Welcome everyone to the webinar, Managing Patients with Normal Thresholds. We're so glad you could be here today to learn about the practical assessment and tools available to hearing health care providers to help manage listening problems and to solve those problems for patients. Your moderators today are me, Diana Cheryville, Associate Director of Marketing, and Fran Vincent, Director of Membership and Marketing. Our expert presenter today is Douglas Elsbeck, AUD, and the Executive Director of Academic Sciences at Oticon. Doug Beck is among the most prolific authors and lecturers in audiology, with 184 published articles and more than 1,240 abstracts, interviews and op-eds written for IHS, AAA from 2008 to 2015, Audiology Online from 1999 to 2005, and The Hearing Review, addressing a wide variety of audiology and professional topics. Doug also sits on the International Institute for Hearing Instrument Studies Committee with the International Hearing Society. He earned his master's degree from the University of Buffalo and his doctorate from the University of Florida. He began his career in Los Angeles at the House Ear Institute in cochlear implant research and intraoperative cranial nerve monitoring and has been with Oticon since 2005. We're so excited to have Doug as our presenter once again today, but before we get started, a few housekeeping items to keep in mind. Please note that we are recording today's presentation so that we may offer it on demand through the IHS website in the future. Also, this webinar is available for one continuing education credit through the International Hearing Society. We've uploaded the CE quiz to the handout section of the webinar, and you may download it at any time. You can also find the quiz and more information about receiving continuing education credit at our website, IHSinfo.org. Click on the webinar banner on the homepage or choose webinars from the navigation menu. You can find the CE quiz along with information on how to submit that quiz to IHS for credit. If you'd like a copy of the slideshow from today's presentation or any of the supporting materials provided by Doug, and we've got a few of those for you, you can download it from the handout section of the webinar dashboard as well, or you can access it from the webinar page on the IHS website. Feel free to download all that material right now. Tomorrow, you will receive an email with a link to the survey on this webinar. It's brief, and your feedback will help us create valuable content for you moving forward. Today, we will be covering the following topics, introductory concepts, SNR50, digital remote mics, and outcomes. At the end, we'll move on to a Q&A session. You can send us a question for Doug at any time by answering your question in the question box on your webinar dashboard, usually located to the right or top of your webinar screen. We'll take as many questions as we can in the time we have available. And now I'm going to turn it over to Doug, who's going to kick off today's presentation. Doug? This is Doug, and I want to thank IHS and, of course, Fran and Diana for their help in assembling these materials and putting on this course, and the entire team at IHS as well as the team at Oticon for helping out on these issues. So what I'm going to do is I just want to remind you there's five handouts. You can get them at this webinar and or you can go to the IHS website. The reason I'm giving you my website address, douglashelbeck.com, there's about 80 or 90 of my last publications up there. So any of the publications we mentioned in passing that are not included, you'll find them there, okay? Any questions, obviously, just send me a note. You can send it to doug.beck at oticon.com or contact Fran or Diana. That would be great. So I want to go through these topics. We've got about 44 and a half minutes, and this could be easily a four-hour course, so I'm going to abbreviate a little bit, and I will take questions at the end, as Diana said. So I want to go through and give you some basic concepts before we get to the meat of it so that we're all on the same page. Hearing is simply perceiving sound. What often happens is patients will come into the office, and they're going to tell you, oh, Grandpa has a hearing problem. You know, he can't understand what people are saying, and actually what that is is actually a listening problem because listening is comprehending sound, making sense of sound, untangling sound. Hearing is perceiving sound. It's very important that we get this right because on a regular basis, you know, audiologists, dispensers, ENTs, and patients mistake the two, and they use the two interchangeably, and they are very different. So to understand speech and noise, to understand any sort of difficult signal, it's not just a matter of perceiving it. It's a matter of your brain organizing the material that it has received into a fashion that makes sense to your brain. So the first 75 years of audiology were all about hearing, but the next 75 are going to be about listening, and this has come about recently because only in the last 8 or 10 years have we started to have hearing aids that substantially improve the signal-to-noise ratio, and we'll talk a lot about this today. So it's actually not as much about the hearing aid as it is about the brain. In fact, it's all about the brain. When you think about it, we can make anybody hear. That is, we can make anybody perceive sound. People with a severe to profound loss, if they can't get by with hearing aids, of course there's cochlear implants. If they don't have an inner ear, they don't have an auditory nerve, we can go to auditory brainstem implants. Those are not yet FDA-approved, even though they've been in the USA for 25, 30 years. I think the first one was done in 1987, but they are approved in Europe. So tremendous progress in auditory brainstem implants, and again, my issue is not to talk about ABI or talk about cochlear implants, but to make the point we can make anybody hear. Hearing is just perceiving sound. What we can't do is make anybody listen. So people actually live in a world where cognition, attention, memory, intention, and hearing interact. And hearing is just one part of that. Hearing, of course, is the concrete basis. Hearing is the foundation upon which listening is formed. But hearing is not the end goal. The end goal is listening. So each of these factors, cognition, attention, memory, hearing, these all interact, and each plays a critical role in listening. So I want to give you this concept. Before, I guess it was 2010, 2011, listening is where hearing meets brain. This was Carol Flexer and I put out a paper on this, and it was this idea that's very highly related to brain hearing. Of course, brain hearing is a proprietary Oticon term, and that is probably a better term because it's one quick word. But people get it right away. The idea is that listening is where hearing meets brain. In other words, you have to hear, you have to perceive sound, but that's not the end goal. The end goal is your brain decoding it, making sense of it, so that it's useful for the person perceiving that sound. So listening is where hearing meets brain in children and adults. And again, this paper is 2011, 2012. When you think about it, to be at the top of the food chain actually depends more on listening than hearing. And this is an interesting concept because, again, as audiologists, as dispensers, as ENTs, we talk about hearing, hearing, hearing, and that's cool. That makes sense. I get that. But that's not why we're at the top of the food chain. In fact, you see, I don't know if you guys can see my cursor up here. That's you and me up here at the very top. And to be at the top of the food chain depends on listening. This cat over here on the lower left with the cool eyes and the gray coat, that cat can hear probably 45,000 hertz. These lions, male and female lions here, yep, they can hear 45,000, 50,000 hertz. Whales, dolphins, porpoises, some of them can hear out to 140,000, 150,000 hertz. They can navigate the Pacific using two hertz cues. Well, human hearing is pretty bad. It's 20 hertz to 20,000 hertz. And out of that, when you think about it, probably the usable span spectrum is maybe 30 hertz to maybe 12,000 hertz. In other words, if I give you a tone at 15k and 20k, you couldn't tell the difference. The difference, Lyman, your resolution ability as a human being to tell the difference between a 15k and an 18k or a 20k tone, not very good. You see this German shepherd down here on the right? That's actually my German shepherd. That's Mia. She turns two this month. And she can hear out to 35,000, 38,000 hertz. So, again, my point is human hearing is not so good in the animal kingdom. All of these animals hear better than we do. The reason we're at the very top of the heap up here is because of our listening ability. And we can attribute meaning. We can talk about things that have happened. We can talk about the past. We can put together crazy stories of things that will never happen. We can talk about the future. None of these other animals have the ability to communicate on that level. And so listening, language, communication, these things are all tied together. And those of you who have ever done language work with speech-language pathology, you're very familiar with this. You have the expressive and receptive aphasia where you may know the word, you may have the word, but you can't say it. That would be expressive aphasia or receptive aphasia. People are speaking to you in a vocabulary and with words you understand, but you can't make sense of it. So listening is attributing meaning to sound. And that's what I want to focus on. The real challenge is actually beyond hearing. Of course, we have to make people hear. I've said that a few times. That's absolutely goal number one, but that's not the end goal. In fact, the opportunity for listening success is the end goal. So it's a little bit beyond hearing. This is my buddy, Jason Galster, wrote this article about a year and a half ago. Some of you know Jason was with Starkey for many years, and he's with Advanced Bionics now. He's director of research, I believe, for their cochlear implant group out in California. But Jason put this very clever article together, and I really like it. And if you ever have a chance to see Jason lecture, you should. He's a wonderful lecturer and a very funny guy. Anyway, an established goal of modern hearing aids is to improve speech understanding for the wearer. This goal is best achieved by improving the signal-to-noise ratio. And, you see, you and I have gotten caught up in thinking that if we do target, right, we do NALNL2, NALNL1, we do DSL5, you know, that that's it. We've done the best we can. Well, that tells us how much gain and compression ratio. So that's critically important. That's hearing. That's step one. But the end goal for the patient, almost 90 percent, 95 percent of the time, the reason they come to see us is actually to understand speech and noise, right? So that's listening. And the thing about this is that most of us go about this the wrong way. You know, we learn that you're supposed to do a communication assessment, a listening assessment, and then you do pure tones and otoscopy and all this stuff. Well, the funny thing is when you're looking at all the people who have hearing loss on an audiogram, that would be 37 million people in the USA have hearing loss on an audiogram. And another 26 million who have difficulty understanding speech and noise and or hearing difficulty. That is, they can't decode speech to make sense of it. So you've got 37 million and you've got 26 million. So that's a lot of people. That's like 63 million people who have hearing and or listening difficulty. So the number one thing you could do is improve the signal-to-noise ratio. See, a lot of these folks don't need anything louder. They can hear it. They can't make sense of it. And I think that's very true in the patients that we see on a regular basis. So keep that in mind as we go through. So speech and quiet does not predict speech and noise. You can have 100 percent word recognition in quiet, and that tells you absolutely nothing about your ability to understand speech and noise. Now, this comes from Rich Wilson, and Rich wrote this eight years ago. This is JAAA based on 3,430 veterans saying, yeah, there's speech in quiet and speech and noise. Kind of unrelated in that you couldn't predict one from the other. So this is a brand-new paper. This came out in May 2019. You're in hearing. And, again, they're looking at over 5,000 people. In occupations with hearing-critical tasks, speech and noise may be more important than thresholds. And that's kind of what we're talking about here today is that the most important factor is actually speech and noise. If I only had one score on somebody and I had to assess their ability to understand and to hear and to listen, it would be a speech and noise score, not an audiogram. So based on 5,487 people peer-reviewed in hearing, details of the audiogram are a relatively insensitive predictor of performance during speech and noise tests. So I am saying, of course, pure tone is very important. You know, it's a gold standard of how we measure hearing. But people don't go around listening to pure tones under TDH39s in sound booths. And that's really all that tells you. So I think we have to do a professional shift here as we move forward through the next 10, 20 years is to not just accept a pure tone average as telling you everything you need to know to base a hearing aid fitting or communication assessment on. As a matter of fact, as hearing loss increases, the required signal-to-noise ratio increases. And this is Harvey Dillon's work. And this comes out in 2012 in probably the most famous hearing aid textbook used in the world. Harvey wrote the second edition in 2011, 2012. And on page 7, he made this point that as hearing loss increases, it's not just that you have to make it louder. You have to improve the signal-to-noise ratio. But to attend to how much hearing they need, how loud does it have to be, how much has to be audible, of course, that's NALNL2 for adults. That would be DSL5 most common for children. So that's fine. But the important underlying thing here is that you're also improving the signal-to-noise ratio while providing that gain in that compression. This is Mead Killian's work, 2002. And this is one of my favorite graphs in all of audiology. And Mead's pointing out here. If you see that curvy line that is solid, again, I'm not sure if you're seeing my cursor. I hope you are. This line up here that says normal, these are people with normal hearing and relatively normal cognitive ability. What's happening here is you see that to understand 50% of the words correct, you need a two-decibel signal-to-noise ratio. And this dashed line, these are people with mild to moderate sensory nerve loss. They need an 8 dB signal-to-noise ratio to get 50% correct. So I'll give you one example because of time constraints. Supposing that I had perfectly normal hearing and the speech in front is at 70 decibels and you were to give me 55 dB of four-talker babble in the back. Now hold on there for just a second. Four-talker babble, very important because if you're using pink noise, speech noise, white noise, those are non-linguistic. So I'd like you to use four-talker babble. You might use six or eight. That's fine. I don't think I'd use anything above that. I wouldn't use 12 because it starts to become a blur. The reason you want four-talker babble is because it's linguistic, and people can make out the individual phoneme, sounds, words, sentences, and that is going to replicate what they're going through at a restaurant, a cocktail party, something like that. Whereas 12-talkers becomes a murmur, so it loses definition of the linguistic qualities. So we have four-talker babble. So you give me 70 decibels of speech in the front, 55 dB in the back. That's a 15 dB signal-to-noise ratio. And I should do fine if I have absolutely normal hearing. So if I get three words in a row correct, same as you would do for a pure-tone audiogram, you're doing Houston-Westlake. You're going to keep the signal exactly where it is at 70 decibels for somebody with normal hearing or mild loss on an audiogram. If they have a moderate, severe, or profound, then you want to do MCL or MCL plus 5. So then I'm going to go 70 and 60. So now that's a 10 dB signal-to-noise ratio. If I get all three or five words in a row correct, then I might go 70 and 65. So that's a 5 dB signal-to-noise ratio. What happens there is the people with mild to moderate loss are going to have real difficulty because if you look at Mead-Killian's chart here, they, in general, are going to need 8 dB signal-to-noise ratio, and you're giving them 5. So that's really going to kind of fall apart. People with normal hearing probably do okay at 70 and 65. Not great. It's difficult, but they can do it. And then if you go and bracket that in 1 or 2 dB steps, you can see, well, it really only takes 18, maybe 20, 25 words, and you can actually bracket this within 1 decibel. So we'll talk more about this, but that's the idea. So you know now that people with normal cognitive ability, normal hearing, should have a 2 dB signal-to-noise ratio requirement. That's called an SNR50, the signal-to-noise ratio to get 50% of the words correct. And people with a mild to moderate loss are going to need 8 dB SNR50 signal-to-noise ratio to get 50% of the words correct. So let's look at Mrs. Smith here. She's a 35-year-old PhD electrical engineer, a pretty smart person, and she's the CEO of her own business. And she comes in and she comes to the office, complains that she has difficulty hearing her husband and kids at home, difficulty hearing employees at staff meetings, can't hear in restaurants, bars, wedding receptions, things like that. So the ENT looks in her ear, normal ear canal, does a head and neck exam, everything looks good, says let's get an audiogram, we do that, pure tone average is zero, SRT is zero, word recognition and quiet is 100%. Well, at that point, most of us start doing what's called the happy talk. We do this counseling where we say, well, you just need better lighting, you need to sit closer, and it's kind of bogus. What we should have done is tested her speech and noise. And had we tested her speech and noise, supposing we found out her SNR 50 is 12. Well, if her SNR 50 is 12, she's one of the 26 million people in the USA who has a very significant problem but has no hearing loss. And again, going back to this idea of the primary thing we can do after making sounds audible is improve the signal-to-noise ratio. And that's how we help somebody like Mrs. Smith is we have to improve her SNR 50. I would recommend every patient, particularly those with normal hearing, absolutely should get a speech and noise test. Because nobody ever came to see you at 3 o'clock on a Tuesday afternoon because they had nothing else to do. Anytime a patient comes in, particularly those with normal hearing, it mandates, in my mind, that we should do a speech and noise test. And by the way, it's not just Doug's thought. I mean, when you go to the AAA best practice guidelines, go to ASHA best practice guidelines, go to IHS best practice guidelines, go to the British Society of Audiology best practice guidelines, they all say the same thing. We should be doing speech and quiet and speech and noise. That is what we have to do to replicate the problem that the patient has. And it's so important to quantify. Supposing that Mrs. Smith, let's go back to Dr. Smith here. Supposing that her SNR 50 is 2, then I could argue, well, now she maybe just needs better lighting and she needs to sit closer. OK. But if her SNR 50 is 12, she's actually performing like somebody with a moderate to severe hearing loss in the real world. And she has a very substantial problem, which if we don't document it, we have no idea what it is and we have no idea how to handle it. If we've got to measure like an SNR 50 and it turns out to be 10 or 12, we know we have to do something fairly substantial to improve the quality of her life because she's struggling. So why would somebody have normal peripheral hearing and, you know, pure tones and have difficulty understanding speech and noise or have hearing difficulty? Well, there's about a bazillion reasons and none of them are new. What if her neuropathy spectrum disorder? So this gets me to in 2012, I did an interview or a paper with Chuck Berlin from Kresge Labs. And Chuck was saying that about 15 percent of all people with moderate, severe, profound loss actually have auditory neuropathy spectrum disorder. Most of us would never catch it or diagnose it because we don't, you know, we don't dig deep enough. We don't do the work that honestly is part of our scope of practice and our best practice guidelines. And I think it's so important before we start treating and telling people what to do that we diagnose correctly. You know, and that's the same in medicine. Diagnosis first, treatment second. So why would somebody have normal, pure tones yet have difficulty understanding speech and noise. So, ANSD, auditory neuropathy spectrum disorder. Oh, and the thing to know about ANSD, what Chuck said in that paper in 2012, which you can find at douglashellbeck.com or audiology.org, AAA's website. Chuck said every time somebody has normal hearing or has hearing loss, you should check their reflexes. Because somebody who does not have reflexes yet has normal pure tones, they're probably an ANSD patient that's been undiagnosed. And it's very interesting. Of course, that doesn't bag the diagnosis. Then you have to go on to do an ADR and other things. But Chuck's suspicion was that anybody with normal hearing, as far as pure tones, who comes in complaining about speech and noise, and you can't find anything but they don't have a reflex, that's an indication of ANSD. Sorry about that, I had to sip a water. Cochlear synaptopathy, I don't have time to get into that today. We have 26 minutes left and I have 25 minutes of work. So, but I do have a few papers that discuss cochlear synaptopathy, as well as hidden hearing loss, as well as auditory processing disorders, neurocognitive disorders. The number one, of course, is Alzheimer's disease. And the rate of Alzheimer's disease in the USA is kind of staggering. By the time you hit age 85 in the USA, you have a 40 to 50% chance of having Alzheimer's disease. Attention deficit disorder, anybody who has a son knows what that's about. ADHD, pretty similar, but a little different. Attention deficit hyperactivity disorder. Alzheimer's, we spoke about briefly. Traumatic brain injury, you may not think that that's such a big deal, but as a matter of fact, in the USA, there's one million new TBI cases every year. Dementia, just, you know, run-of-the-mill dementia, not necessarily Alzheimer's, but people who lose word-finding skills and they lose focus, they lose attention. They might lose some working memory, some short-term memory. Extended high-frequency hearing losses, particularly asymmetric ones. Dyslexia, specific language disorders, blast exposure. You know, all of these things could be the signs and symptoms that a patient has absolutely normal pure tones, but is not doing well listening, and that's why we need to measure it. Because if it's four or five, if their SNR50 is four or five, that's pretty manageable with most hearing aids, because most hearing aids can improve at two or three dB. I published a paper in 16 or 17 with Nick Legoff looking at our products, and I'm not gonna go commercial on you, but yeah, we did find that you can improve the signal-to-noise ratio by 6.3 dB using Oticon Open products, and that's pretty substantial because most directional and beam-forming, you know, you're looking at two or three dB, maybe four dB improvement if the stars align and everything's awesome. So we do need to know what their SNR50 is because that tells us the definition of their problem and gives us a target to overcome. If we just say, oh, everybody has problems with speech and noise, first of all, that's not true, but second of all, there's a world of difference between a patient with an SNR50 of five versus an SNR50 of 18. So here's a bunch of speech and noise tests, and this comes from, these test times were all, Rachel McArdle wrote this over 10 years ago, and I rounded them all up. So, and of course you could do this on kids, but the take-home point is when you're doing things like the HINTS, the QUICSIN, the BKB, or the WIN, these are two and three minutes, and the way that you use this is you get an unaided speech and noise score on every patient, every time, and if you look in the lower left, absolutely you can do this with children. It depends on the kid. You know, I am the world's worst pediatric audiologist, so I probably, you know, I don't like to see kids, you know, who are below 30, but some of you will see children, the audiologists, and when you do, you know, it depends on the kid and the motivation, and did you gamify it and all this stuff? I think a willing child with a competent audiologist, you could probably test them down to four or five. You know, I don't know, I'm not an expert in that, but I think you could. And people ask me, you know, which test to buy. I don't know that I would advocate, I mean, my favorite out of all of these is the BKB-SIN. I like that because you can change in one dB steps, so you can actually bracket and threshold just like you do with pure tones. It uses pediatric words, I like that a lot because when you're thinking about a brand-new hearing aid patient in the USA, the average age that a first-time user presents is between 65 and 69. The last market track said 69, now it goes down a couple of years, but the point is at age 65 to 69, there's a chance of MCI, mild cognitive impairment, and what that means is you use simple words. I mean, I'm not trying to get to a listening thing here, I'm trying to get to a hearing thing, so I don't want aphasia, I don't want memory, I don't want sentences, I don't want any of those things to be in my way. I want to use simple, simple words, and I want to get their true SNR 50. Now, this is one that I just published, and this one is totally free. This is my buddy Lauren Benitez, she is a captain in the US Army, she's an audiologist, and she and I just published this in May and June 2019 through the AAA, so you can get this at audiology.org, just put in Beck Benitez, or go to douglaslbeck.com, you should be able to find it there, and in this one, what we did that was a little bit unusual, we reported on eight or nine patients, we explained how to get a baseline on everybody, we put in an appendix, so you can see that you don't even need to do this in a booth, that's a very common complaint, is, well, I'd like to do speech and noise testing, but I don't have a sound booth big enough. Well, you could do this outside of the sound booth, and there's an appendix on this paper that was written by my colleagues at MedRx, and they talk about how to calibrate this thing and how to set it up out of the sound room, so, and we use NU6s on this, so my point was that you could use NU6s or CIDW22s, any language at all, doesn't matter, as long as it's recorded, because you're testing the patient against themselves, it's a single-subject design. Anyway, get a copy of this paper, it's in the handouts today, which you'll find associated with this webinar or at the IHS website. This is Linda Thibodeau and Dr. Schaper's work saying that wireless technology tools may allow users to approach speech and noise results that were obtained by people with relatively normal hearing ability. Hold on to that thought for a minute, let's move to this one. Excuse me, so this is Galen, Kapesh, and Lewis, as well as Beck, Larson, and Bush. Both of us, both papers describe successful use of FM by vets and patients with blast exposure and normal audiograms, and both papers point out hearing aids were also successful. So it depends on how much of a deficit we're talking about. If we're just trying to improve the SNR50 of somebody with a three, a four, or five, a lot of hearing aids can actually do that. They can improve the signal-to-noise ratio by two, or three, or four, and there are some that can go up to six, or seven, or eight, or nine, although they're very rare. So I don't wanna get your hopes up that you can fit somebody with a hearing aid and expect seven, eight, or nine, but you could get it. In our paper, the one I spoke about earlier with Dr. LeGoff, we found 25 73-year-olds, the average improvement in SNR50 was 6.3. Now, when I say that's the average, that was the average, and you can have a copy of the paper. It's either in your packet or you can get it from douglashealthpack.com, but the point is that when we say 6.3 dB improvement on average, that does mean somebody got 4.3, and that also means somebody got 8.3. So yeah, so that's why it's so important to measure. You can't just say, oh, this hearing aid does X, Y, or Z. That doesn't mean a lot in isolation. You have to test it on the patient in situ, in the real world, to see what they're actually doing with it, and that gets us back to stuff like real ear measures, which are absolutely critically important to doing your very best and my very best, and then giving the very best quality fitting to a patient. You can't do that without measuring the sound pressure of the ear canal. You can measure it a number of ways, of course, but it's important to do it, and this is one of my favorite slides in this presentation. Nothing new under the sun. 1989, my buddy Carissa Bennett published this paper in Otolaryngology Head and Neck Surgery, which is the flagship journal for the American Academy of Otolaryngology Head and Neck Surgery. So she had 20, she had 100 patients, right, and they all had fairly normal hearing, and what she did is she fit them all with hearing aids, and of the 100 patients who completed a 30-day trial, 92% purchased the hearing aids, and six months later, 85% of them considered it to be a worthwhile investment after using the hearing aids six months. Now, please be so clear here. Nobody is saying, I am not saying, Doug is not saying, IHS is not saying, Oticon is not saying fit people with normal hearing. None of us are saying that. We're saying we need to test deeper, test to our scope of practice, come up with a diagnosis before we treat, and if the diagnosis involves a exaggerated, I shouldn't say exaggerated, a very significant signal-to-noise ratio deficit, a supra-threshold deficit, we should diagnose it, we should help the patient manage it, we should allow them to learn about technology that will improve the quality of their life. So if they're totally normal, normal, normal, I wouldn't approach it, absolutely not, but if they have normal pure tones, normal SOT, 100% word recognition, and they have, let's say, an SNR 50 of seven, and they're complaining about speech and noise, of course, there's a zillion things you can do to help them overcome that. So well-fitted hearing aids, speech and noise, and hearing difficulty. Christine Rupp and her colleagues published in ASHA in 2018. She had two groups of patients, 20 normal hearing, younger folks, no self-reported hearing difficulties, and group two is about 20 people, also young, not as young, but young-ish, with self-reported hearing difficulties. So this is kind of a cool study. She fit everybody in group two, those who had hearing difficulty, binaural, mild gain, RICs, four-week trial, directional and noise reduction turned on. She did a huge assessment, look at this, HHIA, APQ, dichotic digits, gaps in noise, MLDs, huge amount of work here. And she gave them five to 10 dB of insertion gain between 1K and 4K. Now you can't do that, of course, unless you're doing real ear, because you would have no idea what's actually happening. And as you know better than any of the other professionals involved with this, if you give too much sound, of course you can damage your hearing, absolutely, no doubt. So that's why we have to measure everybody with real ear to make sure that we're staying in a safe zone, that we're not giving them too much noise, such that we can cause hearing loss, or noise trauma, and all that stuff. So two-thirds of the patients who were fitted with hearing aids in group two, two-thirds said hearing aids helped a little or a lot in quiet, and two-thirds said they helped a little or a lot in noise. So the results indicated that mild gain amplification is viable for some people, about two-thirds, who present with hearing difficulty in this study, and who have thresholds within normal limits. The number one tool that I wanna make sure you're aware of and using is, of course, a remote mic. Now some of you will say, oh, I use an FM. Well, that's okay, there's nothing wrong with FM. The thing about the advantages to a digital remote mic is they cost about a third of the price of an FM, and I can't speak about the other manufacturers, but ours goes out to about 10,000 hertz. Most FM systems, I believe, go out to about 7,000, 7,500 hertz. So not a huge difference, but a very substantial difference in price, and of course these things are so tiny, right? These are, off the top of my head, maybe an inch by two inches. You can see the little clip on one there. So what does a remote mic do? Well, it improves the signal-to-noise ratio by 12 to 15 dB, way above and beyond what your hearing aid can do without it. And so a remote mic improves the signal-to-noise ratio, it reduces reverb, and it minimizes the deleterious effects of distance. Remote mics are kind of cheap, and it's the one tool that you have. You can give a patient, teach them how to use it, and actually make a world of difference in the outcome, because when they're in that restaurant, in that cocktail party, in that tavern, they're trying to pay attention to another person who they're having dinner with. This is the one tool that can improve their signal-to-noise ratio by 12 to 15 dB. Some people will say 20, I'll show you that in a little bit. I like to say 12 to 15, because, you know, I'm kind of conservative. Yeah, we're not talking politics, okay. So, remote mic systems. So most remote mic systems deliver the audio signal via digital radio frequency transmission. And Jane Maydell's new book, Maydell and Flexer, brilliant, brilliant book on pediatric hearing aid fittings, and it's third edition, and Jane and Carol are both friends of mine, so I want to disclose that. But the books on pediatric audiology are brilliant, and the third edition came out in, I want to say April of 19. So Jane Maydell and I were doing an interview for Hearing Review on the new book, and I asked this question very plain. Does everybody need a remote mic? And Jane said, yeah, absolutely. There's no doubt. Children and adults with hearing loss and or listening difficulty absolutely need and would benefit from remote microphones. In fact, superior speech recognition in noise is possible with digital remote mics compared to FM. And look at the date of this. This is Linda Thibodeau back in 2014, five years ago, and Jace Wolfe in 2013, six years ago. Keith and Bertie, 2014. FM systems are being replaced by our digital remote mic. Well, that's not gonna happen tomorrow, or probably in the next year or two. Of course, there are some huge differences in what happens with remote mics versus FM. So FM in a classroom is kind of cool because you can have one person lecturing or teaching, and you could have 25 students wearing an FM receiver. So that's cool. You can also, of course, do that with a telecoil, just as a reminder. With digital remote mics, although I anticipate that's gonna happen in the future, you'd be hard-pressed to do that now. So digital remote mics are primarily for your adults engaged in one-to-one conversation. And don't be waylaid by the whole business about, oh, what are they gonna do at Thanksgiving? Well, Thanksgiving's just gonna suck, like it does for people with normal hearing. But the truth of the matter is that 80% of your conversations in restaurants and cocktail parties, yeah, they're with one other person. And I can give you references on that. So let's not throw out the baby with the bathwater. Let's not say, oh, we're not gonna give you a remote mic or demo it because Thanksgiving is coming. That's just silly. And putting a mic, by the way, in the center of the table, the noisy table, has never helped anybody at any time. So I don't recommend that. I do recommend counseling. The number one and two most important things that we can do as licensed hearing care professionals is counsel appropriately, give realistic expectations, and offer oral rehabilitation strategies with the tools and the tips that we provide. Here's another, well, this is the same one, okay. This is a relatively new paper, it came out a year ago. Salehi Parsad-Vonkert. Hearing aids with directional mics are the most common solution to signal-to-noise problems, but they only give two to three dB of improvement. And that is not new. We've known that for a long time. Now, a lot of people get confused. They see the tear strip from a hearing aid analyzer and it says five, six, seven, eight. Well, that's true on KMAR, right, Nose Electronic Mannequin for Acoustic Research, in an anechoic chamber with sealed ear canals listening to pure tones. But your patient is doing none of that. Your patient is listening to speech in noise, probably with a rick or a right, and so you don't get that same dramatic benefit. Now, you could take a rick or a right and put a full-shell ear mold on there and do a much better job as far as signal-to-noise ratio. But of course, the patient will find that frustrating and they don't really want their ear canal plugged up anymore. Excuse me. So the question for us is are we offering information, hearing aid trials, signal-to-noise ratio, enhancing technologies that could enhance the quality of life for the patient? Or, as Christine Root asked, are we doing a disservice to our patients when we label their hearing as normal or mild despite supra-threshold auditory deficits? In the presence of hearing within normal limits on an audiogram. So I think that's a really good question that we have to pay attention to. We have tools that can make their quality of life better, that can improve their signal-to-noise ratio, that can allow them to do much better in the most deleterious listening situations. But most of us, we don't offer it. We don't demo it. And so the patients walk out frustrated, and there's 26 million of them who come to see, well, they don't all come to see us, of course, but many people come to see us with normal hearing and we do the happy talk rather than showing them technology that could improve the quality of their life. And again, before showing them that technology, I want to measure their SNR 50 because that tells me what my target is, tells me what I need to do. So our challenge is beyond hearing. It's to improve the opportunity for listening success. By way of reminder, 37 million people with hearing loss on an audiogram in the USA, 26 million people who don't have hearing loss on an audiogram but have hearing difficulty and or signal-to-noise ratio deficits. This paper, I was delighted to publish this just about a year ago, came out October of 18. And if you look at my 25 or so co-authors, you'll see that these are really, really smart people. And so this isn't a hearing aid thing. It's not one of the manufacturers. This is an audiology thing. This is a bunch of well-known audiology authors across four continents saying, you know, there are a lot of people with normal hearing sensitivity. They have hearing difficulty and or speech-to-noise problems. And this is not a quick read. This is one of those that, this is about 13,000 words. It was published in the Herald Review. It's in your handouts for this webinar. It's at the IHS website. You could also get it from heraldreview.com, put in Beck, Danauer, and Abrams, it'll pull it up. And it's so important. I think this is among the most important papers I've ever written, and I really wanna encourage you, grab a glass of wine, sit down, spend half an hour reading this. And I think you'll be surprised and hopefully delighted with what's in here. And, you know, Jeff Danauer and I go back 30, 35 years. Jeff's one of the smartest people in audiology in the history of the world. But Jeff and I were thinking about that paper after it got published, and we thought, you know, ENTs need to know this stuff too, and they're probably not gonna read a 13,000-word audiology paper by 25 audiologists. So what we did is Jeff and I composed this simpler version, to be honest, you know, but it's in otologic terminology. It's written for ENTs. It covers much of the same material, but it's in the Journal of Otolaryngology ENT Research, because we wanted to make sure it was accessible and available for ENTs, so that when you start to do speech and noise testing, and you're recommending an FM, or you're recommending digital remote mics, or you're recommending hearing aids or pocket talkers, or, you know, so many of these tools that we have, and, you know, the physician quite often will say, oh, he doesn't need that, he's got normal hearing. Yeah, that's wrong. I mean, there's more to hearing than the perception of sound. Hearing is perceiving sound. Listening is making sense of sound. Listening is untangling sound. Listening is comprehending sound. And there are many, many people of the 63 million who need help just in that area. So this paper was written specifically for ENT docs. Again, it's more in their terminology, less in audiology speak. And I want to close with these ideas from Jane McDonald and Carol Flexer. This is the preface to their second edition of their pediatric book. Access to the brain through audition is essential to brain development. The brain can only organize itself based on the stimuli received. The degree of hearing loss does not determine functional outcome. Performance with technology is what determines functional outcome. So before I go back to our hosts and ask them to take over the Q&A, I want to point out two things. I started speaking earlier about how we do things a little bit sideways in audiology and hearing aid dispensing, right? We do pure tones, otoscopy, video otoscopy, we do history. But remember, when you were learning all this, you were supposed to do a communication assessment first. And I think that's much more important than any of the things that follow. Communication assessments, listening assessments are things like the COSI, which is the Client-Oriented Scale of Intervention, perhaps the Hearing Health Care Inventory for Elderly, that's HHIE, Hearing Health Care Inventory for Adults, that's the HHIA, the AFAB, Abbreviated Profile of Hearing Aid Benefit, and there's plenty of these out there. These scales, they're the ones that tell us whether the patient's having difficulty. Their pure tones don't really tell you that. You can have lots of people who have mild to moderate sensorineural loss who will never seek help. In fact, here are the numbers. You've got 37 million people in the USA who have hearing loss on an audiogram, and you've got 26 million people who don't have hearing loss on an audiogram who have difficulty. But if you were to look at those 37 million who do, only about one out of six will ever seek help. And it may well be that the reason they don't know that they have hearing loss, they're not in denial. Maybe some are, but the vast majority, I don't think so. I've never thought so. I think that the reason most people with a precipitous loss or a mild to moderate loss don't seek help probably has a lot to do with the fact that they're doing fine. So if you did a COSI or an HHIE, HHIE, AFAB, things like that. The other one that I should mention is the IOI, the International Outcomes Inventory, also brilliant. If you were to do those, you'd see that the patient does no problem, no problem, no problem. And then if your pure tones show mild to moderate loss, that doesn't mean they're in denial. That may mean that they're really, really smart. Their brain is absolutely stellar, and they're able to untangle the acoustic information around them that makes sense of it. So they actually don't have much of a problem. They have hearing loss, but they may not have a problem listening. And it's a different way of thinking about hearing and listening and hearing loss and who to treat and who not to treat. But the thing is that we don't know what we don't look for. And we have to do these tests, speech and noise tests, to quantify the degree of difficulty they're having. And so it tells us what we need to do to overcome that or to manage it for the patient. So again, you have the downloads. We have all that stuff covered. And I've got five minutes left, which means we're great. So I'm going to turn it over to my colleague's friend, Diana, and see if you guys want to ask some questions. And I will wait here for further instructions. Thank you so much, Doug. We're so excited to have you here. And we've had over 250 of you join us today and over 440 of you guys registered for today's webinar. So it's been a great experience. And we're hoping that you guys are all enjoying all of the information that Doug is sharing with us today. We've been getting some feedback about some of the handouts. So don't worry if it's not working for you. We're going to make sure that we send that to you directly with our post-event information. So we'll hang on tight for that. But Doug, you are correct. We do have some time for some Q&A. And we've got quite a few flooding in. And I want to start off with a question from one of our guests, Laura. And she wants to know, how long does it take for you to see a new patient? Well, this is an issue, right? Because if you're in a busy ENT practice, you're in a busy speech and hearing, people will assign time slots based on the norm. And you may get 30 minutes, 15 minutes, 60 minutes. I mean, ideally, for me to do everything that I want to do and that my best practices say I should do, new patients, yeah, I'd like to schedule them for at least an hour so we can actually do everything we're supposed to do. I don't like guessing. I don't like doing screenings. I'm that guy. I don't believe that we should do screenings on children or adults. And if you read Asha's literature, you'll see in the screening literature, we catch just as many kids as we miss. So screenings are important. And I get the idea. But I think anybody who self-refers, who comes into the office to see you because they're having difficulty hearing or difficulty listening, I think we have to do it all. And I'm concerned that a lot of the screening protocols that exist today in 2019 were thought of in the 60s and 70s before we had otoacoustic emissions, before we did ipsi and contra reflexes, before we had tympanometry of different frequencies. And so we're able to determine a lot more about why somebody's not understanding speech and noise in 2019. And if you're given 15 minutes, that may be okay in an ENT office to do airborne and speech. But I don't think that's the end-all and be-all of what we do in audiology or hearing aids. And I think it's on us. I mean, we have to make sure that we have the time allotted to take care of people with the tests that are consistent with best practices and to make sure that we avail the time that's needed. And it wouldn't be terrible if at the end of the day, we had an extra hour to write chart notes that would work out instead of taking them home. But yeah, so it takes time to do things properly. But think about this. When you're seeing a physician or a dentist, I mean, you don't want them rushing. You want them to take the time that it takes to do an excellent job and take care of you personally in the manner that you deserve because you're a person, you're a patient, and you're paying them good money to get it done. So the real world, yes, we rush way too much and we try to come up with answers before we've done complete assessments. And that's just not a good idea. That's not in anybody's best interest. So thank you, Laura. I appreciate the question. Those are my thoughts on them. I'm sure it's controversial. But as a patient and as a doctor, I want to tell you that there's no shortcut for putting you in the proper. Thanks, Doug. We've got a question here from Hanan. And Hanan wants to know if you can talk about the issue of closed versus open fittings. Can we expect decent SNR improvement with open fittings when many patients may have normal thresholds but don't accept closed fittings? Can you talk a little bit about that? Yeah, open and closed fittings is an issue because universally, and when I say that, I don't mean every patient, but I do mean about 90 percent prefer open fittings. And we all understand that not including your ears is much more comfortable than including your ear. There was a paper that came out in 2014 or 15. Harvey Dillon was one of the co-authors. And they were talking about if you take a regular old RIC or RITE and you were to do a full shell or a skeleton, you'd get two or three dB more signal-to-noise ratio out of that hearing aid. But patients don't like that. So I'm aware of it. So I think that if you're going to use an open fitting, a RIC or a RITE, and you use then a digital remote mic, that's probably the best way to get a vastly improved signal-to-noise ratio while leaving the ear canal open. If they're willing to let you occlude or close the ear canal, the sky is the limit. You can probably get 20 dB out of a pocket talker. Pocket talkers are great, but they're not exactly convenient or cosmetically pleasing. And I think you can get 25, 26 dB of gain out of a pocket talker. Certainly with digital remote mics and FM systems in a closed ear canal, you could achieve 15 dB easily. And with an open canal, not so easily. So yeah, that's an issue. But of course, the patient's sort of in charge of what they will or won't wear. We can suggest and we can recommend, but the patient is the ultimate authority in what they're actually going to do. Great. Thank you, Doug. We've got another question here from Anne, and Anne wants to know, with the increase in technology and the resulting lack of sleep hygiene leading to overactive brain processing, could this be a factor in depleted SIN abilities, like a top-down versus a bottom-up hearing-wise? That's an interesting question. I'm going to ask you to repeat that and to say that in different words. I'm not sure that I understood exactly what Anne was asking. I think what Anne is looking to find out is if, with an increase in the different technologies available, what can we expect to, does it affect our SIN abilities? Do we have to, is there a different method or a different way to look at this that might be, that might lead to overactive brain processing or how would we work through that? Yeah, well, you know, there's all sorts of things going on here at one time. Remember I said that when we're talking about the ability to listen, you know, we have to attend, we have to intend, we have to have the right vocabulary, we have to have the right language. I mean, it's not just hearing, right? There's much, much more going into this, and I think that as audiology and hearing aid dispensing and ENT moves on, we have to look more globally at the patient because we haven't been doing that. You know, we look at a set of ears, we look at a set of, you know, we look at an audiogram, which is essentially pure tones. 80%, 85% of us do live voice testing, which I would argue has almost no validity at all. Everything should be recorded. Everything should be done properly. I mean, there are so few of us, and boy, I don't mean to upset people, but most people have never read the best practice guidelines. You know, they say, oh, I'm doing best practices, and you ask them whose guidelines they're following. Oh, well, I do. You know, that's not best practice. Best practice is based on peer-reviewed outcomes and expert opinions, and it's published by the national associations, and all of them say that there's so much more to this than simply pure tones. So I do think, yeah, things are going to change dramatically. I think it's up to us to be on top of the game. It's on us to do everything we can to improve the quality of the life of the patient, and I think we have to realize that hearing, although critically important, is step one. Listening is the end game, and that's what we have to focus on. There's more to it than hearing. You know, there's all these other factors, you know, working memory and, of course, attention and intention, as I said earlier. Do they have the right vocabulary? Do they know the topic? Did we get them oriented as to what the topic is? Do we have visual redundancy? You know, all these things are critically important, so I think hearing is essential first step, of course, and I think what we should always measure, which is not a new thought, is the outcome with the equipment being worn as it would be used in the real world, and that's something Jane Maydell and Carol Flexer have really focused on in many of their books, is that, you know, it's the in-situ outcome that matters the most. I mean, if you fit a hearing expertly and you've got NAL-NL2 or you've got DSL-5 and you hit target, that's awesome, and that absolutely is. I don't mean that in any negative. That's exactly what we should be doing, but then the only way that we know it's successful is to measure the result of that person wearing that product in noise and see how they're doing, and if they're doing well there, then we've solved the problem and good for us, but if we haven't even checked to make sure that it would improve their speech and noise ability, we're a little bit at a loss other than to say that we hit target, and, you know, so many people will tell you that simply hitting target is not enough, and I agree. Hitting target, step one, you know, hearing is perceiving sound. That's a matter of making sure that we have the right audibility. We have the right speech intelligibility index information. We have the right audibility or articulation index, you know, and all that's critically important, so no argument at all, but the thing is what matters most to the patient and to us, I think, as professionals is the outcome. How are they doing wearing that equipment in the real world, and did we measure that? Awesome. Thank you, Doug. Now, we've got something here from one of our guests named Rick, and he wants to know if there's any evidence that doing verification and validation increases the outcome. Can you talk a little bit about that? Yeah, as a matter of fact, that's a great question. I think it was 2011, perhaps 2012, there was a whole edition of Hearing Review dedicated to verification and validation, and off the top of my head, I think the numbers go like this. Most of us, from, hi, my name is Dr. Douglas Beck. I'm an audiologist, to, okay, so I'll see you in a year. That's usually about four to six visits for people who verify and validate. It's 2.1 visits. In other words, yes, it takes a little longer, but you're not frustrating the patient sending them out with a fitting that wasn't your very best, and as a result, you know, fewer returns for credit, higher satisfaction rates, and patients will refer more patients to you because you took the time, you did it right, and they got a better result from the get-go, so yes, there's definitely outcomes on this. Mike Valente published a paper recently, 2017, I think it was, no, maybe 18, and he was looking at people who were first fitted versus real ear measures, you know, verification and validation, and about 90%, maybe 86% of all the patients who were fit to target in probe mic measures, they preferred that over the first fittings. Now, the funny thing is, at first fit, all the patients said, wow, this is great, cool, okay, got it, fantastic, yeah, but then when they got to compare it to what it was with a verified fitting, the vast majority, again, it was roughly 90%, chose the verified fitting and said, this is much better, and that's one, but I mean, yeah, there's plenty of papers out there. Thanks, Doug. Kristen wants to know if you have any comments on the technology level for the group of patients. Are advanced features such as extended frequency range or advanced noise management advantageous, or is basic technology adequate since they are typically only using a mild amount of gain? Right, this is a question that comes up all the time, and I think if you look through the peer-reviewed literature, if you look at ear and hearing, look at JAAA, look at the International Journal of Audiology, you'll see outcomes all the time that go beyond gain and compression ratios showing differences in hearing aids, and I think this is a little bit of a miscommunication in our profession, that some people have said, well, basic units and premium limit units, they're all the same, blah, blah, blah. Well, I would say that even I've published in the peer-reviewed literature, as has, you know, hundreds of other audiologists, that there are clear differences in the outcomes when we look beyond gain and compression ratios. We have to look at things like quality of life, we have to look at speech and noise ability, they're SNR50, we have to look at things like, can they tell where the sound is coming from? Again, I'm not going to try to make this commercial, but some hearing aids preserve interaural loudness differences, which are vast, at 5, 6, 7, 8,000 hertz, the difference in somebody speaking from my left side to my right side could be 20 to 22 decibels, and there are some hearing aids that can maintain those differences up to like 13 or 14 decibels, and that's very different from hearing aids that can't. So, you know, we talk a lot about this in audiology in the clinics, well, you know, the technology differences, they don't make very much difference, but I would say they do, and I would say you have to look in the right area. You can't just look at gain and compression ratios, you have to look at signal-to-noise ratio improvement, that would be your SNR50, you have to look at speech and noise ability, you have to look at the ability to localize, can you tell where the sound is coming from when you're wearing hearing aid X, Y, or Z, are they maintaining interaural loudness differences, interaural timing differences, are they allowing binaural fusion, and are they allowing binaural squelch, and these are things that happen when you maintain the differences in the acoustic landscape, and sophisticated hearing aids can do a lot of that, and then, you know, when the patient is doing qualitative measures, you can see it on hearing tracker, you know, there are hearing aids that consistently come out on the top as far as quality rates from, you know, 400, 500 audiologists, and it's not because they're all the same, it's because there are some clear differences, and it's very interesting because they almost always identify the same hearing aids as being in the very top performance as far as satisfaction and very satisfying as rated by the healthcare professionals and the patients, so I think there's a little bit of a misinformation there when people say they're all the same. There are aspects that are the same, but there are performance aspects where they're clearly different. Great, thank you, Doug, and we're going to go for our last question of the afternoon. Carlos wants to know, are dispensers and audiologists allowed to dispense hearing aids if someone has normal hearing aids? Yeah, that's a great question, thank you. You know, you're only allowed to dispense to the scope of your license. I've never seen a state license that says what hearing loss is, and again, I want to underscore nobody's telling you to fit hearing aids on people with normal auditory ability. The only time that we would even discuss fitting hearing aids or FM or digital remote mics or pocket talkers on people is if they have supra threshold auditory deficits, supra, super threshold, and or, you know, well-established hearing loss. I shared with you during this presentation quite a few papers that have shown that it is okay and it's beneficial, and think about with auditory processing disorders, the number one thing we do for children is, of course, FM systems. We don't do that really to make it louder. We do that to improve the signal-to-noise ratio. When you look at the VA literature and you look at veterans, blast exposure, traumatic brain injury, same thing. You know, we're not trying to make things necessarily louder. We're trying to improve the signal-to-noise ratio, so it is okay in my mind and according to all of my co-authors as far as, you know, the audiology phenomena going on here, but I would not even suggest that you do anything beyond your license, so you have to look, and if your state says you can't fit anybody with below 25 dB, then you can't, but I don't think you're going to find that. I do think that they all say, well, this is professional judgment, and it's sort of like in dentistry. There are some dentists who will take a divot in your tooth and, you know, clean it up and fill it, and other people say it's fine. You don't need to do anything unless it causes a problem, and that's professional judgment, and we're professionals, so, you know, I think they give us that ability in our license to make professional judgments. I don't want you to fit anybody who has absolutely normal percept, but when you have found somebody who benefits from improved signal-to-noise ratio, I think it's really important to document that and then to allow them to try technologies that will improve their signal-to-noise ratio as they go about their day, and if they choose, and if they've worn it for 30 days, and they say, yeah, this is beneficial, like the 100 people in Carissa Bennett's study from 1989, you know, if they want to get it, that's fine. If they don't want to get it, that's fine. Christine Rupp's work showed about two-thirds of the patients with normal hearing said, yes, it was beneficial in quiet and or noise, so, you know, so it's not going to be a quick fix for everybody who has super threshold auditory deficits. Some of them didn't like it. A third of them didn't bother with it, but two-thirds did, so those papers that we've got attached to this webinar are really important because they give you this kind of background, so I'm going to urge you to download those, and don't hesitate, send me a note if I can help you on that. Awesome. Thank you so much, Doug. As Doug mentioned, those handouts are available, but if there's some issues having them downloaded, we will make them available for you in our post-event survey, but in closing, I just want to say thank you, Doug, for such an excellent presentation, and thank you all of us for, all of you for joining us today on the IHS webinar, Managing Patients with Normal Thresholds. If you'd like to get in touch with our speaker, Doug, you may email him at Doug.Beck at Oticon.com. For more information about receiving a continuing education credit for this webinar through IHS, visit the IHS website at ihsinfo.org. You can click on the webinar banner or find out more information on the webinar tab on the navigation menu. IHS members receive a substantial discount on CE credits, so if you're not already an IHS member, you can find out more information on ihsinfo.org. And lastly, please do keep an eye out for that feedback survey that you will receive tomorrow via email. We ask that you take just a few moments to answer some brief questions about the quality of today's presentation. Thank you again for being with us today, and we will catch you at the next IHS webinar. Have a great day.

Managing Patients with Normal Thresholds

Douglas Elsbeck

assessment

listening problems

signal-to-noise ratio

speech in noise performance

hearing aids

wireless technology

oral rehabilitation

fitting process