Functional Hearing Difficulties in Blast-Exposed Service Members With Normal to Near-Normal Hearing Thresholds.

OBJECTIVES: Estimated prevalence of functional hearing and communication deficits (FHCDs), characterized by abnormally low speech recognition and binaural tone detection in noise or an abnormally high degree of self-perceived hearing difficulties, dramatically increases in active-duty service members (SMs) who have hearing thresholds slightly above the normal range and self-report to have been close to an explosive blast. Knowing the exact nature of the underlying auditory-processing deficits that contribute to FHCD would not only provide a better characterization of the effects of blast exposure on the human auditory system, but also allow clinicians to prescribe appropriate therapies to treat or manage patient complaints. DESIGN: Two groups of SMs were initially recruited: (1) a control group (N = 78) with auditory thresholds ≤20 dB HL between 250 and 8000 Hz, no history of blast exposure, and who passed a short FHCD screener, and (2) a group of blast-exposed SMs (N = 26) with normal to near-normal auditory thresholds between 250 and 4000 Hz, and who failed the FHCD screener (cutoffs based on the study by Grant et al.). The two groups were then compared on a variety of audiometric, behavioral, cognitive, and electrophysiological measures. These tests were selected to characterize various aspects of auditory system processing from the cochlear to the cortex. A third, smaller group of blast-exposed SMs who performed within normal limits on the FHCD screener were also recruited (N = 11). This third subject group was unplanned at the onset of the study and was added to evaluate the effects of blast exposure on hearing and communication regardless of performance on the FHCD screener. RESULTS: SMs in the blast-exposed group with FHCD performed significantly worse than control participants on several metrics that measured peripheral and mostly subcortical auditory processing. Cognitive processing was mostly unaffected by blast exposure with the exception of cognitive tests of language-processing speed and working memory. Blast-exposed SMs without FHCD performed similarly to the control group on tests of peripheral and brainstem processing, but performed similarly to blast-exposed SMs with FHCD on measures of cognitive processing. Measures derived from EEG recordings of the frequency-following response revealed that blast-exposed SMs who exhibited FHCD demonstrated increased spontaneous neural activity, reduced amplitude of the envelope-following response, poor internal signal to noise ratio, reduced response stability, and an absent or delayed onset response, compared with the other two participant groups. CONCLUSIONS: Degradation in the neural encoding of acoustic stimuli is likely a major contributing factor leading to FHCD in blast-exposed SMs with normal to near-normal audiometric thresholds. Blast-exposed SMs, regardless of their performance on the FHCD screener, exhibited a deficit in language-processing speed and working memory, which could lead to difficulties in decoding rapid speech and in understanding speech in challenging speech communication settings. Further tests are needed to align these findings with clinical treatment protocols being used for patients with suspected auditory-processing disorders.

Estimated Prevalence of Functional Hearing Difficulties in Blast-Exposed Service Members With Normal to Near-Normal-Hearing Thresholds.

OBJECTIVES: Over the past decade, U.S. Department of Defense and Veterans Affairs audiologists have reported large numbers of relatively young adult patients who have normal to near-normal audiometric thresholds but who report difficulty understanding speech in noisy environments. Many of these service members also reported having experienced exposure to explosive blasts as part of their military service. Recent studies suggest that some blast-exposed patients with normal to near-normal-hearing thresholds not only have an awareness of increased hearing difficulties, but also poor performance on various auditory tasks (sound source localization, speech recognition in noise, binaural integration, gap detection in noise, etc.). The purpose of this study was to determine the prevalence of functional hearing and communication deficits (FHCD) among healthy Active-Duty service men and women with normal to near-normal audiometric thresholds. DESIGN: To estimate the prevalence of such FHCD in the overall military population, performance of roughly 3400 Active-Duty service members with hearing thresholds mostly within the normal range were measured on 4 hearing tests and a brief 6-question survey to assess FHCD. Subjects were subdivided into 6 groups depending on the severity of the blast exposure (3 levels: none, far away, or close enough to feel heat or pressure) and hearing thresholds (2 levels: audiometric thresholds of 20 dB HL or better, slight elevation in 1 or more thresholds between 500 and 4000 Hz in either ear). RESULTS: While the probability of having hearing difficulty was low (≈4.2%) for the overall population tested, that probability increased by 2 to 3 times if the service member was blast-exposed from a close distance or had slightly elevated hearing thresholds (>20 dB HL). Service members having both blast exposure and mildly elevated hearing thresholds exhibited up to 4 times higher risk for performing abnormally on auditory tasks and more than 5 times higher risk for reporting abnormally low ratings on the subjective questionnaire, compared with service members with no history of blast exposure and audiometric thresholds ≤20 dB HL. Blast-exposed listeners were roughly 2.5 times more likely to experience subjective or objective hearing deficits than those with no-blast history. CONCLUSIONS: These elevated rates of abnormal performance suggest that roughly 33.6% of Active-Duty service members (or approximately 423,000) with normal to near-normal-hearing thresholds (i.e., H1 profile) are at some risk for FHCD, and about 5.7% (approximately 72,000) are at high risk, but are currently untested and undetected within the current fitness-for-duty standards. Service members identified as "at risk" for FHCD according to the metrics used in the present study, in spite of their excellent hearing thresholds, require further testing to determine whether they have sustained damage to peripheral and early-stage auditory processing (bottom-up processing), damage to cognitive processes for speech (top-down processing), or both. Understanding the extent of damage due to noise and blast exposures and the balance between bottom-up processing deficits and top-down deficits will likely lead to better therapeutic strategies.

Effect of Blast Injury on Auditory Localization in Military Service Members.

OBJECTIVES: Among the many advantages of binaural hearing are the abilities to localize sounds in space and to attend to one sound in the presence of many sounds. Binaural hearing provides benefits for all listeners, but it may be especially critical for military personnel who must maintain situational awareness in complex tactical environments with multiple speech and noise sources. There is concern that Military Service Members who have been exposed to one or more high-intensity blasts during their tour of duty may have difficulty with binaural and spatial ability due to degradation in auditory and cognitive processes. The primary objective of this study was to assess the ability of blast-exposed Military Service Members to localize speech sounds in quiet and in multisource environments with one or two competing talkers. DESIGN: Participants were presented with one, two, or three topic-related (e.g., sports, food, travel) sentences under headphones and required to attend to, and then locate the source of, the sentence pertaining to a prespecified target topic within a virtual space. The listener's head position was monitored by a head-mounted tracking device that continuously updated the apparent spatial location of the target and competing speech sounds as the subject turned within the virtual space. Measurements of auditory localization ability included mean absolute error in locating the source of the target sentence, the time it took to locate the target sentence within 30 degrees, target/competitor confusion errors, response time, and cumulative head motion. Twenty-one blast-exposed Active-Duty or Veteran Military Service Members (blast-exposed group) and 33 non-blast-exposed Service Members and beneficiaries (control group) were evaluated. RESULTS: In general, the blast-exposed group performed as well as the control group if the task involved localizing the source of a single speech target. However, if the task involved two or three simultaneous talkers, localization ability was compromised for some participants in the blast-exposed group. Blast-exposed participants were less accurate in their localization responses and required more exploratory head movements to find the location of the target talker. CONCLUSIONS: Results suggest that blast-exposed participants have more difficulty than non-blast-exposed participants in localizing sounds in complex acoustic environments. This apparent deficit in spatial hearing ability highlights the need to develop new diagnostic tests using complex listening tasks that involve multiple sound sources that require speech segregation and comprehension.

The effects of repeated low-level blast exposure on hearing in marines.

BACKGROUND: The study evaluates a group of Military Service Members specialized in blast explosive training called "Breachers" who are routinely exposed to multiple low-level blasts while teaching breaching at the U.S. Marine Corps in Quantico Virginia. The objective of this study was to determine if there are any acute or long-term auditory changes due to repeated low-level blast exposures used in training. The performance of the instructor group "Breachers" was compared to a control group, "Engineers". METHODS: A total of 11 Breachers and four engineers were evaluated in the study. The participants received comprehensive auditory tests, including pure-tone testing, speech-in-noise (SIN) measures, and central auditory behavioral and objective tests using early and late (P300) auditory evoked potentials over a period of 17 months. They also received shorter assessments immediately following the blast-exposure onsite at Quantico. RESULTS: No acute or longitudinal effects were identified. However, there were some interesting baseline effects found in both groups. Contrary to the expected, the onsite hearing thresholds and distortion product otoacoustic emissions were slightly better at a few frequencies immediately after blast-exposure than measurements obtained with the same equipment weeks to months after each blast-exposure. CONCLUSIONS: To date, the current study is the most comprehensive study that evaluates the long-term effects of blast-exposure on hearing. Despite extensive testing to assess changes, the findings of this study suggest that the levels of current exposures used in this military training environment do not seem to have an obvious deleterious effect on hearing.

Development of a test battery for evaluating speech perception in complex listening environments.

In the real world, spoken communication occurs in complex environments that involve audiovisual speech cues, spatially separated sound sources, reverberant listening spaces, and other complicating factors that influence speech understanding. However, most clinical tools for assessing speech perception are based on simplified listening environments that do not reflect the complexities of real-world listening. In this study, speech materials from the QuickSIN speech-in-noise test by Killion, Niquette, Gudmundsen, Revit, and Banerjee [J. Acoust. Soc. Am. 116, 2395-2405 (2004)] were modified to simulate eight listening conditions spanning the range of auditory environments listeners encounter in everyday life. The standard QuickSIN test method was used to estimate 50% speech reception thresholds (SRT50) in each condition. A method of adjustment procedure was also used to obtain subjective estimates of the lowest signal-to-noise ratio (SNR) where the listeners were able to understand 100% of the speech (SRT100) and the highest SNR where they could detect the speech but could not understand any of the words (SRT0). The results show that the modified materials maintained most of the efficiency of the QuickSIN test procedure while capturing performance differences across listening conditions comparable to those reported in previous studies that have examined the effects of audiovisual cues, binaural cues, room reverberation, and time compression on the intelligibility of speech.

Performance on tests of central auditory processing by individuals exposed to high-intensity blasts.

Thirty-six blast-exposed patients and twenty-nine non-blast-exposed control subjects were tested on a battery of behavioral and electrophysiological tests that have been shown to be sensitive to central auditory processing deficits. Abnormal performance among the blast-exposed patients was assessed with reference to normative values established as the mean performance on each test by the control subjects plus or minus two standard deviations. Blast-exposed patients performed abnormally at rates significantly above that which would occur by chance on three of the behavioral tests of central auditory processing: the Gaps-In-Noise, Masking Level Difference, and Staggered Spondaic Words tests. The proportion of blast-exposed patients performing abnormally on a speech-in-noise test (Quick Speech-In-Noise) was also significantly above that expected by chance. These results suggest that, for some patients, blast exposure may lead to difficulties with hearing in complex auditory environments, even when peripheral hearing sensitivity is near normal limits.

Implications of blast exposure for central auditory function: a review.

Auditory system functions, from peripheral sensitivity to central processing capacities, are all at risk from a blast event. Accurate encoding of auditory patterns in time, frequency, and space are required for a clear understanding of speech and accurate localization of sound sources in environments with background noise, multiple sound sources, and/or reverberation. Further work is needed to refine the battery of clinical tests sensitive to the sorts of central auditory dysfunction observed in individuals with blast exposure. Treatment options include low-gain hearing aids, remote-microphone technology, and auditory-training regimens, but clinical evidence does not yet exist for recommending one or more of these options. As this population ages, the natural aging process and other potential brain injuries (such as stroke and blunt trauma) may combine with blast-related brain changes to produce a population for which the current clinical diagnostic and treatment tools may prove inadequate. It is important to maintain an updated understanding of the scope of the issues present in this population and to continue to identify those solutions that can provide measurable improvements in the lives of Veterans who have been exposed to high-intensity blasts during the course of their military service.

Enjoyment of music by elderly hearing-impaired listeners.

BACKGROUND: Anecdotal evidence suggests that hearing loss interferes with the enjoyment of music, although it is not known how widespread this problem currently is. PURPOSE: To estimate the prevalence of music-listening difficulties among a group of elderly hearing aid wearers. RESEARCH DESIGN: Interview. Telephone interviews were conducted with patients who wore hearing aids. Questions regarding several aspects of music listening were included. STUDY SAMPLE: Sixty-eight hearing-impaired people served as subjects. They had all been seen in the audiology clinic for hearing aid evaluation during the previous year. DATA COLLECTION AND ANALYSIS: Subjects were asked questions concerning their use of hearing aids, the importance of listening to music in their lives, their habits and practices concerning music, and difficulties they experienced in listening to music. RESULTS: Almost 30% of the respondents reported that their hearing losses affected their enjoyment of music. About half of the respondents indicated that music was either too loud or too soft, although only about one-third reported difficulties with level contrasts within musical pieces. In contrast to a similar survey carried out 20 years ago, there were many fewer complaints about listening to music. This result may be due in large part to improvements in hearing aids, especially with regard to nonlinear compression. CONCLUSIONS: Although new hearing aid technologies have somewhat reduced problems of music enjoyment experienced by hearing-impaired people, audiologists should be aware that some 25-30% of patients may have difficulties with listening to music and may require extra attention to minimize those problems.

Acoustic reflexes to Schroeder-phase harmonic complexes in normal-hearing and hearing-impaired individuals.

Harmonic complexes generated with positive or negative Schroeder-phases may result in differences in cochlear excitation, even though their long-term spectra and amplitudes are equal. As a measure of possible differences in cochlear excitation resulting from these harmonic complexes, thresholds and growth of the acoustic reflex were assessed in normal-hearing and hearing-impaired subjects. Harmonic complexes with fundamental frequencies of 50, 100, and 200 Hz were constructed with positive and negative-Schroeder phases. In normal-hearing subjects, acoustic reflex thresholds for the 50- and 100-Hz fundamental waveforms were typically lower for negative Schroeder-phase complexes than for positive Schroeder phase stimuli. At the highest fundamental frequency of 200 Hz, there were no significant threshold differences due to phase. Hearing-impaired subjects showed a similar pattern for thresholds between the two phase selections, but with smaller differences than those observed in normal-hearing subjects. At levels above reflex threshold, the magnitude of the acoustic reflex was greater for the negative-phase than the positive-phase stimuli for the lowest fundamental frequency, but no significant differences were observed at fundamental frequencies of 100 and 200 Hz. These results are consistent with generally greater cochlear excitation in response to negative than to positive Schroeder-phase stimuli when the fundamental frequency is sufficiently low. Increased excitation may reflect a synchronization of response across a wide band of frequencies in the cochlea when the rate of frequency sweep within periods of these harmonic complexes is appropriately matched to timing characteristics of the traveling wave.