# data[].attributes.body
The different types and degree of hearing loss will determine the best treatment plan for your child.

# data[].attributes.attachment_link.provider_name
Centers for Disease Control and Prevention

# data[].attributes.attachment_link.readable_text
A hearing loss can happen when any part of the ear or auditory (hearing) system is not working in the usual way.

Outer Ear
The outer ear is made up of:

the part we see on the sides of our heads, known as pinna

the ear canal

the eardrum, sometimes called the tympanic membrane, which separates the outer and middle ear

Middle Ear
The middle ear is made up of:

the eardrum

three small bones called ossicles that send the movement of the eardrum to the inner ear

Inner Ear
The inner ear is made up of:

the snail shaped organ for hearing known as the cochlea

the semicircular canals that help with balance

the nerves that go to the brain

Auditory (ear) Nerve
This nerve sends sound information from the ear to the brain.

Auditory (Hearing) System
The auditory pathway processes sound information as it travels from the ear to the brain so that our brain pathways are part of our hearing.

There are four types of hearing loss:

The degree of hearing loss can range from mild to profound:

Hearing loss can also be described as:

Fluctuating or Stable
Hearing loss gets either better or worse over time (fluctuating) or stays the same over time (stable).

Congenital or Acquired/Delayed Onset
Hearing loss is present at birth (congenital) or appears sometime later in life (acquired or delayed onset).

# data[].attributes.attachment_link.description
A hearing loss can happen when any part of the ear or auditory (hearing) system is not working in the usual way.

# data[].attributes.body
Direct quote from this article:
"Hearing with only one ear is not enough for a child to function normally."

# data[].attributes.attachment_link.readable_text
This course is an edited transcript of a Phonak webinar on AudiologyOnline.

Learning Outcomes

After this course learners will be able to:

Describe the types of unilateral hearing loss.

Describe the use cases of the Phonak Sky V, CROS II, and Roger Focus.

Describe the process of verification of the Phonak CROS II and Roger Focus.

Introduction and Overview

In today's seminar, we will be addressing unilateral hearing loss (UHL) in children and its impact on those children. Hearing with only one ear is not enough for a child to function normally. Modern hearing solutions from Phonak can help children with a unilateral hearing loss be ready for success. We offer multiple solutions, including the Sky V, the CROS II with the Sky V, and the Roger Focus.

UHL Defined

Unilateral hearing loss means that one ear has normal hearing thresholds, and the impaired ear can have any degree of hearing loss. Unilateral hearing loss is classified as a minimal hearing loss. Single-sided deafness (SSD) is a subset of unilateral hearing loss where there is no usable hearing on the impaired ear.

UHL in Children

How often is unilateral hearing loss present in children? One in 1,000 newborns are identified with unilateral hearing loss at birth. By the time they reach school age, 3 in 100 children may have developed unilateral hearing loss (Bess, Dodd-Murphy, & Parker, 1998). Some of the causes of UHL include bacterial meningitis, malformations of the ear canal, congenital cytomegalovirus (CMV), enlarged vestibular aqueduct syndrome (EVA), and premature birth. In some cases, the cause of UHL is idiopathic; we cannot pinpoint a specific reason why it occurred (Prieve et al., 2000).

Hearing with both ears provides a child binaural advantages that they lack when they have hearing loss in one ear. These advantages include: binaural summation, making up for the head shadow effect, sound localization, spatial release from masking, and help in reverberant situations. Any impairment can result in difficulties in real-world listening environments, such as: hearing at a distance or in noise, sound localization, segregating sounds, selective attention (ability to discern a specific sound or speaker in a noisy situation), and speech understanding.

Impact of UHL on Children: Studies

What is the impact of unilateral hearing loss for these children due to the difficulties in those environments? Because a child with UHL does not hear the full picture, they are more likely to experience difficulty in the following areas:

Speech-language delay

General communication difficulties

Psycholinguistic dysfunction (ability to learn language)

Social-emotional problems

Quality of life effects

Academic and behavioral difficulties

Language Scores

A study by Lieu and colleagues (Lieu, Tye-Murray, Karzon, & Piccirillo, 2010) looked at the effect of unilateral hearing loss on speech and language scores in children. It was a case-control study of 74 matched pairs of siblings (ages 6-12). They found a child with a hearing loss and compared their speech and language scores to their sibling. Their rationale for comparing siblings was that it would take out any socioeconomic factors, and focus only on the delays caused by the unilateral hearing loss.

Some of the children with UHL were unaided, and some weren't. They administered the OWLS assessment (Oral and Written Language Scales). The children with UHL scored worse than their siblings, in language comprehension, oral expression, and oral composite. Unilateral hearing loss was the independent predictor of the OWLS scores. Family income and maternal education were also independent predictors of oral expression and composite scores.

The authors' conclusions were that school age children with unilateral hearing loss demonstrate worse oral language scores than their sibling. In addition, withholding hearing related accommodations should be reconsidered and studied. Parents and educators should be informed of unilateral hearing loss effects on oral language skills.

Language, Cognitive, and Achievement Scores with Differing Audiologic Characteristics

Another study from Lieu and colleagues (2013) similarly compared children with unilateral hearing loss to their siblings. Again, it was a case controlled study, this time with 107 sibling pairs. In this study, they also wanted to compare and see if the outcomes were affected by the unilateral hearing loss.

Once again, the children with UHL had worse OWLS scores than their siblings. As one might expect, the children with profound unilateral hearing loss had the worst scores, in both verbal cognitive and oral language. However, there were no differences in achievement scores using the Wechsler Individual Achievement Test, where recognition scores of the normal ear in quiet and in noise correlate to higher scores.

The authors concluded that school-age children with unilateral hearing loss have worse language scores than their siblings. Furthermore, those with profound unilateral hearing loss tend to have the worst outcomes. There were no differences whether the hearing loss was in the left or the right ear.

Quality of Life

In 2007, Sarah Borton conducted a pilot study to determine whether children (ages 6-17) with UHL experience a lower quality of life. It consisted of a qualitative study, comparing children and parent focus groups, and a quantitative study, using the Pediatric Quality of Life Inventory Version 4.0.

According to the child reports, those with UHL scored more poorly for several scales than those with normal hearing or bilateral hearing loss, on all primary quality of life scales (total, psychosocial and physical). The parent reports were similar to the child reports, except better on psychosocial functioning as compared to bilateral hearing loss. The author's conclusion was that children with unilateral hearing loss demonstrated overall lower and wider range of quality of life scores compared to normal hearing peers, and their peers with bilateral hearing loss.

In summary, UHL affects about 3% of school age children, may cause issues with language and academics, and it results in a difficulty in complex or noisy environments.

Academic/Psychosocial Skill Difficulties

In the Comprehensive Handbook of Pediatric Audiology, Porter and colleagues (2016) state, "All children with permanent minimal hearing loss must be considered at risk for psychoeducational difficulties and managed accordingly" (p. 903). Let's take a look at some of the academic difficulties that may be experienced by children with UHL.

In 2004, Gravel conducted a meta-analysis, comparing the results from six studies to pinpoint the areas where children with UHL are having trouble. Across all six studies, children with UHL who failed one or more grades ranged anywhere from 18% to 40%. According to four of the studies, between 12% to 41% of students required extra help in one or more grades throughout their academic careers. Students who required both resource help and also failed a grade ranged from 48 to 65%. As the evidence suggests, these children have more difficulty in academic situations or in school than children with normal hearing. They are 10 times more likely to repeat a grade, and five times more likely to need additional educational resources. They are clearly being negatively impacted by the unilateral hearing loss in school situations.

Children with UHL had a higher incidence of failure rate or negative comments on their report card (Keller & Bundy, 1980). Furthermore, teachers rated these children more negatively than normal hearing peers (Culbertson & Gilbert, 1986). For example, whether they pay attention to an academic task, in their peer relations and social confidence, their dependence versus independence in the classroom, and emotional ability. Finally, English and Church (1999) found that teachers had behavioral concerns for children with unilateral hearing loss. If you have more trouble paying attention and it's more difficult to hear, it stands to reason that you're going to act out. You're not going to be able to pay attention as well as some of the other children in the class, and those come across as behavior issues.

Typical Classroom Noise Levels

Shield and Dockrell (2004) measured typical noise levels in 140 classrooms using an internal noise survey. They found that if one person is speaking in the classroom, it measures about 61 dB. If students are sitting at tables doing group work, it's about 73 dB; if they are doing group work with movement, it can measure up to 77 dB. Children alone working at tables is about 65 dB. During "silent" reading time, the noise level still measures about 56 dB. If people are simply moving around the classroom, it can be up to 72 dB. It's a complex listening environment. In today's classrooms, students do a lot of group work and work at tables. Gone are the days of students sitting at their individual desks facing forward with the teacher speaking at the front of the room. Today's classrooms are more dynamic listening environments, because they are always changing. It can be very difficult to listen, even if you have normal hearing.

Children with UHL have difficulty hearing in dynamic listening situations and as such, are challenged when faced with complex listening tasks. Although their speech and language scores may be within the normal limits on some tests, as the listening environment becomes more complex, they start to break down and not perform as well as their normal hearing peers. That's why we examined the classroom setting to show that it is a complex and ever-changing listening environment.

Complex Listening Tasks

Lewis et al. (2015) analyzed complex listening tasks, using comprehension and sentence recognition. The subjects included 18 normal hearing children (ages 8-12) matched with 18 children who had either minimal hearing loss, or UHL. They were asked to perform speech recognition tasks in a simulated classroom.

All children performed at or near the ceiling. The children with unilateral hearing loss performed more poorly than children with normal hearing on the complex tasks. Individual looking behavior differed between the two groups. In other words, for those with hearing loss, attempting to visualize, or locate, the speaker may inefficiently utilize cognitive resources. That makes sense, because UHL affects localization.

The authors concluded that children with unilateral hearing loss perform more poorly than peers with normal hearing during complex listening tasks with multiple talkers. Patterns of looking behaviors differ, suggesting differences in the use of visual information. Again, those with hearing loss have trouble finding the main speaker when multiple people are talking. They have more difficulty locating the speaker; as such, they need to look around more.

Solutions for Unilateral Hearing Loss

The American Academy of Audiology (AAA) Pediatric Amplification Protocol addressed fitting of amplification on children with mild bilateral hearing loss (MBHL) and UHL in its Special Consideration section. Here is an excerpt from the guideline:
Children with minimal and mild hearing loss should be considered candidates for amplification and/or personal FM system or sound-field systems for use in school. Use of hearing aid amplification is indicated for some children with unilateral hearing losses. The decision to fit a child with unilateral hearing loss should be made on an individual basis, taking into consideration the child's or family's preference as well as audiologic, developmental, communication, and educational factors.
This decision should be made on an individual basis because there are several types of unilateral hearing loss. Furthermore, every child will be affected differently in different environments; children with UHL are a heterogeneous group. When deliberating which solution to use, the choice should be made based specifically on that child's needs; there is no blanket one-size-fits-all solution for every child with a UHL. As we will demonstrate in the remainder of this presentation, Phonak offers multiple solutions for each type of UHL.

A child might have an aidable unilateral hearing loss, where the impairment may be mild or more severe, but they still have the ability to recognize speech. Or, a child might have severe to profound unilateral hearing loss, where the impaired ear is unaidable. As a result, they have significantly poor speech understanding in the impaired ear. What do we consider appropriate timing for treatment? Delayed amplification may lead to auditory deprivation, and the benefits of amplification have been proven.

Phonak Sky V for Aidable UHL

Let's say that the hearing-impaired ear is aidable. You can have any degree of hearing loss on that ear, from mild to severe. Amplification should be the default fitting option. Benefit can be determined during the trial period. Remote microphone usage for noisy situations or listening at a distance (e.g., in a classroom), is recommended. For this case, we have Phonak Sky V with Roger.

The Phonak Sky V is our current pediatric line of hearing aids along with the fitting range for each (Figure 1). There are five models to fit any hearing loss. The Sky V-M is for mild to moderate loss. It has the 312 battery. The Sky V-P is not just the power aid; the fitting range is very broad. It can fit a mild to moderate hearing loss, and it does have the power to fit a more severe loss. The Sky V-SP has more gain than previous superpower hearing aids, so it also can fit a pretty severe loss. The Sky V-UP has a 675 battery. We also offer the Sky V-RIC, which has three receivers and three possible fitting ranges, including a UP receiver. You can fit a fairly significant loss with the Sky V-RIC.

All Sky V hearing aids have direct audio input and mix and match color options, where you can match the housing and change the color of the tone hook. They all have tamper-proof options. You can optimize the hearing performance, especially for a child's environment, and I'll explain that later in the presentation. The IP rating for all of these hearing aids is IP68. They all have an indicator light, which means the hearing aid is on and the battery is working. When it goes into the Roger program, it can show you with two flashes every few seconds. Three flashes every few seconds indicates a low battery warning, and that you have 30 minutes to change the battery.

Figure 1. Sky V hearing aids and their corresponding fitting ranges.

SoundRecover2

SoundRecover2 is utilized in the Sky V line, which gives children access to a broader range of sounds essential for speech and language development. SoundRecover 2 differs from SoundRecover in that there is still non-linear frequency compression, but it is adaptive. It has two cut-off frequencies: one that is a higher frequency cut-off, and one that is a lower frequency cut off. Whenever low frequency information is coming through the hearing aid, it will only compress to the high frequency cut-off so it doesn't affect the low and mid frequencies. When low or mid frequencies come through the hearing aid, they're unchanged. If you have high frequency information coming through the hearing aid, it will compress down to that lower frequency cut-off. The reason for this is to get more high frequency sound in, even with a hearing loss that slopes off early, so that we can compress to where they need it compressed, but still preserve the mid and low frequencies. For example, if I said the word "she," when I pronounce the "sh" part of the word, it will compress to the lower frequency to make sure that I was able to hear the "sh." When I get to the "e" part of the word "she," it would only compress to the high frequency cut-off, so that the "e" sound is unaffected.

AutoSense Sky OS

Phonak Sky V was specifically created to optimize hearing performance in a child's environment. AutoSense Sky OS is the automatic program used in the Sky V line. It is different from our other automatic program used in our adult hearing aids, because children often participate in situations where adults would not typically be (e.g., playing on a playground or in a park). When we took the adult classifier and we put it through a child's day, we noticed that when they were playing outside on the playground, or in physical education class where they're yelling and screaming in a gymnasium, it was switching into the music program. Therefore, we adjusted the AutoSense to go into speech in noise, and speech and comfort programs at an earlier threshold than it does with our adult hearing aids. Then, we performed research through Dr. Jace Wolf, and found that children performed better and preferred AutoSense Sky to regular AutoSense. It's designed specifically for a child's school day.

Roger and Directional Setting

In previous Phonak hearing aids (and any other manufacturer's hearing aids), when they would go into the Roger or the FM program, it would be Roger plus the hearing aid microphone (+Mic). The +Mic version would essentially be our omnidirectional Program. Now, you have the ability to turn directional microphones on or off within the Roger program. You can set it to one of three settings: Omni (which uses the omnidirectional mic), Real Ear Sound (which is close to omnidirectional, but with the pinna effect added for better localization, as well as some increase in the high and mid frequencies), or Fixed Directionality. If you choose Fixed Directionality, the hearing aid will not go into directional all the time; rather, it's an automatic directional microphone. For example, if the classroom goes above 54 decibels, you'll have Fixed Directionality; if it goes back down below 54 dB, the hearing aid will go back to Real Ear Sound. It's an automatic directional microphone within the Roger program. We chose Fixed Directional instead of "adaptive directional" for a reason. When you're in a classroom, you do a lot of lateral listening; it's important that the hearing aid doesn't reduce voices from the sides of the child. If you have Fixed Directionality, you know exactly what the hearing aid is doing at all times, and you know that it won't cut down specifically the voice of a child to the left or the right that is asking a question. Therefore, you can put the child in the appropriate place and know exactly what the hearing aid is doing at all times for lateral listening.

Quality of Life Improvement Study

McKay (2002) conducted a study to look at the improvement in quality of life for children with aidable UHL after they were fit with hearing aids. They administered surveys to 20 families with children who had mild to moderately severe unilateral hearing loss (ages 2-17). The parents' comments included, "It would be a blessing if we would have put hearing aids on these kids sooner", and "He was missing one half of everything before he got his hearing aid."

Most parents said that since the hearing aid fitting, the children were either doing the same, improved or greatly improved in all areas. In areas specifically related to auditory areas, all children improved. Children liked their hearing aids, parents were happy and wished their children had been fit earlier.

The author concluded: "Children with unilateral hearing loss (who fit candidacy requirements [i.e., they had aidable ears]), should minimally receive a trial with amplification. Fitting these children has appeared to improve their quality of life. We believe that without this opportunity, the children are being denied access to their full potential."

Sometimes, when a professional sees a child with a unilateral hearing loss, there might be a "wait and see" mentality; they may want to wait and see how the child is affected by the hearing loss. It might be a better approach to go ahead and do the trial period with hearing aids. It doesn't hurt to try and see if there is a benefit.

Phonak Solutions for Unaidable UHL: CROS II with Sky V

With severe to profound unilateral hearing loss (a.k.a., single sided deafness), where the hearing-impaired ear is unaidable, the goal of amplification is to bring sound from the impaired ear to the normal hearing ear. Phonak offers two different solutions for this type of hearing loss: CROS II with the Sky V for a more everyday solution, and the Roger Focus receiver used with a Roger transmitter as a solution for noisier situations, such as classrooms and schools. CROS stands for Contralateral Routing of Signal.

CROS II Benefits: Performance

One consideration in CROS fittings is that the child needs to be old enough to recognize the dynamics of the acoustic environment. That is the child needs to determine where the sounds and noise are coming from. A trial period is helpful. The CROS II with Sky V is the best solution for children wanting to wear a CROS, although the CROS II can also be used with Roger, for more challenging listening situations, such as a classroom.

CROS II is on the Venture platform, which provides several performance benefits as compared to earlier versions of CROS. StereoZoom is available for speech in noise. Directional microphones on the CROS transmitter mean we can use Binaural VoiceStream Technology (BVST) for better listening. It has a lower noise floor, which is important for normal hearing listeners using CROS II. It also offers 30% better battery life.

Directionality

There is directionality in all three performance levels of CROS II (Figure 2). The levels of the Sky hearing aids are V50, V70 and V90. On the hearing aid side of the CROS II fitting (i.e. the receiver side), you will have the same directionality that you would have on the aid if you weren't using the CROS II. On the CROS II side (i.e., the transmitter side), if you are using the 50 level, you will have Real Ear Sound; the 70 and the 90 levels give you access to StereoZoom.

StereoZoom is the program that narrows the directional beam to directly in front. In the 70 level hearing aid, StereoZoom can be activated by a manual button in both the hearing aid as well as the transmitter. In the 90 level, the transition to StereoZoom occurs automatically, based on the noise level in the environment.

Figure 2. Directionality in Sky V 50, 70 and 90 performance levels.

Better Battery Life

CROS II provides a 30% better battery life than previous versions of the CROS. With the 312, that adds two days; with the 13, it can add up to three days of battery life as compared to prior models.

StereoZoom and Phonak CROS II

With Sky V 70 and 90, you will be able to have directionality on both sides of the CROS II fitting. Again, Sky V90 automatically goes into the directional program (i.e., StereoZoom). It does that at the lower noise floor when you're using the CROS II than it does when you have two hearing aids. When you're using the CROS II with the Sky V90 level, it will go into StereoZoom whenever the environmental noise gets above 58 dB; that is a little earlier than it would go into directional in a fitting with two hearing aids.

Low Noise Floor

Figure 3 shows a comparison of Phonak's low noise floor to some of the competitive CROS systems as measured at the Phonak Audiology Research Center (Phonak, 2015).

The graphs show the noise floor levels by frequency for the Phonak (green) and the competitor (grey) CROS. Frequency lowering, feedback cancellation and any sound cleaning features were disabled. Standard tubing and an occluded standard earmold without venting was selected in both Phonak Target and the competitor's software. For the measurements, the CROS devices were programmed for 0 dB hearing thresholds in the better ear. Adobe Audition was used to record noise floor levels and stimuli through KEMAR.

The noise floor, or 0 dB HL (normal hearing), is represented by the red line. Ideally, the noise floor should be as close to (or below) normal hearing as possible, so that the wearer doesn't hear any noise in quiet settings. The graph shows that the Phonak CROS II system revealed a lower noise floor. With CROS candidates often presenting with thresholds better than 20dB HL, noise levels between 20 and 35 dB SPL as seen with the competitive device, would certainly be audible and possibly interfere with audibility for soft sounds. With Phonak CROS II, CROS users would not have any audibility of the noise floor thus experience better audibility of soft sounds.

Figure 3. Noise floor: CROS II versus competitive CROS system.

Directional Microphone Benefit

Figure 4 shows the results of a comparison between the Phonak CROS II (left) and the competitor's CROS product (right) as measured by the Phonak Audiology Research Center. You can see that there is more separation between speech from the front and noise from the side with the CROS II, and that the directionality is active at a lower level as compared to the competitive product.

Figure 4. Directional microphone benefit: CROS II versus competitive CROS system.

CROS II Benefits: Ease of Use

Many of the improvements that Phonak implements are based on feedback from professionals. This is evidenced by some of the differences between the CROS and the CROS II. Some improvements as they relate to ease of use include automatic switching to Roger with Sky V RogerReady, as well as a simplified fitting approach.

RogerReady. The Sky V product line has a feature called RogerReady. With RogerReady, the hearing aid will be able to go back and forth between the Roger program and the automatic program, or the CROS program. In the classroom, whenever a teacher speaks into the microphone, it will switch to the Roger program within 400 milliseconds. It's fast and effective because it happens 100% of the time. When a student goes out to the playground or the cafeteria, or anytime it stop getting the Roger signal for 50 seconds, it will switch back into the other programs (e.g., with CROS II, it would switch to the CROS program). It will switch back and forth between CROS and Roger without having to press a button. Therefore, CROS II is easier to use with Sky V than ever before. You don't have to rely on a young child or a teacher pushing a program change button on the hearing aid or remote control. It happens automatically.

CROS II: Simplified Fitting Approach

When performing a CROS II fitting in Junior Mode, you will see a screen similar to the image in Figure 5. You won't have to add in a Roger program, but the default for Junior Mode fittings is to start up in the Roger program. If you are fitting CROS II, you'll change the startup program to AutoSense Sky OS, which is the automatic program. If you don't want to use the automatic program, you can have it start up in Calm (or your preferred start up program). As you can see in Figure 5, there is a check box for RogerReady in the lower right corner. RogerReady is defaulted to "On" in all Junior Mode fittings. With RogerReady on, it will automatically switch back and forth between the Roger program, and the program of your choosing for the startup, based on whether someone is speaking into the Roger microphone.

Figure 5. CROS II fitting in Junior Mode.

As compared to previous CROS fittings, fitting CROS II is easier because with iCube II, the CROS is live during the fitting. With iCube, you won't have to connect and then disconnect everything, then reconnect everything again to return to the programming. The CROS II is during the fitting as long when using the iCube II.

If you don't fit CROS very often, and you want to brush up on it, the Phonak CROS Solution Fitting Guide is a great resource available on our website. You'll notice that it refers to fitting the CROS II or the CROS B. The CROS B is for the Audeo B. It has all the same features as the CROS II, just a new housing. The CROS B works with all of the Audeo B devices, except for the rechargeable device.

CROS II Benefits: Look and Feel

Another difference between the original CROS and the CROS II is the new housings, new housing colors, as well as the ability to use the CROS Hook.

BTE Choices

CROS II is available with either a size 13 battery or 312 battery (Figure 6). With the size 13, you can use a CROS Hook, which is just a regular tone hook, so that you can put a traditional ear mold in the ear. This is helpful for those little ears where you can't keep the SlimTube in the ear because it always falls out. When you use an ear mold on the normal hearing side with the CROS, its purpose is retention. You want to make sure that it is as open as possible, for comfort reasons. You can also use the SlimTube. You can still use the CROS Tip, which is also shown on the hearing aid on the far right in Figure 6. The CROS Tip is a hollowed-out kind of sleeve mold that attaches to the end of the SlimTube.

Figure 6. CROS II BTE choices.

New housing color choices. Previously, with CROS, color choices were limited for the hearing aid side. Now, we have all of the pediatric colors to match the CROS (Figure 7).

Figure 7. Phonak CROS II-13 new colors.

Phonak CROS II-13 with CROS hook: Child friendly design. The child-friendly design includes: BTE size 13 housing; IP67 rating; 18 housing colors; seven CROS Hook colors to mix and match with Sky V; a push button and volume control; high-tech composite material; tamperproof door available. Using the CROS Hook and Sky V-P tamperproof battery door will meet the IEC standards for small children.

To put the ear hook on, simply push the pin towards the center of the hearing aid out. That will allow you to remove the spine. Then you'll just replace that spine with the ear hook, and then push the pin back into place.

Verification of CROS II: Setup and Procedure

Set up. First, position the client in front of the speaker. Next, program the hearing instrument and the CROS II transmitter in the Target software. If you are using the iCube II, hang the iCube II around the client's neck to allow for instant adjustment based upon verification feedback.

Measure the aided response for the "better hearing ear." Place the reference microphones on both ears. You'll place reference mics on both ears, but you'll only put the insert probe microphone in the better ear. Place both the hearing instrument and the CROS II transmitter on the ears. Ensure that the instrument is programmed and active. Select "on ear measure," and record the response at either 55 or 60 dB SPL with the speaker directly facing the better ear (as shown in Figure 8).

Figure 8. Measuring the aided response on the better hearing ear. The better ear response is the green line on the graph (right).

Measure the aided response in the poorer ear. Don't change the positions of the probe microphone, the reference mic, or the CROS system. Ensure that the hearing instrument and the CROS transmitter are still turned on. Change the hearing instrument selection to "CROS." Rotate the client so that the speaker directly faces the poorer ear, and then record the response (Figure 9).

Figure 9. Measuring the aided response on the poorer hearing ear. In this case the better ear response (green line on graph) and poorer ear response (pink line on graph) are similar.

Ideally, the "better ear" and the "poorer ear" responses should be within 2 - 3 dB of each other. If they differ greatly, fine-tuning may be required to allow them to match as closely as possible. If they are very different, always check the position of the speaker when you're switching sides to ensure that the placement of the speaker to the ear is identical. Check the position of the instrument on the ear. Check the position of the hearing aid and the CROS to make sure they're sitting on top of the ear in the same way. Verify that the programming of the CROS is balanced and comfortable. If you are unable to match the two responses, check the CROS system to ensure it is functioning properly. If the CROS system is not working or the transmitter is faulty, you may see very different responses, similar to the ones pictured in Figure 10.

Figure 10. Better ear response (green line) and poorer ear response (pink line) are not within 2-3 dB of each other. This indicates that the CROS system or transmitter may be faulty.

Phonak Solutions for Unaidable UHL: Roger Focus

The second option for children with SSD or unaidable UHL is to wear a remote wireless microphone system like the Roger Focus. For children with severe to profound hearing loss, Roger Focus increases the signal-to-noise ratio (SNR) to the normal hearing ear. It is beneficial not only in classrooms, but also in cars, at social settings, and anytime where noise or distance makes it difficult to hear well.

The Roger transmitter will transmit the signal directly to the Roger Focus providing a better SNR. It's an easy and comfortable receiver (Figure 11). It has a push button volume control, which you can deactivate by pressing and holding the volume control down for five to seven seconds. It is a ready-to-wear design, using a SlimTube and dome. It uses a 312 battery, and opening and closing the battery door will turn it off and on.

Figure 11. Roger Focus easy and comfortable receiver.

SlimTubes are available in four sizes (0-1-2-3) and domes are available in three sizes. At start up there is minimum volume, and you can increase volume by increments of two decibels until it reaches the maximum volume, using the push button volume control. At maximum volume, pressing the volume control will revert down to the minimum volume. If you don't want the child to have control of the volume, press and hold the volume control button for a few seconds to disable the volume control.

When fitting an ear-level wireless receiver like Roger Focus that is used on a normal hearing ear, you should leave the ear canal as open as possible. The child should be able to hear environmental sounds and speech normally from the good side. SlimTube is standard, but Roger Focus can also be used with an ear hook and an open ear mold. If you do have to go with an ear mold, use a regular tone hook and ear mold with as big a vent as possible. SlimTube is standard, but Roger Focus can also be used with an ear hook and an open ear mold. Roger Focus is available in 17 colors.

All Roger microphones and media transmitters are available with Focus (Figure 12). These include the Roger Touchscreen Mic with the Roger Pass-around and Multimedia Hub; you can also go with a Roger Pen, or even the Roger Clip-On microphone.

Figure 12. Roger microphone and transmitter choices.

Maximum Performance Using the Roger Focus

In 2014, Jones and team at the Phonak Audiology Research Center (PARC) conducted a study using 15 school children who were previous users of iSense (our FM solution similar to the Roger Focus) or MicroEar (Figure 13). The goal of the study was to obtain speech-in-noise testing results using no device, and then compare that to results using the Roger device. Some of the children (e.g., subject numbers 2, 4, 12 and 14 in Figure 13), went from being able to hear almost nothing in a noisy situation with no solution, to close to 100% when using the Roger Focus. The data show a wide variety of benefits that can be realized with Roger Focus. This relates back to the importance of fitting children individually, because each child is uniquely affected by his or her unilateral hearing loss. There is not a "one size fits all" management approach when it comes to UHL.

Figure 13. Speech-in-noise testing with Roger Focus as compared to no device. Source: Phonak Field Study News (2014).

Verification of the Roger Focus

In 2008, AAA suggested procedures for fitting remote microphone hearing assistance devices like the Roger Focus, including in the ear probe microphone measures. Schafer and colleagues (2014) conducted a stody to validate the AAA guidelines and recruited 26 normal hearing children. Their goals of obtaining real ear measures for RMHA (remote microphone hearing assistance) were:

To verify the measured output for prescribed-gain targets from 1 to 4 kHz for speech stimuli

To confirm that the RMHA volume did not exceed predicted loudness discomfort levels

To assess changes to the real ear unaided response (REUR) when placing the open sound delivery system in the ear

They found that on average, prescription targets were met from 1 to 4 kHz within +/-3 dB, although at times the high frequency targets at 3 and 4 kHz could not be met. Maximum power output (MPO) of the RMHA never exceeded MPO limits and overall, was significantly less than estimated uncomfortable loudness levels (UCLs). Some change in the REUR due to the open sound delivery system were noted, but the differences were small.

Procedure. To assess changes in REUR, follow this procedure.

1. Insert the probe tube

2. Select 'on ear measures', real ear insertion gain, BTE.

3. Record the client's REUR for a moderate stimulus level (e.g., 65 dB SPL)

4. Insert the RMHA into the ear but leave the device turned off. Select "REAR" (real ear aided response), and present the stimulus at the same level used in Step 3.

If the REUR is similar to REAR1 (i.e. curves overlay one another), it means that the REIG (real ear insertion gain) is approximately 0 dB. This implies minimal disruption of residual hearing function by the presence of the open fit sound delivery system.

Verification of RMHA output. To verify output of the RMHA, follow these steps. Refer to the handout that accompanies this course for supplemental photos of these steps.

1. Enter the pure tone audiogram into the verification system.

2. Select "FM" from the hearing instrument menu.

3. Select the "on-ear" mode.

4. Switch the transmitter into its verification mode and place it in the test box with its mic aligned iwth the reference mic. For dynamic FM, switch into omnidirectional mode. For the Inspiro, you only need to ensure the lapel microphone is in the test box.

5. If the device has a manual volume control, set this to maximum and select the 'MPO' stimulus. If required, adjust the receiver settings to ensure the MPO isn't exceeding targets at this maximum volume setting. If there is no manual volume control, skip this step.

6. At user volume, select Std-Speech (1) or (2) and choose 'FM chest' or 'FM Boom' for level, depending on which type of microphone you are using. Record the speech curve and check against targets in the 1 to 4 kHz region.

7. If desired or required, adjust the RMHA gain setting to try to meet targets from 1 to 4 kHz.

Note: You can only adjust Roger Focus gain with the Roger Inspiro transmitter. For iSense micro, you can use the FM Successware.

8. Re-run the MPO at the user volume setting after any gain adjustments have been made, to make sure that it is not exceeding MPO.

Roger DigiMaster 5000 & 7000

Sometimes, you might not be able to use the Focus because you can't use an on-ear system. For example, if the child has draining ears, sensory issues (they don't like things in their ear), or ear malformations, you may be unable to put a device in the ear. In cases like these, you can use a Roger DigiMaster 5000 or 7000, which are sound field solutions for classrooms.

Summary

Porter and colleagues (2016) stated: "With the known struggles of children with unilateral hearing loss, the most professionally responsible approach is recommended. That is, all children with hearing loss should be provided with the tools necessary to help them reach their full potential"

Phonak can help children with UHL be ready for success with the Phonak Sky V, the Phonak CROS II with the Sky V, and the Roger Focus. The Roger solutions in noise include adding Roger to the CROS II or the Sky V. We also have design-integrated Roger solutions for cochlear implants, as well as bone-anchored hearing aids.

I'd like to leave you with this quote from Krishman and Van Hyfte (2016): "With infants being identified with UHL at a very early age, it is time for clinicians to consider all intervention avenues available, and to take the opportunity to positively impact the development of children with unilateral hearing loss to help them reach their maximum potential."

Questions and Answers
Who chooses whether the FM is in directional or omnidirectional? Is that chosen by the audiologist or in programming, or through the Roger transmitter?
That is done through the Target software. When you're programming the hearing aid, you can go to Program Options in the Roger program options and choose Omni, Real Ear Sound, or Fixed Directional.
Can a child utilize the function of a CROS while also utilizing FM?
Not at the same time. We would like to be able to hear the CROS as well as Roger FM at the same time, but we're not there yet. We can stream from aid to aid, and we can also stream from Roger to the hearing aid, but not at the same time. so we are still working on that. But the CROS II is more easily used than the previous versions of the CROS.
I usually have the student take off the CROS piece when using the DM. Should it be left off?
You can leave the CROS piece on. With the previous version, they didn't switch back and forth, so you had to change the program. Then if you took the CROS piece off, you might be able to save battery. I would leave the CROS on, that way when it switches back and forth. It will work appropriately, and if you take the CROS off, the CROS won't be active until you put it back on.
Is there any way to use the CROS II on a child with atresia or microtia? I have parents who want non-surgical options at home.
They use the Focus at school for these students. You can use the CROS II if there is a way to attach it. I don't know about using a soft band; I've never seen that used in these cases. Just like a hearing aid, you do have to somehow be able to attach the CROS II.
What is the default setting when you use the Sky plus Roger program? Does it start up in Omni, Real Ear Sound, or Fixed Directional?
It will depend on the age of the child. If you go in Target, you can look at all of the default settings. I think from birth to three, it's Omni. For the next age range of four to eight, the default is Real Ear Sound. Above age 8 years it is Fixed Directional, but you can also change the default settings in the Target software.
Is there a solution for putting an FM system on a toddler without removing the tamper-proof battery door?
You can get an integrated Roger receiver that has a tamper-proof solution attached to it. The receiver itself becomes the battery door, and it is tamper-proof. If you need tamper-proof, go with an integrated receiver.
Is there research available addressing the Roger Focus versus classroom amplification?
There is research comparing ear level amplification to sound field amplification but not specifically that I'm aware of with unilateral hearing loss, or specifically to the Roger Focus.
When using the Roger with the CROS II, should you leave the CROS II on the profound ear so the RogerReady can take its place?
With CROS fittings, you'll always have a hearing aid side and a CROS side. When you program, you're actually programming the hearing aid, and letting it know that the CROS II is there. The CROS II would always go on the poorer ear, and then the hearing aid would go on the better ear.

Selected References

American Academy of Audiology (AAA). (2008). American Academy of Audiology Clinical Practice Guidelines: Remote Microphone Hearing Assistance Technologies for Children and Youth Birth-21 Years. AAA Supplement - Supplement A. Fitting and Verification Procedures for Ear-level FM. Available from author: www.audiology.org

Bess, F.H., Dodd-Murphy, J. & Parker, R.A. (1998). Children with minimal sensorineural hearing loss: Prevalence, educational performance, and functional status. Ear & Hearing, 9, 339-354.

Borton, Sarah A., (2007). Quality of life in children with unilateral hearing loss: a pilot study. Independent Studies and Capstones, Paper 201. Program in Audiology and Communication Sciences, Washington University School of Medicine. http://digitalcommons.wustl.edu/pacs_capstones/201

Culbertson, J.L. & Gilbert, L.E. (1986). Children with unilateral sensorineural hearing loss: cognitive, academic, and social development. Ear & Hearing, 7, 38-42.

English, K., & Church, G. (1999). Unilateral hearing loss in children: An update for the 1990's. Language Speech & Hearing Services in Schools, 30, 26-31.

Gravel, J. (2004) Minimal hearing loss in children. Presentation at Phonak Satellite Conference, NHS. Available from phonakpro.com

Keller, W.D., & Bundy, R.S. (1980). Effects of unilateral hearing loss upon educational achievement. Child: Care and Health Development, 6(2), 93-100.

Lewis, D.E. (2016) An update on children with unilateral hearing loss: What do we know and where do we go? Presentation at 2016 Pediatric Audiology Conference, Boys Town National Research Hospital, Omaha, NE.

Lewis, D., Schmid, K., O'Leary, S., Heinrichs-Graham, E., Spalding, J. & High, R. (2016). Effects of noise on speech recognition and listening effort in children with normal-hearing and children with mild bilateral or unilateral hearing loss. Journal of Speech Language Hearing Research, 59(5), 1218-1232. doi: 10.1044/2016_JSLHR-H-15-0207

Lieu, J. (2004). Speech-language and educational consequences of unilateral hearing loss in children. Arch Otolaryngol Head Neck Surg, 130(5), 524-30.

Lieu, J.E.C., Karzon, R.K., Ead, B. & Tye-Murray, N. (2013) Do audiologic characteristics predict outcomes in children with unilateral hearing loss? Otol Neurotol 34(9), 1703-1710.

Lieu, J.E.C., Tye-Murray, N., Karzon, R.K. & Piccirillo, J.F. (2010) Unilateral hearing loss is associated with worse speech-language scores in children. Pediatrics, 125, 2009-2448. doi: 10.1542/peds.2009-2448

McKay, S. (2002, July 22). To aid or not to aid: Children with unilateral hearing loss. AudiologyOnline. Retrieved from www.audiologyonline.com

Phonak Audiology Research Center, PARC-SEDOL Experimental Roger Laboratory. (2014) Roger Focus Validation. Phonak Field Study News.

Phonak. (2015). Phonak CROS II - Electroacoustic measurements look at key performance aspects of two wireless CROS systems. Phonak Field Study News.

Porter, H., Bess, F.H., & Tharpe, A.M. (2016). Minimal hearing loss in children. In A.M. Tharpe and R. Seewald (Eds.), Comprehensive handbook of pediatric audiology (p. 903). San Diego, CA: Plural Publishing.

Prieve, B., Dalzell, L., Berg, A., Bradley, M., Cacace, A., Campbell, D.,...Prieve, B. (2000). The New York State universal newborn hearing screening demonstration project: Outpatient outcome measures. Ear & Hearing, 21(2), 104 -117.

Schafer, E., Bryant, D., Sanders, K., Baldus, N., Algier, K., Lewis, A.,...Amin, A. (2014). Fitting and verification of frequency modulation systems on children with normal hearing. J Am Acad Audiol, 6, 529-40. doi: 10.3766/jaaa.25.6.3

Shield, B.M., & Dockrell, J.E. (2004). External and internal noise surveys of London primary schools. Journal of the Acoustical Society of America, 115, 730-738.

Watier-Launey, C., Soin, C., Manceau, A. & Ployet, M.J. (1998). [Necessity of auditory and academic supervision in patients with unilateral hearing disorder. Retrospective study of 175 children]. Ann Otolaryngol Chir Cervicofac,115(3),149-55. [article in French]

For further references, refer to the handout that accompanies this course, or contact Phonak.

# data[].attributes.attachment_link.authors[].name
Dane Bowers, AuD, CCC-A Pediatric and FM Specialist Dane Bowers is the Pediatric and FM Specialist of the Northeast with Phonak LLC. He received his AuD from thee University of Tennessee. Prior to joining Phonak, he worked as a private practice audiologist in Florida. His clinical experience includes adult and pediatric diagnostics and hearing aid fittings as well as vestibular testing.

# data[].attributes.attachment_link.title
Unilateral Hearing Loss in Children: Impact and Solutions Dane Bowers

# data[].attributes.attachment_link.description
This course is an edited transcript of a Phonak webinar on AudiologyOnline. After this course learners will be able to: Describe the types of unilateral hearing loss. Describe the use cases of the Phonak Sky V, CROS II, and Roger Focus. Describe the process of verification of the Phonak CROS II and Roger Focus.

# data[].attributes.headline
Hearing loss affects language development

# data[].attributes.subject
Hearing loss affects language development

# data[].attributes.body
Children learn language by hearing others and imitating them. Hearing loss slows the developmental process, which is why early identification and intervention is so crucial.

# data[].attributes.attachment_link.keywords[]
how hearing loss affects communication kids language speech speak talk verbal listen hear cincinnati children's hospital medical center

# data[].attributes.attachment_link.description
Information about how hearing loss affects communication, provided by Cincinnati Children's Hospital Medical Center.

# data[].attributes.body
An overview of genetic causes of hearing loss to help

# data[].attributes.body
The first step.

# data[].attributes.attachment_link.description
Children of all ages can use hearing aids. An audiologist can find the best hearing aid for your child.

# data[].attributes.body
How to wash earmolds, perform listening checks, change batteries, etc.

# data[].attributes.attachment_link.title
Caring for Hearing Aids & Earmolds | Children's Hospital Pittsburgh

# data[].attributes.attachment_link.description
Hearing aids are delicate instruments that need attention to ensure good operation. Before you put the hearing aid on your child, follow this checklist.

# data[].attributes.headline
Keeping hearing aids on your child's head

# data[].attributes.subject
Keeping hearing aids on your child's head

# data[].attributes.body
The most difficult part.

# data[].attributes.body
For those with severe to profound hearing loss who do not benefit from traditional hearing aids.

# data[].attributes.attachment_link.readable_text
What is a cochlear implant?

A cochlear implant is a small, complex electronic device that can help to provide a sense of sound to a person who is profoundly deaf or severely hard-of-hearing. The implant consists of an external portion that sits behind the ear and a second portion that is surgically placed under the skin (see figure). An implant has the following parts:

A microphone, which picks up sound from the environment.

A speech processor, which selects and arranges sounds picked up by the microphone.

A transmitter and receiver/stimulator, which receive signals from the speech processor and convert them into electric impulses.

An electrode array, which is a group of electrodes that collects the impulses from the stimulator and sends them to different regions of the auditory nerve.

An implant does not restore normal hearing. Instead, it can give a deaf person a useful representation of sounds in the environment and help him or her to understand speech.

How does a cochlear implant work?

A cochlear implant is very different from a hearing aid. Hearing aids amplify sounds so they may be detected by damaged ears. Cochlear implants bypass damaged portions of the ear and directly stimulate the auditory nerve. Signals generated by the implant are sent by way of the auditory nerve to the brain, which recognizes the signals as sound. Hearing through a cochlear implant is different from normal hearing and takes time to learn or relearn. However, it allows many people to recognize warning signals, understand other sounds in the environment, and understand speech in person or over the telephone.

Who gets cochlear implants?

Children and adults who are deaf or severely hard-of-hearing can be fitted for cochlear implants. As of December 2019, approximately 736,900 registered devices have been implanted worldwide. In the United States, roughly 118,100 devices have been implanted in adults and 65,000 in children. (Estimates provided by the U.S. Food and Drug Administration [FDA], as reported by cochlear implant manufacturers approved for the U.S. market.)

The FDA first approved cochlear implants in the mid-1980s to treat hearing loss in adults. Since 2000, cochlear implants have been FDA-approved for use in eligible children beginning at 12 months of age. For young children who are deaf or severely hard-of-hearing, using a cochlear implant while they are young exposes them to sounds during an optimal period to develop speech and language skills. Research has shown that when these children receive a cochlear implant followed by intensive therapy before they are 18 months old, they are better able to hear, comprehend sound and music, and speak than their peers who receive implants when they are older. Studies have also shown that eligible children who receive a cochlear implant before 18 months of age can develop language skills at a rate comparable to children with normal hearing, and many succeed in mainstream classrooms.

Some adults who have lost all or most of their hearing later in life can also benefit from cochlear implants. They learn to associate the signals from the implant with sounds they remember, including speech, without requiring any visual cues such as those provided by lipreading or sign language.

How does someone receive a cochlear implant?

Use of a cochlear implant requires both a surgical procedure and significant therapy to learn or relearn the sense of hearing. Not everyone performs at the same level with this device. The decision to receive an implant should involve discussions with medical specialists, including an experienced cochlear-implant surgeon. The process can be expensive. For example, a person's health insurance may cover the expense, but not always. Some individuals may choose not to have a cochlear implant for a variety of personal reasons. Surgical implantations are almost always safe, although complications are a risk factor, just as with any kind of surgery. An additional consideration is learning to interpret the sounds created by an implant. This process takes time and practice. Speech-language pathologists and audiologists are frequently involved in this learning process. Prior to implantation, all of these factors need to be considered.

What does the future hold for cochlear implants?

The NIDCD supports research to enhance the benefits of cochlear implants. Scientists are exploring whether using a shortened electrode array, inserted into a portion of the cochlea, for example, can help individuals whose hearing loss is limited to the higher frequencies while preserving their hearing of lower frequencies. Researchers also are looking at the potential benefits of pairing a cochlear implant in one ear with either another cochlear implant or a hearing aid in the other ear.

Where can I find additional information about cochlear implants?

The NIDCD maintains a directory of organizations that provide information on the normal and disordered processes of hearing, balance, taste, smell, voice, speech, and language.

Use the following keywords to help you find organizations that can answer questions and provide information on cochlear implants:

For more information, contact us at:

NIDCD Information Clearinghouse
1 Communication Avenue
Bethesda, MD 20892-3456
Toll-free voice: (800) 241-1044
Toll-free TTY: (800) 241-1055
Email: nidcdinfo@nidcd.nih.gov

NIH Publication No. 00-4798
February 2016
Statistics updated March 2021

# data[].attributes.attachment_link.description
A cochlear implant is a small electronic device that can provide a sense of sound to people who are deaf or hard-of-hearing. Learn more about how they work.

# data[].attributes.body
FM systems are used mainly in schools. Classrooms can be extremely noisy places and FM systems help reduce the amount of noise that your child will hear, making hearing the teacher easier. FM can be used with hearing aids and cochlear implants.

# data[].attributes.attachment_link.title
FM Systems for Hearing Aids - My Baby's Hearing

# data[].attributes.attachment_link.description
FM Systems can be used at home or at school to help children hear and understand speech in areas with noisy backgrounds. Learn about their parts, cost, and where and how they should be used.

# data[].attributes.body
Strategies to develop language and improve communication.

# data[].attributes.body
The goal is to give your child as much access to language as possible

# data[].attributes.attachment_link.title
Communication Options - Decisions - My Baby's Hearing

# data[].attributes.attachment_link.description
There are several communication approaches to consider when deciding how to talk with your child. Learn types and considerations.

# data[].attributes.attachment_link.title
default - Stanford Medicine Children’s Health

# data[].attributes.attachment_link.description
Stanford Medicine Children’s Health The main parts of the ear are the outer ear, the eardrum (tympanic membrane), the middle ear, and the inner ear.

# data[].attributes.body
Receive services in-home from the state.

# data[].attributes.body
Connect with trained parent guides who have been in your situation.

# data[].attributes.body
This website has a lot of wonderful information on all things audiology and ways to maximize the performance of children with each specific type of hearing loss.

# data[].attributes.attachment_link.title
Audiology Program | Patient Resources | Boston Children's Hospital

# data[].attributes.attachment_link.description
Diagnostic Audiology Program at Boston Children's Hospital - Patient Resources

# data[].attributes.attachment_link.readable_text
What information is on an audiogram and what does it mean for the person's hearing ability?

The amount (or degree) of hearing loss a person experiences is based on hearing sensitivity. In order to determine a person's degree of hearing loss, their hearing thresholds must be determined. Hearing thresholds are defined as the lowest level sound that can be heard 50% of the time. The decibel (or dB) is the unit of intensity used to describe hearing sensitivity. During a diagnostic hearing evaluation the threshold is measured at different frequencies (or Hertz, Hz) in each ear.

The degree of hearing loss is expressed by the difference between a person's threshold and the average threshold for people with normal sensitivity. For example, persons with mild hearing loss have thresholds that are 25 to 40 dB higher than the thresholds for those with normal hearing when tested using different at several frequencies. The list below outlines different hearing loss thresholds as they are determined in relation to an individual with a normal hearing threshold.

Mild hearing loss: 25 to 40 dB higher than normal
Moderate hearing loss: 40 to 55 dB higher than normal
Moderate-to-severe hearing loss: 55 to 70 dB higher than normal
Severe hearing loss: 70 to 90 dB higher than normal
Profound loss: 90 dB or more

The graph to the left represents a blank audiogram illustrates the degrees of hearing loss listed above. Frequency is plotted at the top of the graph, ranging from low frequencies(250 Hz) on the left to high frequencies (8000 Hz) on the right. Sound level, in dB, is plotted on the left side of the graph and ranges from very faint sounds (-10 dB) at the top to very intense sounds (120 dB) at the bottom.

Understanding the information shown on an audiogram is easy. Let's look at an example. In the audiogram below, hearing thresholds for the right ear are represented by red circles and thresholds for the left ear are represented by the blue X. In the right ear, this person has normal hearing in the lower pitches indicated by a red circle corresponding to 15 dB at 250 Hz and 20 dB at 500 Hz. Hearing thresholds in the high pitches fall into the severe degree of hearing loss, as the threshold at 2000 Hz is 40 dB, 65 dB at 4000 Hz and 75 dB at 8000 Hz. Can you determine the degree of hearing loss for the left ear?

Image credits:

http://alphaonenow.com/userfiles/image/aud_audiogram.gif

http://baasnotes.com/blog/wp-content/uploads/2008/10/audiogram-presbyacusis-rgb.jpg

# data[].attributes.attachment_link.title
How to Read an Audiogram and Determine Degrees of Hearing Loss

# data[].attributes.attachment_link.description
What information is on an audiogram and what does it mean for the person's hearing ability? The amount (or degree) of hearing loss a person experiences is based on hearing sensitivity. In order to determine a person's degree of hearing loss, their hearing thresholds must be determined.

# data[].attributes.attachment_link.description
There are a number of ways to identify a hearing loss. Each test is used for different people and reasons.

# data[].attributes.attachment_link.description
There are a number of ways to identify a hearing loss. Each test is used for different people and reasons.

# data[].attributes.attachment_link.readable_text
At UPMC Children's Hospital of Pittsburgh, we believe parents and guardians can contribute to the success of this test and invite you to participate. Please read the following information to learn about the test and how you can help.

Fast Facts About the Auditory Brainstem Response (ABR) Test

The ABR test measures the reaction of the parts of a child's nervous system that affect hearing. (The ABR test measures the hearing nerve's response to sounds.)

An ABR test is often ordered if a newborn fails the hearing screening test given in the hospital shortly after birth, or for older children if there is a suspicion of hearing loss that was not confirmed through more conventional hearing tests.

The ABR test is safe and does not hurt.

The ABR test can be completed only if the child is sleeping or lying perfectly still, relaxed and with his or her eyes closed.

If your child is younger than 6 months of age, the ABR test usually can be done while he or she naps.

If your child is older than 7 years, the ABR test usually can be done while your child is awake if he or she can relax and lie still. The test will be done in a special sound-treated suite in the Audiology department.

For children between the ages of 6 months and 7 years, the ABR test is done under anesthesia, which means that your child will need medication to help him or her sleep throughout the test. ABR tests with anesthesia are done through the Same Day Surgery Center.

When anesthesia is needed, there are special rules for eating and drinking that must be followed in the hours before the test. If these rules are not followed, the test cannot be done that day.

When the test is done under anesthesia, your child's primary care provider will need to see your child for a physical in order to fill out a history and physical form.

The test itself takes about 1 hour to 11/2 hours, but the entire appointment will take about 2 hours without anesthesia and up to 4 hours if your child needs anesthesia, due to the recovery time.

What Is the ABR Test?

The Auditory Brainstem Response (ABR) test is a helpful tool in determining a child's ability to hear. The test uses a special computer to measure the way the child's hearing nerve responds to different sounds.
Three to four small stickers called "electrodes" will be placed on your child's head and in front of his or her ears and connected to a computer. As sounds are made through the earphones, -the electrodes measure how your child's hearing nerves respond to them.

The audiologist, or hearing specialist, looks for certain neurological "markers" as your child's hearing nerves respond to sounds. The softest intensity or loudness level at which these markers appear roughly corresponds to the child's hearing level in that frequency range or pitch. By reading a computer printout of your child's responses and interpreting these markers, the audiologist can tell if your child has a hearing problem.

Home Preparation
Babies under 6 months
The most important way to prepare your baby for the test is to show up with a tired, hungry baby. Most young babies will sleep through the entire test if they are brought to the appointment ready for a feeding and a nap. Try to keep your baby awake and hold off feeding him or her until you get to the appointment. Once you are in the testing room and your child has been prepped for the test, you can nurse or feed your baby a bottle so he or she falls asleep naturally. The test will take place while your child sleeps in your arms or in a crib, which-ever is most comfortable for you and your baby.
Children older than 6 months but younger than 7 years
Children in this age range usually need anesthesia medication in order to sleep throughout the test. When anesthesia medication is needed, there are important rules for eating and drinking that must be followed in the hours before the test. If those rules are not followed, your child's ABR test usually will be rescheduled for another day. Please follow the special rules listed under "Home Preparation for Anesthesia."
Children older than 7 years
Most children who are 7 years and older can be tested while they are awake if they relax and lie still during the test. If your child is not able to cooperate, the test might need to be rescheduled so it can be done under anesthesia.

Home Preparation For Anesthesia

When general anesthesia is needed, there are important rules for eating and drinking that must be followed in the hours before the surgery. One business day before your child's test, you will receive a phone call from a nurse between the hours of 1 and 9 p.m. (Nurses do not make these calls on weekends or holidays.) Please have paper and a pen ready to write down these important instructions.

The nurse will give you specific eating and drinking instructions for your child based on your child's age. Following are the usual instructions given for eating and drinking. No matter what age your child is, you should follow the specific instructions given to you on the phone by the nurse.

For children older than 12 months:

After midnight the night before the surgery, do not give any solid food or non-clear liquids. That includes milk, formula, juices with pulp, coffee and chewing gum or candy.

For infants under 12 months:

Up to 6 hours before the scheduled arrival time, formula-fed babies may be given formula.

Up to 4 hours before the scheduled arrival time, breastfed babies may nurse.

For all children:

Up to 2 hours before the scheduled arrival time, give only clear liquids. Clear liquids include water, Pedialyte®, Kool-Aid® and juices you can see through, such as apple or white grape juice.

In the 2 hours before the scheduled arrival time, give nothing to eat or drink.

The Auditory Brainstem Response (ABR) Test

The ABR test without anesthesia is done in a special sound-treated suite in the Audiology Department at Children's Hospital of Pittsburgh. Once you have registered at the Audiology Department, you and your child will be called to the sound-treated suite.

If your child is 7 years or older, he or she will be asked to lie still on a bed or sit in a reclining chair, and the test will begin.

If your child is under 6 months, you will be called to the sound-treated suite, where you may nurse or feed your baby a bottle so that he or she will fall asleep. Once your child is asleep, the electrodes will be placed and the testing will begin.

If your child is having anesthesia, you will register your child at the Same Day Surgery Center. You and your child will be called to meet with a nurse, who will take your child's vital signs, weight and medical history. As the parent or legal guardian, you will be asked to sign a consent form before the sleep medication is given.

The anesthesiologist will meet with you and your child to review your child's medical information and decide which kind of sleep medication he or she should be given.

If your child is very scared or upset, the doctor may give a special medication to help him or her relax. This medication is flavored and takes effect in about 10 to 15 minutes. If you wish, you may stay with your child as the sleep medication is given.

Younger children will get their sleep medication through a "space mask" that will carry air mixed with medication. Your child may choose a favorite scent to flavor the air flowing through the mask. There are no shots or needles used while your child is still awake.

For all children:

Three or four small stickers called "electrodes" will be placed on your child's head.

The electrodes will be connected to a computer. They are completely safe and will not hurt your child.

Earphones will be placed in your child's ears.

Sounds will be made through the earphones at different loudness levels as the computer gathers information from the electrodes.

By reading the computer printout, the audiologist can determine if your child has a hearing problem.

Results from the ABR test, along with other hearing tests, will help the audiologist measure the type and extent of the hearing loss.

Waking Up/Going Home

If your child did not have anesthesia medication, he or she may resume normal activities after the test.

If your child had anesthesia medication, he or she will be moved to the recovery room after the test until the medication wears off. The length of time it will take the medication to wear off will vary, as some children take longer than others to become alert.

When your child is discharged, he or she may still be groggy and should take it easy for the day.

Your child may resume normal activities, eating and drinking at the rate he or she is comfortable with when you get home.

Special Needs

If your child has any special needs or health issues you feel the audiologist needs to know about, please call the Department of Audiology and Speech-Language Pathology at Children's Hospital before the appointment and ask to speak with an audiologist. It is important to notify us in advance about any special needs your child might have.

# data[].attributes.attachment_link.title
Auditory Brainstem Response (ABR) Test | Children's Pittsburgh

# data[].attributes.attachment_link.description
At UPMC Children's Hospital of Pittsburgh, we believe parents and guardians can contribute to the success of this test and invite you to participate. Please read the following information to learn about the test and how you can help. The ABR test measures the reaction of the parts of a child's nervous system that affect hearing.