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Key words: auditory domains, dizziness, hearing aid, nonveteran, pure tone thresholds, smoking, tinnitus, veteran, word recognition in competing message, word recognition in quiet.
Abbreviations: ANOVA = analysis of variance, EHLS = Epidemiology of Hearing Loss Study, HFPTA = high-frequency pure tone average, HHIE-S = Hearing Handicap Inventory for the Elderly-Screening (version), HL = hearing level, LE = left ear, NU-6 = Northwestern University Auditory Test No.
The population-based EHLS was an outgrowth of the Beaver Dam Eye Study of age-related eye disorders that enrolled 4,926 participants between 1988 and 1990 [8-9]. The primary purpose of this study was to determine the prevalence of hearing loss among male veterans and nonveterans aged 48 to 92 years who were enrolled in the EHLS.
1.Is there a higher prevalence of hearing loss for pure tones among veterans compared with nonveterans in the EHLS? 2.Is there a higher prevalence of hearing impairment for word recognition in quiet and in competing message among veterans compared with nonveterans in the EHLS? 3.What is the prevalence of self-assessed hearing handicap among veterans compared with nonveterans?
4.Are veterans more or less likely to use hearing health care services (have their hearing tested, try hearing aids, continue to use hearing aids, etc.) compared with nonveterans? The demographic data in Table 1 provide information about the 590 nonveterans and 999 veterans included in EHLS.
Number and percentage of nonveteran male participants and veterans in four demographic categories.
Table 2 provides the distributions for four general health categories and two ear-related categories for the two groups of participants.
Number and percentage of nonveteran and veteran male participants in six health categories. Table 3 describes certain service-related characteristics of the 999 veterans involved in the study.
Number and percentage of male veterans in respective branches of armed services and years of military service. Pockets of tissue capable of regeneration may be sequestered in various portions of labyrinthine bone.
Recently, I've been trying to organize some of the columns and articles I've written over the past ten years. For audiologists, the audiogram is such a basic dimension and so self-evident that its explanation, after the thousandth time, is often unconsciously truncated and simplified. Yet in spite of the recent advances made in diagnostic audiological evaluations, and they are truly impressive, the information and insights provided by the simple audiogram can still provide the most pertinent information to explain the behavioral implications of a hearing loss. This is a figure of an audiogram (with frequency in Hz along the top and Hearing Loss in decibels down the left side).
In addition to their energy locations on the frequency axis, speech sounds also vary in intensity. Looking at the audiogram again, and relating it to the speech banana, it is apparent that a person with this hearing loss will hear more of the lower frequency speech sounds than the higher ones. I don't want to give the impression that the perception of vowels is unimportant on the contrary, it is and can be very important -- only that by not actually hearing some of the consonants, hearing-impaired people have to struggle to fill in the acoustical gaps they produce in the stream of speech. This is a figure of an audiogram (with Frequency in Hz along the top and Hearing Loss in decibels down the left side). What I have often found useful in explaining the need to understand the audiogram is commenting that it is possible for someone to be completely deaf and have completely normal hearing in the same ear at the same time.
There is another dimension of hearing loss that is sometimes also included on an audiogram and that is the discomfort threshold. The dilemma of the threshold of discomfort for hearing-impaired people is that it is often the same as that observed with normally hearing individuals (perhaps 90 dB or so across frequency).
Finally, it is important for people to be familiar with the details of their audiogram so that they can track any changes with time.
In fact, there is limited knowledge about how children with hearing loss understand speech over the telephone.
Recent reports have suggested that adults with significant bilateral hearing loss hear better on the telephone when listening with both ears compared to one. Unfortunately, wireless streaming devices are not always available for persons with hearing loss­—particularly for young children. A feature called DuoPhone from Phonak is an alternative solution designed to allow users to hear the telephone signal in both ears simultaneously without the need of an accessory.
There are no published studies examining the potential benefits of DuoPhone for pre-school children with hearing loss. 1) Bilateral hearing loss with a better ear four-frequency pure-tone average between 35 and 75 dB HL. 2) Symmetrical hearing loss with no more than a 20-dB difference in air-conduction thresholds between ears at 500, 1000, 2000, and 4000 Hz.
5) Expressive and receptive spoken language abilities within 1 year of their chronological age as indicated by standardized speech and language assessment conducted within the past year.
The Audioscan RM500SL hearing aid analyzer was used to measure real-ear-to-coupler differences (RECD) for each child. The live speech mode of the Audioscan RM500SL analyzer was used to conduct simulated probe-microphone measure to assess the output of the hearing aid while a recorded speech passage was presented over the telephone.
Next, the hearing aid manufacturer’s default “telecoil telephone program” was enabled with the hearing aid microphone attenuated by 10 dB rather than the software default 0 dB of attenuation for pediatric users. Once again, the live speech mode of the Audioscan RM500SL analyzer was used to conduct a probe microphone measure to assess the output of the hearing aid for a recorded speech passage presented over the telephone.
Speech recognition over the telephone in quiet was measured for all 10 children, and speech recognition over the telephone in the presence of competing noise was measured for 8 of the 10 children (two of the children fatigued before testing could be completed in noise). Separate repeated-measures analysis of variance (RANOVA) was used to analyze the results obtained in quiet and in noise because two children were unable to complete the noise condition. 1) Pre-school children achieve substantially better speech recognition on the telephone in quiet and in noise when using the DuoPhone compared to their performance in the monaural condition. 2) Simulated probe-microphone measures were used to ensure that the output of the telephone program was appropriate.
This article reports the results of several auditory measures from 999 veteran and 590 nonveteran males 48 to 92 years of age included in the EHLS. 6, PTA = pure tone average, RE = right ear, SD = standard deviation, SNR = signal-to-noise ratio, VA = Department of Veterans Affairs. Studies indicate the prevalence of hearing loss in the elderly population (>65 years) ranges from 27 to 45 percent and increases with age [1-6]. Of the 4,541 available participants at the 5-year follow-up visit of the Eye Study, 3,753 individuals (82.6%) agreed to participate in the EHLS between March 1993 and July 1995 [7].
The percentage of nonveterans and veterans in each of the four age groups varied, which is reflected in the significant χ2.
Handedness was the same for both groups of participants with 89 percent responding right handed, 7 percent responding left handed, and 4 percent responding ambidextrous (data not shown in Table 2).
These tissue could be activated by the presence of regenerative enzymes in the blood following bone fracture elsewhere in the body. As I was looking through them, it became apparent that I've neglected to discuss what is perhaps most important hearing dimension of all, the simple audiogram.
Perhaps the most important insight of all is an appreciation of how specific audiograms impact upon the perception of certain speech sounds.
Frequency (or pitch) is depicted on the horizontal axis, from low frequencies on the left (250 Hz) to high frequencies on the right (8000 Hz). This is a general, but static, representation of the acoustical speech energy across frequency.
In reality, however, conversational speech is a dynamic and time-varying event, with one speech sound (phoneme) following another in a rapid succession. Those individuals with superior linguistic skills would perform this task better than those with lesser skills. Somebody with this type of hearing loss actually hears better at 250 Hz than the one whose audiogram is shown in figure 1, but much worse at 1000 Hz and higher. Without a hearing aid (and even with one) this person needs to depend upon visual cues (speechreading) to supplement the information received through hearing. Looking at this audiogram, we can state that this person has perfectly normal hearing in the left ear, but this is only true at 250 Hz and 500 Hz.

In a room full of people with hearing loss, it is doubtful that any two would exhibit exactly the same audiogram for both their ears. While an audiogram can help explain much of the auditory behavior of a person, it does not explain it all.
But because their threshold of hearing is elevated, but not their threshold of discomfort, this means that people with hearing loss generally have a reduced listening area (or narrow dynamic range).
In particular, there have been no reported studies that have evaluated whether children with hearing loss may understand speech over the telephone better while listening with two ears compared to one. Picou and Ricketts3,4 recently reported on two studies in which they examined recognition of recorded speech presented over the telephone for a group of adult hearing aid users. These devices typically require an additional investment in technology, and these accessories may not be readily available every time a child chooses or needs to talk on the telephone. DuoPhone uses digital, near-field magnetic induction to wirelessly stream audio signals from one hearing aid to the hearing aid on the opposite ear. As a result, the primary objective of this study was to compare speech recognition in quiet and in noise for a group of pre-school children (ages 2-5 years old) with hearing loss when listening with binaural (DuoPhone) versus monaural telephone input. All subjects were fitted with Phonak Bolero Q90-M13 behind-the-ear (BTE) hearing aids, except for one subject who had a four-frequency pure-tone average of 81 dB HL in the poorer ear and was fitted with Phonak Bolero Q90-SP BTE hearing aids.
Simulated real ear output for standard conversational level speech presented from the Audioscan Verifit loudspeaker (Green), for a recorded speech passage presented to the microphone of the hearing aid (Pink) (ie, “Acoustic Telephone”), and for a recorded speech passage presented to the hearing aid telecoil (Blue). During the procedure, one of the study examiners held the receiver of the telephone handset next to the microphone of the hearing aid.
As before, one of the study examiners held the receiver of the telephone handset next to the body of the hearing aid. Speech recognition was assessed in all conditions with a half-list (25 words) of Northwestern University-Children’s Perception of Speech test (NU-CHIPS) open-set words7 presented by the same female talker throughout the study.
Mean NU-CHIP word recognition scores (with 1 SD bar) in quiet and in the presence of noise for the monaural and DuoPhone conditions.
Mean word recognition scores in the monaural and binaural phone conditions are provided in Figure 3.
Similar measures should be considered for clinical purposes to ensure that the telephone signal is audible for young children. Audiologists should devote time to counseling the families of pre-school children regarding strategies for optimal telephone use. Binaural hearing on the telephone for pre-school children with hearing loss. Hearing Review.
The auditory measures included pure tone thresholds, tympanometry and acoustic reflexes, word recognition in quiet and in competing message, and the Hearing Handicap Inventory for the Elderly-Screening (HHIE-S) version.
The results from one population-based study focusing on the prevalence of hearing loss, the Epidemiology of Hearing Loss Study (EHLS) conducted in Beaver Dam, Wisconsin [7], indicated that 46 percent of older adults were affected by hearing loss.
We examined self-assessed hearing handicap using the Hearing Handicap Inventory for the Elderly-Screening (HHIE-S) version [12]. The encouraging statistic is that current smoking is down to about 15 percent in both groups, which demonstrates a substantial decrease in smoking for both groups of participants.
For people who may not even have heard of a pure-tone audiometer before they stepped into the audiologist's office, this is a quite understandable. Without including speech in the equation, it is simply not possible to intelligibly discuss the audiogram. For some specific purposes, it may be useful to test 125 Hz as well as some frequencies higher than 8000 Hz (for example, a progressive hearing loss above 8000 Hz can occur with certain type of ototoxic medications). Some speech sounds, such as vowels are predominately composed of low frequency energy, with less of their power in the higher frequencies. The specific acoustical composition of speech sounds is partially shaped by the preceding and following sounds in an utterance. Looking at the speech banana, it is apparent that while a great deal of low frequency vowel energy will be perceived, practically no high frequency consonants would be.
Some people, because of their superior ability to utilize some of the secondary cues in a speech signal referred to above, or their superior linguistic ability may do better than these comments would suggest. Or one could assert that he is completely deaf in the left ear, as again indeed he is (but only at 4000 Hz and higher). There would be differences in degree of hearing loss at the different frequencies as well as divergences between the ears. We know that there are other dimensions to auditory experiences that cannot be explained by the audiogram. Specifically, the investigators showed that 16 of 18 adults with moderate-to-severe sensorineural hearing loss achieved less than 50% correct speech recognition over the telephone when assessed in the unilateral condition (ie, the telephone receiver held next to the microphone of one hearing aid). Furthermore, wireless streaming accessories are not usually configured to easily interface with most landline telephones but instead are designed to work primarily with mobile devices. The user simply holds any landline or mobile telephone next to the hearing aid, and the signal that is captured by the hearing aid microphone or telecoil is wirelessly transmitted from one hearing instrument to the other. Digital noise reduction and directional microphone features were disabled for the fitting and for the speech recognition assessment conducted in this study. Then, the hearing aid was set to the manufacturer’s default “acoustic telephone program” (ie, a telephone program intended for placement of the telephone receiver next to the microphone of the hearing aid-no telecoil).
Adjustments were made to the hearing aid gain to ensure that the output of the hearing aid was at least as high as what was obtained to the 60 dB SPL Standard Speech signal (Figure 2). Adjustments were made to the hearing aid gain to ensure that the output of the hearing aid matched (±3 dB) what was obtained for the measurement made with the acoustic telephone program (Figure 2). This improvement is similar to the improvement Picou and Ricketts3,4 reported when comparing binaural telephone performance of adults to monaural use. Studies on bilateral cochlear implants at the University of Wisconsin’s Binaural Hearing and Speech Laboratory.
Efficacy of hearing-aid based telephone strategies for listeners with moderate-to-severe hearing loss.
Remote Microphone Hearing Assistance Technologies for Children and Youth from Birth to 21 Years. Speech recognition in noise in children with cochlear implants while listening in bilateral, bimodal, and FM system arrangements.
Hearing loss in the auditory domains of pure tone thresholds, word recognition in quiet, and word recognition in competing message increased with age but were not significantly different for the veterans and nonveterans. The prevalence of hearing loss increased with age and was more common in men than in women. Because the EHLS queried the participants about their status as a veteran from one of the U.S. Except for 132 homebound residents who were tested in their homes, all other auditory testing was completed in a sound booth.
The nonveteran and veteran groups also were significantly different in the education category.
The two groups of participants did not differ in the three remaining general health categories in Table 2, diabetes, history of myocardial infarction, and history of head injury. Even though just about everybody who receives a hearing aid has his or her hearing tested with a pure-tone audiometer, not everybody receives a comprehensive explanation of exactly what the results mean and what the implications are for them.
To expect them to fully understand how the pattern of their hearing loss impacts upon their listening behavior is not very realistic. This, after all, is the signal we are most interested in hearing (not to minimize the specific needs of certain groups of people for other types of sounds, such as musicians). The amount of hearing loss is shown on the vertical axis with the higher numbers indicating a greater degree of hearing loss.
The intensity of all other speech sounds in the English language fall within these bounds (note, however, that this does not take into consideration inflected speech, which will move the entire speech banana up and down). These specific effects, such as the unique modifications in vowels made by different preceding and following consonants, are actually secondary cues that can be helpful for understanding speech. Yes, but only with some difficulty and then only if the talker is close by and raises his or her voice slightly.
Looking at the audiogram, we can understand somewhat why this should occur: they are not hearing the full range of high frequencies where many of the consonants have their predominant energy.
An individual with this audiogram would have even more difficulty in understanding speech than the one whose audiogram is shown in figure 1.

But there are limits to even the keenest brain and the most developed auditory integration ability; at some point, people do need to detect speech energy in order to understand a spoken message.
While there is merit and often necessity to this practice, there is also the danger of oversimplification. In the right ear, the hearing loss at each of the three frequencies is the same, also resulting in an average of 40 dB. People with bilaterally symmetrical hearing losses (that is, with similar hearing losses in both ears) may have quite different auditory experiences than people with bilaterally asymmetrical hearing losses.
Still, the audiogram is a good place to begin when trying to understand someone's speech perception problems.
Sounds delivered by the hearing aid below the threshold of hearing would not be audible; those exceeding the threshold of discomfort would not be tolerated (the hearing aid user would either turn the volume control down or simply remove the hearing aid). It is a good idea for people to keep copies of all the audiometric tests administered to them so that comparisons can be made (and to be sure that they are dated correctly). In contrast, this group of adult hearing aid users achieved a 22% improvement when listening with both ears at the same time via wireless streaming that delivered the telephone signal to each hearing aid simultaneously. The examiners ensured that the children perceived the recorded speech from the telephone to be comfortably loud.
In summary, performance with use of DuoPhone in both quiet and in noise was significantly better than performance in the monaural condition. No significant differences were found between participant groups on the HHIE-S; however, regarding hearing aid usage, mixed differences were found.
Anecdotally, the percept is that because of noise exposure experienced in the military service, veterans have more hearing loss than do nonveterans.
Finally, from Table 2, the two groups of participants did not differ in the rates at which either dizziness or tinnitus had been experienced in the past year. And even for those that do, at a time when prospective hearing aid purchasers are being inundated with new information, anxious about the test results, and worried about the cost involved, much of this explanation will be forgotten or misconstrued the time several weeks have passed. Indeed, the ability to take advantage of these cues may help explain why some people seem to understand speech much better than one would predict on the basis of their audiogram.
There are, unfortunately, many people with audiograms similar to this who do not, for one reason or another, wear hearing aids.
And we know from many years of research, that consonants contribute more to the understanding of speech than vowels. In truth, they may be hanging on to speech comprehension with their finger tips; any further distortion in the speech signal, such as someone talking rapidly or in a foreign accent, or in the presence of noise and reverberation, and they lose it. These people depend upon whatever low frequency energy they do receive for comprehending speech. And this person is missing just too much of the speech signal to expect easy communication in any oral exchange.
Or perhaps someone's hearing loss is described by employing a single figure (derived usually from averaging the hearing losses at 500 Hz, 1000 Hz, and 2000 Hz). But it should be apparent, just from a visual inspection, that these two ears would perceive speech quite differently. All it would take would to resolve this verbal conundrum would be an understanding of what the audiogram actually signifies (degree of hearing loss across frequency).
While most people exhibit a gradually sloping hearing loss across frequency (such as in figure 1), some people have audiograms that are very atypical. Hearing losses greater than about 70 dB may produce qualitatively different effects than losses less than this.
In brief, the audiogram is perhaps the most important indictor of one's hearing function, the particulars of which everybody who has a hearing loss should be aware of. To date, no studies have focused on the prevalence of hearing loss among the veteran population. In this context, a veteran refers to anyone who served in any branch of the military services. Word-recognition in quiet and in competing message were evaluated on one ear with the Department of Veterans Affairs (VA) female speaker version [14-15] of Northwestern University Auditory Test No. I know that I'm often bemused when I hear what some people recount to me what they think their audiologist told them about their audiogram and its implications. Only the shaded area of the speech banana above the threshold curve is audible; portions below will not be perceived.
Still, there are certain anchor locations for all speech sounds, as displayed on the speech banana, and these can offer valuable insights in understanding the effects of differing hearing losses. And this audiogram depicts only a gradual high frequency hearing loss; were this person's audiogram something like the one shown in figure 2, problems with speech perception would be even more severe. The presence of noise and reverberation (not exactly an uncommon occurrence in our society!) would have a disproportionate effect on them, since it would mask the only speech energy they are able to receive. Quite clearly this example demonstrates that the shorthand description of a hearing loss with a number or a verbal label can be quite deceptive. This would include people with rising thresholds with frequency as well as those with perfectly normal hearing at the very low and high frequencies, but with moderately or severe hearing losses in the mid frequencies. In this instance, it would be more of a challenge to package sound within this more restricted dynamic range (this is where advanced technology can be very helpful, as in hearing aids with fast acting automatic gain control circuits).
Of the 3,753 EHLS participants, 1,021 (27.2%) reported military service with 22 females and 999 males.
After that point, people will usually begin to display some communication difficulties because of the elevated hearing thresholds.
In spite of portrayals to the contrary on some charts, no speech sound can be pinpointed to a speech point on the audiogram; all of them spread their energy somewhat along some segment of the frequency spectrum. For example people with an average 40 dB hearing loss are considered to have just a moderate hearing loss. The varieties are almost (but not quite) endless and many of these differences have behavioral implications. A hearing loss may also involve central auditory pathways and these, too, may affect speech perception quite severely.
Because the 22 females were a substantial minority (2.2%), only the data from 1,589 males (veterans and nonveterans) were analyzed.
The ear selected for word recognition was either the ear with better (lower) pure tone thresholds or the right ear (RE) if the pure tone thresholds were equal. The higher the number, the greater the impact of the hearing loss (referring only to the unaided condition). But such a shorthand label does not reflect the pattern of a hearing loss, a pattern, as we have seen, that may lead to more insights into the behavioral implications of a hearing loss. Nevertheless, in spite of all these caveats, the audiogram is still the most fundamental auditory dimension of all. In quiet, the word-recognition materials were presented nominally 36 dB above the 2,000 Hz threshold in the test ear. The 100 dB point should not be confused with a 100% hearing loss, which is a total lack of hearing.
Of the veterans, 70.3 percent served during wartime, most of which were in World War II (n = 396), Korea (n = 220), and Vietnam (n = 86).
Hearing sensations do continue past this point, with some audiometers extending this vertical range to 120 dB. In a slightly different viewpoint in this article, pure tone thresholds are considered but one domain of auditory function with other domains, including word recognition in quiet and the word recognition in the competing message. The prevalence of hearing loss in the nonveteran and veteran populations of the Beaver Dam cohort was examined in these three domains of auditory function.
The analyses used the chi-square test of association for categorical variables, the Mantel Haenszel chi-square test of trend for ordinal data [17], and t-tests of mean differences for continuous data (SAS Institute, Inc; Gary, North Carolina).

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