Braz. j. . vol.82 número3

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www.bjorl.org

Brazilian

Journal

of

OTORHINOLARYNGOLOGY

ORIGINAL

ARTICLE

Speech

recognition

in

individuals

with

sensorineural

hearing

loss

夽

,

夽夽

Adriana

Neves

de

Andrade

a,∗

,

Maria

Cecilia

Martinelli

Iorio

b

,

Daniela

Gil

a,b

a_Program_of_Human_{Communication}_Disorders,_Campo_{Fonoaudiológico,}_Universidade_Federal_de_São_Paulo_(UNIFESP),

SãoPaulo,SP,Brazil

b_Department_of_Speech_Therapy_and_Audiology,_Universidade_Federal_de_São_Paulo_(UNIFESP),_São_Paulo,_SP,_Brazil

Received10December2014;accepted26May2015 Availableonline6November2015

KEYWORDS

Hearing;

Speechdiscrimination tests;

Hearingtests; Auditoryperception

Abstract

Introduction:Hearinglosscannegativelyinfluence thecommunicationperformanceof indi-viduals,whoshouldbeevaluatedwithsuitablematerialandinsituationsoflisteningcloseto thosefoundineverydaylife.

Objective:Toanalyzeandcomparetheperformanceofpatientswithmild-to-moderate sen-sorineural hearing loss in speech recognition tests carried out in silence and with noise, accordingtothevariablesear(rightandleft)andtypeofstimuluspresentation.

Methods:Thestudyincluded19right-handedindividualswithmild-to-moderatesymmetrical bilateral sensorineuralhearingloss,submitted tothespeech recognitiontestwith wordsin differentmodalitiesandspeechtestwithwhitenoiseandpictures.

Results:Therewasnosignificantdifferencebetweenrightandleftearsinanyofthetests.The meannumber ofcorrect responsesinthespeech recognition testwith pictures,livevoice, and recorded monosyllables was 97.1%, 85.9%, and 76.1%, respectively, whereas after the introductionofnoise,theperformancedecreasedto72.6%accuracy.

Conclusions:ThebestperformancesintheSpeechRecognitionPercentageIndexwereobtained usingmonosyllabicstimuli,representedbypicturespresentedinsilence,withnosignificant differencesbetweentherightandleftears.Aftertheintroductionofcompetitivenoise,there wasadecreaseinindividuals’performance.

夽

Pleasecitethisarticleas:deAndradeAN,IorioMCM,GilD.Speechrecognitioninindividualswithsensorineuralhearingloss.BrazJ Otorhinolaryngol.2016;82:334---40.

夽夽_This_work_is_part_of_the_Ph.D._thesis_in_science_by_the_program_of_Human_{Communications}_Disorders_---_Speech_Therapy_and_Audiology

DepartmentofUniversidadeFederaldeSãoPauloandwasperformedattheNúcleoIntegradodeAssistência,PesquisaeEnsinoemAudic¸ão (NIAPEA)oftheDisciplineofHearingDisordersoftheDepartmentofSpeechTherapyandAudiologyofUniversidadeFederaldeSãoPaulo.

∗_{Corresponding}_author.

E-mail:[email protected](A.N.deAndrade).

http://dx.doi.org/10.1016/j.bjorl.2015.10.002

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PALAVRAS-CHAVE

Audic¸ão; Testesde discriminac¸ãode fala;

Testesauditivos; Percepc¸ãoauditiva

Reconhecimentodefalaemindivíduoscomperdaauditivaneurossensorial

Resumo

Introduc¸ão: Aperdaauditivapodeinfluenciarnegativamenteodesempenhocomunicativoe estesindivíduosdevemseravaliadoscommaterialadequadoeemsituac¸õesdeescutapróximas àsobservadasnocotidiano.

Objetivo: Analisarecompararodesempenhodeindivíduoscomperdaauditivaneurossensorial degrauleveamoderadoemtestesdereconhecimentodefalaapresentadosnosilêncioeno ruídosegundoasvariáveisorelhaetiposdeapresentac¸ãodoestímulo.

Método: Participaramdoestudo19indivíduosdestroscomperdaauditivaneurossensorial bilat-eralsimétricadegrauleveamoderado,submetidosaotestedereconhecimentodefalacom palavrasemdiferentesmodalidadeseaotestedefalacomruídobrancocomfiguras.

Resultados: Nãohouvediferenc¸asignificanteentreasorelhasdireitaeesquerdaparanenhum dostestesrealizados.Amédiadeacertosnotestedereconhecimentodefalacomfiguras,viva vozemonossílabosgravadosfoi97,1%;85,9%e76,1%,respectivamente,e72,6%deacertosno testecomruído.

Conclusões: OmelhordesempenhonoÍndicePercentualdeReconhecimentodeFalafoiobtido utilizando como estímulos monossílabosrepresentadospor figuras apresentadosno silêncio, semdiferenc¸assignificantesentreasorelhasdireitaeesquerda.Comaintroduc¸ãodoruído competitivo,houvedescréscimonodesempenhodosindivíduos.

Introduction

Hearing is one of the most important senses for humans, considering that the entire human culture is based on communication,withmostofitconsistingofsoundpatterns orformsthatrepresentthem.1

Whendamageoccurstotheperipheralauditorysystem, suchaspermanentsensorineuralhearingloss,changescan occur in the patterns of excitatory responses of auditory neurons, aswell aschangesin the tonotopicmaps of the centralauditorynervoussystem(CANS).2

These structuralalterationsmayhindersound informa-tionprocessing,especiallyforcomplexinformation,suchas speechsounds.Toassessspeechrecognition,itisnecessary tousehigher-thresholdmeasuresthatwillallowthe investi-gationofthecommunicationperformanceinideallistening situationsandinunfavorableenvironments.

Speechrecognitionassessmentinsilenceandwithnoise can beperformed usingstimuli presented live or through recordings. The analysis of these tests should be carried outwithcautioninpatientswithsensorineuralhearingloss (SNHL),astheinvolvementoftheinnerearsensorycellscan affecttheperformanceofindividualsinspeechrecognition tasks,especiallyifthefrequenciesof500Hz,1000Hz,and 2000Hzareimpaired.3

Consideringthattheperipheralhearinglossandthetype ofstimulususedintheassessmentcaninfluencethe commu-nication performance of individuals in different everyday environments,4 _whether _in _favorable _or _unfavorable lis-tening situations, it is hypothesized that individuals with sensorineural hearingloss show betterspeech recognition whenexposedtolinguisticstimuliofgreatredundancy asso-ciatedwithothersensorymodalitiesandworseperformance inactivitiesinvolvingauditoryclosureskills.

Thus, this research aims to analyze and compare the performance of individuals with mild-to-moderate sen-sorineuralhearing lossin speechrecognition testscarried outin silence andwithnoise, according to thevariables: ear(rightandleft)andtypesofstimuluspresentation(live, recordedmonosyllables,andpictures).

Methods

ThestudywasregisteredatPlataformaBrasil,andanalyzed andapprovedbytheResearchEthicsCommittee,underNo. 06654913.5.0000.5505.

Across-sectional, observational,surveystudy was con-ducted;the samplewasselected basedontheanalysisof medicalrecordsof patientstreated at aservice that pro-videshearingaiddeviceslocatedinateachinghospital,in theperiodbetweenJanuary2009andDecember2012.

The study inclusion criteriaconsistedof the following: agebetween13and59years(bothgenders);nativespeaker of Brazilian Portuguese; preference for the right hand; fluentreading,regardlessofthelevelofeducation; mild-to-moderatesensorineuralhearingloss(meanofthepuretone auditorythresholdsat the frequenciesof 500Hz, 1000Hz, and2000Hz upto 55dB HL)5 _acquired _in _the_post-lingual period;differencebetweenhearingthresholdsoftheright andleftear≤10dBinall theassessedsoundfrequencies;

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language complaints and/or impairment; minimum score of 50 in the short version of the Edinburgh Handedness Inventory6,7_;_minimum _performance _of_72% _of _accuracy _in theSpeechRecognitionPercentageIndex(SRPI)with mono-syllables, presented live; adequacy in the Brief Cognitive Screening Battery,8 _adequacy _in _the _verbal _fluency _test, accordingtolevelofschooling,9_and_minimum_score_of_nine pointsintheClockDrawingTest.10

From January of 2009 to December of 2012, a total of 4516 hearing-impaired individuals were treated at the service.Thistotalnumberofmedicalrecordswasanalyzed toselect the sample components, and 105 patients were consideredpossiblecandidates.Aftertheinitialcontactby telephone,72 individualswere invitedtoundergo sample selectionprocedures;ofthese,only19individualsmetall eligibilitycriteriaandcompletedallstagesofstudy assess-ment.

Thus, the final sample consisted of 19 individuals, 13 (68.4%)malesand six(31.6%) females.Regarding ageand education,the individuals were aged between 16 and 59 years(mean 39.4 years) and had3---20 yearsof schooling (mean 10.2 years). All individuals had mild-to-moderate symmetricalbilateral sensorineural hearing loss, acquired inthepostlingualperiod.

For the speech recognition assessment in silence and withnoise,thefollowing instrumentswereused:a sound-proofbooth,aPhilipsExpaniumDiscman,aGrason-Stadler GSI-61audiometer,andapairofTDH-50Psupra-aural head-phones, and compact discs and pictures from the books ofbehavioralhearingtestsfor centralauditoryprocessing evaluation.11

The evaluation with the SRPI using monosyllables was performedwithlivevoice(SRPI-L)andwithrecordings (SRPI-R) using a list of monosyllables12 _presented _at ₄₀_dB _SL, consideringthemeanofthepuretoneauditorythresholds atthesoundfrequenciesof500Hz,1000Hz,and2000Hz,or atthecomfortlevelreportedbythepatient.Allevaluations startedintherightear.

ListsD1andD2wereusedforthelivevoicepresentations (SRPI-L),whereaslistsD3andD4wereusedforthe evalu-ationswithrecordedmonosyllables(SRPI-R),recordedona compactdisc.11 _In_both_situations,_the_individual_was_asked torepeatthewordsanda4%percentagewasattributedto eachcorrectresponse.Resultsof92%ofcorrectresponses or more in both ears were considered adequate, i.e., no difficultyinunderstandingspeechinsilence.13

TheSpeechRecognitionPercentageIndexusingpictures (SRPI-P)wasperformedusingthecompactdisc.11_Ten mono-syllabic and disyllabic words were presented, depicted in pictures,toeachearat40dBSL, consideringthemeanof thepuretoneauditorythresholdsatthesoundfrequencies of 500Hz, 1000Hz, and 2000Hz, or at the comfort level reportedby the patient.The individualwasinstructed to point out, on a poster attached to the wall, the picture thatcorrespondedtothewordheard.A10%percentagewas assignedforeverycorrectresponseandthecorrect identi-ficationofatleastninepictureswasconsideredadequate.

Thespeechtestwithwhitenoiseandpictures(STWN-P) wascarriedoutwith20monosyllabicanddisyllabicwords, tenforeachear,recordedonacompactdisc11_and_presented at40dBSL,consideringthemeanofthepuretoneauditory thresholdsatthesoundfrequenciesof500Hz,1000Hz,and 2000Hz,or at the comfort levelreported by thepatient. Simultaneously to the presentation of the stimuli, white noisewasintroducedinthesameear,atasignal/noiseratio of+5.Theindividualwasinstructedtopointout,onaposter attachedtothewall,thepicturethatcorrespondedtothe wordheard.A10%percentagewasassignedforevery cor-rectresponseand90%accuracyormorewasconsideredas anadequateperformance.11

ThestatisticalanalysiswascarriedoutusingMinitab(v. 16), SPSS(v.18), andR(v. 2.14.2).The significance level wassetat0.05foreachhypothesistest.

Results

Initially,thedescriptivestatisticsvaluesofthepercentage ofcorrectresponsesintheSRPItestinallconditions:live voice,recording(recordedmonosyllables),andpicturesare showninTable1.

Theresults obtainedin thispopulation werecompared tothenormalitycriteriafor individualswithnormal hear-ing.Nosignificantdifferenceswereobservedbetweenthe frequency of normal andalteredresults for the right and left ears in any of the presentation conditions (McNemar test:live,p=0.125;recordedmonosyllables,p=0.070; pic-tures,p>0.999).Thefrequencyofindividualswithadequate resultsinthelivetestandthetestwithpictures,considering both ears, was26.3% and 89.5%, respectively. No individ-ual showed the test adequacy for the presentation with recordedmonosyllables.

Table1 DescriptivestatisticsvaluesforthepercentagesofcorrectanswersintheSpeechRecognitionPercentageIndexby ear.

Presentation Ear n Mean(%) Standarddeviation Minimum(%) Median(%) Maximum(%)

Livevoice Right 19 85.1 9.1 72 88 100

Left 19 86.7 8.6 72 84 100

Total 38 85.9 8.8 72 86 100

Recording Right 19 74.6 11.5 52 76 92

Left 19 77.5 13.3 52 80 96

Total 38 76.1 12.3 52 78 96

Pictures Right 19 98.4 5 80 100 100

Left 19 95.8 6.9 80 100 100

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Table2 Descriptivestatisticsvaluesforthepercentagesofcorrectanswersinthespeechtestwithwhitenoiseandpictures accordingtotherightandleftears.

Ear n Mean(%) Standarddeviation Minimum(%) Median(%) Maximum(%)

Right 19 71.1 23.1 30 70 100

Left 19 74.2 22.9 20 80 100

Total 38 72.6 22.7 20 80 100

When comparing the means of correct response per-centages according to the three SRPI test conditions (live×recording×pictures)usinganalysisofvariancewith repeatedmeasures,therewasnostatisticallysignificant dif-ferencebetween themeanpercentageofcorrectanswers intherightandleftears(p=0.628),buttherewasa statis-tically significant difference betweenthe test application conditions(p<0.001*).Theseconclusionswerevalidforthe threeconditionsoftestapplication,astherewasno inter-actionbetween thetestapplication conditionandtheear (p=0.199).

Asthereweredifferencesbetweenthemeansofcorrect answerpercentagesinthethreetestapplicationconditions (live×recording×pictures),theanalysiscontinued,aiming to findwhere these differences occurred. Therefore, the meanpercentagesofcorrectresponseswerecomparedtwo bytwo,usingtheBonferroniprocedure.

When comparing the SRPI test application conditions of live×recording, there was a statistically significant difference in the mean percentage of correct answers (p<0.001*).Theperformanceofthetestsubjectswiththe livepresentationwasbetterthanwiththerecorded mono-syllables; the difference was, on average, 9.8% (95% CI: 6.7---13.0).

ThecomparisonoftheSRPItestapplicationconditionsof live×picturesalsoshowedastatisticallysignificant differ-ence(p<0.001*).Themeanpercentageofcorrectanswers inthetestwithpictureswashigherthanthelivetest;this differencewas,onaverage,11.2%(95%CI:8.1---14.3).

When comparingtheSRPItest applicationconditionsof recordedmonosyllables×pictures,therewasastatistically significant difference in the mean percentage of correct answers(p<0.001*).Theperformanceofthesubjectsinthe testwithpictureswasbetterthanwiththerecorded mono-syllables,butthatdifferencewas, onaverage,21.1% (95% CI:17.9---24.2).

To assess the performance of individuals with mild-to-moderate sensorineuralhearingloss withtheintroduction ofcompetitivenoise,thespeechtestwithpictureswas con-ductedwithwhitenoise(Table2).

When the inferential analysis of the SpeechTest With White Noise was performed using the paired t-test, no statistically significant differences were observed when comparing the means of the percentages of correct responsesintherightandleftears(p=0.301).

Theresultsobtainedinthispopulationwerecomparedto thenormalcriteriaestablishedforindividualswithnormal hearing,inwhichonly26.3%ofindividualsshowedadequate results, considering both ears. There was no statistically significant difference between the right andleft ears for thefrequenciesofthenormalandalteredresults(McNemar test,p=1).

Toassesswhethertheintroductionofcompetitivenoise interfered withspeech recognition, the SRPI-P and STWN withpictureswerecompared(Fig.1).

When comparingthe differences inpercentages of the SRPI-PtestandSTWN-P,itwasobservedthatalldifferences weregreaterorequaltozero,indicatingthatthe percent-ageofcorrectanswersintheSRPI-Pwashigherthaninthe STWN-Pforallindividualsinthesample.

Attheinferentialanalysisusingthepairedt-test,itwas observedthatthemeanofthepercentagesintheSRPI-Pwas higherthanintheSTWN-P(p<0.001*).Themeandifference betweenthepercentagesinthetwotestswas24.5%(95%CI: 14.9---34.0).

Discussion

Theassessmentofspeechrecognitioncapacityusingspecial hearingtestsshouldconsidertheclassificationofthedegree andtypeofhearingloss,toallowtheevaluationofthe sub-jects’actualdifficultycausedbythesensorineuralhearing loss.14

Individuals with sensorineural hearing loss have better performanceinteststhatevaluatespeechrecognitionwhen the words are presented at a more comfortable hearing level.3_Such_care_was_taken_in_this_study,_but_it_also_aimed toassessthepossibleinfluenceofthestimulustypeonthe percentageresultsoftheSRPItests.Therefore,thetestwas carried out with three types of presentation: live voice, recording (recorded monosyllables), and recorded words withpictographicrepresentation(pictures).

The descriptive (Table 1) and inferential analysis of resultsoftheSpeechRecognitionPercentageIndexshowed thatwithinthesameapplicationcondition,themeanresults ontherightandleftearsweresimilar,butthemeansof per-centagesofthecorrectmonosyllableswithrecordedstimuli werelowerthanthemeans obtainedwiththelive presen-tationandwithpictures.

Thesimilarity betweentheresults intheright andleft earsin all SRPItest application conditionswas expected, asallthe individuals hadsymmetrical sensorineural hear-ingloss. Regarding theperformance in theSRPI test with monosyllablespresentedwithlivevoice,thetypeof stim-uluspresentationmostcommonlyusedinclinicalpractice, therewasadivergencebetweentheresultsofthepresent studywhencomparedwithpreviousstudies,14,15_which_found ameanperformanceof75.99%correct14_and_56.4%_correct15 responses.

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70

60

50

40

30

20

10

0

% SRPI-%STWN

Figure1 IndividualvaluesofthedifferencebetweenthepercentagesofcorrectanswersintheSRPIwithpicturesandSTWNwith pictures(SRPI,SpeechRecognitionPercentageIndex;STWN,SpeechTestwithWhiteNoise).

associatedwithadecreasedperformanceinspeech recog-nitiontests,withnoprevioushistoryofsystemicorauditory disorders.16 _Such _alterations _are _due _to _a _deficit _in cen-tralauditoryprocessing,justifyingthepoorperformanceof individualswhencomparedtothoseinthepresentstudy.

Theresultsobtainedarebelowthoseestablishedfor indi-vidualswithnormalhearing,butthisresultwasexpected,as thepopulationassessedinthisstudyhasperipheralhearing loss,which,evenwhenmild,can negativelyinfluencethe capacitytodiscriminatebetweenspeechsoundsusingtests withrecorded audio stimuli, particularly withlow redun-dancyandpredictabilitystimuli.

The analysis of results in comparison to the different formsofstimuluspresentationintheSRPIwasperformedper ear,but therewereno statisticallysignificant differences betweentheperformancesoftherightandleftears. There-fore,theresultswillbediscussedconsideringthatbothears hadnormaloralteredresults.

The frequency of individuals who showed adequate resultsinbothearsfortheSRPIpresentationwithlive mono-syllableswas26.3%.Noneoftheassessedindividualsshowed adequate results bilaterally in the SRPI test presentation withrecordedmonosyllables, showinggreater compatibil-itywithpuretoneaudiometry,and89.5%oftheindividuals showedadequateresultsintheSRPItestpresentationwith pictures.

When comparing the test application conditions, sig-nificant differences were found, in which the subjects’ performance onthe test with the livevoice presentation wasbetter than with recorded monosyllables, and worse than the test with pictures. When comparing the appli-cation conditionsof recordedmonosyllables and pictures, betterresultswereobserved forthe testapplication with pictures.

The extrinsic and intrinsic redundancies of a stimulus directlyinfluenceindividuals’performanceinspeech recog-nitiontests.Extrinsicredundanciesarerelatedtoacoustic

andlinguisticsignalcharacteristics,whereasintrinsic redun-danciesarerelatedtothestructureandphysiologyofthe auditorypathwaysthattransmitinformationtothecentral auditorysystem.17_The_effect_of_the_stimulus_redundancy_on theSRPItestperformancewasobservedinthisstudy, consid-eringthat,astheextrinsicredundancysignaldecreased,the individuals’performanceworsened.

Currently,inclinical practice,most professionalsapply the SRPItest with livepresentation; however, the results shownheredemonstratedthattherecordedstimulishould be routinely used, as the recorded application standard-izestheassessment,allowsthecomparisonofperformance at different moments,and decreases the extrinsic redun-dancyandtheevaluator’sinfluenceonthefinalresult.With alltheseadvantages,theassessmentsensitivityand coher-encewiththecomplaintreportedbyindividualswithSNHL,

i.e.,thattheycanhear,butnotunderstandwhathasbeen said,increases.However,theuseofrecordedstimuliimplies highercostsinauditoryassessment,astheprofessionalwill requireotheravailabletoolsinadditiontotheaudiometer forthiskindoftestpresentation.

Auditory closure skills are related to the individual’s capacitytorecognizefullauditoryinformation,evenwhen part of the information is distorted or suppressed. Indi-vidualswith NSHLhave areduced capacitytounderstand auditory information in acoustically unfavorable environ-ments,especiallyinnoisyones.18

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thattheworsenedperformancewasduetotheintroduction ofcompetitivenoise.

Alterations inthe spatialprocessing ofsoundare asso-ciated with incapacities in the selection and suppression of the sound stimulus that reaches the auditory system, making it difficult to understand speech in acoustically unfavorableenvironments,especiallynoisyones.19_Although the speech test with white noise and pictures is easy to applyandrespondto, itischallengingfortheCANSinthe assessmentofpatientswithmild-to-moderatesensorineural hearingloss,disclosinganalterationintheauditoryclosure skill.

Inclinicalpractice,theperformanceatthespeechtest withwhitenoiseandpicturesisassessedincomparisonwith SRPI-P;inthiscontext,betterresultswereobservedinthe assessmentcarriedoutinsilence.Thus,itcanbesaidthat theintroductionofcompetitivenoise,evenwithapositive signaltonoiseratio(S/N=+5)asintheSTWNwithpictures, hinderedspeechrecognition;thisdifferenceaveraged24.5% whencomparedtotheideallisteningsituation(nonoise). This decreaseinspeechrecognitionperformancewiththe introduction of competitive noise20 _can _occur _under _the influence ofcochlear alterationdue toperipheral hearing lossand/orchangesintheauditoryclosureskills.

Speech recognition tests assess the individual’s social hearing in situations similar to those observed in daily life, and provide information about the skills and limita-tions ofeach individual, whichdetermine the capacityto communicate.21 _When_a_noise_is_introduced_{simultaneously} toastimulusthat mayormay notbespeech,partof the informationisdegradedbytheintroductionofthis compet-itive stimulus,which hinders communication,asobserved withtheindividualsinthisstudy;however,theuseofspeech recognition tests in silence and withcompetitive noise is recommended,22 _especially _in _the _assessment _of _patients with mild hearing loss who report nocommunication dif-ficultiesandperformwellinconventionaltests.

Duetothenegativeinfluenceofperipheralhearingloss onspeechrecognitiontests,thebenefitsofusingcontextual cluesforsuchassessment,16_and_the_findings_observed_in_the presentstudy,itissuggestedthattheevaluationofspeech recognitionandauditoryclosureskillsinsubjectswith mild-to-moderatesensorineuralhearinglossshouldbeperformed usingthe speech recognition test withpictures in silence andwithnoise.Thisisarapidtoolthatcanbeappliedwith earphonesaswellasinasoundfield,andcanalsobeapplied toindividualswithhearing losswithdifferenteducational levels,whetherornottheyareusersofhearingaids.

Knowing that several factors can affect the results obtained in speech recognition tests, further studies are requiredtoassessthepossibleinfluenceofsomevariables, suchaseducationallevel, typeofperipheral hearingloss, and the material used in speech recognition test perfor-mance.

The influenceofeducationcouldbeanalyzedusing dif-ferent educational levels in individuals of same age and gender. The influence of peripheral hearing loss can be investigatedin relationtothetype ofloss (sensorineural, conductive,ormixed), degree ofloss(mild, moderate,or moderatelysevere),andaudiometricconfiguration.Finally, theevaluationofspeechrecognitionusingtest monosylla-bles represented by pictures could becompared to more

redundantstimuli,suchasbyusingsentencesastarget stim-ulus.

Conclusions

Inpatientswithmildtomoderatesensorineuralhearingloss, aged16---59years,whodidnotusehearingaiddevices,itwas concludedthat:

- There wasno differenceregarding the lateralityof the testedearinthefourtestconditions.

- TherewasasignificantdifferencebetweenthefourSRPI testconditions,withbetterresultsobtainedfortheSRPI withpictures.

- TheperformanceattheSTWNwasworsethanthatatthe SRPIwithpictures,showingdifficultyinauditoryclosure skills.

Funding

source

ThisstudywasfundedbyCoordenac¸ãodeAperfeic¸oamento dePessoaldeNívelSuperior---CAPES.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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