Aural Rehab #2

• Visemes
• Homophenes

• The visual unit of speech
• Phoneme- the acoustic unit of speech

10. All english phonemes fall into 1 of 10 discrete visual categories.

• Speech sounds within the same visual category (homophenous)
• *look but don't sound the same.

1) p,b,m

2) f, v

3) w, hw, r

• 1) Th and th (voiced and unvoiced th)
• 2) Sh, ch, j, ig (beige)
• 3) s, z
• 4) j (yellow)
• 5) t, d, n, l

• 1) k, g, ng
• 2)Vowels

• easy
• hard

50%

• Speech - 15 phonemes/sec
• Eye- 12 phonemes/sec

• 50% of words and phonemes are homophenous
• Speech-15 phonemes/sec Eye- 12 phonemes/sec
• Running speech
• Different speakers ( artic movements, familiarity, rate, oral prosthetic, disordered artic, whisper)
• Visual Noise (poor lighting, glare, hand in front of face, food chewing, cigarette, pipe, truning away, gum chewing, mustache beard.

Articulation is different.

the process of decoding the visual cues of speech.

• Analytic method: breaking message down in little parts. Drill on sounds. mueller-walle, jena
• Synthetic method: pull everything together from all info w/o focusing on little parts. nitchie, and kinzie

Nitchie

Synthetic

• The Utley test, 
• Not sure of validity due to lack of science.

• auditory 
• visual

• who is the speaker
• acoutsic cues (signal level, noise level, SNR.)
• Speaker position
• gestures, facial expression
• speaker distance
• rate of speech
• lighting (make sure its good)

voicing.

those persons with substantial disability whom other AR techniques have not been effective.

• limitation of S/R
• difficulty learning s/r in a training program
• availability of more effective AR techniques.

• Figure-ground patterning: Recognizing a stimulus pattern in a background of noise. (focusing in on what you want to focus on in the midst of noise). EX- word search
• Closure: Perception of an incomplete stimulus as being complete. Ex- A win__r _orm warn_ng is in e_e_t

Vision.

• Visual disorders. 
• elderly
• multiply disordered individuals.

Ability to resolve visual stimuli.

20/20 vision is a term used to express normal visual acuity (the clarity or sharpness of vision) measured at a distance of 20 ft. if you have 20/20 vision you can see clearly at 20 feet what should normally be seen at that distance.

it means that you must be as close as 20 ft to see what a person with normal vision can see at 100 feet.

Ability to adjust sensitivity to light.

Genetic. Occurs in usher syndrome.

Usher syndrome

• congenital
• childhood, late teens

• night vision
• peripheral and central vision (in advanced cases)
• complete blindness.

promising research (nature medicine 2013) treating HL in Ushers with RNA injection.

• cataracts
• glaucoma
• macular degeneration
• diabetic retinopathy

Clouding of lens.

• usually excessive pressure in eye
• group of diseases that cause optic nerve damage
• second leading cause of blindness
• early treatment can prevent damage

• Affects central part of retina
• Central vision may blur and eventually advance to a central blindspot.

Damaged blood vessels on retina.

The light sensitive tissue at back of eye.

Hearing loss

Referral to vision specialist

combined hearing loss and visual impairment

• range of impairment ranges for both hearing and vision.
• estimated present in 3/100,000 newborns
• rubella, usher's syndrom and other genetic disorders, illness, trauma
• often severe communication, learning and mobility problems.

• Vision Care Providers:
• *Opthalmologist (m.d., surgery)
• *Optometrist (O.D., Doctor of optometry, 4 year grad program, some diagnosis and treatment, prescribe some meds)
• * Optician (fills lens perscriptions)

• Hearing Care:
• * Otologist or otolaryngologist (M.D)
• *Aduiologist (AUD)
• * Hearing and dispenser

• Acoustic cues
• visual cues
• linguistic cues

• Lexical
• Structural
• Contextual

Closed set of phonemes and words

rules for stringing together words and phonemes

Topic of conversation, speaker-listener relationship setting.

The part of the message that can be lost without significant loss of information *both auditory and visually*

• Speaker ----- encoding and monitoring speech-----message
• -----------decoding
• -----------------listener
• ---------ENVIRONMENT--------------

selected pieces of information regarding paterns of language performance.

• Heterogenous group 
• Pattern

complex

everyday exposure 24/7

exposure

greater deficit

language disorder and delay

language deficit

• Social and emotional relationships
• communication
• reading
• academic performance
• career

• related to age of onset of HL
• Related to degree of HL
• Significantly smaller vocabulary
• Gap between HL and normals widens as age increases
• Islands of deficit (certain situations kids w/ HL are not exposed to)
• Poor understanding of idioms, puns, multiple meanings and subtle differences
• Poor understanding of function words (conjunctions, prepositions, compared to semantic words (nouns))

• Related to degree of HL
• Use shorter sentences
• Use simpler sentences
• Poor understanding of complex sentences
• poor understanding of passive voice
• errors difficult to overcome

certain morphemes are in audible (especially s and z)

92%

• Deaf kids from deaf parents
• those with normal hearing parents
• consistent language exposure.
• *before cochlear implants.

• Acoustic input is critical for development of speech.
• -hearing others
• -hearing self (cannot self monitor)

• Start to babble like normal (throws parents off)
• Difference is that babble does not progress and may regress.

• Normal voice quality
• Normal vowel articulation
• Some consonant misarticulating (final consonants and fricatives
• *Speech is pretty normal*

• Deaf speech
• poor coordination of breathing and speech
• flat intonation contour --- monotone
• high pitch voice (putting in more effort)
• hypernasal (they can hear nasals better)
• articulation errors for both vowels and consonants
• poor control of pitch and loudness
•  poor differentiation of vowels
• omission of consonants
• poor rhythm of speech

• Speech reading instruction:
• Be creative
• make session interesting
• group is hard to facilitate 
• introduce clients to each other
• determine client occupations, interests
• explain the audiogram and typical high-freq. hearing loss
• Talk briefly about hearing aid
• discuss the communication model (don't get to academic)
• Prepare and distribute handouts
• Administer a hearing handicap scale; situational, psychosocial
• Briefly demonstrate the process of speech reading
• Give homework: over the time period until the next session, list situations in which it is especially difficult for you to hear clearly.

• Class two:
• Discuss hw
• s/r pre test
• discuss pretest results
• briefly discuss visibility of speech sounds
• present most recognizable visemes
• S/R exercises -- for example, QRE (quick recognition exercise)
• Homework: watch and analyze three different news casters without sound.

• discuss homework
• more visemes
• more exercises
• S/R post tests.

• Write 3 words up on board (pitch, fish, rich) that look different
• 1) Say words and they listen
• 2) Say it and point
• 3) Say them with you
• 4) you say it and they repeat it.

• -A management procedure
• Manipulate environment to perceive better cues
• get in position for auditor and visual cues 
• avoid noise
• avoid reverberation
• *Don't talk down to them*
• achieve proper lighting
• assert yourself (not aggressive)

profound hl

gestures, fingerspelling, signs

look like what they signify

• position
• configuration
• orientation
• movement

• asl or ameslan
• a non-English lanuage
• The language of the deaf community
• No written form (ie text for everyday reading)

• english language in signs
• a sign for every pronoun, prefix, suffix, etc.
• english order
• many signs the same as asl
• used predominantly only in educational setting (used in schools to teach english)

• SEE I: seeing essential english (early 1970's)
• SEE II: Signing exact english
• Signed english: developed at gallaudet university

Linguistics of visual english

used to fascilitate communication between haring ad hearing impaired individuals.

registry of interpreters for the deaf

between asl and spoken english

between signed english and spoken english

• Talk directly to HI person
• Short breaks
• Don't ask for interpretation of just part of message
• Furnish interpretor with technical vocabulary ahead of time
• Be prepared to slow speech
• only one person should talk at a time.

• 1:1 conversation behind HI person
• Classroom - near instructor
• good lighting
• slide/video presentation near presenter
• Group meeting 
• stage presentation.

american tinitus association

referral to ENT physician or an audiologist who specialized in tinnitus.

• Hearing aids (won't hear tinnitus)
• Tinnitus masker
• simple maskers (radio)
• counsling
• Tinnitus retraining therapy 
• Biofeedback
• Support group
• drugs 
• Diet (less caffine)

• goes with tinnitus masker
• absence of tinnitus for a short time after masking is removed (in HA too)

• long term
• expensive
• good and bad reports

relaxation tech using electrodes

Best treatment for hearing loss

• Hearing aids
• auditory trainers
• assistive listening devices
• cochlear implants
• tactile aids

intensify speech sounds that are inaudible.

The food and drug administration

• 1) Microphone(changes sound to electricity)
• 2) Amplifier (increases magnitude of electrical signal)
• 3) receiver (changes electrical signal back to sound)
• 4) Power supply ( battery or plugged in)

1) Sound---->2 Microphone------> 3) Amplifier --->4) Receiver ----> 5) ear mold ----> 6) ear

• Cell phone
• radio/tv
• amplification system in church or lecture hall
• home stereo system
• classroom amplification 
• mega phone

• Gain (volume)
• Frequency Response
• OSPL (output sound pressure level)

• The amount o amplification by the HA (input sound and gain = output sound)
• gain= use gain and reserve gain (amount you use and amount available)

• relative gain across frequencies
• tailored to compensate for the HL
• typically, increase high-frequency, sound and reduce low frequency sound.
• Programmable on a HA
• Treble and bass controls on a radio or other music playing device.

The maximum output of the HA in dB SPL

Reduced visability and acoustic advantages have produced a resurgence in BTE popularity

BTE

• small size of HA
• clear smooth triming
• absence of ear mold in many cases.

• most commonly fit
• typically best acoustic benefit
• engneered to reduce feedback
• multiple channels:program multiple settings
• ear level is better for localization and head shadow effects
• suitable for directional feature 
• sufficient power.

• rarely fit (young children still use)
• heavy
• aesthetic (not attractive)
• body baffle
• clothing noise
• poor localization cues
• commonly worn in harness (front or back)

1980's

• commonly fit
• good benefit for some
• custom fit to patient
• not available for comparison (cant try on before buying)
• difficult to modify shell if poor or sore fit- may need to remake
• more feedback
• earwax issues
• battery controls smaller and harder to handle
• safely (breakage in ear--children)
• less adaptable to remote mic and other features.

40 years old

similar advantages and disadvantages re: the ITE, sometimes more pronounced.

• Similar to ITE
• Stem or string to remove
• resonance advantage of concha
• close to eardrum, requires less power
• aesthetically preferred

• Worn up to 4 months w/o removing
• must be professionally placed
• battery lasts 4 months
• soft seal- breathable, water resistant
• consumer can remove if necessary (so, not considered implantable) hook loops to remove
• consumer buys a years worth of the service (receives new units as needed within that year.)

implantable ha for s/n hl

• Transducer (changing energy to electricity) lightly touches ossicles
• ~30,000
• why people get them.

• Rarely fit, mostly historical
• more expensive
• fit problems for the glasses 
• problems with bifocals, trifocals (problems)
• Limited selection
• replacement dilema (HA and Glasses)
• Repair (lose both vision and hearing)
• Advantage for CROS

one ear is not working so you could put wire through frames.

• metal head band
• elastic head band - more for kids who will probably get BAHA after 5 yrs 
• Usually good outcome

• Bone anchored HA
• Very stable signal into skull
• no headband or other accessory
• 1. bilateral conductiveHL (permanent or long term Ex: bilateral atresia
• 2. Persons with one aidable ear.

1992

• ABR
• 70%

98%

3/1000

NO

60% volume for 2 hours

in the canal

• Make (name)
• Model (combination of letters and numbers)
• Serial number (different for left and right)
• Year of manufacturer.
• Microphone port (opening to microphone
• Battery Compartment (usually on end)
• Elbow (ear hook)

• gain (volume) wheel (not linear- not even in between levels)
• OTM (on back side. Off, telephone, microphone)
• H or HF switch (high frequency- good in noisy situation)
• Additional controls

• Controls may or may not be present
• Volume
• t-coil
• directionality
• channel
• *programming determines if they will be active or automatic
• *many users prefer totally automatic function.

• Volume control
• telecoil
• Bluetooth
• Channels
• Directional microphone
• Environmental noise reduction
• Impulse noise reduction
• Wind noise reduction
• Feedback reduction
• WDRC
• Digital technology

• One manual-control option
• *Touch control (like an iphone)
• *Touch to change program
• *Sweep to change program

• T-coil
• Receives signals from telephone--electromagnetic.

Recieves external signals from telephone, ipod, tv--RADIO WAVES

Listening programs that are designed for specific listening environments

one

• omnidirectional = equally sensitive to 360 degrees
• Improves SNR in typical communication situations 
• Most newer HA have microphones that switch automatically into directional mode under certain conditions.

Designed for new york city taxi drivers - sensitivity to rear not front

• NO
• Children often don't look at person they are talking to 
• Incidental listening
• saftey (hearing everything around.

HA attempts to automatically sense the presence of non-speech sounds (background noise) and attempts to filter-out the noise

HA automatically senses the presence of very brief, impact sounds and attempts to suppress them

HA automatically senses wind turbulence across the mic and suppresses the noise produced

• HA automatically senses feedback occuring and electronically suppresses it (improved in last several years)
• Allows open ear canal in many cases because of improvements

• Wide Dynamic Range Compression
• Relates to OSPL output SPL = maximum level hearing aid can amplify.

• sensorineural HL as for normals (Recruitment)
• = Reduced dynamic range

30

• little or no compression
• moderate compression
• substantial compression

• Most new HA are digital
• Greater Resolution (clearer) and control of digital (vs. Analog) signals.

$3000-$7000

binaural

batteries

development of batteries

1.4 volts

• 675 (bigger
• 13 (thicker with smaller diameter
• 312 (flatter and most common)
• 10
• 5

• Zinc Air
• -Remove sticker to activate
• - Shelf life up to 3 years if battery remains sealed

Some rechargable available, but problems with initial cost and replacement

4.50-$1.50 each

• Varies with HA type and user
• ~ 10 days

How long they last on the shelf. Purchase fresh batteries.

Insertion one-way.

• National button battery Ingestion Hotline
• (202) 625 -3333
• 8-16 months most common
• seniors
• competent adults
• dogs

Carry extra batteries with you

Flat- stay at stable level but quit all at once

battery checker

1.4 volts

How long it lasts not VOLTAGE

1.0v

A person who needs them, benefits from them, wants them

• degree of HL
• Persons with moderate to severe hearing loss.

• Real ear measurements
• - measure HA output with mic in ear canal, match output to HL (audiogram).
• Subjective
• -during clinical evaluation, 30 day trial *can return it if you dont like it*

custom or general

Bigger

Hold the hearing aid in place.

• Open fit with no ear mold
• to a earmold

• Audiologist makes an impression of the ear
• -cotton damn past second turn in canal
• -use syringe to push putty into ear
• -wait 10 minutes

• HA lab
• $55

• to hold the HA securely on the ear
• to modify acoustics
• =higher frequencies= more open
• Also made for custom earplugs to protect ears from (water, noise)

• Canal
• Sound bore :inside of canal portion
• Snap ring:receives button receiver (body HA)
• Helix: Slips in helix flap of concha, last in holds mold, causes most soreness and can be cut off. 
• Concha rim: fits in concha

• Hard lucite: hard, clear, smooth plastic. Easy to clean--ADULTS
• Soft: rubbery, sillacone, snug fit ---KIDS

enhance high frequencies and reduce low frequencies

electronic modification of the HA

• allow low frequency sound to escape
• allows natural sounds to enter
• allows ventilation

• Improved speech understanding
• natural sound quality
• decreased loudness
• PROBLEM= FEEDBACK

• Feedback (snug fit = less feedback)
• Comfort
• Securing the HA on the ear (disfigured pinna, huggie aid, toupee tape (double sided tape.))

Fun clips

• Impression material that sets up in ~10 min
• New way of digital imaging

tubing glues to earmold and attaches to the elbow on the HA

• feedback or HA not being secure
• easy inexpensive to replace.

• Remove HA
• Warm soapy water (do not use alcohol or cleaning fluid)
• Clear all water from tubing (squeeze bulb)

WATER

• Consult audiologist
• Snug earmold fit
• eliminate or reduce vent size
• soft earmold material (clings to ear)
• Seperate microphone from sound output (body HA)
• Do not reduce gain except as a temporary solution