Today's Train the Trainer webinar series will cover the topic of interpretation. My name is Kristen Wadsworth. I'm a board-certified hearing instrument specialist, and I've been practicing a little over 10 years now. I'm currently employed at HEAR USA as the HEAR Academy manager, where I train apprentices to become hearing instrument specialists, prepare them for their licensure exams, as well as for clinical practice. I do volunteer for the International Hearing Society's committee called the Institute, where we focus on professional development, as well as education. I do thank IHS for allowing me the opportunity to be a part of both the Institute committee as well as this Train the Trainer series webinar today. So first, a little housekeeping before we get into today's content. We first have to address that this is a recorded webinar. There will be a CE credit available if you visit IHSinfo.org for further details. Note-taking handouts, PDF, will be also available at IHSinfo.org on the webinar page. Feel free to download now before we get started with today's session. For today's agenda, we will be introducing the necessary content for the following areas, audiometric interpretation, speech interpretation, and speech and noise interpretation, but with a specific focus on Quicksend for today's presentation. We will also be providing additional training tools, tips, and tricks to help our trainers easily disseminate and teach these important areas to their mentees or apprentices. A few important pieces of information to keep in mind. Interpretation is arguably the most crucial skill set that an HCP must exhibit to make efficient recommendations. Second to completing audiometric testing. Accurate audiometric interpretation will determine whether the provider should proceed with medical referral or the recommendation of hearing devices, or sometimes on occasion, both. There are necessary steps that first must be completed prior to interpretation, including a thorough needs assessment, otoscopic evaluation, and a complete hearing assessment. We will define what our requirements consist of for a test to be considered complete. If a complete test is not conducted, I can't emphasize this enough, these results are not considered valid, and a recommendation one way or another must not be made. Audiogram documentation. First, an apprentice must understand the documentation of an audiogram. Being able to recognize universal audiometric symbols along with the formatting of the audiogram being provided, for example, if there is a single audiometric graph versus each graph being displayed separately. We also do know that audiogram documentation can also be in the form of numeric table. We do strongly recommend that the apprentice experience all three displays while practicing their interpretation skills. It is also fundamentally important for an apprentice to understand the orientation and values represented on the audiogram, including audiometric zero, intensity in dB, HL, and the conversion to dB SPL, and frequency. To gauge apprentice understanding, have them practice explaining the audiogram to family and friends, or perhaps other office staff, in a simple but meaningful way that will make sense to an individual who does not have a background or prior understanding of this information. We do also understand that differences in display as it relates to different testing equipment may be available or may be of issue in your office in terms of apprentice confusion. What we do suggest is if you can have your apprentice first start by plotting measurements by hand, pen to paper, using either a portable audiometer or simply sitting beside you and mimicking the thresholds that you are plotting in your computer-based piece of equipment. It is important that apprentices experience more than one piece of testing equipment, but first and foremost, have the ability to put pen to paper and plot the symbols on a graph. That is often a requirement for practical state exams, not all states, but some states, and it's really just a good skill set, an early skill set that the apprentice should be able to exhibit before they progress to a computer-based audiometer for better learning and overall understanding. Valid testing and testing requirements. So coming back to or further building upon this piece of information, this component here, what do we consider the necessary information for an audiogram to be considered complete? Of course, that would be air conduction, bone conduction testing, tonal UCL measurements, and as far as speech audiometry is concerned, completing word recognition, but doing our best effort to achieve PB max, completing some form of speech and noise testing, and of course, applying masking if necessary. If we see unmasked thresholds where masking may be necessary, those are not considered to be true thresholds or accurate measurements. To build further on each individual category and what frequencies are expected to be tested, obviously this will vary by source, but it is strongly recommended. Air conduction, we test frequencies, as we know, 250 through 8,000 hertz. The more information we can provide to the fitting software, this will result in better programming and better sound quality and a more acceptable first fit for the client. So not only testing the octaves, but if possible, also testing the inter-octaves. And of course, more of a need versus want, when the slope between octave frequencies, when that difference is greater than 15, we know it is necessary to test those inter-octave frequencies. And when we do have to test inter-octaves for the better ear, the first ear, we do recommend keeping the audiogram consistent and also testing those inter-octaves for the poor ear. For bone conduction, of course, the frequency recommendation is a little bit different, recommending we test 250 through 4,000 hertz for that range. And again, following the same principle, if inter-octaves were completed for air, then we also do suggest that they are completed for bone. That way, if there is a need for masking or adjacent air bone gaps, we have the ability to pull those pieces of information together in their totality. And of course, testing tonal UCL measurements, the recommended frequencies there are 500, 1,000, 2, 3, and 4, not in that particular order, of course, but just listing them, providing them to you. And of course, when it does come to masking, we know our analysis is individual, is individually completed, meaning we are looking frequency by frequency and determining if that need is there in completing that task for true measurements. As far as speech audiometry is concerned, when we say we are striving to achieve PBMAX, that PBMAX is word recognition testing, but it's doing so under the perfect conditions, meaning we are using recorded stimulus, recorded speech. We are using the NU6. We are completing a full 50 word list, if possible, if not, 25 words is acceptable. And we are using the 2K presentation method, the sensation level method there. Then we are also completing at least one form of speech and noise testing. And again, for today's presentation, we will be focusing on Quicksend, but of course, there are other speech and noise tests available to you. And of course, again, reinforcing masking, something that's especially important that I often notice is masking for air and bone are often completed, but speech masking is often overlooked. So ensuring that we are effectively masking for speech testing as well when necessary. All right. So let's start with the metric interpretation. So the first piece that I like to address and cover with my students is pure tone audiometric interpretation. I think this is the foundational piece, how we also interpret speech testing and speech and noise testing, I think should come after. So let's first break down this area. The three major components are degree, configuration, and type of course. So focusing first on degree and severity, and here's why. Same tip. Degree and severity is all about memorization, right? For our visual learners, it is plotting a blank audiogram, taking a blank audiogram, and plotting over that blank audiogram the different classifications that we follow our system for identifying the degree or severity of loss. From my pen to paper, reading and writing learners, that's simply listing out the classification system over and over again until it sticks. But I think this is the first piece to address because truly it is the most simple to comprehend and memorize. So how do we define degree or severity? It's the amount that the thresholds are elevated relative to normal hearing, always being mindful and repeating to the apprentices that we know that the audiogram is upside down. So sometimes we see terminology like elevated, that sometimes feels a little bit backwards because in a way it is. In our classification system when we are looking at an audiogram and describing the severity, we can take an average by calculating the PTA, which we'll discuss further in a moment, or we can simply look and measure where the majority of those frequencies are. So our classification system is as follows. 0 to 20 dBHL, that is the range of normal hearing, or as we also identify it as within normal limits, 21 to 40 is the mild hearing loss, 41 to 70 is a moderate hearing loss, 71 to 90 is a severe hearing loss, and 91 and greater is a profound hearing loss. We understand that other classification resources exist, different terminology exists. We understand that other organizations define slight hearing loss and terminology like moderately severe. However, we do politely ask that for the purpose of minimizing confusion and helping your apprentice understand the classification system that they are going to be tested on, this is it, and we do suggest that they follow this system. I have students that have followed their sponsor system, again, different resources, different time of learning, and there's often a lot of confusion where they mean to identify a mild hearing loss, but use terminology like slight, or when it comes to moderate and severe, identifying a loss as moderately severe, and again, there's confusion surrounding what the cutoff is for the different categories. So again, emphasis on sticking to this classification system, because this is what your apprentices will have and experience, both on their exams, as well as clinical practice. So speaking more to calculating PTA, there's a few different ways to go about this. The first of which is your classic three-frequency PTA calculation. So for your typical slope and configuration, that of a gradually sloping loss or a flat configuration, you will go ahead and use the three-frequency PTA, which means for each individual year, we are taking the threshold measurement at 500 hertz, 1,000 hertz, and 2,000 hertz, and we are dividing that by three. When we do, however, come across a configuration, all of which we will discuss later in today's presentation, that we consider to be unusual, I think the most classic example of that would be a precipitously sloping or steep sloping loss, we do suggest when the slope is greater than 15 decibels between octaves, that the two-frequency PTA is utilized. And what we are doing is we are taking the two best thresholds amongst the frequencies, 500, 1,000, and 2,000 hertz, and dividing it by two. The way I explain it to my students is the two thresholds that demonstrate the least amount of loss, we are adding those two together, dividing it by two, and that will give us our PTA calculation, our two-frequency PTA calculation. Be mindful that if we don't first observe and interpret, or identify rather, what that correct configuration type is, that may negatively influence what PTA calculation we use, and that can lead us to misinformation. It's also important, too, to note that the two-frequency PTA calculation may not always depict an accurate average of severity of loss for a given audiogram, and let me show you what I mean by that. Calculating PTA is a quick and easy way to estimate the average severity of hearing loss. When calculating PTA on a gradually sloping loss, like the one that we see in figure A, we take a three-frequency PTA calculation, taking the threshold values at 500, 1,000, and 2,000 hertz, adding them together, and dividing the total by three. This is your PTA, or average severity of hearing loss for that ear. This is one way of estimating that. For example, for the left ear in audiogram A, we would add thresholds 40 for 500, 55 at 1,000, and 60 at 2,000 hertz, add those together, making a total of 160, dividing it by three. That makes 53.3. This falls into the moderate category, so it would be appropriate to identify the loss in the left ear for audiogram A as a moderate loss. For audiogram B, on the other hand, this demonstrates a precipitously sloping loss, so our PTA calculation would be slightly different. You would take the two best thresholds, or those demonstrating the least amount of loss, between 500, 1,000, and 2,000 hertz, and divide the value by two. In this case, that would be 10 at 500, 15 at 1,000, adding it together, making a total of 25, dividing that by two, which equals 12.5, which is in the normal category. Based on the loss we can see here, it's not as accurate of an approach to utilize when we encounter this configuration type. One additional consideration for audiogram B that I want to bring to your attention is that in the event that the two-frequency PTA calculation does not appropriately identify the degree or severity for the audiogram, what then would be recommended is utilizing instead the high-frequency PTA calculation, which is noted on the prior slide as well, and that would be taking the audiometric air conduction thresholds for 1,000, 2,000, 3,000, and 4,000, adding those four values together, and dividing that number by four. That would give a more accurate depiction of degree or severity of loss for this audiogram B on the right-hand side, so that would be a recommended application in the event that the slope or difference between 1,000 hertz and 2,000 hertz really exceeds that 15-to-20 decibel difference. Configuration. The next piece that we want to identify is configuration, and there really are two different components to configuration, the first of which is being able to tell the difference, to be able to understand asymmetric loss or symmetrical loss versus an asymmetric or asymmetrical loss, and what we are looking at is we are quantifying the difference between the better ear's air conduction thresholds and the poorer ear's air conduction thresholds, and we are determining if there is a 20 dB or greater difference between those individual frequencies and those thresholds, so if we do in fact see at least two or more adjacent frequencies where that difference between ears does exist, we would describe that as an asymmetrical loss, and we will talk more about that and what a symmetrical loss is in just a moment, and the second component is slope or pattern that is shown on the audiogram, so when we first look at the audiogram, what shape instinctively do we notate? Symmetry. Symmetrical hearing loss is when hearing loss is similar in both ears, usually within 11 to 15 dB at all frequencies, so it is an individual frequency by frequency analysis. Asymmetrical is where one ear is significantly different from the other, a difference of greater than 15 dB pure tone average exists between ears, and the training tip here is focusing on this component first before we continue in our interpretation really helps the student to understand, am I describing both ears as a single unit, or am I having to separate my focus to each ear individually because there is perhaps a different degree of hearing loss, a different configuration. In an asymmetrical loss, we often find that that be the case, and a different interpretation or explanation of results may be necessary. So it is important to have this component done at the early stages of interpretation to help make the rest of the process easier. So again, if we were to work with a student and first look at this audiogram, the first question really even prior to degree or severity, though we know that is memorization-based and that is easier to focus on first, just in terms of basic knowledge, the first question I often ask my apprentices, my students, when we are interpreting is, is the loss symmetrical or asymmetrical, right? That is the first task, and their responsibility would be to go from left to right, identify the difference in this case between the right ear's air conduction thresholds and the left ear's air conduction thresholds, and determine if a difference of 20 dB or greater does exist, which we know, of course, does exist here in this audiogram. So we would then shift our focus and say, okay, great, let's focus on the better ear first. We will then describe its degree, its configuration type, its shape or pattern, and then we will focus on type of loss. And then we will work through those same exact questions for the left-hand side. But of course, again, trying to always simplify the process and make us have a little bit of a flow as well so the students are prompted and know what questions are going to be asked and in what order so they can kind of get in the habit and respond more quickly as well when they are tasked with interpreting. Something that we often notice a training tip here is when we are also establishing symmetry to ensure the student is not confusing a conductive hearing loss or really type of loss in general with identifying if the loss is symmetrical or asymmetrical. Two classic examples here. We often see that when a student sees an audiogram on the right-hand side, much like this one here, a purely conductive loss where we see those big air bone gaps, the students will often erroneously compare bone to air and not air to air, which is what we are looking for when we are trying to identify symmetrical and asymmetrical. So make sure that you provide that distinction early on in your training, and hopefully that will mitigate some confusion for your mentees as well. So the next big piece is the second component of configuration type is again, when you look at the audiogram instinctively, what shape, what pattern? We know the two main categories or two overarching categories are sloping and flat, of course, but we do have a blueprint that we follow at IHS. And those that are listed here are the configuration types that we do wanna see the apprentices utilizing and identifying when interpreting audiometric data. Again, we do acknowledge and exist that terms are outside of our repertoire here, right? There might be trough shaped, there might be island of hearing, some terminology that is slightly different, but can often be used interchangeably synonymous with those that we have listed here. And same concept training tip applies here, try to stick to what they are learning to minimize confusion as much as possible. So that means us as trainers, we're having to adhere a little bit, be a little bit flexible, and maybe adopt terminology that we may not have been taught. But this is what the students will be basing off of, and that is flat, gradually sloping, markedly sloping, precipitously sloping, or ski slope or steep slope, reverse slope, cookie bite, reverse cookie bite, corner audiogram, and noise notch. So we're gonna focus on one of these each at a time, and we are gonna move through them fairly quickly. The first of which is flat, which occurs when there are relatively equal thresholds, relatively equal hearing loss within a 20 dB range, across frequencies, 500 to 4,000 Hertz, thresholds are approximately equal, right? So what I say to my students is, think of as a good rule of thumb, all of our thresholds will generally fall into the same severity or category of hearing loss, right? So if all of our thresholds fall within that, you know, 40 to 60 dB range, we would constitute that as a flat hearing loss. Though that may not always be applicable, of course. The next configuration type is gradually sloping. We often do find that students confuse flat with gradually sloping. I always say again, ask them instinctively, what is your first guess? Is it sloping or is it flat? But if they're looking for further information, what you can do is you can take the slope between the octave frequencies, add the slope, the five different differences between octave frequencies, add those together and divide them by five. And if the average slope falls within zero to five, we know we would classify that as flat. If the average falls between five and 10, we know we would classify that then as a gradually sloping loss. So again, gradually sloping is when thresholds fall off in higher frequencies at about a five to 10 dB slope per octave. Markedly sloping is also a sloping configuration, but there's a more drastic slope. Thresholds fall off at a 15 to 20 dB per octave slope in the higher frequencies and really prompt the need to test those inter-octave frequencies. Precipitously sloping, furthering that sloping category is when we have hearing loss that has normal thresholds in the lower frequencies, but a very steep drop between 1,000 and 2,000 Hertz that is typically greater than a 15 to 20 dB, or excuse me, that is often greater than a 15 to 20 dB slope. The next is reverse slope. And I often just say to my students, is there more loss in the lows than the highs? Yes, if the answer is yes, then we would classify it as a reverse slope. This is when thresholds are worse in the lower frequencies and improve in the higher frequencies at about five to 10 dB slope per octave. Cookie bite is when thresholds are better in the high and low frequencies than for the mid-range frequencies. I have a coworker, another trainer, that will physically bite into a cookie when teaching this lesson to demonstrate why or where the term cookie bite comes from. So just take a bite into a cookie. That is what you will visualize. Training tip, if you wanna bite into a cookie for your apprentice, it's a good thing to do. They seem to remember that. Be mindful that trough shape and cookie bite are often used synonymously. That is okay. And we do see that reflected. To provide more context about what defines a trough shape, we often see a little bit more improved hearing in the low frequencies as well as the high frequencies. So unlike this audiogram here, where the majority of the loss is mid frequencies, maybe we would see some improved hearing at 500 or 750 in addition to in the highs, maybe 4,000, 6,000, and 8,000 Hertz. So a little bit more of an identified dip, whereas we see a nice half moon rounded shape when we are looking at a cookie bite audiogram. The next is reverse cookie bite. So taking that cookie bite and flipping it upside down or taking that cookie and turning it the opposite way. And again, it is just the opposite of a cookie bite. So we have actually the greatest or most improved hearing in the mid frequencies, and we have more loss exhibited in the low frequencies as well as in the high frequencies. The next is noise notch. We always are looking for that clear identified check mark. That's when there is hearing loss within normal limits in the lows and mid frequencies with a sharp and clear identified drop that occurs somewhere between 3,000 and 6,000 Hertz. And we do see clear identified improvement in the higher frequencies. There can be variability to where this exactly occurs. The main key component here is that we see recovery in the high frequencies, which we wouldn't otherwise see in a classic presbycusis or age-related hearing loss audiogram. Corner audiogram is when we see thresholds that are available only in the lower frequencies. Combination of the client responding and we run into output limiting otherwise, but we see a very severe loss, and we see a configuration where there is not a great deal of measurable hearing. Next is type, the dreaded type. Type we know is a single word that describes where in the total ear system the damage is occurring, where in the anatomy of the total ear the hearing mechanism is impaired. We are focusing on three, the three main categories of loss today, and that is conductive, sensory, neural, and mixed loss, though we do acknowledge and understand that some additional identifiers of type of loss exist outside of these three. So we know without bone information, without a total audiogram, we wouldn't be able to determine type. One of my biggest pet peeves as a trainer is when I only see air conduction and speech testing completed, and I see someone identify that loss as sensory neural because of the configuration type, because maybe we see that sloping loss. Without bone conduction information, we cannot make that determination. So to emphasize, type is determined by the relationship between air and bone thresholds. We must have both before we can determine type of loss. So the first that I'd like to cover is conductive. So when we are learning or thinking about conductive hearing loss, the training tip that I have for you here before we identify and describe the loss is make sure that your apprentices, mentees, students have a clear understanding of the total ear, the different components of the ear, and are able to provide you with at least one type of pathology or breakdown that will lead to or cause a conductive hearing loss. Without that piece in place first, and also understanding how sound travels through the total ear, whether it be by air conduction or bone conduction, the student's gonna have a much more difficult time being able to understand and distinguish conductive from sensory neural from mixed hearing loss. So how do we define conductive then? It's when we see air conduction thresholds outside of the normal range of hearing and bone conduction thresholds that are within the normal hearing range. It indicates pathology in the outer ear and or possibly middle ear, depending on what that condition may be. But we know the conductive mechanism being the outer and middle ear is demonstrating a loss. My training tip here is I always ensure that my apprentices understand audiogram on the right-hand side, the inner ear, drawing a line, also connecting those inner ear or cochlea thresholds. And the question simply then becomes, is there loss at the point of the inner ear? Looking at this audiogram here, we would hope that they would clearly say, no, there's not, there's loss by air though. And when we think of how sound transmits through the total ear system, I always make the analogy that, we can have a student traveling from Boston to Texas, to Dallas, Texas, let's say. They could very well drive and they could fly. We know driving naturally would take much longer. Think of driving as sound transmitting through the air via air conduction. It'll get there, but it'll take longer. Why? Has to travel through the outer ear, middle ear and inner ear. Then of course, through the respective retrocochlear pathway to the brain. Whereas when we are hearing by transmission of bone conduction, we know that that overcomes or bypasses the outer ear and middle ear space. So when we think of this, think of there being a large rock or pebble inside of the outer ear or middle ear, whatever example works best for those that you're teaching and think, okay, that pebble, if we took that pebble out of the ear, what might we expect? We might expect those air conduction thresholds to improve. Not always necessarily the case, but what do we have to do for our client with conductive loss? We have to make things louder so sound can get through or around that pebble and get to the inner ear, right? So this I think is an important and helpful way for these students to learn and better understand what is going on behind the audiogram. Sensory neural, this is when air conduction and bone conduction thresholds are both beyond the range of normal hearing for the majority of the audiogram, if not the audiogram in its entirety. There's no air bone gaps. There's no more than a 10 dB difference for any frequency between the better ear, poor ear. And it indicates pathology to the inner ear. And we know when we encumber sensory neural, we are identifying or discussing both the cochlea and the respective retrocochlear pathway. That being said, same training concept applies here, visualizing and looking at the audiogram on the right-hand side. Where is our bone line? Where is our airline? We know that if there is loss for bone, there's loss for air, and all of the thresholds are symmetrical. They're close to one another. There's no air bone gaps identified. We know that this is a pathology in the inner ear. And again, ensuring that our apprentices, our students, our mentees are able to provide us at least one or two examples of what might be contributing to a loss like this one that we see here. Mixed. Last but not least, we see air conduction and bone conduction thresholds that are both outside of the range for normal hearing with air bone gaps of 15 dB or greater present as well. It indicates pathology in the total ear system, meaning there is a breakdown in the potentially the outer ear, middle ear, sometimes both depending on the condition and also the inner ear. Client patient is experiencing both a conductive and a sensorineural hearing loss. So again, helpful training tip, same concept applies. Can the student provide you a pairing of what might be causing or contributing to a mixed hearing loss? For example, I will first task my apprentices with saying, okay, so if we have a conductive loss, give me an example of what might cause a conductive loss. Oh, an infection of the middle ear. Wonderful. Infection of the middle ear. Great. Also tell me what might be an example of a sensorineural loss. Oh, age-related hearing loss. Beautiful. So when the client has an infection and an age-related hearing loss, that will result in a mixed hearing loss, right? So though that may not be the perfect example provided for this audiogram, the concept still applies. Make sure they understand outer, middle, inner ear, and they understand what disorders occur in which compartments or components of the total ear. So practice identifying those first and foremost. Make sure the anatomy, understanding of the anatomy is solid before we move on to this piece here. And again, referencing the audiogram on the right-hand side, we always want to keep an eye out for our bone line and our total ear, our air conduction line, and asking those simple questions of, is there a loss by both? If there is, also looking at our air bone gaps and to see what that identifies. To build on that, when I am asking those questions, I am a little bit more specific in my process, and I am referencing here Dr. Valente's Back to Basics Pure Tone Testing and Audiometric Interpretation Audiology Online course. I do have the resource on the bottom left-hand side here. This is a wonderful graph that I've referenced from her audiology online course that I utilize with my students. And it's about when we are determining type, being able to break down that question into more discrete questions to help guide the student to being able to identify the correct type given an audiogram. So my questions are always as follows. Is there loss by air? Is there loss by bone? And are there multiple air bone gaps? And it leads us to yes or no questions. And depending on, of course, what those answers are, that will help to clearly identify conductive, sensorineural, or mixed. I always encourage my students to have this graph memorized because it will help guide them to be able to answer those yes or no questions, which will then lead them, of course, to the correct type. Typical audiometric findings. So we have already discussed configuration, meaning first looking at whether or not the loss is symmetrical or asymmetrical. The second piece that we looked at is being able to recognize the different audiometric patterns and or configurations. We've also recommended, as far as a training tip is concerned, how important it is for a individual who is learning audiometric interpretation to be able to associate or understand further type of loss, meaning sensorineural, conductive, or mixed, being able to understand the disorder or the etology that is contributing to the hearing loss. So when we discuss typical audiometric findings, that's exactly what we're doing. We're linking the configuration to the type so we are better understanding and realizing the disorder, the etology, the reason for the loss, and how that reason may typically demonstrate itself as far as the audiometric configuration is concerned. So the first example, which we just discussed, noise-induced hearing loss, again, discussing that notch, that V, where we see a decrease in hearing between 3,000 and 6,000 hertz, but more importantly, we see that recovery at either 6,000 and or 8,000 hertz, really identifying clearly that check mark and remembering another important aspect of noise-induced hearing loss, though it can be symmetrical in the high frequencies. We can often see one ear that is worse than the other due to the nature of the noise-induced hearing loss. For example, if an individual, you know, worked in a line in a loud manufacturing plant, and let's say the noise was closest to the client's left ear throughout the duration of that noise exposure, we might expect to see a noise notch present in both ears, but the severity of the noise notch in the left ear can be more severe. The next piece, the next audiometric finding would be the acoustic trauma. This would happen after a client had exposure maybe to a car accident, any kind of trauma that would impact the ear. Being a nearby firework, having damage to the ear, there can be a number of different causes, but the point being, we do note the asymmetry. We do note the air bone gaps, as well as the severity really indicating acoustic trauma, particularly in this case to the left ear. Presbycusis, or what we also can call age-related hearing loss, we see that typical symmetrical, gradually sloping, just ever so slightly markedly sloping, better hearing in the low frequencies, gradually sloping into the mid and high frequency loss. Again, equally in both ears is extremely important to note. And to list a few middle ear disorders, the first of which is otitis media, or what we know as a middle ear infection. And we do see consistently here, a purely conductive loss in an ever so slight loss by way of air conduction in the lower frequencies, and a little bit in the high frequencies and mids as well. But we do see consistent air bone gaps throughout the entirety of this audiogram, assuming that the client is impacted for both the left and the right side, relatively equally. Otosclerosis, I'd say the most important indicator here, and we know otosclerosis is inherited middle ear disorder that can impact both the middle and inner ear space, but particularly with emphasis to the stapes footplate, there is that sclerotic, that hardening, which really limits or constricts the mobility of the ossicular chain. And the most important identifier or audiometric signature that we are looking for in a case of otosclerosis is the Carhartt notch. When we see that dip at 2000 hertz for bone conduction, which we can clearly see here indicated for the left side. But otosclerosis, we often see that reverse slope configuration, and we can often see loss in the highs as well. And just backpedaling for a moment, the otitis media, we do see a relatively flat configuration type for that middle ear disorder. As far as congenital hearing loss is concerned, congenital hearing loss, we typically, obviously dependent on the particular cause leading to the congenital loss. We often, if it's genetic, can expect to see a cookie bite configuration or a truss shaped configuration, which we do see indicated here where the majority of loss or the worst degree of hearing loss is indicated in the mid frequencies with the better hearing thresholds indicated at the low, very low frequencies and also the higher frequencies. These are a few audiometric configuration types that are relatively consistent with the disorder or cause of hearing loss present. So challenging cases and some additional considerations. First and foremost is how many ear bone gaps? What do we do when we are, you know, in a situation where we need more information? What we would encourage and how I would answer that is, I often will tell my students there, if there is a minimum of two adjacent ear bone gaps or three non-adjacent ear bone gaps, and when is mixed to be considered? I would say if that criteria is met. If we are in a situation where maybe there's one ear bone gap and we are looking for more information, I challenge my students to reference the needs assessment, ensure that they asked all the necessary questions based on the audiogram that we're seeing, making sure that we don't have any red flag conditions present otherwise. Also, if the state permits, completing admittance testing, specifically tympanometry to gather more information. If we complete a utoscopy and the outer ear is otherwise healthy, the only other denominator can be the middle ear space of the conductive mechanism. So that testing will give us more information there. And of course, too, you know, above all, if we feel multiple ear bone gaps are there, and that is what the audiogram is telling us, we need to make the decision to refer to safeguard that client. And what about if we come across a predominantly sensorineural or unspecified loss, like we see on the right-hand side here, where we see those no responses thresholds being depicted here? That can be a challenging audiogram for our new students to kind of take on and understand. It's always about reaching output limiting, ensuring that they understand what that means. So a combination of we reached the limit of this piece of testing equipment and the client did not respond. So we are unable to specify what the type of loss is, and it's important to provide that necessary documentation. What about if not enough information was provided? Let's say maybe we run into a situation where ear and bone was completed, but masking was not, and masking was needed. We would have to complete masking before interpreting the audiometric results. Can't emphasize that enough. As far as alternative configuration types, how to address, you know, island of hearing, truss shaped, there are some that will come up, and that's okay. Encourage your apprentice to think, to try to do some independent research, to try to link some of those themselves, but I think really having these books and this coursework be their guiding light and compass. This is what they're going to be tested on. This is what they're going to experience. Try have them, excuse me, try having them stick to this blueprint here. And last but not least, again, different classification system. We already mentioned this, but if we can avoid terminology like slight and moderately severe as part of our explanations and how we are describing a client's results, this will help to mitigate, minimize confusion as the student is learning, and of course, that is very important. So, training tips. Tackle the lighter areas before taking on the more challenging ones. Prioritizing memorization based information first, like severity and configuration type like we discussed, and covering type last. The apprentices must first have a firm knowledge and understanding of anatomy of the total ear, of disorders as well, and they also need to understand how sound transmits through the total ear system. That's incredibly important as we've discussed, and I think there is evidence to support that mastering pure tone interpretation prior to speech tends to make interpretation much less overwhelming for the learner, and I think where we are, this is the most important piece, and I think the last thing that I will leave you with, and isn't necessarily notated here for this part of the section, is ensuring that you're allowing them the time to practice. I would say copying audiograms, giving them a pack of 20 audiograms from your center, that is the best thing that you can do. Audiometric interpretation really is all about practice, and don't be afraid to have them practice reverse engineering the situation, meaning ask them to take a blank audiogram and draw out a sensorineural audiogram for you, mixed audiogram for you, and a conductive audiogram for you. Something that I do with my students when it comes to this piece is I have them create their own case study. They have to provide the client's, you know, bio. They have to provide the client audiogram, and that shows me that they understand the link between interpretation disorders and anatomy of the ear, and I certainly think that's a good measure to take when we are helping those to understand this section in particular. Training tips. Practice. So at the end of the day, as mentioned earlier, practice, practice, practice. This is a guide as to how I approach audiometric interpretation, the order in which I do ask these questions, not the way in which they're taught, but the way in which they are asked. So the first of which, given any audiogram really is, is the loss asymmetrical or symmetrical? What's the severity? So if we know it's symmetrical and the loss is similar in both ears, they can describe the two ears together as one, or they can separate them if there is a difference. Configuration. So what's the shape? Is it flat? Is it gradually sloping, et cetera? Is there loss by air? Yes or no. Is there loss by bone? Yes or no. Are there multiple air bone gaps? Okay. Based on those questions, what's our type? Great. And of course, never too early to start challenging them as to what device would you recommend? What coupler? What venting? And you can build to that, right? You can build assistive listening device or, you know, what programming? This is really make it your own. But my students do prefer that when we do cover case studies, when we practice audiometric interpretation, I find that they really benefit from an organized system like this. And then of course, providing the key after they've had the opportunity to answer these questions. Next, next up is speech interpretation. So what we'll be focusing on today is word recognition, speech recognition or reception threshold, as well as speech and noise testing, more specifically QICSIN. Before we get into the content for this section, a training tip and something that I like to identify when starting is what's the purpose of the test? At the end of the day, if the student apprentice mentee does not understand why we are completing SRT, why we are completing word recognition and why we are completing QICSIN, what the purpose is and what information does it give us? Does it render to us by completing? So first things first, you know, purpose of the test is fundamentally important before we can understand speech interpretation. So how do we interpret? How do we understand what these results mean? We first have to know why we're testing. So asking thought provoking questions like what does testing information, what testing information does SRT provide us with? What's the purpose? Why do we complete SRT testing? Same questions, of course, would apply for word recognition as well as speech and noise testing and be mindful for today's, you know, for today's purpose and content, we aren't covering MCL, UCL testing or the other associated speech and noise testing options. So SRT first and foremost, because we know we're testing in that sequence as well. We are trying to establish the lowest level that the patient can hear and understand speech. SRT is used to cross check the validity of pure tone thresholds. So we know SRT should be within five to 10 dB of the client's pure tone average. Word recognition, it measures how well the client understands what they hear when speech is presented at an audible, but not loud enough or not too loud, excuse me, presentation level. Sometimes this test we know is referred to as dB max or speech discrimination. We are trying to achieve dB max and we know speech discrimination is an older way of describing word recognition testing. Scores, what does it give us? They're a good indicator of how long a patient has been coping with loss and how they may be experiencing that loss. But we know that word recognition is done in a sound controlled environment and therefore isn't necessarily a real world indication of how the loss is impacting the client. And that's why we test QUICSEN of course, right? That's why we do our speech and noise testing is although it's beneficial for SRT and WordRec to use speech as stimulus, it's often easier for clients to participate in this portion of testing. QUICSEN is really going to give us a more real world understanding of how this client is coping and managing with their hearing loss when noise is added into the mix. So it's much more helpful in establishing realistic expectations and it is very crucial for shaping what our recommendation is. Whether we recommend one device, two devices, a specialty system like a CROSS or a Bi-CROSS, an ALD, what digital features we may or may not need to recommend. So very important providing us with an estimate of the client signal to noise ratio loss which we know is very important for setting expectations as well. So focusing on first and foremost SRT testing. So interpretation of test results, we have to first have our PTA and of course our SRT ensuring that they are within 10 dB of each other. SRT really is utilized to confirm pure tone threshold testing is where it needs to be. If it is not, we need to stop, re-instruct and restart the process from the beginning. And we know that there are situations where SRT can be better than PTA and also situations where SRT can be worse than PTA. If we find that SRT is better, what can that indicate? It could indicate the client is possibly malingering or faking a loss or exaggerating a loss and that there may be a non-organic hearing loss present. It can also be a precipitously high frequency loss which we know sometimes can be tricky to have a truly accurate average between low frequency and high frequency information for that PTA calculation. SRT, when it's worse than PTA, we want to be thinking of a retrocochlear condition, right? Maybe there's cognitive issues as well or perhaps a language barrier, some language difficulty. Reminder that SRT cannot be used as a sole indicator for hearing candidacy. A couple of situations or examples as to why that might be subclinical loss. And again, focusing on that precipitous high frequency loss because we, again, we know our PTA information will be less than accurate. Shifting our focus to word recognition and I think as it relates to speech interpretation, this is really, I think, what we are focusing on in terms of test components. So, we have a classification system much like degree and severity that the students, the mentees, apprentices must memorize to have a bearing and understanding of what an expected word recognition outcome might be based on the degree or severity of loss. And those are as follows. If a client has 90 to 100 percent, that is an excellent outcome. If they score between 80 and 90, that is a good to excellent, I'd emphasize good outcome. 70 to 80 is fair to good. 50 to 70 is poor to fair. And of course, less than 50 is poor. And you would link this to the severity based on the audiogram. So, within normal limits, mild, moderate, severe, and profound. And this can be very helpful for an apprentice, a student, to be able to look at an audiogram, have an idea in their mind what the word recognition score should look like. And when there is a misalignment, being able to reference this classification system and some of the tools that we're going to discuss today, that is how we can encourage that critical thinking and putting these pieces together for that individual. So, we know that completing speech testing is so crucial. We cannot judge a client's functional impact for their hearing loss without completing speech testing. And so, really, word recognition, when we're focusing on this, what does it give us? It gives us an idea of, you know, in comparison, performance in each ear, right? Determining whether monaural performance has changed over time. So, if we saw a client a year ago versus today, was there a significant difference in measurements and is that of concern? And, you know, performance in each ear, building on that as well, coming back to that for a moment, is the difference between ears of concern and otherwise maybe symmetrical loss? And determining whether or not, as mentioned, the word recognition score following our classification system, is it consistent with the degree and configuration of hearing loss that we're seeing? Is the audiogram lining? We always say that the audiogram is like a puzzle, right? And all of the pieces must fit together well. And when there is a piece that isn't fitting well, right, no matter how we orient it, something about that requires our attention. So, when we have a mismatch, when there is a difference between ears, when there is a significant change, you know, in a short period of time, we need to rely on tools, research-based tools, that are going to tell us and direct us to make the most appropriate recommendation for that individual client. So, word recognition, we know, is important information in terms of what are we recommending for the amplification management plan, including whether or not, not only the device selection, but do we need to make a medical referral? Word recognition information does take a pivotal role in that process. And again, emphasizing when we see terminology like PBMAX, being extremely mindful, the tools that we're going to discuss today, are less reliable if we do not have PBMAX information provided, or really cannot be utilized if we do not have PBMAX information provided. Meaning, we are completing word recognition following the criteria listed here, which is, we are using the NU6 word list in its totality, we are using recorded speech stimulus, and the stimulus in the recorded condition, and we are using the 2K sensation level, presentation level method for word recognition testing. So, the first tool that I'd like to identify, and how that plays a role in answering, or addressing these three comparisons, there's two that we're really going to be focusing on. This first tool is called the critical difference chart, and this is in, or used as part of the application, when we are trying to determine, based on our word recognition information and decision making, what next step do we take? With specific emphasis to, are the scores symmetrical between the right and the left ear, and have the word recognition scores changed over time? So, if those are two pending questions, based on the interaction with the client, this is the tool that we want to think to utilize. So, let me explain this a little bit further to you, what this tool is showing us. So, to provide some more explanation about the critical difference chart, it was published by Thornton and Raffin in 1978. The chart is primarily used for determining if a client should be referred for medical evaluation and clearance for amplification, based on their word recognition score, due to a change over time, or a symmetry issue between opposite ears. It follows a binomial model, which refers to two possible conditions or outcome for a given comparison or situation. So, for PVMAX word recognition testing, we know there are two outcomes for each word presented. It's either correct or incorrect, and the statistical construct is therefore binomial. So, provided practitioners, it really provides practitioners the statistical equivalent ranges for all possible values of PVMAX. So, I always say it does the research findings for us, so that we can utilize this tool in clinical practice. So, what we see in this table, it displays possible word recognition scores, ranging from 0% to 100%, and the range of scores represents statistically equivalent scores for a 50-word list, and the second column for a 25-word list, which we know is slightly less accurate, because the NU6 is meant to be completed in its totality, but it can be used for 25 words and, of course, 50 words. Let's do some practical application. I think that's the easiest way to make sense of the critical difference chart. So, we need two scores to compare, such as the right ear versus the left ear, or the current test score versus the previous test score for the same year. So, let's first focus on example one, which is determining whether PVMAX has changed over time. So, today, the client scores 76% correct in the right ear, But this time last year, they scored 88% correct in the right year. We want to double check, ensure whether or not we can proceed with testing or if we need to take action and medically refer. So the first thing that we're going to do is using the first column, we're going to first identify the two scores. And then based on whether or not we use 50 words or 25 words, we'll reference depending either the first column or the second column. Let's go with the option that we utilize the full 50 words. And what we're going to do now is first focus on 76%. And what I'm looking at is in that middle column, I'm looking to see if the second score, which is 88 falls into that acceptable range, we see that it does kind of close to the upper limit, but it does the range is 58 to 90. So we know this is acceptable, and we are going to move forward. But before I just do that, I do also want to check that that 76% is also acceptable when we are verifying the 88th percentile. So sliding down the graph to 88%, I do see and can confirm that 76% does fall in the acceptable range when using the 50 word word list. So although we know there is a difference here, it is in the range, which means it is acceptable and referral is not necessary. Let's now move on to example two, determining whether a client's right ear versus left ear are statistically equivalent when the degree and configuration of hearing loss is the same. So let's say the patient scored 60% in the right ear and 78% correct in the left ear. And let's again say that we utilized the 50 word NU6 word list. So what we first want to do is identify where 60% falls, highlight that area or circle that area, and do the same for 78%. I'm first going to check 60 to determine if 78% falls in that acceptable range when using the 50 word list, which it does. And the same concept applies following going down to 78% correct. Again, we use the 50 NU6 word list, and I can see that 60% also falls into that acceptable range, which tells us that referral is not necessary because these values are statistically equivalent and does not require medical intervention. So again, just really focusing on implementation of the critical difference chart, that's going to tell us if the change in hearing loss over time is significant, is of concern, requires referral, and also, too, if the difference measured in an otherwise symmetrical hearing loss, if the word recognition scores, however, have an asymmetry or a difference between them, and is that different significant enough that it is a cause of concern and requires medical referral? The last question that we were not able to address is whether or not there is a misalignment or mismatch between what the expected word recognition outcome is, and also, if that is misaligned with the severity or degree of hearing loss given that audiogram. So just before we get to that question and address that question using the sprint chart, which is our second tool for speech interpretation, I do want to take a moment and focus and take a step back and also add when counseling clients, when presenting the results to the client, a good training tip is to have your apprentices, your mentees, your students have a speech banana available. It is productive to plot the loss over the speech banana and talk about and identify what sounds are being missed. I think that helps provide additional context in the framework around how we can understand functionally why the patient might be scoring the way that they are in relation to the loss that they have, what sounds are not audible to them, so that they then have the opportunity to be intelligible and to discuss how the hearing technology will help to improve in those areas. And of course, too, to be mindful, there can be a lot of things going on. We know that understanding happens in the brain, and we understand that many things can affect that process. And so understanding that when there is a more significant hearing loss, especially in the high frequencies where we know a lot of that clarity is housed, that can result in poor word recognition scores, meaning we sometimes can see a mismatch, and that's okay. And there are often reasons, if not more than one reason, as to why that might be the case. So to be mindful of those different types of things. The longer a client experiences the loss, especially if it goes untreated, that can also have an impact and negatively impact our word recognition scores. So making sure, above all, we are counseling, we are taking a thorough needs assessment, so that when we do come to this portion of the test, we have additional context, right? If we see a mismatch and we know this client hasn't worn hearing aids and they've needed them for 30 years, perhaps that can be, you know, some type of auditory deprivation that is contributing to this client's word recognition scores that we are seeing today. But by all means, still utilize the critical difference chart, still use what we're going to discuss, which is the spring chart, because this is research-based and it will help guide and support your decision, whether it be recommending hearing aids, everything's clear, move forward, and or medical referral, if that's necessary. The next tool that we would like to introduce as part of word recognition score or PDMAX interpretation is the sprint chart. So to dig further into our three pieces of information that we use to interpret word recognition scores, or that we use as a guide to determine whether or not word recognition scores will cause us to need to medically refer. The third piece here is if there is a mismatch between degree of hearing loss and word recognition score, so specifically a comparison between the PTA for each ear and the word recognition score. We often will see this if there is a more severe hearing loss in the higher frequencies. And why we would apply this tool, it's scientifically proven, research driven, and it is especially a great tool for new professionals really straddling making this decision, whether or not medical referral is in fact necessary because there is a mismatch, and helping to guide them make that decision appropriately. And it should be noted that in the event that we find that the PTA is disproportionately low, then we would want to absolutely refer that client, and this is technically considered an additional red flag condition. This is another image of the sprint chart here. I think it would be helpful to dig a little bit further into the chart itself and understanding its layout and orientation. So the chart itself is divided by a diagonal line through its middle, separating it into two large areas which we see highlighted in the triangle, both the red triangle and the blue triangle. The upper left area of the grid, which is shaded in gray, represents the word recognition scores that are determined by research to be disproportionately low for the degree of hearing loss as defined by the PTA. The lower right area of the grid, which is in blue, represents word recognition scores that are determined by research to be within acceptable range for the degree of hearing loss as defined by the PTA. So if we plot our measurements, and the measurements are on the upper left-hand shaded area of the graph, that is not good. That would indicate or reinforce the recommendation of medical referral. If our measurements fall on the lower right-hand side, the non-shaded area of the graph, we would go ahead and continue with our testing and recommendation process. The next piece of the sprint chart, understanding it a little bit further, is the application of using the sprint chart for comparing word recognition scores between ears to find whether or not the difference between those two scores is statistically equivalent or acceptable, and if it's not, and if it's not, to medically refer then as well. So what do we see in the middle there? We see a series of arrows, and we see this sort of superseded on the sprint chart. This represents the 95 confidence limits for, or range of variability for PBMAX score from zero to 100, and this is shown by the vertical two tailored arrows that collectively form that oval area that we just discussed. So that oval area represents Thornton and Raffens 95% confidence limits for each PBMAX score, or what we know as the critical difference chart. So really, a quick and easy way to understand this is the critical difference chart is right in the middle of that sprint chart. So this can be used again, as mentioned, to compare two word recognition scores to determine if the difference between those two scores is statistically equivalent, meaning acceptable, or if it is not statistically equivalent, meaning it is unacceptable and referral is necessary. So let's practice. Let's use this tool together. So let's first go through the example of word recognition score and PTA mismatch. So for this example, we have a patient whose left ear, the word recognition score is 60%. The left ear PTA is 34 DBHL. And just as a quick reference, I recommend using the workbook for these activities. This is actually where this, this exact activity originates from. There is a very nice large visual of the sprint chart that can be seen there that I would recommend for teaching and using with your apprentices. And just to take a quick step back to understand how I'm going to run through this example, I think it's important to provide additional context about the layout of the sprint chart, excuse me, and how we're going to use that. So the word recognition scores are listed on the x-axis. And we see those scores present at the top and the bottom of the graph. The x-axis is labeled first percent score correct. And the y-axis on the right side is labeled a second percent score. Y-axis is also used with the x-axis to determine if the differences between the two word rec scores exceed expected variability. And for the second example, which we'll get to in just a moment, the y-axis on the left side is labeled PTA DBHL and is used in conjunction with the bottom or top scale to determine if a particular word recognition score can be expected from the degree or hearing loss as defined by the PTA. So what we're looking for is to connect these two lines and determine whether or not they meet in the shaded area or the unshaded area. And that will determine our next steps. So coming back to our example, we see a left ear word recognition score or PB max of 60% and a left ear PTA of 34 DBHL. And I want to make note that we are referencing the workbook for this activity. The workbook has lovely activities surrounding application of the sprinting chart. I heavily encourage instructors to utilize this during teaching and referencing of the sprint chart. It has rather large sizing, which can make this tool easier to use or easier to understand. So coming back to the example, what is the expected category for word recognition score? Well, we know 60% is in the fair to poor category, again, based on our word recognition score classification system. Is this word recognition expected based on the severity of the hearing loss as defined by the PTA? Well, we know 34 DBHL is within the mild range. So we certainly do note a mismatch there. As it relates to the graph, what we would do is we would draw a line where it says word recognition at 60, and we would connect that to the left-hand side where it says 34. But to be more exact, I would think between 32 and 36, we would go for the line at 32, merge those two lines. And what we would find is that where our two lines meet and cross would be in the upper shaded gray area. And what this would indicate is that the word recognition score of 60% is not consistent with the degree of hearing loss as defined by the PTA. And while we already were able to make that judgment and to have that understanding, we can see how the tool further reinforces that knowledge and that understanding. And in terms of what our action would be, we would absolutely refer the client for medical evaluation because, again, the word recognition score and the PTA do not align, and the SPRINT chart helps to reinforce that piece of information. The next application of the SPRINT chart will be used to compare two word recognition scores. So what we're trying to determine now is, is the difference between those two word recognition scores statistically equivalent or is it not equivalent? So let's use this example here. So for the right ear, we have a PBMAX or word recognition score of 56%. And in the left ear, we have a PBMAX or word recognition score of 70%. And of course, again, we are referencing the SPRINT chart and the activities within the speech interpretation section. So are these two scores statistically equivalent? So what I'm going to do is I'm going to take the first percent correct score, and I'm going to take the first PBMAX score, which is 56. I'm going to take the left ear, which is 70%, and I'm going to intersect those two lines coming from the bottom and right-hand side of the graph. And I'm going to see if that first percent score and second percent score, whether those lines intersect, if they intersect in the lower right margin or in the upper left-hand margin. And what it turns out here for this example is the scores are statistically equivalent, meaning they're intersecting in the lower right-hand side of the grid. And that medical referral is not necessary today, and we can proceed with testing. So as you can see, this tool really is simple to use once you have an understanding of its orientation and its application, so why we would think to use it. If we are ever in doubt, if we are ever concerned about asymmetry and word recognition scores in an otherwise symmetrical loss, this is a great tool to use. But disclaimer can only be used if we are performing word recognition score testing in the most perfect conditions, meaning we are achieving PBMAX, so that's incredibly important as well. Last but not least, quicksand interpretation. So we really encourage apprentices to complete quicksand interpretation. We know one of the chief complaints or reasons why clients come in to see us is because they are struggling to hear noise. We often do see that clinicians will utilize word recognition scores solely as a means to counsel regarding expected benefit or outcome with pursuing amplification, but where we're really missing the mark is word recognition score testing is completed in a quiet and controlled listening environment and we know is not indicative of a real-world listening situation. So if a client is coming in and they report that they are struggling in noise, we must complete a form of speech and noise testing. And as it states, quicksand, more often than not, clinicians prefer this type of speech and noise test because it's quick. And so we have a separate module that will discuss how to complete quicksand testing. Today we're really just going to focus on when the results are given to us, what can we do with that information? So the most important piece in quicksand interpretation, and luckily, this is a test that the results will be populated for us, what we have to do is we have to understand how the hearing aid management plan or recommendation is impacted by the quicksand results and to make those necessary modifications. And we also need to communicate realistic expectations to the client and counsel that client based on these test results. So if a client demonstrates a 0 to 3 dB SNR loss, what this indicates is speech and noise testing indicates a normal difficulty with speech clarity when noise is present. So more often than not, a recommendation is not made. 4 to 7 dB SNR loss, speech and noise testing indicated a mild difficulty with speech clarity when noise is present. Directional microphones will be beneficial. So you notice there that there isn't an additional consideration or recommendation as part of this outcome. 8 to 15 dB SNR loss, speech and noise testing indicated moderate difficulty with speech clarity when noise is present. Directional microphones will also be beneficial. If the loss is greater than or worse than a 15 dB SNR loss, speech and noise testing indicates severe difficulty with speech clarity when noise is present and remote microphones or an FM system will be beneficial. So again, really coming back to what additions must be implemented for this client to be able to further separate speech from noise and being able to communicate whether the deficit will be mild, moderate, or severe for a client when they are trying to communicate and converse in noise. And a couple additional training tips about QuickSend. We encourage apprentices to complete a minimum of two sets of word lists to ensure good test reliability. We also really encourage apprentices to experience QuickSend testing or speech and noise testing before they give this test to a client. It's an incredibly challenging test and I think it's important for them to have that familiarity and that added perspective. We want to make sure that they too understand the application of this test when it's appropriate and when it's not. When a client has an extremely severe to profound loss, we know that client's going to struggle in noise and maybe by completing this test we might further add to that client's frustration, which we certainly don't want to do. We also can have clients that may experience cognitive challenges or any type of expressive language disorder, different reasons as to why or additional reasons as to why we wouldn't recommend completing this test. We don't want to increase the level of frustration in a client if we can avoid doing so. And most importantly, after the test is completed, as already mentioned, what recommendations, what additional considerations do we have to make to holistically take care of this client and manage their hearing loss? Okay, that's that. So thank you so much for your time today. Thank you for investing and continuing to mentor and sponsor the next generation of hearing care professionals in our field. Your support is invaluable. If there are any comments or concerns about today's presentation, my contact information is provided here. For more info about obtaining a CE credit for this webinar, please visit www.ihsinfo.org and thank you so much for attending and we look forward to seeing you in our next module.

Train the Trainer

Kristen Wadsworth

hearing instrument specialists

audiometric interpretation

speech interpretation

audiogram documentation

Pure Tone Average

Speech Recognition Threshold

Word Recognition

Speech in Noise testing

hearing assessment

hearing care professionals