More Than the Audiogram

Author: Jennifer Henderson Sabes, Au.D.

Making better recommendations and more satisfied patients by integrating subjective and objective testing with efficiency
While there are literally hours of tests and testing materials available to allow the clinician to assess, diagnose and inform clinical decisions and treatment, it is usually the case that during a hearing evaluation it is the standard comprehensive audiogram with pure tone testing and speech audiometry in quiet that are assessed. This information is important in the diagnostic process, both to monitor changes in hearing and performance, and to make counseling and rehabilitation decisions. However, these tests cannot be expected to give the clinician any predictive information regarding rehabilitative outcomes (e.g. hearing aid benefit or use) (See Taylor, 2008) and they cannot provide information about the real-world subjective experience. Tests such as sentence level speech in noise tests and tests of tolerance (Acceptable Noise Level test, Nabalek et al, 2006) and perceived performance (Performance Perceptual Test, Saunders and Ceinkowski, 2002) are likely to provide more predictive and useful information for the rehabilitative process. With the exception of the QuickSIN, these tests are not widely used clinically. Mueller (2010) reported a survey in which 33% of clinicians used the QuickSIN at least occasionally, less than than 5% reported ever using the PPT or ANL.

The use of additional tests may influence the rehabilitative outcomes of the patient. Recent Marketrak data suggests that hearing aid users who report high satisfaction were more likely to have had additional assessments (Kochkin et al, 2010). Certainly, the clinician can’t include every possible test. With the abundance of tests available, are there assessments and procedures that may be included into the busy clinical practice to provide additional information efficiently?

Objective and Subjective Pre-Tests to Go Beyond the Audiogram
A recent pilot study that was part of the development of a subjective measure (Communication Confidence Test, Sweetow and Henderson Sabes, 2010) aimed to determine what kinds of tests could be included in a standard audiometric appointment in a busy clinic and whether the results of these assessments provided additional useful information for diagnosis or rehabilitation (Sweetow and Sabes, 2010). In this evaluation, a group of outcome measures and assessments were outlined and a brief in-service was provided to insure that the clinicians were confident in administration. The goal of the study was to complete a minimum of two objective and two subjective measures above and beyond the standard test battery. In this case, the standard assessment included pure tone audiometry, immittance measures, speech reception threshold and word recognition scores in quiet. If possible, the clinician noted the additional time that the measures added to the appointment. The clinicians were also asked to note if the additional data from the test measures impacted the therapy plan.

The tests and outcome measures included both subjective and objective measures. The Communication Confidence Profile (CCP, Sweetow and Sabes, 2010) was being validated and was assessed with every patient. All measures that were described and available for use are outlined in Figure 1. Subjective measures included the HHIE (Ventry and Weinstein, 1982), HHIE-S (Weinstein, 1986) or HHIA (Newman et al, 1991), the COSI (Dillon et al, 1997), the SAC (and when appropriate the SOAC, Schow and Nerbonne, 2007), and the SSQ and SSQ-handicap scale (Gatehouse and Noble 2004).

Figure 1. Tests available to clinicians for use in study (Sweetow and Sabes, 2010)
TEST Purpose (Pre-test) Time of Test Availability
Hearing Handicap Inventory-screening Measure handicap due to lifestyle and emotional effects of hearing loss 5 minutes of patient’s time. 1 minute for interpretation
SAC / SOAC Self Assessment of Communication and the Significant Other Assessment of Communication Measure effect of hearing loss and hearing aid outcomes 5 minutes of patient’s time. 1 minute for interpretation
COSI Communication needs and expectations 5-10 minutes of patient’s time
SSQ and SSQ-h Speech Spatial and Qualities of hearing scale Assess speech understanding, spatial hearing, sound quality and handicap 5-10 minutes of patient’s time, 3-5 minutes for interpretation
QuickSIN Speech understanding in modulated noise. Background babble with female speaker. About 5 minutes with interpretation Etymotic, Auditec and Included in LACE training
ANL Acceptable Noise Level Test Measures patient’s willingness to accept background noise when listening to speech Takes about 5-10 minutes with interpretation Frye
HINT Hearing in Noise Test Assesses speech understanding in noise. Utilizes a male speaker and unmodulated noise. Takes 5 minutes CD No longer available commercially
HINT Pro Hardware and software available from Natus
PPT Performance Perceptual Test Assesses the objective and subjective ability to understand speech in noise, permitting a direct comparison between measured and perceived ability to understand speech. Takes 5-10 minutes for perceptual and performance tests Requires HINT test: CD No longer available commercially
HINT Pro Hardware and software available from Natus

Objective measures included the QuickSIN (Killion et al, 2004) and the Acceptable Noise Level Test (ANL). One measure includes both objective assessment and subjective reports: the Perceptual Performance Test (PPT; Sauders and Ceinkowski) which includes both a conventional assessment of speech in noise testing using the HINT test (Nillson et al, 1994) as well as the patient’s subjective assessment of their performance on the same test.

At the conclusion of the pilot study, the data from over 300 patients were assessed. Over 80% of the assessments included subjective tests beyond the CCP. The HHIE/A screening assessment was the measure most frequently used and the COSI was commonly used with patients beginning the amplification process. The SAC, SOAC or SSQ scales were used in less than 10% of patients. QuickSIN was included in testing with 60% of the patients and less than 10% of the appointments included other objective tests, such as the ANL or the PPT.

Reports from the clinicians indicated that the widespread use of the subjective measures was due, at least in part, to the fact that these measures could be provided to the patient before or after the appointment, and required only interpretation time by the clinician. The QuickSIN was the most widely used objective test. Reports from clinicians indicated that was due to familiarity and confidence in the test, face validity, as well as time necessary to complete the test. The additional test time was not available from every appointment, but the sub-set of data indicated that the average additional time added to the appointment time was 6 minutes. The average time of the individual tests varied from one minute or less for interpretation of the screening version of the HHIE/A, to 7 minutes for the PPT.

This additional time can make a quantifiable difference in clinic flow over the course of a busy day in the clinic. The question remained whether any additional information was gained with the additional time investment. The history and outcomes of all of the 300 patients were not reviewed, but anecdotal case studies were observed and documented. The most commonly reported modifications to the diagnostic and rehabilitation plan were: modifications to counseling in order to include additional results (e.g. confidence, cognitive issues), recommending different level of technology or assistive devices, recommending further testing, or changing wearing plan. The results of this study reflected Meuller’s report: clinicians are more likely to use the QuickSIN than other test measures. Even with limited tests, however, clinical decisions changed in many cases due to the inclusion of measures that took five minutes or less to administer and interpret.

In a separate study assessing auditory function in older adults, multiple subjective and objective measures were obsessed in a group of 46 subjects (Henderson Sabes, et al, 2011). The subjects were adults age 63 and older who did not wear hearing aids. Twelve subjects had normal hearing. The measures used with each of the subjects were HHIE, CCT, pure tone thresholds, QuickSIN (binaural and for each ear independently), HINT and PPT. The results of these tests were analyzed for correlations. Most tests were correlated with one another, to differing degrees. However, one test was not correlated with the others, and, thus, could not be predicted based on the other test results. That test was the PPT, which measures the difference between the actual performance on the HINT test and the subject’s perception of their performance on the test. This test added information that was not apparent in the other tests, or predictive based on the results of those tests. The tests and the associated correlations are shown in Figure 2. The binaural QuickSIN results were correlated High Frequency PTA results, as was the case in the previous study. In this study, the QuickSIN, when presented to the poorer hearing ear, also correlated with the subjective measures (HHIE and CCP). Additionally, similar to the previous study, there were many subjects for whom the speech in noise performance was not predicted by the pure tone results or subjective measures.

In a similar study reported by Mueller, Johnson and Weber (2010) many of the same measures were used. In this study, the authors looked at the results on the QuickSIN, the ANL and the PPT and aimed to determine what information could be obtained from these additional tests. This study recruited subjects who were successful bilateral hearing aid wearers with symmetric sensorineural hearing loss. The authors found less correlation across tests than the study described above, however some trends were similar. The PPT was not correlated with the other tests. The ANL, QuickSIN and PPT were not significantly correlated in this study, leading the authors to suggest that each of those tests provide unique information to the rehabilitation process. Although these tests would add time to the hearing assessment, the authors suggest the possibility of modifying the testing procedure to use the QuickSIN as the PPT or ANL test materials for greater efficiency.

Figure 2. Tests used in Sabes et al, 2011. Correlation matrix: Asterisks indicate p<0.0001 and shaded cells indicate r>.65.)

Taken together, these studies indicate that there is novel information obtained with additional testing. However, there may be more benefit for using these tests in particular groups, such as patients with greater degrees of hearing loss or older patients. For example, results from objective testing in the first two studies both showed the strongest correlation between the poorer ear’s high frequency pure tone average and the QuickSIN. The data from these studies were pooled and analyses indicate that QuickSIN testing is likely to provide additional information in the case greater hearing loss and older age. Figure 3 shows the pooled data. Notice that there were no individuals with a poorer ear HF PTA < 30 dB and under the age of 65 who scored greater than 3 dB SNR loss on the QuickSIN (<3 dB SNR Loss = normal to near normal). In a busy clinic, evidence-based criteria may be implemented to most efficiently utilize additional test procedures, in this case using the QuickSIN in patients over 65 with mild or greater high-frequency hearing loss.

Figure 3. Poorer ear HF PTA as a function of QuickSIN score (pooled from Sabes et al, 2011 and Sweetow and Sabes 2010). Note that no subjects under the age of 65 with a HF PTA of <30 dB exceeded a score of 3 dB SNR on the QuickSIN.

Information from these tests may also be integrated for efficient use in the clinic. Taylor and Bernstein introduced a tool that utilizes the information from the QuickSIN and the ANL to give a “Red Flag” indicator for hearing aid users at risk for difficulties with speech understanding in noise or annoyance with sounds. Poor scores on the ANL can indicate annoyance with moderate or loud sounds, and the results correlate with non-use of amplification. Poor scores on the QuickSIN can indicate the need for directional microphones or assistive listening devices. The Red Flag Matrix combines the scores from these tests into a single matrix. The score of the QuickSIN is plotted along the x-axis and the ANL on the y-axis. Four quadrants are as shown in Figure 4 (redrawn from Taylor and Bernstein, 2011) This index allows for a quick and easy interpretation of two of the measures that add information to the decision making process for hearing aids and rehabilitative process. The matrix may also ease patient counseling by allowing the clinician to visually represent the performance of these two different tests to the patient, with a single point in a matrix that provides comparative information about performance relative to normative data.

Figure 4. Redrawn from Taylor and Bernstein (2012)

Using Technology to Go Beyond the Audiogram
Results from many studies support the use of subjective measures, particularly for use in hearing aid fitting outcomes (See Cox., 2003). Subjective measures span many different domains and are easily and efficiently incorporated into the clinical procedure. Technology allows for many subjective measures to be completed, analyzed and saved electronically for even greater efficiency. Some measures may be completed on tablet computers which allow for greater flexibility in the clinic environment. There is a recent increase in clinic management software that allows for subjective assessments and counseling material to be provided through tablets or computers (e.g. CounselEAR,

Tablets allow for other benefits to counseling: more and more apps are being developed to assist in informational counseling, many hearing aid manufacturers have developed applications for counseling or aiding the amplification process. Tablets also allow for a convenient way to demonstrate the effects of hearing loss and amplification, and perhaps increase hearing aid use. Kochkin et al (2010) reported that simulation of amplification reduced returns by 50%. Amplifier apps are available to quickly provide appropriate frequency specific amplification and optional noise reduction (e.g. SoundAMP, BioAid, HearBot) – an efficient alternative to demonstrating hearing aids. Apps can also incorporate communication partners. Hearing loss simulator apps and demos are available (e.g. Starkey and Better Hearing Institute) to allow for significant others to experience hearing loss.

The audiogram and speech audiometry results are integral to diagnoses and treatment of hearing loss. They are not, however, predictive of real-world difficulties or hearing aid outcomes. These basic tests may not provide information about subjective domains or aspects of performance that could change counseling or treatment course. There is no shortage of measures that provide additional clinical data, but incorporating tests means adding time, so decisions about additional tests should be based on evidence and efficiency. The incorporation of speech in noise testing particularly with perceptual assessments and acceptable noise measurements provides novel and predictive clinical information with limited additional time. Subjective measures are a widely utilized method to incorporate additional clinical data and influence outcomes. Technology, like tablets and laptops, can allow the clinician to efficiently use a wide range of outcome measures.    
Jennifer Henderson Sabes, Au.D. is Senior Research and Clinical Audiologist at the University of California, San Francisco. She may be contacted at

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