Unraveling the Vital Role of Speech in Noise Testing: A Conversation with Dr. Douglas Beck

Are you fully aware of just how vital speech in noise testing is in the hearing healthcare field? Let us unravel this topic in our latest episode featuring Dr. Douglas L. Beck. We shed light on the critical importance of determining a person's ability to understand speech amidst noise, an often overlooked aspect in audiology due to time limitations and reimbursement issues. Yet, these tests are pivotal for determining the effectiveness of aural rehabilitation and the fitting of hearing aids.

Curiously, there's a prevalent challenge where patients' hearing is deemed 'normal,' yet they grapple with understanding speech in noisy environments. Dr. Beck and Dr. Delfino share their insights on this predicament, discussing the value of speech in noise scores as a measure of auditory ability. We propose the Beck-Benitez Two-Minute Speech in Noise Test, an accessible tool that can help in these scenarios. The conversation also ventures into the area of verification and validation measures in clinical practice. Despite their crucial role in successful hearing aid fittings, they often remain unimplemented due to lack of awareness. It's our plea to fellow professionals to prioritize speech in noise testing for better patient outcomes. 

Transcript

Speaker 1: 0:06

You're tuned in to the Hearing Matters podcast, the show that discusses hearing technology, best practices and a growing national epidemic hearing loss. Before we kick this episode off, a special thank you to our partners Cycle, built for the entire hearing care practice. Redux faster, drier, smarter, verified AutoSet, the modern ear cleaning device. Welcome back to another episode of the Hearing Matters podcast. I'm your host, blaisdel Fino. During this episode, we're going to be discussing the importance of speech and noise testing. So to our fellow audiologists and licensed hearing health care professionals, listen in, doug. What is speech and noise testing and what exactly does it tell us?

Speaker 2: 0:55

Well, it's a little bit of a complicated answer because speech and noise sounds like it should be simple and it's not. Speech and noise has to do with when we're listening to a conversation, particularly cocktail party, restaurant, tavern, airport. When you're involved in a conversation, there's speech going on clearly and what we try to do is selectively attend to that speech. But in the real world there's background noise that messes up our ability to do that and everybody is different. There are some people who need a signal, which would be the speech, of about eight to 10 decibels louder than the background noise, to make sense of it. Some people only need two or three dB, some people need 15 dB. So it becomes remarkably important to measure speech and noise. Because hearing health care, when we talk about oral rehabilitation, when we talk about hearing aids and amplification, it's actually not so much about making sounds loud, when you make sounds that are audible so they can be perceived at a comfortable level that allows you to participate, that allows you to perceive the sounds. But the more important factor after you can perceive the sounds is can your brain make sense of the sounds? And it turns out that the most striking factor there is the signal to noise ratio. So the signal to noise ratio and speech and noise are highly related. They're referring to the same phenomena.

Speaker 2: 2:17

When you have a normal conversation, let's suppose that's occurring at about 50 decibels. If the background noise is louder is 55 decibels. That's a negative signal to noise ratio of 5 dB. Children to learn language need about 15 dB better signal to noise ratio than adults need to maintain speech and noise perception. So signal to noise ratio, speech and noise these are incredibly important topics and I think Dr Dolfino will agree with me that the number one reason that anybody ever goes to see a hearing healthcare person whether it's an audiologist, an otolaryngologist, a neurotologist, a licensed hearing aid dispenser number one reason, probably 98% of the time, is the inability to understand speech and noise. In other words, they don't come to see us because they need sounds louder. They're complained. Their observation is they can't make sense of what they're hearing and that's the speech and noise problem.

Speaker 1: 3:12

Dr Beck in an article in the hearing review, which I think you're very familiar with. It reported that the majority of hearing healthcare professionals do not conduct speech and noise testing. Why is this, and what can we do to encourage our fellow hearing care professionals to conduct speech and noise testing?

Speaker 2: 3:31

It's an enormous problem because when you're looking at this top down, the American Academy of Audiology, the American Speech Language Hearing Association, the International Hearing Society, these three national Practitioner groups, all say in their best practices that you should be doing speech in quiet and speech and noise. Many people presume that if you have a hundred percent word recognition in quiet that you should do pretty well in noise. That is absolutely ludicrous. There's no relationship at all Mathematically between a speech in quiet score and a speech in noise score. So one is that we have to recognize this is very, very important. All three of these groups say the same thing we should be doing it.

Speaker 2: 4:13

Well, why don't people do it? Well, many of the very busy ear, nose and throat practices don't do it because it takes a lot of time. And when you go see an otolaryngologist because you have hearing loss, they're primarily looking for disease and for things that they can help you with surgically and medical problems. Well, as it turns out, of the 37 to 38 million people with the hearing loss in the USA, only about 5% of those have a medical problem. The other 95% do not. They have a hearing or a listening problem. So it doesn't get done because it's not mandatory for otolaryngologic Diagnosis but it's so important to the patient who can't perceive speech and noise. Another factor to be quite honest is that the professional hearing care providers cannot really get paid for doing a speech and noise test. You know there are codes you can use in some situations, but putting in that extra five or ten minutes which doesn't sound like a lot to normal people, but in a clinical day, five or ten minutes is a lot of time and it's time that you can't really bill separately for. And the results are Remarkably important because if you know somebody's ability to understand speech and noise, you know exactly what to do for them.

Speaker 2: 5:19

You can't just say everybody has a difficult time understanding speech and noise. That is basically not a true statement. If you take the 37 to 38 million people with hearing loss, maybe half of them have difficulty understanding speech and noise maybe more, maybe less, but it's certainly not one to one. And then we have another 26 million who have no hearing loss, who have speech and noise problems, and so if you add all of that together you get about 63 million. Well, there's still 325 million people in the USA. So the vast majority of people don't have that difficulty and if they do, they're certainly not seeking input for that.

Speaker 2: 5:51

So it's a very important test, because the number one reason people come to see us is to better understand speech and noise, and if we don't quantify their difficulty Then we're guessing and best practices are really clear. You should not be guessing. You should be taking a scientific, proven outcomes based approach. Figure out what their SNR is the signal to noise ratio, to get 50% of the words correct, and then, once we know that, we can deal with it. But if we're guessing, we just go to make things louder. We may inadvertently be making the background noise louder as well as making the primary speech signal louder.

Speaker 1: 6:23

Dr Beck, when we talk about making a strong Recommendation to our patient with regard to the hearing technology they need to move forward with and what we recommend that they do move forward with. Dr Del Fino conducts speech and noise testing on every Single patient that we see. We will have those patients that display 100% we're discrimination and quiet, sure and then 20% In noise right. So when we're talking about Making the strong recommendation and the recommendation based off the patient's type and degree of hearing loss, social activity level, speech and noise Testing and also budget. So, doug, many of the hearing aids today have digital noise reduction or DNR. Now, what is that? How does it help and how helpful is it to have a speech and noise Test completed to make the correct hearing aid recommendation for our patients?

Speaker 2: 7:16

I Well, dnr is a fascinating topic. We've been using digital noise reduction since the beginning of the digital age of hearing aids, which was almost 30 years ago now, and primarily it's amplitude modulation. So for folks not familiar with that term, amplitude modulation means that right now, as I'm speaking, the lowest loudness level my voice is creating to the highest level is about 30 dB dynamic range. So my voice is going up and down in loudness. If you were to look at it on a spectrum, you would see this constantly changing signal. That's called a speech envelope.

Speaker 2: 7:49

I see you right now, doug, you can see it right now, because you're looking at the control board and as you're looking at that, that speech modulation is something that happens with conversational speech. So when you have DNR in a hearing aid digital noise reduction it's looking for that amplitude modulation and says, ah, that's a human voice, don't change it, don't do anything. But then when it hears a background noise like a fan, so it's going, shh, that's a steady state noise and the hearing aid is smart enough to say, oh okay, that's not modulating, so decrease that, it's not a very important sound. So amplitude modulation is kind of the go to for hearing aids for the last 40 years, 50 years, and that does decrease some noise by perhaps a dB or two. But when you're talking about cocktail party noise, when you're most likely in a negative signal to noise ratio, even though it does help and it absolutely does it doesn't help enough to make it easy to listen. So you're going from a miserable, horrible situation to just a miserable situation. The goal is to get into a good situation and that's where all of these other technologies deep neural networks, fm systems, remote mics that's where these things really shine, because you can take that cocktail party terrible signal to noise ratio.

Speaker 2: 9:00

Use a remote microphone, a digital remote microphone, and now you can really increase the signal to noise ratio substantially, like 12, 13, 14, 15 dB. I did an article it must have been seven or eight years ago with Harvey Dillon, a very famous engineer in our profession, and Harvey was saying then that a good digital microphone, digital remote microphone, could improve the signal to noise ratio by up to 20 decibels. So these things make quality of life differences. They are that good. And if we're not using advanced noise reduction and we're just using one or two dB or we use directional mics to give us one or two or three dB, well that's good and that's proof positive that we can make it better.

Speaker 2: 9:36

But patients don't want it better, they want it good or they want it excellent. And so it becomes a quality assessment. You can absolutely improve somebody's ability to understand speech and noise with directional mics or beamforming or amplitude modulation. Absolutely, we can show that. But is that going to be enough in a cocktail party or restaurant, a Thanksgiving dinner, a airport? And oftentimes it's not enough. So we have to go to more advanced technologies. So those technologies can start to mimic how the human brain would work if we have a normal brain and normal auditory system.

Speaker 1: 10:12

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Speaker 3: 11:09

There is an array of expectations with regard to listening environments in which someone is going to be in either a cocktail party, family, one-on-one.

Speaker 3: 11:18

So the speech and noise testing really gives me an idea as to the gravity of the problem, of the concern, if I'm seeing what we're going from 100% in quiet to 20% in noise, with a 10 or 15 dB signal to noise ratio. I know that the recommendations need to be aggressive with regard to any accessories or the level of technology in which they're using, because ultimately, what happens is these patients come to us because they are struggling with speech and noise. They know that they're hearing fine, with words and speech being presented at a comfortable loudness level, but in those challenging situations that's what they've come here for, and here at Audiology Services I need to be able to make strong recommendations with regard to what's going to work, to be able to verify that it works and have them feel as though this is making a difference or an impact in their life. Me saying it doesn't mean anything but, again, using the speech and noise to determine the level of technology, whatever accessories they need, implementing that and then watching how satisfied they are with the results.

Speaker 2: 12:15

And if I may add onto that, I'll tell you what. And, Dr Delfino, I'm curious on your opinion on this. I say often, if I only have one measure of a patient's auditory ability, it would be their speech and noise score.

Speaker 3: 12:26

Absolutely. It tells us so much and I have to say, the frustration that patients come. They've been to other places and they've been told you're hearing as normal, you're hearing fine, and they will say to me it's not fine, I struggle, I cannot hear, I can't hear Co-workers. I struggle in a host of situations and they're somewhat desperate and so, yes, that speech and noise score really uncovers lots of their underlying concerns about what's going on. It's not me, there is a real problem.

Speaker 1: 12:49

Dr Beck, there are different speech and noise tests, correct? And you have. I believe it's an article about the two-minute speech and noise test or two-minute speech and noise protocol. Again, a lot of audiologists and hearing health care professionals tune into the Hearing Matters podcast. What are the different speech and noise tests and which spin tests should audiologists and hearing care professionals be conducting to positively influence the patient's hearing journey?

Speaker 2: 13:15

You're exactly right, blaze. There's a number of commercially available tests. There's the AZ Bio, there's the BKB, there's the Quixin. The one that I wrote a few years ago is called the Beck Benitez Two-Minute Speech and Noise Test, and AAA published that If you go to audiologyorg and you put in Beck and Benitez, it's Lauren Benitez and she's an audiologist in the US Army right now.

Speaker 2: 13:37

These tests range in price and they're all good. You have to take them for what they are. Some of them are a little bit more accurate. Some of them take a little bit more time. I don't really care which one people use, as long as they use one. I can tell the professional audience assuredly that if they look up the Beck Benitez Two-Minute Test, they probably don't have to buy anything. They already have everything they need in the office to do that test. It takes less than two minutes, it's highly repeatable and we don't make a dime off it. It's not a capitalist tool, it's an audiology tool and it's free. So I would urge them to look at that and many audiologists and dispensers and ENTs will say well, don't do it because we don't have space in the booth.

Speaker 2: 14:17

The good news is, when we published that test, we did it outside of the booth and we have a schematic showing how we did it. And it's got to be calibrated professionally. You can't just use your phone to calibrate it, but calibrating is very, very easy. Every audiologist, every hearing aid dispenser, every otolaryngologist that does hearing testing they get their booths and their equipment calibrated at least once a year, regardless. This is a very, very easy thing for the technician to calibrate, but it's got to be right and it's got to be accurate, or else there's no point to doing it. So you can do it outside of the booth. It's very inexpensive. You may have to pay for foretalker babble if you don't already own a recording of that. My personal preference is I don't do any monitored live voice at all, ever and everything has to be recorded, so it has statistical validity.

Speaker 2: 15:00

Most audiologists, most hearing aid dispensers, most ENT officers are already going to have the NU6 word list or the CIDW22. That's fine. You can use that as the stimuli. But you need foretalk or background, because what we want to replicate is the cocktail party situation, the restaurant situation. If you're using speech spectrum noise white noise, pink noise those are non-linguistic and so they don't have the same interest to your brain. Right now some people are listening on their phones, some are listening on their computer, some are listening in their car, and so you have background noise going on. You have like a chhhh, and it's easy to ignore that. Your e-farent nervous system can totally take care of that for you, so you don't focus on it. You can attenuate that biologically by one or two dB, but with foretalk or babble you can't do that because it's so interesting to your brain. Your brain is trying to follow all of those conversations. So if you're using speech spectrum noise white noise or pink noise they have no linguistic value. That's much, much easier task than a cocktail party.

Speaker 1: 15:55

Dr Beck speech and noise testing a pragmatic addendum to hearing aid fittings May 2013. It is now June 2021. So this has been a topic of discussion for many years, and you've been talking about the importance of speech and noise testing for a long time, for many, many years, and there still seems to be this lack of awareness of it where hearing care professionals are just like, oh well, I don't have the time to do it. Well, you do have the time to do it. There's a two-minute protocol. We will put that link in the description, sure, but I want to read this quote here.

Speaker 1: 16:34

Frankly, although speech and noise is the number one complaint of the majority of people with hearing loss and the majority of people wearing hearing aids, speech and noise is rarely, if ever, tested in most offices. Indeed verification and validation measures are rarely applied in clinical practice. Kachkin Beck, christensen and colleagues reported over 50% of all dispensing offices own real ear measurement equipment. Yet real ear measurement is used in approximately 25% of all adult hearing aid fittings and the percentage of use is significantly less for behavioral validation measures. Dr Beck, we're going to be talking about best practices in our episode next week. Now, I know that was a long-winded quote, but my gosh, there are so many golden nuggets in that quote. What do we need to do as a profession, as fellow hearing health care providers, to encourage other providers to conduct speech and noise testing? And you've been in the field for over 30 years. What is it?

Speaker 2: 17:35

I think it's primarily time. But here's the thing, what I recommend and I just did a lecture on this last night, because people always say, well, I don't have time to do that so what I say is that anytime you have a patient who complains about speech and noise, particularly in a busy ENT practice, you do the normal clinical stuff air, bone, speech reflexes, temps, OAEs you do all that stuff. And then, if everything is normal normal word recognition scores, normal SRTs, everything lines up with the PTAs all of that looks pretty good. What I would do is I would set them up and I'd say listen, we're going to do an in-depth audiometric evaluation, just like we would do an HAE, a hearing aid evaluation, or an ABR auditory brain stem response. For that we have to schedule you to come back for an hour. The charge for that is XYZ. Whatever the charge is, your insurance may or may not cover that absolutely, but we need to investigate the speech and noise problem that brought you in. So our first level of concern is let's make sure you're healthy, let's make sure that medically, audiologically, we don't see anything that's a problem, and if everything is okay, then we're going to investigate the speech and noise in depth. And that makes it palatable for practices, because when they try to do it in the middle of a very busy clinical day, it'll derail them, because you could be involved with the patient for 45 minutes, maybe an hour, and that is not appropriate when you're just trying to crank patients through to see who has ear disease and who doesn't, who needs to see the physician and who doesn't. It's not the best time for that. So I always think of that as an audiometric evaluation in and of itself, which is a one-hour exploration of the patient's complaints and possible solutions. So in that one hour you might do the quicksend or the BKB or the beck benitez.

Speaker 2: 19:05

You might do different challenges with cognitive screenings, and this is a huge new area for many audiologists, although we started writing about it at Otacon back in 2009. In fact, you and I were kidding around earlier today and I think we won the award for the longest title of a paper ever published by the American Academy of Audiology. The paper in 2009 was called Cognition Matters More as Audition Declines and Audition Matters More as Cognition Declines, and it was a huge title, but it was exactly this idea that we need to sometimes evaluate if the word recognition problem, particularly in noise might be more of a cognitive issue for some patients than it is in audiologic and if we don't screen that to figure that out, then we'll just presume it's audiologic and intervene earlier with our multidisciplinary colleagues, like our associates in psychiatry or psychology or general practitioner or family practitioners. It's so important to do these cognitive screenings because that helps us to understand why the patient is having difficulty in noise. Sometimes it's hearing loss, sometimes it's listening disorders, sometimes it's cognitive issues.

Speaker 1: 20:07

To our listeners tuned in who are not currently wearing hearing aids but are learning a little bit about hearing health care and the importance of wearing hearing instruments. Do yourself a favor Before you make the appointment, whether you live in New Jersey or New York or even California, wherever you go, please ask do you conduct speech noise testing? You're tuned in to the Hearing Matters podcast. During this episode, we discussed the importance of speech and noise testing, featuring the one and only Dr Douglas Beck. Until next time. Hear life story.