Real ear measurement vs. in-situ audiometry

Hearing Aids
#102

What is the prescriptive target for speech?
If, during the speech mapping REM, the software breaks the speech into frequency bands, and compares them with the prescription (target), wouldn’t it be similar to using a bursts of noise that also contain all the frequencies that are in speech)

I know you asked Neville this, but no it doesn’t work like that, unless you turn off the speech processing and speech in noise (ie the core performance) within the hearing aid and just measure a baseline response.

The worst part about this type of verification is; more intelligent and higher rated the hearing aid is, the less you will be able to demonstrate and verify its functionality in noise for 2 reasons:

  1. The emulated speech and speech like noise(babble) and noise will be coming from the same single/paired speaker source - which is never the case in real life.
  2. The emulated speech might not sound enough like the real world speech/or differentiate from noise sufficiently that the hearing aids now recognise it as sampled in their AI/Machine learning algorithms.

This is part of the reason for doing proper ‘live’ demonstrations/verification with human voices and alternative competing noise sources.

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#103

Yeah, I use live speech input a lot, although normally as addendum to recorded speech. It’s particularly useful for finding patient complaints like, “The hearing aids sound weird when I do this [insert sound that no one would reasonably make during day to day life].” Also useful for checking on partner voices, or finding particular distortional issues via the headset, or confirming masker levels.

It depends on the manufacturer and on the ear and on the fit of the hearing aid. I had an Insio AX C&G fitting the other day that hit targets almost perfectly from first fit and only needed very minor adjustments. But you don’t know unless you measure. The manufacturer can only base their settings on an average ear and a predicted physical fit, but variability between people can be high. When you fit a lot of a particular product you get to know where the specific manufacturer is typically under target, so you might go in thinking, ‘okay, I’m going to have to pull 750-1500 up a bit and 3-6k a lot’ but it’s still not every person.

In situ is unnecessary, don’t worry about it. It is sometimes being marketted as an alternative to REM, but at this point it is not.
My experience with autoREM is limited; I ran into some problems with it early on and then just stopped using it, but I’ve been meaning to go back to it I just haven’t gotten the chance. It can probably do a good job, but it still requires the external REM equipment.

You’re in Australia, they’ll use NAL rather than DSL because the National Acoustics Lab is Australian. :grinning: Proprietary targets are typically NAL-based anyway and depending on the clinician and the manufacturer they may or may not leave the proprietary targets on in the software, but will still verify against NAL. It used to be that certain features were turned off outside of the proprietary algorithm, but that’s not typically the case anymore especially with NAL.

No? I mean yes, they are her hearing aids and her ears. However, a new user will quite often just pick whichever strategy has less gain and sounds more like what they are used to through the filter of their hearing loss. Think about going to physiotherapy; sure there are patients that will self-select the harder exercises, but given the choice a lot will pick the easier ones even though those exercises don’t get them walking again as effectively. Would you rather go to the physiotherapist who lets you be lazy, or the one that fixes your problem? Honestly, I’d probably pick a mix of the two–I don’t actually want to go to the absolute drill seargent (some people do!), I’d want the friendly but persistent one.

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#104

I don’t know why, but I thought that the prescription method decision and calculation of the target is done by the audiologist as part of the first fitting in the fitting software, not by the manufacturer.
There wasn’t any document coming with the Signia and Phonak devices to suggest that they did any settings like that.

I can’t see gain should be a problem. Although it is set in the fitting software, it can be adjusted in the app.
Different prescription strategies should, IMO, be demonstrated for speech understanding - the higher frequencies could be unpleasant, but speech could be clearer, and vice versa. And the wearer should decide.
(This is, btw, what one Specsavers audiologist says he does. But he is not in Melbourne.)

Thanks Neville, and thanks to Um_bongo - I do read your posts.

We’ll have a 2-3 week break, and the fun will start again. I hope it will be worth the extra grand.

#105

I have Widex and my audi used REM which improved the fitting somewhat. So you can use REM with Widex.

#106

I’m a little confused about the supposed motivation for why so many audiologists are skipping REM tests. After reading 100+ posts on this thread, it seems like a lot of the pro-REM folks assume that

  1. A substantial number of audiologists are just looking to turn a quick sale;
  2. Most audiologists are trained in REM techniques; and
  3. A 15-20 minute REM test will yield substantially superior results such that any client who has a provider that doesn’t do one should find a new provider.

But if all that is true, wouldn’t it follow that a significant number of these turn-a-quick-buck audiologists would embrace a 15-20 minute test that delivers better results on a first try with minimal effort and minimal capital expenditure? The argument that hack-audiologists are skipping a critically important test that takes only a few minutes because they are lazy and cheap doesn’t seem to make much sense to me if it leads to more device returns, more follow up visits, and fewer repeat customers.

Anyway, I don’t know much about REM tests, but something about this whole argument doesn’t really add up to me. My own guess is that:

  1. Most audiologists want to do right by their clients.
  2. Some audiologists find REM tests to be a useful starting place, some don’t.
  3. There is no silver bullet program or test that will give any given HA user an ideal fitting.
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#107

My current audiologist routinely uses REM with children, those with dementia, or others that he cannot have a meaningful 2 way conversation with. Otherwise, he believes it does not give him enough, or the best information he needs to do a proper fitting. And, because my hearing is better than it has been in many years, and far better than after repeated Costco REM fittings, I don’t have any problem with it.

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#108

My father once told me about an experience he had in a continuing education class for doctors. A question was posed about particular treatment for a particular condition. He carefully researched current guidelines and recent evidence indicating what the best modern standard of care was, and provided his answer with citations. Another doctor answered, “I do [some other answer] because that’s the way I have been doing it for 30 years.”

And that’s why some providers don’t use REM.

4 Likes
#109

I’m sure that’s true for some audiologists, but it seems like an awfully broad generalization. If that were really the answer, then older audiologists would be less likely to use REM and younger ones would be more likely to use it. But someone in this thread noted that REM has been around for over 30 years, and I’ve seen no evidence that adoption of REM is clearly tied to when or where the audiologist went to school.

#110

Not the old audiologists per se, the ones who aren’t interested in purchasing it and learning how to use it properly. Though, I would say that there is not one person in my graduating class who doesn’t use it, so how it was emphasized in the school you went to likely matters. It’s probably also used more commonly among audiologists than HISs.

There are location differences, too. I feel that it is very widely used where I am in Canada–dramatically higher than the old 30% stat you sometimes see floating around. USA is maybe more variable. I think it is less common and less available outside of North America/UK/Australia? Note that if there isn’t a company close-ish, not only would a clinic have to have a device shipped, but it has to be calibrated annually and if you don’t have someone nearby who can do that then shipping back and forth for calibration and repairs could be a barrier. I know that I spoke to a Russian audiologist about 7 years ago who was hoping to be the first to bring REM into Russia. I often see people on these forums who are international and don’t seem to have easy access to REM.

There are some clinicians who work for employers who refuse to purchase the equipment (some ENTs for example). Although, there are basic devices out there now that are cheap enough that I would just purchase one personally in that case.

There are probably clinicians working rurally on their own who would like to implement it but lack easy access to mentors which increases barriers.

So, lots of reasons. But I still think that overwhelmingly the issue is just clinical momentum.

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#111

Thanks for sharing. It’s been a few years since I’ve had a fitting, and I don’t recall my audiologist doing REM, but I’ll ask him about it before my next one. I’ll be interested to hear what he says. In general I think he’s hard working, generous with his time, a straight-shooter, not looking to just make a sale, and he’s an audiologist at a major hospital.

So if he doesn’t do it, I don’t think it’s because he’s lazy, doesn’t have access to the technology, doesn’t have access to training, etc.

#112

I did see one very experienced audiologist who used to do REM routinely, but said he didn’t find it that useful. I suspect it may be part of our “Please the customer; the customer is always right.” mentality. I think this can often lead to caring more about how they sound than speech recognition.

#113

Good morning to all.

Happy new year, healthy and happiness to all.

I would like to know if any one have the Audiometry Chart to be fullfilled and tynpanometry, but on excel or any free software so I can use.

Best Regards,

#114

here is a PDF chart you can download.

https://www.pdffiller.com/jsfiller-desk17/?requestHash=6a4909632b3ad891ca4811f6c4fa46fc2e8156da3067532f0686749b630ba7a2&projectId=1183295282&loader=tips&MEDIUM_PDFJS=true&PAGE_REARRANGE_V2_MVP=true&isPageRearrangeV2MVP=true#601fefec49f4488c8468e1ffa081cc57https://www.pdffiller.com/jsfiller-desk17/?requestHash=57da4c93c495412a839e6470d8ad0b3bf7ba7b47e69f8d068cb79584e6cca854&projectId=1183296016&loader=tips&MEDIUM_PDFJS=true&PAGE_REARRANGE_V2_MVP=true&isPageRearrangeV2MVP=true#912a1eac07e54641b50624a149a6231f

#115

I think REM is still a good starting point, even though the many adjustments to my aids over the last year have deviated from my initial REM setting. But, because many of us have either been without proper hearing or have been using under-fit aids for so long, our brains lose the ability to process and hear many sounds and freqs. REM verifies and matches our loss to our audiogram while aids are being worn. In-situ is dependent on our feedback. If we have lost the ability to hear certain sounds and freqs, we cant provide proper feedback for correct adjustments. Many times it takes months (if at all) of wearing correctly fitted aids to regain the ability to hear those sounds that we have “lost”. So while in-situ can be helpful or assist in adjustments, it may be very dependent on our loss and how much sound(s) our brains have forgotten or retained.

#116

Thanks, I have a Excel table to fufill the aerial, but the bone I need to do after I print. I would like to have all marked automatly.

I appreciate your table, is very nice to have it.

I am looking for a freesoftware like a much simple version of OTOAccess.

BR

#117

You can use any HA manufacturer software to print off your audiogram,BC and anything else you enter.
I’m not sure why you think you need this other software, what are you trying to do?

#118

Thanks to Internet Archive, you can still download AudiogramMaker from AudiogramMaker Downloads

Other tools to consider: Audiogram Plotter, Excel Audiogram

I have a blog post (in Traditional Chinese, oops) comparing these tools and others: https://jedi.org/blog/archives/006286.html

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#119

my audi said that he could do REM but it would be NAL-NL1 or NAL-NL2 not one of hearing aid manufacturer’s propriety algorithm. is this true? I have starkey and I also tried oticon with him.

#120

The manufacturers do not give out the proprietary software targets. Most REM machines I was familiar could develop target in NAL, DSL, and some with 1/2 gain or 1/3 gain. NAL and DSL are the most common used. When REM is run with the manufacturers first fit, it can be compared against the target developed in the RE equipment.

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#121

Manufacturers typically recommend verifying against NL2 for their proprietary algorithms.

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