1.

03 Basic Concepts of Hearing Loss and Aural Rehabilitation

Elmo R. Lago Jr., MD, MSciCA | August 22, 2018

Table 1. 1-3-6 Goals in Universal Hearing Screening

I. HEARING LOSS IN INFANTS
II. HEARING LOSS IN CHILDREN By Goal
III. HEARING LOSS IN ELDERLY < 1 mo. SCREEN for hearing loss (HL)
IV. PROBLEMS OF PEOPLE WITH HEARING IMPAIRMENT < 3 mo. SPECIALIST EVALUATION
V. AIR-FLUID IMPEDANCE MATCHING DEVICE
VI. AURAL REHABILITATION < 6 mo. INTERVENTION PROGRAM / REHABILITATION
VII. OTHER SCREENING TESTS / TECHNIQUES
VIII. REFERENCES / QUIZ E. Screening Techniques for Infants
LEARNING OBJECTIVES/OUTCOMES Table 2. Screening Techniques
1. Learning objectives were presented as an outline Behavioral • Moro / Startle reflex – normally, child startles /
Legend: (2019) awakens from sleep; checked by making loud sound
Cummings Audio Emphasized Notes Feedback • Developmental Milestones – check this if history is
unremarkable
   (text)
Objective • Otoacoustic Emission Test (OAE)
tests • Auditory Brainstem Response (ABR)
I. HEARING LOSS IN INFANTS
A. Characteristic Table 3. Developmental Hearing Milestones
• A silent, hidden handicap Months Milestones
o Why we need to study hearing loss (HL) in infants because they 1st 3 • Quiet when a familiar voice is heard
cannot tell us if they’re hearing well months • Act startled when a loud sound happens nearby
• Early detection prevents delayed speech and language 3-6 • LATERALIZE head to search for the source of voice
development, social and emotional problems, academic months • Enjoys rattles and other noise-making toys
failure  • React to music by COOING
6-10
• Understand common word (“no”, “bye”, “night-night”)
months
B. Statistics • BABBLE sounds like “da”, “ba” or “ma”
• Foreign data: 1-3 of 1000 live births • Know the names of favorite toys and points them
out when asked
• In the Philippines, 5-6 of 1000 live births 10-16
• Respond positively to rhymes and jingles like “peek-
• When comparing reading comprehension scores of hearing and months
a-boo”
deaf pediatric patients, • Imitate simple words and sounds
o If have normal hearing – comprehension (ability to understand) • Follow SIMPLE DIRECTION – “go get your shoes”
scores / grade equivalents are directly proportional with age 15-20 • Recognize names of BODY PART
o If with HL – stagnant reading comprehension scores months • Speak 10-20 words (may not be clear but
• When comparing expressive language scores of hearing impaired understandable)
children identified before and after 6 months, • COMBINE simple words like “daddy work”
20-24
o If an intervention was done < 6 months, the language • Refer to self by name
months
scores are almost at par with the normal, • Show interest in sounds of the radio or television
o If it was done > 6 months, the scores are behind par.
Table 4. Objective Test Screening Techniques Detailed  / 2019
o Thus early diagnosis is important for better language OAE Test ABR
development. • SCREEN neonate/infant • GOLD STANDARD 
• Tests integrity of the outer hair • Electrophysiological
C. History cells of the cochlea tested by the testing among infants
• Infants cannot tell their hearing problems; you go by their history sound produced by the instrument
• There is a 50% incidence of hearing impairment in infants with • Sensitivity – 84% • Sensitivity: 97-100%
high risk conditions (average of 5 studies presented from 1982 – • Specificity – 92% • Specificity: 96%
1991 but is limited to children with bilateral HL of 50 or more dB) • Detect otoacoustic emission (active • Measures potentials from
cochlear vibrations) auditory nerve & brain
• High risk infants – highly suspect HL unless disproved
• Agreement rate w/ ABR – 91% stem structures with
o Family history (tells you if it’s congenital or acquired) • Non-invasive, done at bedside, latency of 10ms with the
o CNS infections (during pregnancy) quick and easy to perform use of electrodes
o ENT defects (cleft lip, cleft palate, microtia) • A plug with sensitive microphone • ACCURATE in
o Ototoxic drugs probe is put in the ear cannal. determining hearing
o Prematurity • Retrograde transmission of function
o Hyperbilirubinemia vibrations from cochlea to TM • Indication: Getting “refer”
o Low birth weight of <1500 grams • Prerequisite: QUIET & STEADY from OAE
child in a quiet room of <40 dB 
• Results: • Drawback: requires well-
D. Recommendation (Joint Committee on Infant Hearing)
• Pass/Pass: Presume baby can trained operator, lengthy
1. Language, cognitive and social development at par if fitted at 4 hear but still check developemtal test (45 minutes to 1 hour),
weeks milestone costly, and child not to
2. Intervention before 6 months – results in better language skills • Refer: problem in hearing but move
3. Early detection minimizes rehabilitation during school years not yet hearing loss (HL); do • If cannot afford, use
repeat test after 1 mo. Developmental
• If refer again for the 2nd time, milestones as a guide
must do ABR. for monitoring

TRANSCRIBERS Arquines, Arnesto, Avanceña, Balaga EDITOR Mark Chan (09778128696)011219 1of7
 PHONEMES

• Basic unit of a language’s phonology, combined with other

phonemes, form meaningful units such as words.
• Each phoneme has both high and low frequencies to
distinguish it from other phonemes especially the vowel
sounds. 
• If there is IMPACTED CERUMEN, you lose the resonant
Figure 1. (A) OAE, (B) ABR.
frequency of the ear canal at 3-4 kHz. 
• Sounds are differentiated by the high and NOT low frequency
II. HEARING LOSS IN CHILDREN
• Importance of an intact ear canal, tympanic membrane (TM)
• Significance: A child can learn speech only until 6-7 y/o, thus
up to the end is all of this have sensitivities to high
opportunities to learn speech are lost more with frequent HL  frequencies, because sensitivity to high frequency
distinguishes the phonemic sounds. 
A. 3 Causes
• IMPACTED CERUMEN – Most common in children due to
impacted cerumen (improper cleaning of the ear, pushing the wax
inside) and patient may complain losing the resonant high
frequency (4kHz). Causing a net loss of 25 dB, the child only
hears a whisper (15dB) from a normal speaking voice (40dB).
• OTITIS MEDIA – 43 – 83% due to acute / recurrent / chronic (25
dB loss d/t effusion; up to 45 dB – level of conversational speech
– if the fluid is thicker)
• PERFORATED EARDRUMS
• Cause the most damage HL at the lowest frequencies
• Bigger perforation = increased HL
• HL varies INVERSE with volume of air within middle ear / Figure 4. Plotted Speech Sounds. The resonant frequency of the
mastoid ear canal is 4 Hz which is high frequency (white arrow), but if you
have impacted cerumen the high frequency is lost so it means that
• HL will depend on the location of perforation the child cannot distinguish between speech sounds properly.
Instead of hearing the original EE sound, the child instead HEARS
an O sound (Cokee to Coko), coinciding with the LOWER
FREQUENCY (black arrow). (2019A)

B. Prevalence & Management

• There is decreasing incidence of HL as child ages.
• As the infant ages, the Eustachian tube remodels from being short
and horizontal to being longer and more diagonal, thus acute
infection of the ear due to a nasal problem is lesser.

Table 5. Prevalence of HL in children per age group.

Age Group Prevalence
<3 years 12%
4-5 years 4-18%
Figure 2. (A) Impacted cerumen; (B) Acute otitis media – bulging TM; 5-8 years 5-7%
(C) Serous effusion otitis media; (D) Chronic otitis media –
6-8 years 3-9%
perforated with discharge.

Table 6. Management (2019B)

Diagnosis Management
Impacted Cerumen Remove
Incise; Administer antibiotics
Acute/Recurrent Otitis Media
and eardrops
Chronic Otitis Media Operate

C. Screening Test for Children (2019B)

1. Visual Re-Inforcement Audiometry
• For younger children
Figure 3. Simulating hearing in the presence of impacted cerumen using • Procedure: (Test one ear at a time.)
ear plugs. In normal hearing, there is a resonance in 3,000 Hz (red o Have the child sit on the parent’s lap and distract the child with
circle). In impacted cerumen, the 3,000 Hz disappears, thus difficult in a toy
distinguishing phonemes. HPD - Hearing Protection Device. SPL - o Suddenly put on a cartoon with sound
Sound Pressure Level in dB (2019B)
o Tendency is for the child to look at the cartoon, but you don’t
Review: The external auditory canal measures 2.5cm! (Q) It produces
a resonant frequency at about 3-4 kHz, thus hearing is sensitive at this
know if the child can hear
frequency. It amplifies the mid-frequency sounds by 15-20 dB. o Turn it off and play with the child again

1.03BASIC CONCEPTS OF HEARING LOSS AND AURAL REHABILITATION 2of7

 o Repeat twice (B) If both lines are below / DOWN-SLOPING but still are at same level
o On the third time, just put the sound on without the cartoon this is SENSORINEURAL HL / PRESBYCUSIS (A) Bone is normal, while
o If the child can hear, they will associate the sound with the air is below (the one with “x”), and there is air-bone gap, hence this is
cartoon, so they will look on the cartoon CONDUCTIVE HL.

2. BEHAVIORAL AUDIOMETRIC TESTING: Puretone / Speech Table 8. Typical Patterns

Audiometry Pattern Suggestive of
• For older children / can follow instructions Notch at 4-6 kHz NOISE-INDUCED
• Most common audiometric test method HEARING LOSS
• Measures hearing sensitivity Low-frequency HL at onset MENIERE DISEASE
• PURE TONE – Standard measure for hearing acuity Conductive loss accompanied by a OTOSCLEROTIC STAPES
• An AUDIOMETER is used to measure sensitivity to pure sine BC notch at immediate frequencies FIXATION
waves by determining the hearing threshold (125Hz – 8kHz) (Carhart notch)
• HEARING THRESHOLD is the lowest level in dB at which he/she
can hear the tone 50% of the time • High Tone Audiometry – for measuring thresholds from 8-16 kHz;
• Tests both air (AC) with the use of headphones and bone (BC) these tests show greater inter-individual variation than routine
conduction, which is normally equal. audiometry
• Speech audiometry measures the recognition / understanding of o Present the tone to the ear using headphones / special insert
speech rather than the threshold for detection of speech signals phone.
• Procedure: o Cross-hearing is prevented by MASKING (shifts the sensitivity
o Patient enters a booth and is instructed to raise his hand upon of the cochlea of the non–test ear to prevent it from hearing the
hearing a sound signal delivered to the test ear) C
• Objective and reliable hearing threshold is determined and plotted ▪ Effective masking - intensity level of the test signal that is
barely masked by presentation of a masking noise to the
Table 7. Pure Tone Audiometry Results. HL = Hearing Loss (20A) ipsilateral ear. C
Interpretation Met the following criteria / results: ▪ Masking dilemma - BC thresholds for both ears are within
NORMAL AC and BC is between 10-20 dB normal limits, and the AC thresholds equal or exceed
HEARING In normal sound conduction, the thresholds for air interaural attenuation seen in bilateral conductive or mixed
conduction (AC) and bone conduction (BC) should HL. C
be equal (AC=BC) o Threshold for BC is measured with a vibrator pressed against
CONDUCTIVE If BC is normal, and AC below normal and the air- the mastoid or forehead
HL bone gap is >10 dB o The cranial bones will vibrate and eventually transmit the test
If the AC threshold > BC threshold sound to the inner ear.
If perception by AC requires a higher loudness
level
SENSORI- If both AC and BC are below normal, and the gap INTERAURAL ATTENUATION C
NEURAL is <10 dB (no air bone gap) • Refers to the reduction in sound when it crosses from one
HL The hearing threshold is raised, often more at high ear to the other.
than at low frequencies • The lower limit for bone-conduction testing is essentially 0 dB
MIXED If both AC and BC are down and air-bone gap > 10 across frequencies.
HL dB
Greater AC loss compared with BC, indicating
impaired sound conduction III. HEARING LOSS IN ELDERLY
An increased threshold for BC • Co-related with social and emotional isolation, clinical depression,
and limited activity (starts as early as the 4th decade)

A. Prevalence
• 3rd most commonly reported chronic problem affecting the aged
population
o Presbycusis in 8% (>50 y/o; due to noise-induced if <50 y/o)
• 25% of 51-65 y/o have hearing loss >30dB in one ear
• 33% among >65 y/o
• >50% among >85 y/o

B. Etiology - Conductive
• Impacted Cerumen
o 95% occlusion
o Factors
1. Age-related ATROPHY OF APOCRINE GLANDS leads to
decreased watery component leads to dry-hard wax
2. TRAGAL HAIRS are longer, thicker and coarser which traps
the cerumen
• History
Figure 5. Pure Tone Audiogram Results.  In pure tone audiogram,
there will be 2 lines, one at the level of BC, and the other, AC. (C) Both
lines are at same level at 10-20 dB therefore this is NORMAL HEARING.

1.03BASIC CONCEPTS OF HEARING LOSS AND AURAL REHABILITATION 3of7

C. Etiology - Sensorineural D. Screening Tests
Table 9. Presbycusis – 4 Types (Bacek & Schuknecht). Speech 1. Puretone Audiometry (PTA) – similar details as with performed
Determination (SD) on a child
Speech Histologic
Type Audiogram Discrimination Changes 2. Speech Discrimination (SD) Score
(SD Score)
• Measures phonetically balanced words that the patient hears and
“Down- Good (very Rapid
Sensory sloping” responsive to degeneration repeats correctly
(most with high hearing aids) of Organ of • Evaluate candidacy for a cochlear implant C
common) frequency Corti
loss Table 11. Certain conditions in relation to SD Scores C
Mechanical Secondary to CONDITION SD SCORE
(noise- “Down- Poor Basilar
induced, sloping” Membrane Conductive HL (test stimuli are presented at a EXCELLENT
trauma, etc.) Changes sufficiently loud level)
Slowly Cochlear sensory HL (stimuli presented are well REDUCED
Strial progressive within their audible range)
(Metabolic) “Flat” Good atrophy of CN VIII lesion (esp. in the presence of normal FURTHER
(DM, HTN) Stria auditory pure-tone thresholds.) REDUCED
vascularis
Cortical lesion (unable to understand speech) EXTREEMELY
Loss of
Neural Poor spiral REDUCED
“Flat”
(Tumors) ganglion
cells • Used 20 monosyllable words (cat, dog)
Good: amenable to rehabilitation, respond to hearing aid o 90-100% correct – Normal
o 75-90% correct – Slight Difficulty
Table 10. Variables that may contribute to Age-Related Hearing Loss o 60-75% correct – Moderate Difficulty
Variables Mechanism of Action o 50-60% correct - Poor
Athero- Causes diminished perfusion and hypoxia of the
sclerosis cochlea
3. Tympanometry
Noise Accumulation over time damages hair cells
exposure • Objectively screen / diagnose central / peripheral auditory disorder
Loop diuretics – Ototoxic to stria vascularis; • Measures status of the Middle Ear Cavity by measuring
affecting all frequencies Compliance (Admittance/Immitance) of the ear drum
Aminoglycosides –Ddamage cochlear hair cells • Naglagay ka ng sound, tumama sa eardrum, moves your eardrum
Streptomycin, Gentamycin – Damage vestibule
(it will peak pataas = UPSLOPE), then eardrum moves back to its
Amikacin – Affect cochlea
Cisplatin – Cochlear high tone loss original position (it will go down = DOWNSLOPE) 
Quinine – Reversible hearing loss at all Hz • For older children if you want to check the status of the middle ear.
Salicylates – Mild / moderate cochlear impair You test the movement of your tympanic membrane (TM).
Drug or chloroquine, vancomycin, IV erythromycin,
exposure salicylates such as aspirin, and some
(2019B) antineoplastic agent, particularly, Table 12. Summary Table of Tympanogram Results (20A) Note: Only
cyclophosphamide. Type B is Immobile. TM = Tympanic Membrane; AOM = Acute Otitis
Media C
Particularly problematic in patients with hepatic or Type Tympanogram Details
renal dysfunction. A NORMAL middle ear pressure
Peak at 0 daPa
Not all ototoxic medications cause permanent
losses (e.g. salicylate- induced HL typically
reverses with cessation of therapy.
Diabetes, Hyperlipidemia, Vascular intimal
Diet and hyperplasia – cause poor cochlear perfusion and
Metabolism subsequent HL B MIDDLE EAR FLUID
Uremia – direct labyrinth damage FLAT; no point of maximum
Predisposed EARLY AGING of the auditory compliance (no movement)
Genetics system or increased susceptibility to other Seen in (serous) otitis media
environmental factors such as noise exposure with effusion / fluid, space-
Solvents Nitrobenzene, aminobenzene occupying lesions of the
Heavy Metal Lead, Arsenic, Mercury
tympanic cavity, and TM
Recreational Alcohol, Heroin, Tobacco, Cocaine
perforations.
Drugs
Bulging Eardrum in AOM,
Adhesive Otitis Media 

1.03BASIC CONCEPTS OF HEARING LOSS AND AURAL REHABILITATION 4of7

C RETRACTED TM normal hearing, (b) sensorineural HL without amplification, and (c)
Slight negative middle-ear sensorineural HL with a constant amount of amplification for all input
levels.
pressure as reflected by a
negative lower pressure peak V. AIR-FLUID IMPEDANCE MATCHING DEVICE
May be indicative of • Impedance – “a measure of resistance to the flow…”
EUSTACHIAN TUBE • “If impedance of two materials, are very different, sound will not
DYSFUNCTION pass easily from to the other”
May be present in the early • The design of the ear is to protect against high frequency loss.
stages of OM without effusion When you put your head underwater, it’s difficult to hear. The
or Perforated TM
sound waves are reflected on the water out.
D
• Just like the ear canal, when sound enters your ear, it hits the TM
A notch in the pressure peak
(mechanical), then it reaches the cochlea (fluid). There is
Often seen with scarred
impedance or loss of air sounds when it reaches the cochlea.
eardrums or with normal,
The function of the ear is to provide the gain to make up for that
hypermobile eardrums.
loss. If you lose 30dB, you should gain 30dB
• The following below are mechanisms / principles on how sound
AD UNUSUALLY HIGH is regained.
PRESSURE PEAK
Possible hypermobility of TM / A. Tympanic Membrane Ossicular Chain (Anatomy)
ossicular chain due to atrophic • Function as an impedance matching device
TM scar or an OSSICULAR • Compensates for impedance between air and fluid
chain discontinuity • Since 97-99% (30 dB) is reflected/lost due to media differences,
DISLOCATION thus this aims to regain almost all of it.
DISPLACED, chain problem
B. Areal Lever Mechanism (Physiology)
AS PEAK IS REDUCED IN
• 99% of the sound waves bounce back when you are swimming
AMPLITUDE
underwater and someone is talking, thus cannot hear.
Pressure peak at 0 (Normal)
• In the ear, sound waves hit the water (endolymph in inner ear).
Caused by the presence of
So theoretically, you lose all sounds you hear when it reaches
ossicular chain fixation /
the inner ear. So, when you remove the TM and ossicles, and the
stiffness, which may be caused
sound waves hit the inner ear, it will cancel everything. You can
by OTOSCLEROTIC stapes
hear the sound, but you cannot distinguish the sound because
footplate fixation.
most of it is reflected back theoretically.
STIFF, THICKENED TM
• But in reality, the 99% deflection is equivalent to 30 dB. Normal
Cannot move like normal TM
speech is 40 and you remove 10 dB and it is just a murmur. So,
Only moves a little ( if
the ear reverses the loss through these mechanisms. The loss is
there’s some fluid)
gained back.
IV. PROBLEMS OF PEOPLE WITH HEARING IMPAIRMENT
(2019A) 1. Areal Mechanism
• 1. Decreased Audibility (mild, moderate, severe, profound) • The TM has a large surface area (55mm2), while the stapes
o Inability to ear most likely the high pitched sounds by females footplate has a small surface area (3.2mm2).
(“ss, sh, th, f sounds”) • Large surface area of the eardrum transfers more energy to the
• 2. Decreased Frequency Selectivity small stapes footplate.
o Manifest as difficulty to hear sound with background noise
• 17:1 GAIN EQUIVALENT TO 25 DB
• 3. Decreased Dynamic Range (can’t distinguish if soft or loud)
o Normally it should be wide. • Disrupted by perforation of the eardrum because you lose the
o Reaches the pain threshold quickly, thus hate loud sound real surface in serous OM because the eardrum cannot move

Figure 6. Dynamic Range. The relationship between the dynamic range Figure 7. Areal Mechanism. With the movement of hydraulic action from
of sounds in the environment and the dynamic range of hearing for: (a) the larger TM (55mm) to the smaller stapes footplate (3.2mm) in the oval

1.03BASIC CONCEPTS OF HEARING LOSS AND AURAL REHABILITATION 5of7

window, the energy is amplified. There is a 17x difference. It equates to Stapedial Reflex Measures C
25 dB. “Parang concentrated / siniksik”
• Part of middle ear battery test
2. Lever Mechanism (2019A) • Measure changes in TM compliance caused by contraction of
the stapedius muscle and are particularly useful for
• Where the remaining dB deficit is gained differentiation of cochlear and retrocochlear lesion sites.
• The ossicular chain of the malleus, incus, and stapes • 1. ACOUSTIC REFLEX THRESHOLD TEST
• Distance from malleus to incus is 1.3 while distance from incus to o Determines the softest level of sound that will elicit
stapes is only 1. stapedial muscle contraction
• The fulcrum is moved so there’s more energy transferred. • 2. ACOUSTIC REFLEX DECAY
• Longer malleolus and shorter incus. This works as a fulcrum. o Measures the ability of the stapedius muscle to maintain
• 1.3 pressure increase (3-4 dB equivalent) sustained contraction
• Disrupted by infection that stiffens the ossicular chain o Signal is presented 10 dB above the acoustic reflex
• In total, only 1 dB is lost through impedance threshold for 10 seconds
o Abnormal if the response amplitude decreases to one half
or less of its original amplitude within 5 seconds (may
indicate retrocochlear disease
o Use 500 or 1000Hz

Electrocochleography (ECOG) C
• Measurement of neuroelectric events generated by cochlear
structures and the auditory nerve in response to acoustic
stimulation.
• Clinical applications: differential diagnosis of hydropic
conditions of the cochlea that may be associated with Meniere
disease or other diseases
Figure 8. Lever Mechanism. The long process of the malleus is a third
longer than the long process of the incus. It is equivalent to about 2.5 dB. VII. AURAL REHABILITATION
3. Amplification-Gain
• The areal and lever mechanisms equate to a gain of 29 dB which
is almost equal to the loss of 30 dB! This is how the middle ear
tries to gain back the change in fluid from air to liquid.

Table 13. Calculating Amplification Gain

ANALOG DIGITAL
Areal Vibrating TM 55
Mechanism Footplate = 3.2 = 17% or 25 dB

Lever Length, long process, Malleus

Mechanism Length, long process, Incus =1.3 = 2.5 dB

Total 1.3 x 17 mm2 = 22.1 mm2

Transformer roughly a pressure amplification gain of 27.5 -
Ratio (ME) 29 dB

VI. OTHER SCREENING TECHNIQUES / TESTS

Tuning Fork Tests
• 512 Hz – best all purpose tuning fork
o Low Hz – felt rather than heard
o High Hz – attenuates readily (dissipates)
• Should not be struck too hard – result to overtones/ gives false Figure 9. Screening Version of the Hearing Handicap Inventory for the
information Elderly (HHIE-S).  Not all elderly with HL need to be fitted. Usually ang
nagpapafit yung kamag-anak, especially they want the most good
A. WEBER TEST looking, and most expensive. But, do they need it? How do we know if
• Test for lateralization they need it? First, we need to establish if they have a handicap. HHIE-S
• Put the handle of the tuning fork on the midline of the vertex is a test, a series of questions patient need to answer. At the end, we
of the skull or forehead could say what is the possibility of his/her handicap (no referral, mild, or
• Ask the patient where they heard the sound sever handicap). And then if he/she has a handicap, then you rehabilitate
• Results: (this is the use of hearing aids).
o Normal – midline
o Unilateral Conductive – affected ear
A. Hearing Aids
o Unilateral Sensorineural – better ear
• Management of choice esp. for moderate to severe HL
B. RINNE TEST • Newer aids can be precisely tailored to pattern of HL
• Measure AC or BC • Provide significant improvement
• Put the fork near the mastoid bone, then the ear • Cannot restore hearing to normal
• Ask the patient which is louder • A miniature sound system (with microphone, a special type of
• Combine with Weber to really know if it is conductive or
acoustic amplifier, and a speaker)
sensorineural HL

1.03BASIC CONCEPTS OF HEARING LOSS AND AURAL REHABILITATION 6of7

• Can adjust HL as to what part of the audiogram they want to 1. Hearing Aid Fitting
improve • Fit binaurally
• BINAURAL is better vs monoaural because (2019A): • Fit on the better ear first
o Provides more natural hearing • Occlude external canal (to prevent feedback)
o Better speech understanding • Fit aid to the individual (not the individual to the aid)
o Better understanding in group or noisy environment
o Better sound localization, quality, identification • Check for Impact Socially (COSI)
o Balanced hearing • Motivation is important for success
• NEVER FORCE
Table 14. Comparing Analog and Digital Hearing Aid • Time for adjustment
ANALOG DIGITAL
Contain BASIC technology Contains ADVANCED degree of TO FIT OR NOT TO FIT A PATIENT FOR HEARING AID?
signal processing
Provides GOOD sound quality Provide BETTER sound quality, • 1ST – The patient should acknowledge the loss
perception of loudness, • 2ND – The patient should want to be fitted & improvement
environmental noise reduction
• If you do not get these 2 factors, DO NOT fit the patient. It
LESS flexible and LESS Uses small computers, HIGHLY is a waste of money. They will not use the hearing aid.
precise precise and MORE flexible
Affordable EXPENSIVE 2. Coping Techniques
Just makes sounds louder Distinguish noise vs. speech • Face to Face, 14 inches away
• Person’s attention
• Better ear and talk to it
• Speak slowly, clearly, distinctly
• DO NOT SHOUT – because it pains them to hear you 
• Prepare to repeat
• Gestures important
• Make sure person understands
VIII. REFERENCES
• Dr. Lago’s Lecture PPT, Audio Recording, 2019 Trans
• Book: Cummings
IX. QUIZ
1. What is the tympanogram result in a patient with a perforation of the pars
tensa?
Figure 10. Different Kinds of Hearing Aids tailored to the pattern of a. Type A
HL. (A) Behind the ear, (B) In the ear, (C), in the canal, (D) Completely in b. Type Ad
the canal. See Table 15. c. Type B
d. Type C
2. If you were to present a hearing aid to an elderly with presbycusis, which
Table 15. Different Kinds of Hearing Aids for typical loss pattern (2019 one of the following types will give you the best benefit in terms of being
A) powerful and economical?
Type Description a. BTE (behind the ear)
Behind the Mild to profound HL. b. CIC (completely in the ear)
Ear (A) Worn behind the ear, connected to a plastic mold c. ITC (in the canal)
d. ITE (in the ear)
inside the ear. 3. Which of the following tests would you prescribe a newborn baby to
The components are held in a case behind the ear. screen for hearing impairment?
Poor fitting ear molds may cause feedback. a. Auditory Brainstem Response (ABR) Audiometry
The most powerful (can be adjusted and long- b. Otoacoustic Emission (OAE) Testing
standing USE FOR THE ELDERLY)  c. Visual Reinforcement Audiometry (VRA)
In the Ear Used for mild to severe HL. d. Pure Tone Audiometry (PTA)
(B) Case is made up of hard and plastic and can 4. Which would be the next step if a baby’s newborn screening results, done
twice, are read as “refer” twice?
accommodate added technical mechanisms like a. Refer for Auditory Brainstem Response Testing
telecoil. b. Response for Temporal Bone CT Scan
Can be damaged by earwax or drainage. c. Refer for hearing and rehabilitation
Usually worn by children. d. Refer for sign language
In the Used for mild to moderately severe HL. 5. Which one of the following coping techniques is NOT recommended for
Canal (C) Customized to fit the size and shape of the ear. an elderly who has moderate to severe hearing loss secondary to
presbycusis?
Completely Used for mild to moderately severe loss.
a. Raise your voice when speaking to them
in the Largely concealed in the ear canal. b. Speak slowly and clearly to them
canal (D) Hard to adjust because of its size. c. Use gestures when talking to them
Not recommended for children. d. Talk within 2 feet from the elderly
Most expensive 6. Using developmental hearing milestones, one is alerted for the absence
of hearing if a 1-month old child:
a. Does not turn his head to the source of your voice
b. Does not react to music by cooing
c. Does not act startled when loud sound happens nearby
d. Does not babble sounds like “da” or “ma”
1C 2A 3B 4A 5A 6C

1.03BASIC CONCEPTS OF HEARING LOSS AND AURAL REHABILITATION 7of7