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Key words: audiology, automated testing, hearing disorders, hearing thresholds, loudness perception, pitch perception, reliability of results, tinnitus.
Abbreviations: ANOVA = analysis of variance, FCDS = forced-choice double-staircase, PAL 3000 = Programmable Auditory Laboratory 3000, SD = standard deviation, SL = sensation level, SPL = sound pressure level, VA = Department of Veterans Affairs, VAMC = VA Medical Center. This material was based on work supported by the Department of Veterans Affairs Rehabilitation Research and Development (RR&D) Service (grant C2300R). Clinical measures of tinnitus loudness and pitch can provide data important for patient assessment and for counseling [1-5]. Without procedures that are uniform and documented for response reliability, measurements indicating changes in the tinnitus percept do not possess clinical value. We used the number of participants and the two testing trials to provide a sufficient number of observations to assess reliability of the different responses. Following pilot testing to ensure proper performance of the system, we recruited 40 individuals who reported constant tinnitus through a local newspaper advertisement and flyers posted at the Portland Department of Veterans Affairs (VA) Medical Center (VAMC), Oregon. Assessment of between-session response reliability required that participants be scheduled for repeat evaluations on separate days. The Portland VAMC Institutional Review Board Committee approved all use of human participants for this research. Testing algorithms for determining hearing threshold, loudness match, and pitch match were completely redesigned. The previous version of the automated system used custom Microsoft Windows dialog and button objects as the interface [3,12,15-17]. Because of the combining of two programmatically linked computers required for testing (previously, one was used for patient control and one for main control of the system), programming advances have made the automated system more portable. The new simplified system includes the knob device, the slate computer, and the Programmable Auditory Laboratory 3000 (PAL 3000) (Figure 3) [18].
We conducted test procedures in a double-walled sound-attenuated suite constructed by Acoustic Systems (Model RE-245S). Prior to testing, participants viewed the series of screens, describing general operation of the automated system (Figure 1). Although participants had direct control over the adjustment of stimulus parameters, the computer program required algorithms to initially present tones for each new task. When the computer obtained thresholds, participants were required to give two responses at each frequency.
Threshold testing at any test frequency was always followed by loudness-matching at the same frequency. After providing five pitch matches, participants took a short break, then returned to the sound booth to repeat the test protocol. Table 1 shows the across-subjects mean hearing thresholds (in decibel SPL) for each of two tests conducted during each of two sessions. We performed a repeated measures analysis of variance (ANOVA) at each test frequency on the four hearing-threshold means (Table 1).
Table 3 displays progressively increasing decibel intervals for the differences to show the range of individual between-session differences in hearing thresholds. Cumulative numbers and percentages of individual responses having between-sessions test minus retest threshold differences within various decibel intervals.
Indispensable in fitting today's more advanced digital and semi-digital tinnitus masking aids. A clinical trial has shown that a therapy called Acoustic Coordinated Reset (ACR) can reduce the loudness and annoyance caused by tinnitus in seven out of ten patients.
In the clinical trial, patients were required to wear special headphones for a few hours each day. Scientists found that playing sufferers the same tone which they a€?heara€? in their mind stops the auditory brain cells from creating the perceived noise. With Acoustic Coordinated Reset (ACR) the clinical trial showed that the brain manages to “unlearn” the neurological processes which cause it to generate the “phantom” sounds of tinnitus.
Acoustic Coordinated Reset (ACR) was originally developed from therapies for neurological diseases such as Parkinson's.
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The Siemens Micon hearing aid and Phonak's Audeo Q provide built-in tinnitus programs that mix with the sounds created by an individual's tinnitus and reduce its level of annoyance. An automated tinnitus evaluation system has been developed in this laboratory, consisting of a patient-controlled touch-screen computer monitor, main computer, and Programmable Auditory Laboratory 3000 (PAL 3000) (a custom-built signal conditioning module).
Traditional approaches to clinical tinnitus measurement require patients to perform the subjective task of balancing a tone generated by a clinical audiometer to either the loudness or the pitch of the perceived tinnitus. A computer-automated clinical procedure for tinnitus evaluation would be capable of consistently evaluating all parameters of tinnitus that are relevant to rehabilitation. The instruction and response screens were completely recreated, and new programming and hardware developed. Based on results of multiple studies conducted in our laboratory, we have established normal variability of responses for the different tests that are performed by the tinnitus test system.

The previous system used a step response bracketing procedure, altered appropriately for the given task. For this study, the slides were launched and controlled via remote control from the tinnitus test platform. The upgraded system uses one slate-type computer (Aqcess Technologies Qbe Personal Computing Tablet) for both patient and main control and supports user-input devices, including mouse, touch screen, and pen-pointing device (Figure 2). The PAL 3000 generates the stimuli that are then delivered to the patient via ER-4B Canal Phone™ insert earphones [15,17].
The knob is used to control loudness of tones for testing hearing thresholds and loudness matches and testing frequency of tones for pitch-matching.
The encoder, digital conversion circuits, and Universal Serial Bus (USB) interface are housed in a 5- ? 8-inch sloped-top instrument case.
The actual divisor number is test-dependent-one divisor was used for obtaining thresholds and loudness matches and another for pitch-matching. As before, a stand-alone Instrument Manager application was used to perform automated calibration and store the data in an instrumentation database.
A critical feature of the automated system is that each time a new tone is presented, it is presented within a range of possible values to ensure that repetitive cues are not provided to the patient that would enable spuriously reliable responses. For the first run, the initial tone was 1,000 Hz presented at 60 dB sound pressure level (SPL).
Clockwise turning of the knob increased loudness levels, and counterclockwise decreased levels.
Thus, two complete tests (hearing thresholds, loudness matches, and pitch matches) were performed during the first session.
Each ANOVA included only participants who provided a threshold response for each of the four tests (numbers [n] at each frequency were just specified). A total of 454 between-session threshold differences were found, and difference scores were grouped according to the indicated intervals ranging from ±1 dB to ±30 dB.
Reliability of computer-automated hearing thresholds in cochlear-impaired listeners using ER-4B Canal Phone earphones. The clinical trial compared Acoustic Coordinated Reset (ACR) against a control treatment in 63 people with long term tinnitus.
The headphones emit a series of tones tuned according to the characteristic frequency of the patient's tinnitus. The tone was played to the volunteers through in-ear headphones for four to six hours a day for 12 weeks.
The only condition is that you provide a direct link to the specific article you use on the page where you quote us. It provides accuracy with its entire clinical test battery which is necessary for investigating the hearing function. The system obtains and records data from tinnitus patients, including hearing thresholds and the pitch and loudness of their tinnitus. The large number of individuals impacted by tinnitus underscores the need for standardized tinnitus assessment methods [9-10].
A system to conduct computer-automated clinical procedures for tinnitus evaluation has been under development in our laboratory since 1995 [11].
With these changes, we intended to (1) reduce testing time by enabling more rapid responses by patients and (2) provide a testing platform that would result in more reliable pitch matches.
We used these values in a series of power analyses to determine that a power of at least 0.80 would be achieved with 40 participants to assess the reliability of hearing thresholds, loudness matches, and pitch matches. These individuals included 33 males (of which 31 were veterans) and 7 females (of which 2 were veterans).
The system would adjust the loudness or frequency of the stimulus, and then the patient's response would determine the next stimulus presented. A custom-built dynamic link library was designed and developed to interface PowerPoint objects with the tinnitus test program and also to allow responses to be sent back to the program. System control parameters and overall testing configuration continue to be database-driven. Depending on the test, too many steps per revolution would make the stimulus change too rapidly, while too few steps could frustrate the patient because so much rotation distance would be needed to change the stimulus.
This instrumentation database was run-time accessed by the control program to provide calibrated stimulus levels. Our experience (and the experience of others) has shown that patients often confuse the concepts of loudness and pitch [8,16]. If the knob was turned beyond the maximum calibrated output level (100 dB SPL), continued turning resulted in continuous presentation of the maximum output.
Clockwise rotation always increased the loudness level, and counterclockwise always decreased the loudness level. Continued clockwise rotation would then descend the frequencies until the minimum was reached; whereupon, continued clockwise rotation would repeat this sawtooth-like frequency-stepping function. The second test session was identical to the first, resulting in a total of four complete tests for each participant. At 8,000 Hz, one participant did not respond during the final test, thus the n = 39 for 8,000 Hz.

Analyzing between-session threshold differences with respect to their proximity to zero was thus of interest.
This is said to disrupt the rhythmic firing patterns of tinnitus-creating auditory nerve cells. The headphones were then taken off for four weeks and then put on again in regular intervals for 22 weeks.
Its dedicated Audiometric Control Panel (ACP) makes the MADSEN Astera a very comfortable audiometer to use. New features have been incorporated into the system to make it more user-friendly and practical for clinical application.
Audiological testing for hearing loss has been standardized for decades, and tinnitus testing needs to achieve comparable standardization. Numerous studies have documented various aspects of the system's performance [3,12-16].
Five of the participants had hearing within normal limits (all thresholds within 25 dB HL), and the remainder had some degree of reduced hearing sensitivity. All participants confirmed that their tinnitus was essentially unchanged from the first to the second appointment.
The present system was designed to enable the patient to reduce test time by directly controlling the relevant stimulus parameters during testing. Patient interface using the upgraded version is now accomplished via on-screen instructions presented using Microsoft PowerPoint 2000. The program uses a custom-built software module to track the knob's movements and direction, which the operating system reports to the control program as mouse-wheel movements. Therefore, it is critical for patients to demonstrate that they understand how these concepts differ so that they will respond appropriately. Following a response, the computer presented the tone at a level randomly selected between the initial response and 10 dB above the response level. With further turning in the same direction (in an attempt to achieve greater output), the program would respond with an instruction screen stating that the maximum output level had been reached.
Reversal of the knob direction would always reverse the direction on the sawtooth function.
At frequencies above 8,000 Hz, a diminishing number of participants provided responses for each of the four tests (which we expected because of hearing loss that is usually associated with tinnitus).
We conducted Sheffe post hoc testing to determine which pairs of means differed significantly. Table 3 also shows cumulative percentages (in parentheses) from the group of 20 cochlear-impaired participants who were tested with the previous version of the system [17].
At the end of the trial, about seven in ten said that their tinnitus had become quieter and less annoying. A set of Pediatric features with regular updates allows the operator to cover the patient?s needs.
Using the system, we evaluated 40 individuals with tinnitus to assess within- and between-session reliability of responses. The system continues to undergo refinements, and although testing with the system has proven reliable for tinnitus loudness-matching, pitch-matching has continued to show considerable test-retest variability. The initial phase of development and testing of the new automated system is described herein. Further, an examination of the data confirmed that those participants who could not return within 1 week did not have increased variability of responses or any other anomalous results.
Patients, therefore, now have the ability to self-adjust stimulus parameters rather than being guided through the program at the computer's pace, which requires additional time and more test steps. While the patient progresses through the system in the same manner as with the past version, an added on-screen help option has been added. When a second threshold response was obtained, the computer averaged the two threshold responses to specify the threshold level at that frequency. All four responses were obtained from 25 participants at 10,080 Hz, 18 at 12,700 Hz, and 9 at 16,000 Hz. The present group of 40 participants apparently had overall greater between-session variability of responses than the group of 20 cochlear-impaired participants. In addition, overall testing time was too lengthy to be acceptable for clinical application. To determine if this difference between the two data sets was significant, we performed the nonparametric Kolmogorov-Smirnov test [19]. Those who were given the control treatment experienced a€?limited and non-significant changesa€?. Incorporating the new features has reduced testing time to an average of less than 19 minutes and has resulted in comparable loudness-match reliability and improved pitch-match reliability compared with the previous results. These data support the technique as suitable for clinical application, indicating the need to develop instrumentation for this purpose.

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