www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Speech
perception
in
noise
in
unilateral
hearing
loss
夽
Maria
Fernanda
Capoani
Garcia
Mondelli
∗,
Marina
de
Marchi
dos
Santos,
Maria
Renata
José
SpeechTherapyCourse,FaculdadedeOdontologiadeBauru,UniversidadedeSãoPaulo(USP),Bauru,SP,Brazil
Received23April2015;accepted12August2015 Availableonline26November2015
KEYWORDS
Speechperception; Unilateralhearing loss;
Noise
Abstract
Introduction:Unilateralhearinglossischaracterizedbyadecreaseofhearinginoneearonly. Inthepresenceofambientnoise,individualswithunilateralhearinglossarefacedwithgreater difficultiesunderstandingspeechthannormallisteners.
Objective: Toevaluate the speech perception ofindividuals with unilateral hearing loss in speechperceptionwithandwithoutcompetitivenoise,beforeandafterthehearingaidfitting process.
Methods:The study included30adultsofboth gendersdiagnosedwith moderateorsevere sensorineuralunilateralhearinglossusingtheHearingIn NoiseTest---HearingInNoise Test-Brazil,inthefollowingscenarios:silence,frontalnoise,noisetotheright,andnoisetothe left,beforeandafterthehearingaidfittingprocess.
Results:Thestudyparticipantshadameanageof41.9yearsandmostofthempresentedright unilateralhearingloss.InallcasesevaluatedwithHearingInNoiseTest,abetterperformance inspeechperceptionwasobservedwiththeuseofhearingaids.
Conclusion: UsingtheHearingInNoiseTest-Braziltestevaluation,individualswithunilateral hearinglossdemonstratedbetterperformanceinspeechperceptionwhenusinghearingaids, bothinsilenceandinsituationswithacompetingnoise,withuseofhearingaids.
© 2015 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).
PALAVRAS-CHAVE
Percepc¸ãodafala; Perdaauditiva unilateral; Ruído
Percepc¸ãodafalanoruídoemperdaauditivaunilateral
Resumo
Introduc¸ão: Aperdaauditivaunilateral(PAUn)écaracterizadapeladiminuic¸ãodaaudic¸ãoem apenasumaorelha.Empresenc¸aderuídoambiental,indivíduoscomPAUnencontrammaiores dificuldadesqueosouvintesnormaisparacompreenderafala.
夽 Please citethisarticleas: MondelliMFCG, dos SantosMM,José MR. Speechperception innoise inunilateral hearingloss. BrazJ Otorhinolaryngol.2016;82:427---32.
∗Correspondingauthor.
E-mail:mfernandamondelli@hotmail.com(M.F.C.G.Mondelli).
http://dx.doi.org/10.1016/j.bjorl.2015.08.019
1808-8694/©2015Associac¸˜aoBrasileiradeOtorrinolaringologiaeCirurgiaC´ervico-Facial.PublishedbyElsevierEditoraLtda.Thisisanopen
Objetivo:Avaliarodesempenhodeindivíduoscomperdaauditivaunilateral,napercepc¸ãoda falasemecomruídocompetidor,antesaapósadaptac¸ãodoAASI.
Método: Estudocom30 adultos,edeambosossexos,comdiagnósticodeperdaauditiva uni-lateralsensorioneural,degrausmoderadoesevero,utilizandooHearingInNoiseTest---HINT ---Brasil,nasseguintessituac¸ões:silêncio,ruídoàfrente,ruídoadireitaeruídoaesquerda. Anteseapósadaptac¸ãodoAASI.
Resultados: Osparticipantesdapesquisaapresentavammédiadeidadede41,9 anosePAUn predominante àdireita. Em todas as situac¸ões propostaspelo HINT foi constatado melhor desempenhonapercepc¸ãodafalacomousodoAASI.
Conclusão:NotesteHINT---Brasil,indivíduoscomPAUndemonstrarammelhordesempenhona percepc¸ãodafala,emtantonosilêncioquantonassituac¸õescomruídocompetidor,comuso doAASI.
© 2015 Associac¸˜ao Brasileira de Otorrinolaringologia e Cirurgia C´ervico-Facial. Publicado por Elsevier Editora Ltda. Este ´e um artigo Open Access sob uma licenc¸a CC BY (http:// creativecommons.org/licenses/by/4.0/).
Introduction
Individuals with unilateral hearing loss (UHL) have lim-itations of communicative activities, especially in noisy environments,1 as well as possible deficits in auditory processingthatpotentially affectthedevelopmentof lan-guageandcommunication.2
Binaural hearing provides sound localization, binaural summation,ashadoweffectoftheheadandreleasefrom masking. The interaction of these factors favors speech recognitionin noise, duetothe ability toperform figure-background.3
Asawhole,UHLcancausedifficultiesincommunication.4 This problem can be minimized with the use of individ-ualsoundamplificationdevices(hearingaids),whichallows rescuing the perception of speech sounds, as well as of environmental sounds, helping to improve conversational ability.5
Soundamplificationisanoptionforindividualswith hear-ing loss, but in isolation such devices may have limited effectiveness in assisting speech understanding in noisy environments, or in the presence of reverberation. Peo-plewithUHLexperiencedifficultiesinthediscriminationof unusualsignals,anautomaticabilityinsubjectswithnormal hearing.6Thiscomponentrequiresspecialattentiononthe partof the speechtherapist when selectingand verifying hearingaiddevices.
InBrazil,testsofspeechperceptionthatusea compet-ingnoisearenotyetpartoftheconventionalaudiological evaluationprotocol,andbasedonprotocolsthecomparison ofperformances inquiet andinnoisy environmentsisnot oftenmade.7
Inordertobestrepresenteverydaylisteningsituations, overtimetheuseofsentencesinspeechperceptiontests, withand without the presence of a competing noise was introduced.7,8
When reaching50% of intelligibility,speechperception teststhatmeasurethespeechsignalrecognitionthresholdin aquietenvironmentdetectonlysmalldifferencesbetween
individualswithnormalhearingandthosewithhearingloss, incontrasttowhenthesepeopleareexposedtonoiseand intelligibilitydeclines.9
TheHearingInNoiseTest(HINT)wasdevelopedin1994,10 tomeasurethedifficultytorecognizespeech,andto com-parethefindingswiththeresultsofindividualswithnormal hearing, both in quiet and in noisy environments. The methodologyproposedbyHINTenablestheuseofthresholds insignal/noise(S/R)ratiotoevaluatespeechrecognitionin noise,insteadofusingthepercentageofcorrectanswers.7 Therearemanyfactorsthatnegativelyimpacttheability tounderstandspeechduringevaluation,includingthe char-acteristicsofthesubjectevaluated,togetherwithhis/her experiencesonlanguageandhearing,thetypeandlevelof presentationofthematerial,andtheanswersproduced.11 Thus,theimportanceofstudyingspeechperceptionintests that simulate the perception of the speech signal in the presenceofacompetitivenoiseisevident.
Therefore,thisstudyaimedtoassessspeechperception ofindividualswithunilateralhearinglossinconditionswith andwithoutacompetitivenoise,withandwithouttheuse ofhearingaids.
Methods
ThestudywasapprovedbytheEthicsinResearch Commit-teeoftheinstitutionwhereitwasconducted(ProtocolNo. 095/2010).
Tobeincludedinthestudy,participantshadtomeetthe followinginclusioncriteria:adultsaged18---50years, diag-nosedwithmoderatetoseveresensorineuralUHL,andwith contralateralhearingwithinnormallimitswhodidnotuse hearingaids.
Table1 Distributionofthesamplebygender,earwithsensorydeprivation,anddegreeofhearingloss.
Degreeofhearingloss
F M %(n) Moderate Severe %(n)
%(n) %(n) %(n) %(n)
LE 36.84%(7) 63.64%(7) 46.7%(14) 42.86%(6) 57.14%(8) 46.7%(14)
RE 63.16%(12) 36.36%(4) 53.3%(16) 50%(8) 50%(8) 53.3%(16)
Total 63.3%(19) 36.7%(11) 100%(30) 46.7%(14) 53.3%(16) 100%(30)
RE,rightear;LE,leftear;F,female;M,male.
Thestudyincluded30subjectswithameanageof41.9 years;46.7%ofthemhadmoderatehearinglossand53.3% hadsevere hearingloss. Table1 liststhe characterization ofthestudyparticipantsregardinggender,earaffectedby sensorydeprivation,anddegreeofhearingloss.
For selecting the type and model of the hearing aid device, the auditory characteristics and communicative needsoftheparticipantswereanalyzed.Accordingtothis analysis,thefollowinghearingaidswereselected:Phonak Una®MAZandUna®SPAZ,suitedformoderateandsevere hearingloss,respectively.
Afterprogrammingofhearingaiddevices,averification procedure was carriedout withmeasurements conducted withaprobe microphone.REARvalues werecomparedto targets ofthe NAL-NL1rulefor weak,medium andstrong sounds.Answerswereconsideredasmatchedwhenthe dif-ferencebetweenthetargetforREARandthevalueobtained inanactualeardidnotexceed10dB.13Forallsubjects,the answerswerematchedtothetargets.
The study participants underwent an assessment of speechperceptionwithouthearingaidsonthedayofdevice adaptation.Thetestwasrepeatedwiththehearingaidthree monthsaftereffectiveuseofthedevice,whichwasdefined asuse ≥8h/day for a period of three months,confirmed bydataloggingandconsideringthesubject’sadaptation.14 Theentiregroupofpatientswasrequiredtomaintaindaily recordsofhearingaidusage,andontheirreturnthatdata wasutilizedtoverifythenumberofhoursofuseeachday.
HINT
The testconsistsof listsofsentences, acompeting noise, and a microprocessor that controls the test application. The stimulus used in thisspeech perception in noise test is thespeechsignal. To present the stimulus,the authors determinedthespeechrecognitionthresholdneededforthe subjectto correctly identify50% of speech stimuli in the establishedsignal/noiseratio.
This valueisdeterminedbytheHINTprotocol,andhas twophases. The first phaseconsists of thefirst four sen-tences; the intensity varies in increments of 4dB. The secondphasestartsfromthefifthsentence,andthe inten-sity varies in increments of 2dB, which gives greater accuracyinthedeterminationofthethreshold.15
The speechstimuluswaspresentedfrontallyandinthe absenceofacompetingnoise.Then,thestimuluswas pre-sentedwiththespeechsignalandafrontalnoise,followed by noise tothe right and by noise tothe left, while the speechsignalwasfrontallypositioned.Thesameprocedure
wascarriedout withandwithout theuse ofhearingaids. Thenoiseintensityremainedfixedat65dBHLandthe stim-ulus intensity was adjusted to a greater or lesser value, dependingontheanswersobtained.
TheHINTequipmenthasastandardizednomenclaturefor thefourtestconditions.Whenacorrectanswerisobtained, theS/Nratiodecreasesbyanequivalentamount.Whenthe answeris incorrect,thesignal/noise(S/N)isincreasedby thesameequivalentvalue.
The signal is presented throughlistsof sentences, and thenoiseusedisthatofthesentencesused.AnegativeS/R
ratioindicatesgreaterdifficultyduringthetest. Thus,the lowertheS/Nratiois,thebetterthesubject’sperformance insituationswithacompetitivenoise.15
The testwasconductedin an openfieldsituation,and thespeechreceptionthresholdwasobtainedbyapplying20 recordedsentencesthatsimulate everydaysituations.The foursituationscarriedoutaredescribedbelow.
Speechwithoutnoise(S):thesignisemittedinfrontof thesubjectinanoise-freetestcondition(0◦
azimuth). Speechwithfrontalnoise(FN):thesignalandthenoise areplaceddirectlyinfrontofthesubjectinanoisecondition at0◦azimuth.
Speechwithnoisetotheright(NR):thesignalisplaced infrontofthesubjectandthenoiseisemittedfrom90◦ on
therightofthesignal(condition:noisetotheright---noise at90◦
azimuth).
Speechwithnoise totheleft(NL):thesignal isplaced infrontofthesubjectandthenoiseisemittedfrom90◦
on theleftofthesignal(condition:noisetotheleft---noiseat 90◦azimuth).
Regardless ofthe wayof application of HINT,the soft-wareitselfcalculates(inopenfieldorwithheadphones)the compoundnoise(CN),whichconsistsofaweightedaverage ofthefourconditions,asfollows:CN=(2*FN+NR+NL)/4.
The HINTresults wereexpressed by thevaluesof sen-tencerecognitionthreshold(SRT)andwerecomparedwith themeans obtainedfromsubjects withnormal peripheral hearing.
Inthestatisticalanalysis,theFisher’sexacttestand Stu-dent’st-testwereused,andadifferencewasconsideredto bestatisticallysignificantwhenp≤0.05.
Results
Table2 ComparisonbetweenearswithunilateralhearinglossineachsituationproposedbytheHearingInNoiseTest(HINT), withoutandwithhearingaids.
SituationproposedbyHINT LE RE Difference
betweenREandLE
ntotal Mean SD ntotal Mean SD p-Value
S1 14 40.18 4.82 16 41.01 4.97 0.64
S2 14 39.36 4.45 16 39.14 4.36 0.89
S12 14 −0.82 3.51 16 −1.86 4.25 0.47
FN1 14 −1.50 1.39 16 −0.70 1.39 0.13
FN2 14 −1.62 1.33 16 −0.99 1.84 0.29
FN12 14 −0.12 1.29 16 −0.28 1.09 0.71
RN1 14 −2.38 2.31 16 −3.24 2.42 0.33
RN2 14 −2.87 2.41 16 −3.87 1.96 0.21
RN12 14 −0.48 2.11 16 −0.63 1.52 0.82
LN1 14 −3.54 2.01 16 0.36 1.70 0.00a
LN2 14 −3.63 1.79 16 −1.35 2.08 0.00a
LN12 14 −0.09 1.57 16 −1.71 2.18 0.02a
S,silence;FN,frontalnoise;NR,noisetotheright;LN,noisetotheleft;1,situationwithouthearingaids;2,situationwithhearing
aids;n,number;SD,standarddeviation;RE,rightear;LE,leftear.
aStatisticallysignificantdifference.
involvementoftheears---46.7%ontheleftand53.3%onthe rightear(Table1).
Table2showsthecomparisonbetweenrightandleftears affectedbyUHLinthefoursituationsproposedbyHINT(S, FN,NR,andNL),withoutandwithhearingaids.Individuals withright UHL showedslightlybetterresults, butthe sig-nificantresultswereobservedfortheleftearresponsesin situationswithnoiseontheleft(p≤0.02).
Table 3 shows the comparison between the degree of UHL --- moderate or severe --- in four situations pro-posed by HINT (S, FN, NR and NL), without and with the use of hearing aids. It was observed that subjects withmoderatelosspresentedbestanswersinallproposed situations.
Table4showsacomparisonbetweentheperformances ofmaleandfemalesubjectswithUHLinthefoursituations proposedbyHINT(S,FN,NR,andNL),withoutandwiththe useofhearingaids,withsignificantresultsforfemalesinS (p≤0.02),andNR(p≤0.03).
Table5showstheperformanceofthegroupof30subjects withUHLinthosefoursituationsproposedbyHINT(S,FN, NR, and NL), withbetter results onNL, regardless of the affectedear.
Discussion
ThepresenceofUHLraisesseveralquestionsconcerningthe consequences of such loss, its etiology, and predominant
Table3 ComparisonofthedegreeofunilateralhearinglossineachsituationproposedbytheHearingInNoiseTest(HINT), withoutandwiththeuseofhearingaids.
SituationproposedbyHINT MHL SHL Differencebetween
MHLandSHL
ntotal Mean SD ntotal Mean SD p-Value
S1 14 40.36 4.55 16 40.85 5.20 0.78
S2 14 37.96 2.50 16 40.36 5.29 0.13
S12 14 −2.4 3.76 16 −0.48 3.90 0.18
FN1 14 −0.97 1.54 16 −1.16 1.36 0.73
FN2 14 −1.76 1.55 16 −0.87 1.63 0.13
FN12 14 −0.78 1.15 16 0.28 0.97 0.00a
NR1 14 −3.77 1.77 16 −2.02 2.57 0.04a
NR2 14 −4.09 2.49 16 −2.80 1.78 0.11
NR12 14 −0.31 1.62 16 −0.78 1.94 0.48
NL1 14 −1.72 2.90 16 −1.22 2.56 0.62
NL2 14 −2.55 2.13 16 −2.30 2.40 0.76
NL12 14 −0.82 2.71 16 −1.07 1.34 0.75
S,silence;FN,frontalnoise;NR,noisetotheright;LN,noisetotheleft;1,situationwithouthearingaids;2,situationwithhearing
aids;n,number;SD,standarddeviation;MHL,moderatehearingloss;SHL,severehearingloss.
Table4 DistributionofsubjectsbygenderinrelationtosituationstestedbytheHearingInNoiseTest(HINT),withoutand withtheuseofhearingaids.
SituationproposedbyHINT M F Difference
betweenMandF
ntotal Mean SD ntotal Mean SD p-Value
S1 11 37.49 3.16 19 42.44 4.76 0.00a
S2 11 38.19 5.40 19 39.85 3.59 0.31
S12 11 0.70 3.97 19 −2.58 3.39 0.02a
RF1 11 −1.57 1.16 19 −0.78 1.51 0.15
RF2 11 −1.52 1.09 19 −1.15 1.88 0.55
FN12 11 0.04 1.17 19 −0.36 1.18 0.36
NR1 11 −3.50 2.47 19 −2.46 2.29 0.25
NR2 11 −3.15 2.53 19 −3.55 2.04 0.64
NR12 11 0.34 1.62 19 −1.08 1.70 0.03a
NL1 11 −1.72 2.50 19 −1.30 2.85 0.68
NL2 11 −2.90 2.61 19 −2.13 2.01 0.37
NL12 11 −1.17 2.04 19 −0.83 2.11 0.67
S,silence;FN,frontalnoise;NR,noisetotheright;LN,noisetotheleft;1,situationwithouthearingaids;2,situationwithhearing
aids;n,number;SD,standarddeviation;M,malegender;F,femalegender.
a Statisticallysignificantdifference.
Table5 Performanceofsubjectswithunilaterallossatthe HearingInNoiseTest(HINT---Brazil).
SituationproposedbyHINT Threshold SD p-Value
S1 40.62 3.89 0.06
S2 39.24
FN1 −1.07 1.17 0.32
FN2 −1.29
NR1 −2.84 1.79 0.09
NR2 −3.40
NL1 −1.45 2.06 0.01a
NL2 −2.41
S,silence;FN,frontalnoise;NR,noisetotheright;LN,noise
totheleft;1,situationwithouthearingaids;2,situationwith
hearingaids;n,number;SD,standarddeviation.
a Statisticallysignificantdifference.
characteristics of individuals suffering this condition. The adaptationofhearingaidsinthispopulationstillgenerates somequestionsastothebenefitsprovidedtothepatient.
Researchersinvestigatedthebenefitfor,andsatisfaction of,individualswithadiagnosisofmixedorsensorineuralUHL (ofamoderate,severe,orprofounddegree)withtheuseof hearingaids.Theyobservedthat,evenwithoutattainingthe gainneededtomeetthedifficultiesimposedbytheirhearing deprivation,these patients reportedsatisfactionwith the useofamplification,relatingittoanimprovementoftheir qualityoflife.16
Individuals with UHL present greater difficulties than normal-hearingpeopletounderstandspeechwhenthe stim-ulus is presented together with a competing noise, even when the ear with better hearing threshold is positioned towardthespeech.14 Thus,teststhatassessspeech intelli-gibilityinthepresenceofacompetitivenoisecanprovide relevantinformationaboutthecommunicativecontextsthat approximatethesituationsexperiencedindailylife.
Table2showsthatonlyinthesituationwherenoisewas positionedtowardtheleftear(LE)ofindividualswith hear-ingimpairmentin this ear,the participantsdemonstrated better signal/noise (S/N) ratio than when noise was pre-sentedtowardtheLEoftheparticipantswithrightear(RE) hearingrestriction.A studyof individuals withUHL found thatthecorticalreorganizationinducedbyunilateral hear-inglossoccursmainlyinindividualswithhearinglossonthe leftside.
Thissuggeststhattheanatomicalandfunctionalchanges relatedtobrain plasticityaremorelikely tooccurin the righthemispherethaninthelefthemisphere.17
Inpeoplewithnormalhearingthresholds,hearingisthe onlysenseinwhicheachearhasitsrepresentationinboth hemispheres,becausetheauditorypathwayscoursethrough bothipsilateralandcontralateralpaths.18
In subjectswithUHL, deficits mayoccur in their audi-tory processingand, consequently,in the developmentof languageandcommunication.19
A study18 has shown that individuals with hearing loss intheirREpresent ahighernumberofcomplaintsrelated tothedevelopmentof speechandlanguage,aswellasin theirschoolperformance.Thisprobablydemonstratesthat hearinglossontherightsidetriggersaneurological imma-turityofauditory pathways ofthe centralnervoussystem thatresultfromthestimulationcomingfromRE,i.e.from informationthatwillbesenttothelefthemisphere,which canalsoberelatedwithalowerabilitytoinhibitcompeting noise.
Thedegreeofhearinglosswasafactorinthesituationof noisetotherightinsubjectswithoutahearingaiddevice, aswellasinthedifferencewithandwithouthearingaids, whennoiseandstimuluswerepresentedfrontally.
Inthissample,itwasobservedthatsubjectswithsevere UHL showed greater difficulty in speech perception com-paredtosubjectswithmoderateUHL.Thiscanbeexplained by the reduction of binaural auditory cues as a result of hearing loss, since it is expected that normal hearing in both ears will assistin the detection andorganization of speech in noise,20,21 whereas the degree of hearing loss mayhaveplayedanaggravatingfactorintestperformance (Table 3).The results indicated significance in two situa-tions,butbetterresponseswereobservedinsubjectswith moderatehearinglossversusthosewithseverehearingloss, withrespecttotheS/Nratio.
In this sample, regarding gender, women have shown betterperformanceinthreesituationsofHINT-Brazilwhen comparedwithmen(Table4).Investigators22havereported that men and women process sound stimuli differently, whichcanbeexplainedbythejointactivationoftheprimary auditory cortexwiththe prefrontal cortex, which is acti-vatedatahigherintensityinwomen,eveninthepresence ofaninsignificantstimulus.Thepre-frontalcortex partici-patesinvariouscognitiveprocesses,andhasamodulating functionintheactivationofothercorticalregions.Forthis reason,the superior performanceof women compared to men in tasks with the presence of competing noise may beduetothesuperiorityofmaintainingattentiontosound stimuli,andeventostimuliwithoutmeaning,suchasnoise. Thus,thedifferentformsofbrainactivationamongmenand womenmayexplainthebetterperformanceofwomeninthe presentstudy.
Analyzing the performance of individuals in situations with the use of hearing aids (Table 5), it was observed that in all test situations, a trend to improved S/N ratio wasnoted; this was more evident in the situation where noise wasdirected to the left.This finding demonstrates theimportanceofconsideringthebenefitsrelatedto hear-ingaid fitting in patients withUHL,regarding the benefit thatamplificationcanprovideinordertominimizethe dif-ficultiesimposedbythistypeofsensorydeprivation.
Thus,additionalstudiesareneededtobetterunderstand thecharacteristicsandpeculiaritiesofhearingaidfittingin individualswithUHL,tobettermeetthedemandsofthese patientsduringtheprocessofselection andverificationof thehearingaiddevice.
Conclusion
IntheHINT-Brazil,individualswithUHLdemonstratedbetter performanceinspeechperception,bothinaquiet environ-mentandinsituationswithacompetitivenoise,withuseof hearingaids.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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