Speech-in-Noise Assessment in the Routine Audiologic Test Battery: Relationship to Perceived Auditory Disability.

OBJECTIVES: Self-assessment of perceived communication difficulty has been used in clinical and research practices for decades. Such questionnaires routinely assess the perceived ability of an individual to understand speech, particularly in background noise. Despite the emphasis on perceived performance in noise, speech recognition in routine audiologic practice is measured by word recognition in quiet (WRQ). Moreover, surprisingly little data exist that compare speech understanding in noise (SIN) abilities to perceived communication difficulty. Here, we address these issues by examining audiometric thresholds, WRQ scores, QuickSIN signal to noise ratio (SNR) loss, and perceived auditory disability as measured by the five questions on the Speech Spatial Questionnaire-12 (SSQ12) devoted to speech understanding (SSQ12-Speech5). DESIGN: We examined data from 1633 patients who underwent audiometric assessment at the Stanford Ear Institute. All individuals completed the SSQ12 questionnaire, pure-tone audiometry, and speech assessment consisting of ear-specific WRQ, and ear-specific QuickSIN. Only individuals with hearing threshold asymmetries ≤10 dB HL in their high-frequency pure-tone average (HFPTA) were included. Our primary objectives were to (1) examine the relationship between audiometric variables and the SSQ12-Speech5 scores, (2) determine the amount of variance in the SSQ12-Speech5 scores which could be predicted from audiometric variables, and (3) predict which patients were likely to report greater perceived auditory disability according to the SSQ12-Speech5. RESULTS: Performance on the SSQ12-Speech5 indicated greater perceived auditory disability with more severe degrees of hearing loss and greater QuickSIN SNR loss. Degree of hearing loss and QuickSIN SNR loss were found to account for modest but significant variance in SSQ12-Speech5 scores after accounting for age. In contrast, WRQ scores did not significantly contribute to the predictive power of the model. Degree of hearing loss and QuickSIN SNR loss were also found to have moderate diagnostic accuracy for determining which patients were likely to report SSQ12-Speech5 scores indicating greater perceived auditory disability. CONCLUSIONS: Taken together, these data indicate that audiometric factors including degree of hearing loss (i.e., HFPTA) and QuickSIN SNR loss are predictive of SSQ12-Speech5 scores, though notable variance remains unaccounted for after considering these factors. HFPTA and QuickSIN SNR loss-but not WRQ scores-accounted for a significant amount of variance in SSQ12-Speech5 scores and were largely effective at predicting which patients are likely to report greater perceived auditory disability on the SSQ12-Speech5. This provides further evidence for the notion that speech-in-noise measures have greater clinical utility than WRQ in most instances as they relate more closely to measures of perceived auditory disability.

Preliminary Guidelines for Replacing Word-Recognition in Quiet With Speech in Noise Assessment in the Routine Audiologic Test Battery.

OBJECTIVES: For decades, monosyllabic word-recognition in quiet (WRQ) has been the default test of speech recognition in routine audiologic assessment. The continued use of WRQ scores is noteworthy in part because difficulties understanding speech in noise (SIN) is perhaps the most common complaint of individuals with hearing loss. The easiest way to integrate SIN measures into routine clinical practice would be for SIN to replace WRQ assessment as the primary test of speech perception. To facilitate this goal, we predicted classifications of WRQ scores from the QuickSIN signal to noise ratio (SNR) loss and hearing thresholds. DESIGN: We examined data from 5808 patients who underwent audiometric assessment at the Stanford Ear Institute. All individuals completed pure-tone audiometry, and speech assessment consisting of monaural WRQ, and monaural QuickSIN. We then performed multiple-logistic regression to determine whether classification of WRQ scores could be predicted from pure-tone thresholds and QuickSIN SNR losses. RESULTS: Many patients displayed significant challenges on the QuickSIN despite having excellent WRQ scores. Performance on both measures decreased with hearing loss. However, decrements in performance were observed with less hearing loss for the QuickSIN than for WRQ. Most important, we demonstrate that classification of good or excellent word-recognition scores in quiet can be predicted with high accuracy by the high-frequency pure-tone average and the QuickSIN SNR loss. CONCLUSIONS: Taken together, these data suggest that SIN measures provide more information than WRQ. More important, the predictive power of our model suggests that SIN can replace WRQ in most instances, by providing guidelines as to when performance in quiet is likely to be excellent and does not need to be measured. Making this subtle, but profound shift to clinical practice would enable routine audiometric testing to be more sensitive to patient concerns, and may benefit both clinicians and researchers.

Remote Intraoperative Neural Response Telemetry: Technique and Results in Cochlear Implant Surgery.

OBJECTIVE: Present results with remote intraoperative neural response telemetry (NRT) during cochlear implantation (CI) and its usefulness in overcoming the inefficiency of in person NRT. STUDY DESIGN: Case series. SETTING: Tertiary academic otology practice. PATIENTS: All patients undergoing primary or revision CI, both adult and pediatric, were enrolled. INTERVENTIONS: Remote intraoperative NRT performed by audiologists using a desktop computer to control a laptop in the operating room. Testing was performed over the hospital network using commercially available software. A single system was used to test all three FDA-approved manufacturers' devices. MAIN OUTCOME MEASURES: Success rate and time savings of remote NRT. RESULTS: Out of 254 procedures, 252 (99.2%) underwent successful remote NRT. In two procedures (0.7%), remote testing was unsuccessful, and required in-person testing to address technical issues.Both failed attempts were due to hardware failure (OR laptop or headpiece problems). There was no relation between success of the procedure and patient/surgical factors such as difficult anatomy, or the approach used for inner ear access. The audiologist time saved using this approach was considerable when compared with in-person testing. CONCLUSIONS: Remote intraoperative NRT testing during cochlear implantation can be performed effectively using standard hardware and remote-control software. Especially important during the Covid-19 pandemic, such a procedure can reduce in-person contacts, and limit the number of individuals in the operating room. Remote testing can provide additional flexibility and efficiency in audiologist schedules.

Outcomes in Patients Meeting Cochlear Implant Criteria in Noise but Not in Quiet.

OBJECTIVE: Evaluate outcomes in cochlear implant (CI) recipients qualifying in AzBio noise but not quiet, and identify factors associated with postimplantation improvement. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary otology/neurotology clinic. PATIENTS: This study included 212 implanted ears. The noise group comprised 23 ears with preoperative AzBio more than or equal to 40% in quiet and less than or equal to 40% in +10 signal-to-noise ratio (SNR). The quiet group included 189 ears with preoperative AzBio less than 40% in quiet. The two groups displayed similar demographics and device characteristics. INTERVENTIONS: Cochlear implantation. MAIN OUTCOME MEASURES: AzBio in quiet and noise. RESULTS: Mean AzBio quiet scores improved in both the quiet group (pre-implant: 12.7%, postimplant: 67.2%, p < 0.001) and noise group (pre-implant: 61.6%, postimplant: 73.8%, p = 0.04). Mean AzBio +10 SNR also improved in the quiet group (pre-implant: 15.8%, postimplant: 59.3%, p = 0.001) and noise group (pre-implant: 30.5%, postimplant: 49.1%, p = 0.01). However, compared with the quiet group, fewer ears in the noise group achieved within-subject improvement in AzBio quiet (≥15% improvement; quiet group: 90.3%, noise group: 43.8%, p < 0.001) and AzBio +10 SNR (quiet group: 100.0%, noise group: 45.5%, p < 0.001). Baseline AzBio quiet (p < 0.001) and Consonant-Nucleus-Consonant (CNC) scores (p = 0.004) were associated with within-subject improvement in AzBio quiet and displayed a higher area under the curve than either aided or unaided pure-tone average (PTA) (both p = 0.01). CONCLUSIONS: CI patients qualifying in noise display significant mean benefit in speech recognition scores but are less likely to benefit compared with those qualifying in quiet. Patients with lower baseline AzBio quiet scores are more likely to display postimplant improvement.

Hearing Dysfunction After Treatment With Teprotumumab for Thyroid Eye Disease.

PURPOSE: To characterize the frequency, severity, and resolution of hearing dysfunction in patients treated with teprotumumab for thyroid eye disease (TED). DESIGN: Prospective observational case series. METHODS: Ophthalmic examination and adverse event assessment, including otologic symptoms, were performed at baseline, after infusions 2, 4, and 8, and at 6-month follow-up in consecutive patients who received at least 4 teprotumumab infusions. Laboratory test results were collected at baseline and during treatment. Audiometry, patulous eustachian tube (PET) testing, and otolaryngology evaluation were obtained for patients with new or worsening otologic symptoms, with a subset obtaining baseline and posttreatment testing. RESULTS: Twenty-seven patients were analyzed (24 females, 3 males, average 56.3 years old). Twenty-two patients (81.5%) developed new subjective otologic symptoms, after a mean of 3.8 infusions (SD 1.8). At 39.2-week average follow-up after the last infusion, most patients with tinnitus (100%), ear plugging/fullness (90.9%), and autophony (83.3%) experienced symptom resolution, whereas only 45.5% (5 of 11) of patients with subjective hearing loss/decreased word comprehension experienced resolution. Six patients underwent baseline and posttreatment audiometry, 5 of whom developed teprotumumab-related sensorineural hearing loss (SNHL) and 1 patient also developed PET. Three of the 5 patients with teprotumumab-related SNHL had persistent subjective hearing loss at last follow-up. A prior history of hearing loss was discovered as a risk factor for teprotumumab-related SNHL (P = .008). CONCLUSIONS: Hearing loss is a concerning adverse event of teprotumumab, and its mechanism and reversibility should be further studied. Until risk factors for hearing loss are better understood, we recommend baseline audiometry with PET testing and repeat testing if new otologic symptoms develop. Screening, monitoring, and prevention guidelines are needed.

Ocular Vestibular-Evoked Myogenic Potential Amplitudes Elicited at 4 kHz Optimize Detection of Superior Semicircular Canal Dehiscence.

Introduction: High-resolution temporal bone computed tomography (CT) is considered the gold standard for diagnosing superior semicircular canal dehiscence (SCD). However, CT has been shown over-detect SCD and provide results that may not align with patient-reported symptoms. Ocular vestibular-evoked myogenic potentials (oVEMPs)-most commonly conducted at 500 Hz stimulation-are increasingly used to support the diagnosis and management of SCD. Previous research reported that stimulation at higher frequencies such as 4 kHz can have near-perfect sensitivity and specificity in detecting radiographic SCD. With a larger cohort, we seek to understand the sensitivity and specificity of 4 kHz oVEMPs for detecting clinically significant SCD, as well as subgroups of radiographic, symptomatic, and surgical SCD. We also investigate whether assessing the 4 kHz oVEMP n10-p15 amplitude rather than the binary n10 response alone would optimize the detection of SCD. Methods: We conducted a cross-sectional study of patients who have undergone oVEMP testing at 4 kHz. Using the diagnostic criteria proposed by Ward et al., patients were determined to have SCD if dehiscence was confirmed on temporal bone CT by two reviewers, patient-reported characteristic symptoms, and if they had at least one positive vestibular or audiometric test suggestive of SCD. Receiver operating characteristic (ROC) analysis was conducted to identify the optimal 4 kHz oVEMP amplitude cut-off. Comparison of 4 kHz oVEMP amplitude across radiographic, symptomatic, and surgical SCD subgroups was conducted using the Mann-Whitney U test. Results: Nine hundred two patients (n, ears = 1,804) underwent 4 kHz oVEMP testing. After evaluating 150 temporal bone CTs, we identified 49 patients (n, ears = 61) who had radiographic SCD. Of those, 33 patients (n, ears = 37) were determined to have clinically significant SCD. For this study cohort, 4 kHz oVEMP responses had a sensitivity of 86.5% and a specificity of 87.8%. ROC analysis demonstrated that accounting for the inter-amplitude of 4 kHz oVEMP was more accurate in detecting SCD than the presence of n10 response alone (AUC 91 vs. 87%). Additionally, using an amplitude cut-off of 15uV reduces false positive results and improves specificity to 96.8%. Assessing 4 kHz oVEMP response across SCD subgroups demonstrated that surgical and symptomatic SCD cases had significantly higher amplitudes, while radiographic SCD cases without characteristic symptoms had similar amplitudes compared to cases without evidence of SCD. Conclusion: Our results suggest that accounting for 4 kHz oVEMP amplitude can improve detection of SCD compared to the binary presence of n10 response. The 4 kHz oVEMP amplitude cut-off that maximizes sensitivity and specificity for our cohort is 15 uV. Our results also suggest that 4 kHz oVEMP amplitudes align better with symptomatic SCD cases compared to cases in which there is radiographic SCD but no characteristic symptoms.

Ambient Pressure Tympanometry Wave Patterns in Patients With Superior Semicircular Canal Dehiscence.

Importance: Superior semicircular canal dehiscence (SSCD) is a treatable condition, but current diagnostic modalities have numerous limitations. Clinicians would benefit from an additional tool for diagnostic workup that is both rapid and widely available. Objective: To assess the utility of ambient pressure tympanometry (APT) in the diagnostic workup of SSCD by determining the sensitivity and specificity of APT for SSCD in comparison to other diagnostic modalities. Design: Retrospective cohort study of patients who underwent APT and temporal bone computerized tomography (CT) scans from May 2017 to July 2018. Setting: Tertiary referral center. Participants: APT was performed as part of routine audiological testing on adult patients. We retrospectively analyzed all patients who received both APT and temporal bone CT scans, and divided ears into SSCD and non-SSCD groups based on the presence or absence of radiographic SSCD. Ears with other radiographic findings that could affect tympanic membrane compliance were excluded. Exposures: All patients in this study underwent APT and temporal bone CT scans. Some patients also underwent pure tone audiometry and vestibular evoked myogenic potentials (VEMPs). Main Outcomes and Measures: The primary outcome measures were sensitivity, specificity, and risk ratio of APT for SSCD. Secondary outcome measures include sensitivity of VEMPs and supranormal hearing thresholds. Results: We describe 52 patients (70 ears) who underwent APT and CT imaging (mean age 47.1 years, 67.1% female). APT detected SSCD with 66.7% sensitivity and 72.1% specificity. In symptomatic patients, sensitivity was 71.4% and specificity was 75%. VEMPs performed best at detecting SSCD when defining a positive test as oVEMP amplitude >17 µV, with a sensitivity of 68.2%, similar to APT (p > 0.99). The combination of APT and VEMPs increased sensitivity to 88.9%, better than APT alone (p = 0.031) and trending toward better than VEMPs alone (p = 0.063). Conclusions and Relevance: Rhythmic wave patterns on APT are associated with SSCD and may raise suspicion for this condition in conjunction with consistent results on other diagnostic modalities. Although clinical utility requires confirmation in a larger prospective study, APT is a simple, rapid, and widely available tool warranting further study.

Rhythmic Wave Patterns on Ambient Pressure Tympanometry in Patients With Objective Tinnitus-associated Pathologies.

OBJECTIVE: To introduce the concept of ambient pressure tympanometry (APT) and its association with pathologies that may present with objective tinnitus. STUDY DESIGN: Retrospective case series. SETTING: Tertiary referral center. SUBJECTS AND METHODS: Audiologists performed APT on adult patients as part of routine audiological testing. Ears with myoclonus and patulous Eustachian tube (PET) were identified via review of patient history and physical examination. All other conditions were verified via computed tomography (CT) temporal bone imaging. Ears with conditions that could impair tympanic membrane compliance, such as otosclerosis or tympanic membrane perforation, were excluded. APT findings were analyzed via a novel algorithm. RESULTS: A radiographic finding associated with objective tinnitus was confirmed in 67 ears that underwent CT imaging; 45 (67%) of these ears displayed rhythmic APT wave patterns. These included 28 ears with superior semicircular canal dehiscence, 4 ears with sigmoid sinus dehiscence, 6 ears with internal carotid artery dehiscence, 4 ears with glomus tumor, and 3 ears with encephalocele. In addition, we identified three ears with myoclonus and one ear with PET. In a subset of 30 ears with objective tinnitus symptoms that underwent CT imaging, 22 displayed rhythmic waves; of these 22 ears, 20 (91%) had a radiographic finding associated with objective tinnitus. CONCLUSIONS: Rhythmic APT wave patterns are common and may be associated with numerous temporal bone pathologies that may present with objective tinnitus. APT is a simple, rapid, and widely available tool that warrants further study to determine its value in screening of these otologic conditions.