Hearing Technology Guidelines – Clinical Training Unit

Checklist

Hearing Aid Programming and Verification Checklist

Calibration: TESTS-CALIBRATE: coupler mic with coupler removed: position 1-2mm directly in front of reference mic, close test box. Real ear mic: place a probe tube on the mic and place end of tube over the ref mic; hold 5 inches in front of speaker; repeat for L/R mics. Select TEST-ON EAR-RECD: place RECD transducer in HA2 coupler and calibrate.
Using HA check kit, clean earmolds or domes, check tubing, check batteries, and do a visual inspection of hearing aids
Prepare Verifit: Select SPEECHMAP. Select instrument (BTE, RITE, FM), patient age, transducer used for measuring thresholds, and threshold values for AC, BC (for CHL, mixed).
RECD: measure the RECD for each ear using a pre-threaded foam tip, or use normative values if measurement is not possible.
Noah Detection

Find patient in Noah
Select fitting software previous settings by clicking on the last fitting session for the patient
Detect instruments using programming interface (iCube, NoahLink, etc) and manufacturer fitting software
Data logging: note and record the average hours of use

Noah Update

Enter the current audiogram in Noah audiogram
Select the audiogram to be used within fitting software and the transducer used to collect thresholds
Select earmold characteristics of current/new earmolds
Recalculate fitting in fitting software

HA programming/electroacoustic evaluation

Un-link R/L aids in fitting software
Turn off frequency lowering and set in omnidirectional mode
Unmute the hearing aid and place in appropriate position in test box attached to coupler
Adjust the gain of the hearing aid across frequency within the fitting software to achieve DSL targets within +/- 5 dB on the Verifit for the following stimuli: MPO, avg speech (65 dB), soft speech (55 dB), and loud speech (75 dB).
Frequency lowering settings: identify maximum audible frequency for avg speech. Check high-frequency filtered stimuli for audibility: 6400=/s/, 4/5200=/sh/
Program/switches:
- FM/Roger+M should be selected within the start-up program, unless the patient prefers to access in a separate program; deactivate EasyRoger
- Easy phone should always be deactivated
- Switches should be activated to access programs if being used OR deactivated.
- Volume control should be activated or deactivated, based on user needs.
- Audible beeps activated.
- Younger children should have visual lights activated
Special tests: evaluate the function of the directional mic program and noise reduction, as needed
Feedback manager: place the muted hearing aids and earmolds on the patient’s ears and run feedback manager on quiet child.

Verify the fitting on the ear, if possible, given tolerance of child
- Prepare the probe tube: adjust black ring to age-appropriate distance: infant/toddler=20-25 mm, 3-5yrs=25-30mm, >5 years=30mm
- Position the patient on the tall chair 18-36 inches from the Verifit speaker
- Position the probe tube in the ear canal so that the ring is at the intertragal notch, then carefully slide the earmold/dome into the ear while maintaining the position of the probe tube
- Hang the probe module on the patient’s ear with the mic opening facing out and attach the probe tube to module
- Verifit: select ON-EAR and SPEECHMAP. For an open fit, select OPEN and following equalizing instructions
- Measure avg/soft/lound stimuli in the on-ear mode and adjust the frequency response of the hearing aid to meet targets
Cross-check settings

Ensure frequency compression is activated before saving
Re-check programs and volume settings
Have your supervisor approve the programming before disconnecting HAs
Save changes to HAs and exit before disconnecting HAs

Print data: Print Verifit data in table form, single ear. Print manufacturer fitting report-short report from. Tape Verifit tables and datalog report to fitting report.

Hearing Aid Programming and Verification For patients with occluding earmolds and BTEs, obtain an RECD measurement on each ear of the child and then all verification measures will be completed in the test box. For patients who have RIC/open fittings or large vented earmolds initial adjustments will be made in the test box and then verified and fine-tuned on the ear.

Calibration of Verifit:
- TESTS-CALIBRATE: coupler mic with coupler removed: position 1-2mm directly in front of reference mic, close test box.
- Real ear mics: place a probe tube on the mic and place end of tube over the ref mic; hold 5 inches in front of speaker; repeat for L/R mics.
- RECD transducer: Select TEST-ON EAR-RECD: place RECD transducer in HA2 coupler and calibrate.
Clean earmolds/domes, check batteries, and do a visual inspection of hearing aids using the prepared HA check box:
- Supplies:

otoscope and tip, alcohol wipes, wax loop, blower, battery checker,
earmold impression supplies: knotted size-appropriate dams, silicone singles, ear light, syringe, splead pad and spatula, earmold box
Earmolds: clean the earmolds with the wax loop, blower, and alcohol pad
Tubing: Do a visual inspection of tubing for cracks and for secure attachment to earmolds; replace tubing if needed
Domes/wax guards: Clean the dome with the wax loop. Do a visual inspection of the dome and wax guard and replace, if needed.
Hearing aid:
Brush off mic ports and switches
Do a visual inspection of battery contacts and clean, if needed.
Inspect the earhook and its threading and replace, if needed.
Batteries: check batteries charge and replace, if needed
1. Prepare Verifit: Select SPEECHMAP and TESTBOX MEASURE. Select instrument type: BTE or RITE. Under AUDIOMETRY, TARGETS should be selected as DSL child. Enter the age of your patient, type of hearing instrument, transducer for collecting thresholds, and hearing thresholds. If you are entering ABR thresholds, choose ABReHL and enter appropriate thresholds. If you have bone conduction thresholds for a conductive or mixed hearing loss, choose BONE CONDUCTION and enter thresholds. If the child demonstrates no response at an equipment level, enter a value 5 dB above the maximum test level.
2. RECD measure:
  - Perform otoscopy prior to RECD measure to ensure that ear canal is not occluded
  - On the Verifit, select Measure under RECD. (If normative measures will be used, select use Avg)
  - Use a foam tip that has been pre-threaded; select appropriate transducer under RECD measure
  - Place probe tube in ear canal
  - attach the probe tube in the ear to the right or left real ear probe module
  - Make sure the child is quiet during the test and then select Measure on the Verifit.
  - The RECD measure across frequency will be displayed in aqua at the bottom of the screen. Note the relationship between the measured RECD values and the average values for this age (dotted line). If you do not have a valid measure, replace the probe tube and re-measure.
  - DSL targets will be adjusted by the Verifit to account for the child’s RECD values
  - Complete RECD measure on the other ear
  - Interpreting RECD measures:

overall negative RECD can be due to the probe tube being blocked by wax or up against the canal. Reposition tube and/or replace tube.
roll off in high frequencies may be due to inadequate insertion depth; insert foam tip deeper and/or extend probe tube deeper.
negative values in the low frequencies may be due to a leak. Add otoferm to the outside of the foam tip or earmold to decrease leaks.
Children with tubes (or TM perforations) will demonstrate extreme negative values in the low frequencies. Children with middle ear effusion will often show increased positive values in the low and mid-frequency region. Middle ear involvement typically requires the use of RECD norms.
1. Noah detection
  - Find patient in Noah (For new patient, enter name and date of birth, hospital#)
  - Select fitting software and settings from last visit by clicking on the last fitting session for the patient (For new patient, select the appropriate fitting software)
  - Detect hearing aids using programming device
  - Data logging: note and record the average hours of use on a post-it
2. Noah update
Ensure that DSL is selected as prescription in fitting software and that the age-appropriate default is selected
Enter current audiogram, by selecting Noah audiogram and entering new thresholds across the frequency range. If NR at equipment limits, enter as such.
Within manufacturer fitting software, select the audiogram to be used for the fitting and ensure that the correct transducer is selected
Select earmold characteristics of current/new earmolds or dome/open fit
Recalculate fitting in fitting software
1. HA programming/electroacoustic evaluation
  - un-link R/L aids in fitting software and then Program the Right and then Left hearing aid;
  - Unmute the hearing aid and place HA in test box for adjustments within the test circle, positioned with the reference mic close to the HA.
  - Ensure that frequency compression/SoundRecover is off and set in omnidirectional mode
  - Adjust the gain of the hearing aid across frequency within the fitting software to achieve DSL targets within +/- 5 dB on the Verifit for the following stimuli: MPO, avg speech (65 dB), soft speech (55 dB), and loud speech (75 dB).
  - For hearing aids that use frequency lowering (e.g., Phonak SoundRecover or Oticon SpeechRescue) the goal is to apply the minimum amount of lowering to ensure that high frequency stimuli are audible and distinguishable. The default in the fitting software is for fairly aggressive frequency compression, and we typically will be choosing less compression for patients. We use a frequency lowering setting that is based on the following measures:

Determine the maximum audible frequency, by noting the frequency at which the avg speech line crosses the child’s audiogram in the high frequencies.
Measure the audibility of /s/ by using the 6300 Hz avg speech stimulus with SoundRecover on and off, ensuring that frequency compression has improved audibility of /s/.
For cuttoff settings with aggressive compression, also measure the /sh/ stimulus (4500 avg speech) and determine that /s/ and /sh/ are distinguishable. Adjust the cutoff frequency and compression characteristics of SoundRecover as needed to achieve audibility with the minimum amount of compression
- Programs/Switches
Programs: determine that appropriate programs and settings are activated
FM/Roger+M should be selected either within the start-up program. Or, if patient prefers, FM/Roger can be one of the user programs.
De-activate easyphone in Phonak software
Program switch should activated to access programs if being used or deactivated
Audible beeps activated, unless the patient prefers these off
Volume control activated or deactivated, depending on patient need
Streaming device: if used, sync this device in the software, by attaching to a USB cable and detecting within the fitting software. Modify Streaming programs as needed, depending on the user preferences.
- Special tests: Directional mic technology: the goal is to determine if there is reduction in gain from the rear microphone.
select the DIRECTIONAL test under the TEST BOX MEASURES.
Positioned the hearing aid in the test box so that a line joining the microphone openings on the instrument is at 45 degrees (select HELP to see a set-up photo). Use the provided coupler clip to keep the instrument off the floor of the test chamber. Position the HIT reference microphone at the front microphone opening on the BTE. Note which speaker (L or R) is in “front” of the hearing instrument for reference.
Select button 1-50 dB: this test presents test signals from both speakers at 50 dB SPL. Two real-time curves appear on the screen – the heavier one is the response to the left speaker signal and the lighter one the response to the right speaker signal. For a non-directional instrument, the two curves will be nearly identical. Setting the instrument for directional operation should produce a separation of the curves.
For an adaptive directional instrument, the separation may change with time and stimulus SPL so you may need to vary the test signal level. For adaptive directional mic HAs, the directionality may take 15 to 45 sec to activate. For speech adaptive directional mic HAs, select the SPEECH S/N stimulus at a 6 dB SNR.
- Special tests: Digital noise reduction (DNR): the goal is to determine if DNR affects the gain and frequency response of the instrument. Measure the frequency response of the HA with noise reduction on and off using the average speech stimulus from one speaker and a broadband noise from the other speaker at different SNRs. Note that the hearing aid should be in an omnidirectional mode for the DNR test.
- Feedback manager: place the muted hearing aids and earmolds on the patient’s ears and run feedback manager while the child is quiet.

Verify the fitting on the ear. If possible given the age and tolerance of the child, verify the fitting on the ear with the custom earmold. This verification is crucial for children with an open/RITE fitting or with an earmold with significant venting.

Prepare the probe tube: Adjust the black ring on the probe tube to 30mm for school-age/teens
Verifit: select ON-EAR measure and SPEECHMAP. For a BTE fitting, select BTE as the device. For an OPEN fit, select OPEN as the device on Verifit. During your first measurement, you will be prompted by the Verifit to EQUALIZE. Mute the hearing aid within the fitting software. After equalization, un-mute the HA and continue with measurements.
Position the patient on the tall chair 18-36 inches from the Verifit speaker
Complete otoscopy to ensure that the ear canal is clear
Hang the probe module on the patient’s ear with the mic opening facing out
Position the probe tube in the ear canal so that the ring is at the intertragal notch, then carefully slide the ear piece into the ear while maintaining the position of the probe tube
attach the probe tube in the ear to the right or left real ear probe module
Ensure that frequency compression is off and HA is unmuted
Measure the speechmap stimuli in the on-ear mode and adjust the frequency response of the hearing aid to +/- 5 dB of targets within the fitting software as needed for avg speech (65 dB), soft speech (55 dB), and loud speech (75 dB). Do not run an MPO on-ear as the stimuli are too loud for most patients.

Cross-check settings

Ensure frequency lowering is activated, as needed, before ending fitting
Re-check programs and volume settings
Have your supervisor approve the programming before disconnecting HAs. It is crucial that your supervisor check over your fitting to ensure quality control!
Save changes to HAs and exit before disconnecting HAs

1. Print data: Print Verifit data in table form, single ear. Print manufacturer fitting report-short report from. Tape Verifit tables to fitting report.

CROS Hearing Aid Check:

Place a probe module on each ear and insert the probe tube into the good ear only. Position the CROS instruments on the ears and turn them ON.
Position the child’s good ear at 45 degrees to the Verifit speaker and set Verifit instrument to [BTE]. Select Test 1 and record a response using [Pink noise] at Soft (55).
Position child’s HL ear at 45 degrees to the Verifit speaker. Set Verifit instrument to [CROS]. (The probe mic remains in the good ear only). Select Test 2 and obtain a response using [Pink noise] at Soft (55). Adjust the frequency response of the HA to match that obtained in previous step.
Position the child at 0 degrees to the Verifit speaker. Select Test 3 and use [Pink noise] at Soft (55) to check for a smooth response. Repeat with Instrument set to either [BTE] or [CROS] as both should be the same, given equidistance from speaker.

FM System Check:

If the child uses a personal FM system, the system should be evaluated with both a listening check and an electroacoustic check.
Listening check: Listen to the HA/FM while someone is talking into the mic at some distance OR rub the mic cover of the FM mic.
Electroacoustic check: Switch the HA and receiver to FM only operation. Place the FM transmitting mic in the test box and position the HAT reference mic (white) as close as possible to the FM transmitter mic. Connect the HA to the HA2 coupler and place outside the test box. Close the test box. Change HA type to FM and choose FM CHEST for the mic during stimulus selection. Now, measure the gain and MPO of the system to match the achieved targets in the hearing aid only measurements.

Interpreting Hearing Aid Verification data

DSL target and measured values: The Verifit printout lists DSL target values and measured values across the frequency range for MPO, soft, average, and loud speech. You will include the values for soft and average speech in the patient report. Interpretation for reports should include if target values could be achieved +/- 5 dB across frequency. Due to the severity of hearing loss, target values for some high frequencies may not be possible.

Aided SII: Aided SII gives an estimate of the proportion of the speech signal that is audible to the child. The Verifit lists the calculated aided SII for each measurement (soft, avg, loud speech). Use the aided SII look-up table (on website) for the expected range of aided SII based on the child’s PTA at ..5, 1, and 2 kHz in each ear and put in the table in the patient report for Target SII for soft/avg speech; for patients with PTA > 90 dB, there are no norms.

Selection

Selection of new hearing aids:

When a child needs hearing aids, we will review all the appropriate options and then present the selected options to the family. You will first determine the features needed for the child and then compare these features across the selected instruments. You should consider the child’s current needs and needs for the next 5 years.

The “Audiologist Hearing Technology Options” document and “CHDD Hearing Technology Prices” attached documents have comparisons of technology that is appropriate for children and teens; use these tables as the basis for your comparisons.
Use the “Hearing Aid Choices for Parents” letter template for communicating with families about appropriate options. Note that all possible features are listed; you should list only the features that are appropriate given your patient’s age and hearing loss.
Send your completed options for your patient to your preceptor by the requested deadline.

Earmolds

Earmolds

Earmold Impressions: Guidelines for making earmold impressions in children:

pre-impression otoscopic inspection: before making an impression, inspect the earcanal to determine the shape and size and if there is any obstruction.
oto-dam placement: choose a size of dam that completely fills the canal. Use an earlite to inset the ear dam using a bracing technique for safety. Insert the dam just beyond the second turn of the canal, if possible.
mix the impression material on the splead pad and place in the syringe. Insert the plunger to extrude some material and to remove air blocks.
express the impression material into the ear canal using the syringe and bracing technique. Allow the impression material to flow back over the syringe tip and start backing the tip slowly out of the canal. Fill the concha bowl, then into the helix, follow the contour of the ear, and finish at the center of the concha.
Remove the impression in 5 minutes by breaking the seal while pulling back on the pinna. Remove the impression from the helix area and rotate forward and out.
Inspect the impression to determine if it is adequate or needs to be remade.
- Is there adequate canal length for the degree of hearing loss?
- Is there adequate helix if needed?
- Are there any defects?
post-impression otoscopic inspection: inspect the earcanal to determine that impression material has been removed

Re-tubing an earmold:

Remove old tubing: Cut the old tubing flush with the outside edge of the earmold. For silicone molds, use a tube-lock tool and push the TRS tube out. Use a pipe cleaner to clean out the sound bore.
Insert new tubing: From the canal tip, insert a tube puller into the earmold and pull the tube through from the quilled end. Adjust the tube by hand until you have the proper angle. For silicone molds, gently work the TRS sleeve into the earmold; the TRS should be 3 mm from the outside edge of the earmold. Cut the tube flush with end of the canal. If a TRS ring is not used, secure the tubing with SuperGlue.

Earmold Styles

style #6-full shell: for young children and for children with hearing loss for whom feedback is a problem due to degree of hearing loss and/or size of ear.
style #2-skeleton: a slimmer profile w/ helix appropriate for children older than preschool with moderate or mild hearing loss.
style #4-canal style: for older children with mild or moderate hearing loss.

Earmold materials:

Vinyl materials are ordered for infants. Tubing is secured in the mold with glue. RX is the softest vinyl earmold (hardness=40) and is available in tan, light brown, med brown, and dark brown. Formula II is a soft vinyl (hardness=55). Colors: light brown, med brown, , dark brown, clear, pink, yellow, red, green, blue, purple, black, neon yellow, neon green, neon pink, neon orange. Vinyl colors are somewhat translucent.
Silicone molds can be ordered for toddlers/children. Tubing cannot be glued in a silicone mold, but is secured with TRS ring. (In infant molds, there is not enough room for a TRS ring). Otoblast is a medical grade silicone that educes radiant feedback more than other materials.W-1 is a less stiff silicone than Otoblast.
- disappear blends into the skin: A(pink), B(tan), C (light brown)
- colors: clear, white, black, brown, yellow, green, orange, purple, red, blue, pink. Otoblast colors are opaque.
- Oto-swyrl: up to 3 colors swirled
- cat eyes: oto-clear with one accent color from above
- glitter: otoclear with glitter colors of blue, green, red, purple, pink, silver, gold (up to 3)
- matte finish is recommended for ease of insertion and looks good with clear or disappEar. A shiny finish is a high gloss glaze that makes colors more vibrant.
- Slick-Sil Anti-Microbial is a finish on a silicone mold that has a velvety finish for ease of insertion and is resistant to bacteria.
Medical grade silicones for allergic/sensitive cases: mediflex (tan) and frosted flex (frosted opaque)

Earmold Options

Venting
Birth to 3 years=no venting
4 to 7 years= < 2mm vent
> 7 years= HL-based venting
Tubing
Dry tube for children with moisture problems
Welded tubing: for better retention
Helix: the helix area of an earmold can cause sore spots for some patients; order a reduced ¾ helix or order without helix

Orientation

Fitting of new hearing aids:

Prior the fitting appointment, you should pre-set the hearing aids using the child’s previous hearing thresholds and estimated RECD using normative values.
Typically the family will receive a care kit that will you use for the fitting; you will need to familiarize yourself with the contents and identify the key components to explain. Infants need double-sided tape for retention. Toddlers and younger children need clips to secure the hearing aids to clothing and prevent loss.
Review the user guides for the devices in detail, so that you are prepared to explain the devices to the family.
Types of fittings
- Initial fitting: Families whose child is receiving hearing aids for the first time need the most detailed orientation. At the same time, it is easy for families to get overwhelmed, so it is important to focus on the essentials only. Additional details as well as review will be covered at subsequent visits.
- Fitting with 2nd, 3rd, etc instruments and advanced features such as multiple programs and streaming devices.
- Remote mic-DM system fitting

Initial HA orientation appointment: Flow of appointment

Demo hearing technology
- Show the family the hearing aids and earmolds at start of appointment
- Trim earmold to fit on child
- Demonstrate putting hearing aids/earmolds on child’s ears
- Provide age and HL-appropriate expectations for child’s responses with HAs
- Allow family to communicate with child while wearing aids
How do we turn HA on and put on?
- Battery door closure/opening and activation chime
- Left/right identification of HA and earmold
- Insertion/removal
- lubricant
How can we tell if HA is working?
- LED light
- Feedback
- Listening check
- Battery check
When do we take HA off?
- Water/bath
- Sleep
How often should the child wear the HAs?
- Full-time use
How do we take care of HA and EM?
- Cleaning
- Cloth wipe, wax loop, blower
- Storage
- “day bed” case
How can we keep them on and not lose the HAs?
- Solutions for retention (clips)
- Solutions for removal (hat)
- warranty coverage
How can we troubleshoot if there is an issue with the HA?
- Blocked earmold tube/earhook
- blocked mic covers
- Battery contacts
How should we talk to our child?
- Listening bubble, face-to-face

Streaming Technology orientation

On/off
Using with Bluetooth devices (cellphone, etc)
Charging

Remote Mic HAT orientation

Transmitter/mic
- Turning on/off the transmitter
- Wearing the transmitter with neck loop or belt clip
- Muting the transmitter: when and how
- Charging the transmitter
Receivers
- Attaching/detaching from hearing aids
- Synching receivers with transmitter
Listening check: rub the transmitter mic and/or listen to someone from distance