Connecting the dots in audiometry: The ‘audiometer à la carte’

Diagnosis Technology

Interacoustics assesment with Eclipse
Objective threshold assessment with Interacoustics Eclipse.

Audiometry is changing at a fast pace. What are the main developments of the past decade and what is still to come? Audiology Worldnews interviewed a professor and several audiologists and manufacturers of audiometrical equipment. They express their views on the past, present and future of audiometry.

Professor Sophia Kramer, VU UMC: “Implement PROMs”

Pure-tone audiometry is a cornerstone method in audiology to identify an individual’s hearing threshold levels at different frequencies and to determine the degree, type and confi guration of the hearing loss. “With the resulting audiogram, pure-tone audiometry is a magnifi cent tool and indispensable in audiological practice”, professor of Auditory Functioning and Participation Sophia Kramer of the VU University Medical Center Amsterdam confirms. “However, whether pure puretone audiometry suffices as a single tool to assess an individual’s hearing difficulties as experienced in daily life is highly questionable. From research we know that the audiogram is a poor predictor of daily hearing difficulties. People with a relatively good audiogram may experience big hearing problems in daily life, whereas those with moderate to severe levels of hearing impairment according to the audiogram may experience relatively small limitations in hearing. It all depends on the context in which an individual is functioning. For example, what are the auditory demands an individual is exposed to?

In order to get an impression of how the hearing loss is perceived by an individual, the use of a questionnaire or a patient-reported outcome measures (PROM) is an adequate option. There is ample evidence showing that self-reported hearing disability is a signifi cant predictor of hearing aid use and hearing aid satisfaction. It is therefore worthwhile to consider implementing PROMs in routine audiological practice.”

There is an additional reason why the use a PROM in audiological practice is warranted: it is now widely known that in order to process degraded speech, a listener needs to exploit cognitive resources to understand the message. Someone’s cognitive abilities therefore affect someone’s ability to understand speech. The pure-tone audiogram reveals the state of a person’s peripheral hearing, but does not take the cognitive aspects of hearing into account. A PROM does because an individual’s cognitive skills are automatically incorporated in the self-reported hearing status.”

A suggestion

The challenge is now, Kramer states, to act upon this conclusion in the audiology practice worldwide. “In the Netherlands the combined use of a pure-tone audiogram and a questionnaire has become standard practice since the introduction of the new protocol for the provision of hearing aids. Personally, I welcome this development. Given the available scientific evidence, I have always recommended including a validated and reliable questionnaire in this protocol. It will definitely benefit the hearing aid user in the end.” Kramer sees opportunities for the audiometer manufacturers: “Why not aim innovation towards incorporating relevant questions or a questionnaire into the equipment, so that kind of a combined score (pure-tone audiometry and self-report) becomes available to assist in the diagnosis of hearing disability? It is a way to make sure a more complete measurement of someone’s hearing status is made and to help the dispenser or audiologist to decide on the appropriate rehabilitation service for the person with the hearing loss.”

Carsten Kind, Interacoustics: “Innovation in ABR”

Carsten Kind is President of Interacoustics in Middelfart, Denmark. Interacoustics developed its first audiometer in 1969. “In the 70’s, our products were always hardwarebased and primarily focused on audiometry. Today, we are a full-line supplier, with products ranging from compact handhelds to sophisticated desktop or PC-based solutions across the fields of balance, audiometry, tympanometry, hearing aid fitting as well as ABR and OAE”, he says. Interacoustics has always aimed at being at the front edge of new technological supplies. “This is why, in addition to our traditional R&D department, we have our own Interacoustics Research Unit at the Technical University of Denmark, Lyngby, Copenhagen. This team of four researchers work in close cooperation with many international academic groups, all involved in Interacoustics’ research projects. Their function is to ensure that relevant new science is developed into applicable functions that can be introduced in our products.”

Threshold assessment

In addition to providing tools for subjective audiometry, Interacoustics also focuses on gaining estimated audiograms through objective ABR measurements. Kind: “By placing electrodes on the scalp, we can extract and record auditory evoked potential from ongoing electrical activity in the brain and thereby obtain an objective audiogram.” Brainstem audiometry is incredibly informative, especially in cases when a patient cannot cooperate with the doctors. It is also an area that is subject to constant innovation, Kind says: “In recent years, we have focused on the development of fast and reliable instruments that are sensitive enough to diagnose children or infants with hearing loss. And we’re still improving technology at high speed. We’re for instance integrating new technology into our Eclipse platform all the time. The technology teaches us a lot about the brain. It helps us define the type of hearing loss and the best treatment possibilities.” New research has also resulted in reduced test time. “A few years ago, a test would take an hour. Today, 10 minutes are sufficient.”

Another crucial development in audiometry has been the shift to software-based solutions. “We move towards software databases and e-health supporting solutions”, Kind says. “This has many advantages. Provided that the patient receives the assistance of a qualified technician, a person living in – for instance – Greenland, can be diagnosed by an ENT doctor in Copenhagen. We are in fact already doing this; we can do a full test of the hearing.”

Mario Cambiaghi, Resonance: “Counseling and Verbal Task Motion Response Test”

Mario Cambiaghi is Sales and Operations Director of Resonance Medical Devices, an Italian-based company offering turnkey solutions for hearing assessment. “We provide innovative, effective and quality solutions for audiology”, Cambiaghi explains. Resonance manufactures a full range of audiometers, middle-ear analyzers and combined systems for clinical, diagnostic and screening purposes. He sees an important trend with both the patient and the doctor; the quest for high quality counseling. “The doctor wants to inform his patient in the best possible manner about his hearing loss. He wants to present test results to the patients in a way that is comprehensible for and useful to the patient. At the same time, the patient is eager to understand his hearing loss. Therefore, the counseling side of the audiometer has become more important. It’s not only about collecting results, it’s also about explaining the hearing loss to the patient.”

Resonance MDS software
Resonance MDS software guarantees an easy audiometric data transfer, analysis and presentation to patients.

Verbal task motion response

Cambiaghi underlines Sophia Kramer’s statement that conditions of use are very relevant for the prescription of a hearing aid. “Audiometry must try to recreate real life conditions in order to be able to check the real hearing capacity of a patient and come to the best diagnosis. Speech-in-noise tests are crucial. At Resonance we are currently investigating a new test, together with the Greater Polyclinic Hospital of Milan. It’s a Verbal Task Motion Response test, which means that we do speech-in-noise tests that incorporate a task. The subsequent patient’s actions inform us about the level of his hearing loss and his brain activity. We not only know whether the brain understands the assignments, but also what part of the brain is active.

Speed up the workflow

Developments in audiometry are going at a high speed, Cambiaghi says. “We’re introducing new features every few years. One of the aims is to speed up the workflow: doctors are required to see more patients per day. Also, doctors want to be able to share information very quickly for consulting purposes. Software enables us to quickly integrate new functionalities in existing devices. Resonance is a relatively small company, but it’s well equipped for the fast development and introduction of upgrades.” At AudiologyNOW!, Resonance was showing its entire line of screening devices, its VRAsystem for children’s tests and the telemedicine functionality of its portable audiometer.

Riccardo Rizzoli, Inventis: “Software, new tests and design”

Riccardo Rizzoli is the International Sales Manager of Inventis, the Padova-based Italian manufacturer of audiometers, tympanometers, fitting equipment and software suites. Inventis is active in 60 countries worldwide. “We’re a high-tech-oriented company developing and manufacturing cutting-edge medical devices for audiology”, he says. “We are guided by four main principles: innovation, design, ergonomics and computer centricity.” Inventis was the first company to introduce an iPad-controlled audiometer, the Piccolo. Through an app, available on the Apple App Store, one can control Piccolo using one’s iPad connected to the audiometer via Bluetooth. “Computers and tablets are incredible sources of computational power”, Rizzoli says. “Stable, easy-to-use software is crucial today.”

REM system Trumpet by Inventis
REM system Trumpet and Maestro easy-to-use software by Inventis.

New tests and design

Inventis is working on a new comprehensive software called Maestro, which has been redesigned for being the unique software interface for all Inventis products, upto- date with the latest clinic demands. Together with the implementation of the TEN test and QuickSIN exams, Maestro is part of a process aimed to bring the daily practice to a new level of technology.

Easy-to-use software can be the key of the success also of other instruments, like the Real Ear Measurement system. Rizzoli: “Inventis has recently released a new REM system, Trumpet. It shows clinicians how simple it can be to run a hearing aid fitting verification if intuitive software guides you through it.”

Rizzoli also underlines the importance of design. “A well designed device can improve the user and patient experience. And when I say ‘well designed’, I mean both the ergonomics and the esthetics of the device. An audiometer can be a thing of beauty too, seducing the patient to cooperate. Good ergonomics help improve the user efficiency and reduce the risk of error.”

Clément Sanchez, audiologist, Otometrics: “À la carte audiometry”

Clément Sanchez is both product manager of Otometrics and audiologist. “Since a couple of years, the trend is to make audiometers more softwarebased. This makes audiometry much more flexible, since it becomes a lot easier to introduce new applications. You just have to have the software online available and connect it to an iPhone or a tablet.” The shift Objective threshold assessment with Interacoustics Eclipse. towards software-based audiometry has also a commercial angle to it; a client does not need to buy all applications, he can just buy the applications that are relevant to his patients. “We’re heading for à la carte audiometers”, Sanchez says. “We’re dematerializing the audiometer and introducing the app.”

Counseling, tinnitus and lip reading

Sanchez agrees with Mario Cambiaghi that software changes the way audiologists and ENT doctors work. “The audiometer is more than a test, it has become a tool for counseling and education of the patient. We can, for instance, make the patient’s wife or child experience the hearing loss of the patient. This helps them understand the situation. We can also simulate the amplification of the hearing aid and thus counsel the patient.”

Otometrics OTOsuite
This is a sample of a tele-audiology cart with Otometrics equipment integrated with the OTOsuite software. This is a practical example of how software integration enables clinicians to help patients in remote areas.

Otometrics has recently introduced a new test, making it possible to measure the maskability of tinnitus. “In the past, we had to work with questionnaires, but with a new test we can do deeper and more precise diagnostics. The questionnaires gave a more subjective outcome, the test enables a more objective outcome. It helps professionals to see if the tinnitus can be masked.”

Another trend is the development of tests that create more realistic environments. “We already have speechin- noise tests, but we are working on even more real life solutions. For that, we need different libraries of sound and the way to root a sound. You need several speakers in a test area, with the voice of your wife coming from the left and music in your back. We’re working at optimizing this test.”

Also, Otometrics is working on lip-reading tests. “With the help of a hearing aid, we can improve a person’s hearing from let’s say 20% to 50%. Lip reading can add an extra 20% to that. We know this to be true, but it’s difficult to convince the patient. With a good test, we could show him the difference.”

Online diagnostics for medical deserts

Sanchez agrees with Carsten Kind that it becomes so much easier to provide online diagnostics. “In countries where distances are huge, technology enables audiometry and hearing aid fitting at a distance. The doctor is in a clinic, a technician or a nurse in a satellite location. It is an ideal solution for what is being called ‘the medical desert’, those areas where there is no doctor available within an hour’s drive. And it’s exactly there where the aging persons live.” With the depopulation of rural areas, it’s a growing problem. “Countries need to come up with a solution. Either they have to resort to telemedicine solutions, or they have to increase the population of doctors dramatically. This not only costs a lot of money, but it also takes years.”

Brent Nissly, Grason-Stadler: “Telemedicine and self-testing”

Brent Nissly, General Manager/COO of Grason-Stadler in Minneapolis, USA, is committed to delivering reliable innovations for audiologists and hearing care professionals to address the growing demand for hearing care services. The company is introducing a solution developed by Audiology Inc. for the Veterans Affairs Hospitals in the USA called the GSI-AMTAS, Nissly says: “GSI-AMTAS is a self-administered assessment tool that provides an automated method for obtaining an audiogram. The test includes air and bone conduction thresholds with masking as well as speech audiometry. The AMTAS software is loaded onto a touch screen computer, our audiometer is attached to provide calibrated tones, the headphones and bone conduction are applied, and the test commences.” The fact that the test is self-administered allows the audiologist to consult with or test other patients at the same time. Test results can be stored in GSI Suite, forwarded to Noah or emailed to a remote location for telehealth evaluation. Telehealth is important, Nissly says: “In less developed countries there is a growing need for audiologists and hearing care professionals. The world population is increasing and living longer, yet many countries still do not have formal audiology programs and too few hearing care professionals to meet this demand. We as an industry need to make sure we are developing products that are easy to use and to maintain for the healthcare professional. Automated clinical testing such as AMTAS will assist the healthcare professional in these countries, increase their level of clinical accuracy and meet the goal that we all share, increased patient care.” Nissly agrees with his colleagues that software-based audiometry is becoming more and more important to the professional. “We for instance have just launched the Pello™, an adaptable mid-level audiometer. It has four configuration options, allowing each practice to mix and match features based on clinic and patient needs. The Pello can be purchased in one form and later upgraded to change or add features.”

Wendy Switalski, audiologist: “Software integration increases connectivity—in more ways than one”

Wendy Switalski, audiologist and Audiology Development Manager of Otometrics/Audiology Systems in Illinois, USA, is very enthusiastic about the development of the audiometer in recent years. Mrs. Switalski works closely with Clément Sanchez and she agrees with him on the benefits of PC-based audiometry. “Audiometers that are integrated with other test equipment help hearing care professionals and audiologists save time, and allow for more time to be spent in patient counseling or to see more patients. We have seen a huge efficiency gain by the integration of the audiometer into the PC. For example, our MADSEN® Astera2 audiometer, combined with other equipment within the OTOsuite® Universe, enables to clinicians to support the full patient journey from the diagnostic phase into hearing instrument fitting and verification.”

New solutions have minimized the possibilities for error. The quality of speech testing has been raised. “Developing new software enables ongoing enhancements. We can build specific modules, like the tinnitus testing modality and new functions for pediatric patients.”

Care at a distance

Wendy Switalski also agrees with Clément Sanchez that today’s technology enables hearing care at a distance. “The PC-integrated platform allows for more patients to be served by providing a method to make audiology telepractice and mobile clinics a reality. It enables clinicians to expand their reach. All you need is a connection between two computers and you can offer high care services to remote areas.” Switalski explains the growing need for telemedicine from the fact that technology allows for it. “There always was a need, but now we have the opportunity. It gives people timely access to hearing care, so more people will use it. And it is welcomed by governmental agencies, since it offers the possibility to minimize the costs of hearing care.” Potentially, telemedicine is possible for all levels of hearing care, she says, provided the right assistance is available. For some pediatric care, for instance, a higher level of skills may be required.

So, what will the future bring? Mrs. Switalski has no doubt that the use of PC and tablet will continue and that remote hearing care will become more common. “Also, we will see the further increase of connectivity: we will be connecting our data on hearing to other healthcare systems, in order to construct an overall health picture. We know, for instance, that diabetes, depression and different cancer treatments have an impact on the hearing. If we connect the dots, we will not only be gaining in efficiency, but also in quality of health care.”

Remco van der Kruit, International Sales Manager of MedRx, Largo, USA: “Smaller, easily updated and portable”

MedRx is manufacturer of PC-based audiometers, REM/LSM fitting systems and software solutions. Van der Kruit: “Over the years we have seen a decrease in the size of audiometers and a move to more software-based control. The move to software-controlled audiometry has allowed the audiometer itself to become smaller, easily updated online and more portable. Softwarecontrolled products are well suited for telemedicine purposes, offering great possibilities for growing practices, hospitals, Veteran Affairs offices and rural areas. A full testing solution, like for instance our MedRx AVANT ARC all-in-one AUD/REM solution, can be placed in a satellite clinic to provide full audiometric and REM testing for an audiologist.” Equipment is HID compatible, and therefore ‘plug and play’. “This eases the installation process of audiometers as the clinician or a technician does not need to install drivers or attach the devices to specific USB ports.” Also, all MedRx audiometers now include built in QuickSIN testing. Van der Kruit: “This provides a greater understanding of the patient’s ability to understand in difficult listening environments.” There are needs for new testing methods as an audiometer can be limiting for certain aspects of hearing like tinnitus assessment. Van der Kruit: “MedRx has implemented a new way to perform tinnitus assessment that is more accurate and very easy for the clinician to perform. The assessment has built-in reporting and general guidance on implementing the results into leading hearing aid manufacturers.” At AudiologyNOW! MedRx showcased the full range of MedRx audiometers, Real Ear Measurement systems, video otoscopes, tympanometers and the new MedRx tinnitus assessment tool. Van der Kruit: “We think it will change the way clinicians think about tinnitus assessment.”

New MedRx ARC device
New MedRx ARC device combines the power of audiometry and Real Ear Measurement into one system.

Photos: Inventis, Interacoustics, MedRx, Otometrics, Resonance.

Learn more on the history of audiometry here

The full article can also be read in the AWN AudiologyNOW! congress special and the AWN ME-OTO congress special.

Alinda Wolthuis and Leendert van der Ent