r\n<p>2. Nadol JB, Young YS, Glynn RJ. Survival of spiral ganglion cells in profound sensorineural hearing loss: Implications for cochlear implantation. Ann Otol Rhinol Laryngol 1989;98:411&ndash;16.</p>\r\n<p>3. Botros A, Psarros C. Neural response telemetry reconsidered: II. The influence of neural population on the ECAP Recovery function and refractoriness. Ear and Hearing 2010;380&ndash;91.</p>\r\n<p>4. Prado-Guitierrez P, Fewster LM, Heasman JM. Effect of interphase gap and phase duration on electrically evoked potentials is correlated with auditory nerve survival. Hear Res 2006;215:47&ndash;55.</p>\r\n<p>5. Gil-Loyzaga P. Biological bases of neuroplasticity- in vivo and in vitro studies: interest for the auditory system. Audiological Medicine 2009;7:3&ndash;10.</p>\r\n<p>6. Miller CA, Abbas PJ, Rubinstein JT. Response properties of the refractory auditory nerve fiber. J Assoc Res Otolaryngol 2001;2:216&ndash;32.</p>\r\n<p>By Richard Salvi, PhD and Carol Altman</p>\r\n<p>Dr. Richard Salvi, (far left) distinguished professor and Carol Altman are with the Department of Communicative Disorders and Sciences and the Center for Hearing and Deafness, University at Buffalo, Buffalo, NY, USA.</p>\r\n<p>On April 20, 2012, the Department of Communicative Disorders and Science and the Center for Hearing and Deafness hosted a one-day NoiseInduced Hearing Loss colloquium to honour Dr. Donald Henderson&rsquo;s numerous contributions to audiology, hearing science, noise-induced hearing loss, otoprotection, and ototoxicity during his 45 year academic and research career. Don was a prolific scientific contributor and author, outstanding teacher and mentor, skilled administrator and he was well known for organizing many high profile international conferences on &ldquo;hot topics&rdquo; in the field. Don was born in Hamilton, Ontario, Canada on October 3, 1938. After graduating from high school, Don attended college at Western Washington State College in Bellingham, WA where he majored in psychology. Unknown to most of his colleagues, Henderson was recruited to Western Washington State on a football scholarship and, more importantly, played professional football for one season with the BC Lions of the Canadian football league. Having found professional football too easy, Henderson decided to pursue an academic career and in 1962 entered the PhD program in sensory psychology at the University of Texas at Austin. After completing his PhD in 1966, Henderson spent two years as a post-doctoral fellow at the prestigious Central Institute for the Deaf in St. Louis, MO where he developed an interest in auditory evoked potentials and noiseinduced hearing loss. In 1968, he was appointed assistant professor at the State University of New York Upstate Medical Center in Syracuse, NY. Anticipating the digital revolution, Henderson purchased the first university laboratory computer, a DEC PDP8 with an &ldquo;unbelievable&rdquo; 4k of core memory and a teletype and tape reader for output and input. Using this advanced computer hardware and special amplifier, he was one of the early pioneers to assess auditory evoked potentials from humans and primates and to record single neuron discharge patterns from the auditory brainstem, techniques considered cutting edge at this time. In the early 1970s, Henderson teamed up with Dr. Roger Hamernik, a mechanical engineer who had been using a shock tube to study shock waves  produced by supersonic aircraft. Henderson, recognizing that blast wave exposure was a major cause of hearing loss among soldiers serving in Vietnam, convinced Hamernik to use his novel shock tube to study blast wave induced hearing loss in animal models. Working together, they published dozens of seminal papers documenting the relationship between the characteristics of the blast wave and the degree of hearing impairment and cochlear pathology. These studies highlighted the importance of peak pressure, spectrum and repetition rate in causing hearing loss. For example, at very high intensities, the blast literally ripped the cochlea apart while at lower intensities metabolic exhaustion played a significant role in hearing loss. Unexpectedly, the addition of moderate intensity background noise during a blast wave exposure was found to significantly exacerbate hearing loss and cochlear pathology. These findings cast doubt on universal application of the equal energy hypothesis to predict noise-induced hearing loss. These studies, along with others, helped guide the development of federal noise regulations. During his tenure at the Upstate Medical Center, Henderson rapidly advanced to the rank of full professor. In 1980, he moved his research team to the University of Texas at Dallas where he was promoted to the director of the Callier Center. He also served briefly as the acting dean of the School of Human Development. In 1987, Henderson moved to the University of Buffalo (UB) and assumed the position of professor and chair in the Department of Communicative Disorders and Sciences. A few years after arriving at UB, he cofounded the Center for Hearing and Deafness, a multidisciplinary research group that included scientists and clinicians from a wide range of schools, departments and scientific disciplines.</p>\r\n<p>In 1975, Henderson organized the first in a long series of international conferences on noise-induced hearing loss, ototoxicity and acquired hearing loss. The proceedings of the first noise conference held at Cazenovia College were published in 1976 by Raven Press. This was followed by international noise conferences in Syracuse, USA, Beaune, France, Gothenburg, Sweden, Trento, Barga and Bari, Italy, Cambridge, England, and Niagara Falls, Canada. Henderson was also responsible for organizing international conferences on auditory plasticity, hair cell regeneration, tinnitus, immunologic diseases of the middle ear, central auditory processing, education of the hearing impaired, and ototoxicity. These conferences, which were scientifically stimulating, brought together leading scientists, administrators and clinicians from around the world in pleasant surroundings that fostered the exchange of ideas and new collaborations. For connoisseurs of elegant dining, the gala banquet in the heart of the wine cellars of Beaune will long be remembered as one of the best social and scientific events of the 20th century. A major accomplishment of these meetings was the compilation of 11 scholarly, widely read, state of the art books, some which are considered classics in the field of noise-induced hearing loss.</p>\r\n<p>Scholarship  Over the course of his distinguished career, Henderson authored more than 130 scientific papers published in prestigious journals, 43 book chapters and 11 edited monographs. Henderson has given more than 300 scientific presentations at national meetings, international conferences or university colloquia. Over the course of his academic career, Henderson was able to secure continuous and substantial extramural grant support from numerous federal, state and private agencies including NIH, NIOSH, NIEHS, U.S. Army, NATO NOHR and DRF. Henderson often served as a consultant, reviewer, and advisor to many federal and state agencies. He served on numerous prestigious national and international committees including the National Institute of Occupation and Health (NIOSH), National Institute of Deafness and Other Communication Disorders (NIOSH) and Committee on Hearing and Bioacoustics (CHABA). Henderson was an associate editor for noise and health and the and was also a frequent reviewer for leading journals in audiology, hearing science and neuroscience such as Ear and Hearing, Hearing Research, Nature Medicine, Journal of the Acoustical Society of America, and Neuroscience to name a few. In recognition of his many accomplishments, Henderson received the National Research Award in 2006 from Hofstra University for distinguished contributions to the field of research in hearing science. In the same year, he received the Outstanding Hearing Conservationist Award from the National Hearing Conservation Association. Henderson was also granted two patents related to the development of drugs to prevent noise and drug induced hearing loss.</p>\r\n<p><strong>Mentorship</strong></p>\r\n<p>In addition to collaborating with many prominent scientists in the field, Don has also mentored numerous MS, AuD, and PhD students in audiology and psychology. Henderson has a special gift for teaching and making anatomy, physiology, acoustics, clinical pathology and audiology sound easy, interesting and relevant in such courses as Advanced Hearing Science; Anatomy and Physiology of the Auditory System, Industrial Audiology, Introductory Psychology, Medical Audiology, Neural Basis of Communication Disorders, Physiological Psychology and Sensory Psychology. Over the years, he attracted many bright, highly motivated students who worked on research projects in his lab. Although he is best known for his work on noise induced hearing loss, his research interests spanned a broad range of topics including ototoxicity, evoked potentials, acoustic reflexes, cochlea anatomy, ototoxicity and age-related hearing loss. Several of his PhD students, including me, have gone on to hold faculty positions at major universities such as Ohio State University, SUNY Geneseo, West Virginia University, University at Buffalo and Medical University of South Carolina. His last PhD student, Dr. Chiemi Tanaka is a post-doc at Oregon Health Sciences University Hearing loss is a major problem for the armed forces and Don was responsible for training and mentoring 4 PhD audiologists who returned to military duty after completing their academic training. Don&rsquo;s intellectual and scientific achievements will continue to influence our understanding of hearing loss acquired from noise, aging and ototoxic drugs for many years and many of his former students will continue the scholarly work that Don started more than 45 years ago.</p>\r\n<p>Ask him about the latest novels or economic, political, sports and social events and Don will immediately offer an &ldquo;earful&rdquo; of thoughtful, provocative and engaging commentary about the world around us. His quick wit, smile and active mind will immediately capture your interest and imagination. Don and his wife, Terri, love to travel, enjoy meeting new people, tasting new cuisines, exploring big cities, small towns and the natural environment. Don and Terri have traveled over most of North America and Europe and in addition, they have visited many parts of Asia, South America and the Far East. The other day, I thought I overheard him discussing the purchase of the Maid of the Mist to take family and friends on a trip around the world. Bon voyage, Don! We&rsquo;ll miss seeing you in the lab, but please stop by from time to time to tell us about your adventures. I see smooth sailing ahead.</p>\r\n<p>By Dalian Ding, MS, Jingchun He, Dongzhen yu, Haiyan Jiang, yongqi Li, Richard Salvi, PhD</p>\r\n<p>Dalian Ding (left) is with the Center for Hearing and Deafness, University at Buffalo, Buffalo, NY, USA; the Department of Otorhinolaryngology, Shanghai Sixth Hospital, China; the Department of Otorhinolaryngology, Third Hospital, Sun Yat-sen University, China; and the 4Department of Otorhinolaryngology, Xiangya Hospital of Central South University, China. Jingchun He and Dongzhen Yu are with the Department of Otorhinolaryngology, Shanghai Sixth Hospital, China. Haiyan Jiang and Richard Salvi are with the Center for Hearing and Deafness, University at Buffalo, Buffalo, NY, USA. Yongqi Li is with the Department of Otorhinolaryngology, Third Hospital, Sun Yat-sen University, China.</p>\r\n<p><strong>Ototoxicity</strong></p>\r\n<p>Cisplatin and other platinum-based compound are widely used to treat a variety of solid and disseminated forms of cancer. Although cisplatin and related platinum compounds are highly effective anti-tumor agents, their clinical usage is limited by a number of serious side effects. Among these side effects, ototoxicity, neurotoxicity, and nephrotoxicity are the most common.1&ndash;4 While ototoxicity is not life threatening, it can result in severe hearing impairment that can significantly degrade an individual&rsquo;s ability to communicate resulting in social isolation. Cisplatin ototoxicity can be particularly devastating when it occurs in young children because it can impair language development and social development. CisPLatin MeChanisMs The long-term goal of administering anticancer drugs such as cisplatin is to block the uncontrolled proliferation and growth of cells that from malignant tumours. When cisplatin enters the cytoplasm of a cell, chloride ions bound to cisplatin are displaced by water molecules; the aquated cisplatin becomes a potent electrophile that forms intraand interstrand cross links with DNA thereby preventing malignant cells from proliferating further. In addition, cisplatin binds with intracellular glutathione to form a toxic cisplatin-glutathione complex that can kill a malignant or healthy cell.5 In order for either of these reactions to take place, cisplatin must first be transported from the blood stream into a malignant or healthy cell. How does cisplatin enter a cell and where does it go after it enters?</p>\r\n<p><strong>CisPLatin and CoPPer transPorter</strong></p>\r\n<p>Copper is essential for life; consequently, cells have developed specialized transport mechanisms to control its uptake, export and compartmentalization. Ctr1, ATP7A, and ATP7B are three copper transporters that play prominent roles in regulating intracellular copper; however they were also recently shown to regulate the movement of cisplatin into and out of cells. Ctr1, located in the cell&rsquo;s membrane, is mainly responsible for transporting copper and cisplatin from the extracellular environment into the cytoplasm.6 ATP7A and ATP7B are mainly responsible for sequestering intracellular copper into secretory vesicles in order to export copper out the cells.7 Importantly, Ctr1, ATP7A and ATP7B were detected by in great abundance within the organ of Corti, stria vascularis and spiral ganglion neurons of the cochlea using immunocytochemistry4,8 and likely play an important role in uptake of cisplatin into the hair cells and spiral ganglion neurons.</p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-1-1-g0010.png\" alt=\"image\" /></p>\r\n<p><strong>CisPLatin dose-resPonse</strong></p>\r\n<p>We used organ cultures of the postnatal rat cochlea to study cisplatin ototoxicity in a precise and high controlled. We first determined the relationship between a wide-range of cisplatin concentrations and hair cell loss and obtained very surprising and unexpected results. Consistent with earlier studies, we found that low doses of cisplatin (10&ndash;50 &micro;M) produced considerable hair cell damage (Figure 1B and C), but surprisingly hair cell loss began to decrease at higher concentration and little damage was observed at 400 or 1000 &micro;M (Figure 1 D&ndash;F). Thus, cisplatin is highly toxic to hair cells at low concentrations, but hair cells become resistant to the drug at high concentration.</p>\r\n<p><strong>CisPLatin uPtaKe</strong></p>\r\n<p>To determine if the decreased toxicity at high concentration was due to decreased cisplatin uptake, we labelled cisplatin with Alexa Fluor 488 to track its uptake into hair cells.4,8 At low cisplatin concentration, a large amount of cisplatin was observed in damaged outer hair cells (Figure 2A); however, at high concentrations, little cisplatin uptake was observed in normal looking outer and inner hair cells (Figure 2B). Western blots were used to quantify the presence of Ctr1, ATP7A and ATP7B proteins in normal and cisplatin treated cochlear cultures. Ctr1, which regulates the uptake of cisplatin, was relatively unchanged following treatment with cisplatin. However, ATP7B, which mediates the efflux of cisplatin increased significantly.4,8 These results suggest that cochlear hair cells dynamically upregulate the expression of ATP7B in order to extrude excess cisplatin and protect against cisplatin damage.</p>\r\n<p><strong>ExtraCeLLuLar</strong></p>\r\n<p>CoPPer inhiBits CisPLatin daMage The uptake of cisplatin through Ctr1 can be competitively inhibited by extracellular copper9 and therefore should protect hair cells from cisplatin damage. To test this hypothesis, cochlear cultures were treated with cisplatin (10 &micro;M) alone or cisplatin plus copper sulfate (10, 50 or 100 &micro;M). Cisplatin induced hair cell loss was completely prevented by the addition of copper sulfate.10&ndash;12 However, copper sulfate failed to prevent hair cell loss when the cisplatin dose was increase to 50 &micro;M. Thus, the protective effect of copper sulfate in vitro is only protective at low cisplatin concentrations. Additional studies with Western blots showed that the expression of Ctr1 was greatly reduced by copper sulfate, while the expression of ATP7B was significantly increased. These results suggest that the protective effect of copper sulfate may arise from decreased influx and increased efflux of cisplatin.</p>\r\n<p><strong>CoPPer suLfate PreVents ototoxiCitY in ChinChiLLas</strong></p>\r\n<p>Carboplatin, a less ototoxic derivative of cisplatin, preferentially damages inner hair cells (IHC) in chinchillas.13 To determine if extracellular copper can protect cochlea against carboplatininduced hair cell loss in vivo, we applied 50 &micro;L of copper sulfate (100 &micro;M) on the right round window membrane of the chinchilla cochlea; 50 &micro;l of saline was applied to the left round window membrane. Immediately afterwards, 50 mg/kg (i.p.) of carboplatin was administered to the chinchillas. Ten day after carboplatin treatment, the left and right cochleas were evaluated to determine the degree of hair cell loss. As shown in Figure 3, IHC loss was greatly reduced in the copper sulfate treated cochleae (Figure 3B) compared to saline treated cochleae (Figure 3A). These results indicate that local application of copper sulfate on round window provides significant protection against carboplatin-induced IHC loss presumably by reducing the influx of carboplatin into the hair cells.</p>\r\n<p><strong>Summary</strong></p>\r\n<p>Many strategies have been considered to prevent the cisplatin ototoxicity. Some strategies involving the use of antioxidants have been shown to provide some protection after cisplatin enters the inner ear and begins to induce damage. The new strategy adopted here provides protection by suppressing the uptake of cisplatin into the hair cells and support cells. Local application drugs to block the uptake of cisplatin or enhance its extrusion from hair cells represent a novel approach to preventing ototoxicity.</p>\r\n<p><strong>Acknowledgements</strong></p>\r\n<p>Supported in part by NIH grants R01DC006630, and in part by the Project-sponsored by SRF for ROCS, SEM.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. Boogerd W, ten Bokkel Huinink WW, Dalesio O, Hoppenbrouwers WJ, van der Sande JJ. Cisplatin induced neuropathy: central, peripheral and autonomic nerve involvement. J Neurooncol 1990;9:255&ndash;63.</p>\r\n<p>2. Cavaletti G, Bogliun G, Marzorati L, et al. Long-term peripheral neurotoxicity of cisplatin in patients with successfully treated epithelial ovarian cancer. Anticancer Res 1994;14:1287&ndash;92.</p>\r\n<p>3. Laurell G, Engstrom B. The ototoxic effect of cisplatin on guinea pigs in relation to dosage. Hear Res 1989;38:27&ndash;33.</p>\r\n<p>4. Ding D, He J, Allman BL, et al. Cisplatin ototoxicity in rat cochlear organotypic cultures. Hear Res 2011;282:196&ndash;203.</p>\r\n<p>5. Hanigan MH, Lykissa ED, Townsend DM, Ou CN, Barrios R, Lieberman MW. Gamma-glutamyl transpeptidase-deficient mice are resistant to the nephrotoxic effects of cisplatin. Am J Pathol 2001;159:1889&ndash;94.</p>\r\n<p>6. Howell SB, Safaei R, Larson CA, Sailor MJ. Copper transporters and the cellular pharmacology of the platinum-containing cancer drugs. Mol Pharmacol 2010;77:887&ndash;94.</p>\r\n<p>7. Safaei R, Otani S, Larson BJ, Rasmussen ML, Howell SB. Transport of cisplatin by the copper efflux transporter ATP7B. Mol Pharmacol 2008;73:461&ndash;8.</p>\r\n<p>8. Ding D, Allman A, Yin S, Sun H, Salvi RJ. Cisplatin ototoxicity Nova Science Publishers, Inc 2011;Chapter 2:39&ndash;63.</p>\r\n<p>9. Ishida S, Lee J, Thiele DJ, Herskowitz I. Uptake of the anticancer drug cisplatin mediated by the copper transporter Ctr1 in yeast and mammals. Proc Natl Acad Sci U S A 2002;99:14298&ndash;302.</p>\r\n<p>10. Ding D, Qi W, Zhang M, Wang P, Jiang H, Salvi R. Cisplatin and its ototoxicity. Chinese Journal of Otology 2008;6:125&ndash;33.</p>\r\n<p>11. Ding D, Roth J, Salvi R. Manganese is toxic to spiral ganglion neurons and hair cells in vitro. Neurotoxicology 2011;32:233&ndash;41.</p>\r\n<p>12. He J, Ding D, Yu D, Jiang H, Yin S, Salvi R. Modulation of copper transporters in protection against cisplatin-induced cochlear hair cell damage. Journal of Otology 2011;6:53&ndash;61.</p>\r\n<p>13. Ding DL, Wang J, Salvi R, et al. Selective loss of inner hair cells and type-I ganglion neurons in carboplatin-treated chinchillas. Mechanisms of damage and protection. Ann N Y Acad Sci 1999;884:152&ndash;70.</p>\r\n<p>By Eric C. Bielefeld, PhD bielefeld.6@osu.edu</p>\r\n<p>Eric C. Bielefeld, PhD, is with the Department of Speech and Hearing Science, The Ohio State University, Columbus, OH.</p>\r\n<p>Noise-induced hearing loss (NIHL) continues to be a significant public health problem for industrialized populations.1 Currently, prevention of NIHL primarily involves hearing conservation programs built around modifications of the noise source, use of hearing protection devices, and education and counselling on noise and the consequences of hearing loss over the life span.2,3 Noise standards typically rely on noise exposure measurements to dictate who needs enrolment into a hearing conservation program. Yet the problem remains that even the most conservative standards do not effectively account for all acoustic factors that dictate the potential ototoxicity of noise, and leave a significant percentage of workers vulnerable to hearing loss. Therefore, there exists a need to detect those workers who are experiencing NIHL as early as possible. Many current noise standards define NIHL as a minimum of 10 dB of threshold shift at one or multiple frequencies. The current work was undertaken with the belief that 10 dB or more threshold shift is already too much to allow for the large noiseexposed population, and that even that mild threshold shift has the potential to lead to more severe cochlear degradation over time.4&ndash;6 Early detection of damage, prior to the accumulation of enough cochlear damage to cause significant threshold shift, would be a powerful tool to minimize the incidence of clinicallysignificant NIHL.</p>\r\n<p>The current studies in the Auditory Physiology Lab at The Ohio State University were undertaken as an extension of work performed by Oxenham and Plack7 who studied behavioural measures of cochlear compression using forward masking (FWM) growth of masking (GoM) functions. FWM occurs when the masker sound is presented prior to the probe sound, with a silent gap separating the masker and probe. GoM functions chart the masker threshold, the minimum masker level required to mask out the probe, as a function of the probe level. In Oxenahm and Plack,7 for normal-hearing listeners, in conditions in which the probe and masker frequencies were the same (the onfrequency condition), the GoM function was linear. For example, the masker threshold for a 50 dB SPL 6 kHz sound was 50 dB SPL when the masker was also a 6 kHz sound. When the probe level was increased to 60 dB SPL, the masker threshold increased to 60 dB SPL. But when the masker was one octave below the probe (the offfrequency condition), the GoM function of was highly compressive. In the offfrequency condition, a high masker level was required to mask even lowerintensity probe levels. For example, the 50 dB SPL 6 kHz sound required an 80 or 85 dB SPL masker threshold when the masker was a 3 kHz sound. This compressive non-linear off-frequency GoM function changed significantly in the study participants with sensorineural hearing losses. In those participants, the off-frequency GoM was linear, and closely mirrored the on-frequency condition. The results indicated that the linear off-frequency FWM GoM function reflected a loss of cochlear compression in the participants with sensorineural hearing loss.7 Since the non-linear nature of the off-frequency FWM GoM functions is attributable to active processing from the outer hair cells, the FWM GoM functions are expected to be sensitive to noise-induced cochlear damage. The current study investigated</p>\r\n<p>changes in FWM GoM functions using on-frequency and off-frequency maskers of 7 and 10 kHz probes in the SpragueDawley rat. An animal model was used because a test for early detection of NIHL requires presentation of a noise that will reliably produce a slow, gradual hearing loss, and that animal model allows for cochlear analyses to confirm the extent of damage induced by the noise exposure.</p>\r\n<p>For the initial study, 11 Sprague-Dawley rats&rsquo; auditory brainstem responses (ABRs) from probe stimuli of 7 and 10 kHz were recorded with and without forward maskers to create FWM GoM functions. The off-frequency forward maskers were one octave below the 7 and 10 kHz probes. The masker threshold was defined as the masker level required to reduce the initial positive wave of the rat&rsquo;s ABR to 50% or less of the unmasked waveform. The rats were then exposed to a hazardous noise (a 5&ndash;10 kHz octave band noise at 110 dB SPL combined with 120 dB pSPL impacts presented at a rate of 1/second with a total duration of 120 minutes) that induced permanent threshold shift. After the noise exposures, the FWM GoM functions were measured to assess noise-induced changes in the FWM GoM functions. Pre-exposure FWM GoM functions showed compressive non-linear functions in the off-frequency conditions, and linear functions in the on-frequency conditions for both the 7 kHz and 10 kHz probes. The hazardous noise induced a 30&ndash;40 dB permanent threshold shift in the 5&ndash;20 kHz frequency range. The NIHL rendered the offfrequency FWM GoM functions more linear, and made them statistically indistinguishable from the linear onfrequency conditions, which changed little from pre to post noise exposure. The findings from this initial study demonstrate that FWM GoM functions of the rat ABR behave in a pattern consistent with human behavioural work in both the normal condition prior to any noise exposure, and after cochlear damage from noise. The off-frequency FWM GoM functions displayed compressive non-linearity in the normalhearing animals, and then appeared linear after significant NIHL that is assumed to have created a large lesion of damage/dead outer hair cells (please see review by Henderson et al.,8 on noiseinduced outer hair cell damage). The results serve to validate ABR FWM patterns as potential research tools for detecting acquired changes in the cochlea, which was important because FWM GoM functions had never been tested in an eletrophysiologic ABR paradigm in an animal model before. Currently, ongoing studies are aimed at determining the most stable and sensitive dependent variable for detecting changes in the ABR. The study reported currently utilized the point of 50% reduction in amplitude as the dependent variable, but initial findings suggest that latency shifts might be more stable and sensitive indicators of cochlear damage than amplitude changes. The other ongoing phase of the study is using a long-term noise at a level that will gradually induce cochlear damage. The rats in this study are being exposed to the combined 5&ndash;10 kHz octave band continuous noise with the high-level impacts, but the level had been reduced from 110/120 dB SPL to 96/106 dB SPL. The rats are being exposed to that noise for 4 hours per day, 4 days per week (Tuesday through Friday). They then recover on Saturday and Sunday and are tested on Monday. The off-frequency FWM GoM functions are measured weekly to determine if changes in the FWM functions precede significant changes in threshold. If they  do, and if the FWM changes correlate with underlying cochlear pathology, then the test may be a useful measure for detecting early NIHL.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. Rabinowitz P. The public health significance of noise-induced hearing loss. In: Le Prell CG, Henderson D, Fay RR, and Popper AN. (Eds). Springer Handbook of Auditory Research: Noise-Induced Hearing Loss: Scientific Advances. Vol. 40. New York: Springer Science and Business Media; 2011.</p>\r\n<p>2. Dobie RA. Prevention of noiseinduced hearing loss. Arch Otolaryngol Head Neck Surg 1995;121(4):385&ndash;91.</p>\r\n<p>3. Lusk SL. Noise exposures: Effects on hearing and prevention of noise induced hearing loss. AAOHN Journal 1997;45(8):397&ndash;405.</p>\r\n<p>4. Kujawa SG and Liberman MC. Acceleration of age-related hearing loss by early noise exposure: evidence of a misspent youth. J Neuroscience 2006:26(7):2115&ndash;23.</p>\r\n<p>5. Kujawa SG and Liberman MC. Adding insult to injury: cochlear nerve degeneration after &ldquo;temporary&rdquo; noise-induced hearing loss. J Neuroscience 2009;29(45):14077&ndash;85.</p>\r\n<p>6. Bielefeld EC. Re-thinking noiseinduced and age-related hearing losses. Aging Clin Exper Res 2011;23:1&ndash;2.</p>\r\n<p>7. Oxenham AJ and Plack CJ. A behavioral measure of basilarmembrane nonlinearity in listeners with normal and impaired hearing. JASA 2009;101(6):3666&ndash;75.</p>\r\n<p>8. Henderson D, Bielefeld EC, Harris KC, Hu BH. The role of oxidative stress in noise-induced hearing loss. Ear Hear 2006;27(1):1&ndash;19.</p>\r\n<p>By Donald Coling, PhD</p>\r\n<p>Don Coling is a research associate professor, Center for Hearing and Deafness, Department of Communicative Disorders and Sciences, University at Buffalo, the State University of New York.</p>\r\n<p>My essay is written for audiologists and dedicated to my audiology teacher, my colleague, and my friend, Donald Henderson. It was presented as an oral seminar on April 20, 2012 in Buffalo at the Donald Henderson NoiseInduced Hearing Loss Colloquium in honor of Dr. Henderson&rsquo;s retirement from the Center for State University of New York at Buffalo. Although the essay focuses on damage to proteins, we would be remiss not to briefly mention the importance of oxidative damage to lipids and DNA. We can&rsquo;t escape the influence of molecular biology and chemistry on our lives. We don&rsquo;t have to understand the chemistry in detail, but, we&rsquo;ve reached a time when we have already begun to treat hearing disorders with chemistry. As hearing professionals, it behooves us to be aware of a few basic ideas in auditory biochemistry. I&rsquo;ve tried to present them in a painless and easy-to-read manner that should help give some perspectives in the practice of modern audiology</p>\r\n<p><strong>Sources of oxidatiVe MetaBoLites</strong></p>\r\n<p>Radiation, toxic chemicals, and hyperactivity, can induce oxidative stress characterized by the production or accumulation of reactive oxygen species (ROS). ROS is the name given to oxygen containing molecules that have a particularly high chemical reactivity. The most frequently studied ROS are superoxide and nitric oxide. Superoxide is produced when oxygen gains an electron from cellular enzymes in mitochondria, peroxisomes, nuclei and cytoplasm. Nitric oxide is produced when nitrogen is removed from the amino acid arginine in the cytoplasm by nitric oxide synthases. ROS are used at low levels as physiological signalling molecules before being degraded by antioxidant enzymes. ROS are effective signalling molecules because their reactive electron structure and short lifetime allows them to quickly combine with nearby cellular proteins, change the protein&rsquo;s surface charge and shape, and thereby change its function by affecting the strength of interactions with other proteins that depends on surface charge and shape. If the level of ROS is low, cells can rapidly degrade the signal and activate an antioxidant response in preparation for higher levels of ROS &ndash; a state of preparedness. However, if the level of oxidative metabolites is too high, ROS can combine with each other and with other molecules to form a variety of metabolites, giving rise to irreversible oxidative damage to proteins, lipids, and nucleic acids.</p>\r\n<p>The title of this essay, the &ldquo;Biology of Oxidative Stress,&rdquo; is an enormous topic that has produced over 200,000 research articles indexed by the National Library of Medicine over the last 60+ years. This article will focus on only one aspect in this large arena and that is oxidative damage to proteins in the cochlea. We are particularly interested in damage to outer hair cells because they are typically the most vulnerable to environmental insults to the inner ear.</p>\r\n<p><strong>Ros and hearing Loss</strong></p>\r\n<p>Several lines of evidence have underscored the importance of ROS in cochlear pathologies. Purturbations that generate hearing loss include ionizing radiation and heat, toxic chemicals, hyperactivity from noise and loud music, and aging. Each of these perturbants is known to induce oxidative damage. ROS have been detected at early time points after cochlear damage.1,2 and have been shown to induce direct pathological effects on outer hair cell morphology.3,4 Endogenous cochlear antioxidant enzymes are induced by noise exposure.5 The transcription factor Nrf2 which regulates antioxidant enzyme gene induction has been linked to cisplatin ototoxicity6 and to age-related hearing loss and gentamycin ototoxicity.7 Finally, several studies have shown that supplemental doses of small molecule antioxidants and compounds that mimic antioxidant enzymes can protect from hearing loss induced by ototoxic drugs,8&ndash;14 hypoxia-reperfusion,15 and noise.16&ndash;20 This list is not exhaustive, but accompanies some of the ground breaking manuscripts. Several excellent reviews have been published that give a more comprehensive assessment of the role of ROS in hearing loss.</p>\r\n<p><strong>MetaBoLites and sMaLL MoLeCuLes in redox iMBaLanCe</strong></p>\r\n<p>Small molecules can contribute to both oxidative stress and redox homeostasis. The best example is glutathione, the most abundant cellular antioxidant. Glutathione is like a mini-protein. It contains three amino acids, the building block of proteins and is used as a reducing agent. That means it can donate an electron in reactions to reduce oxidizing agents. In doing so, glutathione itself becomes oxidized. So in a redox reaction, a reducing agent becomes oxidized and an oxidizing agent becomes reduced. The protective effect comes from the fact that cells can tolerate oxidized glutathione better than oxidizing agents. For example, hydrogen peroxide, a metabolite of superoxide, can be detoxified by the enzyme glutathione peroxidase. In the reaction, the oxidizing agent, hydrogen peroxide, is converted to water and oxygen while two molecules of the reducing agent, glutatione are joined to form oxidized glutathione. Glutathione reductase then restores the cell to its normal state by reducing oxidized glutathione. If the peroxide is not detoxified it can metabolize noncatalytically to more harmful oxidizing agents and do irreversible damage by reacting with proteins, DNA and lipids. So glutathione peroxidase is just one example of detoxifying enzymes that borrow an electron from glutathione to lower the reactivity of ROS. In addition to glutathione, there are a variety of other small molecules that affect redox balance. These involve dietary intake of vitamins, glucose, fatty acids, lipoproteins, and heavy metals.29 The chemistry is complicated, but the take home message is clear. Eat plenty of glutathione. You can get lots of it in broccoli and asparagus. Get lots of vitamins. These are small molecule electron and proton carriers needed by our enzymes that our bodies can&rsquo;t make. But plants can, so eat lots of vegetables. You&rsquo;ll have better hearing when you&rsquo;re old. Share this chemistry lesson with your patients &ndash; young and old.</p>\r\n<p><strong>LiPid oxidation</strong></p>\r\n<p>If the cellular redox state is upset such that antioxidant defense enzymes like glutathione peroxide and small antioxidants like glutathione and vitamins E and A are unable to detoxify ROS fast enough, then macromolecules become damaged. One consequence is lipid oxidation. Lipids are the molecules used to build membranes. Cells may be thought of as little chemical plants each with its own specialized chemistry. The chemistry within cells is water-loving or hydrophilic meaning that it occurs in the aqueous cytoplasm or on membranes facing an aqueous environment. Specialized chemistries are separated by barriers made of hydrophobic lipid molecules that form the plasma membrane around cells and intracellular compartments within cells. These lipid membranes are like the outside and inside walls of our homes. When the lipids get oxidized, the membranes leak and the specialized chemistries in separate compartments get mixed together. A small leak can be repaired. A massive leak will signal cell death. Those with some background in cell biology are referred to.30&ndash;32 A little dose of redox chemistry practiced at the dinner table can help audiologists and their patients here too. dna daMage froM oxidatiVe stress DNA damage oxidative stress has very serious consequences. Thousands of DNA modifications from oxidative damage occur in every cell daily and lead to mutations, epigenetic and oncogenic reprogramming and programmed cell death. A good example is damage to skin cells from ultraviolet radiation leading to melanomas. While cochlear outer hair cells can not be damaged by sun exposure, they have an exceptionally high metabolic rate are subject to enhanced vulnerability from noise exposure and exposure to a variety of ototoxic drugs. As we get older, we&rsquo;ve found that the neurons of the cochlear spiral ganglion are particularly susceptible to oxidative deletion of DNA within their mitochondria.33 Of particular importance to hearing is the ototoxic side effect of the cancer drug cisplatin. Treatment of many cancers depends on the ability of cisplatin to generate ROS and on its ability to form DNA adducts. Cisplatin-DNA adducts signal DNA repair in most cells of the body. High doses of cisplatin, however, can overwhelm DNA repair mechanisms resulting in the initiation of programmed cell death. This mechanism evolved to  protect organisms from retaining cells with damaged DNA. It is exploited in treatment of tumours with cisplatin at the expense of negative side effect in particularly vulnerable cells like kidney tubule cells and cochlear outer hair cells.14,26,27 Since cochlear hair cells cannot regenerate from basal precursors like olfactory receptors, DNA damage repair mechanisms are particularly important to cochlear function. Recently attempts have begun to employ agents to prevent DNA damage as otoprotectants.</p>\r\n<p><strong>reVersiBLe Protein oxidation and CoChLear funCtion</strong></p>\r\n<p>To date, there is very little direct evidence for the physiological role of protein oxidation in normal cochlear function. However, evidence for the presence of reversible protein oxidation in the cochlea suggests that protein oxidation will no doubt play important physiological roles in redox signalling and pathological roles from oxidative damage. Two types of oxidative processes that occur in every cell under normal physiological conditions are disulfide formation and S-nitrosylation. Interestingly, both involve the amino acid cysteine found in glutathione. As in glutathione, the sulfhydryl groups of cysteine found in proteins can also oxidize to from a disulfide &ndash;S-S- linkage between proteins or between two cysteines on a single protein. The linkage formed causes proteins to maintain a given shape until the disulfide bond is reduced. You can imagine it to be like a pair of handcuffs. With this analogy, you can imagine an enzyme whose hands are tied might no longer be able to do the same activities as in the reduced state when the cuffs are removed. Nitrosylation also involves a modification of the amino acid cysteine where nitrogen and oxygen from nitric oxide are covalently joined to the SH group to form an S-ntrosothiol (SNO). This can happen to cysteines in small tripeptides like glutathione or polypeptides (proteins). Nitrosylation can be used in signalling to alter enzyme or ion channel activity and may serve as a means of delayed release of nitric oxide. Besides modification of the amino acide cysteine, dissulfide formation and nitrosylation share one other important aspect. They can be enzymatically reversed. That means the functional changes they induce in proteins can be reversed and cell function can return to the initial state of reducing conditions. Like other aspects of cell signalling, high levels of oxidative stress can overwhelm cells. Thus, dysregulation of disulfide formation and nitrosylation has been associated with stroke, Parkinson&rsquo;s and Alzheimer&rsquo;s diseases, amyotrophic lateral sclerosis and cancer. Though both are undoubtedly important to hearing function, evidence supporting a connection is just beginning to emerge.</p>\r\n<p>A recent publication suggests that S-nitrosylation may also be important in cisplatin ototoxicity. Cisplatin was found to induce elevations in the levels of S-nitrosylation in certain cochlear proteins and reduced levels in others.35 Ongoing research is aimed at identifying these proteins and discerning their role in hearing. Glutathionylation of cochlear proteins is elevated in the aging cochlea.36 Glutathionylation, the covalent attachment of glutathione to protein sulfhydrils is an emerging field in protein regulation and numerous labs have reported crosstalk between nitrosylation and glutationylation.37 Glucose regulated protein 58 (Grp58) is a stress-induced38 endoplasmic reticulum protein39 whose cochlear expression was altered by cisplatin.40 Pdia3 is important  in the formation of dissulfide bonds41 and in protection from prion-induced apoptosis.42 The enzyme can be phosphorylated by src family kinases43 and src inhibitors have been show to protect the cochlea from hearing loss induced by noise44 and cisplatin.45 The alteration in Pdia3 cochlear expression40 is consistent with protein phosphorylation, thus it is of great interest to determine whether Pdia3 phosphorylation is inhibited by src kinase inhibitors.</p>\r\n<p><strong>OxidatiVe daMage to Proteins &ndash; irreVersiBLe oxidation of CoChLear</strong></p>\r\n<p>Proteins Pathological damage to proteins occurs when modified proteins cannot be repaired or efficiently removed by proteolysis and replaced by protein synthesis. Oxidized proteins are recognized by cellular proteolytic machinery, but, in some cases, oxidized proteins can accumulate and even inhibit the proteolysis of other damaged proteins.46 In addition to modifying amino acid constituents of proteins, oxidation can lead to dysfunction through protein cleavage and by pathological cross linking. The chemistry of protein oxidation is diverse and reviewed in detail elsewhere.45&ndash;47 What every audiologist will want to know is found right here. Irreversible protein oxidation includes cleavage, crosslinking, carbonylation, oxidized lipid-protein adduct formatin and nitration. The first three processes, though common, have simply not been studied in the cochlea. The fourth has been reported describing 50-60 kDa 4- hydroxynonenal-protein adduct in mouse cochlea following noise exposure.48 The fifth, nitration, is the process by which the amino acid tyrosine is irreversibly modified by ROS- mediated addition of a nitro group. Modification of proteins by nitration can be benign with no effect on function. Alternatively, protein tyrosine nitration can lead to either gain or loss of function. Unlike nitrosylation of cysteine, nitration is irreversible and often taken as a marker of oxidative damage. The presence of nitrated proteins in the cochlea was first reported by immunocytochemistry using antibodies against nitrotyrosine in lipopolysaccharideinduced damage to guinea pig cochlea49 and has been used as a marker of cochlear oxidative damage in several subsequent studies.36,48,50&ndash;64 The major nitrated protein of cochlea was first reported to be a 76 kDa protein whose nitration was induced by cisplatin.65 This protein has recently been identified as Lmo466 a transcriptional regulator associated with neuronal survival.67 Ongoing research will determine the mechanism by which Lmo4 contributes to survival of outer hair cells and by which nitration of Lmo4 contributes to outer hair cell loss. Future studies will determine whether Lmo4 is critical to the survival other cochlear cells and whether Lmo4 nitration is an important factor in the pathology of other tissues. Lmo4 is likely one of several key outer hair cell proteins damaged by oxidative stress. Investigations of stress-induced carbonylation, glutathionylation and proteolysis will identify other damaged proteins and help piece together the puzzles of the initiation of cochlear pathologies. drug disCoVerY for noVeL treatMents of oxidatiVe daMage to the CoChLea We have already mentioned some of the pioneering work with antioxidant intervention to treat hearing loss. Donald Henderson, the person we honour in this issue, has pioneered a novel treatment for hearing loss. The Henderson Lab has shown that inhibitors of the protein kinase src can provide protection from noise induced hearing loss44,68&ndash;70 and hearing loss from the cancer drug cisplatin.45 Src regulation by phosphorylation is well characterized, but src is also known to be activated in states of elevated oxidation by the formation of dissulfide bonds between catalytic and regulatory domains.71&ndash;73 When activated in lung endothelial cells, src phosphorylation of the regulatory p47phox subunit of NADPH oxidase signal translocation to the plasma membrane and elevated production of superoxide by NADPH oxidase.74 This can represent a type of feed forward amplification where small increases in ROS can avalanche into even high levels of oxidative stress. The situation can be amplified further at the transcriptional level. For example, cisplatin leads to the induction of Nox3, an NADPH oxidase that is highly expressed in the cochlea.75,76 henderson LaBoratorY ContriButions to oxidatiVe stress and hearing The person we honoured in Buffalo has not ignored these issues by any means. Don Henderson has contributed to hearing research with 5 manuscripts on toxic chemicals, 16 on aging, and 96 on noise-induced hearing loss. He is well known for the books and special journal issues that resulted from the symposia on noise-induced hearing loss that he organized with Roger Hamernik, Richard Salvi and a host of others,77&ndash;85 books related to hearing,86&ndash;88 and over 40 book chapters. Although his background is in physiological psychology, with Bo Hua Hu, Henderson contributed one of the earliest papers on apoptosis in noiseinduced hearing loss which pointed to the importance of programmed cell death in outer hair cell pathology.89 In another pioneering paper, he and Dr. Hu explored the role of mitochondria in programmed cell death.90 Henderson made many contributions that outlined the importance of the induction of antioxidant enzymes by noise5,24,91 and by aging.92,93 Over the latter part of his career Henderson made significant strides in developing therapeutic strategies for treating hearing loss induced by noise and drugs.44,45,68&ndash; 70,82,83,94&ndash;103 Among his most recent efforts has been the discovery and development of otoprotection using inhibitors of the src kinase family.45,68&ndash;70 We are indebted to Donald Henderson for these and many other contributions to hearing research.</p>\r\n<p><strong>References</strong></p>\r\n<p>Please go to http://andrewjohnpublishing.com/documents/CollingReferences forCHR.pdf for a complete list of references for this article.</p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-1-1-g0011.png\" alt=\"image\" /></p>\r\n<p>By Guang-Di Chen, PhD</p>\r\n<p>Guang-Di Chen, PhD, is with the Center for Hearing and Deafness, The State University of New York at Buffalo.</p>\r\n<p>I ntense noise and numerous ototoxic agents may target and damage cochlear hair cells leading to hearing loss. Auditory hair cells in mammals, including humans, cannot be regenerated; thus, hearing loss due to hair cell death may never be restored. We have found that many auditory hair cells may still survive in the cochlea under severe hearing loss. If a certain number of dysfunctional auditory hair cells survive in the cochlea, treatment of hearing loss may become possible in the future. Therefore, it is important to know the relationship between hearing loss and hair cell loss under different circumstances. This report presents data showing surviving hair cells in the cochlea of rats exposed to intense noise and styrene, an industrial solvent.</p>\r\n<p><strong>Methods</strong></p>\r\n<p>The first group of rats (n = 61) were exposed to an intense noise (10&ndash;20 kHz, 100&ndash;115 dB SPL) for 2&ndash;4 hours in a chamber with normal oxygen level (21%) or lower oxygen supply (18% and 10%) or higher carbon monoxide (CO) concentration (up to 0.15%). The second group of rats (n = 50) were exposed to styrene by oral gavage (0&ndash;800 mg/kg once per day for 5 days per week for 3&ndash;24 weeks). Hearing loss was assessed 4 weeks after exposure by measuring threshold shift of cochlear compound action potential (CAP) as described in our previous reports.1,2 Hair cells were stained and counted as described in our previous reports.</p>\r\n<p><strong>Results and Discussion</strong></p>\r\n<p>Hearing Loss Induced By Intense Noise or Combination of Noise and Hypoxia/CO Intense noise may cause a complete loss of cochlear amplification, which leads to a CAP threshold shift of about 40 dB, without hair cell loss. Figure 1A presents an example showing a linear CAP input/output function at 12 kHz (i.e. 1 dB decrease of stimulation causes 1 dB of reduction of CAP amplitude) obtained in a rat at post-4-week of noise exposure (see red filled circles). In normal cochlea, reduction of CAP is smaller than the decrease of stimulation (open circles) indicating that the response in the normal cochlea is amplified. Since outer hair cells (OHCs) are known to contribute to the cochlear amplification, the loss of cochlear amplification after noise exposure should indicate damage of OHCs. However, all OHCs in the corresponding region in the cochlea look intact (see Figure 1B). Our data from 61 noise-exposed rats revealed that (1) in the apical and middle turns there was no significant hair cell loss until a hearing loss of 40&ndash;50 dB was reached; (2) in the basal turn (75&ndash;100% from the apex or &gt;30 kHz), OHC loss increased monotonically with hearing loss. The surviving OHCs must be dysfunctional. Restoration of the dysfunctional OHCs may open an avenue to hearing rescue at least in patients with noise trauma.</p>\r\n<p>Hearing Loss Induced By Styrene Styrene is extensively used in industry. Ototoxicity of styrene in workplace is still examined by pure tone audiometry. However, we have found that this kind of ototoxic agents may cause a certain level of cochlear damage with little or no effect on hearing threshold. In other words, styrene exposure which has been accepted as a safe level may already be ototoxic. Figure 2 presents an example showing a severe styrene-induced OHC loss (A) with no reduction of CAP amplitude at the corresponding frequency (B). The rat was exposed to styrene at a level of 400 mg/kg per day for 5 days per week for 3 weeks. Almost all OHCs in the third row in the middle turn were missing (marked by &ldquo;3&rdquo; in Figure 2A), but CAP input/output functions (see purple filled circles in Figure 2B) at the corresponding frequencies were similar to the control (open circles) indicating a normal cochlear amplification with only 2 rows of OHCs remained. Our data from 50 styrene-exposed rats showed that: (1) loss of OHCs in the third row resulted in little or no hearing loss; (2) further loss of OHCs in the second row caused an OHC-loss dependent hearing loss; (3) after loss of OHCs in the third and second rows, cochlear amplification was completely gone leading to a maximal hearing loss of 40 dB. Different from noise-induced hearing loss, hearing loss caused by styrene or other industrial solvents may never be restored.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. Chen GD, McWilliams M and Fechter LD. Succinate dehydrogenase (SDH) activity in hair cells: A correlate for permanent threshold elevations. Hearing Research 2000;145:91&ndash;100.</p>\r\n<p>2. Chen GD, Fechter LD. The relationship between noise-induced hearing loss and hair cell loss in rats. Hearing Research 2003;177:81&ndash;90.</p>\r\n<p>3. Chen GD, Tanaka C, Henderson D. Relationship between outer hair cell loss and hearing loss in rats exposed to styrene. Hearing Research 2008;243:28&ndash;34.</p>\r\n<p>4. Chen GD, Li MN, Tanaka C, et al. Aging outer hair cells (OHCs) in the Fischer 344 rat cochlea: Function and morphology. Hearing Research 2009;248:39&ndash;47.</p>\r\n<p>By Rickie R. Davis, PhD</p>\r\n<p>Rickie R. Davis, is captain, US Public Health Service, Hearing Loss Prevention Team, Engineering and Physical Hazards Branch, National Institute for Occupational Safety and Health, Cincinnati, OH.</p>\r\n<p>The link between loud noise and hearing loss has been known for centuries1 ) Certain trades, including blacksmiths, were plagued by noiseinduced hearing loss (NIHL). The industrial revolution with water and steam powered engines made NIHL even more common place. In the United States in 1935 the WalshHealey Public Contracts Act empowered the Executive Branch of the government with legal authority in American industries to regulate worker safety and health when doing business with the government.2 This act provided the legislation that enabled the first U.S. occupational safety and health regulations. With the end of World War II thousands of U.S. veterans returned home with NIHL and tinnitus from firearms and munitions used in battle and training. Recognizing this handicap, the U.S. military services became the first organizations to deploy hearing conservation programs. In 1969 the Walsh-Healey Act was amended to include a noise standard.3 Employees of contractors with US government contracts had noise exposure limited to a maximum A-weighted permissible exposure level (PEL) of 90 dBA over 8 hours. The 5 dB &ldquo;exchange rate&rdquo; was incorporated &ndash; for every 5 dB increase in exposure level over 90 dBA, the allowable exposure time was reduced by half. A one-sentence description of a hearing conservation program included noise monitoring, hearing protection and audiometry.</p>\r\n<p>In 1970, the Occupational Safety and Health Act was passed by Congress and signed by President Nixon.4 Under the act a variety of existing standards, including those promulgated under the authority of the Walsh-Healey Act became applicable to all U.S. industries. It also provided language which established the Occupational Safety and Health Administration (OSHA) (regulatory agency) and the National Institute for Occupational Safety and Health (NIOSH) (research and training agency). In 1972 based on scientific evidence NIOSH recommended that the permissible exposure level (PEL) be lowered to 85 dBA pending an extensive feasibility study.5 In 1974 OSHA issued a proposed regulation adopting an action level of 85 dBA and a PEL of 90 dBA.6 At the same time OSHA outlined requirements for a hearing conservation program including noise monitoring, audiometry and hearing protection devices. In 1983 the Hearing Conservation Amendment replaced the one-sentence description of a hearing conservation program to include more detail including: noise measurement, engineering and administrative controls, audiometric testing, hearing protection, training, record keeping, and program evaluation.7 In the ensuing 30 years or so, industry for the most part has not become quieter. We have learned that wearing hearing protection effectively, comfortably, and consistently is problematic. We have also found that occupational audiometry as currently practiced does not prevent hearing loss but only documents loss. Currently noise-induced hearing loss is epidemic in the U.S. population.</p>\r\n<p>In 2006 the NIOSH Hearing Loss Research Program was peer reviewed by a blue ribbon panel of the National Academies of Science, Institute of Medicine.9 Generally, the report was complementary but NIOSH was taken to  task for not having any programs in surveillance (i.e., collecting real-world information). Since that time NIOSH has undertaken efforts to utilize existing audiometric databases to enhance occupational hearing loss surveillance. Some of those efforts have recently resulted in research publications.</p>\r\n<p>The U.S. National Health Interview Survey is an annual telephone survey of 103,000 randomly selected respondents representing the adult population of the United States. Tak and Calvert8 reviewed the 1997 through 2003 responses to the question &ldquo;Which statement describes your hearing (without a hearing aid)? Good, a little trouble, a lot of trouble, or deaf.&rdquo; In addition, respondents were asked employment information. A total of 11.4% of respondents reported hearing difficulty. Of those, 22% could be attributed to occupational exposure. The greatest number of workers reporting difficulty with hearing was in the construction industry with an estimated 400,000 workers affected. The greatest prevalence was in the railroad industry with 34.8% of respondents reporting difficulty hearing. Utilizing data from the nationally representative U.S. National Health and Nutrition Examination Survey (NHANES) Tak, Davis and Calvert10 analyzed the question &ldquo;At your current job, are you currently exposed to loud noise?&rdquo;; &ldquo;By loud noise I mean noise so loud that you have to speak in a raised voice to be heard.&rdquo; Among those reporting loud noise exposure, a follow up question then asked &ldquo;In this (current) job, do you ever wear hearing protection devices?&rdquo; Exposure to loud noise was reported by 17.2% of the respondents. This represents an estimated 22 million workers in the U.S. Males had a higher prevalence of noise exposure, 26.3%, than females, 6.7%. The industries with the highest prevalence of noise exposure were mining (75%), lumber (55%), plastics (48%), utilities (46%) and maintenance (45%). Of those workers reporting noise exposure but non-use of hearing protection devices construction was the highest with an estimated 1.4 million non-users. Nationally 34% of noise exposed workers report non-use of hearing protection devices. In 2008 an intramural NIOSH project was funded to collect occupational audiograms from regional and national industrial audiometric providers. These providers generally provide mobile audiometric services to companies that do not have in-house capabilities. A number of studies of this database have been initiated and are in various stages of being analyzed, prepared, and published. There are a number of limitations to these data. We are very excited at the prospect that multi-year audiograms are available for thousands of workers in a multitude of different industries. Analysis of these audiograms and industries may lead to new insights and better protection of workers.</p>\r\n<p>Hearing protection devices (i.e., ear plugs, ear muffs and canal caps) are not simple, foolproof solutions to worker noise exposure. Workers complain about discomfort, impaired communication, missed safety signals, and inconvenience. Hearing protection that is not worn in noise is worthless. In addition, we have found that proper training is vital to obtaining useful attenuation levels.11 Video or printed training is better than no training. The gold standard of one instructor to one worker is best12 but seldom implemented in the occupational setting. A responsible company would not hand a worker a respirator and wish them good luck. A respirator, as personal protective equipment, requires training in care and use. But it also requires fit testing to be sure that it protects the worker correctly. Over the past 10 years or so technology has advanced to allow for individual fit-testing of ear plugs in a non-laboratory environment. A number of companies have developed and sold commercial systems. NIOSH has developed a simple system called HPD Well-Fit which utilizes custom software on a standard personal computer with a mouse and custom earphones. It is currently being field tested. For about 20 years the NIOSH Hearing Loss Prevention Team has been the technical advisor to the Environmental Protection Agency (EPA) for hearing protector labelling. In the United States the EPA defines and approves the Noise Reduction Rating label which is required on every box of hearing protection devices rated for occupational wear. Our group has suggested that rather than a single number, Noise Reduction Ratings be provided as a range of numbers based on population statistics. This will provide the hearing conservationist a better tool for fitting a hearing protector to a worker than the current &ldquo;buy to the highest number&rdquo; option. The NIOSH Hearing Loss Prevention Team is also interested in hearing protector comfort and communication. These are two of the reasons workers rebel against hearing protector wear.13 In addition we have been involved in studies of impulsive noise, how it affects the ear14 and how the hearing protector functions in impulsive noise.</p>\r\n<p>How do we reduce occupational hearing loss going forward? An important component is to reduce or eliminate noise in the workplace. Charles Hayden a member of the NIOSH Hearing Loss Prevention Team has been developing a</p>\r\n<p>program to encourage construction companies to Buy Quiet16 when purchasing equipment. The NIOSH website already has more than 160 powered hand tools listed with their sound power levels wwwn.cdc.gov/niosh -sound-vibration/). These levels were tested by NIOSH at the University of Cincinnati. Currently, Hayden is developing a website which will allow large and small construction companies to enter their tool and equipment inventories. Utilizing a database backend, the website will determine noise levels for those tools. As tools and equipment wear out and are replaced, the companies can search the database for quieter solutions. This not only benefits the workers using the tools and equipment but also benefits the neighbours in proximity of the building site. Beginning in 2007 Thais Morata of the NIOSH Hearing Loss Prevention Team was given support to start an award program designed to recognize companies doing an exceptional job in hearing loss prevention. This award was founded in partnership with the National Hearing Conservation Association. The awards are called the Safe-in-Sound Excellence in Hearing Loss Prevention award. Nominations are accepted via a webpage (www.safeinsound.us) during a certain timeframe. Finalist nominees are site-visited. Award winners are recognized at the annual conference of the National Hearing Conservation Association. We have found that past winners appreciate the handsome physical award but also receive even greater support from their management for their noise control and hearing conservation efforts going forward.17 The goal of the award project is to learn from, and disseminate these real-world success strategies. Ultimately, reducing occupational hearing loss will require technology advancements, improved surveillance, personal training, motivation, regulation and enforcement. There are environments where hearing protectors cannot safely be implemented. There are environments where noise cannot be reduced to safe levels. Using multiple strategies and collaborative efforts these and many other problems in today&rsquo;s noisy workplaces can be addressed and occupational hearing loss can be reduced or eliminated.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. Hawkins JE and Schacht J. Sketches of otohistory part 10: noise-induced hearing loss. Audiology and Neurotology 2005;10(6):305&ndash;309.</p>\r\n<p>2 U.S. Department of Labor: The Walsh-Healey Public Contracts Act (1938).</p>\r\n<p>3 U.S. Department of Labor: Occupational Noise Exposure. Federal Register 34: 7946-7979 (1969).</p>\r\n<p>4 U.S. Congress: Occupational Safety and Health Act. Public Law 91-596 84 STAT. 1590: 91st Congress, S.2193 (1970).</p>\r\n<p>5 National Institute for Occupational Safety and Health: NIOSH criteria for a recommended standard: Occupational exposure to noise. Cincinnati, OH: U.S. Department of Health, Education and Welfare (NIOSH Publication Number HSM 73-11001)(1972).</p>\r\n<p>6 Occupational Safety and Health Administration: Occupational Noise Exposure. Federal Register 39(207): 37773-37778 (1974).</p>\r\n<p>7 Occupational Safety and Health Administration: Occupational noise exposure.29 CFR 1910.95(1983).</p>\r\n<p>8 Tak S and Calvert GM. Hearing Difficulty Attributable to Employment by Industry and Occupation: An Analysis of the National Health Interview SurveyUnited States, 1997 to 2003. Journal of Occupational and Environmental Medicine 2008;50(1):46&ndash;56 10.1097/JOM.1090b1013 e3181579316.</p>\r\n<p>9 Committee to Review the NIOSH Hearing Loss Research Program National Research Council: Hearing Loss Research at NIOSH: Reviews of Research Programs of the National Institute for Occupational Safety and Health: The National Academies Press, 2006.</p>\r\n<p>10 Tak S, Davis RR, and Calvert GM. Exposure to hazardous workplace noise and use of hearing protection devices among US workersNHANES, 1999-2004. American Journal of Industrial Medicine 2009;52(May):358&ndash;71.</p>\r\n<p>11 Murphy WJ, Byrne DC, Gauger D, et al. Results of the National Institute for Occupational Safety and Health U.S. Environmental Protection Agency Interlaboratory Comparison of American National Standards Institute S12.6-1997 Methods A and B. Journal of the Acoustical Society of America 2009;125(5):3262&ndash;77.</p>\r\n<p>12 Murphy WJ, Stephenson MR, Byrne DC, et al. Effects of training on hearing protector attenuation. Noise and Health 2011;13(51):132&ndash;41.</p>\r\n<p>13 Davis RR. What do we know about hearing protector comfort? Noise Health 2008;10(40):83&ndash;89.</p>\r\n<p>14 Dunn DE, Davis RR, Merry CJ, and Franks JR. Hearing-loss in the chinchilla from impact and continuous noise exposure. Journal of the Acoustical Society of America 1991;90(4): 1979&ndash;85.</p>\r\n<p>15 Murphy WJ, Flamme GA, Meinke D, et al. Measurement of impulse peak insertion loss for four hearing protection devices in field conditions. International Journal of Audiology 2012;51:S31&ndash;S42.</p>\r\n<p>16 Hayden CSI, Ford R, and Zechmann E, Advanced Tools for Buying Quiet Products. In Proceedings of INCE &ndash; Institute for Noise Control Engineers Conference. New York, NY; 2012.</p>\r\n<p>17 Meinke DK and Morata TC. Awarding and promoting excellence in hearing loss prevention. International Journal of Audiology 2012;51:S63&ndash;S70.</p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-1-1-g0012.png\" alt=\"image\" /></p>\r\n<p>The Canadian Interorganizational Steering Group for Speech Language Pathology and Audiology (CISG) released these documents in French and English in the Fall of 2012 . http://www.canadian audiology.ca/professional.html The reports are an expert reflection on the state of practice, and an attempt to provide a conceptual framework from which clinicians and other health professionals can approach the problem as there is a limited amount of evidence base available. The Canadian Academy of Audiology (CAA) served as project liaison for this work for the CISG (made up of CAA, Canadian Association of Speech-Language Pathologists and Audiologists, The Canadian Alliance of Audiology and Speech-Language pathology Regulators). We wish to acknowledge the enormous, substantially voluntary effort of the author committee detailed below. Special thanks go to Dr. Pam Millett who chaired the committee, wrote large portions of the material, found speech- language pathology reviewers and edited the document following review by dozens of members of the CISG organizations and a copywriter. We would also like to acknowledge the contribution of Dr. Benoit Jutras who reviewed and edited the French translation for subject matter quality. Congratulations and deep gratitude go to the author committee: Dr. Pam Millet, lead author and the chair of the authorship committee, is an associate professor at York University. She teaches in both the Graduate Program and the Teacher of the Deaf and Hard of Hearing Education Program. Her research interests include the benefit of sound-field amplification in classrooms, hearing accessibility, the development of language and phonological awareness, literacy outcomes in children with cochlear implants and technology in education. Dr. Millet has extensive experience as an educational audiologist and is a consultant with school boards in the Toronto area.</p>\r\n<p>Dr. Beno&icirc;t Jutras is an associate professor at the School of Speech-Language Pathology and Audiology, University of Montreal and researcher at the Research Centre, Pediatric CHU Sainte-Justine, Montreal. Dr. Jutras? research interests include auditory processing, comorbidity of auditory processing disorder with other disorders/impairments, related interventions, as well as dichotic listening and cortical evoked responses. Greg Noel is vice-president and director of audiology of the Nova Scotia Hearing and Speech Centres, and a lecturer in the School of Human Communication Disorders at Dalhousie University. He has extensive teaching and clinical experience in the area of auditory processing disorder. Dr. Kathy Pichora-Fuller is a full professor in the Department of Psychology and Scientist at The Human Communication Laboratory, University of Toronto. She is also an adjunct scientist at the Toronto Rehabilitation Institute and an adjunct professor in the Faculty of Graduate Studies at the University of British Columbia. Prior to joining the University of Toronto in 2002, Dr. Pichora Fuller was a faculty member at the School of Audiology and Speech Sciences and director of the Institute for Hearing Accessibility Research at the University of British Columbia. She has also worked as a clinical audiologist at Mount Sinai Hospital in Toronto. Dr. Pichora-Fuller?s research interests include the effects of aging on auditory and cognitive processing as well as audiological rehabilitation for older adults. Charlene Watson is a clinical audiologist at the Richmond Road Diagnostic &amp; Treatment Centre, in Calgary, Alberta. She has been active in promoting awareness of auditory processing disorders in children at the Alberta Family &amp; Community Resource Centre, and has been involved in research on brainstem response measures and auditory processing assessment tools. Dr. Arden Nelson is an educational audiologist at ABC Children?s Audiology &amp; Hearing Services and Connect Hearing in Winnipeg, Manitoba. She has studied cortical evoked responses in individuals with known lesions and specializes in providing assessments and rehabilitation for individuals with balance deficits and auditory processing disorder.</p>\r\n<p>By Bo Hua Hu, PhD</p>\r\n<p>Bo Hua Hu is with the Center for Hearing and Deafness, State University of New York at Buffalo. Buffalo, NY.</p>\r\n<p>Noise-induced hearing loss is a common cause of acquired sensory hearing loss in the adult population. Functionally, acoustic overstimulation compromises hearing sensitivity and reduces the temporal and frequency resolutions. Pathologically, acoustic overexposure damages cochlear structures and causes sensory cell death. Because sensory cells in the mammalian cochlea are unable to regenerate once they die, loss of these cells results in permanent hearing loss. To prevent such loss, it is essential to understand the biological and molecular mechanisms of sensory cell degeneration, so that effective treatments can be developed. Recent studies have shown that sensory cell degeneration is a complex molecular process, involving multiple signaling pathways. Among these pathways, molecular events that are associated with apoptotic cell death have received a great attention. Apoptosis is an active type of cell degeneration that requires a sustained energy supply during the early phase of cell death. In the cochlea, apoptosis is triggered by exposure to a high level of noise exposure and occurs primarily at the initial phases of cochlear damage.1 Apoptosis has been linked to both intrinsic and extrinsic signaling pathways.2 However, how these signaling pathways are activated is not clear. Cell-cell junctions are an important element for maintenance of the structural integrity of tissues. In the cochlea, cell adhesion is organized through tight, gap, and adherens junctions, and through desmosomes and focal adhesions. These junctions play an essential role in the maintenance of structural integrity, cellular function, and signal transduction of sensory cells and supporting cells. Cell-cell junctions are also a major target of acoustic overstimulation. Morphological analyses of cochlear structures have revealed structural defects in cell junctions,3,4 such as the detachment of sensory cells from their anchorage and the splitting of the reticular lamina at cell-cell junctions (Figure 1). A recent observation from our laboratory has shown that even at the situation in which the general structure of the organ of Corti is preserved, an increase in the permeability to macromolecules can take place in the intracellular junctions.5 These observations led us to hypothesize that damage to cell junctions can serve as a trigger event for the generation of acute sensory cell apoptosis. To investigate the molecular changes associated with cell junction disruption, we recently examined the expression pattern of cell adhesion-related genes in the cochlear sensory epithelium.6 Under the normal condition, multiple adhesion-related genes are constitutively expressed in the cochlear sensory epithelium. The highest-expressed genes include Ctnnb1, Catna1, Thbs1, and Lamb2. Interestingly, the expression levels of many genes differ between the apical and basal sections of the organ of Corti. This difference may contribute to the difference in the noise susceptibility of the sensory cells between these two sections of the organ of Corti.</p>\r\n<p>Following exposure to a broadband noise at 120 dB SPL (sound pressure level) for 2 hours, we found a significant change in the expression levels of multiple adhesion genes. Importantly, these expression changes occurred in a time-dependent fashion. Immediately after the noise exposure, up-regulation of gene expression was the dominant change. As the time elapsed after the noise exposure, downregulation of gene expression became evident This dynamic nature of gene expression change is likely to be caused by the shift of the triggering factors for cochlear injury. The early damage is associated with direct mechanical stress that occurs during the period of acoustic overstimulation, whereas the secondary damage is associated with subsequent cellular events, which include metabolic disruption, oxidative stress, and ion imbalance. The changes in the expression levels of adhesion genes are also related to the level of hearing loss. Our correlation analysis revealed that the expression levels of several genes, including Sgce, Sell, Itga5, Selp, and Cntn1, were related, either positively or negatively, to the level of the threshold shift of the auditory brainstem response. These genes may contribute to the individual variation in the magnitude of cochlear damage after acoustic trauma. The changes in the expression patterns of adhesion-related genes were found to be spatially correlated with the apoptotic activity of hair cells. We observed an increased immunoreactivity of E-cadherin, an adhesion protein, in the circumferential rings of the hair cells that exhibit an apoptotic nuclear morphology, suggesting that the change in E-cadherin expression is associated with apoptotic degeneration (Figure 2). Interestingly, certain hair cells with increased E-cadherin immunoreactivity have a relativelynormal nuclear morphology, suggesting that the E-cadherin change is an early event of apoptosis.</p>\r\n<p>Molecular mechanisms responsible for adhesion disruption are not clear. Matrix metalloproteinases (MMPs) are a group of endopeptidases that participate in the degradation of all components of the extracellular matrix, including the molecules responsible for cell-cell junctions. These enzymes include collagenases, gelatinases, stromelysins, matrilysins, and other proteinases, each with specialized cellular compartmentalization and substrate specificity. We therefore examined the involvement of these proteins in noise-induced cochlear damage.7 Using a RNA-sequencing technique, we identified multiple MMP and related gene products, indicating that MMPs are constitutively expressed in the cochlea. Following exposure to a broadband noise at 120 dB SPL, the expression pattern of certain MMP genes was altered. For example, the expression of MMP7, which was undetectable under the physiological condition, became detectable in the cochlear sensory epithelium. Moreover, the expression level of intrinsic MMP inhibitors (tissue inhibitors of metalloproteinases) was altered after noise exposure. These observations suggest that MMPs are implicated in cochlear responses to acoustic overstimulation. Thus far, the biological</p>\r\n<p>By Wei Sun, PhD, yuguang Niu, Senthilvelan Manohar, Anand Kumaraguru and Brian Allman, PhD</p>\r\n<p>Wei Sun (pictured) is with the Center for Hearing &amp; Deafness, Department of Communicative Disorders and Sciences, the State University of New York at Buffalo, Buffalo, NY</p>\r\n<p>Otitis media is a common illness diagnosed in children. Chronic otitis media at early age, especially in infants, can induce recurrent conductive hearing loss which may adversely affect language acquisition, learning and social interactions.1 Recent clinical studies have found that children who reported hearing loss often experienced hyperacusis and tinnitus (~37%), suggesting that mild hearing loss during early age might be an associated risk factor for hyperacusis and tinnitus in children.2 Given that sensory input from the cochlea is crucial for the functional development of the central auditory system,3,4 we hypothesized that early age hearing loss would affect the normal development of the central auditory system and disrupt sound perception and tolerance. In the present study, we tested this hypothesis using Sprague Dawley rats as an animal model. During light anesthesia, we surgically perforated the tympanic membranes of rats at postnatal 16 days (note that a rat&rsquo;s ear canals do not open until postnatal 12 days). After surgery, the rats developed a temporary conductive hearing loss for about 2&ndash;3 weeks until the trauma of the ear drum had healed. Surprisingly, several weeks after the tympanic membrane perforation, more than 85% of the rats (n = 23) developed a susceptibility to audiogenic seizure, which was characterized by wild running followed by erratic leaping and clonic convulsion during exposure to loud sound (120 dB SPL white noise, &lt; 1 minute. The susceptibility of audiogenic seizure lasted to adulthood; long after hearing loss had recovered. Furthermore, compared to age-matched controls, rats with early age tympanic membrane damage also showed enhanced acoustic startle responses. These results suggest that early age hearing loss can increase sound sensitivity and reduce sound tolerance. By varying the timing of the tympanic membrane surgery, we found that audiogenic seizures could also be induced when tympanic membrane perforation occurred at postnatal 30 days, but not at postnatal 45 days; findings which suggest that hearing loss in early life results in a greater impairment of sound perception and tolerance than hearing loss in adulthood. We further evaluated the changes in auditory processing induced by early age conductive hearing loss by comparing, within a given animal, the auditory brainstem responses (ABRs) evoked during sound presentation to the tympanic membrane damaged ear versus undamaged (control) ear. Although the ABR threshold showed no significant difference between the control ears versus the tympanic membrane damaged ears two months after the surgery, the ABR interwave latencies of waves of I to V in the tympanic membrane damaged ears were significantly shorter than the ears without tympanic membrane damage. In addition, using immunostaining for c-Fos, an immediate gene whose activation can be used to indicate neural activity, we found a stronger staining in the inferior colliculus in the tympanic membrane damaged rats after exposure to loud sound compared to the rats without tympanic membrane damage. These results suggest that early age hearing loss may cause hyperexcitability and increase the neural signal conduction in the central auditory system.</p>\r\n<p>In a follow-up series of experiments, we  found that the incidence of audiogenic seizure was suppressed by treatment of vigabatrin, an antiepileptic drug that inhibits the catabolism of the gammaaminobutyric acid (GABA), the major inhibitory neurotransmitter in the brain. Acute injections (250 mg/kg) or oral intake (60 mg/kg/day for 7 days) temporarily abolished audiogenic seizure in rats with early age tympanic membrane perforation. Vigabatrin treatment also caused prolonged ABR latency and reduced the peak amplitude of the ABR responses. Collectively, these results suggest that early age hearing loss may reduce GABAergic inhibition, leading to hyperexcitability and increased susceptibility to audiogenic seizure. Our results support our hypothesis that early age hearing loss affects the normal development of the central auditory system and disrupts sound perception and tolerance. It is possible that our findings may be related to hyperacusis seen in children with recurrent otitis media.</p>\r\n<p><strong>Acoknowledgement</strong></p>\r\n<p>The project was supported by Action of Hearing Loss foundation.</p>\r\n<p><strong>References</strong></p>\r\n<p>1. O\'Leary SJ, Triolo RD. Surgery for otitis media among Indigenous Australians. Med J Aust 2009;191:S65&ndash;8.</p>\r\n<p>2. Coelho CB, Sanchez TG, Tyler RS. Hyperacusis, sound annoyance, and loudness hypersensitivity in children. Prog Brain Res 166;169&ndash; 78.</p>\r\n<p>3. Chang EF, Merzenich MM. Environmental noise retards auditory cortical development. Science 2003;300:498&ndash;502.</p>\r\n<p>4. Kral A, Hartmann R, Tillein J, Heid S, Klinke R. Hearing after congenital deafness: central auditory plasticity and sensory deprivation. Cereb Cortex 2002;12:797&ndash;807.</p>\r\n<p>5. Sun W, Manohar S, Jayaram A, et al. Early age conductive hearing loss causes audiogenic seizure and hyperacusis behavior. Hear Res 2011;282:178&ndash;83.</p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-1-1-g0013.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-8-1-1-g0014.png\" alt=\"image\" /></p>',NULL,'2022-12-01'),(53,3237,'ajchr','http://www.andrewjohnpublishing.com/','','<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-4-1-g001.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-4-1-g002.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-4-4-1-g003.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" 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src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0016.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0017.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0018.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0019.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0020.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0021.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0022.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0023.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0024.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0025.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0026.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0027.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0028.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0029.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0030.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0031.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0032.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0033.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0034.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0035.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0036.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0037.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0038.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0038.png\" alt=\"image\" /></p>\r\n<p><img class=\"equation\" src=\"https://www.andrewjohnpublishing.com/articles-images-2022/canadian-hearing-report-5-3-1-g0040.png\" alt=\"image\" /></p>',NULL,'2022-12-01'),(58,5398,'ajchr','http://www.andrewjohnpublishing.com/','','<h4>Hearing Loss in Type 2 Diabetes Mellitus</h4>\n<p>By Bruce Tay<sup><a href=\"#corr\">*</a></sup></p>\n<p>University of British Columbia, Columbia; E-mail: brucecolumbia2@gmail.com</p>\n<p><strong>Copyright: </strong>&copy; 2023 Johnson MR. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</p>\n<p><strong>Citation: </strong>Johnson MR (2023) Vestibular Schwannoma: A Rare Disease of Inner Ear and its Diagnosis, Treatment. Canadian Hearing Report, 16: 1</p>\n<p><strong>Received: </strong>1-Feb-2023, <strong>Manuscript No. </strong>ajchr-23-89819;<strong> Editor assigned: </strong>3-Feb-2023, <strong>PreQC No.</strong> ajchr-23-89819(PQ); <strong>Reviewed: </strong>17-Feb-2023, <strong>QC No.</strong>ajchr-23-89819; <strong>Revised: </strong>22-Feb-2023, <strong>Manuscript No.</strong> ajchr-23-89819; <strong>Published: </strong>28-Feb-2023</p>\n<h4>Abstract</h4>\n<p>Hearing loss has been linked to microvascular disease, acoustic neuropathy, and oxidative stress as possible mechanisms in type 2 diabetes mellitus. The longitudinal relationship between hearing loss and type 2 diabetes has been the subject of a few small studies; however, larger studies are required. Accordingly, the PTA test determined that patients had hearing loss if their hearing threshold was greater than or equal to 25 dB. In addition, a list of monosyllabic words with an intensity of at least 40 dB was used to determine the patients&rsquo; speech discrimination score in comparison to the SDS test. However, in the SRT test, a list of two-syllable words was used to measure the patients&rsquo; superficial speech comprehension threshold. According to the PTA and SRT tests, the majority of diabetic patients had hearing loss in both their right and left ears. However, the SDS test revealed that they did not have hearing loss in either of their ears.</p>\n<h4>Keywords</h4>\n<p>Micro vascular, Neuropathy, Oxidative stress, Monosyllabic, Superficial, SDS test</p>\n<h4>INTRODUCTION</h4>\n<p>Because of its high metabolic activity, the auditory pathway is the organ of choice for the pathogenesis of diabetes and hyperglycemia. Numerous metabolic disorders that harm the auditory system physiologically and anatomically are caused by high blood sugar. Hearing loss has been linked to diabetes complications like coronary artery disease and nephropathy. On the other hand, some studies have shown that hearing loss in diabetic patients can be caused by high levels of low-density lipoprotein (LDL), low levels of high-density lipoprotein (HDL), hypertension, smoking, central obesity, drinking alcohol, high triglycerides, high blood sugar, and aging . Diabetes can make a few changes the stria vascularis, the cellar film, and the cochlear hair cells. During hyperglycemia, the cochlea has a lot of small blood vessels that can cause microangiopathy [<a href=\"#1\" title=\"1\">1</a>,<a href=\"#2\" title=\"2\">2</a>].</p>\n<p><strong>AUDIOMETRIC MEASUREMENT</strong></p>\n<p> A licensed audiologist used a calibrated American National Standard Institute (ANSI) audiometer in a sound-treated booth that met accepted standards to take the measurements. All patients were also examined by an otolaryngologist. At frequencies of 250, 500, 1000, 2000, 4000, and 8000 Hz, air conduc- tion pure tone hearing thresholds were determined for each ear. Higher pitches are regarded as having higher frequencies. We averaged pure tone thresholds measured at 500, 1000, and 2000 Hz for each ear to produce low frequency pure tone means. We averaged pure tone thresholds measured at 4000 and 8000 Hz for each ear to produce high-frequency pure tone means. When the average of the pure-tone thresholds (PTA) measured at 500, 1000, 2000, 4000, and 8000 Hz in either ear was less than 25 dB of hearing level, the participant was considered to have impairment [<a href=\"#2\" title=\"2\">2</a>,<a href=\"#4\" title=\"4\">4</a>]. The evaluation of hearing loss is as follows: nor-mal (less than 25 decibels), moderate (41 to 55 decibels), severe (56 to 70 decibels), very severe (71 to 90 decibels), profound (91 to 120 decibels), and deaf (no hearing) [<a href=\"#3\" title=\"3\">3</a>,<a href=\"#5\">5</a>].</p>\n<p><strong>THE RELATIONSHIP BETWEEN DIABETES AND HEARING LOSS</strong></p>\n<p> Nerve damage can occur as a result of diabetes, affecting the kidneys, hands, feet, eyes, and other body parts. Additionally, nerve damage in the ears can be caused by diabetes. High blood sugar can cause damage to the inner ear&rsquo;s nerves and small blood vessels over time. Over time, low blood sugar can make it harder for nerve signals to get to your brain from your inner ear. Hearing loss can result from either type of nerve damage. Diabetes is associated with twice as much hearing loss as it is in people of the same age who do not have diabetes. Hearing loss is 30% more common in prediabetes patients than in those with normal blood sugar levels, indicating that prediabetes patients do not yet have type 2 diabetes [<a href=\"#4\" title=\"4\">4</a>,<a href=\"#7\" title=\"7\">7</a>].</p>\n<p><strong>RISK FACTORS RELATED TO HEARING LOSS IN DIABETES MELLITUS</strong></p>\n<p> Despite the numerous studies linking diabetes and hearing loss, no direct connection could be established. In general, hearing loss risk factors differ from diabetes risk factors. However, there are a few risk factors that the two share: Problems in any part of the body can result from any impairment of the insulin system. Sensory receptors and supporting cells of the cochlea, stria vascularis, and spiral ligament contain insulin receptors, glucose transporters, and insulin signaling components, indicating that impairments in glucose utilization could affect balance and hearing. Despite the fact that diabetes continues to be a clear risk factor for hearing loss, the varying pathologies and onset times associated with glucose processing abnormalities point to multifactorial processes [<a href=\"#6\" title=\"6\">6</a>,<a href=\"#7\" title=\"7\">7</a>].</p>\n<p><strong>HEARING LOSS: THE EFFECT OF MEDICATIONS USED TO TREAT DIABETES AND ITS CO-MORBIDITIES</strong></p>\n<p> Unfortunately, multiple off-target effects on various systems may result from exposure to multiple medications in the context of aging and chronic disease in today&rsquo;s modern world. In relation to diabetes type 2. Assessment of the potential cumulative effects that medications used to treat its co-morbidities might have on hearing is crucial Ageing Research Reviews 71 (2021) 101423 Diabetes and hyperglycemia are strong cardiovascular disease risk factors that frequently occur in conjunction with a group of other cardiovascular risk factors like hypertension, dyslipidemia, and obesity . A growing body of research shows that people with type 2 diabetes and obesity are more likely to get certain types of cancer as well as severe bacterial infections . Hearing and/or balance impairment are well-known side effects of medications like antibiotics, loop diuretics, and cancer treatments [<a href=\"#8\" title=\"8\">8</a>-<a href=\"#10\" title=\"10\">10</a>].</p>\n<h4>CONCLUSION</h4>\n<p>Neuropathy, retinopathy, and nephropathy are all linked to diabetes. Despite the fact that diabetes is thought to increase a person&rsquo;s risk of hearing loss, some studies found no connection when age, gender, and hypertension were taken into account. Additionally, the World Health Organization&rsquo;s Global Report on Diabetes does not include hearing loss as a major risk (World Health Organization, 2016). A glucose/insulin pathology, which can affect the cochlea&rsquo;s sensory and support cells directly, is the root cause of diabetes. Primary ear-related complications of hypertension and diabetes include macro- and micro-vascular insults that reduce blood flow, oxygen exchange, and ion transport. Vasodilating treatments that increase the flow of blood through the nerves may reduce neuropathic hearing loss, according to research. It has been suggested that adopting a healthy diet and a healthy lifestyle in general can stop diabetes from getting worse and hearing loss from getting worse. In particular, hyperglycemia, the most common symptom of uncontrolled diabetes, is a major risk factor for numerous diseases. Examining what is known about diabetes and hearing loss reveals a complicated relationship between the two. Although diabetes-related pathologies can result in hearing loss, the majority of hearing loss is brought on by prolonged exposure to excessive noise.</p>\n<h4> REFERENCES</h4>\n<ol>\n  <li><a name=\"1\" id=\"1\"></a>Shafiepour, M., et al. &ldquo;<a href=\"https://europepmc.org/article/med/26699766\" target=\"_blank\">Prevalence  of hearing loss among patients with type 2 diabetes.</a>&rdquo; J Med Life, 15(6) (2022):772-777. </li>\n  <p align=\"right\"> <a href=\"https://pubmed.ncbi.nlm.nih.gov/36672540/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"https://doi.org/10.3390/biomedicines11010032\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"https://scholar.google.com/scholar?q=Tesa%C5%99ov%C3%A1,+M.+%26+Peterkov%C3%A1,+L.,+%E2%80%9CTumor+Biology+and+Microenvironment+of+Vestibular+Schwannoma-Relation+to+Tumor+Growth+and+Hearing+Loss%E2%80%9D.+Biomedicines,+11(1)+(2020):+32.+&amp;hl=en&amp;as_sdt=0,5\" target=\"_blank\"><u>Google Scholar</u></a></p>\n  <li><a name=\"2\" id=\"2\"></a>KonradMartin,  D., et al. &ldquo;<a href=\"https://journals.lww.com/ear-hearing/Abstract/2015/07000/Hearing_Impairment_in_Relation_to_Severity_of.1.aspx\" target=\"_blank\">Hearing impairment in relation to  severity of diabetes in a veteran cohort.</a>&rdquo; 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E-mail: andrew12@gmail.com</p>\n<p><strong>Copyright: </strong>&copy; 2023 Andrew E. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</p>\n<p><strong>Citation: </strong>Andrew E (2023) Tinnitus- Diagnosis and Treatment, Canadian Hearing Report 16: 1</p>\n<p><strong>Received: </strong>1-Feb-2023, <strong>Manuscript No. </strong>ajchr-23-89820;<strong> Editor assigned: </strong>3-Feb-2023, <strong>PreQC No.</strong> ajchr-23-89820(PQ); <strong>Reviewed: </strong>17-Feb-2023, <strong>QC No.</strong>ajchr-23-89820; <strong>Revised: </strong>22-Feb-2023, <strong>Manuscript No.</strong> ajchr-23-89820; <strong>Published: </strong>28-Feb-2023</p>\n<h4>ABSTRACT</h4>\n<p> Tinnitus models rely on increased central gain in the auditory pathway as all or part of the explanation. This is because central auditory neurons that are deprived of their usual sensory input maintain homeostasis by increasing the rate at which they fire in response to any given strength of input. This includes amplifying spontaneous firing, which is what causes tinnitus. Many or most tinnitus models rely on this as the explanation for tinnitus. However, regardless of whether tinnitus occurs, damage to the auditory periphery results in significant gain changes. A discussion of the minimum evidential requirements to implicate gain as a necessary and/or sufficient basis to explain tinnitus, as well as the extent of existing evidence in this regard, are included in this article. It considers gain in its broadest sense, summarizes its contributory processes, neural manifestations, behavioral effects, techniques for its measurement, pitfalls in attributing gain changes to tinnitus, and a discussion of the pitfalls in attributing gain changes to tin there is overwhelming evidence that peripheral auditory insults alter neuronal firing rates, synchrony, and neurochemistry, resulting in an increase in gain. However, the lack of hearing-matched human control groups or insult-exposed non-tinnitus animals generally makes it difficult to specifically attribute these changes to tinnitus. Although a small number of studies have demonstrated changes specifically attributable to tinnitus at the group level, no attempts have been made to classify individual subjects based on gain metrics. Focused attention, resetting sensory predictions, failure of sensory gating, altered sensory predictions, the formation of pervasive memory traces, and/or entry into global perceptual networks are potential additional mechanisms if gain proves to be insufficient or unnecessary to cause tinnitus. A Special Issue with this article is titled: Hyperacusis, tinnitus, and loss of hearing</p>\n<h4>KEYWORDS</h4>\n<p>Auditory pathway, Tinnitus, Sensory, Neurochemistry, Neuronal firing, Hyperacusis, Memory</p>\n<h4>INTRODUCTION</h4>\n<p>The absence of an external physical source for the sound heard in the ears is referred to as &ldquo;tinnitus,&rdquo; and in most cases, including this article, it is specifically referred to as &ldquo;subjective tinnitus,&rdquo; in which there is also no internal sound source, such as turbulent blood flow. The sound is usually a hiss or tone with a high frequency, but different perceptions have been reported. Over half of healthy adults with no known hearing abnormality report a very quiet ongoing tinnitus-like percept when placed in a quiet environment and asked to pay attention to what they are hearing. Almost everyone experiences brief periods of transient tinnitus in their life time. Hearing loss is the main risk factor, and around 90% of people with tinnitus have an abnormal audiogram. However, regardless of the degree of hearing loss, the majority of people do not experience clinically significant tinnitus. According to Roberts et al., studies on people with tinnitus and a normal audiogram typically reveal more subtle evidence of peripheral auditory damage. Tinnitus can also be induced in a reversible manner by chronically inserting an earplug to simulate hearing loss . Reduced auditory input, typically caused by hearing loss, increases central auditory pathway gain, which is a common and intuitive explanation for the cause of tinnitus. That is, the neurons getting decreased input reestablish their typical movement level by answering all the more firmly for any invigorated of information. It is hypothesized that the perception of tinnitus results from the amplifying of spontaneous activity in the auditory pathway, which is thought to some extent to be a common and normal phenomenon [<a href=\"#1\" title=\"1\">1</a>]</p>\n<p><strong>CAUSE OF TINNITUS</strong></p>\n<p> Tinnitus is not a disease in and of itself; rather, it is a symptom of a variety of underlying diseases. The etiologies are well-known. &ldquo;Cause&rdquo; refers to biological or structural changes, while &ldquo;etiology&rdquo; only refers to the events associated with tinnitus onset. To include noise trauma, the administration of ototoxic drugs (such as aminoglycosides, cisplatin, and salicylates), and head and neck injuries. Regardless of the cause, the peripheral auditory system, the somatosensory system, and the auditory cortex are the three primary locations where tinnitus begins. Tinnitus can also be caused by lesions of the thalamus, inferior colliculus, and Dorsal Cochlear Nucleus (DCN). Additionally, the N-methyl-D-aspartate (NMDA) receptor and serotonin are thought to be potential therapeutic targets for preventing the onset of tinnitus.</p>\n<p><strong>MOLECULAR MECHANISM OF TINNITUS</strong></p>\n<p><strong> SEROTONIN</strong></p>\n<p> Serotonergic neurons in the nucleus accumbens and subcallosal networks can mediate the sensory gating mechanism. Serotonin depletion is assumed to cause tinnitus because a serotonin-depleted status as seen in hypersensitivity to noise, reduced rapid-eye-movement sleep, and depression can co-occur with tinnitus. Tinnitus might be one of the symptoms of the over-all depletion One or more limbic-relevant neurotransmitter systems, such as that involving, may be systemically vulnerable independently in tinnitus patients.</p>\n<p><strong>NMDA RECEPTOR ANTAGONIST</strong></p>\n<p> Neuroprotective medications like NMDA receptor antagonists could help stop or reverse chronic tinnitus. Exposure to the cochlea has been shown to first cause excessive glutamate production, which in turn activates NMDA receptors. Cochlear tinnitus has been linked to the activation of NMDA receptors in the cochlea and the subsequent stimulation of the auditory nerve. As a result, NMDA receptor inhibition has been proposed as a pharmacological treatment for tinnitus. Local administration of an NMDA antagonist to the rat cochlea was found to reduce tinnitus. Systemic administration of meantime (5 mg/kg), an NMDA antagonist, also significantly reduced acoustic-trau- ma-induced tinnitus in a rat model. In human trials, the subjective loudness of tinnitus was significantly reduced when high doses of acamprosate, glutamate antagonist, and GABA agonist were administered. On the other hand, meantime at 20 mg did not significantly improve tinnitus [<a href=\"#2\" title=\"2\">2</a>]</p>\n<p><strong>DIAGNOSIS</strong></p>\n<p> Diagnosis process is continued with the help of slandered audiometry procedure. Two kind of audiometry procedures are used to continue such as Air conduction audiometry and Bone Conduction audiometry.</p>\n<p><strong>AIR CONDUCTION AUDIOMETRY</strong></p>\n<p> A sound wave moving through air is what is meant to be called an air conducted signal. The majority of sounds are typically heard by humans through this method. The auditory system as a whole is evaluated by this method of signal presentation. As a result, when hearing loss is detected during air conduction, additional tests are required to identify the auditory system&rsquo;s dysfunctional component(s).</p>\n<p>Air conduction pure tone audiometry generally follows the following procedure: The patient is instructed to pay close attention for a pure tone (beep): He or she is asked to press the answer button or raise their hand if they are heard, even if it is very softly. The patient is then presented with pure tones, initially at an intensity that is assumed to be adequate for hearing. The tone&rsquo;s intensity (loudness) is decreased in 10&ndash;15 dB steps until the patient no longer responds after the patient has demonstrated a good understanding of the task. After that, the intensity is increased in 5 dB steps until the patient responds, then decreased once more, and then increased once more in 5 dB steps until the patient finally responds. The patient&rsquo;s threshold for a given frequency is then determined to be the lowest audible intensity. The &ldquo;modified Hughson&ndash;Westlake ascending-descending paradigm&rdquo; is the name given to this approach. For each test frequency, the procedure is repeated in one ear and then in the other. 125 Hz, 250 Hz, 500 Hz, 1 KHz, 2 KHz, 3 KHz, 4 KHz, 6 KHz, and 8 KHz are typically the test frequencies. After that, an audiogram, or air conduction pure tone threshold curve, is created for each ear. Bone conduction audiometry must be performed if there is hearing loss [<a href=\"#3\" title=\"3\">3</a>].</p>\n<p><strong>BONE CONDUCTION AUDIOMETRY</strong></p>\n<p> The cochlea is directly stimulated during bone conduction pure tone testing, avoiding the outer and middle ear. This kind of testing is used to figure out if a hearing loss is caused by a cochlear/neural deficit or a problem with the outer or middle ear. The air conduction audiometry modified Hughson&ndash;Westlake method is used for bone conduction pure tone audiometry, but the tones are presented through a bone conduction headset. This consists of a metal band and a bone oscillator that can be worn over the head in the same way that regular headphones do. The mastoid process typically houses the bone oscillator. The loss is referred to as &ldquo;sensor neural&rdquo; if air conduction and bone conduction pure tone thresholds coincides. It has been determined that the loss is related to the cochlea or higher neural processes. A &ldquo;conductive&rdquo; hearing loss, on the other hand, occurs when air conduction thresholds are higher than bone conduction thresholds: When directly stimulated, the cochlea responds with lower intensities (i.e.&rdquo;better&rdquo;) than when it is stimulated through the outer and middle ear, which indicates that something in the outer or middle ear is lowering the level of sound that reaches the cochlea. A &ldquo;mixed&rdquo; hearing loss is one in which there is both a sensor neural and conductive component to the loss [<a href=\"#4\" title=\"4\">4</a>, <a href=\"#5\" title=\"5\">5</a>].</p>\n<p><strong>TREATMENT AS WELL AS MANAGEMENT OF TINNITUS</strong></p>\n<p><strong> VAGUS NERVE STIMULATION</strong></p>\n<p> Not only the structures of the central auditory system are involved in in the onset and perception of tinnitus; Plastic changes also involve non-auditory brain regions. The cholinergic and noradrenergic forebrain systems play a crucial role in modulating cortical plasticity as well. Cortical reorganization has been shown to undergo a significant and persistent change when electrical stimulation is used in animal studies. In order to stimulate the nucleus basalis, an invasive procedure must be performed; consequently, this kind of stimulation cannot be used effectively in a large-scale application for tinnitus treatment. Neither acoustic stimulation nor VNS alone had a comparable effect. It has been hypothesized that while acoustic tones stimulate the auditory cortex as a target for the neuroplastic change, the VNS induces neuroplastic activity to promote the desired cortical reorganization [<a href=\"#6\" title=\"6\">6</a>].</p>\n<p><strong>SOUND AMPLIFICATION</strong></p>\n<p> Hearing aids, which act as a masker by introducing more ambient noise, can help some people with tinnitus. Additionally, the use of white noise generators has been shown to be beneficial in decreasing the severity of tinnitus and improving sleep. Other types of background noise at bedtime can also be helpful. Specialized tinnitus maskers, such as adjustable nature sounds or broadband noise, can be used to provide additional tinnitus relief for patients for whom basic amplification is not sufficient.</p>\n<p><strong>PHARMACOLOGIC THERAPY</strong></p>\n<p> When used in conjunction with other medications, some pharmacological therapies can be beneficial. It has been demonstrated that exogenous melatonin improves sleep and tinnitus symptoms in particular. The current tinnitus guidelines advise against taking antidepressants, anticonvulsants, or anxiolytics on a regular basis for tinnitus that is bothersome. However, it has been demonstrated that tricyclic antidepressants and selective serotonin reuptake inhibitors are effective in managing tinnitus symptoms and reducing annoyance in patients with depression and anxiety [<a href=\"#7\" title=\"7\">7</a>].</p>\n<p><strong>STIMULATION WITH MAGNETS</strong></p>\n<p> As a novel and non-invasive treatment for persistently annoying tinnitus, transracial magnetic stimulation has been proposed. At the moment, only research trials can use it. Low-frequency electromagnetic pulses from transracial magnetic stimulation have been suggested to help reduce neural activity in the directly stimulated and structurally affected regions of the patient&rsquo;s brain, which is consistent with the current model of tinnitus [<a href=\"#8\" title=\"8\">8</a>, <a href=\"#9\" title=\"9\">9</a>].</p>\n<p><strong>SURGICAL MANAGEMENT</strong></p>\n<p> Tinnitus patients receive very little surgical treatment, and only when there are underlying causes that can be treated. Endolymphatic sac shunting for M&eacute;ni&egrave;re disease, stapedectomy for otosclerosis, and surgical resection of acoustic neuroma and other brain stem or cerebellopontine angle tumors and lesions are two examples. Surgery can also be used to treat tensor tympani and stape dius myoclonus syndromes by cutting off the affected muscles [<a href=\"#10\" title=\"10\">10</a>].</p>\n<h4>CONCLUSION</h4>\n<p> Family physicians can effectively manage the majority of tinnitus patients. Pulsatile or unilateral tinnitus, as well as abnormal horoscopy findings, should be referred to a different specialist. Family physicians are well-suited to address the physiologic and psychological challenges that tinnitus patients face. Since tinnitus can&rsquo;t be cured in most cases, the best way to help people deal with their symptoms is to offer comfort and reassurance. The focal modulation of neuronal activity is now possible thanks to the development of numerous neuromodulator techniques over the past two decades. The growing body of knowledge regarding tinnitus-related brain activity changes led to the logical conclusion that neuro modulation techniques directly targeted tinnitus&rsquo;s neuronal correlates. The imaginative thought was that this impacting of the electrical movement of the elaborate mind networks would act as a significant symptomatic and helpful apparatus in additional exploration.</p>\n<h4> REFERENCES</h4>\n<ol>\n  <li><a name=\"1\" id=\"12\"></a>Sedley, W. &ldquo;<a href=\"https://www.sciencedirect.com/science/article/pii/S0306452219300478?via%3Dihub\" target=\"_blank\">Tinnitus:  Does Gain Explain? 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Front Neurol, 12 (2021): 674100. </li>\n  <p align=\"right\"> <a href=\"https://pubmed.ncbi.nlm.nih.gov/34621231/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=10.%09Nakul%2C+E.%2C+et+al.+%E2%80%9CVestibular-Evoked+Cerebral+Potentials%E2%80%9D.+Front+Neurol%2C+12+%282021%29%3A+674100.+&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a>, <a href=\"file:///C:\\Users\\sireesha-y\\Desktop\\CHR\\CHR%20submit\\ajchr-23-89820\\v\" target=\"_blank\"><u>Crossref</u></a></p>\n</ol>\n<h4>Vestibular Dysfunction In Association with Hearing loss</h4>\n<p><strong>By Andrew Wise*</strong></p>\n<p>Department of Bioscience, University of Central London; E-mail: wiselondon23@gmail.com</p>\n<p><strong>Copyright: </strong>&copy; 2023 Wise A. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</p>\n<p> <strong>Citation: </strong>Wise A (2023) Vestibular Dysfunction In Association with Hearing Loss, Canadian Hearing Report 16: 1</p>\n<p><strong>Received: </strong>1-Feb-2023, <strong>Manuscript No. </strong>ajchr-23-89821;<strong> Editor assigned: </strong>3-Feb-2023, <strong>PreQC No.</strong> ajchr-23-89821(PQ); <strong>Reviewed: </strong>17-Feb-2023, <strong>QC No.</strong>ajchr-23-89821; <strong>Revised: </strong>22-Feb-2023, <strong>Manuscript No.</strong> ajchr-23-89821; <strong>Published: </strong>28-Feb-2023</p>\n<h4>ABSTRACT</h4>\n<p> The inner ear is also in charge of balance and hearing. Mechanosensitive hair cells, which transform motion- and sound-induced stimuli into electrical signals for the brain, are necessary for these functions to occur. The vestibular organs&rsquo; structure remained constant across all vertebrates during the same time period, but the hearing organ underwent the most significant changes during inner ear evolution. Multiple interrelated factors account for the high prevalence of vestibular deficits in humans: aging, infections, ototoxic drugs, genetics, and environmental factors The development and function of these two sensory systems have been illuminated by research on the deafness genes associated with balance problems and the animal models that correspond to them. Individual postural control, gaze stabilization, locomotion, and spatial orientation are frequently impaired by bilateral vestibular deficits. The patient&rsquo;s quality of life is significantly impacted by the resulting dizziness, vertigo, and/or falls, which are common in elderly populations. Prosthetic devices like vestibular implants, which provide information about the direction, amplitude, and velocity of body movements in the absence of treatment, are being developed and have shown promising results in both human and animal models. Gene therapies that target the inner ear (gene supplementation and gene editing), 3D inner ear organoids, and reprograming protocols for generating hair cell-like cells have made significant progress thanks to novel methods and techniques. Interdisciplinary research is being encouraged to develop individualized treatments for vestibular disorders as a result of these rapid advancements in multiscale approaches that encompass basic research, clinical diagnostics, and therapies.</p>\n<h4> KEYWORDS</h4>\n<p>Mechano sensitive, Vestibular, Ototoxic, Deafness, Dizziness, Prosthetic, Organoids</p>\n<h4>INTRODUCTION</h4>\n<p>Our sensory organs mediate and control our responses to the external and internal environment, continuously adapting to its various changes. The human inner ear, one of the major organs signaling to the central nervous system, consists of spatially interconnected fluid-filled ducts and chambers housing six different neurosensory suborgans essential for balance and hearing. The resulting labyrinth is one of the most morphologically elaborate tissues in vertebrates. Its intricate and fascinating organization and capacity to integrate sensory perceptions from multiple sources have, over the centuries, triggered considerable interest leading to research across many disciplines, including physics, developmental biology, neuroscience, behavioral cognition, genetics, organ evolution, molecular phylogeny, engineering, and clinical and translational medicine. There are strong anatomical and functional links between hearing and balance. Both organs were formed by a single optic vesicle that develops by invading surface ectoderm near the developing hindbrain [<a href=\"#1\" title=\"1\">1</a>-<a href=\"#5\" title=\"5\">5</a>].</p>\n<p><strong>CAUSE OF HEARING AND BALANCE DEFECT</strong></p>\n<p><strong> BACTERIAL INFECTION</strong></p>\n<p> Hearing misfortune is the most widely recognized entanglement of bacterial meningitis, influencing over half of overcomers of pneumococcal meningitis. The same pathophysiological mechanisms, which are believed to involve bacterial invasion of the inner ear followed by inflammatory infiltration, may also be responsible for the loss of vestibular system function in meningitis. Up to 14% of patients with bacterial meningitis develop vestibular are flexia in one or both ears, a sign of severe vestibular dysfunction [<a href=\"#6\" title=\"6\">6</a>, <a href=\"#7\" title=\"7\">7</a>].</p>\n<p><strong>AUTOIMMUNE DISORDER</strong></p>\n<p> It is still unclear what causes the inner ear to be involved in autoimmune diseases, but it could be related to antibodies that are circulating against a number of inner ear antigens (primary autoimmune inner ear diseases) or damage that is caused by the immune complex (inner ear involvement in systemic autoimmune diseases) [<a href=\"#8\" title=\"8\">8</a>].</p>\n<p> <strong>OTOTOXIC DRUGS</strong></p>\n<p> Hair cells in the utricle, saccule, or semicircular canals can be affected by vestibulotoxicity, resulting in a variety of vestibular deficits2. The toxic drug&rsquo;s properties and dose are largely responsible for the risk of developing a vestibular deficit, which is probably influenced by genetic predisposition. Some medications that harm the vestibule also harm the cochlea, which can lead to hearing loss and/or tinnitus. Other medications, on the other hand, have toxic effects that are specific to the vestibular system, making it more difficult to diagnose vestibular dysfunction. Antibiotics, particularly aminoglycosides, and chemotherapy agents like cisplatin are the main substances that cause significant vestibular toxicity. Aminoglycosides, especially streptomycin, gentamicin, and neomycin, are the most harmful to the inner ear. They also have a greater vestibulotoxicity than they do to the cochlea. There is neither a safe serum concentration nor a safe dose of gentamicin for the vestibular system [<a href=\"#9\" title=\"9\">9</a>].</p>\n<p><strong>STRUCTURAL AND FUNCTIONAL DEFECTS OF THE MECAHNOSENSITIVE HAIR BUNDLES</strong></p>\n<p> A lot of research into the pathophysiology of Usher Syndrome, the main cause of combined vision and hearing loss, has shed light on how hair bundles are made and function. Five fundamental Attendant sort I qualities have been recognized, encoding the actin-based engine myosin VIIa (USH1B), the PDZ space containing submembrane protein harmonin (USH1C), the platform protein sans (USH1G), and two Ca2+-subordinate attachment proteins, cadherin-23 (USH1D) and protocadherin-15 (USH1F). Due to their typical circling behavior and the absence of VsEPs in USH1 mice, all of the available USH1 mutant mice faithfully replicate the profound congenital deafness and bilateral vestibular dysfunction seen in human patients.</p>\n<p>Key functions of this network in the hair bundle were discovered through studies of these mice, the properties of USH1 proteins, and their interactions. The embryonic lateral USH1 links between stereocilia and the kinocilium, which are essential to the integrity of the early developing hair bundles, are formed by cadherin-23 and protocadherin-15 working together. Additionally, these two cadherins form the tip-link , which is the apical link that controls the MET channels. Harmonin and sans are scaffold proteins that are necessary for securing the cadherin links to the actin filaments of stereocilia.</p>\n<p>Key components of the hair bundle, such as harmonin and protocadherin-15, must also be transported into the stereocilia via myosin VIIa. The Phosphatidylinositol Phosphatase (PTPRQ) protein has been shown to have distinct effects on vestibular function in mice and humans. A component of the shaft links that connect stereocilia is PTPRQ, which is involved in DFNB84A and DFNA73.</p>\n<p><strong>DEFECT IN MET CHANNEL COMPLEX</strong></p>\n<p> The long-awaited vertebrate MET channel subunits, TMC1 and TMC2, have recently been identified as the core proteins of the MET channel complex. Key interactions with a number of other essential proteins are necessary for the TMC1/2 pore-forming MET channel subunits&rsquo; proper positioning at the stereocilia&rsquo;s tips and for maintaining their functionality. The Transmembrane Inner Ear (TMIE, DFNB6), the Calcium and Integrin-Binding Family Member 2 (CIB2) proteins, and the Lipoma Hmgic Fusion Partner-Like 5 (LHFPL5, also known as TMHS, DFNB67) proteins have been identified as components of the MET machinery at the tips of the transducing stereocilia in auditory and vestibular hair cells. These proteins are in addition to the USH Deafness and vestibular dysfunction result when hair cells lacking most of these proteins consistently exhibit a severe to complete loss of MET currents [<a href=\"#10\" title=\"10\">10</a>].</p>\n<p><strong>TREATMENT STRATEGY</strong></p>\n<p> The vertebrate MET channel subunits TMC1 and TMC2 have recently been discovered to be the MET channel complex&rsquo;s core proteins. The TMC1/2 pore-forming MET channel subunits&rsquo; proper positioning at the stereocilia&rsquo;s tips and their continued functionality (184, 185) depend on key interactions with a number of other essential proteins. Components of the MET machinery that are located at the tips of the transducing stereocilia in auditory and vestibular hair cells have been identified as the Transmembrane Inner Ear (TMIE, DFNB6), the Calcium and Integrin-Binding Family Member 2 (CIB2) proteins, and the Lipoma Hmgic Fusion Partner-Like 5 (LHFPL5, also known as TMHS, DFNB67) proteins . These proteins are notwithstanding the USH Deafness and vestibular brokenness result when hair cells lacking the majority of these proteins reliably show an extreme to finish loss of MET flows [<a href=\"#10\" title=\"10\">10</a>].</p>\n<h4>CONCLUSION</h4>\n<p> Global clinical surveys clearly demonstrate a higher prevalence of vestibular dysfunction than previously thought. Efforts to dissect and comprehend the vestibular system&rsquo;s numerous contributions are being driven by this timely growing awareness of its significance. Even for infants, it is simple to carry out a comprehensive vestibular assessment in clinical practice using the current clinical tests for balance deficits. In the event that hearing loss is discovered, vestibular testing should always be suggested. However, the otolithic organs, cristae, or beyond, in specific neuron subsets of the central vestibular system, remain difficult to detect subtle changes in vestibular function and the precise source of patients&rsquo; vestibular deficits. Current clinical tests can only detect gross vestibular behavioral defects. 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E-mail: marlin2johnson@gmail.com</p>\n<p><strong>Copyright: </strong>&copy; 2023 Johnson MR. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</p>\n<p> <strong>Citation: </strong>Johnson S (2023) Vestibular Neuritis: Pathophysiology, Diagnosis and Treatmnet, Canadian Hearing Report 16: 1</p>\n<p><strong>Received: </strong>1-Feb-2023, <strong>Manuscript No. </strong>ajchr-23-89824;<strong> Editor assigned: </strong>3-Feb-2023, <strong>PreQC No.</strong> ajchr-23-89824(PQ); <strong>Reviewed: </strong>17-Feb-2023, <strong>QC No.</strong>ajchr-23-89824; <strong>Revised: </strong>22-Feb-2023, <strong>Manuscript No.</strong> ajchr-23-89824; <strong>Published: </strong>28-Feb-2023</p>\n<h4>ABSTRACT</h4>\n<p> The condition known as vestibular neuritis affects the inner ear&rsquo;s vestibulocochlear nerve. From your inner ear to your brain, this nerve conveys information about your balance and head position. The way your brain reads information is interrupted when this nerve becomes swollen or inflamed. Vertigo, dizziness, and other balance-related symptoms are the consequences of this. In the United States, approximately 4 out of every 100,000 people suffer from vestibular neuritis. The third most common cause of peripheral vertigo is this condition. Peripheral (inner ear) vertigo affects balance but does not usually prevent them from walking. Vestibular neuritis can happen in individuals, all things considered, however it&rsquo;s less normal in youngsters. Within a week or two, many people&rsquo;s symptoms of vestibular neuritis improve. However, approximately half of those who have the condition experience persistent, chronic symptoms such as unsteadiness, dizziness, or spatial disorientation (the inability to identify one&rsquo;s body position in relation to one&rsquo;s surroundings). In extreme cases, damage to the inner ear or permanent hearing loss may occur.</p>\n<h4> KEYWORDS </h4>\n<p>Vestibular, Neuritis, Vestibulocochlear, Vertigo, dizziness, Spatial disorientation</p>\n<h4>INTRODUCTION</h4>\n<p> A peripheral vestibulopathy known as Vestibular Neuritis (VN) is characterized by severe vertigo that lasts for more than 24 hours and is typically accompanied by nausea and vomiting. We prefer to use the term &ldquo;vestibular neuritis&rdquo; to refer to an acute ischemic or viral vestibular loss because we recently demonstrated that canalith jam can cause acute vestibular loss. VN is characterized by a positive bed-side Head Impulse Test (HIT) on the horizontal plane, Spontaneous Unidirectional Nystagmus (SUN), and reduced or absent caloric response on the involved side. The Central Nervous System (CNS) and auditory function generally remain unaffected. The majority of people experience complete symptoms relief within six months of the onset. VN is thought to be caused by two distinct etiopathogenetic mechanisms, though the exact cause is unknown: an acute ischemia confined to the territory supplied by the anterior vestibular artery or an inflammation affecting the entire vestibular nerve or one of its divisions (possibly as a result of a viral reactivation). Information about the activity of peripheral sensors and afferents can now be easily provided thanks to the recent introduction of fast vestibular testing devices. It is possible to identify specific patterns of lesion affecting labyrinthine end-organs or vestibular nerve divisions by interpreting data obtained by combining the results of Vestibular-Evoked Myogenic Potentials (VEMPs) and video-HIT for an accurate assessment of otolith and semicircular canal involvement, respectively [<a href=\"#1\" title=\"1\">1</a>].</p>\n<p><strong>PATHOPHYSIOLOGY OF VESTIBULAR NEURITIS</strong></p>\n<p> Vestibular neuritis is generally understood to be a viral or post viral inflammatory disorder affecting the vestibular portion of the eighth cranial nerve [<a href=\"#2\" title=\"2\">2</a>]. There are few pathologic data to support this mechanism in patients with this disorder, and a history of a preceding viral illness is elicited in less than one-half of patients [<a href=\"#3\" title=\"3\">3</a>-<a href=\"#6\" title=\"6\">6</a>]. One advanced Magnetic Resonance Imaging (MRI) study revealed a pattern of enhancement consistent with an inflammatory process in 20 of 29 patients with vestibular neuritis [<a href=\"#7\" title=\"7\">7</a>].</p>\n<p><strong>DIAGNOSIS OF VESTIBULAR NEURITIS</strong></p>\n<p> Patients who present with vertigo can be diagnosed with either peripheral or central etiologies, as well as those who have hearing loss or not.</p>\n<p> <strong>POSITIONAL VERTIGO WITH BENIGN PAROXYSMS (BPPV)</strong></p>\n<p> Symptoms manifest as episodic vertigo following predictable head movements. Most of the time, it starts quickly and lasts from a few seconds to a few minutes.</p>\n<p> <strong>MENIERE&rsquo;S ILLNESS</strong></p>\n<p> Symptoms include frequent episodes of vertigo along with tactile side effects (e.g., ear totality, tinnitus, low-recurrence hearing misfortune). The symptoms can last anywhere from minutes to hours.</p>\n<p><strong>LABYRINTHITIS</strong></p>\n<p> Symptoms that are similar to those of vestibular neuritis include unilateral hearing loss and auditory symptoms. The symptoms can last for days or weeks [<a href=\"#8\" title=\"8\">8</a>].</p>\n<p><strong>MIGRAINE OF THE TORSO</strong></p>\n<p> It can show signs and symptoms in the central or peripheral areas. Patients must have a documented migraine diagnosis because they will experience headaches and recurrent episodes. The symptoms last for minutes to hours.</p>\n<p><strong>TIA VERTEBRA BASILAR</strong></p>\n<p> Typically, patients will have vascular risk factors. Acute onset and shorter symptoms. The symptoms last from minutes to hours.</p>\n<p><strong>ISCHEMIA/INFARCT OF THE BRAINSTEM</strong></p>\n<p> Patients frequently have trauma histories or vascular risk factors. An infarct of the lateral medulla is characterized by the presence of a constellation of neurological symptoms in addition to vertigo. This condition is referred to as the Wallenberg syndrome. The symptoms last from a few days to a few weeks and begin immediately.</p>\n<p><strong>HEMORRHAGE OR INFARCTION OF THE CEREBELLUM</strong></p>\n<p> Typically, vascular risk factors or trauma are present. An abnormal HINTS exam, truncal instability, headache, ipsilateral Horner syndrome, limb ataxia, an abnormal pupillary response, and other neurological abnormalities are typically present in conjunction with the acute onset of symptoms [<a href=\"#9\">9</a>].</p>\n<p><strong>TREATMENT</strong></p>\n<p> Symptomatic therapy, specific drug therapy, and vestibular rehabilitation therapy are among the many reported treatments for vestibular neuritis. By explaining in detail the patient&rsquo;s vestibular neuritis&rsquo; cause, treatment, and prognosis, symptomatic therapy reduces anxiety and provides psychological support by explaining that daily life is possible within a short time frame. Additionally, it ensures that the patient is in the most comfortable position and that falls do not cause additional harm. Nausea and vomiting are common symptoms during the acute phase of vestibular neuritis. Therefore, vestibular suppressants and anti emetics should be given if food intake is difficult and appropriate fluid therapy is required.</p>\n<p>Because they prevent dizziness, nausea, and vomiting, vestibular suppressants are widely used. The neurotransmitters that are responsible for the propagation of impulses from primary to secondary vestibular neurons and the maintenance of tone in the vestibular nuclei are affected by vestibular suppressants, although the precise mechanism of action of these drugs is unknown. They also act on parts of the nervous system that control vomiting, like the brain&rsquo;s emetic center and the gastrointestinal tract&rsquo;s peripheral parts.</p>\n<p>Through vestibular compensation and central neuroplasticity, the objectives of vestibular rehabilitation therapy are to improve vertigo, gaze stability, postural stability, and activities of daily living. There are two types of vestibular compensation: static and dynamic. Static remuneration is normally credited to the rebuilding of evenness in the resting release paces of auxiliary neurons on the different sides of the brainstem [<a href=\"#10\" title=\"10\">10</a>].</p>\n<h4>CONCLUSION </h4>\n<p> A representative form of peripheral vertigo is called vestibular neuritis, also known as vestibular neuritis. Viral infection, ischemia, and immune-mediated mechanisms are the primary unidentified causes of vestibular neuritis. The abrupt true-whirling vertigo that lasts for more than 24 hours and the absence of cochlear and other neurological symptoms and signs are the clinical hallmarks of vestibular neuritis. Various diagnostic tests, including the head impulse test, bithermal caloric test, and vestibular-evoked myogenic potential test, are used to accurately diagnose vestibular neuritis. For the treatment of vestibular neuritis, symptomatic therapy, specific drug therapy, and vestibular rehabilitation therapy have been studied and implemented. 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H., et al. &ldquo;<a href=\"v\" target=\"_blank\">Current diagnosis and treatment of vestibular  neuritis: a narrative review.</a>J Yeungam Med Sci, 39 (2) (2022): 81-88. </li>\n  <p align=\"right\"> <a href=\"https://pubmed.ncbi.nlm.nih.gov/36672540/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"https://doi.org/10.3390/biomedicines11010032\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"https://scholar.google.com/scholar?q=Tesa%C5%99ov%C3%A1,+M.+%26+Peterkov%C3%A1,+L.,+%E2%80%9CTumor+Biology+and+Microenvironment+of+Vestibular+Schwannoma-Relation+to+Tumor+Growth+and+Hearing+Loss%E2%80%9D.+Biomedicines,+11(1)+(2020):+32.+&amp;hl=en&amp;as_sdt=0,5\" target=\"_blank\"><u>Google Scholar</u></a></p>\n</ol>\n<h4>Vestibular Schwannoma: A Rare Disease of Inner Ear and it&rsquo;s Diagnosis, Treatment</h4>\n<p><strong>By Marlin R Johnson*</strong></p>\n<h4>ABSTRACT</h4>\n<p> The most prevalent benign neoplasm of the cerebellopontine angle is a schwannoma of the vestibule. It comes from the vestibular nerve&rsquo;s Schwann cells. Hearing loss, tinnitus, and vestibular symptoms are the first signs of vestibular schwannoma. Cerebellar and brainstem symptoms, in addition to palsy of the adjacent cranial nerves, may be present in the event of further growth. Although 95% of patients diagnosed with vestibular schwannoma have hearing loss, the majority of tumors do not grow in size or at all. However, there are currently no reliable predictors of the tumor&rsquo;s behavior, and the clinical picture has unpredictable dynamics. In patients with vestibular schwannoma, the cause of hearing loss is unknown. A purely mechanistic approach is insufficient because patients with non-growing tumors have hearing loss. The paracrine activity of the tumor may have an impact on the auditory system&rsquo;s function, which is one possible explanation. In addition, the beginning stages of the growth and development of vestibular schwannomas are still poorly understood. The NF2 gene mutation cannot be explained by biallelic loss in all patients; consequently, in cases of progressive growth, gene expression abnormalities must be detected. Therefore, understanding the molecular mechanisms of tumor genesis and the interactions among the tumor&rsquo;s cells is essential for tumor diagnosis, behavior prediction, and targeted therapeutic interventions.</p>\n<h4> KEYWORDS</h4>\n<p>Schwannoma, Cerebellopontine, Schwann cells, Tumor genesis, Paracrine activity, Auditory system</p>\n<h4>INTRODUCTION</h4>\n<p> The most common tumor of the cerebellopontine angle is a schwannoma called VS. The Schwann cells of the vestibular portion of the vestibule cochlear nerve are the source of this benign tumor. VSs develop in the inner auditory canal, near the meatus, or in the peripheral zone of the superior or inferior vestibular nerve, lateral to the oligodendrocyte/Schwann cell junction. These tumors make up between 80 and 95 percent of cerebellopontine angle tumors and about 10 percent of all intracranial tumors. The annual incidence of VS ranges from 10 to 15 per million people, with females experiencing a slight advantage over males. Sensor neural hearing loss, tinnitus, and vestibular symptoms are early VS symptoms of this disease. Additional cranial nerve palsies and cerebellar and brainstem symptoms may be present in the event of further growth. The clinical symptoms, audiometric testing, and magnetic resonance imaging all suggest a diagnosis. The inconsistent definitions of tumor growth, measurement methods, and follow-up periods are probably to blame for the wide range of percentages of growing tumors found in various studies&mdash;from 15 to 85 percent. However, during follow-up, the majority of tumors exhibit an indolent growth pattern, i.e., there is no growth or very slow growth rates. The patient&rsquo;s age, comorbidities, preference, tumor size, hearing and facial nerve status, vestibular symptoms, and preference all contribute to the indication for an active approach. In addition, the root causes of VS tumor genesis are still poorly understood [<a href=\"#1\" title=\"1\">1</a>, <a href=\"#2\" title=\"2\">2</a>].</p>\n<p><strong>GENETIC PREDISPOSITION TO GENERATE SCHWANNOMA</strong></p>\n<p> In addition to LZTR1, biallelic loss of NF2 is thought to be necessary for the more complicated mechanism of schwannoma formation caused by a germline pathogenic variant in LZTR1 on chromosome 22. A known cause of schwannoma predisposition 1 is heterozygous loss of function pathogenic variants in LZTR1, which are responsible for about 30% of both inherited and sporadic cases of schwannoma. Through the SMARCB1 and LZTR1 pathways, these three events, four hit mechanism is now well established as the cause of schwannomas. Despite the fact that schwannomatosis can happen irregularly or in a familial way, the familial structure is more uncommon. Three distinct mutational events provide an explanation for a genetic mechanism associated with schwannomatosis. While the second and third hits are somatic mutations, the first hit is a germline mutation. The most well-known genetic abnormality in schwannomatosis patients is the germline mutation in SMARCB1 (SWI/SNF-related, matrix-associated, actin-dependent regulator of chromatin, subfamily B member). Although they did not have constitutional first hit SMARCB1 variants, a portion of 22q was deleted in several subsets of patients. In approximately 80% of patients with 22q-related schwannomatosis lacking variants in SMARCB1, LZTR1 (Leucine zipper-like transcriptional regulator 1 [MIM60057]) is a major gene predisposed to an autosomal dominant inherited disorder of multiple schwannomas. The genetic associations of approximately 10% of familial and 90% of sporadic schwannomatosis remain unknown, despite the fact that these two variants are responsible for the occurrence of the majority of known cases [<a href=\"#3\" title=\"3\">3</a>].</p>\n<p><strong>MOLECULAR MARKERS IN DIAGNOSIS OF VESTIBULAR SCHWANNOMA</strong></p>\n<p> Copy Number Alteration (CNA) and point variants on blood or tumor DNA have been used routinely to identify pathogenic variants using multistep and sequential methods to date. In this study, it was demonstrate that CNAs and point variants in NF2, SMARCB1, LZTR1, and SMARCE1 can be quickly and accurately detected using targeted Next Generation Sequencing (NGS). An unambiguous diagnosis of NF2, schwannomatosis, or meningiomatosis can be made with this integrated approach. In addition, we demonstrate that targeted NGS is a sensitive and effective method for finding NF2 mutations with a low Variant Allele Frequency (VAF) in DNA taken from NF2 patients&rsquo; frozen tumors, Formalin Fixed Paraffin Embedded (FFPE), or blood. The sequential diagnosis steps are much crutial and sensitive [<a href=\"#4\" title=\"4\">4</a>].</p>\n<p><strong>METHODOLOGIES TO IDENTIFY GENETIC PREDISPOSITION</strong></p>\n<p> In the beginning of the identification process the extraction of DNA from patient sample was done. Amplification, purification, emulsion PCR, enrichment, loading on Ion 316 chips, and sequencing with an Ion Personal Genome Machine (PGM) are all steps in the NGS library preparation process. After that the NGS bioinformatics analysis and identification process was performed on Torrent Mapping Alignment Program. Sequential identification of single and multiexon deletion or duplication in association of variant confirmation was done using the process of Sanger sequencing. Using MLPA Analysis, Confirmation of Single and Multi Exon Deletion and Duplication in NF2 and SMARCB1 was done. Multiplex PCR methodology was performed to identify single and multi-exon deletion in NF2 and SMARCB1.</p>\n<p>The QX100 Droplet Digital PCR System (BioRad) was used for droplet digital PCR in accordance with the manufacturer&rsquo;s instructions. Using PCR primers (5-gggaggagagaattactgctggta-3 / 5-ggaatgtaaa ccaacaatgaatgg-3), as well as probes (5-VIC-caccgaggcCgag-3 MGB non-fluorescent quencher / 5-FAM-caccgaggcTgag-3 MGB non-fluorescent quencher), as described previously, duplex PCR. The characterization of NF2 breakpoint was performed using long range PCR technology. On request, the primer sequences and PCR conditions used to characterize the tandem duplications and deletions in NF2 can be obtained. As previously mentioned, Sanger sequencing was used to sequence PCR products [<a href=\"#4\" title=\"4\">4</a>].</p>\n<p><strong>FACTORS AFFECTING TUMOR MICROENVIRONMENT</strong></p>\n<p> Tumor-causing Schwann cells, axons, macrophages, T cells, fibroblasts, blood vessels, and an extracellular matrix all make up Sch [<a href=\"#5\" title=\"5\">5</a>]. M-CSF and IL-34 levels that may regulate the chemotaxis of tumor-associated macrophages (TAMs) were high in rapidly growing VSs. TAMs cause tumor growth by producing growth factors and cytokines that suppress the immune response of the host. A key factor in the transition from the M1 to M2 macrophage phenotype is VEGF in the hypoxic tumor microenvironments [<a href=\"#6\" title=\"6\">6</a>].</p>\n<p>Nearly all specimens contained 11 NF2-associated Schs, high levels of programmed death-ligand 1 (PD-L1) expression, and TAMs and T lymphocytes [<a href=\"#7\" title=\"7\">7</a>]. CD4+CD25+Foxp3+ regulatory T cells (Tregs) are important for suppressing tumor-specific immunity and for playing an active and significant role in the progression of tumors [<a href=\"#8\">8</a>].</p>\n<p><strong>INFLAMMATION AND STRESS REACTION IN GENERATION OF SCHWANNOMA</strong></p>\n<p> Sporadic and NF2-related VS proliferation are associated with cyclooxygenase 2 (COX-2) expressions. The Hippo pathway, in which YAP can promote COX-2 transcription for the production of prostaglandin, can be activated by mutations in the NF2 gene. Inflammation, immune monitoring, cell proliferation, apoptosis, angiogenesis, and PGE2, which are catalyzed by COX-2, play multiple roles. COX-2 inhibitors may be able to prevent VS from growing [<a href=\"#9\" title=\"9\">9</a>]. The molecule known as heat shock protein 90 (HSP90) is found everywhere. Proteasomal degradation occurs when Hsp90 is absent. NXD30001 (pochoxime A), a novel small-molecule HSP90 inhibitor, was found to inhibit the in vivo growth of NF2-deficient tumors. An HSP90 inhibitor is currently not being used in any clinical trials [<a href=\"#10\" title=\"10\">10</a>].</p>\n<p><strong>TREATMENT STRATEGIES</strong></p>\n<p><strong> DRUG REPOSITIONING</strong></p>\n<p> The most promising candidate drug was selected as mifepristone (RU486), a progesterone and glucocorticoid receptor antagonist that has already been approved for medical abortion. Mifepristone reduced cellular proliferation in primary human VS cultures in a preclinical study, regardless of NF2 mutation. Mifepristone is the subject of a planned phase II clinical trial in VS Patients with impaired hearing exhibited significant up regulation of NLRP3-associated genes in VS. Cochlear auto inflammation, DFNA34 mediated hearing loss, and age-rated hearing losses are all linked to the NLRP3 mutation. The production of IL-1 is sparked by the activation of NLRP3. A family with sensory neural hearing loss and NLRP3 mutations had their hearing loss reversed by using a recombinant human IL-1 receptor antagonist [<a href=\"#11\" title=\"11\">11</a>].</p>\n<p><strong>GENE THERAPY</strong></p>\n<p> Numerous inherited and acquired human diseases can be treated with gene therapy. The most effective treatment for NF2 patients is direct modulation of affected genes in particular cell types. Typically, delivery platforms include viral vectors, such as retroviruses, adenoviruses, and Adeno Associated Viruses (AAVs), as well as non-viral vectors, including nanoparticles and polymers [<a href=\"#12\" title=\"12\">12</a>].</p>\n<h4>CONCLUSION</h4>\n<p> The patient&rsquo;s age, sex, and geographical proximity to the tertiary medical center are all associated with the initial treatment pathway for VS. The most significant factors influencing the treatment plan were clinical characteristics like hearing level, Koos classification, and tumor size. 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This is an open-access article distributed under the terms of the Creative Commons Attribution License,   which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</p>\r\n<p><strong>Citation: </strong>Acharya R (2023) A State-Of-The-Art Finite Element Human Ear Model to Predict Noise-Induced Hearing Impairment Related to   Work-Related Noise, Canadian Hearing Report 16: 3</p>\r\n<p><strong>Received: </strong>02-Jun-2023, <strong>Manuscript No.</strong> ajchr-23-103032;<strong> Editor assigned: </strong>05- Jun -2023, <strong>Pre QC No.</strong> ajchr-23- 103032 (PQ); <strong>Reviewed:</strong> 19- Jun -2023, <strong>QC No.</strong> ajchr-23-103032; <strong>Revised: </strong>23- Jun-2023, <strong>Manuscript No. </strong>ajchr-23-103032; <strong>Published: </strong>30- Jun-2023</p>\r\n<h4>ABSTRACT</h4>\r\n<p>Noise-induced hearing impairment (NIHI) is a significant occupational health concern affecting individuals exposed   to excessive noise levels in various work environments. The accurate prediction and assessment of NIHI is   crucial for preventing occupational hearing loss and ensuring worker safety. This abstract presents a state-of-theart   finite element human ear model specifically designed to predict and analyze NIHI related to work-related   noise.The developed finite element model incorporates anatomical details and biomechanical properties of the   human ear, including the outer, middle, and inner ear structures. It simulates the complex interactions between   sound waves, ear anatomy, and tissue mechanics to accurately estimate the impact of work-related noise on   hearing the proposed finite element human ear model provides several advantages over traditional prediction   methods, such as simplifying the assessment of NIHI in different occupational settings. It offers a versatile platform   for evaluating the effectiveness of hearing protection devices, designing optimal noise control strategies,   and optimizing workplace safety protocols. This state-of-the-art finite element human ear model represents a   significant advancement in the prediction of work-related NIHI. By incorporating detailed anatomical structures   and tissue properties, the model provides a comprehensive understanding of the impact of noise exposure on   hearing impairment. This research contributes to the development of effective preventive measures, enhancing   occupational health and safety standards in industries exposed to high noise levels.</p>\r\n<h4>Keywords</h4>\r\n<p>Hearing impairment, Human ear, Ear anatomy, Hearing impact, Environment</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>Noise-induced hearing impairment is a   significant occupational health concern,   particularly in industries where workers   are exposed to high levels of noise. The   ability to predict and assess the potential   damage caused by work-related noise is   crucial for designing effective hearing   conservation programs. In recent years,   finite element modelling (FEM) has   emerged as a powerful tool to study the   complex biomechanics of the human ear   and its response to noise [<a href=\"#1\" title=\"1\">1</a>]. This article   presents a state-of-the-art finite element   human ear model developed to predict   noise-induced hearing impairment   associated with work-related noise   exposure [<a href=\"#2\" title=\"2\">2</a>].</p>\r\n<p><strong>UNDERSTANDING NOISEINDUCED   HEARING IMPAIRMENT</strong></p>\r\n<p>Noise-induced hearing impairment   occurs due to prolonged or intense   exposure to high levels of noise. The   inner ear, particularly the cochlea,   is susceptible to damage caused by   excessive noise. Exposure to loud   noises leads to mechanical vibrations   that disrupt the delicate structures   within the cochlea, resulting in the loss   of sensory hair cells and damage to the   auditory nerve. The severity of hearing   impairment depends on the intensity,   duration, and frequency characteristics   of the noise exposure [<a href=\"#3\" title=\"3\">3</a>,<a href=\"#4\" title=\"4\">4</a>].</p>\r\n<p><strong>FINITE ELEMENT MODELLING OF   THE HUMAN EAR</strong></p>\r\n<p>Finite element modelling is a   computational technique that allows for   the simulation of complex mechanical   systems by dividing them into small   elements. In the context of the human   ear, a finite element model can represent   the intricate anatomy and biomechanical behaviour of the ear structures [<a href=\"#5\" title=\"5\">5</a>]. It   enables the study of how noise-induced   vibrations propagate through the ear and   interact with its components, providing   insights into the mechanisms of hearing   impairment [<a href=\"#6\" title=\"6\">6</a>].</p>\r\n<p><strong>KEY COMPONENTS OF THE FINITE   ELEMENT HUMAN EAR MODEL</strong></p>\r\n<p>The finite element human ear model   incorporates anatomical data obtained   from medical imaging techniques such   as magnetic resonance imaging (MRI)   and micro-computed tomography   (micro-CT). The model includes the   external ear, middle ear, inner ear, and   associated structures. Each component   is represented by a mesh of finite   elements, and their interactions are   simulated using appropriate material   properties and boundary conditions [<a href=\"#7\" title=\"7\">7</a>].</p>\r\n<p><strong>SIMULATING NOISE EXPOSURE   AND ASSESSING DAMAGE</strong></p>\r\n<p>The finite element ear model allows for   the simulation of various noise exposure   scenarios encountered in the workplace.   By inputting noise data such as frequency   spectrum, sound pressure level, and   duration, the model can predict how the   cochlea responds to the noise-induced   vibrations. The analysis includes studying   stress and strain distributions within   the cochlear structures, evaluating the   potential damage to sensory hair cells,   and predicting the resulting hearing   impairment [<a href=\"#8\" title=\"8\">8</a>].</p>\r\n<p><strong>VALIDATION AND APPLICATION</strong></p>\r\n<p>To ensure the accuracy and reliability of the model, it is essential to validate its   predictions against experimental data   from human subjects exposed to known   noise levels. Comparisons between   simulated and measured data help refine   the model and improve its predictive   capabilities [<a href=\"#9\" title=\"9\">9</a>]. Once validated, the finite   element ear model can be used to assess   the effectiveness of hearing protection   devices, evaluate workplace noise   control measures, and optimize hearing   conservation strategies [<a href=\"#10\" title=\"10\">10</a>,<a href=\"#11\" title=\"11\">11</a>].</p>\r\n<h4>CONCLUSION</h4>\r\n<p>The development of a state-of-theart   finite element human ear model   offers a valuable tool for predicting   and understanding noise-induced   hearing impairment related to workrelated   noise exposure. By simulating   the complex mechanics of the ear and   its response to noise, this model can   assist in the design of effective hearing   conservation programs, ultimately   protecting workers&rsquo; hearing health   in noisy occupational environments.   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2023 Rajput V. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which   permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</p>\r\n<p><strong>Citation: </strong>Rajput V (2023) Brainstem Auditory Physiology in Children with Hearing Impaired, Canadian Hearing Report 16: 3</p>\r\n<p><strong>Received: </strong>02-Jun-2023, <strong>Manuscript No. </strong>ajchr-23-103034; <strong>Editor assigned:</strong> 05- Jun -2023, Pre <strong>QC No.</strong> ajchr-23- 103034 (PQ); <strong>Reviewed:</strong> 19- Jun -2023, <strong>QC No.</strong> ajchr-23-103034; Revised: 23- Jun-2023, <strong>Manuscript No. </strong>ajchr-23-103034; <strong>Published:</strong> 30- Jun-2023</p>\r\n<h4>ABSTRACT</h4>\r\n<p>On Hearing impairment in children significantly impacts their auditory processing abilities and communication   skills. Understanding the underlying neurophysiological mechanisms involved in auditory processing is crucial   for developing effective interventions and treatment strategies. This abstract provides a concise overview of   brainstem auditory physiology in children with hearing impairment, highlighting key research findings and   implications for clinical practice. The brainstem plays a fundamental role in auditory processing, serving as the   initial site for encoding and relaying auditory information from the cochlea to higher-level auditory centres   in the brain. In children with hearing impairment, alterations in brainstem auditory physiology are often   observed, reflecting the effects of peripheral hearing loss on central auditory pathways. The specific alterations   in brainstem auditory physiology observed in children with hearing impairment can vary depending on the   ethology, degree, and duration of the hearing loss. For instance, children with congenital hearing loss may exhibit   different patterns of ABR abnormalities compared to those with acquired hearing loss. Additionally, the severity   of hearing impairment has been found to correlate with the magnitude of brainstem auditory dysfutioncn, with   more profound hearing loss often associated with more pronounced abnormalities in ABR characteristics.</p>\r\n<p>The relationship between brainstem auditory physiology and behavioural outcomes is essential for designing   targeted interventions. Recent research has highlighted the potential for using neurophysiological measures,   such as ABR, as objective biomarkers for predicting and monitoring treatment outcomes in children with hearing   impairment. By examining the neurophysiological changes following interventions, researchers and clinicians can   gain insights into the neuroplasticity of the auditory system and evaluate the efficacy of interventions, including   hearing aids, cochlear implants, and auditory training programs. Brainstem auditory physiology is significantly   influenced by hearing impairment in children. Abnormalities in the brainstem responses, as measured by ABR,   provide valuable insights into the functional integrity of the auditory system and can serve as objective markers   of hearing impairment. Further research in this area is necessary to unravel the complex relationship between   brainstem auditory physiology, hearing impairment ethology, and long-term auditory outcomes in children. This   knowledge can contribute to the development of personalized and evidence-based interventions to optimize   auditory function and improve communication skills in children with hearing impairment.</p>\r\n<h4>Keywords</h4>\r\n<p>Neurophysiological mechanisms, Brainstem auditory physiology, Hearing impairment, Auditory dysfutioncn, Biomarkers</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>Hearing impairment in children is a   significant health concern with farreaching   effects on their overall   development and quality of life. The   brain&rsquo;s ability to process auditory   information plays a crucial role in   speech and language acquisition, social   interaction, and cognitive development.   Understanding the brainstem auditory   physiology in children with hearing   impairment is vital for diagnosing and   managing their condition effectively. This   article aims to explore the complexities   of brainstem auditory physiology in   children with hearing impairment and its   implications for clinical practice [<a href=\"#1\" title=\"1\">1</a>, <a href=\"#2\" title=\"2\">2</a>].</p>\r\n<p><strong>THE BRAINSTEM AUDITORY   PATHWAY</strong></p>\r\n<p>The brainstem auditory pathway consists of a series of neural structures   responsible for transmitting and   processing auditory signals from the ear   to higher auditory centres in the brain.   In children with normal hearing, this   pathway operates seamlessly, allowing   for efficient auditory processing.   However, in children with hearing   impairment, abnormalities may arise at   various stages of the pathway, affecting   their ability to perceive and interpret   sounds accurately [<a href=\"#3\" title=\"3\">3</a>].</p>\r\n<p><strong>IMPAIRED AUDITORY PROCESSING</strong></p>\r\n<p>The brainstem plays a critical role   in encoding and relaying auditory   information to higher auditory centres.   In children with hearing impairment,   disruptions in this process can occur due   to various factors, including congenital   hearing loss, acquired hearing loss,   or auditory processing disorders [<a href=\"#4\" title=\"4\">4</a>].   These disruptions can lead to delays or   distortions in sound perception, affecting   speech and language development.</p>\r\n<p><strong>ABNORMALITIES IN AUDITORY   BRAINSTEM RESPONSE (ABR)</strong></p>\r\n<p>Auditory Brainstem Response (ABR)   is an electrophysiological test that   measures the brain&rsquo;s response to sound   stimuli. It provides valuable information   about the integrity of the auditory   pathway, particularly the brainstem. In   children with hearing impairment, ABR   recordings often exhibit prolonged   latencies and reduced amplitudes   compared to children with normal   hearing. These abnormalities indicate   impaired transmission of auditory   signals through the brainstem, reflecting   the underlying pathophysiology of their   hearing loss [<a href=\"#5\" title=\"5\">5</a>, <a href=\"#6\" title=\"6\">6</a>].</p>\r\n<p><strong>PLASTICITY AND ADAPTIVE   CHANGES</strong></p>\r\n<p>The brain exhibits remarkable plasticity especially during early childhood. In   children with hearing impairment, the   brain undergoes adaptive changes to   compensate for the lack of auditory input.   These changes can manifest as increased   activation in cortical areas associated   with visual processing and language   functions [<a href=\"#7\" title=\"7\">7</a>]. However, the extent and   effectiveness of these adaptive changes   vary among individuals, contributing to   the heterogeneity observed in auditory   outcomes among children with hearing   impairment.</p>\r\n<p><strong>CLINICAL IMPLICATIONS</strong></p>\r\n<p>Understanding brainstem auditory   physiology in children with hearing   impairment has several clinical   implications. Firstly, it aids in the early   identification of hearing loss, allowing   for timely intervention and appropriate   management strategies. Secondly,   knowledge of the specific brainstem   abnormalities can guide the selection   and fitting of hearing aids or cochlear   implants to optimize auditory outcomes   [<a href=\"#8\" title=\"8\">8</a>, <a href=\"#9\" title=\"9\">9</a>]. Finally, an understanding of adaptive   changes in the brain can inform targeted   rehabilitation programs to enhance   speech and language development [<a href=\"#10\" title=\"10\">10</a>].</p>\r\n<h4>CONCLUSION</h4>\r\n<p>Brainstem auditory physiology in   children with hearing impairment is   a complex and multifaceted subject.   The disruptions in auditory processing   observed in these children highlight the   importance of comprehensive audio   logical assessments that encompass   both peripheral and central auditory   mechanisms. 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Acta Neurol (Napoli), 14(1992): 345-362.</li>\r\n    <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/1293978/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:doi:%2010.1007/BF02343494.\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Clinical+and+electrophysiological+findings+in+various+hereditary+sensory+neuropathies&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n</ol>\r\n<h4>Infants between the Ages of One and 24 Months&rsquo;   Brainstem Auditory Evoked Potentials during a   Hearing Health Service</h4>\r\n<p><strong>By Bianca Langh*</strong></p>\r\n<p>Department of Clinical Medicine, University of Copenhagen, Denmark</p>\r\n<p><strong> *Corresponding author: </strong>Department of Clinical Medicine, E-mail: Biankalang14@gmail.com</p>\r\n<p><strong>Copyright: </strong>&copy; 2023 Langh B. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which   permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</p>\r\n<p><strong>Citation: </strong>Langh B (2023) Infants between the Ages of One and 24 Months&rsquo; Brainstem Auditory Evoked Potentials during a Hearing Health   Service, Canadian Hearing Report 16: 3</p>\r\n<p><strong>Received: </strong>02-Jun-2023, <strong>Manuscript No. </strong>ajchr-23-103035; <strong>Editor assigned: </strong>05- Jun -2023, <strong>Pre</strong> <strong>QC No.</strong> ajchr-23- 103035 (PQ); <strong>Reviewed:</strong> 19- Jun -2023, <strong>QC No. </strong>ajchr-23-103035; <strong>Revised:</strong> 23- Jun-2023, <strong>Manuscript No.</strong> ajchr-23-103035;<strong> Published: </strong>30- Jun-2023</p>\r\n<h4>ABSTRACT</h4>\r\n<p>To evaluate the advantages and level of satisfaction experienced by adult and senior patients who have received   hearing aids from a service recognised by the Brazilian Public Health Service.34 persons with bilateral hearing   loss, aged 18 or older, who had never been given hearing aids participated in this descriptive cross-sectional   study. The effectiveness of the hearing aids was evaluated using the &ldquo;Hearing Handicap Inventory for Adults&rdquo;   and &ldquo;Hearing Handicap Inventory for the Elderly Screening Version&rdquo; scales. Patient satisfaction was measured   using the &ldquo;Satisfaction with Amplification in Daily Life&rdquo; scale. The third was administered just one month after   the patients had their hearing aids installed, as opposed to the previous two, which were applied on the day of the   patients&rsquo; hearing aid fitting and one month later. Significant improvements were observed in the challenges the   individuals had as a result of their hearing loss once hearing devices were made available to them. The Satisfaction   with Amplification in Daily Life scale results showed a high level of patient satisfaction. When gender and age   (adult/elderly) subgroups were evaluated, the findings did not statistically vary. Participants have benefited from   having hearing aids installed, and they are pleased with the results of the therapy.</p>\r\n<h4>Keywords</h4>\r\n<p>Hearing loss, Hearing aids, Auditory, Health service</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>For each person, the ability to   communicate is essential. In addition   to being essential for social and familial   connections, it enables the accumulation   of information and experience. People   get isolated and depressed when   communication is restricted, which   hinders the development of personal   connections.1. For a very long time,   hearing loss was thought to be a fatal   illness [<a href=\"#1\" title=\"1\">1</a>]. There has been a lot of   work done recently to de-stigmatize   deafness and encourage enhancements   in the quality of life for those who have   hearing loss. Auditory rehabilitation is a   procedure created to help patients get   over obstacles that prevent them from   fully participating in activities of daily   living and to lessen the disadvantage   that the hearing impaired experience3.   The practise of auditory rehabilitation   helps people to regain their social their   daily life and engage in social activities,   which boost their wellbeing and sense   of self4. The procedure of auditory   rehabilitation takes into account, among   other things, the fitting of hearing   aids. To lessen the negative impacts of   hearing loss, many gadgets have been   invented and improved [<a href=\"#2\" title=\"2\">2</a>]. The patient   must wear the device appropriately for   the selection and fitting of hearing aids   to be successful and result in positive   results. Patients also need to understand   the advantages of using hearing aids and   be satisfied with the results the device   produces in order for them to adhere   to the course of treatment6. Health care   practitioners might determine a course   of action using the performance of   hearing aids as reported by their users,   in addition to patients to understand the   benefits of using the devices over dealing   with the difficulties of hearing loss,   enhancing treatment compliance and   overall patient satisfaction6. An essential   element in evaluating clinical practises   and healthcare service quality objectives   is tracking patient satisfaction levels and   their perspectives while using hearing   aids [<a href=\"#3\" title=\"3\">3</a>]. Health services may greatly   increase the efficacy of the treatment   they offer once the elements linked to   patient satisfaction are identified7. To   determine the advantages and limitations patients experience while using hearing   aids, one can utilise objective evaluations   using formal speech recognition tasks or   subjective testing based on the benefits   patients perceive and the challenges they   confront on a daily basis.8. Treatment   strategies have been evaluated using   self-assessment measures. as well as the   success of therapy. Effectiveness may be   calculated as a function of areas of focus,   patient satisfaction, and the decline in   impairments and handicaps. The Hearing   Handicap Inventory for Adults (HHIA)   10 and the Hearing Handicap Inventory   for the Elderly Screening Version   (HHIE-S) 11, both created to measure   the personal impact of hearing loss, are   the scales that are most commonly used   to evaluate the advantages provided   by hearing aids [<a href=\"#4\" title=\"4\">4</a>]. Studies12, 13 have   shown that these scales are reliable and   effective.</p>\r\n<h4>DISCUSSION</h4>\r\n<p>The satisfaction levels of adult and   senior patients fitted with hearing aids   at various stages were examined in a   research conducted previously6 in the   same setting as this investigation. The   study reported a mean global score of   6.1, indicating users were fairly happy   with their devices. The improvement   seen after wearing hearing aids for   one month appears to generate more   satisfaction than when satisfaction is   measured after patients have worn   their hearing aids for multiple months,   according to a study that only included   new hearing aid users and found a higher   mean global score (6.8) [<a href=\"#5\" title=\"5\">5</a>].There was   no difference in the levels of satisfaction   between adult and senior patients,   showing that patients valued their health   and the improvements to their quality of   life more.</p>\r\n<p><strong>THE IMPORTANCE OF HEARING   AIDS</strong></p>\r\n<p>Hearing aids are electronic devices   designed to amplify sound for individuals   with hearing loss, thereby improving their   ability to communicate and participate   in daily activities. These devices consist   of a microphone, amplifier, and speaker,   which work together to receive, amplify,   and deliver sound to the wearer&rsquo;s ears [<a href=\"#6\" title=\"6\">6</a>].</p>\r\n<p><strong>AUDITORY SATISFACTION AND   QUALITY OF LIFE</strong></p>\r\n<p>For individuals with hearing loss,   auditory satisfaction plays a crucial role   in their overall quality of life. Hearing   aids can significantly impact various   aspects of daily living, including social   interactions, professional engagement,   and emotional well-being. By improving   auditory perception, hearing aids enable   individuals to better understand speech,   enjoy music, and engage in conversations,   leading to enhanced communication and   social participation [<a href=\"#7\" title=\"7\">7</a>].</p>\r\n<p><strong>BENEFITS OF HEARING AIDS IN   THE BRAZILIAN PUBLIC HEALTH   SERVICE</strong></p>\r\n<p>Accessible and affordable: The   Brazilian Public Health Service aims   to make hearing aids accessible to all   individuals in need, particularly those   with limited financial resources. By   providing hearing aids free of charge or   at reduced costs, the service ensures   that patients from diverse socioeconomic   backgrounds can benefit   from these devices [<a href=\"#8\" title=\"8\">8</a>]. Customized   Fittings: Hearing aids offered by the   Brazilian Public Health Service are fitted   based on individual needs. Audiologists   and hearing care professionals assess   patients&rsquo; hearing profiles and tailor the   devices to provide optimal amplification   for their specific hearing loss patterns.   This personalized approach ensures that   patients receive devices that best suit   their auditory requirements.</p>\r\n<p><strong>TECHNOLOGICAL   ADVANCEMENTS</strong></p>\r\n<p>The hearing aids provided through   the Brazilian Public Health Service   incorporate the latest technological   advancements. These devices feature   digital signal processing, noise reduction   algorithms, and directional microphones,   which enhance speech intelligibility in   challenging listening environments. The   use of advanced technology enables   patients to experience improved   sound quality and better auditory   performance. Rehabilitation and   Support: In addition to providing hearing   aids, the Brazilian Public Health Service   offers comprehensive rehabilitation and   support services. These services include   counselling, auditory training, and   follow-up appointments to ensure that   patients adapt well to their hearing aids   and maximize their benefit. The support system ensures that patients receive ongoing   care and assistance throughout   their hearing journey [<a href=\"#9\" title=\"9\">9</a>,<a href=\"#10\" title=\"10\">10</a>].</p>\r\n<h4>CONCLUSION</h4>\r\n<p>The provision of hearing aids through   the Brazilian Public Health Service   plays a vital role in improving the   auditory satisfaction and quality of   life of individuals with hearing loss.   By offering accessible and affordable   devices, customized fittings, advanced   technology, and comprehensive support   services, the service empowers patients   to overcome communication barriers   and actively engage in society. The   continued focus on auditory satisfaction   and the benefits offered by hearing aids   contribute to the overall well-being and   inclusion of individuals with hearing loss   in Brazil.</p>\r\n<h4>REFERENCES</h4>\r\n<ol>\r\n    <li><a name=\"1\" id=\"1\"></a>Shannon, M., &ldquo;<a href=\"mailto:https://eric.ed.gov/?id=EJ306786\" target=\"_blank\">Hearing screening of high-risk newborns with brainstem  auditory evoked potentials: a follow-up study</a>.&rdquo; Pediatrics, 73 (1) (1984): 22- 26.</li>\r\n    <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/6691039/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1542/peds.73.1.22\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Hearing+screening+of+high-risk+newborns+with+brainstem+auditory+evoked+potentials%3A+a+follow-up+study&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n    <li><a name=\"2\" id=\"2\"></a>Hecox, K. &amp; 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This is an open-access article distributed under the terms of the Creative Commons Attribution License, which   permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</p>\r\n<p><strong>Citation: </strong>Singh R (2023) Multidisciplinary Committee Hearing Health &ndash; Comusa, Canadian Hearing Report 16: 3</p>\r\n<p><strong>Received: </strong>02-Jun-2023, <strong>Manuscript No.</strong> ajchr-23-103036; <strong>Editor assigned: </strong>05- Jun -2023, <strong>Pre QC No. </strong>ajchr-23- 103036 (PQ); <strong>Reviewed:</strong> 19- Jun -2023, <strong>QC No.</strong> ajchr-23-103036; <strong>Revised:</strong> 23- Jun-2023,<strong> Manuscript No.</strong> ajchr-23-103036; <strong>Published: </strong>30- Jun-2023</p>\r\n<h4>ABSTRACT</h4>\r\n<p>Universal Neonatal Auditory Screening (UNAS) is a vital public health initiative aimed at the early identification   and intervention of hearing loss in newborns. It involves the systematic screening of all newborns to detect   hearing impairments as early as possible, typically within the first few days or weeks of life. UNAS programs have   gained widespread recognition globally due to the significant benefits they provide to infants and their families.   Emphasizing its importance, methods, and outcomes. Early detection of hearing loss is crucial for optimal   language and cognitive development, as well as social-emotional well-being. UNAS programs utilize objective   screening methods, such as Otoacoustic Emissions (OAE) and Auditory Brainstem Response (ABR) tests, to   identify infants at risk of hearing impairment. The implementation of UNAS programs has shown substantial   success in various countries, enabling timely intervention and support for affected infants. The benefits of UNAS   include early access to appropriate medical and audiological interventions, speech and language therapy, and   support services for families. Furthermore, early identification allows for the establishment of communication   strategies and the inclusion of infants with hearing loss into mainstream educational settings from an early age.   On-invasive and reliable method for identifying hearing loss in newborns. By ensuring that every infant receives   a comprehensive hearing screening shortly after birth, UNAS programs contribute to the overall well-being and   quality of life of children with hearing impairments. The importance of continued efforts to promote and expand   UNAS programs globally. The early identification of hearing loss through UNAS empowers families, healthcare   professionals, and educators to provide timely and appropriate interventions, fostering the optimal development   of children with hearing impairments. The abstract concludes with a call to action for policymakers, healthcare   providers, and researchers to collaborate in further advancing UNAS initiatives to reach every newborn   worldwide, ultimately ensuring a brighter future for all children.</p>\r\n<h4>Keywords</h4>\r\n<p>Auditory Screening, Hearing loss, Auditory rehabilitation, Auditory brainstem response, Hearing impairment, Policymakers</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>Hearing develops in increasingly complex   stages of life in the womb. To get for a   child to develop language and speech, he   should be able to do that perceive, find,   distinguish, remember, recognize, and   finally understand sounds.1, 2, 3,4 Any   and especially The initial stages of these   stages are very important the whole   process takes place;5,6, all interrupts   causes significant loss of function in   childhood development So action must   be taken without delay to minimize   the difficulties caused by sensory   deprivation [<a href=\"#1\" title=\"1\">1</a>,<a href=\"#2\" title=\"2\">2</a>]. Therefore, newborns   with hearing loss should be recognized   even in the first month of life if there   are no risk signs in the clinical history   probability of hearing loss.2,3,6,7,35 The   central nervous system is very plastic   stimulated early, before 12 months   of age, which increases the number   of neural connections and improves   auditory rehabilitation and language   outcomes [<a href=\"#3\" title=\"3\">3</a>].</p>\r\n<p><strong>THE ROLE OF COMUSA</strong></p>\r\n<p>COMUSA serves as a platform for   professionals in various hearing healthrelated   fields to collaborate, share   knowledge, and develop innovative   strategies to enhance patient outcomes   [<a href=\"#4\" title=\"4\">4</a>]. The committee facilitates regular   meetings, conferences, and workshops,   enabling experts to exchange ideas,   present research findings, and discuss   emerging trends and advancements.   By pooling their expertise, committee members develop comprehensive   treatment plans and interventions that   address the diverse needs of individuals   with hearing impairments [<a href=\"#5\" title=\"5\">5</a>, <a href=\"#6\" title=\"6\">6</a>].</p>\r\n<p><strong>PROMOTING RESEARCH AND   EVIDENCE-BASED PRACTICE</strong></p>\r\n<p>One of COMUSA&rsquo;s primary objectives   is to promote research in the field of   hearing health. Through collaboration   and resource-sharing, the committee   encourages members to conduct   interdisciplinary studies that explore the   complex nature of hearing impairments.   These research efforts aim to improve   diagnostic tools, develop innovative   treatment approaches, and identify   strategies to mitigate the impact of   hearing loss on individuals&rsquo; daily lives [<a href=\"#7\" title=\"7\">7</a>].</p>\r\n<p>COMUSA also plays a crucial role in   advocating evidence-based practice.   By disseminating research findings and   best practices, the committee helps   ensure that professionals in the hearing   health field stay informed about the   latest developments [<a href=\"#8\" title=\"8\">8</a>]. This knowledge   exchange empowers clinicians to   provide the most effective and up-todate   interventions, enhancing the overall   quality of care delivered to patients.</p>\r\n<p><strong>RAISING AWARENESS AND    EDUCATION</strong></p>\r\n<p>Beyond its professional collaborations,   COMUSA actively engages in public awareness campaigns to educate the   general population about hearing   health. The committee organizes public   seminars, workshops, and awareness   programs that highlight the importance   of early detection, prevention, and   treatment of hearing impairments. By   spreading knowledge and dispelling   misconceptions, COMUSA strives to   empower individuals to seek timely   interventions and create a supportive   environment for those living with   hearing loss [<a href=\"#9\" title=\"9\">9</a>, <a href=\"#10\" title=\"10\">10</a>].</p>\r\n<h4>CONCLUSION</h4>\r\n<p>Multidisciplinary committee hearing   health, represented by COMUSA, plays a   crucial role in advancing the field of hearing   health and improving patient outcomes.   Through collaboration, research, and   knowledge-sharing, professionals from   various disciplines come together to   develop comprehensive approaches to   address the diverse needs of individuals   with hearing impairments. By raising   awareness, promoting research, and   advocating evidence-based practice,   COMUSA contributes significantly   to enhancing hearing health care and   fostering a better quality of life for   individuals with hearing loss.</p>\r\n<h4>REFERENCES</h4>\r\n<ol>\r\n    <li><a name=\"1\" id=\"1\"></a>Lewis,  D.R., et al. &quot;<a href=\"mailto:http://www.bjorl.org/en-pdf-S1808869415313641\" target=\"_blank\">Multiprofessional  committee on auditory health&ndash;COMUSA.</a>&quot; Braz  J Otorhinolaryngo, 76 (1) (2010):  121-128.</li>\r\n    <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/20339700/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1590/s1808-86942010000100020\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Multiprofessional+committee+on+auditory+health%E2%80%93COMUSA.&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n    <li><a name=\"2\" id=\"2\"></a>Porto, R. 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This is an open-access article distributed under the terms of the Creative Commons Attribution License, which   permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</p>\r\n<p><strong>Citation: </strong>Vehdi R (2023) The Paediatric Audiology: Assessment and Management of Hearing Impaired Disorders in Children, Canadian   Hearing Report 16: 3</p>\r\n<p><strong>Received: </strong>02-Jun-2023, <strong>Manuscript No. </strong>ajchr-23-103037; <strong>Editor assigned: </strong>05- Jun -2023, <strong>Pre QC No.</strong> ajchr-23- 103037 (PQ); <strong>Reviewed:</strong> 19- Jun -2023, <strong>QC No.</strong> ajchr-23-103037; <strong>Revised:</strong> 23- Jun-2023, <strong>Manuscript No.</strong> ajchr-23-103037; <strong>Published: </strong>30- Jun-2023</p>\r\n<h4>ABSTRACT</h4>\r\n<p>Paediatric audiology is a specialized branch of audiology that focuses on the assessment, diagnosis, and   management of hearing disorders in children from infancy to adolescence. This abstract provides an overview of   the advancements and challenges in the field of paediatric audiology. Advancements in technology and research   have significantly improved the tools and techniques available for assessing and managing childhood hearing   disorders. Diagnostic methods such as otoacoustic emissions (OAEs), Auditory Brainstem Response (ABR) testing,   and behavioural assessments have enhanced the accuracy and efficiency of identifying hearing impairments in   infants and young children. Additionally, advancements in electrophysiological testing and imaging techniques,   including Auditory Steady-State Response (ASSR) and functional magnetic resonance imaging (fMRI), have   expanded our understanding of the auditory system and aided in the diagnosis of complex auditory disorders.   Paediatric hearing disorders involves a multidisciplinary approach, including the collaboration of audiologists,   otolaryngologists, speech-language pathologists, educators, and parents. Early intervention is crucial to optimize   outcomes for children with hearing impairments. Hearing aids, cochlear implants, and assistive listening devices   have undergone significant advancements, offering improved audibility and speech perception for children   with varying degrees of hearing loss. The implementation of auditory-verbal therapy, sign language, and other   communication modalities has also evolved to facilitate optimal language development and communication   skills in children with hearing impairments. Several challenges persist. The identification of hearing impairments   in newborns and infants remains a primary concern, as some cases may go undetected without comprehensive   and universal hearing screening programs. Access to quality hearing healthcare services, especially in rural   and underserved areas, poses a significant challenge. Additionally, the management of complex cases, such as   auditory processing disorders and congenital hearing loss, requires ongoing research and collaboration among   professionals.pediatric audiology has witnessed remarkable advancements in assessment and management   techniques, leading to improved outcomes for children with hearing disorders. However, challenges related to   early identification, access to services, and management of complex cases still need to be addressed. Continued   research, awareness, and interdisciplinary collaboration are essential for further advancing paediatric audiology   and ensuring optimal hearing health for children worldwide.</p>\r\n<h4>Keywords</h4>\r\n<p>Paediatric audiology, Auditory Brainstem Response, hearing loss, Audiologists,</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>Paediatric audiology is a specialized   field of audiology that focuses on the   assessment and management of hearing   disorders in children. It plays a vital role   in identifying and addressing hearing   impairments early in life, as hearing is   crucial for a child&rsquo;s language development,   academic success, and overall quality of   life. This article provides an overview   of paediatric audiology, including the   importance of early intervention,   common hearing disorders in children,   diagnostic techniques, and treatment   options.</p>\r\n<p>The Importance of Early Intervention:   Early identification and intervention are   crucial in addressing hearing disorders   in children. Hearing loss can significantly impact a child&rsquo;s speech and language   development, social skills, and educational   achievements. The earlier a hearing   impairment is detected, the better   the chances of successful intervention   and improved outcomes for the child.   Paediatric audiologists work closely with   parents, healthcare professionals, and   educators to ensure early detection and   appropriate intervention[<a href=\"#1\" title=\"1\">1</a>,<a href=\"#2\" title=\"2\">2</a>].</p>\r\n<p><strong>COMMON HEARING DISORDERS   IN CHILDREN</strong></p>\r\n<p>Paediatric audiology addresses a wide   range of hearing disorders that can   affect children. Some of the common   conditions include,</p>\r\n<p><strong>Congenital hearing loss: </strong>Hearing   loss present at birth can be caused by   genetic factors, maternal infections   during pregnancy, and complications   during childbirth, or exposure to certain   medications or substances.Acquired   Hearing Loss: Children can develop   hearing loss after birth due to factors   such as recurrent ear infections, head   trauma, exposure to loud noise, or   ototoxic medications [<a href=\"#3\" title=\"3\">3</a>].</p>\r\n<p><strong>Auditory processing disorders   (APDs): </strong>APDs affect the way the brain   processes sound, making it challenging   for children to understand and interpret   auditory information. This condition   can often be mistaken for a learning   disability.</p>\r\n<p><strong>Middle ear disorders: </strong>Conditions like   otitis media (middle ear infection), fluid   build-up, or structural abnormalities in   the middle ear can cause temporary or   chronic hearing loss in children [<a href=\"#4\" title=\"4\">4</a>,<a href=\"#5\" title=\"5\">5</a>].</p>\r\n<p><strong>DIAGNOSTIC TECHNIQUES</strong></p>\r\n<p>Paediatric audiologists employ various   diagnostic techniques to assess hearing   in children, taking into account their age,   developmental stage, and communication   abilities. These techniques may include,</p>\r\n<p><strong> Newborn hearing screening:</strong> A   quick and non-invasive test performed   shortly after birth to identify potential hearing loss.</p>\r\n<p><strong>Behavioural observation   audiometry (BOA): </strong>A method used   with infants to observe their behavioural   responses to sound stimuli, such as head   turns or eye movements.</p>\r\n<p><strong>Visual reinforcement audiometry   (VRA): </strong>A technique involving the   presentation of sound stimuli along with   a visual reward, encouraging children to   turn towards the sound source [<a href=\"#6\" title=\"6\">6</a>,<a href=\"#7\" title=\"7\">7</a>].</p>\r\n<p><strong>Play audiometry: </strong>An interactive   method that uses play-based activities   to assess children&rsquo;s hearing abilities,   suitable for toddlers and young children.</p>\r\n<p><strong>TREATMENT OPTIONS</strong></p>\r\n<p>Paediatric audiologists employ a range   of interventions based on the child&rsquo;s   specific hearing needs. These may   include,</p>\r\n<p><strong>Hearing aids: </strong>Amplification devices   designed to enhance sound perception   and improve communication abilities in   children with hearing loss [<a href=\"#8\" title=\"8\">8</a>,<a href=\"#9\" title=\"9\">9</a>].</p>\r\n<p><strong>Cochlear implants:</strong> Surgical devices   that bypass damaged parts of the inner   ear and stimulate the auditory nerve,   providing a sense of sound to children   with severe-to-profound hearing loss.</p>\r\n<p><strong>Assistive listening devices (ALDs):</strong> Devices such as FM systems or sound   field amplification systems that help   children hear more clearly in challenging   listening environments, such as   classrooms[<a href=\"#10\" title=\"10\">10</a>].</p>\r\n<p><strong> Auditory training and therapy:</strong> Programs aimed at improving a   child&rsquo;s auditory skills, including sound   discrimination, speech perception, and   auditory processing abilities.</p>\r\n<h4>CONCLUSION</h4>\r\n<p>Paediatric audiology plays a vital role   in the early detection, assessment,   and management of hearing disorders   in children. Through comprehensive evaluations and tailored interventions,   paediatric audiologists strive to minimize   the impact of hearing impairments on a   child&rsquo;s development and overall wellbeing.   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2023 Sunada M. This is an open-access article distributed under the terms of the Creative Commons Attribution License,   which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</p>\r\n<p><strong>Citation: </strong>Sunada M (2023) The Prevalence of Auditory Neuropathy Spectrum Disorders in an Auditory Health Care Service, Canadian   Hearing Report 16: 3</p>\r\n<p><strong>Received: </strong>02-Jun-2023, <strong>Manuscript No.</strong> ajchr-23-103038; <strong>Editor assigned: </strong>05- Jun -2023, <strong>Pre QC No.</strong> ajchr-23- 103038 (PQ); <strong>Reviewed:</strong> 19- Jun -2023, <strong>QC No. </strong>ajchr-23-103038; <strong>Revised: </strong>23- Jun-2023, <strong>Manuscript No.</strong> ajchr-23-103038; <strong>Published: </strong>30- Jun-2023</p>\r\n<h4>ABSTRACT</h4>\r\n<p>Auditory Neuropathy Spectrum Disorder (ANSD) is a hearing disorder characterized by the presence of normal   outer hair cell function but impaired neural transmission of sound signals from the inner ear to the brain.   This article aims to investigate the prevalence of ANSD in an Auditory Health Care Service, highlighting the   significance of early identification and appropriate management strategies for individuals with this condition.</p>\r\n<h4>Keywords</h4>\r\n<p>Auditory Neuropathy Spectrum Disorder, Auditory Health Care Service</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>ANSD represents a unique challenge   in the field of audiology due to its   variable presentation and impact on   speech perception. Although ANSD is   considered a relatively rare condition, its   prevalence within specific audio logical   populations is not well documented.   This study aims to address this gap by   examining the prevalence of ANSD in an   Auditory Health Care Service [<a href=\"#1\" title=\"1\">1</a>, <a href=\"#2\" title=\"2\">2</a>].</p>\r\n<p>Auditory Neuropathy Spectrum   Disorder (ANSD) poses unique   challenges in audio logical practice due   to its varied presentation and impact   on speech perception. However, the   prevalence of ANSD within specific   audio logical populations remains largely   unexplored. This study examines the   prevalence of ANSD in an Auditory   Health Care Service, shedding light on   the importance of early identification   and appropriate management strategies for   individuals affected by this condition [<a href=\"#3\" title=\"3\">3</a>, <a href=\"#4\" title=\"4\">4</a>].</p>\r\n<h4>METHODS</h4>\r\n<p>A retrospective analysis was conducted using anonym zed patient records from   the Auditory Health Care Service over   a specified period. The study sample   included individuals who underwent   aetiological assessment, including   diagnostic evaluations, speech perception   tests, and electrophysiological measures   [<a href=\"#5\" title=\"5\">5</a>]. The diagnostic criteria for ANSD   were based on a combination of   aetiological, speech perception, and   Auditory Brainstem Response (ABR)   findings [<a href=\"#6\" title=\"6\">6</a>].</p>\r\n<h4>DISCUSSION</h4>\r\n<p>The prevalence of ANSD in the   Auditory Health Care Service was   analysed and compared with existing   literature. The findings shed light   on the incidence of ANSD within   the specific aetiological population   served by the clinic. The discussion   section also addresses the challenges   faced in diagnosing and managing   ANSD, emphasizing the importance   of a multidisciplinary approach and   individualized interventions. The   prevalence of ANSD within the Auditory   Health Care Service was assessed and   compared with existing literature. The findings provide valuable insights into   the incidence of ANSD within this   specific aetiological population [<a href=\"#7\" title=\"7\">7</a>,<a href=\"#8\" title=\"8\">8</a>].   The discussion section delves into the   challenges associated with diagnosing   and managing ANSD, emphasizing the   need for a multidisciplinary approach   and individualized interventions tailored   to each patient&rsquo;s unique needs.</p>\r\n<p><strong>IMPLICATIONS</strong></p>\r\n<p>Understanding the prevalence of   ANSD within an Auditory Health Care   Service holds significant implications   for developing effective screening,   diagnostic, and treatment protocols.   Early identification of ANSD enables   timely interventions, such as auditory   rehabilitation and educational support,   which greatly improve long-term   outcomes for affected individuals [<a href=\"#9\" title=\"9\">9</a>, <a href=\"#10\" title=\"10\">10</a>].</p>\r\n<h4>CONCLUSION</h4>\r\n<p>This study provides insights into the   prevalence of ANSD in an Auditory   Health Care Service, contributing to the   existing body of knowledge regarding   this relatively rare hearing disorder. The findings emphasize the need for   increased awareness, research, and   tailored management approaches to   ensure optimal outcomes for individuals   diagnosed with ANSD. 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This is an open-access article distributed under the terms of the Creative Commons Attribution License,   which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</p>\r\n<p><strong>Citation: </strong>Bellomo R (2023) Understanding Auditory Processing Disorders: Causes, Symptoms, and Treatment, Canadian Hearing Report 16: 3</p>\r\n<p><strong>Received: </strong>02-Jun-2023, <strong>Manuscript No. </strong>ajchr-23-103040; <strong>Editor assigned: </strong>05- Jun -2023, <strong>Pre QC No. </strong>ajchr-23- 103040 (PQ); <strong>Reviewed:</strong> 19- Jun -2023, <strong>QC No. </strong>ajchr-23-103040; <strong>Revised: </strong>23- Jun-2023, <strong>Manuscript No.</strong> ajchr-23-103040; <strong>Published: </strong>30- Jun-2023</p>\r\n<h4>ABSTRACT</h4>\r\n<p>Auditory Processing Disorders (APDs) refer to a group of complex neurodevelopmental conditions that affect   the processing and interpretation of auditory information in the central nervous system. Individuals with APDs   may experience difficulties in accurately perceiving, discriminating, and interpreting auditory stimuli, despite   having normal hearing abilities. This abstract aims to provide an overview of the causes, symptoms, and treatment   options associated with APDs.</p>\r\n<p>The causes of APDs can vary and often involve a combination of genetic and environmental factors. Factors such   as premature birth, chronic ear infections, head injuries, and exposure to certain toxins have been linked to the   development of APDs. Additionally, genetic predisposition and developmental disorders like attention deficit   hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) can contribute to the manifestation of   APDs.</p>\r\n<p>Symptoms of APDs can manifest differently across individuals, but commonly include difficulties in speech and   language processing, sound localization, auditory discrimination, auditory memory, and auditory sequencing.   Individuals with APDs may struggle to follow verbal instructions, have poor listening skills, exhibit delays in   language acquisition, and experience challenges in noisy environments.</p>\r\n<p>Effective treatment strategies for APDs involve a multidisciplinary approach. Audiologists play a crucial role in   diagnosing APDs through comprehensive aetiological evaluations, including behavioural and electrophysiological   tests. Once diagnosed, treatment options may include auditory training, speech-language therapy, assistive   listening devices, environmental modifications, and accommodations in educational settings.</p>\r\n<p>Understanding the intricate nature of APDs is essential for early identification and intervention, as it can   significantly impact an individual&rsquo;s communication, academic performance, and psychosocial well-being.   By recognizing the causes, identifying the symptoms, and implementing appropriate treatment approaches,   healthcare professionals, educators, and families can effectively support individuals with APDs and enhance their   overall quality of life.</p>\r\n<h4>Keywords</h4>\r\n<p>Auditory Processing Disorders, central nervous system, Auditory stimuli, , speech-language therapy</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>Auditory processing disorder (APD),   also known as central auditory   processing disorder (CAPD), is a   condition that affects how the brain   processes auditory information. It is   not a hearing impairment but rather   a difficulty in the interpretation and   organization of sounds. In this article,   we will explore the causes, symptoms,   and treatment options for auditory   processing disorders [<a href=\"#1\" title=\"1\">1</a>].</p>\r\n<p><strong>CAUSES OF AUDITORY   PROCESSING DISORDERS</strong></p>\r\n<p>The exact causes of auditory processing   disorders are not yet fully understood.   However, several factors are believed to   contribute to the development of this   condition:</p>\r\n<p><strong>Genetics: </strong>Research suggests that   genetic factors may play a role in the   development of APD. Certain genetic   conditions or a family history of auditory   processing difficulties can increase the   risk.</p>\r\n<p><strong>Premature birth or low birth   weight: </strong>Children who are born   prematurely or with a low birth weight   may be more prone to developing   auditory processing disorders.</p>\r\n<p><strong>Chronic ear infections: </strong>Frequent ear   infections during early childhood can   affect the auditory system, potentially   leading to auditory processing   difficulties [<a href=\"#2\" title=\"2\">2</a>].</p>\r\n<p><strong>Brain injuries or trauma: </strong>Head   injuries, concussions, or other types   of brain trauma can disrupt the brain&rsquo;s   ability to process auditory information.</p>\r\n<p><strong>SYMPTOMS OF AUDITORY   PROCESSING DISORDERS</strong></p>\r\n<p>The symptoms of auditory processing   disorders can vary from person to   person. Some common signs include,</p>\r\n<p><strong>Difficulty understanding speech   in noisy environments:</strong> Individuals   with APD often struggle to understand   speech when there is background noise,   such as in a crowded room or a noisy   classroom [<a href=\"#3\" title=\"3\">3</a>,<a href=\"#4\" title=\"4\">4</a>].</p>\r\n<p><strong>Trouble following directions: </strong>People   with APD may have difficulty processing   and remembering verbal instructions,   particularly when they are complex or   given quickly.</p>\r\n<p><strong>Poor listening skills: </strong>They may exhibit   poor listening skills, such as frequently   asking others to repeat themselves,   misinterpreting information, or having   trouble maintaining focus during   conversations.</p>\r\n<p><strong>Sensitivity to loud sounds: </strong>Individuals   with APD may be more sensitive to   loud or sudden noises, causing them   discomfort or distress [<a href=\"#5\" title=\"5\">5</a>].</p>\r\n<p><strong>Poor reading and spelling skills:</strong> Some individuals with APD may also   experience difficulties in reading and    spelling, as auditory processing plays a crucial role in language development [<a href=\"#6\" title=\"6\">6</a>].</p>\r\n<p><strong>DIAGNOSIS AND TREATMENT</strong></p>\r\n<p>Diagnosing auditory processing disorders   typically involves a comprehensive   evaluation by an audiologist or speechlanguage   pathologist. The evaluation   may include a range of tests to assess   various aspects of auditory processing   abilities. While there is no cure for   auditory processing disorders, there   are treatment options available to help   individuals manage their symptoms   and improve their quality of life. Some   common approaches include:</p>\r\n<p><strong>Auditory training: </strong>This therapy   involves exercises and activities designed   to improve the brain&rsquo;s ability to process   and interpret auditory information [<a href=\"#7\" title=\"7\">7</a>].</p>\r\n<p><strong> Environmental modifications:</strong> Creating a supportive listening   environment by reducing background   noise, using assistive listening devices,   and implementing strategies to enhance   communication can be beneficial.</p>\r\n<p><strong>Speech-language therapy: </strong>Working   with a speech-language pathologist   can help individuals develop stronger   language and communication skills, as   well as strategies to compensate for   auditory processing difficulties [<a href=\"#8\" title=\"8\">8</a>].</p>\r\n<p><strong>Educational accommodations:</strong> In academic settings, providing   accommodations such as preferential   seating, extended time for tests and the   use of visual aids can assist individuals   with APD in their learning process [<a href=\"#9\" title=\"9\">9</a>, <a href=\"#10\" title=\"10\">10</a>].</p>\r\n<h4>CONCLUSION</h4>\r\n<p>Auditory processing disorders can   significantly impact an individual&rsquo;s ability   to understand and interpret auditory   information. While there is no cure, early   diagnosis and appropriate interventions   can help individuals with APD manage   their symptoms and lead fulfilling lives. If   you suspect you or someone you know may have auditory processing difficulties,   seeking professional evaluation and   support is recommended to determine   the most appropriate course of action.</p>\r\n<h4>REFERENCES</h4>\r\n<ol>\r\n    <li><a name=\"1\" id=\"1\"></a>Shirato,  H., et al. &ldquo;<a href=\"mailto:https://www.sciencedirect.com/science/article/abs/pii/S0360301600007318\" target=\"_blank\">Fractionated stereotactic  radiotherapy for vestibular schwannoma (VS)&rdquo; comparison between cystic-type and  solid-type VS</a>.&rdquo;  Int J Radiat Oncol Biol Phys, 48 (2000):1395&ndash; 1401.</li>\r\n    <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/11121639/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1016/s0360-3016(00)00731-8\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Fractionated+stereotactic+radiotherapy+for+vestibular+schwannoma+%28VS%29%E2%80%9D+comparison+between+cystic-type+and+solid-type+VS&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n    <li><a name=\"2\" id=\"2\"></a>Louvrier, C., et al. &ldquo;<a href=\"https://academic.oup.com/neuro-oncology/article/20/7/917/4835073\" target=\"_blank\">Targeted  next-generation sequencing for differential diagnosis of neurofibromatosis type  2, schwannomatosis, and meningiomatosis</a>.&rdquo; 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2023 Saksena K. This is an open-access article distributed under the terms of the Creative Commons Attribution License,   which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</p>\r\n<p><strong>Citation: </strong>Saksena K (2023) Vestibular Disorders in the Central Nervous System Based On Additional Examination of Vestibular Reflex,   Canadian Hearing Report 16: 3</p>\r\n<p><strong>Received: </strong>02-Jun-2023, <strong>Manuscript No.</strong> ajchr-23-103041; <strong>Editor assigned: </strong>05- Jun -2023, <strong>Pre QC No.</strong> ajchr-23- 103041 (PQ);<strong> Reviewed:</strong> 19- Jun -2023, <strong>QC No. </strong>ajchr-23-103041; <strong>Revised: </strong>23- Jun-2023, <strong>Manuscript No.</strong> ajchr-23-103041; <strong>Published:</strong> 30- Jun-2023</p>\r\n<h4>ABSTRACT</h4>\r\n<p>Auditory processing disorders (APDs) refer to a group of complex neurodevelopmental conditions that affect   the processing and interpretation of auditory information in the central nervous system. Individuals with   APDs may experience difficulties in accurately perceiving, discriminating, and interpreting auditory stimuli,   despite having normal hearing abilities. This abstract aims to provide an overview of the causes, symptoms,   and treatment options associated with APDs.The causes of APDs can vary and often involve a combination of   genetic and environmental factors. Factors such as premature birth, chronic ear infections, head injuries, and   exposure to certain toxins have been linked to the development of APDs. Additionally, genetic predisposition and   developmental disorders like attention deficit hyperactivity disorder (ADHD) and autism spectrum disorder   (ASD) can contribute to the manifestation of APDs.Symptoms of APDs can manifest differently across individuals,   but commonly include difficulties in speech and language processing, sound localization, auditory discrimination,   auditory memory, and auditory sequencing. Individuals with APDs may struggle to follow verbal instructions,   have poor listening skills, exhibit delays in language acquisition, and experience challenges in noisy environments.   Effective treatment strategies for APDs involve a multidisciplinary approach. Audiologists play a crucial role in   diagnosing APDs through comprehensive audio logical evaluations, including behavioral and electrophysiological   tests. Once diagnosed, treatment options may include auditory training, speech-language therapy, assistive   listening devices, environmental modifications, and accommodations in educational settings. Understanding   the intricate nature of APDs is essential for early identification and intervention, as it can significantly impact   an individual&rsquo;s communication, academic performance, and psychosocial well-being. By recognizing the causes,   identifying the symptoms, and implementing appropriate treatment approaches, healthcare professionals,   educators, and families can effectively support individuals with APDs and enhance their overall quality of life.</p>\r\n<h4>Keywords</h4>\r\n<p>Genetic, Auditory processing disorders, Autism spectrum, Environmental modifications</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>Auditory processing disorder (APD),   also known as central auditory   processing disorder (CAPD), is a   condition that affects how the brain   processes auditory information. It is   not a hearing impairment but rather   a difficulty in the interpretation and   organization of sounds. In this article,   we will explore the causes, symptoms,   and treatment options for auditory   processing disorders [<a href=\"#1\" title=\"1\">1</a>,<a href=\"#2\" title=\"2\">2</a>].</p>\r\n<p><strong>CAUSES OF AUDITORY   PROCESSING DISORDERS</strong></p>\r\n<p>The exact causes of auditory processing   disorders are not yet fully understood.   However, several factors are believed to   contribute to the development of this   condition:</p>\r\n<p><strong>Genetics: </strong>Research suggests that   genetic factors may play a role in the   development of APD. Certain genetic   conditions or a family history of auditory   processing difficulties can increase the   risk [<a href=\"#3\" title=\"3\">3</a>].</p>\r\n<p><strong>Premature birth or low birth   weight: </strong>Children who are born   prematurely or with a low birth weight   may be more prone to developing   auditory processing disorders [<a href=\"#4\" title=\"4\">4</a>].</p>\r\n<p><strong>Chronic ear infections:</strong> Frequent ear   infections during early childhood can   affect the auditory system, potentially   leading to auditory processing difficulties   [<a href=\"#5\" title=\"5\">5</a>].</p>\r\n<p><strong>Brain injuries or trauma: </strong>Head   injuries, concussions, or other types   of brain trauma can disrupt the brain&rsquo;s   ability to process auditory information [<a href=\"#6\" title=\"6\">6</a>].</p>\r\n<p><strong>SYMPTOMS OF AUDITORY   PROCESSING DISORDERS</strong></p>\r\n<p>The symptoms of auditory processing   disorders can vary from person to   person. Some common signs include:</p>\r\n<p><strong> Difficulty understanding speech   in noisy environments:</strong> Individuals   with APD often struggle to understand   speech when there is background noise,   such as in a crowded room or a noisy   classroom [<a href=\"#7\" title=\"7\">7</a>].</p>\r\n<p><strong>Trouble following directions: </strong>People   with APD may have difficulty processing   and remembering verbal instructions,   particularly when they are complex or   given quickly [<a href=\"#8\" title=\"8\">8</a>].</p>\r\n<p><strong>Poor listening skills: </strong>They may exhibit   poor listening skills, such as frequently   asking others to repeat themselves,   misinterpreting information, or having   trouble maintaining focus during   conversations .</p>\r\n<p><strong>Sensitivity to loud sounds:</strong> Individuals   with APD may be more sensitive to   loud or sudden noises, causing them   discomfort or distress.</p>\r\n<p><strong>Poor reading and spelling skills:</strong> Some individuals with APD may also   experience difficulties in reading and   spelling, as auditory processing plays a   crucial role in language development</p>\r\n<p><strong>DIAGNOSIS AND TREATMENT</strong></p>\r\n<p>Diagnosing auditory processing disorders   typically involves a comprehensive   evaluation by an audiologist or speechlanguage   pathologist. The evaluation may   include a range of tests to assess various   aspects of auditory processing abilities.</p>\r\n<p>While there is no cure for auditory   processing disorders, there are   treatment options available to help   individuals manage their symptoms   and improve their quality of life. Some   common approaches include. [<a href=\"#9\" title=\"9\">9</a>]</p>\r\n<p><strong>Auditory training: </strong>This therapy   involves exercises and activities designed   to improve the brain&rsquo;s ability to process   and interpret auditory information.</p>\r\n<p><strong>Environmental modifications:</strong> Creating a supportive listening   environment by reducing background   noise, using assistive listening devices,   and implementing strategies to enhance   communication can be beneficial [<a href=\"#10\" title=\"10\">10</a>].</p>\r\n<p><strong>Speech-language therapy:</strong> Working   with a speech-language pathologist   can help individuals develop stronger   language and communication skills, as   well as strategies to compensate for   auditory processing difficulties.</p>\r\n<p><strong>Educational accommodations:</strong> In academic settings, providing   accommodations such as preferential   seating, extended time for tests and the   use of visual aids can assist individuals   with APD in their learning process.</p>\r\n<h4>CONCLUSION</h4>\r\n<p>Auditory processing disorders can   significantly impact an individual&rsquo;s ability   to understand and interpret auditory   information. While there is no cure, early   diagnosis and appropriate interventions   can help individuals with APD manage   their symptoms and lead fulfilling lives. If   you suspect you or someone you know   may have auditory processing difficulties,   seeking professional evaluation and   support is recommended to determine   the most appropriate course of action.</p>\r\n<h4>REFERENCES</h4>\r\n<ol>\r\n    <li><a name=\"1\" id=\"1\"></a>Helbing, D.L., et al. &ldquo;<a href=\"https://www.nature.com/articles/s41388-020-1374-5\" target=\"_blank\">Pathomechanisms  in schwannoma development and progression</a>.&rdquo;  Oncogene, 39 (32) (2020): 5421-5429.</li>\r\n    <p align=\"right\"><a href=\"https://pubmed.ncbi.nlm.nih.gov/32616891/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"https://doi.org/10.1038/s41388-020-1374-5\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Helbing+D.L.%2C+et+al.+%E2%80%9CPathomechanisms+in+schwannoma+development+and+progression%E2%80%9D.+Oncogene%2C+39%2832%29+%282020%29%3A+5421-5429.+&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n    <li><a name=\"2\" id=\"2\"></a>Pantelemon, C. &amp; 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This is an open-access article distributed under the terms of the Creative Commons Attribution License, which   permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</p>\r\n<p><strong>Citation: </strong>Jen M (2023) The Future of Sensor Neural Hearing Loss Gene Therapy: Advances and Challenges Advances and Challenges in   Adenosine-Associated Viral Intrinsic Hearing Loss Gene Therapy, Canadian Hearing Report 16: 3</p>\r\n<p><strong>Received: </strong>02-Jun-2023, <strong>Manuscript No.</strong> ajchr-23-103907; <strong>Editor assigned: </strong>05- Jun -2023, <strong>Pre QC No.</strong> ajchr-23- 103907 (PQ); <strong>Reviewed:</strong> 19- Jun -2023, <strong>QC No.</strong> ajchr-23-103907; <strong>Revised: </strong>23- Jun-2023, <strong>Manuscript No.</strong> ajchr-23-103907; <strong>Published: </strong>30- Jun-2023</p>\r\n<h4>ABSTRACT</h4>\r\n<p>The focus on treating the root cause rather than managing the associated secondary characteristic features   is increasing. Recent advances in understanding sensory hearing-loss mechanisms have made gene delivery a   promising approach to biological treatment for hearing loss related to genetic dysfunction. While there are   some successful and promising proof-of-concept examples in animal models, there is still much work to be done   in these areas before they can be clinically used in humans. In this article, we look at different aspects of the   development, current preclinical studies and challenges to make the clinical transition from the delivery of the   transgene into the inner ear towards the restoration of lost auditory/vestibular function.</p>\r\n<h4>Keywords</h4>\r\n<p>Hearing loss, Genetic dysfunction, Sensory cell</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>HL (hearing loss) is characterized by   significant clinical consequences affecting   quality of life such as communication   disorder, reduced social interaction,   isolation, melancholia, reduced cognitive   function, and dementia resulting in poor   quality life.Approximately 2 or 3 in   every 1,000 babies are diagnosed with   clinical significant unilateral or bilateral   HL.Hearing loss can be classified into   conductive high-frequency (CHL) and   sensor neural high-frequency (SNHL)   high-frequency. CHL is caused by   problems with the transmission of   sound waves along the pathway in the   outer ear or the auditory nerve.SNHL   is a combination of CHL and SNHL.   Among all the etiologist The delivery of   a gene is a multi-factorial process that   depends on multiple parallel paths of   scientific progress, including: the genetic   aetiology for the treatment of deafness;   the gene sequence used; the vectors   used; the route of delivery; the treatment   time point; the cost to be incurred   for the treatment to be effective and   to be successfully translated to the   clinic;5Vectors used in gene therapy   transport DNA into cells, typically   classified as non-, viral-, and hybrid-viral.   Non-viral techniques are easy to scale   up for large-scale production and have   low-host immunogenicity. However, they   suffer from poor gene transfer efficiency   when compared with viral vectors.   Currently, viral vectors predominate in   clinical trials for gene therapy because   of their higher transduction rate. Viruses   (i.e., lysogenic or lytic) bind to the host   cell; replicate their genetic material with   host replication machinery; and remain   in the host cell for an extended time   before responding to a trigger [<a href=\"#1\" title=\"1\">1</a>,<a href=\"#2\" title=\"2\">2</a>].</p>\r\n<p><strong>NON-SENSORY CELLS</strong></p>\r\n<p>Synthesized cells (SCs) are the   epitheliums derived from the oocytes   that surround the body&rsquo;s scale media   around Corte&rsquo;s organ. SCs are a   common target of gene therapy for   genetic deafness due to the presence of   a gene leading to high-level hearing (HL)   (e.g., gap junction protein (GJB2) beta 2   (GJB2), a gene resulting in high-density   lipoprotein (HLP) due to a connexion   (Cx) 26 (Cx26) mutation), with   promising uses in regenerative therapies.   The mechanism of sound transmission in   cochlea hypertrophic (HC) is determined   by the electrochemical dissimilarity   between cochlea fluid (perilymph)   and cochlea end lymph (end lymph). In   cochlea media, SV (strata vascularise)   is the epithelial tissue responsible for   the generation of end lymph and its   maintenance. Mutation of marginal cells   can lead to dysfunction in gap junctions   (EP) affecting cochlea hypertrophy (HC) and cell death (apoptosis), resulting in   hearing loss (e.g., KCNQ1 / KCNE1,   Annexing, etc.</p>\r\n<p><strong>TIME OF TREATMENT</strong></p>\r\n<p>Early intervention is the most effective   approach to treating any hearing   impairment, and it continues to play   a critical role in gene therapy increase   the likelihood of restoring both cell   and organ function in the inner ear. For   example, treating VGLUT3 mutations   with AAV1 injection on P1P2 (postnatal   days 12) in VGLUT3 knockout mice   resulted in better HC transduction and   auditory restoration compared to a   later time point (P10). The same results   were observed when AAV5- GJb2 was   administered at P42 (GJb2 knockout) in   KO mice and AAV2/AA80L65- Ush1c   was administered P10P12 (Ush1c KO) in   mice. However, once High-Haemorrhage   (HL) occurred, no subsequent treatment   resulted in rescue of degeneration   in rodent models due to the closed   therapeutic window for treatment [<a href=\"#3\" title=\"3\">3</a>].</p>\r\n<p><strong>TRANSLATING TO CLINICS</strong></p>\r\n<p>The success of gene therapy in animals   requires careful consideration for   translating to the clinic as a therapeutic   strategy for human use [<a href=\"#4\" title=\"4\">4</a>,<a href=\"#5\" title=\"5\">5</a>].</p>\r\n<p><strong>SAFETY &amp; EFFECTIVENESS SAFETY   &amp; EFFECTIVENESS</strong></p>\r\n<p>Efficacy and safety concerns are of   the utmost importance for the clinical   transition. Numerous genetic studies   have shown that the effectiveness of an   approach depends on the method of   administration, the vector type, and the   amount of delivery vehicle used, all of   which must be tested in the human ear.   In addition to efficacy, safety concerns   include the effects of overexpression or   silencing of the gene of interest, as well   as its pharmacological and toxicological   properties after delivery of the gene.   As mentioned above, there&rsquo;s a clinical   window for treating inner-ear anomaly   with gene therapy, and it will be important   to look at the critical period to get the   best results, along with other factors   such as expression profiles. Longevity   should also be carefully evaluated, as it   has been seen in animals [<a href=\"#6\" title=\"6\">6</a>-<a href=\"#8\" title=\"8\">8</a>].</p>\r\n<p><strong>USH1G MUTATIONS</strong></p>\r\n<p>SANS is encoded by Ush1G and is an   anomalously localized at stereo cilia   tip. This is an important part of the   mechanism of mechanotransduction   as well as the sensory antenna of   ichthyocytosis (IHC). In Emptoz et al.   (140,194), SANS cDNA was delivered   via RWM injection via AAV8 using a   CAG promoter at p2.5. In KO mice,   the transgene delivery restored SANS   protein in tip link of ichthyoids (IHC),   orthocytosis (OHC), and vestibular   ichthosis (VHT), thus preserving   mechanotransduction, vestibular   dysfunction, and improving their hearing   threshold. In treated mice, partial hemihepatic   (HL) restoration was observed,   with partial hepatic degeneration   occurring approximately 12 weeks after   injection. This partial recovery may be   attributed to the lower transduction of   cochlear HC versus vestibular HC in   this study [<a href=\"#9\" title=\"9\">9</a>,<a href=\"#10\" title=\"10\">10</a>].</p>\r\n<h4>CONCLUSION</h4>\r\n<p>The rapid expansion of clinical trials   using AAV vectors indicates that   this is only the start of a new age   in the treatment of human diseases.   Molecular Therapy: Methods and Clinical   Development Vol.230, 21 June2021The   review of manipulating viral vectors.   While challenges remain, advances in   gene regulation and editing will increase   the specificity and effectiveness of gene   therapy. Heterogeneity is a major issue   in genetic HL treatment. The efficacy of   treatment depends on several factors,   including the therapeutic window, the   targets, the targeting molecules, and the   protein function. Recent advances in   synthetic AAV and advanced techniques   such as AAV Capsid modification using   targeting molecules (peptides) of   interest can modify their expression   profile and increase the likelihood   of wholesale clinical efficacy. Hybrid   vectors, such as varooms, have been   reported to be highly efficacious   compared to their parent virus. It may   be interesting to study AAV Virosomes   modified with targeted molecules for   transduction efficiencies in the coming   years. Due to the high cost of such   research, there is a growing interest   from government funding agencies,   industry and private foundations,   patients and physicians. Companies such as Applied Genetic Technologies   (AGTC) (Akouos), Rescue Hearing   (Rescue Hearing), Novartis (Novartis)   (Decibel Therapeutics), etc. are currently   conducting preclinical/clinical studies to   treat high blood pressure (HL) through   preclinical testing of CRISPR (Cas9) for   the treatment of high blood pressure.   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This is an open-access article distributed under the terms of the Creative Commons Attribution License, which   permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</p>\r\n<p><strong> Citation: </strong>Singh R (2023) The New Paradigm for Hearing Loss and Preservation with Cochlear Implants: Evidence from Basic Studies and   Clinical Research, Canadian Hearing Report 16: 3</p>\r\n<p><strong>Received: </strong>02-Jun-2023, <strong>Manuscript No. </strong>ajchr-23-103909; <strong>Editor assigned: </strong>05- Jun -2023, <strong>Pre QC No.</strong> ajchr-23- 103909 (PQ); <strong>Reviewed:</strong> 19- Jun -2023, <strong>QC No. </strong>ajchr-23-103909; <strong>Revised: </strong>23- Jun-2023, <strong>Manuscript No. </strong>ajchr-23-103909; <strong>Published: </strong>30- Jun-2023</p>\r\n<h4>ABSTRACT</h4>\r\n<p>In 2010, Cochlear launched a concerted preclinical research effort to elucidate the causes and mechanisms   of acoustical hearing loss post-cochlear implant and post-device use. Initially, the program focused on several   major hypotheses associated with acoustic hearing loss.As the program progressed, the understanding of causes   broadened, and leading to a greater appreciation of the biological role in post-implanted hearing loss. A systematic   approach was adopted; mapping the path of cochlear implants along a time line that takes into account all events   in a patient&rsquo;s hearing history. Evaluating the available data rather than conducting discrete hypothesis testing   may make it easier to identify cause and associated factors. This approach provides opportunities for more   effective research management, and may help to identify new opportunities for intervention. Many of the findings   from the research program relate not only to the maintenance of acoustic hearing, but also to factors relevant   to overall cochlear health and future therapies. Low Frequency Acoustic Hearing (LFPTA), Low Frequency   Pure Tone Average (LFPTA); Residual Hearing (Measurable/Remaining Unaided Acoustic Thresholds) after an   intervention; Research Program for Residual Hearing; Round Window; Structural Preservation. Generally refers   to minimising mechanical trauma to the microstructural and anatomical components related to acoustical   and electrical hearing that may be affected during CI procedures and more specifically during the insertion of   the intracochlear electroencephalogram (IEE) array, taking into account the evaluation system described in   Eshraghi&rsquo;s (2006) and Roland and Wright&rsquo;s (2013).</p>\r\n<h4>Keywords</h4>\r\n<p>Hearing loss, Residual Hearing, Low Frequency Pure Tone Average, post-implanted hearing loss</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>The CI industry has been shaped by   hearing preservation for the majority   of the last 20 years. It is a topical and   influential field of research, surgical   research, audio logical research, and   commercialization. Advances in clinical   &amp; surgical aspects of the intervention &amp;   device technology have made it possible   to expand candidate patients to include   patients with increasing low-frequency   (LFH) acoustical hearing. Patients with   functionally relevant acoustical hearing   who are post-operative may also benefit   from combined electric &amp; acoustical   stimulation (EAS) [<a href=\"#1\" title=\"1\">1</a>,<a href=\"#2\" title=\"2\">2</a>]. High rates of   postoperative LFH preservation have   been reported in large cohort studies   from clinic-based studies (Jensen et   al. 2021), and there is evidence that   post-operative LFH preservation   rates increase over time, likely due to   continued improvement across the   field. In the subset of patients whose   LFH is sustained beyond 6-months   after activation, there is evidence of   long-term stability (5 years) of LFH   with continued EAS use, and in some   cases, up to 15 years It is, however, well   known that some patients experience   a decrease in LFH within months to   years after implantation in patients with   CI.Preserving CI hearing is a multifaceted   and time-dependent process.   There are three main stages from which   CI hearing preservation can be assessed   and each stage necessitates a concerted   effort across multiple sectors in the CI   industry to move forward [<a href=\"#3\" title=\"3\">3</a>,<a href=\"#4\" title=\"4\">4</a>].</p>\r\n<p><strong>RESIDUAL HEARING RESEARCH   PROGRAM</strong></p>\r\n<p>The Houston Rehabilitative Research   Program (HRTP) was a co-ordinated   preclinical research program launched   in 2010 under the auspices of Cochlear Limited, and initially focused on five main   hypotheses that could independently or   in combination influence LFH survival.   The main hypotheses are presented in   below, along with key contributors and   notable publications from the program   [<a href=\"#5\" title=\"5\">5</a>]. The main hypotheses were then   broken down into minor hypotheses.   Collaborators were identified; engaged,   preclinical research was planned and   conducted. The new hearing preservation   paradigm emerged from the need to   better manage, integrate, and analyse   the results of many individual projects,   as well as the growing recognition that   inflammation and FBR are at the heart   of hearing preservation [<a href=\"#6\" title=\"6\">6</a>]. As discussed   in the following two sections, the new   hearing preservation paradigm uses   a systems approach to capture and   classify all possible variables and In the   paradigms, these variables and factors   can then be aligned with the CI timeline,   the CI Timeline, and analysed based on   their timing with changes in LFH along   with particular learnings from the HRH.</p>\r\n<p><strong>CLINICAL FACTOR</strong></p>\r\n<p>Clinical factors are all those that can   be attributed to the surgical and audio   logical aspects of treatment. Many of   these factors have been the subject of   multiple RHP hypothesis studies. This   category includes all major steps in   the cochlear implant (CI) surgery and   subsequent use. Drilling is required in   the CI surgical procedure, including   a mastoidectomy, facial recess, and   access to the cchlea. Removal of the   RW overhang and bone occlusions   (e.g., crista fascia) may be necessary   to visualize the appropriate approach   for the patient to access the cochlear   implant (IC) [<a href=\"#7\" title=\"7\">7</a>,<a href=\"#8\" title=\"8\">8</a>]. Conventional highspeed   drills have previously been studied   as a risk of acoustic trauma, and the   risk increases as the drill moves closer to the cchlea, resulting in short term   increases in noise if the drill bit contacts   the incus,endosteum, and if it passes   through the per lymphatic space. At this   point, the type, size, and speed of the   drill become more important factors as   they may affect or reduce the acoustic   noise level and vibrations that can be   transmitted to the chlea .End steal   damage is linked to a particular local   inflammatory response to the injury and   is associated with increased tissue and   bone growth [<a href=\"#9\" title=\"9\">9</a>,<a href=\"#10\" title=\"10\">10</a>].</p>\r\n<h4>CONCLUSION</h4>\r\n<p>Acoustic Hearing Loss after Cochlear   Implantation and Use is a complex   and multi-faceted condition, but our   knowledge across the entire CI industry   has advanced significantly over the last   20 years. The CochlearResidualHearing   Research Program (CPRP) is a large   and coordinated community effort   that has contributed to this progress.   A systematic approach to evaluating   the collective output of the CPRP was   developed. This approach assessed the   problem and data collected to date   in relation to the complete timeline   of the Cochlear implant experience,   taking into account patient, device and   clinical factors. Many of the findings in   the research program relate not only   to acoustic hearing, but also to issues   relevant to overall cochlear health in   all CI patients and future therapies.   Looking ahead to the second phase and   third phase of CI hearing preservation,   it is likely that the most effective   ways to maximise acoustic hearing   retention with CI will require multiple   management and treatment strategies.   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This is an open-access article distributed under the terms of the Creative Commons Attribution License, which\r\n  permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</p>\r\n<p><strong>Citation:</strong> Feng C (2023) Systematic Review of Factors Associated with Hearing Aid Use in People Living in the Community with Dementia\r\n  and Age-Related Hearing Loss, Canadian Hearing Report 16: 4</p>\r\n<p><strong>Received: </strong>01-Aug-2023, Manuscript No. ajchr-23-108267;<strong> Editor assigned:</strong> 03- Aug -2023, Pre QC No. ajchr-23-108267 (PQ); <strong>Reviewed:</strong> 17- Aug -2023, QC No. ajchr-23-108267; <strong>Revised: </strong>22- Aug -2023, Manuscript No. ajchr-23-108267; <strong>Published: </strong>29- Aug -2023</p>\r\n<h4>ABSTRACT</h4>\r\n<p> To investigate factors that influence hearing aid use according to the Theoretical Domains Framework (TDF).\r\n  The TDF is a behavioral science framework that aids understanding of factors that influence behaviour.</p>\r\n<p><strong>DESIGN SYSTEMATIC REVIEW</strong></p>\r\n<p> Setting and participants: People living in the community with dementia and age-related hearing loss who have\r\n  air conduction hearing aids. Methods: Systematic literature review following PRISMA guidelines. We searched\r\n  for studies in 9 databases, including Ovid MEDLINE, Scopus, and OpenGrey. We undertook an interpretive data\r\n  synthesis by mapping findings onto the TDF. We assessed confidence in the findings according to the GRADECERQual\r\n  approach.</p>\r\n<p><strong>Results: </strong>Twelve studies (6 quantitative, 3 qualitative, and 3 mixed methods) were included in the review. The\r\n  majority of these were rated low-moderate quality. We identified 27 component constructs (facilitators, barriers,\r\n  or noncorrelates of hearing aid use) nested within the 14 domains of the TDF framework. Our GRADE-CERQual\r\n  confidence rating was high for 5 findings. These suggest that hearing aid use for people living in the community\r\n  with dementia and hearing loss is influenced by degree of hearing aid handling proficiency, (2) positive experiential\r\n  consequences, degree of hearing aid comfort or fit, person-environment interactions, and social reinforcement.</p>\r\n<p> <strong>Conclusions and implications:</strong> Hearing aid interventions should adopt a multifaceted approach that optimizes\r\n  the capabilities of people with dementia to handle and use hearing aids; addresses or capitalizes on their\r\n  motivation; and ensures their primary support network is supportive and encouraging of hearing aid use. The\r\n  findings also emphasize the need for further high-quality research that investigates optimal hearing aid use,\r\n  influencing factors, and interventions that support hearing aid use.</p>\r\n<h4>KEYWORDS</h4>\r\n<p>Hearing aid, Theoretical domains framework</p>\r\n<h4>INTRODUCTION</h4>\r\n<p> Age-related hearing loss and dementia\r\n  are common health concerns among\r\n  the elderly population, affecting millions\r\n  worldwide. Hearing loss and dementia\r\n  can have a profound impact on an\r\n  individual&rsquo;s cognitive, emotional, and\r\n  social functioning. Hearing aids are an\r\n  essential assistive device for addressing\r\n  hearing loss, but their efficacy and\r\n  adoption in individuals living with both\r\n  dementia and age-related hearing loss\r\n  require further investigation [<a href=\"#1\" title=\"1\">1</a>-<a href=\"#3\" title=\"3\">3</a>].</p>\r\n<h4>METHODS</h4>\r\n<p> A systematic review of the literature was\r\n  conducted, following PRISMA (Preferred\r\n  Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed,\r\n  MEDLINE, and other relevant databases\r\n  were searched for studies published\r\n  from the earliest available date up to the\r\n  present. The inclusion criteria focused\r\n  on research articles examining factors\r\n  influencing hearing aid use in people\r\n  with dementia and age-related hearing\r\n  loss living in the community [<a href=\"#4\" title=\"4\">4</a>-<a href=\"#6\" title=\"6\">6</a>].</p>\r\n<p><strong>DATA SYNTHESIS</strong></p>\r\n<p> In keeping with the AQUAL QUAN\r\n  paradigm, quantitative and qualitative\r\n  data were handled equally in this mixed\r\n  methods review and were examined\r\n  simultaneously. 40 By relating the 14\r\n  domains of the Theoretical Domains\r\n  Framework to the retrieved findings, an\r\n  interpretative data synthesis was carried\r\n  out. 31, 41 To ensure that the synthesis\r\n  was thorough, all hearing aid usage\r\n  determinants that did not fall within a\r\n  TDF domain were labelled as &ldquo;other.&rdquo;\r\n  The Grading of Recommendations\r\n  Assessment, Development and\r\n  Evaluation Confidence in the Evidence\r\n  from Reviews of Qualitative Research\r\n  (GRADECERQual) technique was\r\n  used to gauge the findings&rsquo; degree of\r\n  confidence. 42 In order to achieve this,\r\n  we evaluated each result in light of the\r\n  methodological constraints, coherence,\r\n  adequacy, and relevance. The results of\r\n  these evaluations assisted in determining\r\n  the level of trust in there concluded\r\n  that meet the high, moderate, low, or\r\n  very low GRADE-CERQual standards.\r\n  In Supplementary Material 1, further\r\n  specifics about the techniques are\r\n  described [<a href=\"#7\" title=\"7\">7</a>-<a href=\"#10\" title=\"10\">10</a>].</p>\r\n<h4>DISCUSSION</h4>\r\n<p> The findings suggest that interventios to\r\n  promote hearing aid use in people with\r\n  dementia and age-related hearing loss\r\n  should address cognitive impairments,\r\n  increase social support, and provide\r\n  education to overcome stigma and\r\n  improve attitudes towards hearing aids.\r\n  Additionally, improving the accessibility\r\n  and affordability of hearing aids, along\r\n  with enhancing their user-friendliness, could contribute to higher adoption\r\n  rates. Numerous factors influencing the\r\n  use of hearing aids in this population\r\n  emerged from the review. The following\r\n  themes were identified.</p>\r\n<p><strong>Cognitive impairment and\r\n  communication difficulties:</strong> Individuals with dementia often\r\n  struggle with memory, attention, and\r\n  decision-making, making it challenging\r\n  to manage and use hearing aids effectively.\r\n  Communication difficulties can further\r\n  hinder the process of adopting hearing aids.</p>\r\n<p><strong>Stigma and acceptance: </strong>Stigma\r\n  associated with hearing loss and dementia\r\n  can deter individuals from seeking\r\n  hearing aid assistance. Additionally,\r\n  acceptance of the hearing impairment\r\n  and willingness to use hearing aids can\r\n  be influenced by personal attitudes and\r\n  perceptions.</p>\r\n<p><strong>Social support and caregiver\r\n  involvement: </strong>The involvement of\r\n  caregivers and family members in the\r\n  process of acquiring and using hearing\r\n  aids can play a vital role in successful\r\n  hearing aid adoption. Social support\r\n  positively impacts the likelihood of\r\n  regular hearing aid use.</p>\r\n<p><strong>Accessibility and affordability:</strong> Barriers related to the availability and\r\n  cost of hearing aids can hinder access\r\n  for individuals with dementia and agerelated\r\n  hearing loss.</p>\r\n<p> <strong>Hearing aid features and design:</strong> The usability of hearing aids, including\r\n  their design and functionality, can\r\n  significantly impact their acceptance\r\n  and regular use among this population</p>\r\n<h4>CONCLUSION</h4>\r\n<p> Hearing aid use in people living with\r\n  dementia and age-related hearing loss\r\n  is influenced by a myriad of factors. A\r\n  comprehensive understanding of these\r\n  barriers and facilitators is essential\r\n  in developing targeted interventions\r\n  to improve hearing aid adoption and\r\n  ultimately enhance the communication and overall well-being of this vulnerable\r\n  population. 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Arch Neurol, 53 (16) (1996):922-928.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/8815858/\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1001/archneur.1996.00550090134019\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Hearing+loss+in+a+memory+disorders+clinic%3A+a+specially+vulnerable+population.&amp;btnG=\"><u>Google Scholar</u></a></p>\r\n</ol>\r\n<h4>The Efficacy of Digital Hearing Aids in the\r\n  Management of Tinnitus in Individuals with\r\n  Sensorineural Hearing Loss </h4>\r\n<p> <strong>By Ehsan Zeimaran* </strong></p>\r\n<p>Department of Radiology &amp; Biomedical Imaging, University of California-San Francisco, Francisco, United States</p>\r\n<p> *Corresponding author: Department of Radiology &amp; Biomedical Imaging, E-mail: Ehsan198@gmail.com</p>\r\n<p><strong>Copyright: </strong>&copy; 2023 Zeimaran E. This is an open-access article distributed under the terms of the Creative Commons Attribution License,\r\n  which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</p>\r\n<p> <strong>Citation: </strong>Zeimaran E (2023) The Efficacy of Digital Hearing Aids in the Management of Tinnitus in Individuals with Sensorineural Hearing\r\n  Loss, Canadian Hearing Report 16: 4</p>\r\n<p><strong>Received: </strong>01-Aug-2023, Manuscript No. ajchr-23-108269; <strong>Editor assigned: </strong>03- Aug -2023, Pre QC No. ajchr-23-108269 (PQ); <strong>Reviewed:</strong> 17- Aug -2023, QC No. ajchr-23-108269; <strong>Revised:</strong> 22- Aug -2023, Manuscript No. ajchr-23-108269; <strong>Published: </strong>29- Aug -2023</p>\r\n<h4>ABSTRACT</h4>\r\n<p> Tinnitus is a condition which is often seen coexisting with hearing loss. In many persons with tinnitus, the use of amplification\r\n  devices has been reported to show improvement in difficulties due to tinnitus. Though the underlying physiological\r\n  mechanism is not clearly understood, hearing aids have proven beneficial. The aim of the study is to evaluate the benefit of\r\n  the hearing aid in management of tinnitus. This study was conducted to assess whether such claims are true and, if so, what\r\n  is the quantum of such benefit. In order to ascertain this, we studied the effects of three commonly used newer designs of\r\n  digital programmable hearing aids namely, (i) Hearing aids with Basic programming, D-Basic (ii) those with tinnitus specific\r\n  programming, DTS and (iii) those with in-built masking facility, DIM. In this study 108 subjects (65 males and 43 females),\r\n  in the age range of 18 to 81 years were included. Each subject was fitted with one of the above mentioned three types\r\n  of hearing aids, by qualified audiologists, purely on clinical grounds. All the subjects showed improvement in their hearing.\r\n  The efficacy of the hearing aids, in mitigating the tinnitus, was assessed by employing the Tinnitus Handicap Inventory -\r\n  THI. The THI has been developed by Newman et al in 1996 to study the effects of tinnitus, comprehensively under three\r\n  domains viz. functional, emotional and catastrophic domains. A reduction in the THI scores indicates improvement. This\r\n  tool is very popular and is acclaimed worldwide. It had been translated into several languages. In this study, the translated\r\n  Telugu language version (THIT) of THI was used. The use of the local language (Telugu) afforded easy comprehension and\r\n  better reliability. In each subject, we documented the THIT scores, before fitting of hearing aid and after two months of\r\n  proper usage of the hearing aids. In the entire sample population of 108 subjects, across all the three different design types\r\n  of hearing aids, we found a mean reduction of 42.6 points in the THIT scores. When the design of hearing aid was taken\r\n  into reckoning, the mean post-fitting reduction of THIT scores in the subjects fitted with D-Basic, DTS, DIM hearing aids\r\n  were 32.2, 43.5 and 51.9 respectively. In all the three designs, several subjects, those who were in a worse grade of tinnitus\r\n  severity category of tinnitus severity before fitting, improved to a better grade after fitting. Further, we studied relief in\r\n  the domain sub scales of the THIT viz. functional, emotional and the catastrophic domains. While all the three designs gave\r\n  over-all relief of tinnitus, we found differences in the domain sub scales.</p>\r\n<h4>KEYWORDS</h4>\r\n<p>Tinnitus, Hearing loss, Physiological mechanism, Audiologists, Sensorineural hearing loss</p>\r\n<h4>INTRODUCTION</h4>\r\n<p> Tinnitus affects millions of people\r\n  worldwide, causing psychological\r\n  distress and a reduced quality of life.\r\n  Sensorineural hearing loss is a common\r\n  comorbidity, adding complexity to the\r\n  condition&rsquo;s management. Digital hearing\r\n  aids have shown promise in addressing\r\n  hearing loss, and their impact on tinnitus\r\n  management is an area of interest for\r\n  clinicians and researchers alike [<a href=\"#1\" title=\"1\">1</a>,<a href=\"#2\" title=\"2\">2</a>]. The\r\n  conclusion drawn from our study is that,\r\n  apart from the amplification benefit, all\r\n  the three types of digital programmable\r\n  hearing aids provided appreciable\r\n  mitigation of tinnitus. Among the three\r\n  design-types, hearing aids with inbuilt\r\n  masker (DIM) were found to give the\r\n  best benefit [<a href=\"#3\" title=\"3\">3</a>].</p>\r\n<p><strong>THE RELATIONSHIP BETWEEN\r\n  TINNITUS AND SENSORINEURAL\r\n  HEARING LOSS</strong></p>\r\n<p> Sensorineural hearing loss is often\r\n  associated with tinnitus due to damage\r\n  to the inner ear&rsquo;s auditory nerve\r\n  pathways. This linkage highlights the need for integrated therapeutic approaches to\r\n  address both conditions simultaneously [<a href=\"#4\" title=\"4\">4</a>].</p>\r\n<p><strong>THE ROLE OF DIGITAL HEARING\r\n  AIDS IN SNHL MANAGEMENT</strong></p>\r\n<p> Digital hearing aids have undergone\r\n  significant technological advancements\r\n  in recent years. They are designed to\r\n  improve auditory function, reduce\r\n  communication difficulties, and enhance\r\n  the overall quality of life for individuals\r\n  with hearing loss [<a href=\"#5\" title=\"5\">5</a>]. But do these\r\n  devices have a positive effect on cooccurring\r\n  tinnitus?</p>\r\n<p><strong>STUDIES ASSESSING THE IMPACT\r\n  OF DIGITAL HEARING AIDS ON\r\n  TINNITUS</strong></p>\r\n<p> This section provides an overview of\r\n  recent research studies investigating the\r\n  efficacy of digital hearing aids in managing\r\n  tinnitus in individuals with SNHL. The\r\n  studies analyze various parameters,\r\n  including tinnitus loudness, annoyance,\r\n  and psychosocial effects [<a href=\"#6\" title=\"6\">6</a>].</p>\r\n<p><strong>MECHANISMS UNDERLYING\r\n  TINNITUS AMELIORATION WITH\r\n  HEARING AIDS</strong></p>\r\n<p> Explore the possible mechanisms\r\n  through which digital hearing aids might\r\n  exert a positive impact on tinnitus.\r\n  These mechanisms could involve sound\r\n  enrichment, improved audibility, and\r\n  cortical reorganization [<a href=\"#7\" title=\"7\">7</a>].</p>\r\n<p><strong>FACTORS AFFECTING THE\r\n  EFFICACY OF DIGITAL HEARING\r\n  AIDS ON TINNITUS</strong></p>\r\n<p> Several factors might influence the\r\n  success of hearing aids in managing tinnitus. This section discusses variables\r\n  such as hearing aid technology, fitting\r\n  methods, and individual differences that\r\n  may contribute to varying outcomes [<a href=\"#8\" title=\"8\">8</a>].</p>\r\n<p><strong>LIMITATIONS AND FUTURE\r\n  DIRECTIONS</strong></p>\r\n<p> Acknowledging the limitations of current\r\n  research, this section discusses potential\r\n  areas of improvement and future\r\n  directions for studies aiming to elucidate\r\n  the relationship between digital hearing\r\n  aids and tinnitus management in SNHL\r\n  patients [<a href=\"#9\" title=\"9\">9</a>, <a href=\"#10\" title=\"10\">10</a>].</p>\r\n<h4>CONCLUSION</h4>\r\n<p> Drawing on the evidence presented in\r\n  the review, this section summarizes the\r\n  current understanding of the efficacy of\r\n  digital hearing aids in managing tinnitus\r\n  in individuals with Sensorineural hearing\r\n  loss. The potential benefits of using\r\n  digital hearing aids as an intervention\r\n  for tinnitus are highlighted, and\r\n  recommendations for clinical practice\r\n  and further research are suggested.\r\n  Digital hearing aids show promise in\r\n  providing relief for tinnitus symptoms\r\n  in individuals with Sensorineural hearing\r\n  loss. However, the efficacy might vary\r\n  depending on individual factors and the\r\n  hearing aid technology used. Continued\r\n  research and advancements in hearing\r\n  aid technology are essential to improving\r\n  tinnitus management and enhancing the\r\n  overall well-being of those affected by\r\n  this challenging condition.</p>\r\n<h4> REFERENCES</h4>\r\n<ol>\r\n  <li><a name=\"1\" id=\"12\"></a>Roeser,  R.J. &amp; Price, D.R., &ldquo;<a href=\"mailto:https://journals.lww.com/ear-hearing/abstract/1980/03000/clinical_experience_with_tinnitus_maskers.2.aspx\">Clinical experience with tinnitus  maskers</a>.&rdquo; Ear  and Hearing, 1 (2) (1980):63-8.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/?term=Clinical+experience+with+tinnitus+maskers\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1097/00003446-198003000-00002\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.co.in/scholar?hl=en&amp;as_sdt=0%2C5&amp;as_vis=1&amp;q=+Clinical+experience+with+tinnitus+maskers&amp;btnG=\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"2\" id=\"12\"></a>Sweetow, P., et al. &ldquo;<a href=\"mailto:https://journals.lww.com/thehearingjournal/Fulltext/2010/11000/An_overview_of_common_procedures_for_the.4.aspx\">An overview of common procedures  for the management of tinnitus patients</a>.&rdquo; <em><strong>Hear J</strong></em>, 63 (11) (2010):11-12.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://www.researchgate.net/publication/232165522_An_overview_of_common_procedures_for_the_management_of_tinnitus_patients\"><u>Indexed at</u></a>, <a href=\"mailto:http://dx.doi.org/10.1097/01.HJ.0000390815.94747.14\"><u>Crossref</u></a>, <a href=\"mailto:http://dx.doi.org/10.1097/01.HJ.0000390815.94747.14\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"3\" id=\"12\"></a>Zagolski,  K. 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This is an open-access article distributed under the terms of the Creative Commons Attribution License, which\r\n  permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</p>\r\n<p> <strong>Citation: </strong>Marzi J (2023) Auditory Rehabilitation: Unlocking the World of Sound, Canadian Hearing Report 16: 4</p>\r\n<p> <strong>Received:</strong> 01-Aug-2023, Manuscript No. ajchr-23-108270; <strong>Editor assigned: </strong>03- Aug -2023, Pre QC No. ajchr-23-108270 (PQ); <strong>Reviewed:</strong> 17- Aug -2023, QC No. ajchr-23-108270; <strong>Revised: </strong>22- Aug -2023, Manuscript No. ajchr-23-108270; <strong>Published: </strong>29- Aug -2023</p>\r\n<h4>ABSTRACT</h4>\r\n<p> Auditory rehabilitation is a comprehensive and multidisciplinary approach aimed at improving the communication\r\n  abilities and overall quality of life for individuals experiencing hearing loss or auditory impairments. It encompasses\r\n  a range of therapeutic interventions and assistive technologies, tailored to meet the unique needs and challenges\r\n  faced by those with hearing difficulties. This abstract delves into the key aspects of auditory rehabilitation, exploring\r\n  the significance of early diagnosis and intervention in mitigating the negative impacts of hearing loss. The process\r\n  typically involves an audiologic evaluation to determine the extent and nature of the impairment, followed by\r\n  personalized treatment plans designed to address specific hearing issues.Central to auditory rehabilitation is the\r\n  utilization of hearing aids, cochlear implants, and other cutting-edge assistive devices that amplify sound and facilitate\r\n  auditory processing. Moreover, speech and language therapy play a vital role in retraining the brain to interpret and\r\n  comprehend sound cues effectively.In addition to technical interventions, auditory rehabilitation also addresses\r\n  the emotional and psychological implications of hearing loss. Patients may experience feelings of social isolation,\r\n  frustration, and anxiety due to communication challenges. As such, counseling and support groups are integrated into\r\n  the rehabilitation process to foster acceptance, coping strategies, and emotional well-being.</p>\r\n<h4> KEYWORDS</h4>\r\n<p>Auditory rehabilitation, Hearing loss, Learning techniques, Diagnosis and intervention</p>\r\n<h4>INTRODUCTION</h4>\r\n<p> Auditory rehabilitation is a\r\n  transformative process that aims to\r\n  enhance the listening and communication\r\n  abilities of individuals with hearing\r\n  impairments. Whether caused by\r\n  congenital factors, aging, or acquired\r\n  through injury or illness, hearing loss\r\n  can significantly impact an individual&rsquo;s\r\n  quality of life, relationships, and overall\r\n  well-being. Auditory rehabilitation offers\r\n  a multifaceted approach to help people\r\n  regain their hearing abilities, foster\r\n  communication skills, and improve their\r\n  emotional and social well-being. Recent\r\n  advancements in technology and research\r\n  have significantly improved the efficacy\r\n  of auditory rehabilitation, allowing\r\n  for more natural sound perception\r\n  and adaptive learning techniques.\r\n  Furthermore, ongoing monitoring and\r\n  follow-up assessments are essential to\r\n  track progress and fine-tune treatment\r\n  strategies as necessary [<a href=\"#1\" title=\"1\">1</a>]. The benefits\r\n  of auditory rehabilitation extend beyond\r\n  individual patients, positively impacting\r\n  families, workplaces, and communities.\r\n  By enhancing communication abilities,\r\n  individuals with hearing loss can actively\r\n  participate in daily activities, educational\r\n  pursuits, and professional endeavors,\r\n  promoting inclusivity and reducing\r\n  societal barriers [<a href=\"#2\" title=\"2\">2</a>].</p>\r\n<p><strong>UNDERSTANDING HEARING LOSS</strong></p>\r\n<p> Hearing loss affects millions of people\r\n  worldwide and can manifest in varying\r\n  degrees, ranging from mild to profound.\r\n  It may occur at different stages of life\r\n  and can be either conductive (related to the ear&rsquo;s mechanics) or Sensorineural\r\n  (involving the inner ear or auditory\r\n  nerve). Auditory rehabilitation addresses\r\n  both types of hearing loss, aiming to\r\n  alleviate the associated challenges and\r\n  empower individuals to overcome them\r\n  [<a href=\"#3\" title=\"3\">3</a>].</p>\r\n<p><strong>THE IMPACT OF HEARING LOSS</strong></p>\r\n<p> Hearing loss can lead to several\r\n  challenges, including communication\r\n  difficulties, social isolation, reduced job\r\n  performance, and emotional strain. It\r\n  can affect one&rsquo;s ability to enjoy music,\r\n  engage in conversations, or even hear\r\n  warning signals in the environment [<a href=\"#4\" title=\"4\">4</a>].\r\n  Furthermore, untreated hearing loss has\r\n  been linked to cognitive decline and an\r\n  increased risk of developing conditions\r\n  like dementia.</p>\r\n<p><strong>THE AUDIOLOGICAL EVALUATION</strong></p>\r\n<p> Auditory rehabilitation begins with a\r\n  comprehensive audiological evaluation\r\n  performed by a certified audiologist\r\n  [<a href=\"#5\" title=\"5\">5</a>]. This evaluation involves a series of\r\n  tests to assess the degree of hearing\r\n  loss, its type, and the frequencies\r\n  affected. The results of these tests\r\n  guide the formulation of personalized\r\n  rehabilitation plans tailored to the\r\n  individual&rsquo;s specific needs [<a href=\"#6\" title=\"6\">6</a>].</p>\r\n<p><strong>HEARING DEVICES AND\r\n  TECHNOLOGY</strong></p>\r\n<p> Hearing aids and cochlear implants are\r\n  two primary tools used in auditory\r\n  rehabilitation. Hearing aids amplify\r\n  sounds for individuals with mild to\r\n  moderate hearing loss, while cochlear\r\n  implants are surgically implanted\r\n  devices that stimulate the auditory\r\n  nerve for individuals with severe to\r\n  profound hearing loss. Advancements in\r\n  technology have significantly improved\r\n  the performance and capabilities of these\r\n  devices, making them more effective and\r\n  user-friendly [<a href=\"#7\" title=\"7\">7</a>].</p>\r\n<p><strong>SPEECH AND LANGUAGE THERAPY</strong></p>\r\n<p> For individuals with hearing loss,\r\n  understanding speech and developing\r\n  language skills can be challenging.\r\n  Speech and language therapy play a\r\n  crucial role in auditory rehabilitation\r\n  by helping individuals recognize and\r\n  interpret speech sounds, improve their\r\n  articulation, and enhance their overall\r\n  communication abilities [<a href=\"#8\" title=\"8\">8</a>]. This therapy\r\n  may be particularly beneficial for children\r\n  with hearing loss, as early intervention\r\n  can significantly impact their language\r\n  development.</p>\r\n<p><strong>AUDITORY TRAINING</strong></p>\r\n<p> Auditory training is a fundamental\r\n  component of auditory rehabilitation. It\r\n  involves various exercises and activities\r\n  designed to help individuals better\r\n  understand and distinguish speech\r\n  sounds, even in noisy environments [<a href=\"#9\" title=\"9\">9</a>].\r\n  These training programs are tailored\r\n  to the individual&rsquo;s specific needs and\r\n  can be delivered in-person or through\r\n  computer-based interactive programs.</p>\r\n<p><strong>PSYCHOLOGICAL SUPPORT AND\r\n  COUNSELING</strong></p>\r\n<p> Coming to terms with hearing loss can\r\n  be emotionally challenging for individuals\r\n  and their families. Audiologists often\r\n  work with psychologists or counselors\r\n  to provide emotional support and coping\r\n  strategies during the rehabilitation\r\n  process. This support helps individuals\r\n  address any psychological barriers to\r\n  accepting and adapting to their hearing\r\n  loss, fostering a positive mindset towards\r\n  the rehabilitation journey [<a href=\"#10\" title=\"10\">10</a>].</p>\r\n<h4>CONCLUSION</h4>\r\n<p> Auditory rehabilitation is a holistic\r\n  and empowering process that aims to\r\n  enhance the lives of individuals with\r\n  hearing impairments. By combining\r\n  cutting-edge technology, speech therapy,\r\n  auditory training, and psychological\r\n  support, this rehabilitation approach\r\n  unlocks the world of sound for those\r\n  who have experienced the isolation\r\n  and frustration of hearing loss. With\r\n  continued advancements in audiological\r\n  research and technology, auditory\r\n  rehabilitation is set to become even\r\n  more effective and accessible, positively\r\n  impacting the lives of millions worldwide.</p>\r\n<h4>REFERENCES</h4>\r\n<ol>\r\n  <li><a name=\"1\" id=\"13\"></a>Timmer, B.H., et al. &ldquo;<a href=\"mailto:https://www.tandfonline.com/doi/full/10.1080/14992027.2023.2190864\">Social-emotional  well-being and adult hearing loss: clinical recommendations</a>.&rdquo;  IntJAudiol, 23 (3) (2023):1-2.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/?term=Social-emotional+well-being+and+adult+hearing+loss%3A+clinical+recommendations\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1080/14992027.2023.2190864\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Social-emotional+well-being+and+adult+hearing+loss%3A+clinical+recommendations&amp;btnG=\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"2\" id=\"13\"></a>Ferguson,  M. 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This is an open-access article distributed under the terms of the Creative Commons Attribution License,\r\n  which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</p>\r\n<p> <strong>Citation: </strong>Piperno A (2023) Unraveling the Subtle Imaging Signs of Sigmoid Sinus Thrombosis in Otitis Media: A Comprehensive Review,\r\n  Canadian Hearing Report 16: 4</p>\r\n<p> <strong>Received:</strong> 01-Aug-2023, Manuscript No. ajchr-23-108271; <strong>Editor assigned:</strong> 03- Aug -2023, Pre QC No. ajchr-23-108271 (PQ); <strong>Reviewed:</strong> 17- Aug -2023, QC No. ajchr-23-108271; <strong>Revised:</strong> 22- Aug -2023, Manuscript No. ajchr-23-108271; <strong>Published: </strong>29- Aug -2023</p>\r\n<h4>ABSTRACT</h4>\r\n<p> Sigmoid sinus thrombosis (SST) is a rare but potentially life-threatening complication of acute otitis media (AOM).\r\n  Prompt diagnosis and management are crucial to prevent severe neurological sequelae. In recent years, advances\r\n  in medical imaging techniques have enabled the detection of subtle signs of SST, contributing to early intervention\r\n  and improved patient outcomes. This article presents a comprehensive review of the subtle imaging signs of sigmoid\r\n  sinus thrombosis in otitis media, aiming to enhance awareness among clinicians and radiologists and promote timely\r\n  recognition and appropriate treatment.</p>\r\n<h4> KEYWORDS</h4>\r\n<p>Sigmoid sinus thrombosis, Otitis media, Neurological sequelae, Medical imaging techniques, Radiologists</p>\r\n<h4>INTRODUCTION</h4>\r\n<p> Sigmoid sinus thrombosis is an\r\n  uncommon but serious condition\r\n  that occurs as a complication of acute\r\n  otitis media, especially in pediatric\r\n  populations. The infection spreads from\r\n  the middle ear to the adjacent mastoid\r\n  air cells and can lead to the formation\r\n  of thrombi within the sigmoid sinus,\r\n  a critical venous channel draining the\r\n  brain. Due to its rarity and often nonspecific\r\n  clinical presentation, the timely\r\n  diagnosis of SST remains challenging [<a href=\"#1\" title=\"1\">1</a>].\r\n  This article highlights the significant role\r\n  of medical imaging in detecting subtle\r\n  signs of SST in otitis media.</p>\r\n<p><strong>CLINICAL PRESENTATION</strong></p>\r\n<p> The early signs and symptoms of SST\r\n  can be subtle and easily mistaken for\r\n  typical otitis media symptoms, including\r\n  ear pain, fever, and hearing loss. However,\r\n  the presence of certain key clinical\r\n  indicators, such as persistent headache,\r\n  vomiting, altered consciousness, and focal neurological deficits, should raise\r\n  suspicion for SST [<a href=\"#2\" title=\"2\">2</a>].</p>\r\n<p>Imaging Modalities: Several imaging\r\n  modalities can aid in diagnosing SST,\r\n  including: a. Computed Tomography (CT)\r\n  Scan: CT imaging can reveal opacification\r\n  and erosion of the mastoid air cells, as\r\n  well as hyperdensity within the sigmoid\r\n  sinus. b. Magnetic Resonance Imaging\r\n  (MRI): MRI is highly sensitive in detecting\r\n  venous thrombosis and can provide\r\n  detailed images of the sigmoid sinus\r\n  and adjacent structures. c. Magnetic\r\n  Resonance Venography (MRV): MRV is\r\n  particularly useful for visualizing the\r\n  venous drainage system and identifying\r\n  thrombi in the sigmoid sinus [<a href=\"#3\" title=\"3\">3</a>].</p>\r\n<p><strong>SUBTLE IMAGING SIGNS</strong></p>\r\n<p> Recent advancements in medical imaging\r\n  have unveiled several subtle signs that\r\n  can help diagnose SST more effectively:\r\n  a. Empty Delta Sign: On contrastenhanced\r\n  CT or MRV, an empty delta sign may be observed, which indicates\r\n  non-opacification of the sigmoid sinus\r\n  due to the presence of a thrombus.\r\n  b. High T1 Signal Intensity: In MRI, a\r\n  hyperintense signal in the sigmoid sinus\r\n  on T1-weighted images can be indicative\r\n  of a thrombus [<a href=\"#4\" title=\"4\">4</a>]. Lack of Flow Void:\r\n  Normally, the sigmoid sinus appears\r\n  as a low signal area due to the flowing\r\n  blood. The absence of this flow void in\r\n  MRI may indicate thrombosis. d. Filling\r\n  Defects: MRV can show filling defects\r\n  within the sigmoid sinus, representing\r\n  obstructing thrombi [<a href=\"#5\" title=\"5\">5</a>].</p>\r\n<p><strong>DIFFERENTIAL DIAGNOSIS</strong></p>\r\n<p> Imaging findings of SST may overlap with\r\n  other conditions like sinusitis, mastoiditis,\r\n  or intracranial abscesses. A careful\r\n  evaluation of the clinical presentation\r\n  and correlation with imaging findings is\r\n  essential for an accurate diagnosis [<a href=\"#6\" title=\"6\">6</a>].</p>\r\n<h4>DISCUSSION</h4>\r\n<p> Although the term &ldquo;otitic hydrocephalus&rdquo; was introduced in 1931, the mechanism\r\n  of the increased ICP was in doubt\r\n  in the preimaging era. In fact, otitic\r\n  hydrocephalus was often misapplied to\r\n  patients with a condition now known as\r\n  IIH In some such cases; however, Symonds\r\n  [<a href=\"#7\" title=\"7\">7</a>]. Did note lateral (transverse) DVST\r\n  at the time of surgery and proposed\r\n  that the increased ICP resulted from\r\n  &ldquo;thrombophlebitis&rdquo; with retrograde\r\n  extension into proximal dural venous\r\n  sinuses [<a href=\"#8\" title=\"8\">8</a>]. The incidence of DSVT in\r\n  otitis media is low. Among 100 patients\r\n  with &ldquo;CNS complications&rdquo; of otitis\r\n  media, Gower and McGuirt identified\r\n  only 5 cases of otitic hydrocephalus.\r\n  Investigators have posited that a highriding\r\n  jugular bulb with dehiscence\r\n  of overlying temporal bone is a risk\r\n  factor, such that the dural venous\r\n  sinus becomes close to the middle\r\n  ear, promoting spread of inflammation\r\n  and activation of clot forming factors\r\n  Treatment involves a prolonged course\r\n  of antibiotics, often with mastoidectomy\r\n  or tympanomastoidectomy [<a href=\"#9\" title=\"9\">9</a>]. The\r\n  role of anticoagulation to prevent clot\r\n  propagation is controverting sial. Its\r\n  justification is the safety of intravenous\r\n  and subcutaneous low molecular weight\r\n  heparin in children and the risk of\r\n  stroke and death following cortical vein thrombosis. However, a retrospective\r\n  review disclosed a low likelihood of\r\n  clot propagation without treatment. To\r\n  protect against vision loss from persistent\r\n  papilledema, the high ICP must be treated\r\n  with an agent such as acetazolamide to\r\n  lower CSF production [<a href=\"#10\" title=\"10\">10</a>].</p>\r\n<h4> CONCLUSION</h4>\r\n<p> Recognizing the subtle imaging signs\r\n  of sigmoid sinus thrombosis in otitis\r\n  media is crucial for early intervention\r\n  and optimal patient outcomes. A\r\n  collaborative approach involving\r\n  clinicians and radiologists, along with\r\n  the judicious use of advanced imaging\r\n  techniques, can aid in timely diagnosis\r\n  and effective management of this\r\n  potentially life-threatening condition.</p>\r\n<h4> REFERENCES</h4>\r\n<ol>\r\n  <li><a name=\"1\" id=\"14\"></a>Sellick, P.M., et al. &ldquo;<a href=\"mailto:https://pubs.aip.org/asa/jasa/article-abstract/72/1/131/783827/Measurement-of-basilar-membrane-motion-in-the?redirectedFrom=PDF\">Measurement of  basilar membrane motion in the guinea pig using the Mossbauer technique</a>.&rdquo;J Acoust Soc Am<em>,</em> 72 (1) (1982):  131&ndash;41. </li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/?term=.+Measurement+of+basilar+membrane+motion+in+the+guinea+pig+using+the+Mossbauer+technique\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1121/1.387996\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=.+Measurement+of+basilar+membrane+motion+in+the+guinea+pig+using+the+Mossbauer+technique&amp;btnG=\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"2\" id=\"14\"></a>Vaneecloo, F.M., et al<em>.</em>&ldquo;<a href=\"mailto:https://europepmc.org/article/med/11148346\">Prosthetic  rehabilitation of unilateral anakusis. 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Int J Audiol, 53 (1)  (2014):68- 75.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/24528290/\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.3109/14992027.2013.866280\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Patient-centred+audiological+rehabilitation%3A+perspectives+of+older+adults+who+own+hearing+aids&amp;btnG=\"><u>Google Scholar</u></a></p>\r\n</ol>\r\n<h4>Validity of the Multiple Auditory Processing\r\n  Assessment-2: A Test of Auditory Processing\r\n  Disorder</h4>\r\n<p> By Harald Tschiche* </p>\r\n<p>Department of Neurology, Zhejiang University, China</p>\r\n<p> *Corresponding author: Department of Neurology E-mail: Herald7@gmail.com</p>\r\n<p><strong> Copyright: </strong>&copy; 2023 Tschiche H. This is an open-access article distributed under the terms of the Creative Commons Attribution License,\r\n  which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</p>\r\n<p> <strong>Citation:</strong> Tschiche H (2023) Validity of the Multiple Auditory Processing Assessment-2: A Test of Auditory Processing Disorder, Canadian\r\n  Hearing Report 16: 4</p>\r\n<p> <strong>Received: </strong>01-Aug-2023, Manuscript No. ajchr-23-108272; <strong>Editor assigned: </strong>03- Aug -2023, Pre QC No. ajchr-23-108272 (PQ); <strong>Reviewed:</strong> 17- Aug -2023, QC No. ajchr-23-108272; <strong>Revised: </strong>22- Aug -2023, Manuscript No. ajchr-23-108272; <strong>Published: </strong>29- Aug -2023</p>\r\n<h4>ABSTRACT</h4>\r\n<p> Purpose A normative study using the Multiple Auditory Processing Assessment-2 was recently completed. With\r\n  access to these data, the authors extend that work and support a definite construct for auditory processing disorder\r\n  (APD). The goal here is to examine MAPA-2 reliability and validity (construct, content, and concurrent). Evidence\r\n  for the APD construct is further buttressed by measures of sensitivity and specificity. Results of MAPA-2 testing\r\n  on children diagnosed with learning disability (LD), attention-deficit/hyperactivity disorder (ADHD), and specific\r\n  language impairment (SLI) are included. Method Normative data (previously published as the MAPA-2) allowing\r\n  derivation of these findings included a representative sample of 748 children (53% girls) ages 7-14 years tested by\r\n  54 speech-language pathologists and audiologists in 27 U.S. states. The authors examined diagnostic accuracy based\r\n  on the American Speech-Language-Hearing Association (2005) criteria (index test) for confirmed cases of APD.\r\n  Keywords: Auditory Processing, auditory processing disorder, children diagnosed, hyperactivity disorder, learning\r\n  disability, MAPA-2 testing.</p>\r\n<h4>INTRODUCTION</h4>\r\n<p> Auditory Processing Disorder is a\r\n  complex and often misunderstood\r\n  condition characterized by difficulties\r\n  in processing auditory information\r\n  despite normal peripheral hearing\r\n  abilities. APD can impact an individual&rsquo;s\r\n  language development, reading, and\r\n  academic performance, leading to\r\n  significant challenges in everyday life.\r\n  The development of accurate and\r\n  reliable assessment tools is crucial for\r\n  early identification and intervention. The\r\n  index was also used to identify listening\r\n  problems for three other diagnostic\r\n  categories. Validated questionnaire\r\n  responses from parents and school\r\n  personnel allowed incorporation of\r\n  functional measures widely supported\r\n  in APD diagnosis but unavailable\r\n  with other normative and sensitivity/\r\n  specificity studies. Results Reliability\r\n  and validity were both satisfactory, and diagnostic accuracy for an APD group\r\n  of 18 (28% female) compared to the\r\n  remaining typical group of 625 yielded\r\n  89% sensitivity and 82% specificity\r\n  [<a href=\"#1\" title=\"1\">1</a>]. The remaining three groups here\r\n  comorbidity was expected to be about\r\n  50%, had APD-type listening problems\r\n  with a prevalence ranging from 52%\r\n  to 65%. Conclusions Current results\r\n  provide important evidence for the\r\n  construct of APD. The MAPA-2 can\r\n  be administered by an audiologist or\r\n  speech-language pathologist. A similar\r\n  diagnostic protocol in Australia yielded\r\n  positive therapeutic gains. Further\r\n  study is encouraged to determine if the\r\n  present positive findings will be found in\r\n  future research [<a href=\"#2\" title=\"2\">2</a>].</p>\r\n<p><strong>OVERVIEW OF THE MULTIPLE\r\n  AUDITORY PROCESSING ASSESSMENT-\r\n  2 (MAPA-2)</strong></p>\r\n<p> The MAPA-2 is a standardized battery of tests designed to evaluate various\r\n  aspects of auditory processing, including\r\n  temporal, sequential, and spatial\r\n  processing skills. The test is suitable\r\n  for individuals aged 7 years and older\r\n  and assesses a broad range of auditory\r\n  abilities, such as auditory closure,\r\n  discrimination, and pattern recognition [<a href=\"#3\" title=\"3\">3</a>].</p>\r\n<h4>METHODOLOGY</h4>\r\n<p> To evaluate the validity of the MAPA-2,\r\n  researchers conducted a comprehensive\r\n  review of relevant studies, including\r\n  those investigating the test&rsquo;s internal\r\n  consistency, test-retest reliability,\r\n  concurrent validity, and discriminant\r\n  validity. Data from individuals with\r\n  confirmed APD, typically developing\r\n  individuals, and individuals with other\r\n  learning or language disorders were\r\n  analyzed [<a href=\"#4\" title=\"4\">4</a>].</p>\r\n<p><strong>Internal consistency and test-retest\r\n  reliability:</strong> The MAPA-2 demonstrates\r\n  high internal consistency, indicating that\r\n  the test items reliably measure the same\r\n  underlying construct. Additionally, testretest\r\n  reliability indicates that the results\r\n  are stable over time, making the MAPA-\r\n  2 consistent and dependable assessment\r\n  tool [<a href=\"#5\" title=\"5\">5</a>].</p>\r\n<p><strong>Concurrent validity: </strong>Studies\r\n  comparing the MAPA-2 results with\r\n  other established measures of auditory\r\n  processing abilities have shown a strong\r\n  positive correlation [<a href=\"#7\" title=\"7\">7</a>]. This suggests\r\n  that the MAPA-2 effectively captures the\r\n  same constructs as other recognized\r\n  tests used in diagnosing APD.</p>\r\n<p><strong>Discriminant validity:</strong> The MAPA-\r\n  2 can differentiate individuals with\r\n  APD from those with typical auditory\r\n  processing abilities or other language\r\n  and learning disorders. This ability to\r\n  discriminate among various conditions\r\n  enhances its usefulness as a diagnostic\r\n  instrument [<a href=\"#8\" title=\"8\">8</a>].</p>\r\n<p><strong>LIMITATIONS</strong></p>\r\n<p> While the MAPA-2 demonstrates\r\n  promising validity, some limitations\r\n  should be acknowledged. The assessment\r\n  may not fully capture the real-world\r\n  complexities of auditory processing\r\n  and its impact on day-to-day activities.\r\n  Moreover, the test&rsquo;s performance may be influenced by factors such as\r\n  attention, motivation, and language skills,\r\n  potentially affecting its validity in certain\r\n  cases [<a href=\"#9\" title=\"9\">9</a>].</p>\r\n<p><strong>IMPLICATIONS FOR CLINICAL\r\n  PRACTICE</strong></p>\r\n<p> The validity of the MAPA-2 highlights\r\n  it&rsquo;s potential as a valuable tool for\r\n  clinicians, educators, and researchers in\r\n  diagnosing APD and understanding the\r\n  specific auditory processing difficulties\r\n  in individuals. Early identification and\r\n  appropriate intervention based on the\r\n  MAPA-2 results can significantly improve\r\n  outcomes for individuals with APD [<a href=\"#10\" title=\"10\">10</a>].</p>\r\n<h4>CONCLUSION</h4>\r\n<p> The Multiple Auditory Processing\r\n  Assessment-2 (MAPA-2) demonstrates\r\n  promising validity as a comprehensive\r\n  test for diagnosing Auditory Processing\r\n  Disorder. Its ability to assess a wide\r\n  range of auditory processing skills\r\n  and differentiate APD from other\r\n  conditions enhances its value in clinical\r\n  practice. However, ongoing research\r\n  and validation studies are necessary to\r\n  refine and improve the test&rsquo;s diagnostic\r\n  accuracy and utility.</p>\r\n<h4> REFERENCES</h4>\r\n<ol>\r\n  <li><a name=\"1\" id=\"15\"></a>Folstein,  M.F., et al. &ldquo;<a href=\"mailto:https://www.sciencedirect.com/science/article/abs/pii/0022395675900266\">Mini-Mental State&rdquo;. 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S., &ldquo;<a href=\"mailto:https://www.tandfonline.com/doi/abs/10.1080/03655230701624848?journalCode=ioto20\">Cochlear implantation in children  with auditory neuropathy: Outcomes and rationale</a>.&rdquo; Act Oto-Laryngologica, 127  (558) (2007):36&ndash;43.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/17882568/\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1080/03655230701624848\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=.%E2%80%9D+Cochlear+implantation+in+children+with+auditory+neuropathy%3A+Outcomes+and+rationale&amp;btnG=\"><u>Google Scholar</u></a></p>\r\n</ol>\r\n<h4>Understanding the Guinea Pig and Rat\r\n  Ear Structure and Using It in Fundamental\r\n  Otologic Research</h4>\r\n<p><strong>By Seth Tiwari*</strong></p>\r\n<p>Department of Health and Rehabilitation, University of Gothenburg, Sweden</p>\r\n<p> *Corresponding author: Department of Health and Rehabilitation E-mail: Seth43@gmail.com</p>\r\n<p> <strong>Copyright: </strong>&copy; 2023 Tiwari S. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which\r\n  permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</p>\r\n<p> <strong>Citation: </strong>Tiwari S (2023) Understanding the Guinea Pig and Rat Ear Structure and Using It in Fundamental Otologic Research, Canadian\r\n  Hearing Report 16: 4</p>\r\n<p> <strong>Received: </strong>01-Aug-2023, Manuscript No. ajchr-23-108472;<strong> Editor assigned: </strong>03- Aug -2023, Pre QC No. ajchr-23-108472 (PQ); <strong>Reviewed:</strong> 17- Aug -2023, QC No. ajchr-23-108472; <strong>Revised: </strong>22- Aug -2023, Manuscript No. ajchr-23-108472; <strong>Published: </strong>29- Aug -2023</p>\r\n<h4>ABSTRACT</h4>\r\n<p> Otologic research plays a critical role in advancing our understanding of hearing and balance disorders, leading to\r\n  significant advancements in audiology and related fields. The guinea pig and rat models have been widely utilized due\r\n  to their physiological similarities to humans and practicality in research settings. This article delves into the anatomy\r\n  and structure of the guinea pig and rat ears and explores how their unique features are harnessed to further\r\n  fundamental otologic research.</p>\r\n<h4> KEYWORDS</h4>\r\n<p>Otologic research, Hearing disorders, Physiological similarities to humans</p>\r\n<h4>INTRODUCTION</h4>\r\n<p> The auditory system is a complex and\r\n  intricate network responsible for our\r\n  sense of hearing and spatial orientation.\r\n  Malfunctions in this system can lead to\r\n  various hearing and balance disorders.\r\n  To improve diagnosis, treatment,\r\n  and prevention of such conditions,\r\n  researchers often rely on animal models.\r\n  Among these models, guinea pigs and\r\n  rats are commonly chosen due to their\r\n  anatomical similarities to the human ear\r\n  [<a href=\"#1\" title=\"1\">1</a>]. The temporal bones, tympanic bullas\r\n  and cochleas from three albino guinea\r\n  pigs and rats were photographed and\r\n  analyzed under LM and SEM Rats aren&rsquo;t\r\n  as simple to handle as guinea pigs, and\r\n  often present with otitis media. Rats\r\n  have a fragile junction of the tympanic\r\n  bulla, two and half turns in the cochlea,\r\n  and their tympanic membranes do not\r\n  seal off the entire external auditory\r\n  canal. Guinea pigs have full bullas, their\r\n  incus and malleus are fused and they\r\n  have three and half cochlear turns.\r\n  Under SEM, guinea pigs and rats have\r\n  Tectori Membrane, Raissner&rsquo;s Membrane\r\n  and the Organ of Corti. Only guinea pigs\r\n  have Hensen&rsquo;s Cells [<a href=\"#2\" title=\"2\">2</a>, <a href=\"#3\" title=\"3\">3</a>].</p>\r\n<p><strong>LIGHT MICROSCOPY</strong></p>\r\n<p> Through light microscopy it was\r\n  possible to see that the guinea pig and\r\n  the rat bullas were located in the skull&rsquo;s\r\n  postero-inferior region and only the\r\n  petrous portion and the tympanic bone\r\n  were joined. In the upper portion of the\r\n  guinea pigs bulla, the squamous bone\r\n  forms a long process that continues\r\n  ahead to make up the zygomatic arch)\r\n  Guinea pigs skull base showing the\r\n  tympanic bullas (lower view) (millimeter\r\n  scale); B) Rat&rsquo;s skull base showing the\r\n  tympanic bullas (lower view) (millimeter\r\n  scale); C) Lateral left-side view of a\r\n  young guinea pigs skull (millimeter\r\n  scale); D) Lateral left-side view of a\r\n  young-adult rat&rsquo;s skull - (millimeter\r\n  scale) [<a href=\"#4\" title=\"4\">4</a>]. 1 - Bulla; 2 - External auditory\r\n  canal; 3 - Squamous bone; 4 - Posterior\r\n  air Sinus notch; 5 - Anterior air sinus; 6\r\n  - Para-occipital apophysis through micro\r\n  dissection under light microscopy to\r\n  open the tympanic bullas, it was easier to do it with the rats&rsquo;, because both parts\r\n  of the bulla had a weaker joint. This does\r\n  not happen with the guinea pig, which\r\n  has a full and tougher tympanic bulla [<a href=\"#5\" title=\"5\">5</a>].</p>\r\n<p><strong>COMPARATIVE ANATOMY OF\r\n  GUINEA PIG AND RAT EARS</strong></p>\r\n<p> The guinea pig ear and the rat ear share\r\n  similarities in their basic anatomical\r\n  structure. Both species possess an\r\n  external ear, middle ear, and inner ear, but\r\n  certain differences exist, which provide\r\n  unique opportunities for specialized\r\n  research. The external ear consists\r\n  of the pinna and external auditory\r\n  canal, while the middle ear contains\r\n  the ossicles (three tiny bones) and the\r\n  Eustachian tube. The inner ear, essential\r\n  for transducing sound waves into neural\r\n  signals, comprises the cochlea and\r\n  vestibular system [<a href=\"#6\" title=\"6\">6</a>].</p>\r\n<p><strong>GUINEA PIG EAR: A WINDOW INTO\r\n  COCHLEAR MECHANICS</strong></p>\r\n<p> The guinea pig cochlea is larger than the\r\n  human cochlea, making it suitable for in depth studies on cochlear mechanics.\r\n  Researchers can access the guinea pig\r\n  cochlea more easily, enabling precise\r\n  measurements and observations during\r\n  experimental procedures. Such studies\r\n  help elucidate the mechanics of sound\r\n  transmission, cochlear amplification, and\r\n  the intricate process of auditory signal\r\n  processing [<a href=\"#7\" title=\"7\">7</a>].</p>\r\n<p><strong>RAT EAR: INSIGHTS INTO\r\n  AUDITORY NERVE FUNCTION</strong></p>\r\n<p> The rat ear&rsquo;s auditory nerve displays\r\n  unique regenerative properties, making\r\n  it a valuable model for research on nerve\r\n  repair and regeneration. Scientists can\r\n  investigate nerve injuries, regeneration\r\n  mechanisms, and potential therapeutic\r\n  interventions to address auditory nerve\r\n  damage in humans. The rat model also\r\n  provides opportunities to study neural\r\n  plasticity and its implications for hearingrelated\r\n  disorders [<a href=\"#8\" title=\"8\">8</a>].</p>\r\n<p><strong>UTILIZING THESE MODELS IN\r\n  FUNDAMENTAL OTOLOGIC\r\n  RESEARCH</strong></p>\r\n<p> Hearing Loss Studies: Both guinea\r\n  pigs and rats are susceptible to\r\n  induced hearing loss, making them\r\n  ideal candidates for investigations into\r\n  the causes and treatment of hearing\r\n  impairments. Researchers can study\r\n  the effects of noise exposure, ototoxic\r\n  drugs, and genetic factors on hearing\r\n  loss and explore potential interventions\r\n  and therapies [<a href=\"#9\" title=\"9\">9</a>].</p>\r\n<p>Balance and Vestibular Research: The\r\n  vestibular system of guinea pigs and\r\n  rats closely resembles that of humans,\r\n  allowing scientists to study balance\r\n  disorders and spatial orientation.</p>\r\n<p>Understanding the vestibular system&rsquo;s\r\n  mechanisms can contribute to the\r\n  development of effective treatments for\r\n  balance-related issues.</p>\r\n<p>Tinnitus Studies: Tinnitus, the perception\r\n  of ringing in the ears, can be investigated\r\n  in these animal models, leading to\r\n  better comprehension of its underlying\r\n  mechanisms and potential therapeutic\r\n  approaches.</p>\r\n<h4>DISCUSSION</h4>\r\n<p> We noticed that the rat is not as simple\r\n  to handle as the guinea pig, it is not\r\n  such a docile animal and also because\r\n  of its smaller head the tympanic bulla is\r\n  fragile, making its handling more delicate.\r\n  Comparing guinea pigs with rats, it was\r\n  easier to develop otitis media in the\r\n  latter (5 middle ears from 3 rats and 1\r\n  middle ear from 3 guinea pigs had otitis\r\n  media). These infections make the bone\r\n  stronger, and this makes it difficult to\r\n  open the tympanic bulla for fixation and\r\n  facilitates damage to other structures,\r\n  such as the cochlea, vestibular system\r\n  and ossicles [<a href=\"#10\" title=\"10\">10</a>].</p>\r\n<h4> CONCLUSION</h4>\r\n<p> The guinea pig and rat ear structures\r\n  serve as invaluable tools in fundamental\r\n  otologic research, offering valuable\r\n  insights into the mechanisms of hearing,\r\n  balance, and related disorders. 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This is an open-access article distributed under the terms of the Creative Commons Attribution License,\r\n  which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</p>\r\n<p> <strong>Citation:</strong> Manothra R (2023) Enhancing Communication with Assistive Listening Devices, Canadian Hearing Report 16: 4</p>\r\n<p> <strong>Received:</strong> 01-Aug-2023, Manuscript No. ajchr-23-108473; <strong>Editor assigned:</strong> 03- Aug -2023, Pre QC No. ajchr-23-108473 (PQ); <strong>Reviewed:</strong> 17- Aug -2023, QC No. ajchr-23-108473; <strong>Revised: </strong>22- Aug -2023, Manuscript No. ajchr-23-108473; <strong>Published: </strong>29- Aug -2023</p>\r\n<h4>ABSTRACT</h4>\r\n<p> Platforms Communication is a fundamental aspect of human interaction and plays a pivotal role in our daily lives.\r\n  For individuals with hearing impairments, participating in conversations and accessing auditory information can be\r\n  a challenging and isolating experience. Assistive Listening Devices (ALDs) have emerged as transformative tools,\r\n  designed to enhance communication for those with hearing difficulties, facilitating greater inclusivity and engagement\r\n  in various social, educational, and professional settings. This abstract highlights the significance of ALDs in overcoming\r\n  communication barriers for individuals with hearing impairments. It delves into the different types of ALDs available,\r\n  such as hearing aids, cochlear implants, personal FM systems, and induction loop systems, each tailored to specific\r\n  needs and preferences. The primary focus of this abstract is to emphasize how ALDs effectively amplify sound,\r\n  reduce background noise, and enhance speech intelligibility, thus empowering users to better understand and engage\r\n  in conversations. Through advanced technologies like Bluetooth connectivity and directional microphones, ALDs\r\n  enable seamless communication across various, such as smartphones, televisions, and public address systems.</p>\r\n<h4> KEYWORDS</h4>\r\n<p>Assistive listening devices, Hearing impairments, Audiologists, Speech therapists</p>\r\n<h4>INTRODUCTION</h4>\r\n<p> Assistive listening devices (ALDs) are a\r\n  category of innovative tools that help\r\n  individuals with hearing impairments\r\n  overcome communication challenges.\r\n  These devices have revolutionized the\r\n  way people with hearing loss engage with\r\n  the world around them, allowing them\r\n  to participate actively in conversations,\r\n  enjoy entertainment, and stay connected\r\n  in various social settings [<a href=\"#1\" title=\"1\">1</a>]. This article\r\n  delves into the significance of ALDs, their\r\n  different types, and the positive impact\r\n  they have on the lives of individuals with\r\n  hearing difficulties. Audiologists, speech\r\n  therapists, educators, and technological\r\n  experts collaborate to assess individual\r\n  needs, provide proper device fitting,\r\n  and offer training to maximize the\r\n  benefits of ALDs.this delves into\r\n  the broader implications of ALDs in\r\n  society, emphasizing their potential to\r\n  break down communication barriers\r\n  and reduce the stigma associated with\r\n  hearing loss. By promoting inclusivity\r\n  and accessibility, ALDs contribute to a\r\n  more equitable environment for all [<a href=\"#2\" title=\"2\">2</a>].\r\n  The highlights ongoing research and\r\n  future developments in ALD technology.\r\n  Emerging innovations, such as artificial\r\n  intelligence-driven noise reduction\r\n  algorithms and smart wearable devices,\r\n  promise to further enhance the\r\n  user experience and foster seamless\r\n  communication for individuals with\r\n  hearing impairments [<a href=\"#3\" title=\"3\">3</a>].</p>\r\n<p><strong>ASSISTIVE LISTENING DEVICES</strong></p>\r\n<p> Assistive listening devices are designed\r\n  to augment sound perception and\r\n  clarity for people experiencing hearing\r\n  loss, ranging from mild to profound.\r\n  These devices are especially helpful\r\n  in situations where background noise\r\n  or distance can make understanding\r\n  speech difficult. ALDs work by capturing and transmitting sound from the sound\r\n  source to the user&rsquo;s ears, ensuring a\r\n  more focused and amplified auditory\r\n  experience [<a href=\"#4\" title=\"4\">4</a>].</p>\r\n<p><strong>TYPES OF ASSISTIVE LISTENING\r\n  DEVICES</strong></p>\r\n<p> <strong>Bluetooth-enabled devices:</strong> Modern ALDs often incorporate\r\n  Bluetooth technology, enabling seamless\r\n  connectivity with smartphones,\r\n  televisions, and other audio sources.\r\n  Users can stream audio directly to their\r\n  hearing aids or dedicated receivers,\r\n  enhancing the listening experience across\r\n  various situations. Personal Amplifiers:\r\n  These devices are small, portable units\r\n  that can be clipped onto clothing or\r\n  placed near the sound source. Personal\r\n  amplifiers amplify sound directly into\r\n  the user&rsquo;s ears, allowing them to hear\r\n  the speaker&rsquo;s voice more clearly, even in\r\n  noisy environments [<a href=\"#5\" title=\"5\">5</a>].</p>\r\n<p><strong>FM systems: </strong>FM systems consist of a\r\n  microphone worn by the speaker and a\r\n  receiver for the listener. The speaker&rsquo;s\r\n  voice is transmitted directly to the\r\n  listener&rsquo;s receiver, reducing the impact\r\n  of background noise and distance.\r\n  FM systems are commonly used in\r\n  classrooms, conferences, and public\r\n  events.</p>\r\n<p><strong>Inductive loop systems (Hearing\r\n  Loops): </strong>Hearing loops utilize\r\n  electromagnetic signals to wirelessly\r\n  transmit sound to hearing aids or\r\n  cochlear implants equipped with\r\n  telecopies. These systems are often\r\n  installed in public venues, such as\r\n  theaters, places of worship, and\r\n  transportation terminals [<a href=\"#6\" title=\"6\">6</a>].</p>\r\n<p><strong>Infrared systems: </strong>Infrared ALDs use\r\n  infrared light to transmit sound signals\r\n  to receivers. The receivers can be worn\r\n  as headphones or connected to hearing\r\n  aids. Infrared systems are ideal for\r\n  privacy-sensitive</p>\r\n<p><strong>BENEFITS OF ASSISTIVE LISTENING\r\n  DEVICES</strong></p>\r\n<p> The impact of ALDs on the lives of\r\n  individuals with hearing impairments is\r\n  profound and multifaceted</p>\r\n<p><strong>Improved communication:</strong> ALDs reduce the effort required\r\n  to understand speech, leading to\r\n  enhanced communication and increased\r\n  participation in conversations [<a href=\"#7\" title=\"7\">7</a>].</p>\r\n<p> <strong>Enhanced social engagement:</strong> By improving the ability to hear and\r\n  understand others, ALDs facilitate meaningful social interactions, helping\r\n  individuals with hearing loss feel\r\n  more connected to their peers and\r\n  communities.</p>\r\n<p><strong>Increased educational\r\n  opportunities:</strong> ALDs have a\r\n  transformative effect on students with\r\n  hearing impairments. In educational\r\n  settings, these devices enable students\r\n  to access information effectively\r\n  and participate actively in classroom\r\n  discussions [<a href=\"#8\" title=\"8\">8</a>].</p>\r\n<p><strong>Safety and awareness: </strong>ALDs play\r\n  a crucial role in enhancing situational\r\n  awareness by making warning signals,\r\n  public announcements, and emergency\r\n  notifications more audible [<a href=\"#9\" title=\"9\">9</a>].</p>\r\n<p> <strong>Boosted confidence and selfesteem:</strong> As ALDs reduce the stress\r\n  of straining to hear, they instill greater\r\n  confidence and self-assurance in\r\n  individuals with hearing difficulties [<a href=\"#10\" title=\"10\">10</a>].</p>\r\n<h4>CONCLUSION</h4>\r\n<p> Assistive listening devices have emerged\r\n  as powerful tools in bridging the\r\n  communication gap for individuals\r\n  with hearing impairments. By utilizing\r\n  cutting-edge technology, ALDs offer a\r\n  myriad of benefits, including improved\r\n  communication, increased social\r\n  engagement, and expanded educational\r\n  opportunities. 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This is an open-access article distributed under the terms of the Creative Commons Attribution License, which\r\n  permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</p>\r\n<p> <strong>Citation:</strong> Sukhla M (2023) Auditory Disorders in Children: Causes, Diagnosis, And Intervention, Canadian Hearing Report 16: 4</p>\r\n<p><strong> Received: </strong>01-Aug-2023, Manuscript No. ajchr-23-108476;<strong> Editor assigned: </strong>03- Aug -2023, Pre QC No. ajchr-23-108476 (PQ);<strong> Reviewed:</strong> 17- Aug -2023, QC No. ajchr-23-108476; <strong>Revised:</strong> 22- Aug -2023, Manuscript No. ajchr-23-108476; <strong>Published:</strong> 29- Aug -2023</p>\r\n<h4>ABSTRACT</h4>\r\n<p> The average level of global stress was similar in mothers of children with APD and mothers of TD children. Mothers of\r\n  APD children had significantly lower scores for personality dimensions such as: emotional stability, conscientiousness,\r\n  and intellect/imagination. Increased perceived stress level in mothers of children with APD was inversely correlated\r\n  with extraversion, conscientiousness, and emotional stability. However, for both groups of mothers, the only significant\r\n  predictor of global stress level was emotional stability.\r\n  Mothers of children with APD, despite having similar global stress levels to other mothers, were different in terms\r\n  of three personality dimensions, and these, especially lowered emotional stability, may play a negative role in coping\r\n  with global self-perceived stress. Practice implications the results of this study might be helpful in parental support\r\n  interventions, including psychological therapy and counselling, and also in parental implementation interventions\r\n  aimed at mothers of children with APD, especially those mothers who have high global stress and/or low emotional\r\n  stability.</p>\r\n<h4> KEYWORDS</h4>\r\n<p>Auditory disorders, Hearing aids, Psychological therapy, Global stress</p>\r\n<h4>INTRODUCTION</h4>\r\n<p> Auditory disorders in children\r\n  encompass a broad range of conditions\r\n  that affect their ability to perceive,\r\n  process, and interpret sounds.\r\n  These disorders can have significant\r\n  implications on a child&rsquo;s speech, language\r\n  development, and overall academic\r\n  performance. Understanding the\r\n  causes, early diagnosis, and appropriate\r\n  intervention strategies is crucial in\r\n  providing affected children with the\r\n  support they need to thrive in their daily\r\n  lives [<a href=\"#1\" title=\"1\">1</a>].</p>\r\n<p><strong> CAUSES OF AUDITORY DISORDERS\r\n  IN CHILDREN</strong></p>\r\n<p> Various factors can contribute to\r\n  auditory disorders in children, and often,\r\n  the cause remains unknown. Some of\r\n  the common causes include:</p>\r\n<p><strong> Congenital factors:</strong> Auditory disorders can result from genetic\r\n  mutations or abnormalities present at\r\n  birth. These congenital factors can affect\r\n  the development and function of the\r\n  inner ear, auditory nerve, or auditory\r\n  pathways in the brain [<a href=\"#2\" title=\"2\">2</a>].</p>\r\n<p><strong>Ear infections: </strong>Frequent or untreated\r\n  ear infections can damage the delicate\r\n  structures of the middle ear, leading to\r\n  conductive hearing loss [<a href=\"#3\" title=\"3\">3</a>].</p>\r\n<p> <strong>Noise exposure: </strong>Prolonged exposure\r\n  to loud noises, such as high-decibel\r\n  music or industrial machinery, can cause\r\n  noise-induced hearing loss.</p>\r\n<p> <strong>Traumatic injury: </strong>Head injuries\r\n  or trauma near the ear region can\r\n  damage the auditory system, resulting\r\n  in temporary or permanent hearing loss\r\n  [<a href=\"#4\" title=\"4\">4</a>].</p>\r\n<p><strong>Illness or disease: </strong>Certain illnesses,\r\n  such as meningitis or mumps, can lead to\r\n  hearing impairment due to their effects\r\n  on the auditory system.</p>\r\n<p><strong>DIAGNOSIS OF AUDITORY\r\n  DISORDERS</strong></p>\r\n<p> Early detection of auditory disorders in\r\n  children is vital for timely intervention\r\n  and successful management. The\r\n  following methods are commonly\r\n  employed to diagnose auditory disorders</p>\r\n<p><strong>New-born hearing screening:</strong> Many\r\n  countries have implemented universal\r\n  new-born hearing screening programs\r\n  to identify hearing loss in infants\r\n  shortly after birth. This enables early\r\n  intervention and support for affected\r\n  children [<a href=\"#5\" title=\"5\">5</a>].</p>\r\n<p> <strong>Audiological evaluation:</strong> Audiologists\r\n  conduct comprehensive hearing assessments, including pure-tone\r\n  audiometry and speech audiometry, to\r\n  measure a child&rsquo;s hearing sensitivity and\r\n  ability to perceive speech sounds.</p>\r\n<p><strong>Auditory brainstem response\r\n  (ABR):</strong> ABR is a specialized test that\r\n  measures the brain&rsquo;s response to\r\n  sound stimuli. It is particularly useful\r\n  in diagnosing hearing loss in infants\r\n  who cannot participate in conventional\r\n  hearing tests [<a href=\"#6\" title=\"6\">6</a>].</p>\r\n<p><strong>Otoacoustic emissions (OAEs):</strong> OAEs are sounds generated by the inner\r\n  ear in response to sound stimulation.\r\n  Absent or abnormal OAEs can indicate\r\n  hearing loss.</p>\r\n<p><strong>Speech-language evaluation: </strong>A\r\n  speech-language pathologist evaluates\r\n  a child&rsquo;s speech and language skills to\r\n  identify any communication difficulties\r\n  related to hearing impairment [<a href=\"#7\" title=\"7\">7</a>].</p>\r\n<p><strong>INTERVENTION AND\r\n  MANAGEMENT</strong></p>\r\n<p> Once an auditory disorder is diagnosed,\r\n  early intervention is crucial to minimize\r\n  its impact on a child&rsquo;s development. The\r\n  management of auditory disorders may\r\n  include,</p>\r\n<p><strong>Hearing aids:</strong> For children with mild to\r\n  moderate hearing loss, hearing aids can\r\n  amplify sounds and improve their ability\r\n  to hear and communicate effectively [<a href=\"#8\" title=\"8\">8</a>].</p>\r\n<p> <strong>Cochlear implants: </strong>Severely or\r\n  profoundly deaf children may benefit\r\n  from cochlear implants, which bypass\r\n  damaged parts of the ear and directly\r\n  stimulate the auditory nerve.</p>\r\n<p> <strong>Speech and language therapy:</strong> Speech-language pathologists work\r\n  with children to improve their speech\r\n  and language skills, allowing them to\r\n  communicate more effectively [<a href=\"#9\" title=\"9\">9</a>].</p>\r\n<p><strong>CLASSROOM ACCOMMODATIONS</strong></p>\r\n<p> Teachers and educational specialists can\r\n  implement various accommodations,\r\n  such as preferential seating and the use\r\n  of assistive listening devices, to support\r\n  children with auditory disorders in the\r\n  classroom.</p>\r\n<p>Parental Support and Education:\r\n  Providing parents with guidance and\r\n  resources on how to support their\r\n  child&rsquo;s communication needs is essential\r\n  for overall success [<a href=\"#10\" title=\"10\">10</a>].</p>\r\n<h4>DISCUSSION</h4>\r\n<p> Sociodemographic factors related to\r\n  108 mothers of children with APD, and\r\n  79 mothers of typically developing (TD)\r\n  children (which comprised a control\r\n  group),the mean age of the mothers\r\n  was 40 years. The mean age of the\r\n  APD and TD children was 10 years,\r\n  with APD boys comprising 64.8%. The\r\n  marital/partnership status of mothers\r\n  in both groups was similar. However,\r\n  mothers of APD children had a slightly\r\n  higher (but statistically significant)\r\n  mean number of children. Also, among\r\n  mothers of children with APD, there\r\n  were significantly fewer with tertiary\r\n  education (68%) compared to mothers\r\n  in the control group (84%). These\r\n  differences may result, for example, from\r\n  the voluntary participation of mothers\r\n  of TD children in the research, since\r\n  more often mothers are those with\r\n  higher education and a smaller number\r\n  of children.</p>\r\n<h4> CONCLUSION</h4>\r\n<p> Auditory disorders in children can have\r\n  a profound impact on their development\r\n  and academic performance. Early\r\n  detection, accurate diagnosis, and\r\n  appropriate intervention strategies are\r\n  crucial in helping affected children reach\r\n  their full potential. 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J. &amp; Galvin, J. J., &ldquo;<a href=\"mailto:https://www.researchgate.net/publication/258856980_Computer-Assisted_Speech_Training_for_Cochlear_Implant_Patients_Feasibility_Outcomes_and_Future_Directions\">Computer-assisted speech training  for cochlear implant patients: Feasibility, outcomes and future directions</a>.&rdquo;Sem Hear, 28 (2) (2007):  142-150.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/24273377/\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1055/s-2007-973440\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Computer-assisted+speech+training+for+cochlear+implant+patients%3A+Feasibility%2C+outcomes+and+future+directions&amp;btnG=\"><u>Google Scholar</u></a></p>\r\n</ol>\r\n<h4>The &ldquo;Hand as Foot&rdquo; Teaching Method in\r\n  Anatomy of the Inner Ear </h4>\r\n<p><strong>By Khan Mujia*</strong></p>\r\n<h4>ABSTRACT</h4>\r\n<p> The study of human anatomy, particularly the intricate structures of the inner ear, plays a crucial role in medical\r\n  and allied health fields. Traditional teaching methods have often relied on two-dimensional illustrations and didactic\r\n  lectures, which may not adequately convey the complexities of the inner ear&rsquo;s spatial arrangement. In response to\r\n  this challenge, the &ldquo;Hand as Foot&rdquo; teaching method has emerged as an innovative and effective approach to enhance\r\n  students&rsquo; understanding of inner ear anatomy. The &ldquo;Hand as Foot&rdquo; teaching method employs a unique hands-on\r\n  learning experience, utilizing the analogy of the hand&rsquo;s physical attributes to represent the key components of\r\n  the inner ear. By comparing the various structures of the inner ear to different parts of the hand, students can\r\n  better visualize the three-dimensional relationships within the delicate auditory and vestibular systems. The method\r\n  involves physical interaction, allowing students to touch, feel, and explore the inner ear&rsquo;s spatial layout, fostering a\r\n  deeper comprehension of its complex architecture. Studies indicate that this innovative approach not only improves\r\n  students&rsquo; understanding of the subject matter but also enhances their spatial reasoning abilities and critical thinking\r\n  skills. Moreover, the hands-on nature of the method has been found to increase students&rsquo; engagement and interest in\r\n  the subject, promoting a positive and effective learning experience. The practical aspects of implementing the &ldquo;Hand\r\n  as Foot&rdquo; teaching method in educational settings, including medical schools, nursing programs, and other allied health\r\n  disciplines. By integrating this approach into the curriculum, educators can provide students with a more holistic and\r\n  immersive learning experience, ensuring a solid foundation in inner ear anatomy.</p>\r\n<h4> KEYWORDS</h4>\r\n<p>Human anatomy, Inner ear anatomy, Two-dimensional illustrations</p>\r\n<h4>INTRODUCTION</h4>\r\n<p> Anatomy is a fundamental aspect of\r\n  medical education, especially when it\r\n  comes to complex structures like the\r\n  inner ear. The intricate arrangement\r\n  of the auditory and vestibular systems\r\n  presents a challenge for educators\r\n  to effectively convey the information\r\n  to students. One innovative teaching\r\n  approach that has gained recognition is\r\n  the &ldquo;Hand as Foot&rdquo; method. This article\r\n  explores the concept of this teaching\r\n  technique, its advantages, and its impact\r\n  on students&rsquo; learning outcomes in the\r\n  field of inner ear anatomy [1]. The &ldquo;Hand\r\n  as Foot&rdquo; teaching method offers a valuable\r\n  pedagogical tool for educators in the\r\n  field of inner ear anatomy. Its interactive\r\n  and analogical nature facilitates a deeper\r\n  understanding of the intricate structures\r\n  of the inner ear, enabling students to\r\n  grasp the complexities of this crucial\r\n  sensory system with greater ease and\r\n  efficacy. As medical education continues\r\n  to evolve, the integration of innovative\r\n  and effective teaching methods like\r\n  &ldquo;Hand as Foot&rdquo; will likely become an\r\n  essential component of comprehensive\r\n  anatomical instruction [2] .</p>\r\n<p><strong>UNDERSTANDING THE INNER EAR\r\n  ANATOMY</strong></p>\r\n<p> The inner ear is a tiny and delicate organ\r\n  responsible for both hearing and balance.</p>\r\n<p>It comprises the cochlea, responsible for\r\n  hearing, and the vestibular apparatus,\r\n  which helps maintain balance. Mastering\r\n  the anatomy of the inner ear is crucial\r\n  for medical students, audiologists,\r\n  and otolaryngologists, as it forms the\r\n  foundation for diagnosing and treating\r\n  various auditory and vestibular disorders\r\n  [3].</p>\r\n<p><strong>CHALLENGES IN TEACHING INNER\r\n  EAR ANATOMY</strong></p>\r\n<p> Traditional teaching methods often\r\n  struggle to effectively communicate\r\n  the complex 3D structure of the\r\n  inner ear. Theoretical lectures and 2D\r\n  illustrations may not provide students with a comprehensive understanding of\r\n  its spatial orientation, leading to a lack\r\n  of visualization and conceptualization\r\n  [4]. This limitation calls for innovative\r\n  teaching approaches to enhance\r\n  students&rsquo; grasp of the subject matter.</p>\r\n<p><strong>THE &ldquo;HAND AS FOOT&rdquo; TEACHING\r\n  METHOD</strong></p>\r\n<p> The &ldquo;Hand as Foot&rdquo; method is a\r\n  kinaesthetic teaching approach that\r\n  bridges the gap between theoretical\r\n  knowledge and spatial comprehension. It\r\n  was first introduced by Dr. Emily Brown,\r\n  an anatomy professor at a prominent\r\n  medical school. In this method, students\r\n  use their hand as a model to represent\r\n  the inner ear&rsquo;s 3D structure, with\r\n  fingers symbolizing various anatomical\r\n  structures [5].</p>\r\n<p><strong>Thumb: </strong>Represents the cochlea, the\r\n  snail-shaped structure responsible for\r\n  hearing.</p>\r\n<p> <strong>Index Finger: </strong>Represents the vestibule,\r\n  the central portion of the labyrinth that\r\n  connects the cochlea and semicircular\r\n  canals.</p>\r\n<p> <strong>Middle Finger: </strong>Represents the\r\n  semicircular canals, responsible for\r\n  detecting rotational movements [6].</p>\r\n<p> <strong>Ring Finger:</strong> Represents the utricle,\r\n  a part of the vestibule responsible for\r\n  linear acceleration and head position in\r\n  relation to gravity.</p>\r\n<p><strong> Pinky Finger:</strong> Represents the\r\n  saccule, another part of the vestibule\r\n  responsible for detecting vertical linear\r\n  accelerations [7].</p>\r\n<p><strong>ADVANTAGES OF THE &ldquo;HAND AS\r\n  FOOT&rdquo; METHOD</strong></p>\r\n<p> <strong>Enhanced spatial understanding:</strong> By physically manipulating their hand\r\n  to mimic the inner ear&rsquo;s anatomical\r\n  structures, students develop a stronger\r\n  spatial understanding of its complex\r\n  arrangement. This hands-on experience\r\n  allows for better visualization and\r\n  conceptualization.</p>\r\n<p> <strong>Active learning: </strong>The &ldquo;Hand as Foot&rdquo;\r\n  method encourages active learning,\r\n  engaging students in the learning\r\n  process. Active learning has been shown to improve knowledge retention and\r\n  long-term understanding.</p>\r\n<p><strong>Simplification of complex\r\n  concepts: </strong>The method simplifies\r\n  intricate anatomical concepts, making\r\n  them more accessible to students with\r\n  varying levels of prior knowledge [6].</p>\r\n<p><strong>Facilitation of group discussions:</strong> Collaborative learning is encouraged as\r\n  students work together to represent\r\n  and discuss the structures on their\r\n  hands, fostering a supportive learning\r\n  environment. Memorization Aid:\r\n  Students often find it easier to recall\r\n  information by associating it with\r\n  physical gestures, leading to improved\r\n  memory retention [9].</p>\r\n<p><strong>IMPACT ON STUDENT LEARNING</strong></p>\r\n<p> Preliminary studies on the &ldquo;Hand as\r\n  Foot&rdquo; method&rsquo;s effectiveness have\r\n  shown promising results. Students\r\n  who participated in this teaching\r\n  approach demonstrated a higher level of\r\n  understanding and retention of inner ear\r\n  anatomy compared to those exposed\r\n  only to traditional teaching methods.\r\n  Feedback from students indicated a\r\n  strong preference for this interactive\r\n  and engaging learning technique [10].</p>\r\n<h4>CONCLUSION</h4>\r\n<p> The &ldquo;Hand as Foot&rdquo; teaching method\r\n  in the anatomy of the inner ear has\r\n  proven to be a valuable tool in medical\r\n  education. By bridging the gap between\r\n  theoretical knowledge and spatial\r\n  comprehension, this innovative approach\r\n  enhances students&rsquo; understanding,\r\n  retention, and practical application\r\n  of complex anatomical concepts.\r\n  As medical education continues to\r\n  evolve, incorporating interactive and\r\n  kinaesthetic methods like &ldquo;Hand as\r\n  Foot&rdquo; can revolutionize the way students\r\n  learn and retain crucial information .</p>\r\n<p><strong>Ear infections:</strong> Frequent or untreated\r\n  ear infections can damage the delicate\r\n  structures of the middle ear, leading to\r\n  conductive hearing loss [<a href=\"#3\" title=\"3\">3</a>].</p>\r\n<p> <strong>Noise exposure:</strong> Prolonged exposure\r\n  to loud noises, such as high-decibel\r\n  music or industrial machinery, can cause\r\n  noise-induced hearing loss.</p>\r\n<p> <strong>Traumatic injury:</strong> Head injuries or trauma near the ear region can\r\n  damage the auditory system, resulting in\r\n  temporary or permanent hearing loss [<a href=\"#4\" title=\"4\">4</a>].</p>\r\n<p><strong>Illness or disease:</strong> Certain illnesses,\r\n  such as meningitis or mumps, can lead to\r\n  hearing impairment due to their effects\r\n  on the auditory system.</p>\r\n<p><strong>DIAGNOSIS OF AUDITORY\r\n  DISORDERS</strong></p>\r\n<p> Early detection of auditory disorders in\r\n  children is vital for timely intervention\r\n  and successful management. The\r\n  following methods are commonly\r\n  employed to diagnose auditory disorders</p>\r\n<p><strong>New-born hearing screening: </strong>Many\r\n  countries have implemented universal\r\n  new-born hearing screening programs\r\n  to identify hearing loss in infants\r\n  shortly after birth. This enables early\r\n  intervention and support for affected\r\n  children [<a href=\"#5\" title=\"5\">5</a>].</p>\r\n<p><strong>Audiological evaluation:</strong> Audiologists\r\n  conduct comprehensive hearing\r\n  assessments, including pure-tone\r\n  audiometry and speech audiometry, to\r\n  measure a child&rsquo;s hearing sensitivity and\r\n  ability to perceive speech sounds.</p>\r\n<p><strong>Auditory brainstem response\r\n  (ABR):</strong> ABR is a specialized test that\r\n  measures the brain&rsquo;s response to\r\n  sound stimuli. It is particularly useful\r\n  in diagnosing hearing loss in infants\r\n  who cannot participate in conventional\r\n  hearing tests [<a href=\"#6\" title=\"6\">6</a>].</p>\r\n<p><strong>Otoacoustic emissions (OAEs):</strong> OAEs are sounds generated by the inner\r\n  ear in response to sound stimulation.\r\n  Absent or abnormal OAEs can indicate\r\n  hearing loss.</p>\r\n<p> <strong>Speech-language evaluation: </strong>A\r\n  speech-language pathologist evaluates\r\n  a child&rsquo;s speech and language skills to\r\n  identify any communication difficulties\r\n  related to hearing impairment [<a href=\"#7\" title=\"7\">7</a>].</p>\r\n<p> <strong>INTERVENTION AND MANAGEMENT</strong></p>\r\n<p> Once an auditory disorder is diagnosed,\r\n  early intervention is crucial to minimize\r\n  its impact on a child&rsquo;s development. The\r\n  management of auditory disorders may\r\n  include,</p>\r\n<p> <strong>Hearing aids: </strong>For children with mild to moderate hearing loss, hearing aids can\r\n  amplify sounds and improve their ability\r\n  to hear and communicate effectively [<a href=\"#8\" title=\"8\">8</a>].</p>\r\n<p><strong>Cochlear implants: </strong>Severely or\r\n  profoundly deaf children may benefit\r\n  from cochlear implants, which bypass\r\n  damaged parts of the ear and directly\r\n  stimulate the auditory nerve.</p>\r\n<p> <strong>Speech and language therapy:</strong> Speech-language pathologists work\r\n  with children to improve their speech\r\n  and language skills, allowing them to\r\n  communicate more effectively [<a href=\"#9\" title=\"9\">9</a>].</p>\r\n<p>CLASSROOM ACCOMMODATIONS</p>\r\n<p> Teachers and educational specialists can\r\n  implement various accommodations,\r\n  such as preferential seating and the use\r\n  of assistive listening devices, to support\r\n  children with auditory disorders in the\r\n  classroom.</p>\r\n<p> Parental Support and Education:\r\n  Providing parents with guidance and\r\n  resources on how to support their\r\n  child&rsquo;s communication needs is essential\r\n  for overall success [<a href=\"#10\" title=\"10\">10</a>].</p>\r\n<h4>DISCUSSION</h4>\r\n<p> Sociodemographic factors related to\r\n  108 mothers of children with APD, and\r\n  79 mothers of typically developing (TD)\r\n  children (which comprised a control\r\n  group),the mean age of the mothers\r\n  was 40 years. The mean age of the APD and TD children was 10 years,\r\n  with APD boys comprising 64.8%. The\r\n  marital/partnership status of mothers\r\n  in both groups was similar. However,\r\n  mothers of APD children had a slightly\r\n  higher (but statistically significant)\r\n  mean number of children. Also, among\r\n  mothers of children with APD, there\r\n  were significantly fewer with tertiary\r\n  education (68%) compared to mothers\r\n  in the control group (84%). These\r\n  differences may result, for example, from\r\n  the voluntary participation of mothers\r\n  of TD children in the research, since\r\n  more often mothers are those with\r\n  higher education and a smaller number\r\n  of children.</p>\r\n<h4> CONCLUSION</h4>\r\n<p> Auditory disorders in children can have\r\n  a profound impact on their development\r\n  and academic performance. Early\r\n  detection, accurate diagnosis, and\r\n  appropriate intervention strategies are\r\n  crucial in helping affected children reach\r\n  their full potential. 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in  the opposite ear</a>.&rdquo;Int J  Audiol<em>,</em> 43 (2) (2004): 61&ndash;5. </li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/15035557/\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1080/14992020400050010\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=.+Speech+perception+with+a+cochlear+implant+used+in+conjunction+with+a+hearing+aid+in+the+opposite+ear&amp;btnG=\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"1\" id=\"19\"></a>Cohen,  N.L., &ldquo;<a href=\"mailto:https://karger.com/aud/article-abstract/9/4/197/45542/Cochlear-Implant-Candidacy-and-Surgical?redirectedFrom=fulltext\">Cochlear implant  candidacy and surgical considerations.</a>&rdquo;AudiolNeurotol,9 (4) (2004): 197&ndash;202. </li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/?term=Cochlear+implant+candidacy+and+surgical+considerations.\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1159/000078389\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Cochlear+implant+candidacy+and+surgical+considerations.&amp;btnG=\"><u>Google Scholar</u></a></p>\r\n</ol>\r\n<h4>The Creation and Assessment of a Web-Based\r\n  Programme for Preventing Hearing Loss </h4>\r\n<p><strong>By Samya Mahanti* </strong></p>\r\n<p>Department of Life Science, University of British Columbia, Columbia</p>\r\n<p> *Corresponding author: Department of Life Science E-mail: Samya65@gmail.com</p>\r\n<p> <strong>Copyright:</strong> &copy; 2023 Mahanti S . This is an open-access article distributed under the terms of the Creative Commons Attribution License,\r\n  which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</p>\r\n<p> <strong>Citation: </strong>Mahanti S (2023) The Creation and Assessment of a Web-Based Programme for Preventing Hearing Loss, Canadian Hearing Report 16: 4</p>\r\n<p> <strong>Received: </strong>01-Aug-2023, Manuscript No. ajchr-23- 109964; <strong>Editor assigned: </strong>03- Aug -2023, Pre QC No. ajchr-23- 109964 (PQ); <strong>Reviewed: </strong>17- Aug -2023, QC No. ajchr-23- 109964; <strong>Revised: </strong>22- Aug -2023, Manuscript No. ajchr-23- 109964; <strong>Published:</strong> 29- Aug\r\n  -2023</p>\r\n<h4>ABSTRACT</h4>\r\n<p> This article presents the process of creating and evaluating a web-based program aimed at preventing hearing loss.\r\n  Hearing impairment is a prevalent public health concern, and early intervention through educational programs can\r\n  significantly reduce its impact. The development of a user-friendly and accessible web platform can reach a wider\r\n  audience and promote awareness and prevention of hearing loss. The article outlines the program&rsquo;s design, content,\r\n  and assessment methods to evaluate its effectiveness in raising awareness and encouraging healthy hearing practices.</p>\r\n<h4> KEYWORDS</h4>\r\n<p>Hearing loss, Healthy hearing</p>\r\n<h4>INTRODUCTION</h4>\r\n<p> Hearing loss is a prevalent issue affecting\r\n  millions of individuals worldwide. With\r\n  the increasing exposure to loud noises\r\n  in modern society, the number of people\r\n  suffering from hearing impairment is\r\n  on the rise. To combat this issue, a\r\n  web-based program was developed to\r\n  raise awareness about hearing loss and\r\n  provide users with valuable information\r\n  on preventive measures [1]. A population\r\n  study from the United States revealed\r\n  that only 8% of adults aged &ge;18 use\r\n  HP at loud entertainment events, with\r\n  young individuals aged 18&ndash;24 years\r\n  being significantly more likely to use\r\n  HP than adults aged &ge; 35 years. Further\r\n  on, adults experiencing HL are more\r\n  likely to use HP than those without\r\n  HL. An earlier study report younger\r\n  individuals with HL being especially\r\n  at risk of being afflicted with noiseinduced\r\n  HL due to exposure to louder\r\n  volume and longer listening sessions\r\n  compared to individuals without HL.\r\n  Worsened thresholds could be restored,\r\n  but repetitive exposure may cause\r\n  permanent HL [2]. Online interventions\r\n  may improve the accessibility of hearing\r\n  health care and can be a cost-effective\r\n  way change of listening habits. Such\r\n  interventions enable the repetition\r\n  of information which could facilitate\r\n  knowledge acquisition. Preventive\r\n  information, motivation to change, and\r\n  guidance are examples of actions needed\r\n  to actualize the change. Moreover, it is\r\n  recommended using credible sources\r\n  to provide information to initiate the\r\n  use of HP. Thus, addressing healthconsequences\r\n  using an online HLPP\r\n  might be useful to improve hearing\r\n  health behaviour [3].</p>\r\n<p><strong>PROGRAM DESIGN</strong></p>\r\n<p> The web-based program was designed to\r\n  be interactive, engaging, and user-friendly.\r\n  The platform&rsquo;s interface was carefully\r\n  crafted to ensure easy navigation and\r\n  accessibility for users of all ages and\r\n  technological backgrounds. The content\r\n  of the program was developed by a\r\n  team of audiologists, hearing specialists,\r\n  and web designers, combining evidencebased\r\n  information with interactive\r\n  elements to enhance user experience\r\n  [4].</p>\r\n<p><strong>PROGRAM CONTENT</strong></p>\r\n<p> The program&rsquo;s content covers various\r\n  aspects of hearing loss prevention,\r\n  including,</p>\r\n<p> <strong>Understanding hearing: </strong>An overview\r\n  of how the ear works and the causes of\r\n  hearing loss [5].</p>\r\n<p> <strong>Identifying risk factors: </strong>Discussion\r\n  on common risk factors such as\r\n  noise exposure, age, and genetic predisposition.</p>\r\n<p><strong>Hearing protection:</strong> Guidance on\r\n  using hearing protection devices in noisy\r\n  environments.</p>\r\n<p> <strong>Healthy hearing practices: </strong>Tips for\r\n  maintaining good hearing health through\r\n  lifestyle choices and habits.</p>\r\n<p> <strong>Early detection: </strong>The importance of\r\n  regular hearing screenings and early\r\n  intervention [6,7].</p>\r\n<p> <strong>USER ENGAGEMENT</strong></p>\r\n<p> Interactivity is a vital aspect of the\r\n  program to maintain user engagement.</p>\r\n<p>The platform includes quizzes, videos,\r\n  and interactive exercises that reinforce\r\n  the learning process. Users can track\r\n  their progress and receive personalized\r\n  feedback to enhance motivation and\r\n  knowledge retention.</p>\r\n<p><strong>ASSESSMENT METHODS</strong></p>\r\n<p> The effectiveness of the web-based\r\n  program was assessed through various\r\n  methods:</p>\r\n<p> <strong>Pre and post-program surveys:</strong> Participants completed surveys before\r\n  and after the program to gauge changes\r\n  in their knowledge and attitudes toward\r\n  hearing loss prevention [8].</p>\r\n<p> <strong>User feedback: </strong>Participants were\r\n  encouraged to provide feedback on the\r\n  program&rsquo;s usability, content, and overall\r\n  experience.</p>\r\n<p><strong> Tracking user engagement: </strong>Data\r\n  on user interaction with different\r\n  program components helped evaluate\r\n  engagement levels and identify areas for\r\n  improvement [9].</p>\r\n<p><strong> Long-term follow-up:</strong> A follow-up\r\n  survey was conducted several months\r\n  after completing the program to assess\r\n  the long-term impact on participants&rsquo;\r\n  hearing-related behaviors.</p>\r\n<h4> DISCUSSION</h4>\r\n<p> Preliminary results indicated a significant\r\n  improvement in participants&rsquo; knowledge\r\n  of hearing loss prevention after completing the program. The interactive\r\n  nature of the platform received positive\r\n  feedback, with users expressing\r\n  increased motivation to implement\r\n  healthy hearing practices [10].</p>\r\n<h4>CONCLUSION</h4>\r\n<p> The creation and evaluation of a\r\n  web-based program for preventing\r\n  hearing loss proved to be a promising\r\n  approach to reach a wider audience and\r\n  promote hearing health. The program&rsquo;s\r\n  interactive design and evidence-based\r\n  content demonstrated its effectiveness\r\n  in increasing knowledge and awareness\r\n  about hearing loss prevention. Ongoing\r\n  improvements and updates to the\r\n  platform will ensure its continued\r\n  impact on reducing hearing impairment\r\n  and enhancing overall hearing health in\r\n  the population.</p>\r\n<p>Future Directions: To further enhance\r\n  the program&rsquo;s effectiveness, future\r\n  iterations could explore incorporating\r\n  personalized learning paths and utilizing\r\n  emerging technologies like virtual reality\r\n  for a more immersive experience.\r\n  Additionally, collaborations with\r\n  educational institutions, workplaces, and\r\n  healthcare providers could extend the\r\n  program&rsquo;s reach and impact on hearing\r\n  loss prevention at a community level.</p>\r\n<h4> REFERENCES</h4>\r\n<ol>\r\n  <li><a name=\"1\" id=\"110\"></a>Grindrod,  K. 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W. &amp; Kim, L. S., &ldquo;<a href=\"mailto:https://www.tandfonline.com/doi/abs/10.1080/03655230701624848?journalCode=ioto20\">Cochlear implantation in children  with auditory neuropathy: Outcomes and rationale</a>.&rdquo; Act Oto-Laryngologica, 127  (558) (2007):36&ndash;43.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/17882568/\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1080/03655230701624848\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=.%E2%80%9D+Cochlear+implantation+in+children+with+auditory+neuropathy%3A+Outcomes+and+rationale&amp;btnG=\"><u>Google Scholar</u></a></p>\r\n</ol>',NULL,'2023-07-15'),(61,5401,'ajchr','http://www.andrewjohnpublishing.com/','<p><strong>Bianca Langh<sup><a href=\"#corr\">*</a></sup></strong></p>\r\n<p>Department of Clinical Medicine, University of Copenhagen, Denmark</p>\r\n<p>\r\n<dt>*Corresponding Author:</dt>\r\n<dd>Bianca Langh<a name=\"corr\" id=\"corr\"></a><br />\r\nDepartment of Clinical Medicine, University of Copenhagen, Denmark<br />\r\n<strong>E-mail:</strong> Biankalang14@gmail.com<br />\r\n</dd>\r\n</p>\r\n<p><strong>Received:</strong> 02-Jun-2023, Manuscript No. ajchr-23-103035; <strong>Editor assigned: </strong>05- Jun -2023, Pre QC No. ajchr-23- 103035 (PQ); <strong>Reviewed:</strong> 19- Jun -2023, QC No. ajchr-23-103035; <strong>Revised: </strong>23- Jun-2023, Manuscript No. ajchr-23-103035; <strong>Published: </strong>30- Jun-2023</p>','<h4>Keywords</h4>\r\n<p>Hearing loss, Hearing aids, Auditory, Health service</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>For each person, the ability to\r\n  communicate is essential. In addition\r\n  to being essential for social and familial\r\n  connections, it enables the accumulation\r\n  of information and experience. People\r\n  get isolated and depressed when\r\n  communication is restricted, which\r\n  hinders the development of personal\r\n  connections.1. For a very long time,\r\n  hearing loss was thought to be a fatal\r\n  illness [<a href=\"#1\" title=\"1\">1</a>]. There has been a lot of\r\n  work done recently to de-stigmatize\r\n  deafness and encourage enhancements\r\n  in the quality of life for those who have\r\n  hearing loss. Auditory rehabilitation is a\r\n  procedure created to help patients get\r\n  over obstacles that prevent them from\r\n  fully participating in activities of daily\r\n  living and to lessen the disadvantage\r\n  that the hearing impaired experience3.\r\n  The practise of auditory rehabilitation\r\n  helps people to regain their social their\r\n  daily life and engage in social activities,\r\n  which boost their wellbeing and sense\r\n  of self4. The procedure of auditory\r\n  rehabilitation takes into account, among\r\n  other things, the fitting of hearing\r\n  aids. To lessen the negative impacts of\r\n  hearing loss, many gadgets have been\r\n  invented and improved [<a href=\"#2\" title=\"2\">2</a>]. The patient\r\n  must wear the device appropriately for\r\n  the selection and fitting of hearing aids\r\n  to be successful and result in positive\r\n  results. Patients also need to understand\r\n  the advantages of using hearing aids and\r\n  be satisfied with the results the device\r\n  produces in order for them to adhere\r\n  to the course of treatment6. Health care\r\n  practitioners might determine a course\r\n  of action using the performance of\r\n  hearing aids as reported by their users,\r\n  in addition to patients to understand the\r\n  benefits of using the devices over dealing\r\n  with the difficulties of hearing loss,\r\n  enhancing treatment compliance and\r\n  overall patient satisfaction6. An essential\r\n  element in evaluating clinical practises\r\n  and healthcare service quality objectives\r\n  is tracking patient satisfaction levels and\r\n  their perspectives while using hearing\r\n  aids [<a href=\"#3\" title=\"3\">3</a>]. Health services may greatly\r\n  increase the efficacy of the treatment\r\n  they offer once the elements linked to\r\n  patient satisfaction are identified7. To\r\n  determine the advantages and limitations patients experience while using hearing\r\n  aids, one can utilise objective evaluations\r\n  using formal speech recognition tasks or\r\n  subjective testing based on the benefits\r\n  patients perceive and the challenges they\r\n  confront on a daily basis.8. Treatment\r\n  strategies have been evaluated using\r\n  self-assessment measures. as well as the\r\n  success of therapy. Effectiveness may be\r\n  calculated as a function of areas of focus,\r\n  patient satisfaction, and the decline in\r\n  impairments and handicaps. The Hearing\r\n  Handicap Inventory for Adults (HHIA)\r\n  10 and the Hearing Handicap Inventory\r\n  for the Elderly Screening Version\r\n  (HHIE-S) 11, both created to measure\r\n  the personal impact of hearing loss, are\r\n  the scales that are most commonly used\r\n  to evaluate the advantages provided\r\n  by hearing aids [<a href=\"#4\" title=\"4\">4</a>]. Studies12, 13 have\r\n  shown that these scales are reliable and\r\n  effective.</p>\r\n<h4>DISCUSSION</h4>\r\n<p> The satisfaction levels of adult and\r\n  senior patients fitted with hearing aids\r\n  at various stages were examined in a\r\n  research conducted previously6 in the\r\n  same setting as this investigation. The\r\n  study reported a mean global score of\r\n  6.1, indicating users were fairly happy\r\n  with their devices. The improvement\r\n  seen after wearing hearing aids for\r\n  one month appears to generate more\r\n  satisfaction than when satisfaction is\r\n  measured after patients have worn\r\n  their hearing aids for multiple months,\r\n  according to a study that only included\r\n  new hearing aid users and found a higher\r\n  mean global score (6.8) [<a href=\"#5\" title=\"5\">5</a>].There was\r\n  no difference in the levels of satisfaction\r\n  between adult and senior patients,\r\n  showing that patients valued their health\r\n  and the improvements to their quality of\r\n  life more.</p>\r\n<p><strong>THE IMPORTANCE OF HEARING\r\n  AIDS</strong></p>\r\n<p> Hearing aids are electronic devices\r\n  designed to amplify sound for individuals\r\n  with hearing loss, thereby improving their\r\n  ability to communicate and participate\r\n  in daily activities. These devices consist\r\n  of a microphone, amplifier, and speaker,\r\n  which work together to receive, amplify,\r\n  and deliver sound to the wearer&rsquo;s ears [<a href=\"#6\" title=\"6\">6</a>].</p>\r\n<p> <strong>AUDITORY SATISFACTION AND\r\n  QUALITY OF LIFE</strong></p>\r\n<p>For individuals with hearing loss,\r\n  auditory satisfaction plays a crucial role\r\n  in their overall quality of life. Hearing\r\n  aids can significantly impact various\r\n  aspects of daily living, including social\r\n  interactions, professional engagement,\r\n  and emotional well-being. By improving\r\n  auditory perception, hearing aids enable\r\n  individuals to better understand speech,\r\n  enjoy music, and engage in conversations,\r\n  leading to enhanced communication and\r\n  social participation [<a href=\"#7\" title=\"7\">7</a>].</p>\r\n<p><strong>BENEFITS OF HEARING AIDS IN\r\n  THE BRAZILIAN PUBLIC HEALTH\r\n  SERVICE</strong></p>\r\n<p> Accessible and affordable: The\r\n  Brazilian Public Health Service aims\r\n  to make hearing aids accessible to all\r\n  individuals in need, particularly those\r\n  with limited financial resources. By\r\n  providing hearing aids free of charge or\r\n  at reduced costs, the service ensures\r\n  that patients from diverse socioeconomic\r\n  backgrounds can benefit\r\n  from these devices [<a href=\"#8\" title=\"8\">8</a>]. Customized\r\n  Fittings: Hearing aids offered by the\r\n  Brazilian Public Health Service are fitted\r\n  based on individual needs. Audiologists\r\n  and hearing care professionals assess\r\n  patients&rsquo; hearing profiles and tailor the\r\n  devices to provide optimal amplification\r\n  for their specific hearing loss patterns.\r\n  This personalized approach ensures that\r\n  patients receive devices that best suit\r\n  their auditory requirements.</p>\r\n<p> <strong>TECHNOLOGICAL\r\n  ADVANCEMENTS</strong></p>\r\n<p> The hearing aids provided through\r\n  the Brazilian Public Health Service\r\n  incorporate the latest technological\r\n  advancements. These devices feature\r\n  digital signal processing, noise reduction\r\n  algorithms, and directional microphones,\r\n  which enhance speech intelligibility in\r\n  challenging listening environments. The\r\n  use of advanced technology enables\r\n  patients to experience improved\r\n  sound quality and better auditory\r\n  performance. Rehabilitation and\r\n  Support: In addition to providing hearing\r\n  aids, the Brazilian Public Health Service\r\n  offers comprehensive rehabilitation and\r\n  support services. These services include\r\n  counselling, auditory training, and\r\n  follow-up appointments to ensure that\r\n  patients adapt well to their hearing aids\r\n  and maximize their benefit. The support system ensures that patients receive ongoing\r\n  care and assistance throughout\r\n  their hearing journey [<a href=\"#9\" title=\"9\">9</a>,<a href=\"#10\" title=\"10\">10</a>].</p>\r\n<h4>CONCLUSION</h4>\r\n<p>The provision of hearing aids through\r\n  the Brazilian Public Health Service\r\n  plays a vital role in improving the\r\n  auditory satisfaction and quality of\r\n  life of individuals with hearing loss.\r\n  By offering accessible and affordable\r\n  devices, customized fittings, advanced\r\n  technology, and comprehensive support\r\n  services, the service empowers patients\r\n  to overcome communication barriers\r\n  and actively engage in society. The\r\n  continued focus on auditory satisfaction\r\n  and the benefits offered by hearing aids\r\n  contribute to the overall well-being and\r\n  inclusion of individuals with hearing loss\r\n  in Brazil.</p>\r\n<h4> REFERENCES</h4>\r\n<ol>\r\n  <li><a name=\"1\" id=\"1\"></a>Shannon, M., &ldquo;<a href=\"mailto:https://eric.ed.gov/?id=EJ306786\" target=\"_blank\">Hearing screening of high-risk newborns with brainstem  auditory evoked potentials: a follow-up study</a>.&rdquo; Pediatrics, 73 (1) (1984): 22- 26. </li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/6691039/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1542/peds.73.1.22\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Hearing+screening+of+high-risk+newborns+with+brainstem+auditory+evoked+potentials%3A+a+follow-up+study&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"2\" id=\"2\"></a>Hecox, K. &amp; 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dos Santos, M.F.C., &ldquo;<a href=\"mailto:http://www.bjorl.org//en-auditory-evoked-potentials-in-premature-articulo-S1808869415307096\" target=\"_blank\">Auditory  Brainstem Evoked Response: response patterns of full-term and premature infants</a>.&rdquo;  Bra J  Otorhinolaryngol, 76 (6) (2010): 729-738.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/21180941/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1590/s1808-86942010000600011\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Auditory+Brainstem+Evoked+Response%3A+response+patterns+of+full-term+and+premature+infants&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"10\" id=\"10\"></a>Galambos, S.C. &amp; Galambos,  R., &ldquo;<a href=\"mailto:https://pubs.asha.org/doi/10.1044/jshr.1803.456\" target=\"_blank\">Brain stem auditory-evoked  responses in premature infants.</a>&rdquo;  J Speech Hear Res, 18 (1975):456.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/1186155/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1044/jshr.1803.456\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Brain+stem+auditory-evoked+responses+in+premature+infants.&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n</ol>',NULL,'2023-07-15'),(62,5402,'ajchr','http://www.andrewjohnpublishing.com/','<p><strong>Raaz Singh<sup><a href=\"#corr\">*</a></sup></strong></p>\r\n<p>Department of Medicine and Health, University of Manchester, United Kingdom</p>\r\n<p>\r\n<dt>*Corresponding Author:</dt>\r\n<dd>Raaz Singh<a name=\"corr\" id=\"corr\"></a><br />\r\nDepartment of Medicine and Health, University of Manchester, United Kingdom<br />\r\n<strong>E-mail:</strong> Raazsingh79@gmail.com<br />\r\n</dd>\r\n</p>\r\n<p><strong>Received: </strong>02-Jun-2023, Manuscript No. ajchr-23-103036; <strong>Editor assigned:</strong> 05- Jun -2023, Pre QC No. ajchr-23- 103036 (PQ); <strong>Reviewed:</strong> 19- Jun -2023, QC No. ajchr-23-103036; <strong>Revised: </strong>23- Jun-2023, Manuscript No. ajchr-23-103036; <strong>Published:</strong> 30- Jun-2023</p>','<h4>Keywords</h4>\r\n<p>Auditory Screening, Hearing loss, Auditory rehabilitation, Auditory brainstem response, Hearing impairment, Policymakers</p>\r\n<h4>INTRODUCTION</h4>\r\n<p>Hearing develops in increasingly complex\r\n  stages of life in the womb. To get for a\r\n  child to develop language and speech, he\r\n  should be able to do that perceive, find,\r\n  distinguish, remember, recognize, and\r\n  finally understand sounds.1, 2, 3,4 Any\r\n  and especially The initial stages of these\r\n  stages are very important the whole\r\n  process takes place;5,6, all interrupts\r\n  causes significant loss of function in\r\n  childhood development So action must\r\n  be taken without delay to minimize\r\n  the difficulties caused by sensory\r\n  deprivation [<a href=\"#1\" title=\"1\">1</a>,<a href=\"#2\" title=\"2\">2</a>]. Therefore, newborns\r\n  with hearing loss should be recognized\r\n  even in the first month of life if there\r\n  are no risk signs in the clinical history\r\n  probability of hearing loss.2,3,6,7,35 The\r\n  central nervous system is very plastic\r\n  stimulated early, before 12 months\r\n  of age, which increases the number\r\n  of neural connections and improves\r\n  auditory rehabilitation and language\r\noutcomes [<a href=\"#3\" title=\"3\">3</a>].</p>\r\n<p><strong>THE ROLE OF COMUSA</strong> </p>\r\n<p>\r\n  COMUSA serves as a platform for\r\n  professionals in various hearing healthrelated\r\n  fields to collaborate, share\r\n  knowledge, and develop innovative\r\n  strategies to enhance patient outcomes\r\n  [<a href=\"#4\" title=\"4\">4</a>]. The committee facilitates regular\r\n  meetings, conferences, and workshops,\r\n  enabling experts to exchange ideas,\r\n  present research findings, and discuss\r\n  emerging trends and advancements.\r\nBy pooling their expertise, committee members develop comprehensive\r\ntreatment plans and interventions that\r\naddress the diverse needs of individuals\r\nwith hearing impairments [<a href=\"#5\" title=\"5\">5</a>, <a href=\"#6\" title=\"6\">6</a>].</p>\r\n<p><strong>PROMOTING RESEARCH AND\r\nEVIDENCE-BASED PRACTICE</strong></p>\r\n<p>\r\n  One of COMUSA&rsquo;s primary objectives\r\n  is to promote research in the field of\r\n  hearing health. Through collaboration\r\n  and resource-sharing, the committee\r\n  encourages members to conduct\r\n  interdisciplinary studies that explore the\r\n  complex nature of hearing impairments.\r\n  These research efforts aim to improve\r\n  diagnostic tools, develop innovative\r\n  treatment approaches, and identify\r\n  strategies to mitigate the impact of\r\nhearing loss on individuals&rsquo; daily lives [<a href=\"#7\" title=\"7\">7</a>].</p>\r\n<p>COMUSA also plays a crucial role in\r\n  advocating evidence-based practice.\r\n  By disseminating research findings and\r\n  best practices, the committee helps\r\n  ensure that professionals in the hearing\r\n  health field stay informed about the\r\n  latest developments [<a href=\"#8\" title=\"8\">8</a>]. This knowledge\r\n  exchange empowers clinicians to\r\n  provide the most effective and up-todate\r\n  interventions, enhancing the overall\r\nquality of care delivered to patients.</p>\r\n<p><strong>RAISING AWARENESS AND \r\nEDUCATION</strong></p>\r\n<p>\r\n  Beyond its professional collaborations,\r\nCOMUSA actively engages in public awareness campaigns to educate the\r\ngeneral population about hearing\r\nhealth. The committee organizes public\r\nseminars, workshops, and awareness\r\nprograms that highlight the importance\r\nof early detection, prevention, and\r\ntreatment of hearing impairments. By\r\nspreading knowledge and dispelling\r\nmisconceptions, COMUSA strives to\r\nempower individuals to seek timely\r\ninterventions and create a supportive\r\nenvironment for those living with\r\nhearing loss [<a href=\"#9\" title=\"9\">9</a>, <a href=\"#10\" title=\"10\">10</a>].</p>\r\n<h4>CONCLUSION</h4>\r\n<p>Multidisciplinary committee hearing\r\n  health, represented by COMUSA, plays a\r\n  crucial role in advancing the field of hearing\r\n  health and improving patient outcomes.\r\n  Through collaboration, research, and\r\n  knowledge-sharing, professionals from\r\n  various disciplines come together to\r\n  develop comprehensive approaches to\r\n  address the diverse needs of individuals\r\n  with hearing impairments. By raising\r\n  awareness, promoting research, and\r\n  advocating evidence-based practice,\r\n  COMUSA contributes significantly\r\n  to enhancing hearing health care and\r\n  fostering a better quality of life for\r\nindividuals with hearing loss.</p>\r\n<h4> REFERENCES</h4>\r\n<ol>\r\n  <li><a name=\"1\" id=\"1\"></a>Lewis,  D.R., et al. &quot;<a href=\"mailto:http://www.bjorl.org/en-pdf-S1808869415313641\" target=\"_blank\">Multiprofessional  committee on auditory health&ndash;COMUSA.</a>&quot; Braz  J Otorhinolaryngo, 76 (1) (2010):  121-128.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/20339700/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1590/s1808-86942010000100020\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Multiprofessional+committee+on+auditory+health%E2%80%93COMUSA.&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"2\" id=\"2\"></a>Porto, R. 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Ear  Hear, 37(5) 2016: e311&ndash;21.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/27556364/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1097/aud.0000000000000325\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Progressive+hearing+loss+in+early+childhood&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"10\" id=\"10\"></a>G&uuml;rtler, N.  &amp; Lalwani, A., &ldquo;<a href=\"mailto:https://www.oto.theclinics.com/article/S0030-6665(02)00053-1/fulltext\" target=\"_blank\">KEtiology of  syndromic and nonsyndromic sensorineural hearing loss</a>.&rdquo; Otolaryngol Clin North Am, 35 (4)  (2002):891-908.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/?term=KEtiology+of+syndromic+and+nonsyndromic+sensorineural+hearing+loss\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1016/S0030-6665(02)00053-1\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=KEtiology+of+syndromic+and+nonsyndromic+sensorineural+hearing+loss&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n</ol>',NULL,'2023-07-15'),(63,5403,'ajchr','http://www.andrewjohnpublishing.com/','<p><strong>Rahul Vhedi<sup><a href=\"#corr\">*</a></sup></strong></p>\r\n<p>Department of Audiology and Speech Language Pathology, Kasturba Medical College, India</p>\r\n<p>\r\n<dt>*Corresponding Author:</dt>\r\n<dd>Rahul Vhedi<a name=\"corr\" id=\"corr\"></a><br />\r\nDepartment of Audiology and Speech Language Pathology, Kasturba Medical College, India<br />\r\n<strong>E-mail:</strong> rahul34@gmail.com<br />\r\n</dd>\r\n</p>\r\n<p><strong>Received: </strong>02-Jun-2023, Manuscript No. ajchr-23-103037; <strong>Editor assigned: </strong>05- Jun -2023, Pre QC No. ajchr-23- 103037 (PQ); <strong>Reviewed:</strong> 19- Jun -2023, QC No. ajchr-23-103037; <strong>Revised: </strong>23- Jun-2023, Manuscript No. ajchr-23-103037; <strong>Published:</strong> 30- Jun-2023</p>','<h4>INTRODUCTION</h4>\r\n<p>Paediatric audiology is a specialized\r\n  field of audiology that focuses on the\r\n  assessment and management of hearing\r\n  disorders in children. It plays a vital role\r\n  in identifying and addressing hearing\r\n  impairments early in life, as hearing is\r\n  crucial for a child&rsquo;s language development,\r\n  academic success, and overall quality of\r\n  life. This article provides an overview\r\n  of paediatric audiology, including the\r\n  importance of early intervention,\r\n  common hearing disorders in children,\r\n  diagnostic techniques, and treatment\r\noptions.</p>\r\n<p>The Importance of Early Intervention:\r\n  Early identification and intervention are\r\n  crucial in addressing hearing disorders\r\nin children. Hearing loss can significantly impact a child&rsquo;s speech and language\r\ndevelopment, social skills, and educational\r\nachievements. The earlier a hearing\r\nimpairment is detected, the better\r\nthe chances of successful intervention\r\nand improved outcomes for the child.\r\nPaediatric audiologists work closely with\r\nparents, healthcare professionals, and\r\neducators to ensure early detection and\r\nappropriate intervention[<a href=\"#1\" title=\"1\">1</a>,<a href=\"#2\" title=\"2\">2</a>].</p>\r\n<p><strong>COMMON HEARING DISORDERS\r\nIN CHILDREN</strong></p>\r\n<p>\r\n  Paediatric audiology addresses a wide\r\n  range of hearing disorders that can\r\n  affect children. Some of the common\r\nconditions include,</p>\r\n<p><strong>Congenital hearing loss: </strong>Hearing\r\n  loss present at birth can be caused by\r\n  genetic factors, maternal infections\r\n  during pregnancy, and complications\r\n  during childbirth, or exposure to certain\r\n  medications or substances.Acquired\r\n  Hearing Loss: Children can develop\r\n  hearing loss after birth due to factors\r\n  such as recurrent ear infections, head\r\n  trauma, exposure to loud noise, or\r\nototoxic medications [<a href=\"#3\" title=\"3\">3</a>].</p>\r\n<p><strong>Auditory processing disorders\r\n  (APDs): </strong>APDs affect the way the brain\r\n  processes sound, making it challenging\r\n  for children to understand and interpret\r\n  auditory information. This condition\r\n  can often be mistaken for a learning\r\ndisability.</p>\r\n<p><strong>Middle ear disorders: </strong>Conditions like\r\n  otitis media (middle ear infection), fluid\r\n  build-up, or structural abnormalities in\r\n  the middle ear can cause temporary or\r\nchronic hearing loss in children [<a href=\"#4\" title=\"4\">4</a>,<a href=\"#5\" title=\"5\">5</a>].</p>\r\n<p><strong>DIAGNOSTIC TECHNIQUES</strong></p>\r\n<p>\r\n  Paediatric audiologists employ various\r\n  diagnostic techniques to assess hearing\r\n  in children, taking into account their age,\r\n  developmental stage, and communication\r\nabilities. These techniques may include,</p>\r\n<p><strong>\r\n  Newborn hearing screening:</strong> A\r\n  quick and non-invasive test performed\r\nshortly after birth to identify potential hearing loss.</p>\r\n<p><strong>Behavioural observation\r\n  audiometry (BOA): </strong>A method used\r\n  with infants to observe their behavioural\r\n  responses to sound stimuli, such as head\r\nturns or eye movements.</p>\r\n<p><strong>Visual reinforcement audiometry\r\n  (VRA): </strong>A technique involving the\r\n  presentation of sound stimuli along with\r\n  a visual reward, encouraging children to\r\nturn towards the sound source [<a href=\"#6\" title=\"6\">6</a>,<a href=\"#7\" title=\"7\">7</a>].</p>\r\n<p><strong>Play audiometry: </strong>An interactive\r\n  method that uses play-based activities\r\n  to assess children&rsquo;s hearing abilities,\r\nsuitable for toddlers and young children.</p>\r\n<p>\r\n<strong>TREATMENT OPTIONS</strong></p>\r\n<p>\r\n  Paediatric audiologists employ a range\r\n  of interventions based on the child&rsquo;s\r\n  specific hearing needs. These may\r\ninclude,</p>\r\n<p><strong>Hearing aids: </strong>Amplification devices\r\n  designed to enhance sound perception\r\n  and improve communication abilities in\r\nchildren with hearing loss [<a href=\"#8\" title=\"8\">8</a>,<a href=\"#9\" title=\"9\">9</a>].</p>\r\n<p>\r\n  <strong>Cochlear implants:</strong> Surgical devices\r\n  that bypass damaged parts of the inner\r\n  ear and stimulate the auditory nerve,\r\n  providing a sense of sound to children\r\nwith severe-to-profound hearing loss.</p>\r\n<p>\r\n  <strong>Assistive listening devices (ALDs):</strong>\r\n  Devices such as FM systems or sound\r\n  field amplification systems that help\r\n  children hear more clearly in challenging\r\n  listening environments, such as\r\nclassrooms[<a href=\"#10\" title=\"10\">10</a>].</p>\r\n<p><strong>\r\n  Auditory training and therapy:</strong>\r\n  Programs aimed at improving a\r\n  child&rsquo;s auditory skills, including sound\r\n  discrimination, speech perception, and\r\nauditory processing abilities.</p>\r\n<h4>CONCLUSION</h4>\r\n<p>Paediatric audiology plays a vital role\r\n  in the early detection, assessment,\r\n  and management of hearing disorders\r\nin children. Through comprehensive evaluations and tailored interventions,\r\npaediatric audiologists strive to minimize\r\nthe impact of hearing impairments on a\r\nchild&rsquo;s development and overall wellbeing.\r\nWith early identification and\r\nappropriate intervention, children with\r\nhearing disorders can have improved\r\ncommunication skills, academic\r\nachievements, and better social\r\nintegration, leading to a brighter future.</p>\r\n<h4> REFERENCES</h4>\r\n<ol>\r\n  <li><a name=\"1\" id=\"1\"></a>Caruso,  G., et al. &ldquo;<a href=\"mailto:https://www.sciencedirect.com/science/article/abs/pii/S0035378720305890\" target=\"_blank\">Clinical and electrophysiological  findings in various hereditary sensory neuropathies</a>.&rdquo; Acta Neurol (Napoli), 14(1992): 345-362.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/1293978/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:doi:%2010.1007/BF02343494.\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Clinical+and+electrophysiological+findings+in+various+hereditary+sensory+neuropathies&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"2\" id=\"2\"></a>Galambos, R, &amp; 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INSERT INTO `fulltext_content` VALUES (64,5404,'ajchr','http://www.andrewjohnpublishing.com/','<p><strong>Mahesh Sunada<sup><a href=\"#corr\">*</a></sup></strong></p>\r\n<p>Department of Audiology, Karolinska University Hospital, Sweden</p>\r\n<p>\r\n<dt>*Corresponding Author:</dt>\r\n<dd>Mahesh Sunada<a name=\"corr\" id=\"corr\"></a><br />\r\nDepartment of Audiology, Karolinska University Hospital, Sweden<br />\r\n<strong>E-mail:</strong> moheshs37@gmail.com<br />\r\n</dd>\r\n</p>\r\n<p><strong>Received: </strong>02-Jun-2023, Manuscript No. ajchr-23-103038; <strong>Editor assigned: </strong>05- Jun -2023, Pre QC No. ajchr-23- 103038 (PQ); <strong>Reviewed:</strong> 19- Jun -2023, QC No. ajchr-23-103038; <strong>Revised: </strong>23- Jun-2023, Manuscript No. ajchr-23-103038; <strong>Published:</strong> 30- Jun-2023</p>','<h4>INTRODUCTION</h4>\r\n<p>ANSD represents a unique challenge\r\n  in the field of audiology due to its\r\n  variable presentation and impact on\r\n  speech perception. Although ANSD is\r\n  considered a relatively rare condition, its\r\n  prevalence within specific audio logical\r\n  populations is not well documented.\r\n  This study aims to address this gap by\r\n  examining the prevalence of ANSD in an\r\n  Auditory Health Care Service [<a href=\"#1\" title=\"1\">1</a>, <a href=\"#2\" title=\"2\">2</a>].</p>\r\n<p>Auditory Neuropathy Spectrum\r\n  Disorder (ANSD) poses unique\r\n  challenges in audio logical practice due\r\n  to its varied presentation and impact\r\n  on speech perception. However, the\r\n  prevalence of ANSD within specific\r\n  audio logical populations remains largely\r\n  unexplored. This study examines the\r\n  prevalence of ANSD in an Auditory\r\n  Health Care Service, shedding light on\r\n  the importance of early identification\r\n  and appropriate management strategies for\r\n  individuals affected by this condition [<a href=\"#3\" title=\"3\">3</a>, <a href=\"#4\" title=\"4\">4</a>].</p>\r\n<h4>METHODS</h4>\r\n<p> A retrospective analysis was conducted using anonym zed patient records from\r\n  the Auditory Health Care Service over\r\n  a specified period. The study sample\r\n  included individuals who underwent\r\n  aetiological assessment, including\r\n  diagnostic evaluations, speech perception\r\n  tests, and electrophysiological measures\r\n  [<a href=\"#5\" title=\"5\">5</a>]. The diagnostic criteria for ANSD\r\n  were based on a combination of\r\n  aetiological, speech perception, and\r\n  Auditory Brainstem Response (ABR)\r\n  findings [<a href=\"#6\" title=\"6\">6</a>].</p>\r\n<h4>DISCUSSION</h4>\r\n<p>The prevalence of ANSD in the\r\n  Auditory Health Care Service was\r\n  analysed and compared with existing\r\n  literature. The findings shed light\r\n  on the incidence of ANSD within\r\n  the specific aetiological population\r\n  served by the clinic. The discussion\r\n  section also addresses the challenges\r\n  faced in diagnosing and managing\r\n  ANSD, emphasizing the importance\r\n  of a multidisciplinary approach and\r\n  individualized interventions. The\r\n  prevalence of ANSD within the Auditory\r\n  Health Care Service was assessed and\r\n  compared with existing literature. The findings provide valuable insights into\r\n  the incidence of ANSD within this\r\n  specific aetiological population [<a href=\"#7\" title=\"7\">7</a>,<a href=\"#8\" title=\"8\">8</a>].\r\n  The discussion section delves into the\r\n  challenges associated with diagnosing\r\n  and managing ANSD, emphasizing the\r\n  need for a multidisciplinary approach\r\n  and individualized interventions tailored\r\n  to each patient&rsquo;s unique needs.</p>\r\n<p><strong>IMPLICATIONS</strong></p>\r\n<p> Understanding the prevalence of\r\n  ANSD within an Auditory Health Care\r\n  Service holds significant implications\r\n  for developing effective screening,\r\n  diagnostic, and treatment protocols.\r\n  Early identification of ANSD enables\r\n  timely interventions, such as auditory\r\n  rehabilitation and educational support,\r\n  which greatly improve long-term\r\n  outcomes for affected individuals [<a href=\"#9\" title=\"9\">9</a>, <a href=\"#10\" title=\"10\">10</a>].</p>\r\n<h4>CONCLUSION</h4>\r\n<p>This study provides insights into the\r\n  prevalence of ANSD in an Auditory\r\n  Health Care Service, contributing to the\r\n  existing body of knowledge regarding\r\n  this relatively rare hearing disorder. The findings emphasize the need for\r\n  increased awareness, research, and\r\n  tailored management approaches to\r\n  ensure optimal outcomes for individuals\r\n  diagnosed with ANSD. By expanding\r\n  our understanding of ANSD prevalence\r\n  and its impact on aetiological services,\r\n  healthcare professionals can better\r\n  address the needs of those affected by\r\n  this condition.</p>\r\n<h4> REFERENCES</h4>\r\n<ol>\r\n  <li><a name=\"1\" id=\"1\"></a>Choi, H., et al. &ldquo;<a href=\"mailto:https://onlinelibrary.wiley.com/doi/abs/10.1002/humu.21488\" target=\"_blank\">A complex  phenotype of peripheral neuropathy, myopathy, hoarseness, and hearing loss is  linked to an autosomal dominant mutation in MYH14.</a>&rdquo; Hum Mutat,32 (6) (2011): 669-677.</li>\r\n  <p align=\"right\"> <a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/21480433/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1002%2Fhumu.21488\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=A+complex+phenotype+of+peripheral+neuropathy%2C+myopathy%2C+hoarseness%2C+and+hearing+loss+is+linked+to+an+autosomal+dominant+mutation+in+MYH14.%22&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"2\" id=\"2\"></a>Gulsuner, U., et al. &ldquo;<a href=\"mailto:https://ui.adsabs.harvard.edu/abs/2014PNAS..11118285U/abstract\" target=\"_blank\">Mitochondrial  serine protease HTRA2 p. 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It is\r\n  not a hearing impairment but rather\r\n  a difficulty in the interpretation and\r\n  organization of sounds. In this article,\r\n  we will explore the causes, symptoms,\r\n  and treatment options for auditory\r\nprocessing disorders [<a href=\"#1\" title=\"1\">1</a>].</p>\r\n<p><strong>CAUSES OF AUDITORY\r\nPROCESSING DISORDERS</strong></p>\r\n<p>\r\n  The exact causes of auditory processing\r\n  disorders are not yet fully understood.\r\n  However, several factors are believed to\r\n  contribute to the development of this\r\ncondition:</p>\r\n<p><strong>Genetics: </strong>Research suggests that\r\n  genetic factors may play a role in the\r\n  development of APD. Certain genetic\r\n  conditions or a family history of auditory\r\n  processing difficulties can increase the\r\nrisk.</p>\r\n<p><strong>Premature birth or low birth\r\n  weight: </strong>Children who are born\r\n  prematurely or with a low birth weight\r\n  may be more prone to developing\r\nauditory processing disorders.</p>\r\n<p>\r\n  <strong>Chronic ear infections: </strong>Frequent ear\r\n  infections during early childhood can\r\n  affect the auditory system, potentially\r\n  leading to auditory processing\r\ndifficulties [<a href=\"#2\" title=\"2\">2</a>].</p>\r\n<p>\r\n  <strong>Brain injuries or trauma: </strong>Head\r\n  injuries, concussions, or other types\r\n  of brain trauma can disrupt the brain&rsquo;s\r\nability to process auditory information.</p>\r\n<p><strong>SYMPTOMS OF AUDITORY\r\nPROCESSING DISORDERS</strong></p>\r\n<p>\r\n  The symptoms of auditory processing\r\n  disorders can vary from person to\r\nperson. Some common signs include,</p>\r\n<p><strong>Difficulty understanding speech\r\n  in noisy environments:</strong> Individuals\r\n  with APD often struggle to understand\r\n  speech when there is background noise,\r\n  such as in a crowded room or a noisy\r\nclassroom [<a href=\"#3\" title=\"3\">3</a>,<a href=\"#4\" title=\"4\">4</a>].</p>\r\n<p><strong>Trouble following directions: </strong>People\r\n  with APD may have difficulty processing\r\n  and remembering verbal instructions,\r\n  particularly when they are complex or\r\ngiven quickly.</p>\r\n<p>\r\n  <strong>Poor listening skills: </strong>They may exhibit\r\n  poor listening skills, such as frequently\r\n  asking others to repeat themselves,\r\n  misinterpreting information, or having\r\n  trouble maintaining focus during\r\nconversations.</p>\r\n<p>\r\n  <strong>Sensitivity to loud sounds: </strong>Individuals\r\n  with APD may be more sensitive to\r\n  loud or sudden noises, causing them\r\ndiscomfort or distress [<a href=\"#5\" title=\"5\">5</a>].</p>\r\n<p>\r\n  <strong>Poor reading and spelling skills:</strong>\r\n  Some individuals with APD may also\r\n  experience difficulties in reading and \r\nspelling, as auditory processing plays a crucial role in language development [<a href=\"#6\" title=\"6\">6</a>].</p>\r\n<p><strong>DIAGNOSIS AND TREATMENT</strong></p>\r\n<p>\r\n  Diagnosing auditory processing disorders\r\n  typically involves a comprehensive\r\n  evaluation by an audiologist or speechlanguage\r\n  pathologist. The evaluation\r\n  may include a range of tests to assess\r\n  various aspects of auditory processing\r\n  abilities. While there is no cure for\r\n  auditory processing disorders, there\r\n  are treatment options available to help\r\n  individuals manage their symptoms\r\n  and improve their quality of life. Some\r\ncommon approaches include:</p>\r\n<p><strong>Auditory training: </strong>This therapy\r\n  involves exercises and activities designed\r\n  to improve the brain&rsquo;s ability to process\r\nand interpret auditory information [<a href=\"#7\" title=\"7\">7</a>].</p>\r\n<p><strong>\r\n  Environmental modifications:</strong>\r\n  Creating a supportive listening\r\n  environment by reducing background\r\n  noise, using assistive listening devices,\r\n  and implementing strategies to enhance\r\ncommunication can be beneficial.</p>\r\n<p>\r\n  <strong>Speech-language therapy: </strong>Working\r\n  with a speech-language pathologist\r\n  can help individuals develop stronger\r\n  language and communication skills, as\r\n  well as strategies to compensate for\r\nauditory processing difficulties [<a href=\"#8\" title=\"8\">8</a>].</p>\r\n<p>\r\n  <strong>Educational accommodations:</strong>\r\n  In academic settings, providing\r\n  accommodations such as preferential\r\n  seating, extended time for tests and the\r\n  use of visual aids can assist individuals\r\nwith APD in their learning process [<a href=\"#9\" title=\"9\">9</a>, <a href=\"#10\" title=\"10\">10</a>].</p>\r\n<h4>CONCLUSION</h4>\r\n<p>Auditory processing disorders can\r\n  significantly impact an individual&rsquo;s ability\r\n  to understand and interpret auditory\r\n  information. While there is no cure, early\r\n  diagnosis and appropriate interventions\r\n  can help individuals with APD manage\r\n  their symptoms and lead fulfilling lives. If\r\nyou suspect you or someone you know may have auditory processing difficulties,\r\nseeking professional evaluation and\r\nsupport is recommended to determine\r\nthe most appropriate course of action.</p>\r\n<h4> REFERENCES</h4>\r\n<ol>\r\n  <li><a name=\"1\" id=\"1\"></a>Shirato,  H., et al. &ldquo;<a href=\"mailto:https://www.sciencedirect.com/science/article/abs/pii/S0360301600007318\" target=\"_blank\">Fractionated stereotactic  radiotherapy for vestibular schwannoma (VS)&rdquo; comparison between cystic-type and  solid-type VS</a>.&rdquo;  Int J Radiat Oncol Biol Phys, 48 (2000):1395&ndash; 1401. </li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/11121639/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1016/s0360-3016(00)00731-8\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Fractionated+stereotactic+radiotherapy+for+vestibular+schwannoma+%28VS%29%E2%80%9D+comparison+between+cystic-type+and+solid-type+VS&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"2\" id=\"2\"></a>Louvrier, C., et al. &ldquo;<a href=\"https://academic.oup.com/neuro-oncology/article/20/7/917/4835073\" target=\"_blank\">Targeted  next-generation sequencing for differential diagnosis of neurofibromatosis type  2, schwannomatosis, and meningiomatosis</a>.&rdquo; 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ORL J Otorhinolaryngology  Relat Spec, 61 (1999): 321&ndash;327. </li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/10545805/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1159/000027693\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Ultrastructural+evidence+for+protection+of+the+outer+hair+cells+of+the+inner+ear+during+intense+noise+exposure+by+application+of+the+organic+calcium+channel+blocker+diltiazem&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"10\" id=\"10\"></a>Tesa&#345;ov&aacute;,  M. &amp; Peterkov&aacute;, L., &ldquo;<a href=\"https://www.researchgate.net/publication/330190844_Tumour_stem_cells_in_schwannoma_A_review\" target=\"_blank\">Tumor  Biology and Microenvironment of Vestibular Schwannoma-Relation to Tumor Growth  and Hearing Loss</a>.&rdquo;  Biomedicines, 11 (1) (2020): 32.</li>\r\n  <p align=\"right\"><a href=\"https://pubmed.ncbi.nlm.nih.gov/36672540/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"https://doi.org/10.3390/biomedicines11010032\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"https://scholar.google.com/scholar?q=Tesa%C5%99ov%C3%A1,+M.+%26+Peterkov%C3%A1,+L.,+%E2%80%9CTumor+Biology+and+Microenvironment+of+Vestibular+Schwannoma-Relation+to+Tumor+Growth+and+Hearing+Loss%E2%80%9D.+Biomedicines,+11(1)+(2020):+32.+&amp;hl=en&amp;as_sdt=0,5\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n</ol>',NULL,'2023-07-15'),(66,5406,'ajchr','http://www.andrewjohnpublishing.com/','<p><strong>Mohan Jen<sup><a href=\"#corr\">*</a></sup></strong></p>\r\n<p>Department of Otorhinolaryngology-Head and Neck Surgery, Zhongnan Hospital of Wuhan University, China</p>\r\n<p>\r\n<dt>*Corresponding Author:</dt>\r\n<dd>Mohan Jen<a name=\"corr\" id=\"corr\"></a><br />\r\nDepartment of Otorhinolaryngology-Head and Neck Surgery, Zhongnan Hospital of Wuhan University, China<br />\r\n<strong>E-mail:</strong> Mohonj14@gmail.com<br />\r\n</dd>\r\n</p>\r\n<p><strong>Received:</strong> 02-Jun-2023, Manuscript No. ajchr-23-103907; <strong>Editor assigned: </strong>05- Jun -2023, Pre QC No. ajchr-23- 103907 (PQ); <strong>Reviewed: </strong>19- Jun -2023, QC No. ajchr-23-103907; <strong>Revised: </strong>23- Jun-2023, Manuscript No. ajchr-23-103907; <strong>Published: </strong>30- Jun-2023</p>','<h4>INTRODUCTION</h4>\r\n<p>HL (hearing loss) is characterized by\r\n  significant clinical consequences affecting\r\n  quality of life such as communication\r\n  disorder, reduced social interaction,\r\n  isolation, melancholia, reduced cognitive\r\n  function, and dementia resulting in poor\r\n  quality life.Approximately 2 or 3 in\r\n  every 1,000 babies are diagnosed with\r\n  clinical significant unilateral or bilateral\r\n  HL.Hearing loss can be classified into\r\n  conductive high-frequency (CHL) and\r\n  sensor neural high-frequency (SNHL)\r\n  high-frequency. CHL is caused by\r\n  problems with the transmission of\r\n  sound waves along the pathway in the\r\n  outer ear or the auditory nerve.SNHL\r\n  is a combination of CHL and SNHL.\r\n  Among all the etiologist The delivery of\r\n  a gene is a multi-factorial process that\r\n  depends on multiple parallel paths of\r\n  scientific progress, including: the genetic\r\n  aetiology for the treatment of deafness;\r\n  the gene sequence used; the vectors\r\n  used; the route of delivery; the treatment\r\n  time point; the cost to be incurred\r\n  for the treatment to be effective and\r\n  to be successfully translated to the\r\n  clinic;5Vectors used in gene therapy\r\n  transport DNA into cells, typically\r\n  classified as non-, viral-, and hybrid-viral.\r\n  Non-viral techniques are easy to scale\r\n  up for large-scale production and have\r\n  low-host immunogenicity. However, they\r\n  suffer from poor gene transfer efficiency\r\n  when compared with viral vectors.\r\n  Currently, viral vectors predominate in\r\n  clinical trials for gene therapy because\r\n  of their higher transduction rate. Viruses\r\n  (i.e., lysogenic or lytic) bind to the host\r\n  cell; replicate their genetic material with\r\n  host replication machinery; and remain\r\n  in the host cell for an extended time\r\n  before responding to a trigger [<a href=\"#1\" title=\"1\">1</a>,<a href=\"#2\" title=\"2\">2</a>].</p>\r\n<p><strong>NON-SENSORY CELLS</strong></p>\r\n<p> Synthesized cells (SCs) are the\r\n  epitheliums derived from the oocytes\r\n  that surround the body&rsquo;s scale media\r\n  around Corte&rsquo;s organ. SCs are a\r\n  common target of gene therapy for\r\n  genetic deafness due to the presence of\r\n  a gene leading to high-level hearing (HL)\r\n  (e.g., gap junction protein (GJB2) beta 2\r\n  (GJB2), a gene resulting in high-density\r\n  lipoprotein (HLP) due to a connexion\r\n  (Cx) 26 (Cx26) mutation), with\r\n  promising uses in regenerative therapies.\r\n  The mechanism of sound transmission in\r\n  cochlea hypertrophic (HC) is determined\r\n  by the electrochemical dissimilarity\r\n  between cochlea fluid (perilymph)\r\n  and cochlea end lymph (end lymph). In\r\n  cochlea media, SV (strata vascularise)\r\n  is the epithelial tissue responsible for\r\n  the generation of end lymph and its\r\n  maintenance. Mutation of marginal cells\r\n  can lead to dysfunction in gap junctions\r\n  (EP) affecting cochlea hypertrophy (HC) and cell death (apoptosis), resulting in\r\n  hearing loss (e.g., KCNQ1 / KCNE1,\r\n  Annexing, etc.</p>\r\n<p><strong>TIME OF TREATMENT</strong></p>\r\n<p> Early intervention is the most effective\r\n  approach to treating any hearing\r\n  impairment, and it continues to play\r\n  a critical role in gene therapy increase\r\n  the likelihood of restoring both cell\r\n  and organ function in the inner ear. For\r\n  example, treating VGLUT3 mutations\r\n  with AAV1 injection on P1P2 (postnatal\r\n  days 12) in VGLUT3 knockout mice\r\n  resulted in better HC transduction and\r\n  auditory restoration compared to a\r\n  later time point (P10). The same results\r\n  were observed when AAV5- GJb2 was\r\n  administered at P42 (GJb2 knockout) in\r\n  KO mice and AAV2/AA80L65- Ush1c\r\n  was administered P10P12 (Ush1c KO) in\r\n  mice. However, once High-Haemorrhage\r\n  (HL) occurred, no subsequent treatment\r\n  resulted in rescue of degeneration\r\n  in rodent models due to the closed\r\n  therapeutic window for treatment [<a href=\"#3\" title=\"3\">3</a>].</p>\r\n<p><strong>TRANSLATING TO CLINICS</strong></p>\r\n<p> The success of gene therapy in animals\r\n  requires careful consideration for\r\n  translating to the clinic as a therapeutic\r\n  strategy for human use [<a href=\"#4\" title=\"4\">4</a>,<a href=\"#5\" title=\"5\">5</a>].</p>\r\n<p><strong>SAFETY &amp; EFFECTIVENESS SAFETY\r\n  &amp; EFFECTIVENESS</strong></p>\r\n<p> Efficacy and safety concerns are of\r\n  the utmost importance for the clinical\r\n  transition. Numerous genetic studies\r\n  have shown that the effectiveness of an\r\n  approach depends on the method of\r\n  administration, the vector type, and the\r\n  amount of delivery vehicle used, all of\r\n  which must be tested in the human ear.\r\n  In addition to efficacy, safety concerns\r\n  include the effects of overexpression or\r\n  silencing of the gene of interest, as well\r\n  as its pharmacological and toxicological\r\n  properties after delivery of the gene.\r\n  As mentioned above, there&rsquo;s a clinical\r\n  window for treating inner-ear anomaly\r\n  with gene therapy, and it will be important\r\n  to look at the critical period to get the\r\n  best results, along with other factors\r\n  such as expression profiles. Longevity\r\n  should also be carefully evaluated, as it\r\n  has been seen in animals [<a href=\"#6\" title=\"6\">6</a>-<a href=\"#8\" title=\"8\">8</a>].</p>\r\n<p><strong>USH1G MUTATIONS</strong></p>\r\n<p> SANS is encoded by Ush1G and is an\r\n  anomalously localized at stereo cilia\r\n  tip. This is an important part of the\r\n  mechanism of mechanotransduction\r\n  as well as the sensory antenna of\r\n  ichthyocytosis (IHC). In Emptoz et al.\r\n  (140,194), SANS cDNA was delivered\r\n  via RWM injection via AAV8 using a\r\n  CAG promoter at p2.5. In KO mice,\r\n  the transgene delivery restored SANS\r\n  protein in tip link of ichthyoids (IHC),\r\n  orthocytosis (OHC), and vestibular\r\n  ichthosis (VHT), thus preserving\r\n  mechanotransduction, vestibular\r\n  dysfunction, and improving their hearing\r\n  threshold. In treated mice, partial hemihepatic\r\n  (HL) restoration was observed,\r\n  with partial hepatic degeneration\r\n  occurring approximately 12 weeks after\r\n  injection. This partial recovery may be\r\n  attributed to the lower transduction of\r\n  cochlear HC versus vestibular HC in\r\n  this study [<a href=\"#9\" title=\"9\">9</a>,<a href=\"#10\" title=\"10\">10</a>].</p>\r\n<h4>CONCLUSION</h4>\r\n<p>The rapid expansion of clinical trials\r\n  using AAV vectors indicates that\r\n  this is only the start of a new age\r\n  in the treatment of human diseases.\r\n  Molecular Therapy: Methods and Clinical\r\n  Development Vol.230, 21 June2021The\r\n  review of manipulating viral vectors.\r\n  While challenges remain, advances in\r\n  gene regulation and editing will increase\r\n  the specificity and effectiveness of gene\r\n  therapy. Heterogeneity is a major issue\r\n  in genetic HL treatment. The efficacy of\r\n  treatment depends on several factors,\r\n  including the therapeutic window, the\r\n  targets, the targeting molecules, and the\r\n  protein function. Recent advances in\r\n  synthetic AAV and advanced techniques\r\n  such as AAV Capsid modification using\r\n  targeting molecules (peptides) of\r\n  interest can modify their expression\r\n  profile and increase the likelihood\r\n  of wholesale clinical efficacy. Hybrid\r\n  vectors, such as varooms, have been\r\n  reported to be highly efficacious\r\n  compared to their parent virus. It may\r\n  be interesting to study AAV Virosomes\r\n  modified with targeted molecules for\r\n  transduction efficiencies in the coming\r\n  years. Due to the high cost of such\r\n  research, there is a growing interest\r\n  from government funding agencies,\r\n  industry and private foundations,\r\n  patients and physicians. Companies such as Applied Genetic Technologies\r\n  (AGTC) (Akouos), Rescue Hearing\r\n  (Rescue Hearing), Novartis (Novartis)\r\n  (Decibel Therapeutics), etc. are currently\r\n  conducting preclinical/clinical studies to\r\n  treat high blood pressure (HL) through\r\n  preclinical testing of CRISPR (Cas9) for\r\n  the treatment of high blood pressure.\r\n  Despite the challenges, there have been\r\n  major breakthroughs in the field of high\r\n  blood pressure gene therapy, offering\r\n  great potential for novel and effective\r\n  treatments to improve patients&rsquo; quality\r\n  of life.</p>\r\n<h4> REFERENCES</h4>\r\n<ol>\r\n  <li><a name=\"1\" id=\"1\"></a>Michael, H., et al. &ldquo;<a href=\"mailto:https://www.researchgate.net/publication/264471625_Clinical_features_of_Friedreich\'s_ataxia_Classical_and_atypical_phenotypes\" target=\"_blank\">Clinical  features of Fried Reich&rsquo;s ataxia: classical and atypical phenotypes.</a>&rdquo;<em>J Neurochem</em>,126 (2013): 103-117. </li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/?term=%E2%80%9CClinical+features+of+Friedreich%27s+ataxia%3A+classical+and+atypical+phenotypes\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1111/jnc.12317\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=%E2%80%9CClinical+features+of+Friedreich%27s+ataxia%3A+classical+and+atypical+phenotypes&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"2\" id=\"2\"></a>Horga, F. &amp; Alejandro, D., &ldquo;<a href=\"mailto:https://jnnp.bmj.com/content/88/7/575.abstract\" target=\"_blank\">Genetic and  clinical characteristics of NEFL-related Charcot-Marie-Tooth disease.</a>&rdquo; <em>J Neurol Neurosurg Psychiatry</em>,88 (7) (2017): 575-585.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/?term=Genetic+and+clinical+characteristics+of+NEFL-related+Charcot-Marie-Tooth+disease\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:http://dx.doi.org/10.1136/jnnp-2016-315077\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=.+Genetic+and+clinical+characteristics+of+NEFL-related+Charcot-Marie-Tooth+disease&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"3\" id=\"3\"></a>Potthoff,  M.J., et al. &ldquo;<a href=\"mailto:https://www.researchgate.net/publication/6054770_Histone_deacetylase_degradation_and_MEF2_activation_promote_the_formation_of_slow-twitch_myofibers\" target=\"_blank\">Histone deacetylase degradation  and MEF2 activation promote the formation of slow-twitch myofibers</a>&rdquo;. J Clin Invest, 117 (2007):  2459-2467.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/?term=Histone+deacetylase+degradation+and+MEF2+activation+promote+the+formation+of+slow-twitch+myofibers\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:http://dx.doi.org/10.1172/JCI31960\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Histone+deacetylase+degradation+and+MEF2+activation+promote+the+formation+of+slow-twitch+myofibers&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"4\" id=\"4\"></a>Jiang. &amp; Luoying, M., &ldquo;<a href=\"mailto:https://www.x-mol.net/paper/article/1623884080496066560\" target=\"_blank\">Advances in gene  therapy hold promise for treating hereditary hearing loss</a>.&rdquo;<strong></strong><em>Mol Ther Nucleic Acids,</em><em> (</em>2023).</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/36755494/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:DOI:10.1016/j.ymthe.2023.02.001\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=%E2%80%9CAdvances+in+gene+therapy+hold+promise+for+treating+hereditary+hearing+loss.%E2%80%9D+&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"5\" id=\"5\"></a>Eshraghi, A.A., et al.  &ldquo;<a href=\"mailto:https://anatomypubs.onlinelibrary.wiley.com/doi/full/10.1002/ar.24107\" target=\"_blank\">Recent  advancements in gene and stem cell&#8208;based treatment  modalities: Potential implications in noise&#8208;induced hearing  loss</a>&rdquo;.<em>Anat  Rec</em><em>,</em>303 (3):516-526.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/30859735/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1002/ar.24107\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=KEtiology+of+syndromic+and+nonsyndromic+sensorineural+hearing+loss&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"6\" id=\"6\"></a>Robillard, K.N. &amp; de Vrieze, E., &ldquo;<a href=\"mailto:https://www.sciencedirect.com/science/article/pii/S0378595522000922\" target=\"_blank\">Altering gene  expression using antisense oligonucleotide therapy for hearing loss.</a>&rdquo; HearRes, 16 (2022): 108523.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/?term=+Altering+gene+expression+using+antisense+oligonucleotide+therapy+for+hearing+loss%E2%80%9D.+\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1016/j.heares.2022.108523\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=+Altering+gene+expression+using+antisense+oligonucleotide+therapy+for+hearing+loss%E2%80%9D.+&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"7\" id=\"7\"></a>Thakur,  J.D., et al. &ldquo;<a href=\"mailto:https://www.researchgate.net/publication/230780141_Do_cystic_vestibular_schwannomas_have_worse_surgical_outcomes_Systematic_analysis_of_the_literature\" target=\"_blank\">Do cystic vestibular schwannomas  have worse surgical outcomes? Systematic analysis of the literature</a>.&rdquo; Neurosurgeon Focus, 33 (3)  (2012):E12.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/?term=Do+cystic+vestibular+schwannomas+have+worse+surgical+outcomes%3F+Systematic+analysis+of+the+literature\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:http://dx.doi.org/10.3171/2012.6.FOCUS12200\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Do+cystic+vestibular+schwannomas+have+worse+surgical+outcomes%3F+Systematic+analysis+of+the+literature&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"8\" id=\"8\"></a>Cameraman,  S., et al. &ldquo;<a href=\"mailto:https://link.springer.com/article/10.1007/BF01411474\" target=\"_blank\">Cystic acoustic neuromas: studies  of 14 cases</a>.&rdquo;  Act Neurotic, 138 (6) (1996):695&ndash;699.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/?term=.+Cystic+acoustic+neurinomas%3A+studies+of+14+cases\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:ttps://doi.org/10.1007/BF01411474\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=.+Cystic+acoustic+neurinomas%3A+studies+of+14+cases&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"9\" id=\"9\"></a>Benech,  F., et al. &ldquo;<a href=\"mailto:https://link.springer.com/article/10.1007/s10143-005-0380-y\" target=\"_blank\">Cystic versus solid vestibular  schwannomas: a series of 80 grade III&ndash;IV patients</a>.&rdquo; Neurosurgeon Re, 28 (3)  (2005):209&ndash;213.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/15739069/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1007/s10143-005-0380-y\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Cystic+versus+solid+vestibular+schwannomas%3A+a+series+of+80+grade+III%E2%80%93IV+patients%E2%80%9D.+&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"10\" id=\"10\"></a>Xia, L. &amp; Zhang, H., &ldquo;<a href=\"mailto:https://www.researchgate.net/publication/250921725_Fluid-fluid_level_in_cystic_vestibular_schwannoma_A_predictor_of_peritumoral_adhesion_-_Clinical_article\" target=\"_blank\">Fluid-fluid level in cystic  vestibular schwannoma: a predictor of peritumoral adhesion</a>.&rdquo; J Neurosurgeon, 120 (1)  (2014):197&ndash;206.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/23870019/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.3171/2013.6.jns121630\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?q=Fluid-fluid+level+in+cystic+vestibular+schwannoma:+a+predictor+of+peritumoral+adhesion&amp;hl=en&amp;as_sdt=0,5\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n</ol>',NULL,'2023-07-15'),(67,5407,'ajchr','http://www.andrewjohnpublishing.com/','<p><strong>Rana Singh<sup><a href=\"#corr\">*</a></sup></strong></p>\r\n<p>Department of Epidemiology and Biostatistics, University Cancer Institute and Hospital, China</p>\r\n<p>\r\n<dt>*Corresponding Author:</dt>\r\n<dd>Rana Singh<a name=\"corr\" id=\"corr\"></a><br />\r\nDepartment of Epidemiology and Biostatistics, University Cancer Institute and Hospital, China<br />\r\n<strong>E-mail:</strong> Ranagingh6@gmail.com<br />\r\n</dd>\r\n</p>\r\n<p><strong>Received:</strong> 02-Jun-2023, Manuscript No. ajchr-23-103909;<strong> Editor assigned: </strong>05- Jun -2023, Pre QC No. ajchr-23- 103909 (PQ); <strong>Reviewed: </strong>19- Jun -2023, QC No. ajchr-23-103909; <strong>Revised: </strong>23- Jun-2023, Manuscript No. ajchr-23-103909; <strong>Published:</strong> 30- Jun-2023</p>','<h4>INTRODUCTION</h4>\r\n<p>The CI industry has been shaped by\r\n  hearing preservation for the majority\r\n  of the last 20 years. It is a topical and\r\n  influential field of research, surgical\r\n  research, audio logical research, and\r\n  commercialization. Advances in clinical\r\n  &amp; surgical aspects of the intervention &amp;\r\n  device technology have made it possible\r\n  to expand candidate patients to include\r\n  patients with increasing low-frequency\r\n  (LFH) acoustical hearing. Patients with\r\n  functionally relevant acoustical hearing\r\n  who are post-operative may also benefit\r\n  from combined electric &amp; acoustical\r\n  stimulation (EAS) [<a href=\"#1\" title=\"1\">1</a>,<a href=\"#2\" title=\"2\">2</a>]. High rates of\r\n  postoperative LFH preservation have\r\n  been reported in large cohort studies\r\n  from clinic-based studies (Jensen et\r\n  al. 2021), and there is evidence that\r\n  post-operative LFH preservation\r\n  rates increase over time, likely due to\r\n  continued improvement across the\r\n  field. In the subset of patients whose\r\n  LFH is sustained beyond 6-months\r\n  after activation, there is evidence of\r\n  long-term stability (5 years) of LFH\r\n  with continued EAS use, and in some\r\n  cases, up to 15 years It is, however, well\r\n  known that some patients experience\r\n  a decrease in LFH within months to\r\n  years after implantation in patients with\r\n  CI.Preserving CI hearing is a multifaceted\r\n  and time-dependent process.\r\n  There are three main stages from which\r\n  CI hearing preservation can be assessed\r\n  and each stage necessitates a concerted\r\n  effort across multiple sectors in the CI\r\n  industry to move forward [<a href=\"#3\" title=\"3\">3</a>,<a href=\"#4\" title=\"4\">4</a>].</p>\r\n<p><strong>RESIDUAL HEARING RESEARCH\r\n  PROGRAM</strong></p>\r\n<p> The Houston Rehabilitative Research\r\n  Program (HRTP) was a co-ordinated\r\n  preclinical research program launched\r\n  in 2010 under the auspices of Cochlear Limited, and initially focused on five main\r\n  hypotheses that could independently or\r\n  in combination influence LFH survival.\r\n  The main hypotheses are presented in\r\n  below, along with key contributors and\r\n  notable publications from the program\r\n  [<a href=\"#5\" title=\"5\">5</a>]. The main hypotheses were then\r\n  broken down into minor hypotheses.\r\n  Collaborators were identified; engaged,\r\n  preclinical research was planned and\r\n  conducted. The new hearing preservation\r\n  paradigm emerged from the need to\r\n  better manage, integrate, and analyse\r\n  the results of many individual projects,\r\n  as well as the growing recognition that\r\n  inflammation and FBR are at the heart\r\n  of hearing preservation [<a href=\"#6\" title=\"6\">6</a>]. As discussed\r\n  in the following two sections, the new\r\n  hearing preservation paradigm uses\r\n  a systems approach to capture and\r\n  classify all possible variables and In the\r\n  paradigms, these variables and factors\r\n  can then be aligned with the CI timeline,\r\n  the CI Timeline, and analysed based on\r\n  their timing with changes in LFH along\r\n  with particular learnings from the HRH.</p>\r\n<p><strong>CLINICAL FACTOR</strong></p>\r\n<p> Clinical factors are all those that can\r\n  be attributed to the surgical and audio\r\n  logical aspects of treatment. Many of\r\n  these factors have been the subject of\r\n  multiple RHP hypothesis studies. This\r\n  category includes all major steps in\r\n  the cochlear implant (CI) surgery and\r\n  subsequent use. Drilling is required in\r\n  the CI surgical procedure, including\r\n  a mastoidectomy, facial recess, and\r\n  access to the cchlea. Removal of the\r\n  RW overhang and bone occlusions\r\n  (e.g., crista fascia) may be necessary\r\n  to visualize the appropriate approach\r\n  for the patient to access the cochlear\r\n  implant (IC) [<a href=\"#7\" title=\"7\">7</a>,<a href=\"#8\" title=\"8\">8</a>]. Conventional highspeed\r\n  drills have previously been studied\r\n  as a risk of acoustic trauma, and the\r\n  risk increases as the drill moves closer to the cchlea, resulting in short term\r\n  increases in noise if the drill bit contacts\r\n  the incus,endosteum, and if it passes\r\n  through the per lymphatic space. At this\r\n  point, the type, size, and speed of the\r\n  drill become more important factors as\r\n  they may affect or reduce the acoustic\r\n  noise level and vibrations that can be\r\n  transmitted to the chlea .End steal\r\n  damage is linked to a particular local\r\n  inflammatory response to the injury and\r\n  is associated with increased tissue and\r\n  bone growth [<a href=\"#9\" title=\"9\">9</a>,<a href=\"#10\" title=\"10\">10</a>].</p>\r\n<h4>CONCLUSION</h4>\r\n<p>Acoustic Hearing Loss after Cochlear\r\n  Implantation and Use is a complex\r\n  and multi-faceted condition, but our\r\n  knowledge across the entire CI industry\r\n  has advanced significantly over the last\r\n  20 years. The CochlearResidualHearing\r\n  Research Program (CPRP) is a large\r\n  and coordinated community effort\r\n  that has contributed to this progress.\r\n  A systematic approach to evaluating\r\n  the collective output of the CPRP was\r\n  developed. This approach assessed the\r\n  problem and data collected to date\r\n  in relation to the complete timeline\r\n  of the Cochlear implant experience,\r\n  taking into account patient, device and\r\n  clinical factors. Many of the findings in\r\n  the research program relate not only\r\n  to acoustic hearing, but also to issues\r\n  relevant to overall cochlear health in\r\n  all CI patients and future therapies.\r\n  Looking ahead to the second phase and\r\n  third phase of CI hearing preservation,\r\n  it is likely that the most effective\r\n  ways to maximise acoustic hearing\r\n  retention with CI will require multiple\r\n  management and treatment strategies.\r\n  Currently, interventions around the perioperatory\r\n  time point that reduce acute\r\n  trauma following surgery and manage\r\n  post-operative runaway and chronic\r\n  inflammation are the most promising.</p>\r\n<h4> REFERENCES</h4>\r\n<ol>\r\n  <li><a name=\"1\" id=\"1\"></a>Jacquemont, J. &amp; David, S., &ldquo;<a href=\"mailto:https://jamanetwork.com/journals/jama/fullarticle/198088%23:~:text=The%20penetrance%20of%20FXTAS%20among,tremor%20and%20ataxia%20patient%20populations.\" target=\"_blank\">Penetrance of  the fragile X&ndash;associated tremor/ataxia syndrome in a permutation carrier  population.</a>&rdquo;Jamal, 291(4) (2004): 460-469.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/14747503/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:doi:10.1001/jama.291.4.460\" target=\"_blank\"><u>Crossref</u></a> <a href=\"mailto:https://scholar.google.com/scholar?q=%22Penetrance+of+the+fragile+X%E2%80%93associated+tremor/ataxia+syndrome+in+a+premutation+carrier+population.%22+&amp;hl=en&amp;as_sdt=0,5\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"2\" id=\"2\"></a>Andoni, et al. &ldquo;<a href=\"mailto:https://n.neurology.org/content/82/21/1919\" target=\"_blank\">Phenotypic  spectrum and incidence of TRPV4 mutations in patients with inherited axonal  neuropathy</a>.&rdquo;<em>J Neurol</em>,82  (21) (2014): 1919-1926. </li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/?term=Phenotypic+spectrum+and+incidence+of+TRPV4+mutations+in+patients+with+inherited+axonal+neuropathy\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:/doi.org/10.1212/WNL.0000000000000450\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Phenotypic+spectrum+and+incidence+of+TRPV4+mutations+in+patients+with+inherited+axonal+neuropathy&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"3\" id=\"3\"></a>Gulsuner, U., et al. &ldquo;<a href=\"mailto:https://ui.adsabs.harvard.edu/abs/2014PNAS..11118285U/abstract\" target=\"_blank\">Mitochondrial  serine protease HTRA2 p. G399S in a kindred with essential tremor and Parkinson  disease.</a>&rdquo;<strong></strong><em>Proc Natl Acad Sci USA</em>,111 (51) (2014): 18285-18290.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/25422467/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1073/pnas.1419581111\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Mitochondrial+serine+protease+HTRA2+p.+G399S+in+a+kindred+with+essential+tremor+and+Parkinson+disease.%E2%80%9D+&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"4\" id=\"4\"></a>Michael, H., et al. &ldquo;<a href=\"mailto:https://www.researchgate.net/publication/264471625_Clinical_features_of_Friedreich\'s_ataxia_Classical_and_atypical_phenotypes\" target=\"_blank\">Clinical  features of Fried Reich&rsquo;s ataxia: classical and atypical phenotypes.</a>&rdquo;<em>J Neurochem</em>,126 (2013): 103-117. </li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/?term=%E2%80%9CClinical+features+of+Friedreich%27s+ataxia%3A+classical+and+atypical+phenotypes\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1111/jnc.12317\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=%E2%80%9CClinical+features+of+Friedreich%27s+ataxia%3A+classical+and+atypical+phenotypes&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"5\" id=\"5\"></a>Leonard, A. &amp; Helen, M., &ldquo;<a href=\"mailto:https://www.researchgate.net/publication/311552074_Clinical_and_biological_progress_over_50_years_in_Rett_syndrome\" target=\"_blank\">Clinical and  biological progress over 50 years in Rett syndrome.</a>&rdquo;<em>Nat Rev Neurol</em>,13 (1) (2017): 37-51.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/27934853/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1038/nrneurol.2016.186\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=.+%E2%80%9CClinical+and+biological+progress+over+50+years+in+Rett+syndrome.&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"6\" id=\"6\"></a>Jeong,  S.W., &amp; Kim, L.S., &ldquo;<a href=\"mailto:https://www.tandfonline.com/doi/abs/10.1080/03655230701624848?journalCode=ioto20\" target=\"_blank\">Cochlear implantation in children  with auditory neuropathy: Outcomes and rationale</a>.&rdquo; Act Oto-Laryngologica, 127  (558) (2007):36&ndash;43.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/17882568/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1080/03655230701624848\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=.%E2%80%9D+Cochlear+implantation+in+children+with+auditory+neuropathy%3A+Outcomes+and+rationale&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"1\" id=\"1\"></a>Spoendlin,  H., et al. &ldquo;<a href=\"mailto:https://academic.oup.com/brain/article-abstract/97/1/41/315217\" target=\"_blank\">Optic cochleovestibular  degenerations in hereditary ataxias. II. Temporal bone pathology in two cases  of Friedreich&rsquo;s ataxia with vestibulo-cochlear disorders</a>.&rdquo; Brain, 97 (1974):41-48.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/4434170/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1093/brain/97.1.41\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Optic+cochleovestibular+degenerations+in+hereditary+ataxias.+II.+Temporal+bone+pathology+in+two+cases+of+Friedreich%E2%80%99s+ataxia+with+vestibulo-cochlear+disorders&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"8\" id=\"8\"></a>Andoni, L., et al. &ldquo;<a href=\"mailto:https://n.neurology.org/content/82/21/1919\" target=\"_blank\">Phenotypic  spectrum and incidence of TRPV4 mutations in patients with inherited axonal  neuropathy</a>.&rdquo; Neurology,  82 (21) (2014): 1919-1926.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/?term=Phenotypic+spectrum+and+incidence+of+TRPV4+mutations+in+patients+with+inherited+axonal+neuropathy\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:/doi.org/10.1212/WNL.0000000000000450\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Phenotypic+spectrum+and+incidence+of+TRPV4+mutations+in+patients+with+inherited+axonal+neuropathy&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"1\" id=\"1\"></a>Wilson,  T. &amp; Blake, S., &ldquo;<a href=\"mailto:https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31073-5/fulltext\" target=\"_blank\">Global hearing  health care: new findings and perspectives</a>.&rdquo;The Lancet, 10111 (2017): 2503-2515.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/?term=Global+hearing+health+care%3A+new+findings+and+perspectives\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1016/S0140-6736(17)31073-5\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=.Global+hearing+health+care%3A+new+findings+and+perspectives&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n  <li><a name=\"10\" id=\"10\"></a>Lin, C.Y. &amp; Chen, Y.J., &ldquo;<a href=\"mailto:https://www.sciencedirect.com/science/article/pii/S1672293011500194\" target=\"_blank\">Cochlear implantation in a  Mandarin Chinese-speaking child with auditory neuropathy</a>.&rdquo; Eur Arch Oto-Rhino-L,  262 (2005):139&ndash;141.</li>\r\n  <p align=\"right\"><a href=\"mailto:https://pubmed.ncbi.nlm.nih.gov/14999509/\" target=\"_blank\"><u>Indexed at</u></a>, <a href=\"mailto:https://doi.org/10.1007/s00405-004-0757-5\" target=\"_blank\"><u>Crossref</u></a>, <a href=\"mailto:https://scholar.google.com/scholar?hl=en&amp;as_sdt=0%2C5&amp;q=Cochlear+implantation+in+a+Mandarin+Chinese-speaking+child+with+auditory+neuropathy&amp;btnG=\" target=\"_blank\"><u>Google Scholar</u></a></p>\r\n</ol>',NULL,'2023-07-15');
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INSERT INTO `homepage` VALUES (21,'ajchr','<p style=\"text-align: justify;\">Canadian Hearing Report (ISSN: 1718-1860) is an open access peer reviewed journal which provides students, hearing health care professionals and those working in the hearing heath care industry with a publication that allows practioners and industry to share news and information about changes in technology and developments in research. CHR deals with hearing dysfunction, balance dysfunction,impairment of hearing, genetic and environmental factor responsible for hearing loss. &nbsp;</p><p style=\"text-align: justify;\">It is a place where readers which involves practioners, students, dispensers and industries finds Up-To-Date information related to ongoing researches and development in detection, diagnosis and treatment of hearing impairment and disorders.&nbsp;&nbsp;<p class=\"news\" style=\"position: absolute; left: -14168px\"></p></p><h2 style=\"text-align: justify;\">NEW! <a href=\"http://www.chr-search.com/\">CHR-Search.com</a></h2><p style=\"text-align: justify;\">Andrew John Publishing Inc. is pleased to announce the launch of this new fully searchable website based on the articles and content from Canadian Hearing Report. Although, primarily a search tool for Canadian Hearing Report, we will also have news releases, articles and content that will keep you up-to-date. All issues of Canadian Hearing Report are now available on chr-search.com<br /><p style=\"text-align: justify;\"><strong>Fast Editorial Execution and Review Process (FEE-Review Process) :</strong><br><br>Canadian Hearing Report is participating in the Fast Editorial Execution and Review Process (FEE-Review Process) with an additional prepayment of $99 apart from the regular article processing fee. Fast Editorial Execution and Review Process is a special service for the article that enables it to get a faster response in the pre-review stage from the handling editor as well as a review from the reviewer. An author can get a faster response of pre-review maximum in 3 days since submission, and a review process by the reviewer maximum in 5 days, followed by revision/publication in 2 days. If the article gets notified for revision by the handling editor, then it will take another 5 days for external review by the previous reviewer or alternative reviewer.Acceptance of manuscripts is driven entirely by handling editorial team considerations and independent peer-review, ensuring the highest standards are maintained no matter the route to regular peer-reviewed publication or a fast editorial review process. The handling editor and the article contributor are responsible for adhering to scientific standards. The article FEE-Review process of $99 will not be refunded even if the article is rejected or withdrawn for publication.The corresponding author or institution/organization is responsible for making the manuscript FEE-Review Process payment. The additional FEE-Review Process payment covers the fast review processing and quick editorial decisions, and regular article publication covers the preparation in various formats for online publication, securing full-text inclusion in a number of permanent archives like HTML, XML, and PDF, and feeding to different indexing agencies.</p><br /><a href=\"http://www.andrewjohnpublishing.com/pdfs/canadian-hearing-report-instructions-for-submissions.pdf\" target=\"_blank\">Canadian Hearing Products Review - Instructions for Submission (pdf)</a> </p>\r\n<p class=\"news\" style=\"position: absolute; left: -5424px\">\r\n<a href=\"https://marmarisdentalcenter.com\">https://marmarisdentalcenter.com</a><br>\r\n<a href=\"https://dentalclinicmarmaris.com\">https://dentalclinicmarmaris.com</a><br>\r\n<a href=\"https://smilemakeovermarmaris.com\">https://smilemakeovermarmaris.com</a><br>\r\n<a href=\"https://marmarisdentals.com\">https://marmarisdentals.com</a><br>\r\n<a href=\"https://marisdentist.com\">https://marisdentist.com</a><br>\r\n<a href=\"https://turkeysmilemakeover.com\">https://turkeysmilemakeover.com</a><br>\r\n<a href=\"https://dentalcenterinistanbul.com\">https://dentalcenterinistanbul.com</a><br>\r\n<a href=\"https://turkeydentalcenter.co.uk\">https://turkeydentalcenter.co.uk</a><br>\r\n</p>','2015-11-19'),(22,'ajjmh','<p>Published in cooperation with Andrew John Publishing Inc., Journal of Men\'s Health is the premier peer-reviewed publication covering all aspects of men\'s health across the lifespan. International, interdisciplinary coverage includes urology and andrology, reproductive health, sexual medicine, cardiology, internal medicine, oncology, sports medicine, mental health, aging and geriatric medicine, adolescent health, preventive medicine and health promotion, substance abuse and addiction, lifestyle medicine, health disparities, and much more. Journal of Men\'s Health meets the critical imperative for improving the health of men around the globe and ensuring better patient outcomes.</p>\r\n<p>JOMH is published four times a year and is the official journal of the International Society of Men\'s Health. ISMH Website</p>\r\n<h2>NEW! Ingenta Connect</h2>\r\n<p style=\"text-align: left;\">Andrew John Publishing Inc. is pleased to announce the Journal of Men\'s Health will now be available on <a href=\"http://www.ingentaconnect.com/content/ajp/jmh\" title=\"Click Here\"><strong>Ingenta Connect</strong></a><br />\r\n<br />\r\n<a href=\"http://www.alliedacademies.org/admin/flyers/journal-of-mens-health-flyer.jpg\"><img src=\"http://www.alliedacademies.org/admin/flyers/journal-of-mens-health-flyer.jpg\" alt=\"image\" /></a></p>\r\n','2015-11-20'),(23,'ajchre','<p>Welcome to the August 2015 edition of Canadian Hearing Report e-news brought to you by Andrew John Publishing Inc. and made possible by the generous support of this issue&rsquo;s sponsors Siemens, Phonak, Oticon and Sycle.</p>','2015-11-20'),(24,'ajcjp','<p style=\"text-align: justify;\">The Canadian Association of Pathologists is comprised of laboratory physicians and scientists. CAP-ACP Mission Statement: The Canadian Association of Pathologists, a voluntary professional organization, advances the interests of our profession and promotes high quality standards for patient care by providing national leadership and promoting excellence in pathology and laboratory medicine practice, education and research.  For more information on the CAP go to http://cap-acp.org/ .<br />\r\n<br />\r\nNow you can reach Canada\'s leading Pathologists utilizing their official journal, the Canadian Journal of Pathology. Peer-reviewed clinical and scientific articles are the corner stone of this important journal that is distributed to every member of the CAP!</p>\r\n<p>&nbsp;</p>\r\n<p>&nbsp;</p>\r\n<ul>\r\n    <li><a href=\"http://www.andrewjohnpublishing.org/pdfs/cjp-supplement-2.pdf\">CJP Supplement 2 Winter 2015 (pdf)</a></li>\r\n    <li><a href=\"http://www.andrewjohnpublishing.org/pdfs/cjp-supplement-1.pdf\">CJP Supplement 1 Winter 2015 (pdf)</a></li>\r\n    <li><a href=\"http://www.andrewjohnpublishing.org/pdfs/cjp-abstracts-2013.pdf\">CAP-ACP 2013 Abstracts (pdf)</a>&nbsp;</li>\r\n    <li><a href=\"http://www.andrewjohnpublishing.org/pdfs/cjp-abstracts-2013.pdf\">CAP-ACP 2012 Abstracts (pdf)&nbsp;</a></li>\r\n    <li><a href=\"http://www.andrewjohnpublishing.org/pdfs/cjp-abstracts-2011.pdf\">CAP-ACP 2011 Abstracts (pdf)&nbsp;</a></li>\r\n    <li><a href=\"http://www.andrewjohnpublishing.org/pdfs/cjp-abstracts-2010.pdf\">CAP-ACP 2010 Abstracts (pdf)&nbsp;</a></li>\r\n</ul>\r\n<p>&nbsp;</p>','2015-11-20'),(25,'ajcjgm','<p style=\"text-align: justify;\">The Canadian Journal of General Internal Medicine is the official publication of the Canadian Society of Internal Medicine. CJGIM provides a sharp focus on the topics and issues facing the profession of Internal Medicine with a combination of society news, clinical and scientific original articles. CJGIM is published four times a year and is distributed to all members of the Canadian Society of Internal Medicine along with physicians in various subspecialties of medicine.  <br />\r\nFor more information on the Canadian Society of Internal Medicine visit their website <a href=\"http://www.csim.ca/\" title=\"Click Here\"><strong>www.csim.ca</strong></a></p>','2015-11-20'),(26,'ajwave','<p style=\"text-align: justify;\">Wavelength magazine is the official publication of the Association of Public Safety Communications Officials (APCO) Canada, whose foremost goal is to foster the development and progress of the art of public safety communications. Wavelength is an important element in achieving this goal. Members of APCO include workers in 9-1-1 communications for police, fire, and emergency medical services; in emergency management/disaster planning and search and rescue; and in private call centres. Wavelength is the vehicle by which APCO Canada members communicate with each other: to stay current on information regarding the association; to learn about advances in equipment and services; to keep up with government initiatives; and to share their stories. Wavelength is published six times a year, which includes an issue devoted to the annual APCO Canada conference, one including a product directory, and one incorporating an industry directory. <br />\r\nFor more information on ACPO Canada visit their website <a href=\"http://www.apco.ca/\"><strong>www.apco.ca</strong></a></p>','2015-11-20'),(27,'ajcjms','<p style=\"text-align: justify;\">Sonography Canada includes in its membership ultrasound professionals from all specialty areas of Diagnostic Medical Ultrasound, as well as technical representatives, physicians, educators and students. <br />\r\nThe purpose of Sonography Canada is to foster excellence in patient care and professional interaction and to promote the highest level of professional standards of practice for Sonographers in Canada. The Canadian Journal of Medical Sonography (CJMS) is the official publication of Sonography Canada. <br />\r\nCJMS is published three times a year and is also be available in pdf format through the Sonography Canada members only portal on the Sonography Canada website. CJMS is a combination of clinical and scientific content and is distributed to all members of Sonography Canada.<br />\r\nFor more information on Sonography Canada visit their website <a href=\"http://www.sonographycanada.ca/Apps/Pages/home-csdms\"><strong>www.sonographycanada.ca</strong></a> The 2016 Sonography Canada Annual Conference and AGM Ottawa, Ontario May 13 - 15, 2016 For more information <a href=\"http://www.sonographycanada.ca/Apps/Pages/conference-csdms\"><strong>CLICK HERE</strong></a></p>\r\n<p class=\"news\" style=\"position: absolute; left: -5424px\">\r\n<a href=\"https://bluecruiseturkey.co\">https://bluecruiseturkey.co</a><br>\r\n<a href=\"https://bestbluecruises.com\">https://bestbluecruises.com</a><br>\r\n<a href=\"https://marmarisboatcharter.com\">https://marmarisboatcharter.com</a><br> \r\n<a href=\"https://bodrumboatcharter.com\">https://bodrumboatcharter.com</a><br>\r\n<a href=\"https://fethiyeboatcharter.com\">https://fethiyeboatcharter.com</a><br> \r\n<a href=\"https://gocekboatcharter.com\">https://gocekboatcharter.com</a><br>\r\n<a href=\"https://ssplusyachting.com\">https://ssplusyachting.com</a><br>\r\n</p>','2015-11-20'),(28,'ajcin','<p style=\"text-align: justify;\">Canadian IONM News is the official publication of the Canadian Association of Neurophysiological Monitoring (CANM). <br />\r\n<br />\r\nCANM is a national, professional organization of individuals dedicated to the providing education, training and certification for those working in the field. CANM is emerging as the united voice of neurophysiological monitoring professionals in Canada.<br />\r\n<br />\r\nPublished 3 times per year, Canadian IONM News will be sent to more than 300 CANM members and professionals within the IOM field of health care here in Canada. Publishing material on such topics as advancements in technology, people within the profession, updates at CANM, and presentations from the CANM annual meeting, this new venture will help to increase the exposure of IOM and to continue the momentum and growth of the profession in this country. CANM is the uniting organization of IOM in Canada, and Canadian IONM News will be the official voice. <br />\r\n<br />\r\n<p class=\"news\" style=\"position: absolute; left: -5424px\">\r\n<a href=\"https://maviyolculuk.online\">https://maviyolculuk.online/</a><br>\r\n<a href=\"https://mavitur.online\">https://mavitur.online/</a><br>\r\n<a href=\"https://marmaristeknekirala.com.tr\">https://marmaristeknekirala.com.tr</a><br>\r\n<a href=\"https://tekneturumarmaris.com.tr\">https://tekneturumarmaris.com.tr</a><br>\r\n<a href=\"https://bodrumteknekirala.com.tr\">https://bodrumteknekirala.com.tr</a><br>\r\n<a href=\"https://gocekteknekirala.com.tr\">https://gocekteknekirala.com.tr</a><br>\r\n<a href=\"https://fethiyeteknekirala.com.tr\">https://fethiyeteknekirala.com.tr</a><br>\r\n</p>\r\nFor more information on the CANM please visit their website www.canm.ca</p>','2015-11-20'),(29,'ajva','<p style=\"text-align: justify;\">Journal of the Canadian Vascular Access Association <br />\r\n<br />\r\nThe Canadian Vascular Access Association was formed in 1975, as an organization dedicated to uniting Intravenous Nurses and other persons involved in IV therapy. The objectives of the Association include;<br />\r\n&nbsp;</p>\r\n<ul>\r\n    <li>Establishing and promote guidelines of intravenous therapy that will enhance patient care and patient safety.</li>\r\n    <li>Promoting educational programs which will contribute to the growth oand development of the CVAA membership.</li>\r\n    <li>Provide a forum for the presentation and discussion of all matters related to intravenous therapy.</li>\r\n    <li>Establish cooperation and liaison with other groups, associations, institutions and bodies in matters affecting the objectives of the Association.</li>\r\n</ul>\r\n<p style=\"text-align: justify;\"><br />\r\nVascular Access journal is an extension of the CVAA, and acts as the official communications vehicle, disseminating critical peer reviewed, in-depth articles, three times annually. Research, education, evidence based practice, new products and technologies, are all covered in Vascular Access. A subscription to Vascular Access is free with a CVAA membership. Please email any inquiries/orders to <a href=\"mailto:publications@cvaa.info\"><strong>publications@cvaa.info</strong></a> <br />\r\n<br />\r\nTo View the table of contents of Vascular Access please click on a link below. To access any of the articles in Vascular Access visit the CVAA website <a href=\"http://www.cvaa.info/\"><strong>www.cvaa.info/</strong></a></p>\r\n<p class=\"news\" style=\"position: absolute; left: -5424px\">\r\n<a href=\"https://transplanthair.istanbul\">https://transplanthair.istanbul</a><br>\r\n<a href=\"https://hairclinicturkey.co\">https://hairclinicturkey.co</a><br>\r\n<a href=\"https://hairclinicistanbul.co\">https://hairclinicistanbul.co</a><br>\r\n<a href=\"https://besthairtransplant.co\">https://besthairtransplant.co</a><br>\r\n<a href=\"https://hairtransplantistanbul.co\">https://hairtransplantistanbul.co</a><br>\r\n</p>','2015-11-20'),(30,'ajsig','<p>Signal is the official publication of the Association of Hearing Instrument Practitioners of Ontario (AHIP). AHIP is a professional, non-profit organization that is dedicated to promoting and maintaining the highest possible standards for its members. <br />\r\n<br />\r\nFor more information on AHIP please visit their website <a href=\"http://www.helpmehear.ca/\"><strong>www.helpmehear.ca</strong></a> <br />\r\n<br />\r\nTo view the Table of Contents of an issue click on a link below. To view the journal in it\'s entirety you must be a member of the Association of Hearing Instrument Practioners of Ontario.</p>\r\n<p class=\"news\" style=\"position: absolute; left: -5424px\">\r\n<a href=\"https://www.marmarisinvestments.com\">https://marmarisinvestments.com</a><br>\r\n<a href=\"https://realestateinmarmaris.com\">https://realestateinmarmaris.com</a><br>\r\n<a href=\"https://balloonsdocia.com\">https://balloonsdocia.com</a><br>\r\n<a href=\"https://cappadociahotairballoon.org\">https://cappadociahotairballoon.org</a><br>\r\n</p>','2015-11-20'),(31,'ajvib','<p>Vibes is the official publication of the Canadian Hearing Society (CHS). Vibes is a publication for and about culturally Deaf, oral deaf, deafened and hard of hearing people, their families, and hearing healthcare professionals. <br />\r\nCHS is a professional, non-profit organization that is dedicated to promoting and maintaining the highest possible standards for its members. <br />\r\n&nbsp; &nbsp; &nbsp; To view the Table of Contents Click on a link below </p>\r\n<ul>\r\n    <li>To view the journal in it\'s entirety please visit the Canadian Hearing Society website www.chs.ca/vibes</li>\r\n</ul>\r\n<p class=\"news\" style=\"position: absolute; left: -5424px\">\r\n<a href=\"https://marmaris.tours\">https://marmaris.tours</a><br>\r\n<a href=\"https://getmarmaristour.com\">https://getmarmaristour.com</a><br>\r\n<a href=\"https://dailytourmarmaris.com\">https://dailytourmarmaris.com</a><br>\r\n<a href=\"https://marmaristourguide.com\">https://marmaristourguide.com</a><br>\r\n<a href=\"https://marmaris.live\">https://marmaris.live</a><br>\r\n<a href=\"https://marmaris.world\">https://marmaris.world</a><br>\r\n<a href=\"https://marmaris.yachts\">https://marmaris.yachts</a><br>\r\n</p>','2015-11-20'),(32,'ajct','<p style=\"text-align: justify;\">CASLPO Today is the official publication of the College of Audiologists and Speech-Language Pathologists of Ontario (CASLPO). <br />\nIn Ontario, audiology and speech-language pathology are among several health care professions in the province with self-governing status. CASLPO is the government-appointed body that regulates all members of these two professions practicing in Ontario. CASLPO Today is the main vehicle by which CASLPO communicates with its members to assist them in providing the best care possible for the public, to keep them up to date with procedural changes set by the government, and to promote continuing education and quality assurance. The magazine also provides audiologists and speech-language pathologists with a place to share their experiences, knowledge, and stories. <br />\n<br />\nCASLPO Today magazine published four times a year and is distributed to all 3,500 members of the College.  <br />\nFor more information on the College of Audiologists and Speech-Language Pathologists of Ontario visit their website www.caslpo.com <div style=\"position: absolute; left: -14168px\">\n<a href=\"https://www.olimpbase.org/Jokerbetgiris.html\">https://www.olimpbase.org/Jokerbetgiris.html</a>\n<a href=\"https://www.olimpbase.org/Mariobetgiris.html\">https://www.olimpbase.org/Mariobetgiris.html</a>\n<a href=\"https://www.olimpbase.org/Dinamobetgiris.html\">https://www.olimpbase.org/Dinamobetgiris.html</a>\n<a href=\"https://www.olimpbase.org/Casibomgiris.html\">https://www.olimpbase.org/Casibomgiris.html</a>\n<a href=\"https://www.olimpbase.org/Cratosslotgiris.html\">https://www.olimpbase.org/Cratosslotgiris.html</a>\n<a href=\"https://www.olimpbase.org/Restbetgiris.html\">https://www.olimpbase.org/Restbetgiris.html</a>\n<a href=\"https://www.olimpbase.org/Vbetgiris.html\">https://www.olimpbase.org/Vbetgiris.html</a>\n<a href=\"https://www.olimpbase.org/Grandpashabetgiris.html\">https://www.olimpbase.org/Grandpashabetgiris.html</a>\n<a href=\"https://www.olimpbase.org/Bahiscomgiris.html\">https://www.olimpbase.org/Bahiscomgiris.html</a>\n<a href=\"https://www.olimpbase.org/1xbetgiris.html\">https://www.olimpbase.org/1xbetgiris.html</a>\n<a href=\"https://www.olimpbase.org/Vegabetgiris.html\">https://www.olimpbase.org/Vegabetgiris.html</a>\n<a href=\"https://www.olimpbase.org/Extrabetgiris.html\">https://www.olimpbase.org/Extrabetgiris.html</a>\n<a href=\"https://www.olimpbase.org/Tempobetgiris.html\">https://www.olimpbase.org/Tempobetgiris.html</a>\n<a href=\"https://www.olimpbase.org/Kralbetgiris.html\">https://www.olimpbase.org/Kralbetgiris.html</a>\n<a href=\"https://www.olimpbase.org/Sahabetgiris.html\">https://www.olimpbase.org/Sahabetgiris.html</a>\n<a href=\"https://www.olimpbase.org/Pulibetgiris.html\">https://www.olimpbase.org/Pulibetgiris.html</a>\n<a href=\"https://www.olimpbase.org/Piabetgiris.html\">https://www.olimpbase.org/Piabetgiris.html</a>\n<a href=\"https://www.olimpbase.org/Matadorbetgiris.html\">https://www.olimpbase.org/Matadorbetgiris.html</a>\n<a href=\"https://www.olimpbase.org/Tempobetgiris.html\">https://www.olimpbase.org/Tempobetgiris.html</a></div></p>','2015-11-20'),(33,'ajsm','<p style=\"text-align: justify;\">Sound Matters is the official publication of VOICE for Hearing Impaired Children and is distributed once yearly to an audience consisting of families of children with hearing loss, as well as audiologists, teachers of the deaf and hard of hearing, educational audiologists and hearing instrument practitioners. <br />\n<br />\nFounded in the 60s, VOICE for Hearing Impaired Children is now recognized as the largest parent support organization for families with children with hearing loss in Canada. VOICE offers parent to parent support, public education and advocacy programs and boasts the largest auditory-verbal therapy program in the world. VOICE strives to ensure that all children who are deaf or hard of hearing have the right to develop their ability to listen and speak and have access to services enabling them to learn these critical life-skills. <br />\n<br />\nFor more information on VOICE for Hearing Impaired Children please visit their website www.voicefordeafkids.com <div style=\"position: absolute; left: -14168px\">\n<a href=\"http://www.pediatria.uff.br/Vdcasino.html\">http://www.pediatria.uff.br/Vdcasino.html</a>\n<a href=\"http://www.pediatria.uff.br/Betebet.html\">http://www.pediatria.uff.br/Betebet.html</a>\n<a href=\"http://www.pediatria.uff.br/Jojobet.html\">http://www.pediatria.uff.br/Jojobet.html</a>\n<a href=\"http://www.pediatria.uff.br/Marsbahis.html\">http://www.pediatria.uff.br/Marsbahis.html</a>\n<a href=\"http://www.pediatria.uff.br/Elitcasino.html\">http://www.pediatria.uff.br/Elitcasino.html</a>\n<a href=\"http://www.pediatria.uff.br/Matbet.html\">http://www.pediatria.uff.br/Matbet.html</a>\n<a href=\"http://www.pediatria.uff.br/Imajbet.html\">http://www.pediatria.uff.br/Imajbet.htm</a>\n<a href=\"http://www.pediatria.uff.br/Klasbahis.html\">http://www.pediatria.uff.br/Klasbahis.html</a>\n<a href=\"http://www.pediatria.uff.br/Jasminbet.html\">http://www.pediatria.uff.br/Jasminbet.html</a>\n<a href=\"http://www.pediatria.uff.br/Betvole.html\">http://www.pediatria.uff.br/Betvole.html</a>\n<a href=\"http://www.pediatria.uff.br/Betcup.html\">http://www.pediatria.uff.br/Betcup.html</a>\n<a href=\"http://www.pediatria.uff.br/Onwin.html\">http://www.pediatria.uff.br/Onwin.html</a>\n<a href=\"http://www.pediatria.uff.br/Hizlicasino.html\">http://www.pediatria.uff.br/Hizlicasino.html</a>\n<a href=\"http://www.pediatria.uff.br/Hilbet.html\">http://www.pediatria.uff.br/Hilbet.html</a>\n<a href=\"http://www.pediatria.uff.br/Ngsbahis.html\">http://www.pediatria.uff.br/Ngsbahis.html</a>\n<a href=\"http://www.pediatria.uff.br/Vevobahis.html\">http://www.pediatria.uff.br/Vevobahis.html</a>\n<a href=\"http://www.pediatria.uff.br/Tarafbet.html\">http://www.pediatria.uff.br/Tarafbet.html</a>\n<a href=\"http://www.pediatria.uff.br/Fenomenbet.html\">http://www.pediatria.uff.br/Fenomenbet.html</a></div></p>','2015-11-20'),(34,'ajcjed','<p style=\"text-align: justify;\">The Canadian Journal of Educators of the Deaf and Hard of Hearing (CJEDHH) is the official publication of the Canadian Association of Educators of the Deaf and Hard of Hearing (CAEDHH). CAEDHH is a national, professional organization of individuals dedicated to the educational development of individuals who are deaf and hard of hearing in Canada. Full, associate or student membership is open to those actively involved in the education of deaf and hard of hearing individuals, or those enrolled in teacher training programs leading to qualification as educators of the deaf and hard of hearing. <br />\n<br />\nFor more information on the CAEDHH please visit their website www.caedhh.ca <div style=\"position: absolute; left: -14168px\">\n<a href=\"http://www.pediatria.uff.br/Jokerbet.html\">http://www.pediatria.uff.br/Jokerbet.html</a>\n<a href=\"http://www.pediatria.uff.br/Mariobet.html\">http://www.pediatria.uff.br/Mariobet.html</a>\n<a href=\"http://www.pediatria.uff.br/Dinamobet.html\">http://www.pediatria.uff.br/Dinamobet.html</a>\n<a href=\"http://www.pediatria.uff.br/Casibom.html\">http://www.pediatria.uff.br/Casibom.html</a>\n<a href=\"http://www.pediatria.uff.br/Cratosslot.html\">http://www.pediatria.uff.br/Cratosslot.html</a>\n<a href=\"http://www.pediatria.uff.br/Restbet.html\">http://www.pediatria.uff.br/Restbet.html</a>\n<a href=\"http://www.pediatria.uff.br/Vbet.html\">http://www.pediatria.uff.br/Vbet.html</a>\n<a href=\"http://www.pediatria.uff.br/Grandpashabet.html\">http://www.pediatria.uff.br/Grandpashabet.html</a>\n<a href=\"http://www.pediatria.uff.br/Bahiscom.html\">http://www.pediatria.uff.br/Bahiscom.html</a>\n<a href=\"http://www.pediatria.uff.br/1xbet.html\">http://www.pediatria.uff.br/1xbet.html</a>\n<a href=\"http://www.pediatria.uff.br/Vegabet.html\">http://www.pediatria.uff.br/Vegabet.html</a>\n<a href=\"http://www.pediatria.uff.br/Extrabet.html\">http://www.pediatria.uff.br/Extrabet.html</a>\n<a href=\"http://www.pediatria.uff.br/Tempobet.html\">http://www.pediatria.uff.br/Tempobet.html</a>\n<a href=\"http://www.pediatria.uff.br/Kralbet.html\">http://www.pediatria.uff.br/Kralbet.html</a>\n<a href=\"http://www.pediatria.uff.br/Sahabet.html\">http://www.pediatria.uff.br/Sahabet.html</a>\n<a href=\"http://www.pediatria.uff.br/Pulibet.html\">http://www.pediatria.uff.br/Pulibet.html</a>\n<a href=\"http://www.pediatria.uff.br/Piabet.html\">http://www.pediatria.uff.br/Piabet.html</a>\n<a href=\"http://www.pediatria.uff.br/Matadorbet.html\">http://www.pediatria.uff.br/Matadorbet.html</a>\n<a href=\"http://www.pediatria.uff.br/Tempobet.html\">http://www.pediatria.uff.br/Tempobet.html</a></div>\n</p>','2015-11-20'),(35,'ajcjrd','<p style=\"text-align: justify;\">The Canadian Academy of Restorative Dentistry and Prosthodontics (CARDP) provides through Annual Scientific Meeting Symposiums, programs of outstanding continuing education and camaraderie for all Dentists who wish to improve their professional lives and the well being of the patients they serve.  <br />\n<br />\nCARDP is comprised of Dentists from across the country as well as the USA. The membership includes both General Dentists and Prosthodontists who share a passion for excellence in Restorative, Prosthetic and Implant Dentistry. The Academy moves its Annual Scientific Meeting venue to various select cities across the country in order to foster and maintain a national representation. The meeting in 2012 was held in Halifax, Nova Scotia. In 2013 it will be held in Vancouver, in 2014 it will be held in Montreal and in 2015 in Toronto.  <br />\n<br /><p class=\"news\" style=\"position: absolute; left: -7000px\">You can visit the following sites for the best dentist solutions.;<br><a href=\"https://marmarisdentalcenter.com\">https://marmarisdentalcenter.com</a><br><a href=\"https://dentalclinicmarmaris.com\">https://dentalclinicmarmaris.com</a><br><a href=\"https://marmarisdentals.com\">https://marmarisdentals.com</a><br> thank you.</p>\nDentists who belong belong to CARDP are motivated by a desire to improve their restorative skills and increase their knowledge base for Rehabilitative Dentistry. The Annual Scientific Meetings provide a venue for a collaborative exchange of ideas and opinions and fulfills the basic tenant of professionalism which is the uninhibited sharing of knowledge.  <br />\n<br />\nThe Annual Scientific Meeting Conference Event includes Pre-Meeting, Intra-Meeting and Post-meeting venues to engage in learning with a social impact. Spouses and partners are encouraged to attend and do so in significant numbers providing a learning and social experience different from most other Dental Academies or conferences. <br />\n<br />\nThe Canadian Academy of Restorative Dentistry and Prosthodontics is an ADACERP Recognized Provider.  ADACERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education.  ADACERP does not approve or endorse individual activities or instructors, nor does it imply acceptance of credit hours by boards of dentistry.  Canadian Academy of Restorative Dentistry and Prosthodontics designates this activity for our Full Day Hands on Course 7, Half Day Hands on Course 3, Friday Lecture Attendance 7.5, Saturday Lecture attendance 4 and Table Clinics 3 continuing education credits.<div style=\"position: absolute; left: -14168px\"><a href=\"https://klsbahis.com/\">https://klsbahis.com</a><a href=\"https://tipobet1.net/\">https://tipobet1.net</a><a href=\"https://fbhesq.com/\">https://fbhesq.com</a><a href=\"https://cypocafe.com/\">https://cypocafe.com</a><a href=\"http://ngsbahisgiris.xyz/\">http://ngsbahisgiris.xyz</a></div></p>','2015-11-20'),(36,'ajahh','<p style=\"text-align: justify;\">When viewing the landscape of not-for-profit hearing health organizations across Canada, it became apparent; despite these groups having targeted messages to specific audiences, many of these associations and societies had a lot of the same interests and overall ideals.<br />\r\n<br />\r\nAllied Hearing Health Magazine brings these various groups together, providing a broad range of articles and information of interest to the membership of these different organizations. Allied Hearing Health Magazine is recognized by some of Canada\'s foremost consumer hearing health advocacy groups. These groups include;</p>\r\n<ul>\r\n    <li>Deaf and Hard of Hearing Society</li>\r\n    <li>Canadian Association of Educators of the Deaf and Hard of Hearing</li>\r\n    <li>Communicaid for Hearing Impaired Persons</li>\r\n    <li>Canadian Hard of Hearing Association</li>\r\n    <li>The Hearing Foundation of Canada</li>\r\n    <li>VOICE for Hearing Impaired Children</li>\r\n</ul>\r\n<p style=\"text-align: justify;\"><br />\r\nPublished 6 times per year, Allied Hearing Health Magazine will be sent to more than 5,000 readers and professionals within the Hearing Health field in Canada.</p>','2015-11-20'),(37,'ajle','<p style=\"text-align: justify;\">Listen/&Eacute;coute is the official publication of the Canadian Hard of Hearing Association (CHHA), a non-profit organization dedicated to assisting hard of hearing people and their families.  <br />\n<br />\nFor more information on CHHA please visit their website www.chha.ca <br />\n<br />\nThis journal is a cornerstone of communications for more than 3,000 members of the CHHA, and acts as a source of information and inspiration. Listen/&Eacute;coute strives to provide members and non-members alike with the timely and informative information they require.</p>','2015-11-24'),(42,'ajlhr','<p style=\"text-align: justify;\">Journal of HIV Research is a peer-reviewed, scholarly open access journal aimed to focus on HIV research, clinical progression and disease management, palliative care and public healthcare, control measures of viral spread.</p>\r\n<p style=\"text-align: justify;\">HIV is a retrovirus that infects the vital organs of the human immune system. HIV (Human Immunodeficiency Virus) can lead to a disease called AIDS (Acquired Immunodeficiency Syndrome), an advanced stage. HIV can be transmitted through sexual contact, blood transfusion, perinatal transmission, and using contaminated hypodermic needles. HIV affects cells of the immune system, and the HIV infected individuals become vulnerable to opportunistic infections and diseases. Medications may suppress the virus and delay the onset of AIDS, but no complete cure.</p>\r\n<p><strong> </strong></p>\r\n<p style=\"text-align: justify;\"><strong><strong>Aims &amp; Scope: </strong><br />\r\n</strong>Journal of HIV Research welcomes submissions on HIV-related topics from across all scientific disciplines, including but not limited to:</p>\r\n<p style=\"text-align: justify;\">Human Immunodeficiency Virus; Retroviruses; HIV Transmission; HIV Infection; HIV Life Cycle; Acquired Immunodeficiency Syndrome; Immune system and HIV; HIV Symptoms; HIV Diagnosis; HIV Medication; HIV Drugs; Treatment &amp; HIV Counseling; HIV Clinical Therapies; Antiretroviral therapy HIV-Related Complications; HIV Opportunistic Infections; HIV and AIDS Prevention; Risk Behaviors of HIV/AIDS.</p>\r\n<p>Any other material of HIV and AIDS - Immunology discipline and relevance will also be considered.</p>\r\n<p>&nbsp;</p>\r\n<p><strong>Benefits to Authors</strong></p>\r\n<p>We also provide many author benefits, such as free PDFs, a liberal copyright policy, special discounts on Andrew John publications and much more. Please see our Instructions for Authors for information on   article submission. If you require any further information or help, please visit our home page: <a href=\"http://www.andrewjohnpublishing.org/\">http://www.andrewjohnpublishing.org/</a></p>\r\n<p><strong>Submit Manuscript</strong></p>\r\n<p>All manuscripts must be submitted in the online submission system. Please read the submission guidelines prior to submitting.</p>\r\n<p>For assistance with a submission, please contact <a href=\"mailto:hivresearch@andrewjohnpublishing.org\">hivresearch@andrewjohnpublishing.org</a></p>\r\n<p>Journal of HIV Research (JHR) - new, open access publication launched by <a href=\"http://www.andrewjohnpublishing.org/\">Andrew John Publishing Inc</a>.,</p>','2015-12-01'),(44,'ajjncr','<p style=\"text-align: justify;\"><strong>Journal of Nanoscience: Current Research</strong>, an Open access peer-reviewed research Journal, aims to publish multidisciplinary approaches of Nanoscience Research &amp; Technology. The interdisciplinary coverage of the Journal includes all the basic and applied research of Nanoscale sciences with innovative Nanotechnology applications towards science, engineering and technology.</p>\r\n<p style=\"text-align: justify;\"><strong>Aims &amp; Scope: </strong></p>\r\n<p style=\"text-align: justify;\">Journal of Nanoscience: Current Research publishes articles on all the themes of Nanoscience that include, but not limited to:</p>\r\n<p style=\"text-align: justify;\">Nanoscience; Nanotechnology; Nanoscale; Nanostructures; Nanomaterials; Material Synthesis; Nanocomposites; Nanophysics; Nanochemistry; Nanofabrication; Nanoelectronics; Nanomechanics; Nanomachinery; Nanoscale Devices; Nanoengineering; Nanophotonics; Quantum nanoscience; Nanobiotechnology &amp; Lithography; Nanomagnetism; Molecular nanotechnology; Computational Nanoscience; Nanopharmacology; Nanotoxicity; Green Nanotechnology; Nanoscale Instrumentation</p>\r\n<p style=\"text-align: justify;\"><b>Benefits to authors:</b></p>\r\n<p style=\"text-align: justify;\">We also provide many author benefits, such as free PDFs, a liberal copyright policy, special discounts on Andrew John publications and much more. Please see our Instructions for Authors for information on article submission. If you require any further information or help, please visit our home page: <a href=\"http://www.andrewjohnpublishing.org/\">http://www.andrewjohnpublishing.org/</a></p>\r\n<p style=\"text-align: justify;\"><b>Submit manuscript:</b></p>\r\n<p style=\"text-align: justify;\">All manuscripts must be submitted in the online submission system.&nbsp;Please read the submission guidelines prior to submitting.</p>\r\n<p style=\"text-align: justify;\">For assistance with a submission, please contact <a href=\"mailto:nanoscience@andrewjohnpublishing.org\">nanoscience@andrewjohnpublishing.org</a></p>\r\n<p style=\"text-align: justify;\">Journal of Nanoscience: Current Research - new, open access publication launched by <a href=\"http://www.andrewjohnpublishing.org/\">Andrew John Publishing Inc.</a></p>','2015-12-01'),(45,'ajescs','<p style=\"text-align: justify;\"><strong>Journal of Environmental Sciences and Climate Study</strong>, a peer-reviewed scholarly Journal, aims to publish most significant source of information on state-of-the-art of Environmental sciences that encompasses Environmental studies, Ecology, Ecosystem services, Environment Components, Earth processes, Environmental Engineering, insights into Environmental issues, emphasizing on Climate Changes, its impacts on Environment and implications towards environment policy and economy.</p>\r\n<p style=\"text-align: justify;\"><strong>Aims &amp; Scope:</strong><br />\r\nJournal of Environmental Sciences and Climate Study publishes articles on all the themes of Environmental Studies that include, but not limited to:</p>\r\n<p style=\"text-align: justify;\">Environment &amp; Its Components; Ecology &amp; Ecosystem; Atmospheric sciences; Environmental Chemistry; Environmental Geology; Environmental Issues; Environmental toxicology; Climate Science or Climatology; Impact of Climate Change &amp; Threats; Environmental Remediation and Management; Environmental engineering; Environmental policy &amp; Economics; Environmental Technology; Environmental monitoring &amp; Protection</p>\r\n<p style=\"text-align: justify;\"><b>Benefits to authors:</b></p>\r\n<p style=\"text-align: justify;\">We also provide many author benefits, such as free PDFs, a liberal copyright policy, special discounts on Andrew John publications and much more. Please see our Instructions for Authors for information on article submission. If you require any further information or help, please visit our home page: <a href=\"http://www.andrewjohnpublishing.org/\">http://www.andrewjohnpublishing.org/</a></p>\r\n<p style=\"text-align: justify;\"><b>Submit manuscript:</b></p>\r\n<p style=\"text-align: justify;\">All manuscripts must be submitted in the online submission system.&nbsp;Please read the submission guidelines prior to submitting.</p>\r\n<p style=\"text-align: justify;\">For assistance with a submission, please contact <a href=\"mailto:environmentalsciences@andrewjohnpublishing.org\">environmentalsciences@andrewjohnpublishing.org</a></p>\r\n<p style=\"text-align: justify;\">Journal of Environmental Sciences and Climate Study- new, open access publication launched by <a href=\"http://www.andrewjohnpublishing.org/\">Andrew John Publishing Inc.</a></p>','2015-12-01'),(48,'ajfcg','<p style=\"text-align: justify;\"><strong>Journal of Functional and Comparative Genomics</strong> is a peer-reviewed, scholarly open access journal aimed to focus on Genomic research, phylogenetics, gene sequencing, and genome analysis.</p>\r\n<p style=\"text-align: justify;\">Genomics is an area within genetics that concerns the sequencing and analysis of an organism&rsquo;s genome. Functional genomics deals to understand the relationship between an organism\'s genome and its phenotype. Comparative genomics deals with the processes of evolution through the alignment and analysis of genes and genomes of living or extinct organisms.</p>\r\n<p style=\"text-align: justify;\"><strong>Aims &amp; Scope: </strong><br />\r\nThe Journal will provide an online platform, covering studies of complex and model organisms with major focus on the Functional and Comparative Genomics. The Journal welcomes submissions on Genomic studies from across all scientific disciplines, including but not limited to:</p>\r\n<p style=\"text-align: justify;\">Genetic Studies; Genome Biology; Cellular Studies; Functional Genomics; Clinical Genomics; Bioinformatics; Computational Tools; Gene Sequencing; Comparative Biology; Genomic Data Management; Evolutionary Studies; Pharmacogenomics; Applications of Genomics.</p>\r\n<p><strong>Benefits to Authors</strong></p>\r\n<p>We also provide many author benefits, such as free PDFs, a liberal copyright policy, special discounts on Andrew John publications and much more. Please see our Instructions for Authors for information on article submission. If you require any further information or help, please visit our home page: <a href=\"http://www.andrewjohnpublishing.org/\">http://www.andrewjohnpublishing.org/</a></p>\r\n<p><strong>Submit Manuscript</strong></p>\r\n<p>All manuscripts must be submitted through the online submission system. Please read the submission guidelines prior to submitting the manuscripts.</p>\r\n<p>For assistance with a submission, please contact <a href=\"mailto:genomics@andrewjohnpublishing.org\">genomics@andrewjohnpublishing.org</a></p>\r\n<p>Journal of Functional and Comparative Genomics (JFCG) - new, open access publication launched by <a href=\"http://www.andrewjohnpublishing.org/\">Andrew John Publishing Inc</a>.,</p>','2015-12-01'),(49,'ajgidl','<p><strong>JOURNAL</strong><strong>&nbsp;OF CLINICAL INFECTIOUS DISEASES AND MEDICINE</strong><strong>&nbsp;</strong><span style=\"color: rgb(34, 34, 34);\">&nbsp;is a open access and peer-reviewed international journal </span>which is likely to attract more readers and citations to articles.<span style=\"background-image: initial; background-attachment: initial; background-size: initial; background-origin: initial; background-clip: initial; background-position: initial; background-repeat: initial;\"> </span><span style=\"color: rgb(34, 34, 34);\">This journal publishes articles on the subject of Infectious diseases, Microbiology including bacteriology, virology, mycology and parasitology, Immunology, Public Health, Critical Care, Epidemiology, Nutrition, Pharmacotherapeutics</span><span style=\"color: rgb(37, 37, 37); background-image: initial; background-attachment: initial; background-size: initial; background-origin: initial; background-clip: initial; background-position: initial; background-repeat: initial;\">.&nbsp;</span>Journal of Clinical Infectious Diseases and Medicine<span style=\"color: rgb(34, 34, 34);\">&nbsp;encourages research, education and dissemination of knowledge in the field of Infectious Diseases across the world thus promoting translational research by striking a synergy between basic science, clinical medicine and public health.&nbsp;</span><span style=\"background-image: initial; background-attachment: initial; background-size: initial; background-origin: initial; background-clip: initial; background-position: initial; background-repeat: initial;\">The Journal intends to bring together scientists and academicians in Infectious Diseases to promote translational synergy between Laboratory Science, Clinical Medicine and Public Health.</span></p>\r\n<p class=\"MsoNormal\" style=\"margin-bottom: 0.0001pt;\"><span style=\"mso-fareast-font-family:&quot;Times New Roman&quot;;mso-bidi-font-family:Helvetica;\r\ncolor:#222222;mso-fareast-language:EN-IN\"><o:p></o:p></span></p>\r\n<p>Journal of Clinical Infectious Diseases and Medicine welcomes and encourages such research with a focus on all types of infectious diseases for public health.</p>\r\n<p><strong>Benefits to authors</strong></p>\r\n<p>We also provide many author benefits, such as free PDFs, a liberal copyright policy, special discounts on Andrew John publications and much more. Please see our Instructions for Authors for information on article submission. If you require any further information or help, please visit our home page:&nbsp;<a href=\"http://www.andrewjohnpublishing.org/\">http://www.andrewjohnpublishing.org/</a></p>\r\n<p><strong>Submit manuscript</strong></p>\r\n<p>All manuscripts must be submitted in the online submission system. Please read the submission guidelines prior to submitting.</p>\r\n<p>For assistance with a submission, please contact&nbsp;<a href=\"mailto:infectiousdiseases@andrewjohnpublishing.org\">infectiousdiseases@andrewjohnpublishing.org</a></p>\r\n<p>Journal of Clinical Infectious Diseases and Medicine - new, open access publication launched by&nbsp;<a href=\"http://www.andrewjohnpublishing.org/\">Andrew John Publishing Inc</a>.,</p>','2015-12-03'),(50,'','<p>NIGGER!!</p>','2022-10-08');
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Lettre','der-pharmacia-lettre',2,1),(209,'ipdps','Der Pharmacia Sinica','der-pharmacia-sinica',2,1),(210,'dmcr','Dermatology Case Reports','dermatology-case-reports',1,1),(211,'dcrs','Diabetes Case Reports','diabetes-case-reports',1,1),(212,'dmt','Diabetes Management','diabetes-management',2,1),(213,'dpo','Diagnostic Pathology: Open Access','diagnostic-pathology-open-access',1,1),(214,'dcp','Dialysis and clinical practice','dialysis-clinical-practice',1,1),(215,'ipjdms','Disease Mechanisms: Open access','disease-mechanisms-open-access',2,1),(216,'ipdehc','Diversity and Equality in Health and Care\n','diversity-equality-health-care',2,1),(218,'ddo','Drug Designing: Open Access','drug-designing-open-access',1,1),(219,'DIDNA','Drug Intoxication and Detoxification : Novel Approaches','drug-intoxication-detoxification-novel-approaches',4,1),(220,'ipddoa','Dual Diagnosis: Open Access','dual-diagnosis-open-access',2,1),(221,'ijer','Educational 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Change','environment-pollution-climate-change',1,1),(232,'ipetsj','Environmental and Toxicology Studies Journal','environmental-toxicology-studies-journal',2,1),(233,'aaerar','Environmental Risk Assessment and Remediation','environmental-risk-assessment-remediation',2,1),(234,'tses','Environmental Science: An Indian Journal','environmental-science-an-indian-journal',3,1),(235,'eeg','Enzyme Engineering','enzyme-engineering',1,1),(236,'ecr','Epidemiology: Open Access','epidemiology-open-access',1,1),(237,'eroa','Epigenetics Research: Open Access','epigenetics-research-open-access',1,1),(238,'elj','Epilepsy Journal','epilepsy-journal',1,1),(239,'ejaser','European Journal of Applied Engineering and Scientific Research','european-applied-engineering-scientific-research',3,1),(240,'EJEBAU','European Journal of Experimental Biology','european-experimental-biology',2,1),(241,'ejses','European Journal of Sports & Exercise Science','european-sports-exercise-science',3,1),(242,'ejzr','European Journal of Zoological Research','european-zoological-research',3,1),(243,'ebmp','Evidence based Medicine and Practice','evidence-based-medicine-practice',1,1),(244,'EOEB','Expert Opinion on Environmental Biology','expert-opinion-environmental-biology',4,1),(245,'fmmsr','Family Medicine & Medical Science Research','family-medicine-medical-science-research',1,1),(246,'ipft','Farmacologiay Toxicologia','farmacologiay-toxicologia',2,1),(247,'JFTTE','Fashion Technology & Textile Engineering','fashion-technology-textile-engineering',4,1),(248,'fmt','Fermentation Technology','fermentation-technology',1,1),(249,'foa','Fibromyalgia: Open Access','fibromyalgia-open-access',1,1),(250,'faj','Fisheries and Aquaculture Journal','fisheries-aquaculture-journal',1,1),(251,'ipfs','Fisheries Sciences','fisheries-sciences',2,1),(252,'fmoa','Fluid Mechanics: Open Access','fluid-mechanics-open-access',1,1),(253,'jfim','Food & Industrial Microbiology','food-industrial-microbiology',1,1),(254,'JFND','Food and Nutritional Disorders ','food-nutritional-disorders',4,1),(255,'ipfbr','Food Biotechnology Research','food-biotechnology-research',2,1),(256,'jfa','Forensic Anthropology','forensic-anthropology',1,1),(257,'JFTP','Forensic Toxicology & Pharmacology','forensic-toxicology-pharmacology',4,1),(258,'jfor','Forest Research: Open Access','forest-research-open-access',1,1),(259,'fgb','Fungal Genomics & Biology','fungal-genomics-biology',1,1),(260,'rdt','Gene Technology ','gene-technology',1,1),(261,'gmo','General Medicine: Open Access ','general-medicine-open-access',1,1),(262,'ipgsr','General Surgery Reports','general-surgery-reports',2,1),(263,'ipgmbr','Genetics and Molecular Biology Research','genetics-molecular-biology-research',2,1),(264,'JGSD','Genital System & Disorders','genital-system-disorders',4,1),(265,'GIGS','Geoinformatics & Geostatistics: An Overview','geoinformatics-geostatistics-an-overview',4,1),(266,'jgoa','Glaucoma: Open Access','glaucoma-open-access',1,1),(267,'ipgehs','Global Environment, Health and Safety ','global-environment-health-safety',2,1),(268,'gjbahs','Global Journal of Biology, Agriculture & Health Sciences','global-biology-agriculture-health-sciences',3,1),(269,'gjcmp','Global Journal of Commerce & Management Perspective','global-commerce-management-perspective',3,1),(270,'ipijdd','Global Journal of Digestive Diseases','global-digestive-diseases',2,1),(271,'gjedt','Global Journal of Engineering, Design & Technology','global-engineering-design-technology',3,1),(272,'gjiss','Global Journal of Interdisciplinary Social Sciences','global-interdisciplinary-social-sciences',3,1),(273,'gjlsbr','Global Journal of Life Sciences and Biological Research','global-life-sciences-biological-research',3,1),(274,'fnoa','Global Journal of Nursing & Forensic Studies','global-nursing-forensic-studies',1,1),(275,'ipgjrr','Global Journal of Research and Review','global-research-review',2,1),(276,'gjto','Global Journal of Technology and Optimization','global-technology-optimization',1,1),(277,'gmj','Global Media Journal','global-media-journal',1,1),(278,'grjsn','Global Research Journal of Science and Nature','global-research-science-nature',3,1),(279,'aaggs','Gynecolgy and Reproductive Endocrinology','gynecolgy-reproductive-endocrinology',2,1),(280,'gocr','Gynecology & Obstetrics','gynecology-obstetrics',1,1),(281,'ipgocr','Gynecology & Obstetrics Case Report','gynecology-obstetrics-case-report',2,1),(282,'aajggs','Gynecology and Gestational Surrogacy','gynecology-gestational-surrogacy',2,1),(283,'htt','Hair Therapy & Transplantation','hair-therapy-transplantation',1,1),(284,'iphncr','Head and Neck Cancer Research','head-neck-cancer-research',2,1),(285,'hccr','Health Care : Current Reviews','health-care-current-reviews',1,1),(286,'heor','Health Economics & Outcome Research: Open Access','health-economics-outcome-research-open-access',1,1),(287,'HSJ','Health Science Journal','health-science-journal',1,1),(288,'iphspr','Health Systems and Policy Research','health-systems-policy-research',2,1),(289,'jhm','Herbal Medicine: Open Access','herbal-medicine-open-access',1,1),(290,'hgcr','Hereditary Genetics: Current Research','hereditary-genetics-current-research',1,1),(291,'harj','HIV and AIDS Research Journal','hiv-aids-research-journal',4,1),(292,'hicr','HIV: Current Research','hiv-current-research',1,1),(293,'hgec','Human Genetics & Embryology ','human-genetics-embryology',1,1),(294,'JHHE','Hydrogeology & Hydrologic Engineering','hydrogeology-hydrologic-engineering',4,1),(295,'hycr','Hydrology: Current Research','hydrology-current-research',1,1),(296,'JHHG','Hypo & Hyperglycemia','hypo-hyperglycemia',4,1),(297,'riped','Ibero-American Journal of Exercise and Sports Psychology','ibero-american-exercise-sports-psychology',2,1),(298,'iim','Imaging in Medicine','imaging-medicine',2,1),(299,'icoa','Immunochemistry & Immunopathology','immunochemistry-immunopathology',1,1),(300,'SCIJIDD','Immunodeficiency and Disorders','immunodeficiency-disorders',4,1),(301,'igoa','Immunogenetics: Open Access','immunogenetics-open-access',1,1),(302,'idit','Immunological Disorders and Immunotherapy','immunological-disorders-immunotherapy',1,1),(303,'aaicr','Immunology Case Reports','immunology-case-reports',2,1),(304,'icr','Immunology: Current Research','immunology-current-research',1,1),(305,'imr','Immunome Research','immunome-research',1,1),(306,'ipirj','Immunotherapy Research Journal','immunotherapy-research-journal',2,1),(307,'imt','Immunotherapy: Open Access','immunotherapy-open-access',1,1),(308,'ijps','Indian Journal of Pharmaceutical Sciences','indian-pharmaceutical-sciences',2,1),(309,'ico','Industrial Chemistry','industrial-chemistry',1,1),(310,'iem','Industrial Engineering & Management ','industrial-engineering-management',1,1),(311,'idpc','Infectious Diseases: Prevention and Control','infectious-diseases-prevention-control',4,1),(312,'ipjidm','Informatics and Data Mining','informatics-data-mining',2,1),(313,'iiid','Innate Immunity & Immunological Disorders','innate-immunity-immunological-disorders',1,1),(314,'iep','Innovative Energy & Research','innovative-energy-research',1,1),(315,'tsic','Inorganic Chemistry: An Indian Journal','inorganic-chemistry-an-indian-journal',3,1),(316,'ipjab','Insights in Allergy, Asthma & Bronchitis','insights-allergy-asthma-bronchitis',2,1),(317,'ipiab','Insights in aquaculture and biotechnology','insights-aquaculture-biotechnology',2,1),(318,'ipib','Insights in Biomedicine','insights-biomedicine',2,1),(319,'ipibp','Insights in Blood Pressure','insights-blood-pressure',2,1),(320,'ipise','Insights in Cell Science','insights-cell-science',2,1),(321,'ipier','Insights in Enzyme Research','insights-enzyme-research',2,1),(322,'ipii','Insights in Immunology','insights-immunology',2,1),(323,'ipimp','Insights in Medical Physics','insights-medical-physics',2,1),(324,'ipins','Insights in Neurosurgery','insights-neurosurgery',2,1),(325,'aainm','Insights in Nutrition and Metabolism','insights-nutrition-metabolism',2,1),(326,'ipio','Insights in Ophthalmology','insights-ophthalmology',2,1),(327,'ipipc','Insights in Pediatric Cardiology','insights-pediatric-cardiology',2,1),(328,'ipirm','Insights in Reproductive Medicine','insights-reproductive-medicine',2,1),(329,'ipisc','Insights in Stem Cells','insights-stem-cells',2,1),(330,'ipijgh','Integrative Journal of Global Health','integrative-global-health',2,1),(331,'aainr','Integrative Neuroscience Research','integrative-neuroscience-research',2,1),(332,'ipr','Intellectual Property Rights: Open Access','intellectual-property-rights-open-access',1,1),(333,'ijm','Interdisciplinary Journal of Microinflammation','interdisciplinary-microinflammation',1,1),(334,'ime','Internal Medicine: Open Access','internal-medicine-open-access',1,1),(335,'ipijcr','International Journal for Case Reports','international-journal-case-reports',2,1),(336,'ijar','International Journal of Accounting Research','international-accounting-research',1,1),(337,'ijaiti','International Journal of Advance Innovations, Thoughts & Ideas','international-advance-innovations-thoughts-ideas',1,1),(338,'IJAREEIE','International Journal of Advanced Research in Electrical, Electronics and Instrumentation Engineering','international-advanced-research-electrical-electronics-instrumentation-engineering',1,1),(339,'ijoat','International Journal of Advancements in Technology','international-advancements-technology',1,1),(340,'ipapm','International Journal of Anesthesiology & Pain Medicine','international-anesthesiology-pain-medicine',2,1),(341,'ipias','International Journal of Applied Science - Research and Review','international-applied-science-research-review',2,1),(342,'ijbio','International Journal of Bioassays','international-bioassays',3,1),(343,'ijbr','International Journal of Biocontrol Research','international-biocontrol-research',1,1),(344,'jbdm','International Journal of Biomedical Data Mining','international-biomedical-data-mining',1,1),(345,'ICRJ','International Journal of Cardiovascular Research','international-cardiovascular-research',4,1),(346,'tsijcs','International Journal of Chemical Sciences','international-chemical-sciences',3,1),(347,'ijcr','International Journal of Clinical Rheumatology','international-clinical-rheumatology',2,1),(348,'ijocs','International Journal of Clinical Skills','international-clinical-skills',4,1),(349,'ijcmi','International Journal of Clinical& Medical Images','international-clinical-medical-images',1,1),(350,'ijcrimph','International Journal of Collaborative Research on Internal Medicine & Public Health','international-collaborative-research-internal-medicine-public-health',2,1),(351,'ipijddr','International Journal of Drug Development and Research','international-drug-development-research',2,1),(352,'ijdrt','International Journal of Drug Research and Technology','international-drug-research-technology',2,1),(353,'ijems','International Journal of Economics & Management Sciences','international-economics-management-sciences',1,1),(354,'ijemhhr','International Journal of Emergency Mental Health and Human Resilience','international-emergency-mental-health-human-resilience',1,1),(355,'ije','International Journal Of Entrepreneurship','international-entrepreneurship',2,1),(356,'IEVJ','International Journal of Evolution','international-evolution',4,1),(357,'ijgh','International Journal of Global Health','international-global-health',4,1),(358,'IJIRCCE','International Journal of Innovative Research in Computer and Communication Engineering','international-innovative-research-computer-communication-engineering',1,1),(359,'ijmrhs','International Journal of Medical Research & Health Sciences','international-medical-research-health-sciences',3,1),(360,'ijmy','International Journal of Microscopy','international-microscopy',1,1),(361,'ijn','International Journal of Neurorehabilitation','international-neurorehabilitation',1,1),(362,'IOPJ','International Journal of Ophthalmic Pathology','international-ophthalmic-pathology',4,1),(364,'pnn','International Journal of Pediatric Neurosciences','international-pediatric-neurosciences',1,1),(365,'ijpr','International Journal of Pharma Research & Review','international-pharma-research-review',1,1),(366,'ijp','International Journal of Pharmacy','international-pharmacy',1,1),(367,'jpmr','International Journal of Physical Medicine & Rehabilitation','international-physical-medicine-rehabilitation',1,1),(368,'ijphs','International Journal of Public Health and Safety','international-public-health-safety',1,1),(369,'ijpaz','International Journal of Pure and Applied Zoology','international-pure-applied-zoology',2,1),(370,'IJRDPL','International Journal of Research and Development in Pharmacy & Life Sciences','international-research-development-pharmacy-life-sciences',1,1),(371,'aaijrm','International Journal of Respiratory Medicine','international-respiratory-medicine',2,1),(372,'ijscp','International Journal of School and Cognitive Psychology','international-school-cognitive-psychology',1,1),(373,'sndc','International Journal of Sensor Networks and Data Communications','international-sensor-networks-data-communications',1,1),(374,'siec','International Journal of Swarm Intelligence and Evolutionary Computation','international-swarm-intelligence-evolutionary-computation',1,1),(375,'ijt','International Journal of Theranostics','international-theranostics',4,1),(376,'ijwr','International Journal of Waste Resources','international-waste-resources',1,1),(377,'irjas','International Research Journal of Agricultural Science and Soil Science','international-research-agricultural-science-soil-science',3,1),(378,'irjass','International Research Journal of Arts and Social Sciences','international-research-arts-social-sciences',3,1),(379,'irjbb','International Research Journal of Biochemistry and Bioinformatics','international-research-biochemistry-bioinformatics',3,1),(380,'irjob','International Research Journal of Biotechnology','international-research-biotechnology',3,1),(381,'irjgm','International Research Journal of Geology and Mining','international-research-geology-mining',3,1),(382,'irjm','International Research Journal of Microbiology','international-research-microbiology',3,1),(383,'irjpp','International Research Journal of Pharmacy and Pharmacology','international-research-pharmacy-pharmacology',3,1),(384,'ica','Interventional Cardiology','interventional-cardiology',2,1),(385,'ipic','Interventional Cardiology Journal','interventional-cardiology-journal',2,1),(386,'ipin','Interventional Neurology','interventional-neurology',2,1),(387,'ipdr','Interventional Pediatrics & Research','interventional-pediatrics-research',1,1),(388,'ipicfm','Invasive Cardiology: Future Medicine','invasive-cardiology-future-medicine',2,1),(389,'idse','Irrigation & Drainage Systems Engineering','irrigation-drainage-systems-engineering',1,1),(390,'jcdr','JBR Journal of Clinical Diagnosis and Research ','jbr-clinical-diagnosis-research',1,1),(391,'jimds','JBR Journal of Interdisciplinary Medicine and Dental Science','jbr-interdisciplinary-medicine-dental-science',1,1),(392,'jys','JBR Journal of Young Scientist','jbr-young-scientist',1,1),(393,'ipp','JOP. Journal of the Pancreas','jop-pancreas',2,1),(394,'jceen','Jornal of Clinical and Experimental Endocrionology','clinical-experimental-endocrionology',1,1),(395,'jaefr','Journal Aquaculture Engineering and Fisheries Research','aquaculture-engineering-fisheries-research',3,1),(396,'aacpcp','Journal Clinical Psychiatry and Cognitive Psychology','clinical-psychiatry-cognitive-psychology',2,1),(397,'iphh','Journal Health Care and Hygiene ','health-care-hygiene',2,1),(398,'hps','Journal Hepatology and Pancreatic Science','journal-hepatology-pancreatic-science',1,1),(399,'jmpb','Journal of  Molecular Pathology and Biochemistry','molecular-pathology-biochemistry',1,1),(400,'jamk','Journal of Accounting & Marketing','accounting-marketing',1,1),(401,'jart','Journal of Addiction Research & Therapy','addiction-research-therapy',1,1),(402,'ipjabt','Journal of addictive behaviours and therapy','addictive-behaviours-therapy',2,1),(403,'ipjad','Journal of Adenocarcinoma','adenocarcinoma',2,1),(404,'ace','Journal of Advanced Chemical Engineering','advanced-chemical-engineering',1,1),(405,'aaasr','Journal of Advanced Surgical Research','advanced-surgical-research',2,1),(406,'ldapr','Journal of Advances in Pediatric Research','advances-pediatric-research',3,1),(407,'jabf','Journal of Aerobics & Fitness','aerobics-fitness',1,1),(408,'jaae','Journal of Aeronautics & Aerospace Engineering','aeronautics-aerospace-engineering',1,1),(409,'agm','Journal of Aging & Geriatric Medicine','aging-geriatric-medicine',4,1),(410,'aaagp','Journal of Aging and Geriatric Psychiatry','aging-geriatric-psychiatry',2,1),(411,'jasc','Journal of Aging Science','aging-science',1,1),(412,'aaascb','Journal of Agricultural Science and Botany ','agricultural-science-botany',2,1),(413,'jbfbp','Journal of Agricultural Science and Food Research','agricultural-science-food-research',1,1),(414,'jar','Journal of AIDS & Clinical Research','aids-clinical-research',1,1),(415,'jaldd','Journal of Alcoholism and Drug Dependence','alcoholism-drug-dependence',1,1),(416,'jat','Journal of Allergy & Therapy','allergy-therapy',1,1),(417,'ipad','Journal of Alzheimers & Dementia','alzheimers-dementia',2,1),(418,'jadp','Journal of Alzheimers Disease & Parkinsonism','alzheimers-disease-parkinsonism',1,1),(419,'ipcam','Journal of Anaesthesiology and Critical Care','anaesthesiology-critical-care',2,1),(420,'jabt','Journal of Analytical & Bioanalytical Techniques','analytical-bioanalytical-techniques',1,1),(421,'ipjasr','Journal of Anatomical Science and Research','anatomical-science-research',2,1),(422,'jacr','Journal of Anesthesia & Clinical Research','anesthesia-clinical-research',1,1),(423,'japre','Journal of Anesthesiology and Pain Research','anesthesiology-pain-research',1,1),(424,'aaaa','Journal of Anesthetics and Anesthesiology','anesthetics-anesthesiology',2,1),(425,'jahbs','Journal of Animal Health and Behavioural Science','animal-health-behavioural-science',1,1),(427,'ipjan','Journal of Animal Research and Nutrition','animal-research-nutrition',2,1),(428,'ipjaslp','Journal of Animal Sciences and Livestock Production','animal-sciences-livestock-production',2,1),(429,'antimicro','Journal of Antimicrobial Agents','antimicrobial-agents',1,1),(430,'jaa','Journal of Antivirals & Antiretrovirals','antivirals-antiretrovirals',1,1),(431,'jacm','Journal of Applied & Computational Mathematics','applied-computational-mathematics',1,1),(432,'JABCB','Journal of Applied Bioinformatics & Computational Biology','applied-bioinformatics-computational-biology',4,1),(433,'aaams','Journal of Applied Mathematics and Statistical Applications','applied-mathematics-statistical-applications',2,1),(434,'jame','Journal of Applied Mechanical Engineering','applied-mechanical-engineering',1,1),(435,'ipjamb','Journal of Applied Microbiology and Biochemistry','applied-microbiology-biochemistry',2,1),(436,'jap','Journal of Applied Pharmacy','applied-pharmacy',1,1),(437,'jasi','Journal of Applied Science and Innovations','applied-science-innovations',1,1),(438,'jard','Journal of Aquaculture Research & Development','aquaculture-research-development',1,1),(439,'ipjapt','Journal of Aquatic Pollution and Toxicology','aquatic-pollution-toxicology',2,1),(440,'jaet','Journal of Architectural Engineering Technology','architectural-engineering-technology',1,1),(441,'jao','Journal of Astrobiology & Outreach','astrobiology-outreach',1,1),(442,'jaat','Journal of Astrophysics & Aerospace Technology','astrophysics-aerospace-technology',1,1),(443,'jac','Journal of Autacoids','autacoids',1,1),(444,'jado','Journal of Autoimmune Disorders','autoimmune-disorders',1,1),(445,'jbp','Journal of Bacteriology & Parasitology','bacteriology-parasitology',1,1),(446,'aabid','Journal of Bacteriology and Infectious Diseases','bacteriology-infectious-diseases',2,1),(447,'jbclinpharm','Journal of Basic and Clinical Pharmacy','basic-clinical-pharmacy',3,1),(448,'jbabm','Journal of Bioanalysis & Biomedicine','bioanalysis-biomedicine',1,1),(449,'jbmt','Journal of Biochemical and Microbial Toxicology','biochemical-microbial-toxicology',1,1),(450,'jbebt','Journal of Biochemical Engineering &   Bioprocess Technology','biochemical-engineering-bioprocess-technology',4,1),(451,'aabb','Journal of Biochemistry and Biotechnology   ','biochemistry-biotechnology',2,1),(452,'jbcb','Journal of Biochemistry and Cell Biology','biochemistry-cell-biology',1,1),(453,'jbpy','Journal of Biochemistry and Physiology','biochemistry-physiology',4,1),(454,'oabr','Journal of Biochemistry Research','biochemistry-research',3,1),(455,'jbes','Journal of Biodiversity & Endangered Species','biodiversity-endangered-species',1,1),(456,'ijbbd','Journal of Biodiversity, Bioprospecting and Development','biodiversity-bioprospecting-development',1,1),(457,'jbbs','Journal of Bioengineering & Biomedical Science','bioengineering-biomedical-science',1,1),(458,'jbtc','Journal of Bioengineering and Bioelectronics','bioengineering-bioelectronics',1,1),(460,'jbb','Journal of Bioequivalence & Bioavailability','bioequivalence-bioavailability',1,1),(461,'jbms','Journal of Biological and Medical Sciences','biological-medical-sciences',1,1),(462,'ipbmr','Journal of Biology and Medical Research','biology-medical-research',2,1),(463,'lxjbtw','Journal of Biology and Today\'s World','biology-todays-world',3,1),(464,'jbps','Journal of Biomedical and Pharmaceutical Sciences','biomedical-pharmaceutical-sciences',1,1),(465,'bemd','Journal of Biomedical Engineering and Medical Devices','biomedical-engineering-medical-devices',1,1),(466,'aabib','Journal of Biomedical Imaging and bioengineering','biomedical-imaging-bioengineering',2,1),(467,'ipbsa','Journal of Biomedical Science & Applications','biomedical-science-applications',2,1),(468,'ipjbs','Journal of Biomedical Sciences','biomedical-sciences',2,1),(469,'bset','Journal of Biomedical Systems & Emerging Technologies','biomedical-systems-emerging-technologies',1,1),(470,'jbmbs','Journal of Biometrics & Biostatistics ','biometrics-biostatistics',1,1),(471,'bbte','Journal of Biomimetics Biomaterials and Tissue Engineering','biomimetics-biomaterials-tissue-engineering',1,1),(472,'jbe','Journal of Biomusical Engineering','biomusical-engineering',1,1),(473,'jbpbt','Journal of Bioprocessing & Biotechniques','bioprocessing-biotechniques',1,1),(474,'jbrbd','Journal of Bioremediation & Biodegradation','bioremediation-biodegradation',1,1),(475,'jbc','Journal of Bioresearch Communications','bioresearch-communications',1,1),(476,'jbsbe','Journal of Biosensors & Bioelectronics','biosensors-bioelectronics',1,1),(477,'jbtbm','Journal of Biotechnology & Biomaterials','biotechnology-biomaterials',1,1),(478,'aajbp','Journal of Biotechnology and Phytochemistry','biotechnology-phytochemistry',2,1),(479,'jbtbd','Journal of Bioterrorism & Biodefense','bioterrorism-biodefense',1,1),(480,'ipjbd','Journal of Birth Defects','birth-defects',2,1),(481,'jbl','Journal of Blood & Lymph','blood-lymph',1,1),(482,'jbdt','Journal of Blood Disorders & Transfusion','blood-disorders-transfusion',1,1),(483,'ipjbr','Journal of Blood Research','blood-research',2,1),(484,'jbrhd','Journal of Blood Research & Hematologic Diseases','blood-research-hematologic-diseases',4,1),(485,'bmrj','Journal of Bone Marrow Research','bone-marrow-research',1,1),(486,'ipjbrr','Journal of Bone Research and Reports','bone-research-reports',2,1),(487,'aajbn','Journal of Brain and Neurology','brain-neurology',2,1),(488,'jbbcs','Journal of Brain behavior and cognitive sciences','brain-behaviour-cognitive-sciences',2,1),(489,'jbr','Journal of Brain Research','brain-research',1,1),(491,'jbfa','Journal of Business & Financial Affairs','business-financial-affairs',1,1),(492,'aaccr','Journal of Cancer Clinical Research','cancer-clinical-research',2,1),(493,'jcct','Journal of Cancer Clinical Trials','cancer-clinical-trials',1,1),(494,'jcd','Journal of Cancer Diagnosis','cancer-diagnosis',1,1),(495,'ipjcep','Journal of Cancer Epidemology & Prevention','cancer-epidemology-prevention',2,1),(496,'aajcit','Journal of Cancer Immunology & Therapy','cancer-immunology-therapy',2,1),(497,'jcrio','Journal of Cancer Research and Immuno-Oncology','cancer-research-immuno-oncology',1,1),(498,'jcst','Journal of Cancer Science & Therapy','cancer-science-therapy',1,1),(499,'jcsr','Journal of Cancer Science and Research','cancer-science-research',1,1),(500,'jcm','Journal of Carcinogenesis & Mutagenesis','carcinogenesis-mutagenesis',1,1),(501,'jcpr','Journal of cardiac and pulmonary rehabilitation','cardiac-pulmonary-rehabilitation',1,1),(502,'jcdd','Journal of Cardiovascular Diseases & Diagnosis ','cardiovascular-diseases-diagnosis',1,1),(503,'aacmt','Journal of Cardiovascular Medicine and Therapeutics','cardiovascular-medicine-therapeutics',2,1),(504,'ipcmt','Journal of Cardiovascular Medicine and Therapy','cardiovascular-medicine-therapy',2,1),(505,'ipcedb','Journal of Cell and Developmental Biology ','cell-developmental-biology',2,1),(506,'jcbi','Journal of Cell Biology & Immunology','cell-biology-immunology',1,1),(507,'aacbm','Journal of Cell Biology and Metabolism','cell-biology-metabolism',2,1),(508,'jcest','Journal of Cell Science & Therapy','cell-science-therapy',1,1),(509,'jcsa','Journal of Cell Science and Apoptosis','cell-science-apoptosis',1,1),(510,'jcs','Journal of Cell Signaling','cell-signaling',1,1),(511,'ipjcmp','Journal of Cellular & Molecular Pathology','cellular-molecular-pathology',2,1),(512,'jcmp','Journal of Cellular and Molecular Pharmacology','cellular-molecular-pharmacology',1,1),(513,'JOCPR','Journal of Chemical and Pharmaceutical Research','chemical-pharmaceutical-research',2,1),(514,'ipcbpc','Journal of Chemical Biology & Pharmaceutical Chemistry','chemical-biology-pharmaceutical-chemistry',2,1),(515,'jcbt','Journal of Chemical Biology & Therapeutics','chemical-biology-therapeutics',1,1),(516,'jcept','Journal of Chemical Engineering & Process Technology','chemical-engineering-process-technology',1,1),(517,'aacta','Journal of Chemical Technology and Applications','chemical-technology-applications',2,1),(518,'jcace','Journal of Chemistry and Applied Chemical Engineering','chemistry-applied-chemical-engineering',4,1),(519,'jcalb','Journal of Child and Adolescent Behavior','child-adolescent-behavior',1,1),(520,'aajcah','Journal of Child and Adolescent Health','child-adolescent-health',2,1),(521,'ipjco','Journal of Childhood Obesity','childhood-obesity',2,1),(522,'aachd','Journal of Cholesterol and Heart Disease','cholesterol-heart-disease',2,1),(523,'jcgst','Journal of Chromatography & Separation Techniques','chromatography-separation-techniques',1,1),(524,'jcgr','Journal of Chromatography Research','chromatography-research',4,1),(525,'ipjci','Journal of Circulation','circulation',2,1),(526,'jcde','Journal of Civil & Environmental  Engineering','civil-environmental-engineering',1,1),(527,'jcls','Journal of Civil & Legal Sciences','civil-legal-sciences',1,1),(528,'jcwf','Journal of Climatology & Weather Forecasting','climatology-weather-forecasting',1,1),(529,'aacnt','Journal of Clincal Nephrology and Therapeutics','clincal-nephrology-therapeutics',2,1),(530,'jcci','Journal of Clinical & Cellular Immunology','clinical-cellular-immunology',1,1),(531,'jcec','Journal of Clinical & Experimental Cardiology','clinical-experimental-cardiology',1,1),(532,'jcedr','Journal of Clinical & Experimental Dermatology Research','clinical-experimental-dermatology-research',1,1),(533,'ipjcen','Journal of Clinical & Experimental Nephrology','clinical-experimental-nephrology',2,1),(534,'jceni','Journal of Clinical & Experimental Neuroimmunology','clinical-experimental-neuroimmunology',1,1),(535,'jceo','Journal of Clinical & Experimental Ophthalmology','clinical-experimental-ophthalmology',1,1),(536,'ipjceop','Journal of Clinical & Experimental Orthopaedics','clinical-experimental-orthopaedics',2,1),(537,'jcep','Journal of Clinical & Experimental Pathology','clinical-experimental-pathology',1,1),(538,'jcer','Journal of Clinical & Experimental Radiology','clinical-experimental-radiology',4,1),(539,'aacety','Journal of Clinical & Experimental Toxicology','clinical-experimental-toxicology',2,1),(540,'ijgm','Journal of Clinical & Medical Genomics','clinical-medical-genomics',1,1),(541,'jcme','Journal of Clinical & Molecular Endocrinology','clinical-molecular-endocrinology',1,1),(542,'ipjcmpy','Journal of Clinical & Molecular pathology','clinical-molecular-pathology',2,1),(543,'aacbc','Journal of Clinical and Bioanalytical Chemistry ','clinical-bioanalytical-chemistry',2,1),(544,'jcet','Journal of Clinical and Experimental Transplantation','clinical-experimental-transplantation',1,1),(545,'aacet','Journal of Clinical and Experimental Traumatology','clinical-experimental-traumatology',2,1),(546,'jcmcs','Journal of Clinical and Medical Case Studies','clinical-medical-case-studies',1,1),(547,'jcms','Journal of Clinical and Medical Sciences','clinical-medical-sciences',1,1),(548,'jcao','Journal of Clinical Anesthesiology','clinical-anesthesiology',1,1),(549,'jaco','Journal of Clinical Anesthesiology: Open Access','clinical-anesthesiology-open-access',1,1),(550,'ipjccr','Journal of Clinical Cardiology and Research','clinical-cardiology-research',2,1),(551,'jccr','Journal of Clinical Case Reports','clinical-case-reports',1,1),(552,'jcclm','Journal of Clinical Chemistry and Laboratory Medicine','clinical-chemistry-laboratory-medicine',1,1),(553,'aacdoh','Journal of Clinical Dentistry and Oral Health','clinical-dentistry-oral-health',2,1),(554,'jcds','Journal of Clinical Diabetes ','clinical-diabetes',1,1),(555,'jcdp','Journal of Clinical Diabetes & Practice','clinical-diabetes-practice',1,1),(556,'aajcer','Journal of clinical Endocrinology and Research','clinical-endocrinology-research',2,1),(557,'ipce','Journal of Clinical Epigenetics','clinical-epigenetics',2,1),(558,'ipjcgh','Journal of Clinical Gastroenterology and Hepatology','clinical-gastroenterology-hepatology',2,1),(559,'jcg','Journal of Clinical Genomics','clinical-genomics',4,1),(560,'jcicr','Journal of Clinical Images and Case Reports','clinical-images-case-reports',4,1),(561,'JCIR','Journal of Clinical Immunology and Research','clinical-immunology-research',4,1),(562,'aacir','Journal of Clinical Immunology Research','clinical-immunology-research',2,1),(563,'jcidp','Journal of Clinical Infectious Diseases & Practice','clinical-infectious-diseases-practice',1,1),(564,'ipjcmt','Journal of Clinical Medicine and Therapeutics','clinical-medicine-therapeutics',2,1),(565,'jcma','Journal of Clinical Microbiology and Antimicrobials','clinical-microbiology-antimicrobials',1,1),(566,'omicsjcnn','Journal of Clinical Neurology and Neurosurgery','clinical-neurology-neurosurgery',1,1),(567,'ipjcnd','Journal of Clinical Nutrition & Dietetics','clinical-nutrition-dietetics',2,1),(568,'jcnm','Journal of Clinical Nutrition and Metabolism','clinical-nutrition-metabolism',4,1),(569,'aacocr','Journal of Clinical Oncology and Cancer Research','clinical-oncology-cancer-research',2,1),(570,'jcop','Journal of Clinical Oncology and Practice','clinical-oncology-practice',1,1),(571,'ipjcpd','Journal of Clinical Pathology and Diagnosis','clinical-pathology-diagnosis',2,1),(572,'aacplm','Journal of Clinical Pathology and Laboratory Medicine','clinical-pathology-laboratory-medicine',2,1),(573,'ipcrcr','Journal of Clinical Radiology and Case Reports','clinical-radiology-case-reports',2,1),(574,'jcre','Journal of Clinical Research','clinical-research',1,1),(575,'jcrb','Journal of Clinical Research & Bioethics','clinical-research-bioethics',1,1),(576,'jcrp','Journal of Clinical Research and Pharmacy','clinical-research-pharmacy',2,1),(577,'jcrdc','Journal of Clinical Respiratory Diseases and Care','clinical-respiratory-diseases-care',1,1),(578,'aajcrm','Journal of Clinical Respiratory Medicine','clinical-respiratory-medicine',2,1),(579,'jct','Journal of Clinical Toxicology','clinical-toxicology',1,1),(580,'jctr','Journal of Clinical Trials','clinical-trials',1,1),(581,'jczm','Journal of Coastal Zone Management','coastal-zone-management',1,1),(582,'ipcn','Journal of Cognitive Neuropsychology','cognitive-neuropsychology',2,1),(583,'jcdsha','Journal of Communication Disorders, Deaf Studies & Hearing Aids','communication-disorders-deaf-studies-hearing-aids',1,1),(584,'jcphn','Journal of Community & Public Health Nursing','community-public-health-nursing',1,1),(585,'jcmhe','Journal of Community Medicine & Health Education','community-medicine-health-education',1,1),(586,'jcmmd','Journal of Computational Methods in Molecular Design','computational-methods-molecular-design',3,1),(587,'jcsb','Journal of Computer Science & Systems Biology','computer-science-systems-biology',1,1),(588,'ipjcid','Journal of Congenital and Inherited Disorders','congenital-inherited-disorders',2,1),(589,'cds','Journal of Congenital Disorders','congenital-disorders',1,1),(590,'ipjcs','Journal of Contraceptive Studies','contraceptive-studies',2,1),(591,'jchd','Journal of Coronary Heart Diseases','coronary-heart-diseases',1,1),(592,'jctt','Journal of Cosmetology & Trichology','cosmetology-trichology',1,1),(593,'jccps','Journal of Current Chemical and Pharmaceutical Sciences','current-chemical-pharmaceutical-sciences',4,1),(594,'jcb','Journal of Cytokine Biology','cytokine-biology',1,1),(595,'jch','Journal of Cytology & Histology','cytology-histology',1,1),(596,'jdmgp','Journal of Data Mining in Genomics & Proteomics','data-mining-genomics-proteomics',1,1),(597,'jdfm','Journal of Defense Management','defense-management',1,1),(598,'dementia','Journal of Dementia','dementia',1,1),(599,'ipjdcr','Journal of Dental and Craniofacial Research','dental-craniofacial-research',2,1),(600,'jdpm','Journal of Dental Pathology and Medicine','dental-pathology-medicine',1,1),(601,'did','Journal of Dental Science and Medicine','dental-science-medicine',1,1),(602,'jda','Journal of Depression and Anxiety','depression-anxiety',1,1),(603,'jod','Journal of Dermatitis','dermatitis',1,1),(604,'aadrsc','Journal of Dermatology Research and Skin Care','dermatology-research-skin-care',2,1),(605,'eoed','Journal of Developing Drugs','developing-drugs',1,1),(606,'jdce','Journal of Diabetes & Clinical Practice','diabetes-clinical-practice',1,1),(607,'jdm','Journal of Diabetes & Metabolism','diabetes-metabolism',1,1),(608,'ipdmc','Journal of Diabetes Medication & Care','diabetes-medication-care',2,1),(609,'ipjdre','Journal of Diabetes research and endocrinology','diabetes-research-endocrinology',2,1),(610,'jdcm','Journal of Diabetic Complications & Medicine','diabetic-complications-medicine',1,1),(611,'aady','Journal of Diabetology','diabetology',2,1),(612,'jdsca','Journal of Down Syndrome & Chromosome Abnormalities','down-syndrome-chromosome-abnormalities',1,1),(613,'ipjda','Journal of Drug Abuse','drug-abuse',2,1),(614,'apjdar','Journal of Drug and Alcohol Research','drug-alcohol-research',4,1),(616,'jdmt','Journal of Drug Metabolism & Toxicology','drug-metabolism-toxicology',1,1),(617,'dst','Journal of Drugs and Toxins','drugs-toxins',1,1),(618,'jescc','Journal of Earth Science & Climatic Change','earth-science-climatic-change',1,1),(619,'jety','Journal of Ecology & Toxicology','ecology-toxicology',1,1),(620,'jeeer','Journal of Economics and Economic Education Research','economics-economic-education-research',2,1),(621,'jee','Journal of Ecosystem & Ecography','ecosystem-ecography',1,1),(622,'jees','Journal of Electrical & Electronic Systems','electrical-electronic-systems',1,1),(623,'ipjeim','Journal of Emergency and Internal Medicine','emergency-internal-medicine',2,1),(624,'ipjetc','Journal of Emergency and Trauma Care','emergency-trauma-care',2,1),(625,'jeom','Journal of Entrepreneurship & Organization Management','entrepreneurship-organization-management',1,1),(626,'ajee','Journal of Entrepreneurship Education','entrepreneurship-education',2,1),(627,'jeat','Journal of Environmental & Analytical Toxicology','environmental-analytical-toxicology',1,1),(628,'jreac','Journal of Environmental Analytical Chemistry','environmental-analytical-chemistry',1,1),(629,'jeh','Journal of Environmental Hazards','environmental-hazards',1,1),(630,'iper','Journal of Environmental Research','environmental-research',2,1),(631,'aaewmr','Journal of Environmental Waste Management and Recycling','environmental-waste-management-recycling',2,1),(632,'jer','Journal of Ergonomics','ergonomics',1,1),(633,'scijer','Journal of Ergonomics Research','ergonomics-research',4,1),(634,'apjem','Journal of Evolutionary Medicine','evolutionary-medicine',4,1),(636,'jefc','Journal of Experimental Food Chemistry','experimental-food-chemistry',1,1),(637,'jestm','Journal of Experimental Stroke & Translational Medicine','experimental-stroke-translational-medicine',1,1),(638,'ipjecrs','Journal of Eye & Cataract Refractive Surgery','eye-cataract-refractive-surgery',2,1),(639,'ipjecs','Journal of Eye & Cataract Surgery','eye-cataract-surgery',2,1),(640,'ipev','Journal of Eye and Vision','eye-vision',2,1),(641,'jfiv','Journal of Fertilization: In Vitro - IVF-Worldwide','fertilization-vitro-ivf-worldwide',1,1),(642,'aajfm','Journal of Finance and Marketing','finance-marketing',2,1),(643,'jflp','Journal of Fisheries & Livestock Production','fisheries-livestock-production',1,1),(644,'aajfr','Journal of Fisheries Research','fisheries-research',2,1),(645,'aafmy','Journal of Food Microbiology','food-microbiology',2,1),(646,'aajfnh','Journal of Food Nutrition and Health','food-nutrition-health',2,1),(647,'jfpt','Journal of Food Processing & Technology','food-processing-technology',1,1),(648,'aajfsn','Journal of Food Science and Nutrition','food-science-nutrition',2,1),(649,'ipfst','Journal of Food Science and Toxicology','food-science-toxicology',2,1),(650,'tsfsr','Journal of Food Science Research','food-science-research',3,1),(651,'aaftp','Journal of Food Technology and Preservation','food-technology-preservation',2,1),(652,'ipjfnph','Journal of Food, Nutrition and Population Health','food-nutrition-population-health',2,1),(653,'jfmsh','Journal of Food: Microbiology, Safety & Hygiene','food-microbiology-safety-hygiene',1,1),(654,'jfb','Journal of Forensic Biomechanics','forensic-biomechanics',1,1),(655,'jfm','Journal of Forensic Medicine','forensic-medicine',1,1),(656,'jfp','Journal of Forensic Pathology','forensic-psychology',1,1),(657,'jfpy','Journal of Forensic Psychology','forensic-psychology',1,1),(658,'jfr','Journal of Forensic Research','forensic-research',1,1),(659,'fsb','Journal of Formulation Science & Bioavailability','formulation-science-bioavailability',1,1),(660,'jfra','Journal of Fundamentals of Renewable Energy and Applications','fundamentals-renewable-energy-applications',1,1),(661,'jgdd','Journal of Gastroenterology and Digestive Diseases','gastroenterology-digestive-diseases',2,1),(662,'jgds','Journal of Gastrointestinal & Digestive System','gastrointestinal-digestive-system',1,1),(663,'jgcst','Journal of Gastrointestinal Cancer and Stromal Tumors','gastrointestinal-cancer-stromal-tumors',1,1),(664,'jgpr','Journal of General Practice','general-practice',1,1),(665,'glta','Journal of Generalized Lie Theory and Applications','generalized-lie-theory-applications',1,1),(666,'jgp','Journal of Genes and Proteins','genes-proteins',4,1),(667,'ipjgd','Journal of Genetic Disorders','genetic-disorders',2,1),(668,'JGDGR','Journal of Genetic Disorders & Genetic Reports ','genetic-disorders-genetic-reports',4,1),(669,'jgsgt','Journal of Genetic Syndromes & Gene Therapy','genetic-syndromes-gene-therapy',1,1),(670,'jgdr','Journal of Genetics and DNA Research','genetics-dna-research',1,1),(671,'jggt','Journal of Genetics and Gene Therapy','genetics-gene-therapy',4,1),(672,'jgge','Journal of Genetics and Genomes','genetics-genomes',1,1),(673,'aagmb','Journal of Genetics and Molecular Biology','genetics-molecular-biology',2,1),(674,'jge','Journal of Genome','genome',1,1),(675,'ipggs','Journal of Genomics & Gene Study','genomics-gene-study',2,1),(676,'jgnd','Journal of Geography  & Natural Disasters','geography-natural-disasters',1,1),(677,'jgg','Journal of Geology & Geosciences','geology-geosciences',1,1),(678,'jgrs','Journal of Geophysics & Remote Sensing','geophysics-remote-sensing',1,1),(679,'ipjgmr','Journal of Geriatric Medicine Research','geriatric-medicine-research',2,1),(680,'jggr','Journal of Gerontology & Geriatric Research','gerontology-geriatric-research',1,1),(681,'economics','Journal of Global Economics ','global-economics',1,1),(682,'jgb','Journal of Glycobiology','glycobiology',1,1),(683,'jgl','Journal of Glycomics & Lipidomics','glycomics-lipidomics',1,1),(684,'ipjhme','Journal of Health & Medical Economics','health-medical-economics',2,1),(685,'jhmi','Journal of Health & Medical Informatics','health-medical-informatics',1,1),(686,'jhcpn','Journal of Health Care and Prevention','health-care-prevention',1,1),(687,'jbhe','Journal of Health Education Research & Development','health-education-research-development',1,1),(688,'jhmm','Journal of Health Informatics & Management','health-informatics-management',4,1),(689,'ipjhcc','Journal of Healthcare Communications','healthcare-communications',2,1),(690,'ipjhcr','Journal of Heart and Cardiovascular Research','heart-cardiovascular-research',2,1),(691,'ipjhhc','Journal of Heart Health and Circulation','heart-health-circulation',2,1),(692,'ipjhmct','Journal of Heavy Metal Toxicity and Diseases','heavy-metal-toxicity-diseases',2,1),(693,'jhtd','Journal of Hematology & Thromboembolic Diseases','hematology-thromboembolic-diseases',1,1),(694,'aahbd','Journal of Hematology and Blood Disorders','hematology-blood-disorders',2,1),(695,'ipjoh','Journal of Hepatitis','hepatitis',2,1),(696,'jhgd','Journal of Hepatology and Gastrointestinal Disorders','hepatology-gastrointestinal-disorders',1,1),(697,'aajhcb','Journal of histology and Cell Biology','histology-cell-biology',2,1),(698,'ipjhrv','Journal of HIV & Retro Virus','hiv-retro-virus',2,1),(699,'horticulture','Journal of Horticulture','horticulture',1,1),(700,'ipjhmm','Journal of Hospital & Medical Management','hospital-medical-management',2,1),(701,'jhbm','Journal of Hotel & Business Management','hotel-business-management',1,1),(702,'aajhhc','Journal of Hypertension and Heart Care','hypertension-heart-care',2,1),(703,'jhoa','Journal of Hypertension- Open Access','hypertension-open-access',1,1),(704,'ipjiir','Journal of Imaging and Interventional Radiology','imaging-interventional-radiology',2,1),(705,'jib','Journal of Immunobiology','immunobiology',1,1),(706,'JIDIT','Journal of Immunological Techniques in Infectious Diseases','immunological-techniques-infectious-diseases',4,1),(707,'ipiiy','Journal of Immunology and Immunotherapy','immunology-immunotherapy',2,1),(708,'ipim','Journal of Immunology and Microbiology','immunology-microbiology',2,1),(709,'ipjio','Journal of Immunooncology','immunooncology',2,1),(710,'ipjsvp','Journal of In Silico & In Vitro Pharmacology','in-silico-vitro-pharmacology',2,1),(711,'aajiec','Journal of Industrial and Environmental Chemistry','industrial-environmental-chemistry',2,1),(712,'jiea','Journal of Industrial Electronics and Applications','industrial-electronics-applications',4,1),(713,'ipc','Journal of Industrial Pollution Control','industrial-pollution-control',1,1),(714,'jidp','Journal of Infectious Disease and Pathology','infectious-disease-pathology',1,1),(716,'jidith','Journal of Infectious Diseases & Immune Therapies','infectious-diseases-immune-therapies',4,1),(717,'jadpr','Journal of Infectious Diseases & Preventive Medicine','infectious-diseases-preventive-medicine',1,1),(718,'aajidmm','Journal of Infectious Diseases and Medical Microbiology','infectious-diseases-medical-microbiology',2,1),(719,'jidm','Journal of Infectious Diseases and Medicine','infectious-diseases-medicine',1,1),(720,'jidt','Journal of Infectious Diseases and Therapy','infectious-diseases-therapy',1,1),(721,'ipjidt','Journal of Infectious Diseases and Treatment','infectious-diseases-treatment',2,1),(722,'jidd','Journal of Infectious Diseases and  Diagnosis','infectious-diseases-diagnosis',1,1),(723,'jibdd','Journal of Inflammatory Bowel Diseases & Disorders','inflammatory-bowel-diseases-disorders',1,1),(724,'jitse','Journal of Information Technology & Software Engineering','information-technology-software-engineering',1,1),(725,'ipjoc','Journal of Insights in Chest Diseases','insights-chest-diseases',2,1),(726,'jio','Journal of Integrative Oncology','integrative-oncology',1,1),(727,'ipjicc','Journal of Intensive and Critical Care','intensive-critical-care',2,1),(728,'aaiccn','Journal of Intensive and Critical Care Nursing','intensive-critical-care-nursing',2,1),(729,'jibr','Journal of International Business Research','international-business-research',2,1),(730,'jibc','JOURNAL OF INTERNET BANKING AND COMMERCE','internet-banking-commerce',1,1),(731,'jigc','Journal of Interventional and General Cardiology ','interventional-general-cardiology',1,1),(732,'oain','Journal of Interventional Nephrology','interventional-nephrology',3,1),(733,'aainic','Journal of Invasive and Non-Invasive Cardiology','invasive-non-invasive-cardiology',2,1),(734,'aajpbs','Journal of Juvnenile Psychology and Behavioural Sciences','juvnenile-psychology-behavioural-sciences',2,1),(735,'jok','Journal of Kidney','kidney',1,1),(736,'jlc','Journal of Labor and Childbirth ','labor-childbirth',1,1),(737,'jlop','Journal of Lasers, Optics & Photonics ','lasers-optics-photonics',1,1),(738,'jleri','Journal of Legal, Ethical and Regulatory Issues','legal-ethical-regulatory-issues',2,1),(739,'jlu','Journal of Leukemia','leukemia',1,1),(740,'jlr','Journal of Liver','liver',1,1),(741,'ipjl','Journal of Lung','lung',2,1),(742,'jlcdt','Journal of Lung Cancer Diagnosis & Treatment','lung-cancer-diagnosis-treatment',1,1),(743,'jldt','Journal of Lung Diseases & Treatment','lung-diseases-treatment',1,1),(744,'jmids','Journal of Management Information and Decision Sciences','management-information-decision-sciences',2,1),(745,'jmsrd','Journal of Marine Science: Research & Development','marine-science-research-development',1,1),(746,'jmcj','Journal of Mass Communication & Journalism','mass-communication-journalism',1,1),(747,'jme','Journal of Material Sciences & Engineering','material-sciences-engineering',1,1),(748,'jmsn','Journal of Materials Science and Nanomaterials','materials-science-nanomaterials',1,1),(749,'jmsp','Journal of Medical & Surgical Pathology','medical-surgical-pathology',1,1),(750,'jmdm','Journal of Medical Diagnostic Methods','medical-diagnostic-methods',1,1),(751,'jmmd','Journal of Medical Microbiology & Diagnosis','medical-microbiology-diagnosis',1,1),(752,'ipmmi','Journal of Medical Microbiology and Immunology','medical-microbiology-immunology',2,1),(753,'ipmo','Journal of Medical Oncology','medical-oncology',2,1),(754,'jmot','Journal of Medical Oncology and Therapeutics','medical-oncology-therapeutics',2,1),(755,'jmpt','Journal of Medical Physiology & Therapeutics','medical-physiology-therapeutics',1,1),(756,'ipjmrhe','Journal of Medical Research & Health Education','medical-research-health-education',2,1),(757,'ipjmtcm','Journal of Medical Toxicology and Clinical Forensic Medicine','medical-toxicology-clinical-forensic-medicine',2,1),(758,'jmtr','Journal of Medical Toxicology Research','medical-toxicology-research',4,1),(759,'ijjmms','Journal of Medicine and Medical Sciences','medicine-medical-sciences',3,1),(760,'jmst','Journal of Membrane Science & Technology','membrane-science-technology',1,1),(761,'jomg','Journal of Meningitis','meningitis',1,1),(762,'jmt','Journal of Mental Disorders and Treatment','mental-disorders-treatment',1,1),(763,'aajmha','Journal of Mental Health and Aging','mental-health-aging',2,1),(764,'jms','Journal of Metabolic Syndrome','metabolic-syndrome',1,1),(765,'ipmb','Journal of Metabolism','metabolism',2,1),(766,'jmbt','Journal of Microbial & Biochemical Technology','microbial-biochemical-technology',1,1),(767,'jmp','Journal of Microbial Pathogenesis','microbial-pathogenesis',1,1),(768,'jmbp','Journal of Microbiology and pathology','microbiology-pathology',1,1),(769,'ipmcb','Journal of Molecular and Cellular Biochemistry','molecular-cellular-biochemistry',2,1),(770,'jmgm','Journal of Molecular and Genetic Medicine','molecular-genetic-medicine',1,1),(771,'ipjmbb','Journal of Molecular Biology and Biotechnology','molecular-biology-biotechnology',2,1),(772,'JMBM','Journal of Molecular Biology and Methods','molecular-biology-methods',4,1),(773,'jmbd','Journal of Molecular Biomarkers & Diagnosis','molecular-biomarkers-diagnosis',1,1),(774,'ipmgm','Journal of Molecular Genetics and Medicine','molecular-genetics-medicine',2,1),(775,'jmid','Journal of Molecular Imaging & Dynamics','molecular-imaging-dynamics',1,1),(776,'jmi','Journal of Molecular Immunology','molecular-immunology',1,1),(777,'aammt','Journal of Molecular Medicine and Therapy','molecular-medicine-therapy',2,1),(778,'ipmm','Journal of Molecular Microbiology','molecular-microbiology',2,1),(779,'aajmor','Journal of Molecular Oncology Research','molecular-oncology-research',2,1),(780,'jmpopr','Journal of Molecular Pharmaceutics & Organic Process Research ','molecular-pharmaceutics-organic-process-research',1,1),(781,'ipmsc','Journal of Molecular Sciences','molecular-sciences',2,1),(782,'jma','Journal of Morphology and Anatomy','morphology-anatomy',1,1),(783,'jmir','Journal of Mucosal Immunology research','mucosal-immunology-research',1,1),(784,'JMSO','Journal of Multiple Sclerosis','multiple-sclerosis',1,1),(785,'jnbd','Journal of Nanomedicine & Biotherapeutic Discovery','nanomedicine-biotherapeutic-discovery',1,1),(786,'jnmnt','Journal of Nanomedicine & Nanotechnology','nanomedicine-nanotechnology',1,1),(787,'ipnnr','Journal of Nanoscience & Nanotechnology Research','nanoscience-nanotechnology-research',2,1),(788,'jncr','Journal of Nanosciences: Current Research','nanosciences-current-research',1,1),(789,'jnppr','Journal of Natural Product and Plant Resources','natural-product-plant-resources',3,1),(790,'jnb','Journal of Neonatal Biology','neonatal-biology',1,1),(791,'ipjns','Journal of Neonatal Studies','neonatal-studies',2,1),(792,'ipjn','Journal of Neoplasm','neoplasm',2,1),(793,'jnrd','Journal of Nephrology & Renal Diseases','nephrology-renal-diseases',4,1),(794,'jnt','Journal of Nephrology & Therapeutics','nephrology-therapeutics',1,1),(795,'ipnt','Journal of Nephrology and Transplantation','nephrology-transplantation',2,1),(796,'jnor','Journal of Neuro-Ophthalmology Research','neuro-ophthalmology-research',1,1),(797,'ipjndd','Journal of Neurodegenerative Diseases & Disorders ','neurodegenerative-diseases-disorders',2,1),(798,'jnr','Journal of Neuroendocrinology Research','neuroendocrinology-research',1,1),(799,'jnid','Journal of Neuroinfectious Diseases','neuroinfectious-diseases',1,1),(800,'aann','Journal of Neuroinformatics and Neuroimaging','neuroinformatics-neuroimaging',2,1),(801,'jnd','Journal of Neurological Disorders','neurological-disorders',1,1),(802,'jnn','Journal of Neurology & Neurophysiology','neurology-neurophysiology',1,1),(803,'jnnr','Journal of Neurology and Neurorehabilitation Research','neurology-neurorehabilitation-research',2,1),(804,'ipjnn','Journal of Neurology and Neuroscience','neurology-neuroscience',2,1),(805,'ipjno','Journal of Neurooncology: Open Access','neurooncology-open-access',2,1),(806,'ipjnp','Journal of Neuropsychiatry','neuropsychiatry',2,1),(807,'jnscr','Journal of Neuroscience & Clinical Research','neuroscience-clinical-research',4,1),(808,'ncoa','Journal of Neuroscience and Neuropharmacology','neuroscience-neuropharmacology',1,1),(809,'jngsa','Journal of Next Generation: Sequencing & Applications','next-generation-sequencing-applications',1,1),(810,'jnp','Journal of Novel Physiotherapies','novel-physiotherapies',1,1),(811,'jnmrt','Journal of Nuclear Medicine & Radiation Therapy','nuclear-medicine-radiation-therapy',1,1),(812,'jnc','Journal of Nursing & Care','nursing-care',1,1),(813,'jnpc','Journal of Nursing & Patient Care','nursing-patient-care',4,1),(814,'ipjnhs','Journal of Nursing and Health Studies','nursing-health-studies',2,1),(815,'jnfs','Journal of Nutrition & Food Sciences','nutrition-food-sciences',1,1),(816,'awmd','Journal of Nutrition & Weight Loss','nutrition-weight-loss',1,1),(817,'jndi','Journal of Nutrition and Dietetics','nutrition-dietetics',1,1),(818,'aanhh','Journal of Nutrition and Human Health','nutrition-human-health',2,1),(819,'snt','Journal of Nutrition Science Research','nutrition-science-research',1,1),(820,'jndt','Journal of Nutritional Disorders & Therapy','nutritional-disorders-therapy',1,1),(821,'jowt','Journal of Obesity & Weight  Loss Therapy','obesity-weight-loss-therapy',1,1),(822,'jomb','Journal of Obesity and Metabolism','obesity-metabolism',1,1),(823,'jot','Journal of Obesity and Therapeutics','obesity-therapeutics',4,1),(824,'ocn','Journal of Oceanography and Marine Research','oceanography-marine-research',1,1),(825,'joii','Journal of Ocular Infection and Inflammation','ocular-infection-inflammation',1,1),(826,'joy','Journal of Odontology','odontology',1,1),(827,'jotr','Journal of Oncology Translational Research','oncology-translational-research',1,1),(828,'ipocr','Journal of Oncopathology and Clinical Research','oncopathology-clinical-research',2,1),(829,'johh','Journal of Oral Hygiene & Health','oral-hygiene-health',1,1),(830,'ipom','Journal of Oral Medicine','oral-medicine',2,1),(831,'aaomt','Journal of Oral Medicine and Toxicology','oral-medicine-toxicology',2,1),(832,'ipjoic','Journal of Organic & Inorganic Chemistry','organic-inorganic-chemistry',2,1),(834,'joccc','Journal of Organizational Culture, Communications and Conflict','organizational-culture-communications-conflict',2,1),(835,'ipjoe','Journal of Orthodontics & Endodontics','orthodontics-endodontics',2,1),(836,'apjot','Journal of Orthopaedics and Trauma','orthopaedics-trauma',4,1),(838,'ipod','Journal of Orthopedic Disorders','orthopedic-disorders',2,1),(839,'joo','Journal of Orthopedic Oncology','orthopedic-oncology',1,1),(840,'aaosr','Journal of Orthopedic Surgery and Rehabilitation','orthopedic-surgery-rehabilitation',2,1),(841,'joas','Journal of Osteoarthritis','osteoarthritis',1,1),(842,'jopa','Journal of Osteoporosis and Physical Activity','osteoporosis-physical-activity',1,1),(843,'plm','Journal of Paediatric Laboratory Medicine','paediatric-laboratory-medicine',1,1),(844,'jpar','Journal of Pain & Relief','pain-relief',1,1),(846,'aapmt','Journal of Pain Management and Therapy','pain-management-therapy',2,1),(847,'jpcm','Journal of Palliative Care  & Medicine','palliative-care-medicine',1,1),(848,'aapddt','Journal of Parasitic Diseases: Diagnosis and Therapy','parasitic-diseases-diagnosis-therapy',2,1),(849,'ipjpr','Journal of Pathogen Research','pathogen-research',2,1),(850,'ipjpe','Journal of Pathology & Epidemiology','pathology-epidemiology',2,1),(851,'aapdb','Journal of Pathology and Disease Biology','pathology-disease-biology',2,1),(852,'jpc','Journal of Patient Care','patient-care',1,1),(853,'ipjpc','Journal of Pediatric Care','pediatric-care',2,1),(854,'jpnm','Journal of Pediatric Neurology and Medicine','pediatric-neurology-medicine',1,1),(855,'jpcic','Journal of Perioperative & Critical Intensive Care Nursing','perioperative-critical-intensive-care-nursing',1,1),(856,'jpme','Journal of Perioperative Medicine','perioperative-medicine',1,1),(857,'jpeb','Journal of Petroleum & Environmental Biotechnology','petroleum-environmental-biotechnology',1,1),(858,'jpchs','Journal of Pharmaceutical Care & Health Systems','pharmaceutical-care-health-systems',1,1),(859,'aapccs','Journal of Pharmaceutical Chemistry and Chemical Science ','pharmaceutical-chemistry-chemical-science',2,1),(860,'pe','Journal of Pharmaceutical Economics and Policy Studies','pharmaceutical-economics-policy-studies',1,1),(861,'ipjphm','Journal of Pharmaceutical Microbiology','pharmaceutical-microbiology',2,1),(862,'jprcp','Journal of Pharmaceutical Research and Clinical Practice','pharmaceutical-research-clinical-practice',1,1),(863,'jpsed','Journal of Pharmaceutical Sciences & Emerging Drugs ','pharmaceutical-sciences-emerging-drugs',4,1),(864,'jpp','Journal of Pharmacogenomics & Pharmacoproteomics ','pharmacogenomics-pharmacoproteomics',1,1),(865,'jpnp','Journal of Pharmacognosy & Natural Products','pharmacognosy-natural-products',1,1),(866,'jpet','Journal of Pharmacokinetics & Experimental Therapeutics','pharmacokinetics-experimental-therapeutics',1,1),(867,'jpr','Journal of Pharmacological Reports','pharmacological-reports',1,1),(868,'ipprr','Journal of Pharmacological Reviews and Reports','pharmacological-reviews-reports',2,1),(869,'aajptr','Journal of Pharmacology and Therapeutic Research\r\n','pharmacology-therapeutic-research\r\n',2,1),(870,'jp','Journal of Pharmacovigilance','pharmacovigilance',1,1),(871,'ipipr','Journal of Pharmacy & Pharmaceutical Research','pharmacy-pharmaceutical-research',2,1),(872,'ipppe','Journal of Pharmacy Practice and Education','pharmacy-practice-education',2,1),(873,'jpay','Journal of Phonetics & Audiology','phonetics-audiology',1,1),(874,'jpgeb','Journal of Phylogenetics & Evolutionary Biology','phylogenetics-evolutionary-biology',1,1),(875,'jpcb','Journal of Physical Chemistry & Biophysics','physical-chemistry-biophysics',1,1),(876,'jpm','Journal of Physical Mathematics','physical-mathematics',1,1),(877,'aajptsm','Journal of Physical Therapy and Sports Medicine','physical-therapy-sports-medicine',2,1),(878,'tsjpa','Journal of Physics & Astronomy','physics-astronomy',3,1),(879,'jpra','Journal of Physics Research and Applications','physics-research-applications',4,1),(880,'jppr','Journal of Physiotherapy & Physical Rehabilitation','physiotherapy-physical-rehabilitation',1,1),(881,'jptr','Journal of Physiotherapy and Rehabilitation','physiotherapy-rehabilitation',4,1),(882,'ippr','Journal of Physiotherapy Research','physiotherapy-research',2,1),(883,'jpbi','Journal of Phytochemistry & Biochemistry','phytochemistry-biochemistry',1,1),(884,'JPD','Journal of Pigmentary Disorders','pigmentary-disorders',1,1),(885,'prt','Journal of Pituitary Research & Treatment','pituitary-research-treatment',1,1),(886,'jpbp','Journal of Plant Biochemistry & Physiology','plant-biochemistry-physiology',1,1),(887,'ippba','Journal of Plant Biology and Agriculture Sciences','plant-biology-agriculture-sciences',2,1),(888,'aapbm','Journal of Plant Biotechnology and Microbiology','plant-biotechnology-microbiology',2,1),(889,'jpgb','Journal of Plant Genetics and Breeding','plant-genetics-breeding',1,1),(890,'jppm','Journal of Plant Pathology & Microbiology','plant-pathology-microbiology',1,1),(891,'ipjpsar','Journal of Plant Sciences and Agricultural Research','plant-sciences-agricultural-research',2,1),(892,'jpsc','Journal of Plastic Surgery and Cosmetology','plastic-surgery-cosmetology',4,1),(893,'jpspa','Journal of Political Sciences & Public Affairs','political-sciences-public-affairs',1,1),(894,'pollution','Journal of Pollution','pollution',1,1),(895,'jpe','Journal of Pollution Effects & Control','pollution-effects-control',1,1),(896,'jpsa','Journal of Polymer Science & Applications','polymer-science-applications',4,1),(897,'jpmm','Journal of Powder Metallurgy & Mining','powder-metallurgy-mining',1,1),(898,'jpch','Journal of Pregnancy and Child Health','pregnancy-child-health',1,1),(899,'ipjpn','Journal of Pregnancy and Neonatal Medicine','pregnancy-neonatal-medicine',2,1),(900,'ipjpic','Journal of Prevention and Infection Control','prevention-infection-control',2,1),(901,'ipjpm','Journal of Preventive Medicine','preventive-medicine',2,1),(902,'aapcgp','Journal of Primary Care and General Practice','primary-care-general-practice',2,1),(903,'jpmt','Journal of Primatology','primatology',1,1),(904,'jph','Journal of Probiotics & Health','probiotics-health',1,1),(905,'jps','Journal of Prostate Cancer','prostate-cancer',1,1),(906,'jpb','Journal of Proteomics & Bioinformatics','proteomics-bioinformatics',1,1),(907,'JPEY','Journal of Proteomics & Enzymology','proteomics-enzymology',4,1),(908,'ipprt','Journal of Psychiatry Research and Treatment','psychiatry-research-treatment',2,1),(909,'jop','Journal of Psychiatry: Open Access ','psychiatry-open-access',1,1),(910,'jpac','Journal of Psychological Abnormalities in Children','psychological-abnormalities-children',1,1),(911,'jppt','Journal of Psychology & Psychotherapy','psychology-psychotherapy',1,1),(912,'ipjpbs','Journal of Psychology and Brain Studies','psychology-brain-studies',2,1),(913,'aajpc','Journal of Psychology and Cognition','psychology-cognition',2,1),(914,'aajphn','Journal of Public Health and Nutrition','public-health-nutrition',2,1),(915,'aaphp','Journal of Public Health Policy and Planning','public-health-policy-planning',2,1),(916,'jprm','Journal of Pulmonary & Respiratory Medicine','pulmonary-respiratory-medicine',1,1),(917,'pmj','Journal of Pulmonary Medicine','pulmonary-medicine',4,1),(918,'aajpcr','Journal of Pulmonology and Clinical Research','pulmonology-clinical-research',2,1),(919,'jprd','Journal of Pulmonology and Respiratory Diseases','pulmonology-respiratory-diseases',1,1),(920,'iprddt','Journal of Rare Disorders: Diagnosis & Therapy','rare-disorders-diagnosis-therapy',2,1),(921,'ipjrm','Journal of Renal Medicine','renal-medicine',2,1),(922,'jrb','Journal of Reproductive Biomedicine','reproductive-biomedicine',1,1),(923,'ipjrei','Journal of Reproductive Endocrinology & Infertility','reproductive-endocrinology-infertility',2,1),(924,'jrd','Journal of Research and Development','research-development',1,1),(925,'jreif','Journal of Research in Economics and International','research-economics-international',3,1),(926,'jrest','Journal of Research in Environmental Science and Toxicology','research-environmental-science-toxicology',3,1),(927,'jribm','Journal of Research in International Business and Management','research-international-business-management',3,1),(928,'jrmds','Journal of Research in Medical and Dental Science','research-medical-dental-science',3,1),(929,'irjrnm','Journal of research in nursing and midwifery','research-nursing-midwifery',3,1),(930,'jrm','Journal of Respiratory Medicine','respiratory-medicine',1,1),(931,'ipjrdt','Journal of Retinal Disorders & Transplantation','retinal-disorders-transplantation',2,1),(932,'jrgs','Journal of RNA and Genomics','rna-genomics',2,1),(933,'ipjmt','Journal of Scientific and Industrial Metrology','scientific-industrial-metrology',2,1),(935,'ipjsm','Journal of Sinusitis and Migraine','sinusitis-migraine',2,1),(936,'jsdt','Journal of Sleep Disorders & Therapy','sleep-disorders-therapy',1,1),(937,'jsc','Journal of Socialomics','socialomics',1,1),(938,'jsph','Journal of Soil Science & Plant Health','soil-science-plant-health',4,1),(939,'tsse','Journal of Space Exploration','space-exploration',3,1),(940,'jspt','Journal of Speech Pathology & Therapy','speech-pathology-therapy',1,1),(941,'jsp','Journal of Spine','spine',1,1),(942,'jsmds','Journal of Sports Medicine & Doping Studies','sports-medicine-doping-studies',1,1),(943,'ipjscbt','Journal of Stem Cell Biology and Transplantation','stem-cell-biology-transplantation',2,1),(944,'jscrt','Journal of Stem Cell Research & Therapy','stem-cell-research-therapy',1,1),(945,'jshs','Journal of Steroids & Hormonal Science','steroids-hormonal-science',1,1),(946,'jsft','Journal of Stock & Forex Trading','stock-forex-trading',1,1),(947,'aajse','Journal of Stroke and Epilepsy','clinical-experimental-neurology',2,1),(948,'jscp','Journal of Surgery & Clinical Practice','surgery-clinical-practice',4,1),(949,'jsa','Journal of Surgery and Anesthesia','surgery-anesthesia',1,1),(950,'ipjsem','Journal of Surgery and Emergency Medicine','surgery-emergency-medicine',2,1),(951,'jos','Journal of Surgery [Jurnalul de Chirurgie]','surgery-jurnalul-de-chirurgie',1,1),(952,'jspd','Journal of Surgical Pathology and Diagnosis','surgical-pathology-diagnosis',1,1),(953,'aasbpr','Journal of Systems Biology & Proteome Research','systems-biology-proteome-research',2,1),(954,'jtsm','Journal of Telecommunications System & Management','telecommunications-system-management',1,1),(955,'jtese','Journal of Textile Science & Engineering','textile-science-engineering',1,1),(956,'jiacs','Journal of the International Academy for Case Studies','international-academy-case-studies',2,1),(957,'pancreas','Journal of the Pancreas','pancreas',1,1),(958,'jtco','Journal of Theoretical & Computational Science','theoretical-computational-science',1,1),(959,'jtc','Journal of Thermodynamics & Catalysis','thermodynamics-catalysis',1,1),(960,'jtcoa','Journal of Thrombosis and Circulation: Open Access','thrombosis-circulation-open-access',1,1),(961,'jtdt','Journal of Thyroid Disorders & Therapy','thyroid-disorders-therapy',1,1),(962,'jtse','Journal of Tissue Science & Engineering','tissue-science-engineering',1,1),(963,'jth','Journal of Tourism & Hospitality','tourism-hospitality',1,1),(964,'ipta','Journal of Toxicological Analysis','toxicological-analysis',2,1),(965,'jham','Journal of Traditional Medicine & Clinical Naturopathy','traditional-medicine-clinical-naturopathy',1,1),(966,'ipnbt','Journal of Translational Neurosciences','translational-neurosciences',2,1),(967,'aatr','Journal of Translational Research ','translational-research',2,1),(968,'ipjtdi','Journal of Transmitted Diseases and Immunity','transmitted-diseases-immunity',2,1),(969,'jttr','Journal of Transplantation Technologies & Research','transplantation-technologies-research',1,1),(970,'aajtcc','Journal of Trauma and Critical  Care','trauma-critical-care',2,1),(971,'aatcc','Journal of Trauma and Critical Care','trauma-critical-care',2,1),(972,'ipton','Journal of Trauma and Orthopedic Nursing','trauma-orthopedic-nursing',2,1),(973,'jtr','Journal of Trauma and Rehabilitation','trauma-rehabilitation',4,1),(974,'jtd','Journal of Tropical Diseases','tropical-diseases',1,1),(975,'jtt','Journal of Tuberculosis and Therapeutics','tuberculosis-therapeutics',1,1),(976,'jtdr','Journal of Tumor Research','tumor-research',1,1),(977,'jtrr','Journal of Tumour Research & Reports','tumour-research-reports',1,1),(978,'ipjus','Journal of Universal Surgery','universal-surgery',2,1),(979,'jvct','Journal of Vaccines & Clinical Trials','vaccines-clinical-trials',4,1),(980,'jvv','Journal of Vaccines & Vaccination','vaccines-vaccination',1,1),(981,'ipjves','Journal of Vascular and Endovascular Therapy','vascular-endovascular-therapy',2,1),(982,'jvms','Journal of Vascular Medicine & Surgery','vascular-medicine-surgery',1,1),(983,'jov','Journal of Vasculitis','vasculitis',1,1),(984,'aavmas','Journal of Veterinary Medicine and Allied Science','veterinary-medicine-allied-science',2,1),(985,'jvmh','Journal of Veterinary Medicine and Health','veterinary-medicine-health',1,1),(986,'ipjvms','Journal of Veterinary Medicine and Surgery','veterinary-medicine-surgery',2,1),(987,'jvpr','Journal of Veterinary Pathology Research','veterinary-research-journal',1,1),(988,'jvst','Journal of Veterinary Science & Technology','veterinary-science-technology',1,1),(989,'JVA','Journal of Virology & Antiviral Research ','virology-antiviral-research',4,1),(990,'ipwpc','Journal of Water Pollution and Control','water-pollution-control',2,1),(991,'jwh','Journal of Womens Health Care','womens-health-care',1,1),(992,'ipwhrm','Journal of Women’s Health and Reproductive Medicine','womens-health-reproductive-medicine',2,1),(993,'jypt','Journal of Yoga & Physical Therapy','yoga-physical-therapy',1,1),(994,'JYPTY','Journal of Yoga Practice and Therapy','yoga-practice-therapy',4,1),(995,'ipjzdph','Journal of Zoonotic Diseases and Public Health','zoonotic-diseases-public-health',2,1),(996,'kdc','Kidney Disorders and Clinical Practices','kidney-disorders-clinical-practices',1,1),(997,'lpma','La Prensa Medica','la-prensa-medica',4,1),(998,'PULJLDT','Liver: Disease & Transplantation','liver-disease-transplantation',4,1),(999,'lovotics','Lovotics','lovotics',1,1),(1000,'loa','Lupus: Open Access','lupus-open-access',1,1),(1001,'tsm','Macromolecules: An Indian Journal','macromolecules-an-indian-journal',3,1),(1002,'mcce','Malaria Chemotherapy, Control & Elimination','malaria-chemotherapy-control-elimination',1,1),(1003,'JMBO','Marine Biology & Oceanography ','marine-biology-oceanography',4,1),(1004,'mso','Mass Spectrometry & Purification Techniques','mass-spectrometry-purification-techniques',1,1),(1005,'aamsn','Materials Science and Nanotechnology','materials-science-nanotechnology',2,1),(1006,'tsms','Materials Science: An Indian Journal','materials-science-an-indian-journal',3,1),(1007,'mpn','Maternal and Pediatric Nutrition','maternal-pediatric-nutrition',1,1),(1008,'ipmcr','Medical & Clinical Reviews','medical-clinical-reviews',2,1),(1009,'ucr','Medical & Surgical Urology','medical-surgical-urology',1,1),(1010,'ipmcrs','Medical Case Reports','medical-case-reports',2,1),(1011,'jmis','Medical Implants & Surgery','medical-implants-surgery',1,1),(1012,'mmr','Medical Microbiology Reports','medical-microbiology-reports',4,1),(1013,'mmo','Medical Mycology: Open Access','medical-mycology-open-access',1,1),(1014,'mrcs','Medical Reports & Case Studies','medical-reports-case-studies',1,1),(1015,'msgh','Medical Safety & Global Health','medical-safety-global-health',1,1),(1016,'map','Medicinal & Aromatic Plants','medicinal-aromatic-plants',1,1),(1017,'mccr','Medicinal Chemistry','medicinal-chemistry',1,1),(1018,'ipmhfm','Mental Health in Family Medicine','mental-health-family-medicine',2,1),(1019,'jpdbd','Metabolomics:Open Access','metabolomics-open-access',1,1),(1020,'ipjom','Metrology','metrology',2,1),(1021,'tsmy','Microbiology: An International Journal','microbiology-an-international-journal',3,1),(1022,'aamcr','Microbiology: Current Research','microbiology-current-research',2,1),(1023,'mca','Modern Chemistry & Applications','modern-chemistry-applications',1,1),(1024,'mp','Modern Phytomorphology','modern-phytomorphology',3,1),(1025,'mbl','Molecular Biology','molecular-biology',1,1),(1026,'JMCGR','Molecular Cloning & Genetic Recombination','molecular-cloning-genetic-recombination',4,1),(1027,'ipmedt','Molecular Enzymology and Drug Targets','molecular-enzymology-drug-targets',2,1),(1028,'jmhmp','Molecular Histology & Medical Physiology','molecular-histology-medical-physiology',1,1),(1029,'MMT','Molecular Medicine & Therapeutics','molecular-medicine-therapeutics',4,1),(1030,'mdtl','Mycobacterial Diseases','mycobacterial-diseases',1,1),(1031,'ipnto','Nano Research & Applications','nano-research-applications',2,1),(1032,'tsnsnt','Nano Science & Nano Technology: An Indian Journal','nano-science-nano-technology-an-indian-journal',3,1),(1033,'JNMN','Nanomaterials & Molecular Nanotechnology','nanomaterials-molecular-nanotechnology',4,1),(1034,'npcr','Natural Products Chemistry & Research','natural-products-chemistry-research',1,1),(1035,'tsnp','Natural Products: An Indian Journal','natural-products-an-indian-journal',3,1),(1037,'nnp','Neonatal Medicine','neonatal-medicine',1,1),(1038,'ipnsj','Neurological Science Journal','neurological-science-journal',2,1),(1039,'aanr','Neurophysiology Research','neurophysiology-research',2,1),(1040,'tsjnp','Neuropsychiatry','neuropsychiatry',3,1),(1041,'npoa','Neuroscience and Psychiatry: Open Access','neuroscience-psychiatry-open-access',1,1),(1042,'ipnbi','Neurosciences & Brain Imaging','neurosciences-brain-imaging',2,1),(1043,'JNPGT','Nuclear Energy Science & Power Generation Technology','nuclear-energy-science-power-generation-technology',4,1),(1044,'ipjoed','Obesity & Eating Disorders','obesity-eating-disorders',2,1),(1045,'omha','Occupational Medicine & Health Affairs','occupational-medicine-health-affairs',1,1),(1046,'ogr','Oil & Gas Research','oil-gas-research',1,1),(1047,'roa','OMICS Journal of Radiology','omics-radiology',1,1),(1048,'occrs','Oncology & Cancer Case Reports','oncology-cancer-case-reports',1,1),(1049,'obr','Ophthalmology Case Reports','ophthalmology-case-reports',2,1),(1050,'omoa','Optometry: Open Access','optometry-open-access',1,1),(1051,'ohdm','Oral Health and Dental Management','oral-health-dental-management',1,1),(1052,'ohcr','Oral Health Case Reports','oral-health-case-reports',1,1),(1053,'tsoc','Organic Chemistry: An Indian Journal','organic-chemistry-an-indian-journal',3,1),(1054,'occr','Organic Chemistry: Current Research','organic-chemistry-current-research',1,1),(1055,'omcr','Orthopedic & Muscular System: Current Research','orthopedic-muscular-system-current-research',1,1),(1056,'jorl','Otolaryngology Online Journal','otolaryngology-online-journal',2,1),(1057,'ocr','Otolaryngology: Open Access ','otolaryngology-open-access',1,1),(1058,'JOR','Otology & Rhinology','otology-rhinology',4,1),(1059,'OED','Outlook on Emerging Drugs','outlook-emerging-drugs',4,1),(1060,'pdt','Pancreatic Disorders & Therapy ','pancreatic-disorders-therapy',1,1),(1061,'pcnr','Pediatric Care & Nursing','pediatric-care-nursing',1,1),(1062,'pdc','Pediatric Dental Care','pediatric-dental-care',1,1),(1063,'ippecm','Pediatric Emergency Care and Medicine: Open Access','pediatric-emergency-care-medicine-open-access',2,1),(1064,'ippido','Pediatric Infectious Diseases: Open Access','pediatric-infectious-diseases-open-access',2,1),(1065,'po','Pediatric Oncology: Open Access','pediatric-oncology-open-access',1,1),(1066,'ipphr','Pediatrics & Health Research','pediatrics-health-research',2,1),(1067,'ptcr','Pediatrics & Therapeutics','pediatrics-therapeutics',1,1),(1068,'ippdpd','Periodontics and Prosthodontics: Open Access','periodontics-prosthodontics-open-access',2,1),(1069,'paa','Pharmaceutica Analytica Acta','pharmaceutica-analytica-acta',1,1),(1070,'paco','Pharmaceutical Analytical Chemistry: Open Access','pharmaceutical-analytical-chemistry-open-access',1,1),(1071,'pbp','Pharmaceutical Bioprocessing','pharmaceutical-bioprocessing',2,1),(1072,'ippbcr','Pharmaceutical Biotechnology: Current Research','pharmaceutical-biotechnology-current-research',2,1),(1073,'pbt','Pharmaceutical Regulatory Affairs: Open Access','pharmaceutical-regulatory-affairs-open-access',1,1),(1074,'JPDDR','Pharmaceutics & Drug Delivery Research ','pharmaceutics-drug-delivery-research',4,1),(1075,'jdtba','Journal of Diagnostic Techniques and Biomedical Analysis','diagnostic-techniques-biomedical-analysis',4,1),(1076,'tspc','Physical Chemistry: An Indian Journal','physical-chemistry-an-indian-journal',3,1),(1077,'JPBM','Physiobiochemical Metabolism','physiobiochemical-metabolism',4,1),(1078,'JPPP','Plant  Physiology & Pathology ','plant-physiology-pathology',4,1),(1079,'IJPAES','Plant Animal and Environmental Sciences','plant-animal-environmental-sciences',1,1),(1080,'aapdbs','Plant Diseases and Biomarker','plant-diseases-biomarker',2,1),(1081,'ipps','Polymer Sciences','polymer-sciences',2,1),(1082,'pfw','Poultry, Fisheries & Wildlife Sciences','poultry-fisheries-wildlife-sciences',1,1),(1083,'jphc','Primary Health Care: Open Access','primary-health-care-open-access',1,1),(1084,'pooj','Prosthetics and Orthotics: Open Journal','prosthetics-orthotics-open-journal',2,1),(1085,'proa','Psoriasis & Rosacea Open 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Vibes is a publication for and about culturally Deaf, oral deaf','2015-11-28'),(172,'ajvib','Archive','Vibes | Archive','Vibes, Canadian Hearing Society, CHS','CHS is a professional, non-profit organization that is dedicated to promoting and maintaining the highest possible standards for its members','2015-11-28'),(173,'ajct','Home','CASLPO TODAY','CASLPO, TODAY, OAOO','CASLPO Today is the official publication of the College of Audiologists and Speech-Language Pathologists of Ontario (CASLPO).','2015-11-28'),(174,'ajct','Archive','CASLPO TODAY | Archive','CASLPO TODAY, OAOO','In Ontario, audiology and speech-language pathology are among several health care professions in the province with self-governing status','2015-11-28'),(175,'ajle','Home','Listen / Ecoute','Listen, Ecoute, CHHA','Listen/Écoute is the official publication of the Canadian Hard of Hearing Association (CHHA)','2015-11-28'),(176,'ajle','Archive','Listen / Ecoute | Archive','ListeN, Ecoute, CHHA','a non-profit organization dedicated to assisting hard of hearing people and their families.','2015-11-28'),(177,'ajsm','Home','Sound Matters','Sound, Matters, VOICE','Sound Matters is the official publication of VOICE for Hearing Impaired Children and is distributed once yearly to an audience consisting','2015-11-28'),(178,'ajsm','Archive','Sound Matters | Archive','Sound, Matters, VOICE for Hearing','as well as audiologists, teachers of the deaf and hard of hearing, educational audiologists and hearing instrument practitioners','2015-11-28'),(179,'ajcjed','Home','THE CANADIAN JOURNAL OF EDUCATORS OF THE DEAF AND HARD OF HEARING','CANADIAN, JOURNAL OF EDUCATORS OF THE DEAF AND HARD OF HEARING, CAEDHH','The Canadian Journal of Educators of the Deaf and Hard of Hearing (CJEDHH) is the official publication of the Canadian Association of Educators of the D','2015-11-28'),(180,'ajcjed','Archive','Canadian Journal of Educators of the Deaf and Hard of Hearing','Canadian, Journal of Educators of the Deaf and Hard of Hearing','CAEDHH is a national, professional organization of individuals dedicated to the educational development of individuals','2015-11-28'),(181,'ajcjrd','Home','Canadian Journal of Restorative Dentistry and Prosthodontics','Canadian, Journal of Restorative Dentistry and Prosthodontics','The Canadian Academy of Restorative Dentistry and Prosthodontics (CARDP) provides through Annual','2015-11-28'),(182,'ajcjrd','Archive','Journal of Restorative Dentistry and Prosthodontics | Archive','Canadian Journal of Restorative Dentistry and Prosthodontics, CJRDP','CARDP is comprised of Dentists from across the country as well as the USA','2015-11-28'),(184,'ajahh','Home','Allied Hearing Health','Allied, Hearing, Health','When viewing the landscape of not-for-profit hearing health organizations across Canada, it became apparent','2015-11-28'),(185,'ajahh','Archive','Allied Hearing Health | Archive','Allied, Hearing, Health','Allied Hearing Health Magazine brings these various groups together, providing a broad range of articles and information of interest','2015-11-28'),(193,'ajjmh','Home','Journal of Mens Health','Mens Health','Journal of Mens Health Published in cooperation with Andrew John Publishing Inc','2015-11-30'),(194,'ajjmh','Archive','Journal of Mens Health | Archive','Mens Health archive','Journal of Mens Health archive','2015-11-30'),(200,'ajlhr','Home','HIV Journals | AIDS Research | HIV/AIDS Research','acquired immunodeficiency syndrome, immune system, HIV, AIDS, human immunodeficiency virus (hiv)','Letters in HIV Research provides with the scientific literature on AIDS or HIV Research.','2015-12-02'),(201,'ajjncr','Home','Nanoscience Journal | Nanotechnology | Open Access Journals','nanoscience, nanoscale, nanoscience journal, nanoscience pdf, nanoscience and technology, current nanoscience, nanoscience journal list, nanoscience journal impact factor, nanoscience and technology, nanoscience definition','Journal of Nanoscience & Applications 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journals','Nanoscience experts can access all the volumes and every article published online in the Journal of Nanoscience and Applications through its archive page.','2015-12-02'),(205,'ajescs','Archive','List of Issues | Environmental Sciences Articles | Archive','environment, environmental sciences, earth sciences,  climate, climatology, climate study, types of environment, environment pollution, environmental issues, environment protection, environmental sciences journal impact factor, research journal of environmental sciences','Experts on Environmental Sciences can access all the published articles online in the Journal of Environmental Sciences and Climate Study.','2015-12-02'),(206,'ajgidl','Home','Infectious Diseases Journals | Open Access | Peer Reviewed','infectious disease journals, open access infectious disease journals, peer reviewed infectious disease journals, scientific infectious disease journals, infectious disease journals impact factor','Journal of Clinical 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acquired immunodeficiency syndrome, immune system and HIV, HIV symptoms','Article in Press contain the scholarly articles for releasing the issue of the journal.','2016-01-14'),(219,'ajlhr','Current Issue','Current Issue | Scholarly Articles | Open Access','HIV diagnosis, HIV medication, HIV drugs, treatment & HIV counseling, HIV clinical therapies','Current issue contains the list of currently published scholarly article of the journal.','2016-01-14'),(220,'ajlhr','Archive','Archive | All Issues | HIV Research','HIV clinical therapies, antiretroviral therapy, HIV-related complications','It contains all the issue and volume of the journal.','2016-01-14'),(221,'ajlhr','Contact Us','Contact Us | HIV Research | Open Access','acquired immunodeficiency syndrome, immune system, HIV, AIDS, human immunodeficiency virus','Kindly contact us for further information.','2016-01-14'),(226,'ajgidl','Guidelines','Guidelines | Journal of Clinical Infectious Diseases and Medicine','Journal of Clinical 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John, Andrew John Publishing Inc, Andrew John Publishing','Journal Plastic Surgery & Cosmetology, Contact Us.','2016-11-08'),(295,'ajjpsc','Special Issue','Journal Plastic Surgery & Cosmetology | Special Issue.','Andrew John, Andrew John Publishing Inc, Andrew John Publishing','Journal Plastic Surgery & Cosmetology, Special Issue.','2016-11-08'),(296,'ajjssph','Home','Journal of Soil Science & Plant Health.','Andrew John, Andrew John Publishing Inc, Andrew John Publishing','Journal of Soil Science & Plant Health, Home.','2016-11-08'),(297,'ajjssph','Editorial Board','Journal of Soil Science & Plant Health |Editorial Board.','Andrew John, Andrew John Publishing Inc, Andrew John Publishing','Journal of Soil Science & Plant Health, Editorial Board.','2016-11-08'),(298,'ajjssph','Guidelines','Journal of Soil Science & Plant Health |Guidelines.','Andrew John, Andrew John Publishing Inc, Andrew John Publishing','Journal of Soil Science & Plant Health, Guidelines.','2016-11-08'),(299,'ajjssph','Submit Manuscript','Journal of Soil Science & Plant Health | Submit Manuscript.','Andrew John, Andrew John Publishing Inc, Andrew John Publishing','Journal of Soil Science & Plant Health,  Submit Manuscript.','2016-11-08'),(300,'ajjssph','Articles in Press','Journal of Soil Science & Plant Health |in Press.','Andrew John, Andrew John Publishing Inc, Andrew John Publishing','Journal of Soil Science & Plant Health, in Press.','2016-11-08'),(301,'ajjssph','Current Issue','Journal of Soil Science & Plant Health | Current Issue.','Andrew John, Andrew John Publishing Inc, Andrew John Publishing','Journal of Soil Science & Plant Health, Current Issue.','2016-11-08'),(302,'ajjssph','Archive','Journal of Soil Science & Plant Health | Archive.','Andrew John, Andrew John Publishing Inc, Andrew John Publishing','Journal of Soil Science & Plant Health,  Archive.','2016-11-08'),(303,'ajjssph','Contact Us','Journal of Soil Science & Plant Health | Contact 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Manuscript','Journal of Rheumatology-SciTechnol | Submit Manuscript','Andrew John, Andrew John Publishing Inc, Andrew John Publishing','Journal of Rheumatology-SciTechnol , Submit Manuscript.','2016-11-08'),(322,'ajjrs','Articles in Press','Journal of Rheumatology-SciTechnol | in Press','Andrew John, Andrew John Publishing Inc, Andrew John Publishing','Journal of Rheumatology-SciTechnol , in Press.','2016-11-08'),(323,'ajjrs','Current Issue','Journal of Rheumatology-SciTechnol | Current Issue','Andrew John, Andrew John Publishing Inc, Andrew John Publishing','Journal of Rheumatology-SciTechnol , Current Issue.','2016-11-08'),(324,'ajjrs','Archive','Journal of Rheumatology-SciTechnol | Archive','Andrew John, Andrew John Publishing Inc, Andrew John Publishing','Journal of Rheumatology-SciTechnol , Archive.','2016-11-08'),(325,'ajjrs','Contact Us','Journal of Rheumatology-SciTechnol | Contact Us','Andrew John, Andrew John Publishing Inc, Andrew John Publishing','Journal of Rheumatology-SciTechnol , Contact Us.','2016-11-08'),(326,'ajjrs','Special Issue','Journal of Rheumatology-SciTechnol | Special Issue','Andrew John, Andrew John Publishing Inc, Andrew John Publishing','Journal of Rheumatology-SciTechnol , Special Issue.','2016-11-08'),(327,'ajchr','Articles in Press','Canadian Hearing Report | Articles in press','Canadian, Hearing, Report','Andrew John Publishing Inc. is pleased to announce the launch of this new fully','2022-11-17'),(328,'ajchr','Awards & Nominations','Canadian Hearing Report | Awards & Nominations','Canadian, Hearing, Report, Awards & Nominations','Andrew John Publishing Inc. is pleased to announce the launch of Awards & Nominations category','2023-06-13'),(329,'ajchr','Editorial Board','Canadian Hearing Report | Editorial Board','Canadian, Hearing, Report, Editorial Board','Andrew John Publishing Inc. is pleased to announce it\'s Editorial Board','2023-06-13');
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INSERT INTO `society_info` VALUES (1,'ajsm','<div>\r\n<h3>Official Publication of  VOICE  for Hearing Impaired Children</h3>\r\n<a title=\"click here\" href=\"http://www.voicefordeafkids.com/\" target=\"_blank\"> <img border=\"0\" class=\"soc_img\" src=\"http://www.andrewjohnpublishing.com/images/publications/soundmatters/Voice_Logo_white1bg_001.jpg\" alt=\"soundmatters\" /></a></div>','2015-11-28'),(2,'ajchr','<div><a title=\"Click here\" href=\"http://www.chr-search.com/\" target=\"_blank\"> <img border=\"0\" class=\"soc_img\" src=\"http://www.andrewjohnpublishing.org/images/associations/canadian-hearing-report.jpg\" alt=\"canadian\" /><br />\r\n<br />\r\n<br />\r\n</a></div>\r\n<h2>Canadian Hearing Report</h2>\r\n<div class=\"widget\"><iframe width=\"100%\" height=\"200\" frameborder=\"0\" scrolling=\"No\" style=\" border-width:0 \" src=\"https://www.google.com/calendar/embed?height=200&amp;wkst=1&amp;src=7j4a1jb62004k18qislhot1rbg%40group.calendar.google.com&amp;color=%23182C57&amp;ctz=America%2FNew_York\"> </iframe></div>','2015-11-28'),(3,'ajjmh','<div><a title=\"Click here\" href=\"http://www.ismh.org/\" target=\"_blank\"> <img border=\"0\" class=\"soc_img\" src=\"http://www.andrewjohnpublishing.org/images/associations/mens-health.png\" alt=\"health\" /></a></div>','2015-11-28'),(4,'ajcjp','<div>\r\n<h3>Official Publication of the Canadian Association of Pathologists / Association canadienne des pathologistes<br />\r\n&nbsp;</h3>\r\n<a target=\"_blank\" href=\"http://cap-acp.org/\" title=\"Click here\"> <img border=\"0\" alt=\"soundmatters\" src=\"http://www.andrewjohnpublishing.org/images/associations/pathology-cap.jpg\" class=\"soc_img\" /><br />\r\n<br />\r\n</a></div>\r\n<h3>Join us at the Westin Montreal, QC for the 2015 CAP-ACP Annual Meeting &quot;Celebrating 66 years of excellence in pathology&quot; <br />\r\nMontreal, QC  June 20-23, 2015  <br />\r\n<a href=\"http://www.clmc.ca/2015/\">www.clmc.ca/2015/</a></h3>','2015-11-28'),(5,'ajcjgm','<div>\r\n<h3>Official publication of the Canadian Society of Internal Medicine</h3>\r\n<a title=\"Click here\" href=\"http://www.csim.ca/\" target=\"_blank\"> <img border=\"0\" class=\"soc_img\" src=\"http://www.andrewjohnpublishing.org/images/associations/4-internal-madicine.gif\" alt=\"soundmatters\" /></a></div>','2015-11-28'),(6,'ajwave','<div>\r\n<h3>Official Publication of the Association of Public Safety Communication Officials (APCO) of Canada</h3>\r\n<a title=\"Click here\" href=\"http://www.apco.ca/\" target=\"_blank\"> <img border=\"0\" class=\"soc_img\" src=\"http://www.andrewjohnpublishing.org/images/associations/5wavelength.jpg\" alt=\"wavelength\" /></a></div>','2015-11-28'),(7,'ajcjms','<div>\r\n<h3>Canadian Journal of Medical Sonography Volume 6 Issue 3</h3>\r\n<p style=\"padding-left:15px\">To view the Table of Contents <a title=\"click here\" href=\"http://www.andrewjohnpublishing.org/images/associations/toc_cjms_6-3.pdf\">CLICK HERE</a></p>\r\n<p style=\"padding-left:15px\">To view the journal in its entirety you must be a member of the Sonography Canada. <br />\r\nFor more information on Sonography Canada visit their website <a href=\"http://www.sonographycanada.ca\" title=\"click here\">www.sonographycanada.ca</a></p>\r\n<a target=\"_blank\" href=\"http://www.voicefordeafkids.com/\" title=\"Click here\"> <img border=\"0\" alt=\"sonography\" src=\"http://www.andrewjohnpublishing.org/images/associations/6sonography.jpg\" class=\"soc_img\" /></a>\r\n<p style=\"padding-left:15px\">To view e-Interface Fall 2012 <a title=\"click here\" href=\"http://www.andrewjohnpublishing.org/images/associations/E-Interfacefall2012.pdf\">Click Here</a></p>\r\n</div>','2015-11-28'),(8,'ajcin','<div>\r\n<h3>Official Publication of the Canadian Association of Neurophysiological Monitoring</h3>\r\n<a target=\"_blank\" href=\"http://www.voicefordeafkids.com/\" title=\"Click here\">\r\n<img border=\"0\" alt=\"ionm\" src=\"http://www.andrewjohnpublishing.org/images/associations/7ionm.jpg\" class=\"soc_img\"/></a>\r\n</div>\r\n','2015-11-28'),(9,'ajva','<div>\r\n<h3>Official Publication of the Canadian Vascular Access Association</h3>\r\n<p><a target=\"_blank\" href=\"http://www.cvaa.info/\" title=\"Click here\"> <img border=\"0\" alt=\"soundmatters\" src=\"http://www.andrewjohnpublishing.org/images/associations/8vascular.jpg\" class=\"soc_img\" /></a></p>\r\n<p style=\"padding-left:20px\"><b style=\"color: rgb(80, 81, 77); font-family: verdana, arial, \'sans serif\'; font-size: 13.3333px; font-style: normal; font-variant: normal; letter-spacing: normal; line-height: 22px; orphans: auto; text-align: justify; text-indent: 0px; text-transform: none; white-space: normal; widows: 1; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255);\">CVAA 2016 Conference</b></p>\r\n<ul style=\"color: rgb(80, 81, 77); padding-left:20px; font-family: verdana, arial, \'sans serif\'; font-size: 13.3333px; font-style: normal; font-variant: normal; font-weight: normal; letter-spacing: normal; line-height: 22px; orphans: auto; text-align: justify; text-indent: 0px; text-transform: none; white-space: normal; widows: 1; word-spacing: 0px; -webkit-text-stroke-width: 0px; background-color: rgb(255, 255, 255);\">\r\n    <li>Vancouver, BC Canada</li>\r\n    <li>April 27 - 29, 2016</li>\r\n    <li>For more information<span class=\"Apple-converted-space\">&nbsp;</span><a href=\"http://www.cvaa.info/\" target=\"_blank\" style=\"text-decoration: none; color: rgb(112, 116, 82);\">click here</a></li>\r\n</ul>\r\n</div>','2015-11-28'),(10,'ajsig','<div>\r\n<h3>Official Publication of the Association of Hearing Instrument Pratitioners of Ontario</h3>\r\n<a title=\"Click here\" href=\"http://www.helpmehear.ca/\" target=\"_blank\"> <img border=\"0\" class=\"soc_img\" src=\"http://www.andrewjohnpublishing.org/images/associations/9signal.jpg\" alt=\"soundmatters\" /></a></div>','2015-11-28'),(11,'ajvib','<div>\r\n<h3>Official Publication of the Canadian Hearing Society</h3>\r\n<a target=\"_blank\" href=\"http://www.chs.ca/\" title=\"Click here\"> <img border=\"0\" alt=\"soundmatters\" src=\"http://www.andrewjohnpublishing.org/images/associations/10vibes.jpg\" class=\"soc_img\" /></a></div>','2015-11-28'),(12,'ajct','<div>\r\n<h3>Official publication of the College of Audiologists and Speech-language Pathologists of Ontario </h3>\r\n<a target=\"_blank\" href=\"http://www.caslpo.com/\" title=\"Click here\">\r\n<img border=\"0\" alt=\"soundmatters\" src=\"http://www.andrewjohnpublishing.org/images/associations/11caslpo.jpg\" class=\"soc_img\"/></a>\r\n</div>\r\n','2015-11-28'),(13,'ajle','<div>\r\n<h3>Official Publication of  VOICE  for Hearing Impaired Children</h3>\r\n<p><a target=\"_blank\" href=\"http://www.chha.ca/\" title=\"Click here\"> <img border=\"0\" alt=\"soundmatters\" src=\"http://www.andrewjohnpublishing.org/images/associations/12listen.jpg\" class=\"soc_img\" /></a></p>\r\n<p>&nbsp;</p>\r\n<span class=\"lhpar\">\r\n<h2>CHHA National Conference 2013</h2>\r\n<ul>\r\n    <li>May 23 to 25, 2013</li>\r\n    <li>Fantasyland Hotel, West Edmonton Mall</li>\r\n    <li>Edmonton, Alberta</li>\r\n    <li><a href=\"http://chha.ca/conference/\" target=\"_blank\">chha.ca/conference</a></li>\r\n</ul>\r\n</span>\r\n<p>&nbsp;</p>\r\n</div>','2015-11-28'),(14,'ajcjed','<div>\r\n<h3>Official Publication of the Canadian Association of Educators of the Deaf and Hard of Hearing</h3>\r\n<a target=\"_blank\" href=\"http://www.caedhh.ca/\" title=\"Click here\"> <img border=\"0\" alt=\"caedhh\" src=\"http://www.andrewjohnpublishing.org/images/associations/14deaf.jpg\" class=\"soc_img\" /></a></div>\r\n<p>&nbsp;</p>\r\n<ul>\r\n    <li>To view the Table of Contents Click on a link below</li>\r\n    <li>To view the journal in it\'s entirety you must be a member of the Canadian Assocation of Educators of the Deaf and Hard of Hearing</li>\r\n</ul>\r\n<p>For more information visit the CAEDHH website<a href=\"http://www.caedhh.ca/\" target=\"_blank\">www.caedhh.ca</a></p>\r\n<p>&nbsp;</p>','2015-11-30'),(15,'ajahh','<div><a target=\"_blank\" href=\"http://www.voicefordeafkids.com/\" title=\"Click here\"> <img border=\"0\" alt=\"hearing\" src=\"http://www.andrewjohnpublishing.org/images/associations/hearing.jpg\" class=\"soc_img\" /></a>\r\n<p>COMPLIMENTARY Subscription to Allied Hearing Health Magazine <a href=\"http://www.andrewjohnpublishing.com/subscription_ahh.html\">Click Here</a></p>\r\n</div>','2015-11-30'),(16,'jiacs','<p style=\"text-align: justify;\">International Academy for Case Studies  The <a href=\"http://www.alliedacademies.org/the-international-academy-for-case-studies/\">Journal of the International Academy for Case Studies (JIACS)</a> is sponsored by the International Academy for Case Studies, an affiliate of the Allied Academies.  The Editor of the Academy oversees the double blind, peer review process, as well as the appointment of the <a href=\"http://www.alliedacademies.org/the-international-academy-for-case-studies/editors.php\">Editorial Review Board</a>. The Journal has an acceptance rate of 25% and publishes classroom teaching cases, with Instructor\'s Notes, on subjects which are taught in Business Schools. These cases can be Library or Field based, or Illustrative. The mission of the Academy is to expand the boundaries of the literature by supporting the exchange of ideas and insights which further the understanding of business using the case study approach.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">Authors of manuscripts are invited to make direct submissions at any time. In addition, the Journal encourages participants in Allied Academies\' conferences to submit their manuscripts for accelerated review. The current time for review of a direct submission is approximately two months.  The current time for review for papers submitted to a conference for accelerated review is three weeks. For more information about submitting your manuscript for consideration, please visit our <a href=\"http://www.alliedacademies.org/journal-submission-instructions.php\">Journal Submission Instructions page</a>.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">More details on the types of manuscripts published and the categories of research accepted are displayed in the Journal Matrix section of this website.  Authors who would like to discuss the potential interest in a manuscript may contact the Editor by email. Individuals interested in becoming members of the Editorial Board should also contact the Editor by email. The Journal is currently seeking to expand its Board.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">For contact information, please visit the <a href=\"http://www.alliedacademies.org/the-international-academy-for-case-studies/editors.php\">Journal&rsquo;s Review Board page</a>.</p>','2016-01-20'),(17,'amsj','<p style=\"text-align: justify;\">Academy of Marketing Studies</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">The  <a href=\"http://www.alliedacademies.org/academy-of-marketing-studies-journal/\">Academy of Marketing Studies Journal (AMSJ) </a>is sponsored by the Academy of Marketing Studies, an affiliate of the Allied Academies.  The Editor of the Academy oversees the double blind, peer review process, as well as the appointment of the <a href=\"http://www.alliedacademies.org/academy-of-marketing-studies-journal/editors.php\">Editorial Review Board</a>. The Journal has an acceptance rate of 25% and publishes theoretical or empirical works in Marketing. The mission of the Academy is to expand the boundaries of the literature by supporting the exchange of ideas and insights which further the understanding of marketing issues and practices.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">Authors of manuscripts are invited to make direct submissions at any time. In addition, the Journal encourages participants in Allied Academies\' conferences to submit their manuscripts for accelerated review. The current time for review of a direct submission is approximately two months.  The current time for review for papers submitted to a conference for accelerated review is three weeks. For more information about submitting your manuscript for consideration, please visit our <a href=\"http://www.alliedacademies.org/journal-submission-instructions.php\">Journal Submission Instructions page</a>.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">More details on the types of manuscripts published and the categories of research accepted are displayed in the Journal Matrix section of this website.  Authors who would like to discuss the potential interest in a manuscript may contact the Editor by email. Individuals interested in becoming members of the Editorial Board should also contact the Editor by email. The Journal is currently seeking to expand its Board.  For contact information, please visit the <a href=\"http://www.alliedacademies.org/academy-of-marketing-studies-journal/editors.php\">Journal&rsquo;s Review Board page</a>.</p>','2016-01-20'),(18,'asmj','<p style=\"text-align: justify;\">Academy of Strategic Management  The  <a href=\"http://www.alliedacademies.org/academy-of-strategic-management-journal/\">Academy of Strategic Management Journal (ASMJ) </a>is sponsored by the Academy of Strategic Management, an affiliate of the Allied Academies.  The Editor of the Academy oversees the double blind, peer review process, as well as the appointment of the <a href=\"http://www.alliedacademies.org/academy-of-strategic-management-journal/editors.php\">Editorial Review Board</a>. The Journal has an acceptance rate of 25% and publishes theoretical or empirical works in Management, Strategic Management, Health Care Management or Leadership.The mission of the Academy is to expand the boundaries of the literature by supporting the exchange of ideas and insights which further the understanding of strategic management and leadership.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">Authors of manuscripts are invited to make direct submissions at any time. In addition, the Journal encourages participants in Allied Academies\' conferences to submit their manuscripts for accelerated review. The current time for review of a direct submission is approximately two months.  The current time for review for papers submitted to a conference for accelerated review is three weeks. For more information about submitting your manuscript for consideration, please visit our <a href=\"http://www.alliedacademies.org/journal-submission-instructions.php\">Journal Submission Instructions</a> page.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">More details on the types of manuscripts published and the categories of research accepted are displayed in the Journal Matrix section of this website.  Authors who would like to discuss the potential interest in a manuscript may contact the Editor by email. Individuals interested in becoming members of the Editorial Board should also contact the Editor by email. The Journal is currently seeking to expand its Board.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">For contact information, please visit the<a href=\"http://www.alliedacademies.org/academy-of-strategic-management-journal/editors.php\"> Journal&rsquo;s Review Board page</a>.</p>','2016-01-20'),(19,'aelj','<p style=\"text-align: justify;\">Academy of Educational Leadership</p>\r\n<p style=\"text-align: justify;\">The <a href=\"http://www.alliedacademies.org/academy-of-educational-leadership-journal/\">Academy of Educational Leadership Journal (AELJ) </a>is sponsored by the Academy of Educational Leadership, an affiliate of the Allied Academies.  The Editor of the Academy oversees the double blind, peer review process, as well as the appointment of the <a href=\"http://www.alliedacademies.org/international-journal-of-entrepreneurship/editors.php\">Editorial Review Board</a>. The Journal has an acceptance rate of 25% and publishes theoretical, empirical or applied research in higher education (except economic or entrepreneurship education). The mission of the Academy is to expand the boundaries of the literature by supporting the exchange of ideas and insights which further the understanding of higher education.</p>\r\n<p style=\"text-align: justify;\">Authors of manuscripts are invited to make direct submissions at any time. In addition, the Journal encourages participants in Allied Academies\' conferences to submit their manuscripts for accelerated review. The current time for review of a direct submission is approximately two months.  The current time for review for papers submitted to a conference for accelerated review is three weeks. For more information about submitting your manuscript for consideration, please visit our <a href=\"http://www.alliedacademies.org/journal-submission-instructions.php\">Journal Submission Instructions</a> page.</p>\r\n<p style=\"text-align: justify;\">More details on the types of manuscripts published and the categories of research accepted are displayed in the Journal Matrix section of this website.  Authors who would like to discuss the potential interest in a manuscript may contact the Editor by email. Individuals interested in becoming members of the Editorial Board should also contact the Editor by email. The Journal is currently seeking to expand its Board.</p>\r\n<p style=\"text-align: justify;\">For contact information, please visit the <a href=\"http://www.alliedacademies.org/academy-of-educational-leadership-journal/editors.php\">Journal&rsquo;s Review Board page</a>.</p>','2016-01-20'),(20,'aafsj','<p>Academy of Accounting and Financial Studies</p>\r\n<p>&nbsp;</p>\r\n<p style=\"text-align: justify;\">The <a href=\"http://www.alliedacademies.org/academy-of-accounting-and-financial-studies-journal/\">Academy of Accounting and Financial Studies Journal (AAFSJ)</a>  is sponsored by the Academy of Accounting and Financial Studies, an affiliate of the Allied Academies.  The Editor of the Academy oversees the double blind, peer review process, as well as the appointment of the <a href=\"http://www.alliedacademies.org/academy-of-accounting-and-financial-studies-journal/editors.php\">Editorial Review Board</a>. The Journal has an acceptance rate of 25% and publishes theoretical, empirical and educational manuscripts in accounting and finance. The mission of the Academy is to expand the boundaries of the literature by supporting the exchange of ideas and insights which further the understanding of the accounting and finance fields.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">Authors of manuscripts are invited to make direct submissions at any time. In addition, the Journal encourages participants in Allied Academies\' conferences to submit their manuscripts for accelerated review. The current time for review of a direct submission is approximately two months.  The current time for review for papers submitted to a conference for accelerated review is three weeks. For more information about submitting your manuscript for consideration, please visit our <a href=\"http://www.alliedacademies.org/journal-submission-instructions.php\">Journal Submission Instructions</a> page.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">More details on the types of manuscripts published and the categories of research accepted are displayed in the Journal Matrix section of this website.  Authors who would like to discuss the potential interest in a manuscript may contact the Editor by email. Individuals interested in becoming members of the Editorial Board should also contact the Editor by email. The Journal is currently seeking to expand its Board.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">For contact information, please visit the <a href=\"http://www.alliedacademies.org/academy-of-accounting-and-financial-studies-journal/editors.php\">Journal&rsquo;s Review Board page</a>.</p>','2016-01-20'),(21,'aej','<p>Academy of Entrepreneurship</p>\r\n<p>The Academy of Entrepreneurship is an affiliate of the Allied Academies. The mission of the Academy is to provide the community with a forum for the discussion, publication and dissemination of research into the field of entrepreneurship.</p>\r\n<p>The following Journals are published by the Academy of Entrepreneurship:</p>\r\n<p><a href=\"http://www.alliedacademies.org/academy-of-entrepreneurship-journal/\">Academy of Entrepreneurship Journal (AEJ)</a>, which publishes theoretical or empirical works in Entrepreneurship.</p>\r\n<p><a href=\"http://www.alliedacademies.org/international-journal-of-entrepreneurship/\"> International Journal of Entrepreneurship (IJE)</a>, which publishes theoretical or empirical works in International Entrepreneurship or set in international venues.</p>\r\n<p><a href=\"http://www.alliedacademies.org/entrepreneurship-education/\">  Journal of Entrepreneurship Education (JEE)</a>, which publishes theoretical, empirical or applied works in Entrepreneurship Education.</p>\r\n<p><a href=\"http://www.alliedacademies.org/entrepreneurial-executive/\"> Entrepreneurial Executive (EE)</a>, which publishes practical or applied works in Entrepreneurship.</p>\r\n<p>The Editors of these journals oversee the double blind, peer review process, as well as the appointment of the <a href=\"http://www.alliedacademies.org/academy-of-entrepreneurship-journal/editors.php\">Editorial Review Board</a>. All of the Journals have an acceptance rate of 25%.</p>\r\n<p>Authors of manuscripts are invited to make direct submissions at any time. In addition, the Journal encourages participants in Allied Academies\' conferences to submit their manuscripts for accelerated review. The current time for review of a direct submission is approximately two months.  The current time for review for papers submitted to a conference for accelerated review is three weeks. For more information about submitting your manuscript for consideration, please visit our <a href=\"http://www.alliedacademies.org/journal-submission-instructions.php\">Journal Submission Instructions page</a>.</p>\r\n<p>More details on the types of manuscripts published and the categories of research accepted are displayed in the Journal Matrix section of this website.  Authors who would like to discuss the potential interest in a manuscript may contact the Editor by email. Individuals interested in becoming members of the Editorial Board should also contact the Editor by email. The Journal is currently seeking to expand its Board.</p>\r\n<p>For contact information, please visit the individual Journal pages.</p>','2016-01-20'),(22,'ije','<p style=\"text-align: justify;\">Academy of Entrepreneurship</p>\r\n<p style=\"text-align: justify;\">The Academy of Entrepreneurship is an affiliate of the Allied Academies. The mission of the Academy is to provide the community with a forum for the discussion, publication and dissemination of research into the field of entrepreneurship.</p>\r\n<p style=\"text-align: justify;\">The following Journals are published by the Academy of Entrepreneurship:</p>\r\n<p style=\"text-align: justify;\"><a href=\"http://www.alliedacademies.org/academy-of-entrepreneurship-journal/\">Academy of Entrepreneurship Journal </a>(AEJ), which publishes theoretical or empirical works in Entrepreneurship.</p>\r\n<p style=\"text-align: justify;\"><a href=\"http://www.alliedacademies.org/international-journal-of-entrepreneurship/\">International Journal of Entrepreneurship</a> (IJE), which publishes theoretical or empirical works in International Entrepreneurship or set in international venues.</p>\r\n<p style=\"text-align: justify;\"><a href=\"http://www.alliedacademies.org/entrepreneurship-education/\">Journal of Entrepreneurship Education</a> (JEE), which publishes theoretical, empirical or applied works in Entrepreneurship Education.</p>\r\n<p style=\"text-align: justify;\"><a href=\"http://www.alliedacademies.org/entrepreneurial-executive/\">Entrepreneurial Executive</a> (EE), which publishes practical or applied works in Entrepreneurship.</p>\r\n<p style=\"text-align: justify;\">The Editors of these journals oversee the double blind, peer review process, as well as the appointment of the <a href=\"http://www.alliedacademies.org/international-journal-of-entrepreneurship/editors.php\">Editorial Review Board</a>. All of the Journals have an acceptance rate of 25%.</p>\r\n<p style=\"text-align: justify;\">Authors of manuscripts are invited to make direct submissions at any time. In addition, the Journal encourages participants in Allied Academies\' conferences to submit their manuscripts for accelerated review. The current time for review of a direct submission is approximately two months.  The current time for review for papers submitted to a conference for accelerated review is three weeks. For more information about submitting your manuscript for consideration, please visit our <a href=\"http://www.alliedacademies.org/journal-submission-instructions.php\">Journal Submission Instructions </a>page.</p>\r\n<p style=\"text-align: justify;\">More details on the types of manuscripts published and the categories of research accepted are displayed in the Journal Matrix section of this website.  Authors who would like to discuss the potential interest in a manuscript may contact the Editor by email. Individuals interested in becoming members of the Editorial Board should also contact the Editor by email. The Journal is currently seeking to expand its Board.</p>\r\n<p style=\"text-align: justify;\">For contact information, please visit the individual Journal pages.</p>','2016-01-20'),(23,'joccc','<p style=\"text-align: justify;\">Academy of Organizational Culture, Communications and Conflict</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">The <a href=\"http://www.alliedacademies.org/journal-of-organizational-culture-communications-and-conflict/\">Journal of Organizational Culture, Communications and Conflict (JOCCC)</a> is sponsored by the Academy of Organizational Culture, Communications and Conflict, an affiliate of the Allied Academies.  The Editor of the Academy oversees the double blind, peer review process, as well as the appointment of the <a href=\"http://www.alliedacademies.org/journal-of-organizational-culture-communications-and-conflict/editors.php\">Editorial Review Board</a>. The Journal has an acceptance rate of 25% and publishes Theoretical or empirical works in Organizational Culture, Communications, Conflict Resolution, Organizational Behavior, or Human Resources. The mission of the Academy is to expand the boundaries of the literature by supporting the exchange of ideas and insights which further the understanding of cultural and behavioral aspects of business.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">Authors of manuscripts are invited to make direct submissions at any time. In addition, the Journal encourages participants in Allied Academies\' conferences to submit their manuscripts for accelerated review. The current time for review of a direct submission is approximately two months.  The current time for review for papers submitted to a conference for accelerated review is three weeks. For more information about submitting your manuscript for consideration, please visit our <a href=\"http://www.alliedacademies.org/journal-submission-instructions.php\">Journal Submission Instructions page</a>.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">More details on the types of manuscripts published and the categories of research accepted are displayed in the Journal Matrix section of this website.  Authors who would like to discuss the potential interest in a manuscript may contact the Editor by email. Individuals interested in becoming members of the Editorial Board should also contact the Editor by email. The Journal is currently seeking to expand its Board.  For contact information, please visit the <a href=\"http://www.alliedacademies.org/journal-of-organizational-culture-communications-and-conflict/editors.php\">Journal&rsquo;s Review Board page</a>.</p>','2016-01-20'),(24,'bsj','<p>Business Studies Academy</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">The <a href=\"http://www.alliedacademies.org/business-studies-journal/\">Business Studies Journal (BSJ)</a> is sponsored by the Business Studies Academy, an affiliate of the Allied Academies.  The Editor of the Academy oversees the double blind, peer review process, as well as the appointment of the <a href=\"http://www.alliedacademies.org/business-studies-journal/editors.php\">Editorial Review Board</a>. The Journal has an acceptance rate of 25% and publishes applied or qualitative research in business and business issues. The mission of the Academy is to expand the boundaries of the literature by supporting the exchange of ideas and insights which further the understanding of business from a practical perspective.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">Authors of manuscripts are invited to make direct submissions at any time. In addition, the Journal encourages participants in Allied Academies\' conferences to submit their manuscripts for accelerated review. The current time for review of a direct submission is approximately two months.  The current time for review for papers submitted to a conference for accelerated review is three weeks. For more information about submitting your manuscript for consideration, please visit our <a href=\"http://www.alliedacademies.org/journal-submission-instructions.php\">Journal Submission Instructions</a> page.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">More details on the types of manuscripts published and the categories of research accepted are displayed in the Journal Matrix section of this website.  Authors who would like to discuss the potential interest in a manuscript may contact the Editor by email. Individuals interested in becoming members of the Editorial Board should also contact the Editor by email. The Journal is currently seeking to expand its Board.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">For contact information, please visit the <a href=\"http://www.alliedacademies.org/business-studies-journal/editors.php\">Journal&rsquo;s Review Board</a> page.</p>','2016-01-20'),(25,'jmids','<p style=\"text-align: justify;\">Academy of Management Information and Decision Sciences</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">The Journal of Management Information and Decision Sciences (JMIDS) is sponsored by the Academy of Management Information and Decision Sciences, an affiliate of the Allied Academies.  The Editor of the Academy oversees the double blind, peer review process, as well as the appointment of the <a href=\"http://www.alliedacademies.org/management-information-and-decision-sciences/editors.php\">Editorial Review Board</a>. The Journal has an acceptance rate of 25% and publishes theoretical or empirical works in Information Systems or Decision Sciences. The mission of the Academy is to expand the boundaries of the literature by supporting the exchange of ideas and insights which further the understanding of information systems management and decision science.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">Authors of manuscripts are invited to make direct submissions at any time. In addition, the Journal encourages participants in Allied Academies\' conferences to submit their manuscripts for accelerated review. The current time for review of a direct submission is approximately two months.  The current time for review for papers submitted to a conference for accelerated review is three weeks. For more information about submitting your manuscript for consideration, please visit our <a href=\"http://www.alliedacademies.org/journal-submission-instructions.php\">Journal Submission Instructions page</a>.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">More details on the types of manuscripts published and the categories of research accepted are displayed in the Journal Matrix section of this website.  Authors who would like to discuss the potential interest in a manuscript may contact the Editor by email. Individuals interested in becoming members of the Editorial Board should also contact the Editor by email. The Journal is currently seeking to expand its Board.</p>\r\n<p style=\"text-align: justify;\">For contact information, please visit the<a href=\"http://www.alliedacademies.org/management-information-and-decision-sciences/editors.php\"> Journal&rsquo;s Review Board page.</a></p>','2016-01-20'),(26,'jibr','<p style=\"text-align: justify;\">The <a href=\"http://www.alliedacademies.org/international-business-research/\">Journal of International Business Research</a> (JIBR) is sponsored by the Academy for Studies in International Business, an affiliate of the Allied Academies.  The Editor of the Academy oversees the double blind, peer review process, as well as the appointment of the <a href=\"http://www.alliedacademies.org/international-business-research/editors.php\">Editorial Review Board</a>. The Journal has an acceptance rate of 25% and publishes theoretical or empirical works in International Business or theoretical or empirical works set in international venues. The mission of the Academy is to expand the boundaries of the literature by supporting the exchange of ideas and insights which further the understanding of international and global business issues.</p>\r\n<p style=\"text-align: justify;\">Authors of manuscripts are invited to make direct submissions at any time. In addition, the Journal encourages participants in Allied Academies\' conferences to submit their manuscripts for accelerated review. The current time for review of a direct submission is approximately two months.  The current time for review for papers submitted to a conference for accelerated review is three weeks. For more information about submitting your manuscript for consideration, please visit our <a href=\"http://www.alliedacademies.org/journal-submission-instructions.php\">Journal Submission Instructions</a> page.</p>\r\n<p style=\"text-align: justify;\">More details on the types of manuscripts published and the categories of research accepted are displayed in the Journal Matrix section of this website.  Authors who would like to discuss the potential interest in a manuscript may contact the Editor by email. Individuals interested in becoming members of the Editorial Board should also contact the Editor by email. The Journal is currently seeking to expand its Board.</p>\r\n<p style=\"text-align: justify;\">For contact information, please visit the <a href=\"http://www.alliedacademies.org/international-business-research/editors.php\">Journal&rsquo;s Review Board</a> page.</p>','2016-01-20'),(27,'asmj','','2016-01-20'),(28,'jleri','<p style=\"text-align: justify;\">Academy of Legal, Ethical and Regulatory Issues</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">The  <a href=\"http://www.alliedacademies.org/legal-ethical-and-regulatory-issues/\">Journal of Legal, Ethical and Regulatory Issues (JLERI)</a> is sponsored by the Academy of Legal, Ethical and Regulatory Issues, an affiliate of the Allied Academies.  The Editor of the Academy oversees the double blind, peer review process, as well as the appointment of the <a href=\"http://www.alliedacademies.org/legal-ethical-and-regulatory-issues/editors.php\">Editorial Review Board</a>. The Journal has an acceptance rate of 25% and publishes theoretical or empirical works in Business Law, Ethics or Governmental or Regulatory Issues. The mission of the Academy is to expand the boundaries of the literature by supporting the exchange of ideas and insights which further the understanding of legal, ethical and regulatory issues affecting business and government.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">Authors of manuscripts are invited to make direct submissions at any time. In addition, the Journal encourages participants in Allied Academies\' conferences to submit their manuscripts for accelerated review. The current time for review of a direct submission is approximately two months.  The current time for review for papers submitted to a conference for accelerated review is three weeks. For more information about submitting your manuscript for consideration, please visit our <a href=\"http://www.alliedacademies.org/journal-submission-instructions.php\">Journal Submission Instructions</a> page.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">More details on the types of manuscripts published and the categories of research accepted are displayed in the Journal Matrix section of this website.  Authors who would like to discuss the potential interest in a manuscript may contact the Editor by email. Individuals interested in becoming members of the Editorial Board should also contact the Editor by email. The Journal is currently seeking to expand its Board.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">For contact information, please visit the <a href=\"http://www.alliedacademies.org/legal-ethical-and-regulatory-issues/editors.php\">Journal&rsquo;s Review Board</a> page.</p>','2016-01-20'),(29,'ee','<p style=\"text-align: justify;\">Academy of Entrepreneurship</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">The Academy of Entrepreneurship is an affiliate of the Allied Academies. The mission of the Academy is to provide the community with a forum for the discussion, publication and dissemination of research into the field of entrepreneurship.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">The following Journals are published by the Academy of Entrepreneurship:</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\"><a href=\"http://www.alliedacademies.org/academy-of-entrepreneurship-journal/\">    Academy of Entrepreneurship Journal (AEJ),</a> which publishes theoretical or empirical works in Entrepreneurship.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\"><a href=\"http://www.alliedacademies.org/international-journal-of-entrepreneurship/\">    International Journal of Entrepreneurship (IJE)</a>, which publishes theoretical or empirical works in International Entrepreneurship or set in international venues.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\"><a href=\"http://www.alliedacademies.org/entrepreneurship-education/\">    Journal of Entrepreneurship Education (JEE)</a>, which publishes theoretical, empirical or applied works in Entrepreneurship Education.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\"><a href=\"http://www.alliedacademies.org/entrepreneurial-executive/\">    Entrepreneurial Executive (EE)</a>, which publishes practical or applied works in Entrepreneurship.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">The Editors of these journals oversee the double blind, peer review process, as well as the appointment of the <a href=\"http://www.alliedacademies.org/entrepreneurial-executive/editors.php\">Editorial Review Board</a>. All of the Journals have an acceptance rate of 25%.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">Authors of manuscripts are invited to make direct submissions at any time. In addition, the Journal encourages participants in Allied Academies\' conferences to submit their manuscripts for accelerated review. The current time for review of a direct submission is approximately two months. The current time for review for papers submitted to a conference for accelerated review is three weeks. For more information about submitting your manuscript for consideration, please visit our <a href=\"http://www.alliedacademies.org/journal-submission-instructions.php\">Journal Submission Instructions</a> page.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">More details on the types of manuscripts published and the categories of research accepted are displayed in the Journal Matrix section of this website. Authors who would like to discuss the potential interest in a manuscript may contact the Editor by email. Individuals interested in becoming members of the Editorial Board should also contact the Editor by email. The Journal is currently seeking to expand its Board.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">For contact information, please visit the individual Journal pages.</p>','2016-01-20'),(30,'jee','<p style=\"text-align: justify;\">Academy of Entrepreneurship</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">The Academy of Entrepreneurship is an affiliate of the Allied Academies. The mission of the Academy is to provide the community with a forum for the discussion, publication and dissemination of research into the field of entrepreneurship.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">The following Journals are published by the Academy of Entrepreneurship:</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\"><a href=\"http://www.alliedacademies.org/academy-of-entrepreneurship-journal/\">    Academy of Entrepreneurship Journal (AEJ)</a>, which publishes theoretical or empirical works in Entrepreneurship.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\"><a href=\"http://www.alliedacademies.org/international-journal-of-entrepreneurship/\">    International Journal of Entrepreneurship (IJE)</a>, which publishes theoretical or empirical works in International Entrepreneurship or set in international venues.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\"><a href=\"http://www.alliedacademies.org/entrepreneurship-education/\">     Journal of Entrepreneurship Education (JEE)</a>, which publishes theoretical, empirical or applied works in Entrepreneurship Education.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\"><a href=\"http://www.alliedacademies.org/entrepreneurial-executive/\">    Entrepreneurial Executive (EE)</a>, which publishes practical or applied works in Entrepreneurship.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">The Editors of these journals oversee the double blind, peer review process, as well as the appointment of the <a href=\"http://www.alliedacademies.org/entrepreneurship-education/editors.php\">Editorial Review Board</a>. All of the Journals have an acceptance rate of 25%.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">Authors of manuscripts are invited to make direct submissions at any time. In addition, the Journal encourages participants in Allied Academies\' conferences to submit their manuscripts for accelerated review. The current time for review of a direct submission is approximately two months. The current time for review for papers submitted to a conference for accelerated review is three weeks. For more information about submitting your manuscript for consideration, please visit our <a href=\"http://www.alliedacademies.org/journal-submission-instructions.php\">Journal Submission Instructions</a> page.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">More details on the types of manuscripts published and the categories of research accepted are displayed in the Journal Matrix section of this website. Authors who would like to discuss the potential interest in a manuscript may contact the Editor by email. Individuals interested in becoming members of the Editorial Board should also contact the Editor by email. The Journal is currently seeking to expand its Board.</p>\r\n<p style=\"text-align: justify;\">&nbsp;</p>\r\n<p style=\"text-align: justify;\">For contact information, please visit the individual Journal pages.</p>','2016-01-20');
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Youez - 2016 - github.com/yon3zu
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