Rehab Aud Exam 2 flashcards |

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Auditory Visual Speech Recognition

Need both signals for optimum recognition and comprehension
Use sight to help in loud environments

Residual Hearing

Use this and visual cues to help understand speaker

AV Integration Theory

Addresses communication problems of people with HL
Serve as guide for developing signal processing strategies
Framework of AR

Bottom-Up Cues

Segmental and Suprasegmental
Auditory Cues
Visual Cues

Top-Down Cues

Cognitive/Linguistic Information

People with HL May Have Difficulty Understanding Speech

Perception with auditory or visual stimuli
Integrate auditory and visual cues
Applying cognitive and linguistic constraints
Working memory


McGurk Effect
Seen more in females
Combine auditory and visual cues and get something in the middle

Visual Cues for Speechreading

20% of words are recognized through vision alone
Place is visible
Voicing and manner are invisible


Classify phonemes by place of articulation and shape of mouth
Not a 1:1 correspondance
9-12 groups


Visemes can change depending on neighboring phonemes
Limits perception


Words that look a like when spoken even though they sound different
Lips and tongue look the same
Different speech sounds that look the same

McGurk Effect

Graded phenomenon
Depends on listener and talker
Gender: Females integrate more
Individuals with an array of disorders don't get effected

Infants and Integration

Present ~20 weeks old
Prefer when auditory matches visual cues

Integration and Age of Implantation

Early implanted children do better at A-only and AV
Later implanted children do better at V only
If child gets implanted 2.5 years or later they are more reliant on visual cues

Talker Factors

Articulatory Style
Facial Expression

Articulatory Style

Exaggerated mouth movement is harder to understand
Mumbling is hard because you can't see articulator placement
Accents are a struggle as well

Gender Factors

Woman are easier then men
Facial Hair is an issue because they hide the mouth

Expression Factors

How they are using their body and help add redundancy to message

Position Factors

Face-to-face is best
Within 45 degrees of speaker
To the right of speaker is best

Message Factors

Morphosyntax and semantic constraints

Length Factors

Longer the message harder to speech read
Grammar helps with predicatbility

Semantic Factors

Words relate to each other if we have a good vocabulary it is easier to fill in the blanks

Context Factors

Facial Expression and events help you predict what is being said

Environmental Factors

Background noise/distractor
Viewing angle


Only attending to position and movement of lips


Do more than just watch lips
Look at facial expression
Use residual Hearing
Linguistic Constraints
Modify Environment

Speechreading in AR

Not much current research because of technology

Assessing Speechreading

Helps determine teaching methods
May predict CI benefit in kids
Live speech test preferred
Want visual acuity


Most central aspect of counseling is listening
Delay Judgement
Accept what the client has to say


No HL is the same
Negative reactions can develop on misperception
Social Dysfunction perceived
Harder for children with a HL to socialize

Emotional Development

Children with HL struggle to "read" people
Harder to make friends
Language abilities effect perception

Educational Issues

Americans want their child to succeed
Will my child talk?
Certain values are more important than others depending on the family

Acquired Hearing Loss

Elderly make up majority of people with HL
Accidents, Illness, Age factors of HL

Impact of Acquired HL

Varied among individuals
Many people are reluctant to seek treatment
People don't want to look old
Social withdrawal


Focus on supporting personal adjustment
May need to refer to a professional
We only focus on the HL

Counseling with Children

Family based
Parents more assertive now

Family Focused Model

System Information: SpEd laws, available services
General Information: Child's prognosis, treatment options
Parents role at home
Family assistance: Counseling network
Resources: Financial, medical, emotional, respit care


Grief Cycle, Stages of Grieving
Often seen as a re-cycling
Pattern and reaction to loss

Grief Cycle



Initial reaction, helps them mobilize
HL is invisible
Professional Response: Accept and offer service to child and family


Something they/you did caused the problem
Multicultural differences: Religious, cultural
Punishment for transgression
Don't condeme, provide scientific rationale


Parent that is around the child has the most
Reaction to loss
Rage directed towards child, family, professionals
Professional response: Acknowledge frustration, depersonalize attack


With self, God
Superparent Syndrom
Professional Response: Help parents establish realistic goals


Reality is painful
Reoccurs at life milestones
Professional response: Listen quietly
If severe enough may reffere to professional


Ultimate goal
First evidence of resolved grief
Professional Response: Energies and constructive actions of parent can now be more focused on intervention

Counseling Pitfalls

Stereotyping what a response might be
Transference: Strong reaction possitiveor negative to parent
Projecitons; Responding ot predicaments as if they were our own
Implicit Expectation

Counseling Process

Help Child/parent tell their story
Help them to clarify their problems
Help children to take responsibility for listening problems
Help them establish goals
Develop an action plan
Implement the plan
On going reassesment

Basic Listening Skills

Use minimal encouragers (uh-hh, hmm) keeps person talking
Paraphrase-this helps lead to solutions without directly acknowledging them
Acknowledge/ reflect feelings
HL children don't have feeling vocabulary

Counseling Basics by Wallace

Listen to what they say to you
Be honest: Be fair, objective, yet understanding
Provide information: Regulate level, amount, level of understanding on parents part
Focus on what family does well
Respect family decision
Seek information if you do not know
Agree to try something
Watch jargon use
Give families time
be sensitive to culture
Reiterate, Rephrase, Repeat

What is a CI

A prosthesis that provides direct electrical stimulation to auditory never
Bypasses the ME
Used with individuals who have severe to profound HL who receive little benefit from HA

Intended Benefits of CI

Improve sound awareness
Improve speech perception and production
Improve language development

Parts of External CI

Speech Processor
Transmitter Coil


Picks up acoustic signal


Converts the acoustic signal from the microphone to an electric signal

Transmitter Coil

Sends the electric signal from the external device to the internal device

Parts of Internal CI

Electrode Array


Receives input from external device and sends it to electrode array

Electrode Array

Stimulates auditory nerve

Alessandro Volta

First person to stimulate auditory nerve electrically
Connected a battery of 30 couples to two metal rods and inserted them into his ears

Djourno and Eyries

Implanted the VIIIth Nerve stump in a patient with bilateral temporal bone resection
Patient could differentiate between high and low frequencies


Inserted an array of electrode into a cochlea of a totally deaf person
Patient was able to repeat phrases with lipreading cues

International Audiences of CI Research

House (HEI)
Michelson (UCSF)
Simmons (Stanford)
Graeme Clark (Melbourne)

First FDA Approved CI

House-3M Single electrode Array for adults


Ci's introduced in clinical trials
Only implant post-lingual adults
Bilateral profound SNHL and 0% speech perception
Received 1 CI


FDA lowers the approved age to 2 years


FDA lowers age to 18 months


FDA lowers age to 12 months

Traditional Child CI Candidate

12 months of age
Profound bilateral HL
Receive minimal benefit from HA

Traditional Adult CI Candidate

Profound bilateral HL
Receive minimal "benefit" from HA
Speech recognition < 50% (private insurance) <40% (Medicare)

Evaluation for a CI

Audiologic Evaluation
Otological Examination
CT/MRI to see for abnormalities
For children: Require a 3 month HA trial and Speech/Language Evaluation

Audiologic Evaluation for CI

Determined by an array of exams
Steady state evoked potential
More test on children to see if they have residual hearing

Imaging for a CI

Is the cochlea an abnormal shape
Is a cochlea present
Is an auditory nerve present
Surgical anatomy anomalies

Cochlear Implant Surgery

General Anesthesia
2-4 hours in length
Typically overnight stay for observations

Risks of CI Surgery

Loss of residual hearing in implanted ear
Risk associated with every surgery

Device Stimulation

Initial fitting 1 month after surgery
Follow ups 2 weeks after and 1 month after
Additional follow ups in 3 month intervals for first year
Then annual visits
Starts sound signal soft to not scare the patient
Audiologist slowly increases the sound volume

Auditory Stimulation by CI

Perception of sound through CI differs from acoustic hearing
People report a tactile sensation rather than hearing initially
People need time to adjust to CI

Programming CI

AKA Mapping
Requires frequent adjustments "tune-ups"
Many things affect a persons success with a CI
Need to readjust after every appointment to CI

Types of CI Users

Unilateral CI and Deaf
Bilateral CI
Unilateral CI and HI (Bimodal)
Unilateral CI and Normal Hearing (SSD)
Hybrid CI

Unilateral CI

Patient is deaf in both ears
CI attached to one cochlea

Bilateral Sequential CI

Two different surgeries to get two CI's
Helps with localization of sound
Insurance may not cover the second CI


CI in one ear
HA in the other ear, residual hearing is in this ear
Helps with localization of sound
Some people may stop wearing their HA

Single Sided Deafness

CI in one ear
Normal hearing in the other

Bilateral Simultaneous CI

Two CI's implanted in 1 surgery
Patient has two "working" cochleas now
Helps with localization of sound
Insurance may not cover second CI

Adult Simultaneous Implantation

Each ear needs to meet CI candidacy individually
Does insurance cover this surgery?

Adult Sequential Implantation

Meet criteria for CI
Patient has obsolete internal device
Patient wants benefits of bilateral hearing

Why have 2 CI's

Insures that "the best" ear will be implanted
Increases access to sound
Helps with sound localization and speech understanding

Benefits of Binaural Hearing

Quality of sound
Speech in noise
Directional Hearing
Natural Hearing Experience
Ease of listening
Still have functioning ear if one device breaks down
Helps avoid auditory deprivation

Disadvantage of Two CI's

Two devices
Might have poor fusion of auditory signal

Bilateral CI vs Unilateral CI

Greater benefit from two CI
Duel implantation is more expensive though
Insurance doesn't reimburse equally for second CI

Advantages of Bimodal Hearing (CI+HA)

Auditory stimulation might prevent deterioration of auditory pathways on non implanted ear
Helps with localization
Increases SNR

Post-Lingual Bimodal Adults

Have better balance and localization when using both CI and HA
Some stop using HA and cite interference

Prelingually deaf Bimodal CHildren

Encourage HA use for maximum language exposure
Want to keep ear stimulated for future technology

Factors with Bimodal Hearing

Don't assume their HA fits
May need to remove HA to acclimate CI
Fit independently

Conclusion of Modal Hearing

Speech perception performance in quiet and noisey is similar with CI and CI
Localizaiton is better with CI-CI

Osseointegrated Implants

Bone Anchored Hearing AId
Called this for insurance reasons

Problems with BAHAs

Doesn't restore binaural hearing
Provide no improvement in sound localization
Modest improvement in SNR
CI is only method to restore auditory perception to deafened ear

Conclusion of SSD

Hard to localize sound
CROS and OI do little to restore binaural auditory processing

Contralateral Routing of Offside Signal

HA that transmits sound from bad ear to good ear

Types of Hybrid CI

S12=10 mm
L24=24 mm

Hybrid CI

Shorter electrode array
Stimulates only basal end of cochlea
Preserves residual hearing of low frequencies
FDA clinical trials
Profound HL > 1500 Hz

Sound Delivered in Hybrid CI

Electronic Hearing for High frequencies by CI
Acoustic hearing with amplification for low frequencies

Benefits of Acoustic and Electric Hearing

Improved Speech perception abilities
Better frequency selectivity
Helps with background noise
Helps with music
Helps with sound localizaiton

Four Factors of Speech Reading

Speech reader

Where should Talker be Located for a Speechreader

Face-to-Face or 45 degree angle
to the speakers right is prefered

How to Talk to a Person Needing SPeechreading

Slightly slower speech
exaggerated lip movement

Speech Feature Conveyed Best via Speech Reading

Place of Articulation

Percentage of Speech that is Distinguished Visually

50% of Words

Optimal Distance Between Speaker and LIpreader

5 feet

Importance of No Ceiling Effect for Tests

If client gets 100% you don't know what they have difficulty with

Therapy that Emphasizes Speechreading

Auditory Oral

Audiovisual Integration

Process of using hearing and eyes to understand speech
AV scores are better than A and V alone
Do not add A and V to get AV

What is the Limitation Bergeson Described

Ceiling Effects

Bergeson said these kids best

Oral Communication
Audiovisual Testing

Condition that Improved Slowest Over Time in Bergeson Study

Visual Only

Older Implanted Children did better on Common Phrase than younger, in Bergerson Explain Discrepancy

Earlier implanted children do better on outcome measures
Kids were 3 years older than early implanted children at the time of testing
had small sample group of early implanted group

Kricos wanted Clients to do this

Take their time accepting their childs HL

Parents often Find that They change this with their HL Child

Change their own verbal behavior

How you know a Parent Trusts You

If the patient follows their recommendation

The Average Time an Adult with a HL waits before seeing Help

7 years

Skills Kids with HL Struggle With

Maintaining Positive relationships
Self Control
Knowing the Feelings of Others

Adults who are deafened face these challenges

No ties to Deaf Community
Limited Communication Skills
Can't Speech Read

Need this for True Membership in the Deaf Community

To be Deaf

Most Psychologic Problems Result From

More related with communication problems rather than the HL

Questionnaires Evaluate

Activity Limitations posed by HL
Participation restrictions posed by HL
Efficacy of AR Groups

Preminger and Yoo Lacked this Making Them Unable to Conclude their Data

Control Group

Seeing how Others Cope with HL may help others

Cope with their HL in an AR Therapy

In Preminger and Yoo's Study this Group had the Best Quality of Life

Communication Stratagies and Psychosocial training Group

Three CI COmpanies

Advanced Bionics
Cochlear Corp

CI's and MRIs

Need to remove internal magnet before MRI because MRI would disrupt internal magnet placement

Members of a CI Team

Social Worker
teacher of Deaf/ Hard of hearing

CI Criteria for Adults of Aided Speech Perception

50% or less in implanted ear
60% or better in unimplanted ear

CI Criteria for Children 2-18 for Aided Speech

30% or Less W0rd Recognition Measures

Absence of VIIIth Nerve

Medical Contradiction to getting a CI
Need this to send audio signal to the brain

How long a CI procedure takes

2-4 hours


Techniques that allow Audiologist to test integrity of Internal Device

Three Reasons Speech Perception Scores have Improved for CI Recipiants

Advancement in internal/external Components
Speech Coding Strategies
More liberal criteria for who can get a CI

CI Candidacy

Varies on CI manufacturers and Health Insurance

According to Gifford what Questionnaire is most used for Assessing Auditory Skills Birth-3


Why Shouldn't we use 70 dB for Presentation Level for Implant Candidacy

Not representative for Real World listening Situation
May inflate Scores
Exclude people who would benefit from CI

Hybrid CI Candidates

Good hearing at low frequencies
Poor hearing at high frequencies

Adults with high frequency hearing Loss

California Consonant Test is sensitive to speech perception problems for this population

Why the Minimal Auditory Capabilities (MAC) Battery was developed

Evaluated the performance n individuals with profound HL


Most common in High Frequencies
With a SNHL
Progresses gradually


Increasing gain of hearing aid is useful strategy for dealing with phonemic regression because the damage involves peripheral auditory patways

Most effective way to use research to demonstrate that aural rehabilitation program works

Randomized Controlled Trial

Aging adults may experience greater speech perception difficulties than

what would be expected based on their audiometric thresholds

Monosyllabic word lists

Good for children
Bad for Adults it doesn't test thier everyday listening

Benefits of self-report questionnairs in AR

Easy to administer

When conducting consonant recognition training, when whould the AR therapist provide feedback?

Immediately after the client's response

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