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Introduction: Currently, the Brazilian government has certificated nearly 140 specialized centers in hearing aid fittings through the Brazilian National Health System (SUS). Vice President of Audiology and Professional Relations, OticonDon Schum currently serves as Vice President for Audiology & Professional Relations for Oticon, Inc. When viewed within the broader context of life change, it is not surprising that so many older adults resist the idea of using hearing aids. This course discusses the relationship between expected outcome and satisfaction with the hearing aid process. Improving speech understanding, especially in complex listening environments, is clearly the main focus in hearing aid fittings for patients with sensorineural hearing loss. Effective speech understanding in environments with multiple sources of sound is the greatest challenge for those with sensorineural hearing loss.
This is the first in a series of 4 seminars that will examine the way current and future signal processing works within realistic, everyday contexts. Adults with sensorineural hearing loss can improve their hearing and quality of life by using cochlear implants. A review of 42 studies exploring the effects of cochlear implants has revealed that adults with a sensorineural hearing loss experienced a significant improvement in communication-related results and quality of life after receiving a cochlear implant. The review also showed that unilateral and bilateral implantations have different benefits. Among the studies evaluating quality of life, the average improvement after cochlear implantation was 25%, while most of the results indicated at least a trend toward improved quality of life. The review included 16 studies of unilateral implantation in 3,000 patients, 15 studies of bilateral implantation involving 461 people and 15 studies comparing quality of life before and after cochlear implantation.
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Remote fitting through the Internet can allow a broader and more efficient coverage with a higher likelihood of success for patients covered by the SUS, as they can receive fittings from their own homes instead of going to the few and distant specialized centers. Previous to his position at Oticon in Somerset, Don served as the Director of Audiology for the main Oticon office in Copenhagen Denmark. This seminar examines techniques developed by related professions in encouraging the older patient to be willing to make a health care change.
Given the inherent limitations imposed by sensorineural hearing loss, there will be limits to how well a newly fit patient will be able to perform with amplification.
It is essential then that the professional have a comprehensive appreciation for the nature of the speech signal and the effects of amplification.
A variety of technologies have been developed or are currently under investigation to address these complex situations.
Many professionals have an inaccurate understanding of how approaches such as noise reduction, directionality, open fittings, real ear analysis, etc. Improvements in sound localisation are noted for bilateral implantation," said the researchers, led by James M.
The only condition is that you provide a direct link to the specific article you use on the page where you quote us. Aim: To describe a case of remote fitting between 2 cities, with revision of the literature. In 1965, after the launch of the first intercontinental satellite, DEBAKEY performed a surgical aortic valve replacement at Methodist Hospital in Houston, Texas (USA) while being observed by his colleagues among the Geneva University Medical Faculty in Geneva, Switzerland (2). In addition, he served as the Director of the Hearing Aid Lab at the University of Iowa, School of Medicine (1990-1995) and as an Assistant professor at the Medical University of South Carolina (1988-1990). However, satisfaction with the process can still be high, especially if the focus is placed on the professional care provided by the audiologist. Much of what we do in hearing aid fittings is based on attempts to maximize effective audibility for the patient. However, in order to appreciate what these current and future technologies can actually offer our patients, it is essential to have a realistic understanding of how these technologies address complex environments.
Although this approach has served us well up to this point in time, further improvements in patient performance will require a more sophisticated approach to managing the speech signal.This is the second course in a seminar series on AudiologyOnline in 2010 by Dr. In addition, speech-based signal processing approaches that have been developed by other industries or have been investigated in research labs could conceivably make their way into hearing aids at some point in the future. Case study: An audiologist located in a specialized center introduced a new hearing aid and its fitting procedure to a remote center (200 km away). Schum has been an active researcher in the areas of Hearing Aids, Speech Understanding, and Outcome Measures.
Schum that examines the truths that we sometimes take for granted when we go about the task of fitting patients with amplification.
Now is as a good a time as any for the audiologist to begin to see how these systems work and how they can be applied to help those with hearing loss. The specialized center helped the remote center in fitting a hearing aid in 2 patients, and performed fitting in one of its own patients.
For more information on other courses in this series, visit the AudiologyOnline course library.
Department of Health and Human Services (5) describes telemedicine as "the use of telecommunications technology for medical diagnosis, monitoring and therapeutic purposes when distance separates the users." As TOHME et al.


Conclusions: Remote fitting of hearing aids is possible through the Internet, as well as further supplying technical training to a remote center about the fitting procedures. Such a technological approach can help the government advance public policies on hearing rehabilitation, as patients can be motivated about maintaining their use of hearing aids with the option to ask for help in the comfort of their own homes. The WHO estimates that the best hearing health policies are related to primary prevention activities (51-52). Every hearing impaired person is a candidate for an electronic hearing aid, which is an electronic device for selective amplification intended to minimize the effects of hearing loss when it is not possible by other medical or surgical means (53).
Cochlear implants are indicated for cases of profound hearing loss (54-55).The WHO notes that due to lack of infrastructure, services for hearing rehabilitation in developing countries are more difficult to manage when compared to developed countries (56).
GOULIOS and PATUZZI (57) conducted a study in 2008 that included 78% of the worldwide population; this study showed that Brazil has 6,971 inhabitants per audiologist, lower than the number in the USA (19,603), Australia (15,178), Sweden (12,055), and Israel (11,208), though this number was lower than that reported for Argentina (5,490). This same research reported significant numbers of inhabitants per audiologist in Mexico (258,643), Botswana (297,500), Russia (477,487), India (1,065,462), Thailand (1,243,860), Libya (2,775,500), and Pakistan (21,939,714).
GOULIOS and PATUZZI stated that Brazil has 29,745 inhabitants per otolaryngologist, fewer than that in Costa Rica (55,640), Nicaragua (273,300), Indonesia (362,843), and Cambodia (282,880), but more than that in Italy (12,761), Denmark (15,326), Sweden (16,681), or the USA (24,504). This population benefitted from the convenience of care services provided closer to their homes and reduced transportation costs, showing higher rates of acceptance among treatments.KRUMM et al. Bloom (61) stated that a specialized team using satellite clinics in the region of Honolulu saved about $25 million (US) compared with face-to-face consultation.
Ordinance Act number 402 (February 24, 2010) of the Health Ministry established the nationwide program Tele-Health Brazil, structured in a telemedicine format and aimed to quantify and expand solvability and strengthen strategies to improve family health.
The design of the hearing aid used in this study was conducted within the Laboratory of Medical Research (LIM-32) at the Medical School, Universidade de Sao Paulo. The development of the Tele-audiology program was conducted by the Otorhinolaryngology Department in conjunction with the Fundacao Otorrinolaringologia (Otorhinolaryngology Foundation) with funds from these units.The participants in this study were sufficiently advised about the purpose of the study and voluntarily signed the Statement of Free Consent and Explanation (TCLE).
This research was conducted on April 8, 2010, with an audiologist in the Otorhinolaryngology Department University de Sao Paulo in a specialized unit (SU) supervised by an otorhinolaryngologist and another team of 3 audiologists under the supervision of an otorhinolaryngologist at the Instituto Sul Mineiro de Otorrinolaringologia (ISMO), a Brazilian Otorhinolaryngology Institute located in Pouso Alegre city. Figure 1 shows a conceptual diagram of the related study here described.Both units belong to the National Health System (SUS) certified specialized centers, in which by 2011, there were approximately 140 units (68). Pertinent data of participants are reported in Table 1.This study included adult patients of both genders with sensorineural hearing loss (SNHL) losses from moderate to severe-moderate in at least 1 ear and moderate SNHL in both ears according to the classification proposed by NORTHERN and DOWNS and cited in BENTO et al.
For the transmission and reception of audio and video over the Internet, SkypeT was chosen because it is a free application and it is used universally without reported difficulty of installation or operation.
The Anyplace Control, an application for remote access, was chosen after heavy trials using a 30-day trial version, and it was found to be a simple application with a low cost. The Avast® antivirus application was used because it is free and has good market reputation. After testing, the unit was taken back to the SU.A Remote Training Protocol (RTP) was established to provide systematic training in the use of the hearing aid and AdaptEASY. Additional information about the documents used in this study is listed in Table 5.Prior to performing tests with study participants, the Internet connection reliability between the 2 units was tested and confirmed. Connection reliability performance comprises Skype®, Anyplace Control, and AdaptEASY and lasts for approximately 40 minutes.
In our performance tests, some delay in receiving video transmission from the SU was detected, which did not cause confusion, but did interfere with the original research goal of maximum approximation of face-to-face consultation. Because the speed of the Internet at the RU was limited to 300 kilobits per second (Kbps), which is low for maintaining audio, video, and adaptation programs simultaneously, the specialists decided to temporarily shut down the antivirus and firewall protection at the RU.
To avoid exposing network data to viruses, no other terminal at the RU was connected to the Internet.All tests were thus performed on patients by the audiologists. Initially, the units were introduced trough Skype® to further review the purposes of the research. For AdaptEASY basic training, a Remote Training Protocol, Annex 1, in Portuguese, was read and understood by the RU. That limitation in the protocol was justified in order to focus on the Tele-audiology processes instead of on the features of the hearing aid itself. Figure 2 shows the audiologist from SU, and in Figure 3, the audiologist appears on the notebook screen from the RU.All patients are binaural hearing aids users but were fitted only in 1 ear in this test.
This was decided because there was not a secondary objective assessment of satisfaction with the hearing aid. The adaptation sessions were carried out individually.All of the study participants were introduced to the SU audiologist while Skype connected the human element to the computerized process. The first subject (Table 3) was an in-the-canal user, and we made use of a standard dome earplug (without reference) to fit the left ear.
The RU audiologists entered patient data in the AdaptEASY, and adjustments were made by the SU audiologist, who explained the criteria used to the RU audiologists. The dynamic response of the patient was transferred directly to the SU specialist through online audio, with everyone in the room using a pair of speakers. The first fitting took approximately 20 minutes.The second participant was a behind-the-ear user with open technology (Open Fit), and again, a standard dome earplug (without reference) was used to fit the hearing aid. Similarly, the patient data were updated by RU audiologists, and adjustments were made by the SU audiologist with the hearing aid in the patient right ear.
The interaction between the SU and the patient was exactly the same as that described for the first subject.
This session lasted for 15 minutes.The third patient was also a behind-the-ear user, and an ear mold of the right ear was used to fit the hearing aid.


The audiologists from the RU updated patient data into the system and executed the whole process of fitting while being remotely assisted by the SU.
This session lasted for approximately 20 minutes.At the end of each session, the patients returned to using their regular hearing aids without any changes to the original fitting. After all the procedures, the RU network was scanned for virus, and no viruses were detected. The SU was also submitted to antivirus tests, and no viruses were detected.RESULTSThrough the Internet, RU audiologists were trained by the SU to understand the features of a hearing aid (Florianopolis) and its fitting (adaptEASY).
The SU audiologist introduced and discussed the electro-acoustic hearing aid features with RU audiologists.
RU audiologists highlighted the fitting program simplicity by fitting a hearing aid in a test patient without intervention of the SU. Patients interacted with both RU and SU audiologists, and they approved the remote fitting, picked out the subjective good quality of Florianopolis sound, and confirmed that remote fitting can have benefits in the fitting process.Figure 1. SU audiologist on the RU screen.DISCUSSIONHearing aid manufacturers (or importers) provide hearing aids designed in developed countries that are adjusted by increasingly complex fitting programs that demand increasingly advanced computer resources and continuous training for audiologists.
In this context, information technology and Tele-audiology specialists intend to provide training and forum discussions from specialized centers in any area in Brazil to ensure training uniformity and excellent outcomes. Features that can be added to the adaptEASY program include streaming training videos (for beginners and advanced audiologists), electronic manuals, and conference calls. These resources should promote training and professional skills for the staff involved (e.g. In cases of imported hearing aids supplied by the SUS, once the warranty expires, patients may be unable to repair their hearing aids, because they are identified as retail customers and therefore subject to the same price practices as retail customers, although they are part of a wholesale practice. Another facet of imported hearing aids lies in the complex fitting applications, meaning they are unable to provide uniform fittings because they demand specific knowledge defined by international manufacturers. Thus, more friendly and less complex fitting programs may represent a greater uniformity in fittings and, as a consequence, better results for SUS patients. Fitting programs of less complexity demand smaller investments in hardware upgrades, which may be interesting to the government as resources invested for this purpose would be less expensive and less time consuming.One aspect that may also help in successful implementation of Tele-audiology in Brazil is the fact Brazil has no major deficiencies with regard to institutional infrastructure in the fields of otorhinolaryngology and audiology, relying on several excellence centers in these medical areas.
To avoid conflicts in policy implementation, preservation of autonomy and task-sharing among activities of otorhinolaryngologists and audiologists is necessary.The small number of SUS certified centers for hearing health policies in Brazil (approximately 140) require patients, and often their companions, to travel from their homes to these centers in detriment of their secular duties (paid or unpaid) and to assume responsibility for transportation and food expenses, when sometimes, it is necessary only to make adjustments in the (re) programming of their hearing aids.
The hearing health program based on Tele-audiology can be implemented together with other nationwide operational units such as the Basic Health Units (UBS).Some aspects of technological implementation deserve to be highlighted. Anyplace Control enables message exchange in chat format between the SU and the RU, which is relevant if there are difficulties regarding transmission rate restrictions between centers. This feature is important when video cannot be maintained or when there are successive interruptions with loss during the fitting process. The hearing aid interface (in this case the Hi-Pro) may be replaced by an application to be downloaded from the Internet and installed on the computer of the certified center in order to cut costs of equipment acquisition.In KRUMM et al. The pioneering work in Brazil highlighted in this report serves both modes.To attend the SUS at the ambulatory level, there are 4,287 UBSs spread through Sao Paulo state, of which 537 are in the Sao Paulo city extended area. There are a large number of specialized centers to attend SUS patients for fittings that are purposed as walk-in or scheduled appointment centers.
Remote locations that permanently or temporarily do not have Internet service can be assisted through telephone services. To ensure this, group coordinators can assemble an implementation plan with greater restrictions for places where verbal communication cannot be ruled out.Important issues that must be considered with the practice of telemedicine include skills, competencies, and responsibilities of professionals involved, along with safety and privacy, effectiveness, efficiency, ethical aspects, restricted access, handling of patient information and whole-system information, and costs (69). The 2 additional features that should compose telemedicine are related to network stability and simultaneous functions when combined with other operating systems.Future Tele-audiology tests should be compared with clinical results that are obtained from face-to-face sessions, contextualizing and analyzing their differences.
NR - without ReferenceCONCLUSIONFocused on existing laws and aiming at improvement of public policies regarding hearing rehabilitation and health in Brazil, this pioneering work featured a remote hearing aid fitting with cooperation between specialists in 2 cities that are 200 km apart.
There can be great benefits in Tele-audiology implementation in Brazil, even though the Internet is not yet available in many places in the country.REFERENCES1. Wireless telemedicine services as part of an integrated system for e-medicine; Electrotechnical Conference, 2008. Saenz-Lechon N, Osma-Ruiz V, Godino-Llorente JI, Blanco-Velasco M, Cruz-Roldan F, Arias-Londono JD. World Health Organization - Situation review and update on deafness, hearing loss and intervention programmes: proposed plans of actions for prevention and alleviation of hearing impairment in countries of the South-East Asia Region. World Health Organization - Deafness and hearing impairment survey: Report of the consultative meeting of principal investigators. Traveling an audiologist to provide otolaryngology care using store-and-forward telemedicine.
Using a telehealth medium for objective hearing testing: implications for supporting rural universal newborn hearing screening programs.
XIX Congresso Internacional da International Federation of Oto-rhino-laringological Societes (IFOS), Sao Paulo, 31 de maio - 4 junho de 2009.
Full-time Researcher, Fundacao Otorrinolaringologia.2) PhD from the Federal University of Sao Paulo. Deputy Professor, Medical School, University of Sao Paulo.5) Professor and Chairman, Otorhinolaryngology Department, Medical School, University of Sao Paulo.



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