Troubleshooting Complaints

Question 1

What do real ear measurements allow us to see?

Answer 1

The amount of audibility we provided
Its purpose is to provide us with a visual aid to guide our clinical expertise as we make changes for improved user satisfaction
Based on researched standard deviations, its expected about 1/3 of patients will prefer gain that is either higher or lower our +/- 5 dB guideline

Question 2

What do you need to consider before starting to finetune a program?

Answer 2

Is this a problem that can be fixed through follow-up programming, or is it a counseling issue?
Communication strategy training? (go closer to the person speaking when they are in the other room)
Speech or visual perception training?
Will fixing one problem create a new problem?
Will the problem solve itself over time through acclimatization?
Does the patient know what is best for them? (yes, it’s not just matching the target; we are the experts so we should be responsible with making these decisions)

Question 3

What are pitfalls of environmental classifications?

Answer 3

Advanced DSP features are intended to adapt the corresponding signal processing to a scene class to improve listener experiences
There are potentially hundreds of acoustic parameters that could positively or negatively influence the quality of each of the classification schemes they design

Question 4

Is patient empowerment needed?

Answer 4

Yes
The process of helping clients discover personal strengths and capacities to take control of their lives (empowerment)

Question 5

How can we empower our patients?

Answer 5

Explaining all aspect of audiologic rehabilitation (including non-HA solutions)
Conveying sufficient information in an easy-to-understand manner
Involving the client in decision-making and supporting the client’s choices

Question 6

Does audiologic rehabilitation involve more than amplification?

Answer 6

Yes
Group aural rehab, communication strategies perceptual training

Question 7

Will adaptation happen without the patient wearing the device?

Answer 7

No
Explain the importance of adaptation but then modify prescription to for improved tolerance
Lower volume or increase compression and gradually change these settings over time

Question 8

Should we give the patient control of the device?

Answer 8

Yes
Enable VC or “pseudo” VC by adding a manual program that reduces output

Question 9

Is it important to fully understand the complaint (no communication mismatch)?

Answer 9

Yes
Clarify your interpretation of the patient’s descriptors (Low? High? Everything?)
Sometimes descriptors aren’t words
I hear tst-tst-tst when people speak
Once you figure out its meaning teach patient an alternative descriptor, so you understand each other
“I think that “tst-tst-tst” sound means consonant sounds are annoying to you. Let’s call that tinny”
Or begin using “their” descriptor during fine-tuning: “Okay so if I make this adjustment does that “tst-tst-tst” improve?”

Question 10

How should you conduct systematic fine-tuning?

Answer 10

Establish a baseline setting for comparison (this will be the original program that they weren’t satisfied with)
Change the program and check in with your patient. Keep their response simple:
“Does this sound better- worse- the same?”
Return to the baseline after every change for comparison

Question 11

Should the changes to the fine-tuning be significant at first?

Answer 11

Yes
Make significant intensity changes initially- 4-6 dB
Initially select broad frequency ranges: i.e., all frequencies above/below 1.5k Hz
Final adjustments should be minimal when compared to the baseline (about 2-3 dB)
If initial programming was verified be cautious of changes > 12 dB SPL (based on research suggesting that programs close to target have an overall high satisfaction rate)

Question 12

Does systematic change require careful tracking of adjustments so you can return to baseline?

Answer 12

Yes
Carefully count the number of ‘clicks’ you made
Use the back arrows to return to the baseline settings

Question 13

What should you do if you get lost in the land of adjustments?

Answer 13

Exit programming module without “saving” to instrument or Noah data base
The device will revert to originally programmed settings

Question 14

How is an occlusion effect diagnosed?

Answer 14

Prevalent when low frequency thresholds are < 40 dB HL
The complaint persists when the device is turned off

Question 15

How you manage the occlusion effect?

Answer 15

Open vent, increase canal length
If a non-occluding dome doesn’t allow enough high frequency gain due to feedback, a custom hollow-shell earmold with a 2mmor larger vent effectively allows low frequency energy to escape from the ear canal and offers significant reduction of occlusion-related complaints

Question 16

What is the low frequency amplification origin of own voice complaints (not OE)?

Answer 16

Complaint is due to low frequency amplification
It can combine with the occlusion effect to exacerbate the complaint
Sound of their voice amplified through the hearing aid (voice is much louder bc it is closer to the mic)

Question 17

How is low frequency amplification complaints diagnosed?

Answer 17

The complaint stops with the hearing aid turned off
A gain-related complaint will not be present when the hearing aid is turned off

Question 18

How do you manage LF amp complaints of own voice?

Answer 18

Too much - or surprisingly - too little gain in the low frequency region can lead wearers to complain that their own voice sounds too loud
Try lowering LF band 4-6 dB for improvement
If complaint persists, try increasing LF band 4-6 dB to overcome a combination of mild occlusion and under amplification
Try the manufacturer’s fitting assistant

Question 19

Is the occlusion effect test different from the REOR?

Answer 19

Yes

Question 20

What does the occlusion effect test tell you?

Answer 20

“PROBE MICROPHONE” scale shows the SPL reaching probe microphone tip
“REFERENCE MICROPHONE” scale shows the SPL of speech signal reaching the reference mic
“OCCLUSION” scale shows the degree of occlusion in dB SPL

Question 21

How do you conduct the occlusion effect test?

Answer 21

Insert probe tube in canal
Place device in ear- muted or off
Patient vocalizes “eee” at moderate vocal effort
Press “stop test” to capture OE

Question 22

For every 1 mm increase in vent diameter, how much will the occlusion effect be reduced?

Answer 22

4 dB

Question 23

What is an alternative assessment to determine origin of complaint (without the occlusion effect test)?

Answer 23

Step 1: place the device in the ear but turned off
Step 2: ask patient to say, “Baby Jeanie is teeny tiny”
Step 3: turn on device & repeat steps 1 & 2
Step 4: ask if there is a difference in the quality of their voice when the device is turned on
If it sounds better with the device on or no difference - it is probably a shell origin
If it sounds better with the device off - amplifier origin (modify device output/gain)

Question 24

How do you check the physical fit of the device?

Answer 24

Push on the hearing aids so it is tighter/deeper and pull them out slightly?
If sound improves when device pushed in? Recase to increase canal length of device or improve aperture seal
If sound improves when device is pull out of ear slightly? Increase size of vent or shorten canal length
If there’s no difference - It may be amplifier origin (try modifications to gain/output)

Question 25

Should you ask if their voice changes when they speak louder or softer?

Answer 25

Yes
If complaint is worse with loud speech? Indicates saturation or excessive gain (adjust MPO or loud input)
If complaint is worse with soft speech? Indicates insufficient gain (increase low frequency band or soft inputs)
If there’s no difference, it’s OE

Question 26

Is there a high frequency origin to complaints of own voice?

Answer 26

Yes, but it is less likely

Question 27

How is the high frequency origin diagnosed?

Answer 27

The hearing aid wearer may describe own voice as sounding like it has an echo, lisping, raspy, or muffled.
They may also report an unnatural perception, as if their voice is coming from somewhere else

Question 28

What is the management for the high frequency amplification origin?

Answer 28

Increase gain in mid frequencies
Try the manufacturer’s fitting assistant

Question 29

What is the processing delay origin of own voice complaints?

Answer 29

The patient may be hearing a delayed signal resulting from digital signal processing

Question 30

How is the processing delay origin diagnosed?

Answer 30

Patient complains voice echoes or, it sounds like they’re head is in a barrel

Question 31

How do you manage the processing delay origin?

Answer 31

Reduce vent size if possible (Test this solution by placing finger over vent while they vocalize)
Change brand for faster processing speed
Note, it’s not unusual for monaural hearing aid use to increase a perception of an echo because of processing differences

Question 32

Can adjustments to soft input signals or loud impact CR?

Answer 32

Yes
Reversing changes may not reset changes to CR (need to use the back arrow)

Question 33

Can MPO adjustments change the CR?

Answer 33

It shouldn’t, but it can if changes are significant
CR can increase if MPO settings limit output
Lower headroom limits audibility of crest factor for louder speech

Question 34

What is the procedure for trying to fix a shell origin OE?

Answer 34

Try pulling it out and have them repeat the phrase, if it gets better, you need to add a larger vent
Try pushing it in further, if that helps, you need a longer canal of the earmold

Question 35

If a patient has a larger ear canal than normal, is the patient under amplified if you use the average ear canal size?

Answer 35

Yes

Question 36

Review DNR

Question 37

Review ILD and spatial hearing