Fausti SA, Wilmington DJ, Helt PV, Helt WJ, & Konrad-Martin D. Hearing health and care -The need for improved hearing loss prevention and hearing conservation practices. Journal of Rehabilitation Research and Development 2005, 42 (Supplement 2):45-62.

Hearing loss affects 31 million Americans, particularly veterans who were exposed to harmful levels of noise during military functions. Many veterans also receive treatment with ototoxic medications, which may exacerbate preexisting hearing loss. Thus, hearing loss is the most common and tinnitus the third most common service-connected disability among veterans. Poor implementation of hearing protection programs and a lack of audiometric testing during medical treatment leave veterans vulnerable to unrecognized and untreated hearing loss until speech communication is impaired. Individualized audiometric testing techniques, including assessment of high frequencies, can be used in clinical and occupational settings to detect early hearing loss. Antioxidants also may alleviate cochlear damage caused by noise and ototoxicity. Ultimately, hearing loss prevention requires education on reducing occupational and recreational noise exposure and counseling on the risks and options available to patients. Technological advances will improve monitoring, allow better noise engineering controls, and lead to more effective hearing protection.

Henry JA, Dennis KC, Schechter MA. General Review of Tinnitus: Prevalence, Mechanisms, Effects, and Management. Journal of Speech, Language, and Hearing Research 2005; 48 (5): 1-32.

Tinnitus is an increasing health concern across all strata of the general population. Although an abundant amount of literature has addressed the many facets of tinnitus, wide-ranging differences in professional beliefs and attitudes persist concerning its clinical management. These differences are detrimental to tinnitus patients because the management they receive is based primarily on individual opinion (which can be biased) rather than on medical consensus. It is thus vitally important for the tinnitus professional community to work together to achieve consensus. To that end, this article provides a broad-based review of what is presently known about tinnitus, including prevalence, associated factors, theories of pathophysiology, psychological effects, effects on disability and handicap, workers' compensation issues, clinical assessment, and various forms of treatment. This summary of fundamental information has relevance to both clinical and research arenas.

Konrad-Martin D, Wilmington DJ, Gordon JS, Reavis KM, Fausti SA. Audiological Management of Patients Receiving Aminoglycoside Antibiotics. The Volta Review 2005; 105(3):229-250.

Aminoglycoside antibiotics, commonly prescribed for adults and children for a wide range of bacterial infections, are potentially ototoxic, often causing irreversible damage to the auditory and vestibular systems. Ototoxic hearing loss usually begins at the higher frequencies and can progress to lower frequencies necessary for understanding speech. Individual susceptibility to aminoglycoside ototoxicity is determined by multiple physiologic and genetic factors. Children are especially vulnerable to ototoxic-induced damage, which can affect speech and language development even when limited to the high frequencies. Monitoring hearing loss during and after treatment by conventional and ultra-high frequency audiometry allows early detection of ototoxic hearing loss. Objective measures such as auditory brainstem responses (ABRs) and otoacoustic emissions (OAEs) can provide information about auditory function for individuals unable to provide reliable behavioral data, including young children. Early detection and subsequent alteration of treatment, as well as the potential future use of otoprotectants, may minimize or prevent ototoxic hearing loss.

Leigh-Paffenroth E, Reavis KM, Gordon JS, Dunckley KT, Fausti SA, & Konrad-Martin D: Objective Measures of Ototoxicity. ASHA Special Interest Division 6, Hearing and Hearing Disorders: Research and Diagnostics 2005; 9: 10-16.

A leading cause of preventable sensorineural hearing loss is therapeutic treatment with medications that are toxic to inner ear tissues, including certain drugs used to fight cancer and life-threatening infectious diseases. Ototoxic-induced hearing loss typically begins in the high frequencies and progresses to lower frequencies as drug administration continues (Campbell & Durrant, 1993; Campbell et al., 2004; Macdonald, Harrison, Wake, Bliss, & Macdonald, 1994). It is important to detect ototoxicity before damage occurs to the region of hearing < 4 kHz, which is important for speech perception (De Paoli, Janota & Frank, 1996). Sensitive and time-efficient behavioral techniques have been developed to monitor high frequency (> 8 kHz) hearing to detect ototoxic-induced changes before damage has progressed to lower frequencies (Fausti et al. 1999). Hearing thresholds obtained through behavioral audiometry are the current gold standard for detecting ototoxic-induced changes in hearing. However, behavioral techniques are not effective for a large population of patients who are unable to provide reliable responses; subsequently, many of these patients do not receive monitoring for ototoxic-induced changes in their hearing. The development of objective measures that do not require patient cooperation is necessary to monitor all patients receiving ototoxic drugs.

Konrad-Martin D, Gordon JS, Reavis KM, Wilmington DJ, Helt, WJ, & Fausti SA: Audiological Monitoring of Patients Receiving Ototoxic Drugs. ASHA Special Interest Division 6, Hearing and Hearing Disorders: Research and Diagnostics 2005; 9: 17-21.

Over 200 medications commonly prescribed for the treatment of cancers and some infections can cause inner ear damage, or ototoxicity (ASHA, 2004). Ototoxicity can result in auditory and/or vestibular dysfunction, and the effects can be temporary, but are often permanent. Symptoms of ototoxicity include tinnitus, dizziness, and difficulty understanding speech in noise. Approximately 4 million patients annually in the U.S. are at risk for hearing loss from aminoglycoside antibiotics (e.g. gentamicin) and platinum-based chemotherapy agents (e.g. cisplatin). Loop diuretics (e.g. furosemside) can also cause ototoxicity, particularly when administered concurrently with other ototoxic drugs (Brummett, 1980). Furthermore, noise exposure has a synergistic effect, increasing the risk of hearing loss during therapeutic treatment with ototoxic drugs (Brown, Brummett, Fox, & Bendrick, 1980). For patients treated with ototoxic drugs, hearing loss can adversely affect speech communication, coping skills and quality of life. Ototoxicity is poorly correlated with drug dosage (Blakley & Meyers, 1993), peak serum levels (Black & Pesznecker, 1993), and other toxicities, such as renal toxicity (Rougier et al., 2003), making it difficult to predict when symptoms will present. Ototoxic hearing loss often progresses unnoticed until a communication problem becomes apparent, signifying that hearing loss within the speech frequency range has occurred. Therefore, the early detection of ototoxicity must involve direct auditory function assessment.

Henry JA, Zaugg T, Schechter MA. (2005). Clinical guide for audiologic tinnitus management I: Assessment. American Journal of Audiology 14:21-48.

Purpose: This article is the first of 2 that present basic guidelines for audiologists to provide clinical management of tinnitus. The method, termed audiologic tinnitus management (ATM), was developed to incorporate management strategies that can be implemented most efficiently by audiologists.

Method: Development of ATM has been drawn from the clinical and research experience of the authors and numerous audiologists. Certain elements of ATM are adapted from the methods of tinnitus masking and tinnitus retraining therapy. Procedures are described in the present article for performing the intake assessment, while the companion article (J. A. Henry, T. L. Zaugg, & M. A. Schechter, 2005) describes treatment methodology.

Results: Development of ATM has resulted in defined procedures to conduct a basic tinnitus assessment that includes written questionnaires, an intake interview, audiologic evaluation, and a psychoacoustic assessment of tinnitus perceptual characteristics. If patients report a sound tolerance problem (hyperacusis), loudness discomfort levels are measured at audiometric frequencies. There are special procedures for selecting hearing aids, ear-level noise generators, combination devices (noise generator and hearing aid combined), and personal listening devices (i.e., portable radios and tape, CD, and MP3 players).

Conclusions: This article explains each of these assessment components in detail. Adoption of the ATM assessment protocol by audiologists can contribute to the establishment of uniform procedures for the clinical management of tinnitus patients

Henry JA, Zaugg T, Schechter MA. (2005). Clinical guide for audiologic tinnitus management II: Treatment. American Journal of Audiology 14:49-70.

Purpose: This article is the second of 2 that address the need for basic procedures that can be used commonly by audiologists to manage patients with clinically significant tinnitus, as well as hyperacusis. The method described is termed audiologic tinnitus management (ATM).

Method: ATM was developed specifically for use by audiologists. Although certain procedural components were adapted from the methods of tinnitus masking and tinnitus retraining therapy, ATM is uniquely and specifically defined. A detailed description of the ATM assessment procedures is provided in the companion article (J. A. Henry, T. L. Zaugg, & M. A. Schechter, 2005). The present article describes a specific clinical protocol for providing treatment with ATM.

Results: The treatment method described for ATM includes structured informational counseling and an individualized program of sound enhancement that can include the use of hearing aids, ear-level noise generators, combination instruments (noise generator and hearing aid combined), personal listening devices (wearable CD, tape, and MP3 players), and augmentative sound devices (e.g., tabletop sound generators). Ongoing treatment appointments involve primarily the structured counseling, evaluation, and adjustment of the use of sound devices, and assessment of treatment outcomes. The informational counseling protocol and an interview form for determining treatment outcomes are each described in step-by-step detail for direct clinical application.

Conclusion: This article can serve as a practical clinical guide for audiologists to provide treatment for tinnitus in a uniform manner.

Konrad-Martin, D. Helt, WJ, Reavis, KM, Gordon, JS, Coleman, LL, Bratt, GW, Fausti, SA: Ototoxicity: Early detection and monitoring. Clinical Feature Story ASHA Leader, 10:1,11,12-14, 2005.

Various therapeutic medications damage the inner ear, including certain drugs used to fight cancer and life-threatening infectious diseases. Drug-related inner ear damage, or ototoxicity, results in auditory and/or vestibular dysfunction that is often permanent. Symptoms of ototoxicity include tinnitus, dizziness, and difficulty understanding speech in noise.

Unfortunately, ototoxic hearing loss may go unnoticed by patients until a communication problem becomes apparent, signifying that hearing loss within the frequency range important for speech understanding has already occurred. Similarly, by the time a patient complains of dizziness, permanent vestibular system damage probably has already occurred. Because symptoms of ototoxicity are poorly correlated with drug dosage, peak serum levels, and other toxicities, the only way to detect ototoxicity is by assessing auditory and vestibular function directly.

Early Identification

For patients with life-threatening illnesses that warrant treatment with ototoxic drugs, communication ability is a central quality of life issue. Identifying ototoxic damage early can improve treatment outcome by minimizing hearing loss progression, and by counseling and rehabilitation.

Initial ototoxic drug exposure typically affects cochlear regions coding the high frequencies. Continued exposure results in a spread of damage to progressively lower frequencies. Early identification of ototoxic hearing loss provides physicians the opportunity to adjust the therapeutic treatment in order to minimize or prevent hearing loss requiring rehabilitation, depending on a patient's overall treatment picture.

Monitoring hearing in patients receiving ototoxic drugs provides audiologists opportunities to counsel patients and their families regarding ototoxicity-induced hearing loss, tinnitus, and dizziness, communication strategies, and the synergistic effects of noise and ototoxic damage. Early identification and monitoring of ototoxic hearing loss also provides audiologists the opportunity to perform appropriate rehabilitation during and after treatment.

Many of the same considerations are required for the successful implementation of ototoxicity monitoring programs as for hearing conservation programs and newborn hearing screening programs. Perhaps most important is consideration of key questions related to the program's goals. These key questions include: What is the purpose of identifying ototoxic changes? What is the target population to be monitored? What are the methods to be used for identifying patients? What are the timelines to be used for baseline and monitoring tests? What are the tests to be used, and how can they be adapted for the target population in order to meet the program goals?

Defining the Purpose of the Program

The purpose of the program drives many decisions about program implementation. For example, if the purpose is to prevent or minimize spread of ototoxic hearing loss into frequencies important for understanding speech, including ultra-high-frequency audiometry in the test protocol may be warranted.
Ototoxic hearing loss, particularly in the pediatric population, may be tolerated in favor of survival. In such cases, family counseling and rehabilitation planning is a major goal. If the program is to include patient counseling regarding realistic expectations, communication strategies, and aural rehabilitation as soon as is practical, there must be mechanisms in place to communicate test results not only to a patient's medical provider, but also to the patient and family directly. Discussions with stakeholders such as the audiology, oncology, infectious disease, and nursing staff are critical for determining perceived program needs and developing appropriate program goals.

Defining the Target Population

The chemotherapeutic agents cisplatin and carboplatin, and certain aminoglycoside antibiotics have a high incidence of ototoxic hearing loss. A program might target patients scheduled to receive drugs showing high incidence of ototoxicity, as well as the ototoxic drugs prescribed most often at the particular hospital serviced by the program. In addition, a program might target individuals with risk factors for ototoxicity including age (children and the elderly), co-morbidities, poor general physical health, and treatment with multiple ototoxic agents. A target population comprising children, sedated adults, or patients confined to the hospitalized ward will affect the choice of tests to be used for ototoxicity monitoring as described below.

Methods for Identifying Patients

Two primary resources for patient identification include key medical staff and hospital pharmacy medication lists. Identifying patients for whom ototoxicity monitoring is an appropriate part of a therapeutic management plan requires a coordinated effort between the audiologist and members of the patient's health care team.

It is important, therefore, to establish and maintain a relationship with key medical personnel. This relationship is supported by education regarding the purposes and benefits of ototoxicity monitoring. Ideally, the medical or nursing staff will discuss ototoxicity monitoring evaluations with their patients and provide referrals for monitoring. Computer-generated pharmacy lists are also an excellent refe rral source, as such lists may include a patient's name, treatment medication, and location on the ward.

Timeline for Baseline and Monitoring Tests

Ototoxicity is determined by comparing baseline data, ideally obtained prior to ototoxic drug administration, to the results of subsequent monitoring tests. In this way, each patient serves as his or her own control.

ASHA's "Guidelines for the Audiologic Management of Individuals Treated with Cochleotoxic Drug Therapy" (1994), based in part on the results of large clinical studies, state that the Baseline Evaluation should occur no later than 24 hours after the administration of chemotherapeutic drugs and no more than 72 hours following administration of aminoglycoside antibiotics. A recheck of thresholds within 24 hours of the Baseline Test can be helpful for determining patient reliability for pure-tone threshold testing.

The frequency of Monitoring Evaluations depends upon a patient's particular drug regimen, which can be determined by reviewing the patient's medical chart. Monitoring Evaluations, which may be a pared-down version of the Baseline Evaluation, are performed periodically throughout treatment, usually prior to each dose for chemotherapy patients, and 1ÿ2 times per week for patients receiving ototoxic antibiotics.

Monitoring and appropriate referrals for further auditory and vestibular testing also are warranted any time a patient reports increased hearing difficulties, tinnitus, aural fullness, or dizziness. Confirming significant changes by retest will reduce false positive rates and is recommended by ASHA (1994). Post-treatment evaluations are necessary to confirm that hearing is stable because ototoxic hearing loss can occur up to 6 months following drug exposure.

Tests

Detecting changes in pure-tone thresholds directly using serial audiograms is considered the most effective indicator of ototoxic hearing loss, particularly when ultra-high frequency thresholds are included. The goal of serial monitoring tests for detection of ototoxic hearing loss is typically to categorize patients into two groups: those who exhibit hearing change or those who do not based on a cutoff or hearing change criterion value. Although the ASHA guidelines have been implemented in many clinical settings, use of well-accepted statistical methods for determining test performance in large groups of patients receiving ototoxic drugs and hospitalized (control) patients receiving non-ototoxic drugs will likely be required in order for standard criteria to be fully acknowledged.

Test performance for ototoxicity monitoring can be determined by examining the sensitivity and specificity obtained using a particular criterion threshold shift to identify ototoxic hearing loss. The percentage of times patients exhibiting hearing change are identified as showing change using a criterion threshold shift is a measure of that test's hit rate or sensitivity. Specificity or correct rejection rate refers to the percentage of times patients with stable hearing are correctly labeled using the criterion threshold shift.

Sensitivity and specificity have related diagnostic errors. Failure to correctly identify hearing change results in a miss; diagnosing a hearing change when hearing sensitivity is unaltered results in a false positive. The likelihood of making diagnostic errors in ototoxicity monitoring depends on how a criterion threshold shift relates to normal test-retest variability intrinsic to serial testing. A statistical method for examining test performance, which borrows from clinical decision theory, involves the construction of receiver-operator characteristic (ROC) curves, in which hit rates for a range of criterion threshold shifts can be plotted as a function of the corresponding false alarm rates.

For serial audiograms, ASHA (1994) developed criteria for a clinically significant hearing change based on results of large clinical research studies, reported normal test-retest variability in healthy subjects not receiving ototoxic drugs, and to a limited extent on ROC curves constructed for threshold shift data obtained in drug- or noise-exposed individuals. These criteria include: >20 dB pure-tone threshold shift at one frequency, >10 dB shift at two consecutive test frequencies, threshold response shifting to "no response" at three consecutive test frequencies. Change must be confirmed by retest.

The ASHA criteria employ a comparatively large (20 dB) single frequency threshold shift or smaller shifts at more than one frequency because threshold shifts for two or three frequency averages have been shown to increase test performance for detecting ototoxicity- and noise-induced hearing shifts. This is presumably because threshold shifts at adjacent test frequencies indicate more systematic change compared to shifts at any single frequency. The ASHA criteria include confirmation of test results because threshold shifts obtained on repeat tests are more likely to represent a true hearing change compared to results obtained on a single test.

The ASHA guidelines for ototoxicity monitoring emphasize the increased test sensitivity achieved using ultra-high-frequency monitoring to detect ototoxicity. Test-retest differences for ultra-high-frequency thresholds using modern equipment is generally reported to be within +10 dB for frequencies between 9 and 14 kHz. False positive rates indicating a change in ultra-high-frequency thresholds in subjects that were not exposed to ototoxic drugs is low in young and older adults, even when thresholds are tested on the hospital ward under controlled conditions.

Ultra-high-frequency sensitivity can be monitored in older children; however, test-retest variability is generally poorer in young children. Consequently, ultra-high-frequency testing in young children will likely result in lower sensitivity and higher false positive rates compared to adults.

Additional Factors to Consider

Effectiveness of particular test protocols for detecting and monitoring ototoxicity depends on a variety of factors in addition to test sensitivity and specificity. Other important factors to consider are the status of patients typically targeted for testing (both their ability to provide reliable behavioral data and their pre-exposure hearing sensitivity), speed of the test and its analysis, cost of performing and interpreting the test, and availability of equipment.

Patient responsiveness can be determined, in part, by physician or nurse reports in the patient's medical chart. The ASHA 1994 guidelines recommend a full audiometric evaluation for patients who are alert and responsive. Objective measures of auditory status should be included in the Baseline Evaluation if there is a possibility that the patient will become less responsive over the course of treatment.

An abbreviated test battery is required for patients who tire easily or show limited responsiveness or awareness, such as difficulty identifying their location or purpose for being in the hospital. In order to reduce test time while maintaining high sensitivity to ototoxic hearing damage, a shortened protocol is recommended that targets for monitoring a range of frequencies near each patient's upper frequency limit of hearing. The reported hit rate for this protocol is approximately 90% in large groups of adult patients with ototoxic hearing changes observed using full-frequency testing.

A more complete Monitor Evaluation is necessary if hearing change is observed using the shortened protocol described above. Data obtained using a test-battery approach allow hearing changes to be verified, threshold shifts due to middle ear dysfunction to be ruled out, and the effect of hearing changes on speech recognition to be determined. Objective measures, such as evoked otoacoustic emissions (OAEs) and auditory brainstem response tests (ABRs) are particularly useful to include in the Monitor Evaluations test battery for children with limited attention spans.

There is a class of patients unable to provide reliable behavioral data that includes infants and non-responsive adults on the hospital ward. Objective tests must be used to monitor changes in auditory function in non-responsive patients. As described above, middle ear dysfunction must be ruled out in order to determine that any changes noted are likely due to changes in cochlear function. If middle ear function is normal and hearing is good, OAEs appear to be an excellent indicator of early ototoxic damage. However, abnormal middle ear function and baseline hearing loss greater than about 40 dB HL may preclude effective monitoring using OAEs. Use of ABR testing may be more appropriate in such cases.

Determining effective ototoxicity detection and monitoring strategies using objective measures of auditory function is an active area of research. However, there currently are no accepted protocols or criteria for ototoxic change using objective measures. Most reports in patients receiving ototoxic drugs have focused on ABR or OAE test sensitivity, in which sensitivity was defined as a clinically significant change in the value of the objective measure.

Test-retest variability in subjects not receiving ototoxic drugs has been used to provide criteria for a clinically significant response change and to estimate false positive rates. Such studies have been useful for developing potential objective protocols for ototoxicity, which need to be validated. Further research is needed comparing test performance for each objective test (i.e., its sensitivity and specificity) to a behavioral standard.

Lilly, D., Feeney, P., and Rosowski, J. Current and emerging tools for assessing middle-ear function. ASHA leader, 10, 5 (April), 6, 24-26. 

Objective measurement of middle-ear function continues to be refined. Over the course of the last 30 years there has been a trend toward increasing the frequency of measurement in middle-ear assessment.

Current technology offers the opportunity for improved diagnosis of middle-ear disorders by using multifrequency and multicomponent tympanometry. The emerging technologies of wideband energy reflectance and laser Doppler vibrometry offer an indication of middle ear function over the same frequency range as the pure-tone audiogram.

Early results with energy reflectance measurements appear promising for assessing middle ear disorders and measuring the acoustic reflex. Similarly, the early findings with laser Doppler vibrometry show this approach to hold great promise for the diagnosis of conductive hearing disorders involving the ossicular chain.

Lewis, M.S., Valente, M., Horn, J., & Crandell, C. (2005). Effect of hearing aids and frequency modulation technology on results from the Communication Profile for the Hearing Impaired. Journal of the American Academy of Audiology 16(4): 252-263.

Hearing impairment has been associated with decline in psychosocial function. Previous investigations have reported that the utilization of hearing aids can ameliorate reductions in psychosocial health. To date, few investigations have examined the effects of frequency modulation (FM) technology on hearing handicap, adjustment to hearing loss, and communicative strategies. The purpose of this investigation was to examine these effects and to compare them to the benefits obtained when using hearing aids alone. Subjects ranged in age from 34 to 81 years and had mean pure-tone thresholds consistent with a bilateral moderate to severe sloping sensorineural hearing loss (SNHL). All subjects wore hearing aids only and hearing aids plus FM system in a randomized fashion. The Communication Profile for the Hearing Impaired (CPHI) was administered prior to fitting the study devices and once a month for three months in each of the two conditions. A statistically significant difference between device conditions was obtained for the Importance of Communication in Work Situations subscale. Additionally, statistically significant differences across time were noted in several CPHI subscales. Despite statistical significance, none of these results were clinically significant. The implications of these results will be discussed.

Saunders GH & Fausti SA (2005) Advanced Hearing Aid Features: Directional Microphones and Telecoils. Guest Editors Saunders & Fausti of Special Issue of Seminars in Hearing 26(2).

Saunders GH & Fausti SA Plasticity, Outcome Measures, and Evidence-based Practice. Guest Editors Saunders & Fausti of Special Issue of Seminars in Hearing 26(3).

This special issue of Seminars in Hearing is a publication that has arisen out of the national conference that was organized by the National Center for Rehabilitative Auditory Research (NCRAR) in Portland, Oregon. The conference was titled "Auditory Rehabilitation: A Multidisciplinary Approach' and took place on October 9th and 10th 2003 in downtown Portland. The conference was attended by over 164 delegates, among which were audiologists, researchers, engineers and university faculty from across the US and Europe. The conference brought together internationally respected clinical researchers and practicing clinicians who discussed the latest advances in the field of auditory rehabilitation with the aim of facilitating learning and scientific discussion.

The meeting had four special sessions that were carefully selected by the Program Committee to represent the current most pertinent issues in the field of clinical audiology. We invited two world-renowned researchers to present at each special session. In addition, between one and three case studies pertinent to the particular session topic were presented by practicing audiologists. These case presentations were submitted by clinicians from around the country and were selected for presentation by the program committee based on their clinical and scientific relevance to the session topic. Finally, to end each special session there was an hour-long round-table discussion during which panel members responded to questions posed by members of the audience. Each discussion session had a different panel. Members consisted of the invited speakers for each session plus one or two other conference participants that had particular clinical and/or research experience in the area under discussion. These panel discussions gave rise to interesting exchanges between panel members and the audience. This special issue consists of a written form of each presentation and case study, along with a transcription of each round-table discussion.

The first session was on Directional Hearing Aids. The opening talk was by Todd Ricketts of the Department of Hearing and Speech Sciences at Vanderbilt University. Dr. Ricketts provided us with an introduction to directional technology and then described to us a series of experiments he has been conducting in his laboratory comparing the benefits provided by adaptive and fixed directional hearing aids for understanding speech in noise. It was particularly enlightening to learn of the practical difficulties that he and his research team have encountered when trying to provide a moving noise source required for investigating the effectiveness of adaptive directionality! In summary he has shown that adaptive directionality does provide a substantial advantage over fixed directionality in very specific listening situations. However, he warns that these situations, in which there are discrete uniform low level noise sources, may not be very common in the real world. Dr. Brian Walden of Walter Reed Army Medical Center presented the second paper on directional hearing aids. His presentation specifically addressed the question of the effectiveness of directional hearing aids in real world listening. He began by pointing out how real-world listening differs from laboratory listening, highlighting such factors as reverberation, variable noise sources and the need for the user to switch between microphone modes. He presented data showing that many individuals fail to use their hearing aids in the directional mode, and that many had difficulties determining listening situations in which directional microphones would be more advantageous than omnidirectional microphones. He concluded by stating that although directional microphones provide advantages in specific listening situations, omnidirectional microphones should be the default setting for most hearing impaired individuals.

The second session was "Implications of Plasticity of the Neural System for Auditory Rehabilitation". Dr. Michael Merzenich from the Keck Center for Integrative Neuroscience at the University of California at San Francisco was the first presenter. Dr. Tremblay of the Department of Speech and Hearing Science at the University of Washington, Seattle was the second speaker. She provided us with an explanation of how the principles of neural plasticity are central to aural rehabilitation and offered suggestions as to how these principles can be applied in the clinic. She presented data from some of her laboratory experiments showing that auditory evoked potentials, specifically the N1-P2 complex, change following perceptual training, suggesting that these measures reflect newly learned perceptual skills. She postulates that in the future we might be able to use such measures to monitor the effectiveness of the fitting of an auditory prosthesis, such as a hearing aid or cochlear implant.

The second day of the conference began with the topic of Outcomes Measurement. Dr. Robyn Cox of University of Memphis TN and Dr. Harvey Abrams, Bay Pines VA Medical Center, FL were the speakers. Dr. Cox' presentation focused on the selection of a self-report outcome measure to evaluate hearing aid outcomes. She pointed out that with so many different measures available, choosing the most appropriate tool can be difficult. She then presented a five-step approach that will enable clinicians to select the best tool for their specific application. Her technique is particularly appealing because it guides the clinician though each level of decision making, from prioritizing his/her goals, to specifying the essential features required and ultimately to developing a 'report card' for each measure. Dr. Abrams also discussed selection of appropriate outcome measures relating this to the principles used in evidence-based practice (EBP). He reminded us of the many reasons why outcome measurement is critical and provided us with an introduction to the World Health Organization's (WHO) classification system known as the International Classification of Functioning, Disability and Health (ICF). He also defined the grading system used in EBP for evaluation of clinical research studies. He concluded that as a field, it is critical for Audiologists to have clinical practice guidelines based upon high quality research studies.

The final session of the conference was Issues associated with telephone use and hearing aids. Dr. Harry Levitt and Dr. Mark Ross presented different perspectives on this matter. Dr. Levitt's presentation focused on electromagnetic interference in hearing aids. He described the background behind a new ANSI standard for measuring and specifying the electromagnetic field generated by a wireless telephone and the immunity of a hearing aid relative to the electromagnetic field. He then described an important experiment that he and co-workers had conducted to determine how much interference is acceptable to hearing aid users in terms of telephone usability. The research team evaluated three different telephone transmission technologies with a number of different hearing aid styles from a variety of manufacturers. They found that signal-to-interference ratios (SIR) had to be in the range of 28-32dB to achieve a rating of 'highly useable' and that once the SIR dropped to 12-15dB subjects reported major limitations in usability. These data are so important because the provide a relationship between the physical measurement of SIR and subjective usability ratings. Dr. Ross provided for us a history of the telecoil (or 'audiocoil', as he believes it should be termed), pointing out that the name telecoil implies it only has application for telephone use, while they do, in fact, have many applications. He described some of these for us, such as their use as receivers in large area loop systems, counter-top portable loop convincingly that we should adjust the frequency response of the telecoil to meet that of the microphone, which he points out is almost never done in clinical practice. Finally, he explained that in Europe, loop systems are ubiquitous in public places and much appreciated by hearing-impaired individuals, and that in the US we should strive for the same.

There is insufficient space in this publication for a summary of each case presentation and roundtable discussion. However, I hope this summary has inspired you to read on and appreciate the content of the NCRAR conference.

The next NCRAR conference is scheduled for September 22nd and 23rd, 2005. It is titled 'The Aging Auditory System: Considerations for Rehabilitation' and will feature presentations from Bob Frisina Jr., Sandra Gordon-Salant, James Jerger, Jack Mills, Kathleen Pichora-Fuller, Pam Souza, Therese Walden and Arthur Wingfield on Behavioral Studies of Auditory Aging, Pathophysiology of the Aging Auditory System, Cognitive Components to Auditory Aging and Amplification and Beyond: Issues Associated with treating the Geriatric Patient.

Saunders, GH; Chisolm, T, & Abrams HB (in press) Measuring Hearing Aid Outcomes - not as easy as it seems. Invited paper for special issue of Journal of Rehabilitation Research and Development.

Outcomes measurement in Audiology has received much attention due to the need to demonstrate efficacy of treatment, provide evidence for third-party payment, carry out cost-benefit analyses and justify resource allocation. Outcomes measurement shows the benefits obtained from a hearing aid, and determines the costs of obtaining those benefits.

Here, we discuss why the seemingly simple issue of outcomes measurement is highly complex. We discuss the use of generic and disease specific tools, and the relationship between them, and provide information regarding the International Classification of Functioning (ICF) system for selecting outcome measures. We then discuss factors complicating outcomes measurement, including discrepancies between clinically derived outcomes and functional outcomes, the ways clinicians can impact outcomes, and factors intrinsic to the patient that influence outcome. We conclude that to realize the vision of moving quickly and efficiently from bench to chairside, outcomes must be measured routinely and further research must be conducted.

In this paper the importance of measuring hearing aid outcomes is discussed, procedures for selecting appropriate tools for doing so are provided and some of the patient-based and clinician-based factors that complicate measurement are described.

Saunders, GH, Cienkowski, KM, Forsline, A & Fausti, SA Normative data for the Attitudes towards Loss of Hearing Questionnaire. Journal of the American Academy of Audiology.

Investigations have shown that patient attitudes toward hearing loss and hearing aids impact self-reported handicap and disability, hearing aid benefit and hearing aid use. The Attitudes towards Loss of Hearing Questionnaire (ALHQ) was developed by Saunders & Cienkowski (1996) to examine some of the psychosocial factors underlying the use and acquisition of hearing aids. Here we report data from a new version of questionnaire (ALHQ v2.1) which examines attitudes towards hearing loss and hearing aids on five scales: Denial of Hearing Loss, Negative Associations, Negative Coping Strategies, Manual Dexterity and Vision and Hearing-related Esteem. Reliability values, internal consistency values and cut-points for typical and atypical scores are provided, along with comparison of the scores of women, men, current hearing aid users, non-hearing aid users, and paying versus non-paying individuals. The ALHQ takes about 10 minutes to complete and identifies for the clinician some of the issues that might jeopardize successful hearing aid outcome.

Konrad-Martin, D, Keefe, D.H. (2005). Transient-evoked stimulus-frequency and distortion-product otoacoustic emissions in normal and impaired ears. J. Acoust. Soc. Am. 117, 3799-3815.

     Transient-evoked stimulus-frequency otoacoustic emissions (SFOAEs), recorded using a nonlinear differential technique, and distortion-product otoacoustic emissions (DPOAEs) were measured in 17 normal-hearing and 10 hearing-impaired subjects using pairs of tone pips (pp), gated tones (gg), and for DPOAEs, continuous and gated tones (cg). Temporal envelopes of stimulus and OAE waveforms were obtained by narrow-band filtering at the stimulus or DP frequency. Mean SFOAE latencies in normal ears at 2.7 and 4.0 kHz decreased with increasing stimulus level and were larger at 4.0 kHz than latencies in impaired ears. Equivalent auditory filter bandwidths were calculated as a function of stimulus level from SFOAE latencies by assuming that cochlear transmission is minimum phase. DPOAE latencies varied less with level than SFOAE latencies. The ppDPOAEs often had two (or more) peaks separated in time with latencies consistent with model predictions for distortion and reflection components. Changes in ppDPOAE latency with level were partly explained by a shift in relative amplitudes of distortion and reflection components. The ppSFOAE SPL within the main spectral lobe of the pip stimulus was higher for normal ears in the higher-frequency half of the pip than the lower-frequency half, which is likely an effect of basilar membrane two-tone suppression.

Gordon JS, Phillips DS, Helt WJ, Konrad-Martin D, Fausti SA: The evaluation of insert earphones for high-frequency bedside ototoxicity monitoring. Journal of Rehabilitation Research and Development, 42(3): May/June 2005, pages 353-363.

Ototoxic hearing loss is usually detected earliest through monitoring of the highest audible frequencies in individuals administered ototoxic medications. Conducting ototoxicity monitoring may require testing patients in the hospital room. This study evaluated the use of insert earphones for obtaining reliable threshold responses at bedside. Twenty adult subjects were tested during two different sessions in the sound booth and on the ward. Thresholds were obtained for frequencies from 5 to 16 kHz and at 2 kHz with the use of the KOSS Pro/4X Plus earphones and Etymotic ER-4B MicroPro insert earphones. Results indicate that ER-4B insert earphones are as reliable as KOSS earphones for testing on the ward for high-frequency ototoxicity monitoring.