Other People’s Ideas
Calvin Staples, MSc, will be selecting some of the more interesting blogs from HearingHealthMatters.org which now has almost a half a million hits each month. This blog is the most well read and best respected in the hearing health care industry and Calvin will make a regular selection of some of the best entries for his column, Other People’s Ideas.
Bruno Mars, who knew? I definitely was impressed by his performance at the Super Bowl halftime show. Unfortunately the Chili Peppers simply reminded me that I am getting old and the game itself was a bust.
However, all was not lost, especially for audiologists, as the weeks prior to the game has some audiology related news. A significant amount of public interest was paid to both the sound level measurements at the Seattle Seahawks stadium: CenturyLink Field and the Seattle Seahawks player who is hearing impaired. The two weeks prior to the Super Bowl had the usual chatter about the teams playing the game, but social media was also abuzz as CenturyLink Field recorded noise decibel levels in excess of 135 dB SPL. Additionally, Seattle’s Derrick Coleman was receiving lots of press as he had overcome a significant hearing loss to not only make the NFL, but now be a Super Bowl Champion!
I thought this month’s blog submission could focus on all things related to sound.
There were a lot of hearing angles to the 2014 Super Bowl, played last Sunday in New Jersey. For one thing, there was the Seattle Seahawks’ much heralded (and much criticized) “12th Man,” as the team’s incredibly noisy legion of fans came to be known. As noted by ASHA’s Joe Cerquone on the Hearing Views blog, the din created by these fans at Seattle home games has been measured at up to 136.6 dB.
This may have helped inspire the home team while discombobulating visiting teams, who have jumped offside at an unusually high rate. The Seahawks have won 17 of their past 18 home games at CenturyLink Field, the best home record of any team in the National Football League (NFL) over the past two seasons. On the other hand, it’s virtually certain that fans who failed to wear effective ear protection to the games have been paying a high price for their team’s success in the form of tinnitus and hearing loss.
On a happier note, Seattle backup fullback, Derrick Coleman, has become a hero for his remarkable personal story. Despite having had profound hearing loss since early childhood, Coleman defied the odds and the naysayers. First he became a football star at UCLA and then, despite going undrafted and being released by the Minnesota Vikings, he refused to give up. He won a spot with the Seahawks, and also became a star of a YouTube video sponsored by Duracell Batteries, which has been viewed more than 18 million times.
Hearing Care Organizations Join the Party
Coleman’s inspiring story also caught the attention of Oticon, whose U.S. headquarters in Somerset, NJ, is just 40 miles from East Rutherford, where Super Bowl XLVIII was played.
Recently, 9-year-old Riley Kovalcik, a hearing aid wearer from Roxbury, NJ, wrote to Coleman, telling him he was an “inspiration” to her. Her letter and his heartfelt response captured nationwide media attention. So, Oticon brought Riley and her twin sister, Erin, to pre-game media events. There they showed their support for Coleman’s team by wearing their Seahawks blue-and-green Oticon Sensei hearing aids.
Meanwhile, the day before the big game, Derrick Coleman joined a host of pro athletes and other celebrities at a service mission sponsored by the Starkey Hearing Foundation and hosted by the New York Yankees at Yankee Stadium in New York. The running back, who attended the event with his parents and sister, volunteered and received a new pair of hearing devices.
Other volunteers at the event included active and former NFL stars Larry Fitzgerald, A.J. Green, and Tommie Harris; the TV actor Daymond John; Yankee manager Joe Girardi; the singer Garth Brooks; and Barbara Bush, daughter of former President George W. Bush. During the two-day mission, more than 100 people were given hearing aids.
Gallaudet Gridders Win Hearstrong Award
While Derrick Coleman is one of the few NFL players who wears hearing aids, a whole team of college players with hearing loss was honored the day before the Super Bowl by the HearStrongFoundation. The foundation, which is sponsored by EarQ, celebrates individuals worldwide who have “not only faced hearing loss, but conquered it with a determined spirit, a focused mind and an unwavering heart!”
At an NFL Players Association event held February 1 event in Manhattan, the Gallaudet University head football coach, Chuck Goldstein, and the team’s five senior co-captains, Ryan Bonheyo, Nicholas Elstad, Mike Hantge, Chris Langan, and Adham Talaat, accepted the HearStrong Foundation’s Champion Award on behalf of the whole team.
Last fall, the Gallaudet gridders had their best season ever, qualifying for its first-ever NCAA Division III playoff game.
And Then They Played
After all the hoopla, the Seattle Seahawks and the Denver Broncos finally played the game on February 2. And, as you may have heard, Seattle won 43–8. The 12th Man couldn’t take credit for this one, as most of the seats were filled, not with Seahawk and Bronco fans, but with relatively quiet folks who had the right connections to get tickets.
While he didn’t get to carry the ball, Derrick Coleman did make a mark. Playing on Seattle’s special teams, he raced downfield on the opening kickoff and made a hard tackle on the Bronco return man at the 14. He seemed to be telling Denver that it wasn’t going to be their day.
In their last series of meetings before this most recent municipal election, he New Orleans City Council and Mayor Mitch Landrieu had called for legislation that would in effect decree that no toilets can be flushed in New Orleans; no telephones can be used; no conversations can be held where there are more than four people talking; and no music can be played in excess of 70 dB. These are among the implications of passing a proposed new bylaw that is before the city council in New Orleans. Mayor Landrieu has since been re-elected and with this new group of councillors, the issue is still pending.
The old New Orleans noise bylaw states that action can be taken at 80 dB (presumably 80 dBA?). Now under consideration is a new bylaw that would change the legal noise limit to 70 dB.
Before getting into the silliness that is before the New Orleans City Council, let’s review what 70 dB means. I will assume that “70 dB” means 70 dBA and not 70 dB peak. If it is 70 dB “peak” then legally people of New Orleans will only be allowed to whisper, never cough, and never drive cars with internal combustion engines. Consider the following:
- Average conversational speech by one person at 1 meter is 60-65 dBA.
- Average conversational speech by 4 people talking at 1 meter is about 70 dBA.
- A toilet flushing is 77 dBA (and with your head in the bowl, it is 85 dBA).
- Running water is about 72 dBA.
- Coughing is about 77 dBA.
- A telephone dial tone on a land line (and speech on the telephone) is about 84 dBA.
- The sound of an ocean wave hitting a beach is about 70–75 dBA.
In short, the New Orleans City Council is considering outlawing all of these sounds. If this new bylaw is passed, presumably phones will be outlawed; toilets will not be allowed to be flushed; and groups of more than 4 people will not be able to legally congregate – well they can, but only 1 or 2 will be able to talk at the same time; and all beaches will need to be closed. And did I mention that after you illegally flush your toilet, you will not legally be allowed to wash your hands?
To be fair, the city council did commission a study by Dave Woolworth near the end of 2012 and the study was presented to the council in August 2013. It suggested that “in the French Quarter and Bourbon Street in particular, noise be capped somewhere between 90 and 100 decibels, measured at the open doors and windows of venues.” This is very reasonable and is consistent with the noise bylaws found in other parts of the world. The 70 dBA proposed bylaw is inconsistent with reality.
I tried playing my clarinet (it was Mozart), and even when I played very softly, the output was far in excess of 70 dBA. I then asked my son to strum his acoustic classical guitar – well, that would be outlawed in New Orleans, as well. And of course, we would not be able to sing along with his guitar music – that would be over 70 dB as well.
I would still urge all readers to visit beautiful New Orleans – it is a wonderful city – but when there, if this bylaw does pass, you will not legally be able to drive or talk to anyone, and you will not be able to flush the toilet (or for that matter, use running water to wash your hands).
This issue came to my attention since I am one of the hearing health consultants for the New Orleans Musicians Clinic, and some of this has been sourced from an article by Michael Patrick Welsh entitled The Music Lover’s Guide to the New Orleans Election.”
On a more serious tone, this is a very complex situation. Clearly having a city noise bylaw where action is deemed necessary at 70 dBA is silly, but the solutions are not always obvious. Some balance is needed between the music levels and the listeners, the music levels and the bystanders on the street (who don’t necessarily want to listen to the music), and the hearing health of the musicians and the other club personnel as well.
On January 27, 2014, the New Orleans Housing and Human Needs Committee held a special meeting, and many public depositions regarding this issue were presented. For those who like to listen to a 3-hour meeting, a video is available. Those submitting depositions include musicians, musician union representatives, local residents, and hearing health professionals. If you only want to listen to several minutes of this meeting, I suggest that you go to time counter 01:18:58 and listen to what John Moore has to say. John is affectionately referred to as Deacon John and he is the president of the New Orleans Musicians’ Union. Deacon John provides us with a balanced voice of reason that many cities can learn from.
This several minute portion of the tape (starting at 01:18:58) should be required material in any graduate audiology program course on noise and its effects.
It is Amazing What One Can Find About Hearing Aids when Looking for Something Else
In her recent post on the HHTM blog, Gael Hannan commented on the “whisper game” that hearing-impaired individuals are not particularly good at, and provided an accurate and entertaining commentary as to why this is. She reported that some family physicians use the whispered voice test to detect possible hearing loss in their patients, but also use it to test the effectiveness of hearing aid fittings. She asked her fellow HHTM bloggers who are audiologists what we thought of the whisper test for this use, and that is when a hoped-for simple answer became complicated.
To be honest, I don’t think many of us had really given it much thought, other than to remember that it had been used as part of a battery of crude tests before the introduction of audiometers to determine if a person had a hearing loss. Most likely we had given little thought to its use with hearing aids. For my part, I don’t recall reading or hearing anything positive about it from any source. Still, the question bothered me, primarily because I was wondering why people were talking about it again – or, had the talk never ended?
Historical Events Related to the Whisper Test
The use of speech to determine hearing levels has most likely been performed since times immemorial, even if not conducted specifically for that purpose (but for basic communication between a physician and patient). Pfingsten (1802)  was apparently the first to attempt a scientific study of the hearing acuity for speech. He divided speech sounds into three classes: (1) vowels; (2) voiced consonants; (3) voiceless (“noisy”) consonants. He distinguished three degrees of hearing disorders, depending upon which of these three classes of speech sounds were still understood by his patients. He obviously knew already that the intelligibility of vowels is usually better than that of consonants.
Schmalz (1846)  advocated a classification of hearing losses for speech into four categories. The rank ordering was based upon the distance at which speech could be understood, as well as various kinds of clocks and pocket watches. He differentiated between speech at moderate levels and at normal levels. He paid attention to the difference in audibility between vowels and consonants and quoted Pfingsten and Itard in this respect. Whispered speech was not widely used in the middle of the 19th century, because it was not mentioned, and nothing was said about test words or test sentences.
A few years after Schmalz, Frank (1949) and then later von Tröltsch (1962) reported there was not always a simple relation between the distance at which watches and other sound sources could be heard and that at which speech could be understood. These statements touched upon problems that are still being discussed today.
The Whisper Test Explained to the Uninformed (one of the methods used)
- The examiner stands arm’s length (0.6 m or other distance) behind the seated patient (to prevent lipreading) and whispers a combination of numbers and letters (for example, 4-K-2) and then asks the patient to repeat the sequence.
- Variation: Ask the patient to repeat a set of three different random numbers (e.g., 6,1,9) presented to the tested ear at four decreasing levels of loudness: conversational voice at 6 inches and at 2 feet from the ear, and whispered voice at 6 inches and at 2 feet from the ear. Exhale completely prior to testing with whispered voice.
- The examiner should quietly exhale before whispering to ensure as quiet a voice as possible.
- If the patient responds correctly, hearing is considered normal; if the patient responds incorrectly, the test is repeated using a different number/letter combination.
- The patient is considered to have passed the screening test if they repeat at least three out of a possible six numbers or letters correctly. Patients with no cerumen occlusion of the ear canal and who fail this test are considered to have a hearing loss that correlates with a 30-dB hearing loss.
- Variation: A passing score is given if the patient can repeat all three numbers correctly at each level of loudness or achieve greater than 50% success over three successive triplet sets. Failure to hear a whisper at 2 feet indicates hearing loss and may be the most discriminating test of the set.
- Each ear is tested individually, starting with the ear with better hearing, and during testing, the non-test ear is masked by gently occluding the auditory canal with a finger and rubbing the tragus in a circular motion (by patient or examiner) to ensure occlusion.
- The other ear is assessed similarly with a different combination of numbers and letters.
In addition to whispering having an advantage over conversational voice in that it is relatively easy to standardize (at the end of expiration), the whisper represents at fairly even intensity the range of frequencies needed for good understanding of speech. The intensity with which the whisper is varied as the tester comes closer and closer to the subject must be understood because the intensity of sound varies inversely as the square of the distance it travels. In practice, this rule almost always breaks down badly because of reverberations from the walls of the room.
What is the Status of the Whisper Test Today?
Today’s professionals involved in hearing threshold evaluation know the history of the “Whisper Test” and would be hard pressed to qualify any “results” due to the myriad lack of controls and rationale. The Whisper Test, along with the Conversational Voice, Coin Click, and Watch Tick tests, are considered crude tests of hearing sensitivity. Each of these simple tests was intended to solve, in different ways, the issues as to which frequencies were being tested. The whisper test had an advantage over conversational voice in that loudness standardization of the whisper was easier (especially if at the end of an expiration) than vocalization. However, an important feature of any hearing sensitivity test is an interest not merely in knowing that someone can hear and/or repeat whispered stimuli at a certain distance, but how the results compare with fellow men.
Hearing professionals might be surprised that the whisper test is still used today. For example, in the United Kingdom, general practitioners have been obliged to screen the elderly for hearing loss since the 1990 National Health Service contract. While its diagnostic value continues to be debated, the Royal College of General Practitioners has chosen the whispered voice as the first test for hearing loss.
In the United States, the U.S. Department of Transportation, Federal Motor Carrier Safety Administration, provides “Physical Qualifications for Drivers,” via regulations current to August 30, 2012. In the Current Medical Fitness Standards and Guidelines for CMV (Commercial Motor Vehicle) drivers in the United States (49 CFR 391.41(b)(11)), the following is stated relative to physical qualifications for drivers:
First perceives a forced whispered voice in the better ear at not less than 5 feet with or without the use of a hearing aid, or, if tested by use of an audiometric device, does not have an average hearing loss in the better ear greater than 40 decibels at 500 Hz, 1,000 Hz, and 2,000 Hz with or without a hearing aid when the audiometric device is calibrated to American National Standard (formerly ASA Standard) Z24.5-1941.
The document further states that “Either test may be administered first,” and “..the second test may be omitted when the test results of the initial test meet the hearing requirement for that test.” The document goes on to say in (b)(5), “Hearing shall not be less than 10/20 in the better ear, for conversational tones, without a hearing aid.” In the forced whisper test a hearing aid may be worn while testing. When a hearing aid is used to qualify, the hearing aid must be worn while driving. The test area should be free from noise that could interfere with a valid test. Measure and mark the five-foot passing distance. When a driver who wears a hearing aid is unable to pass a forced whisper test, referral to an audiologist, otolaryngologist, or hearing aid center is required.
I didn’t look further into the use of the Whisper Test by other U.S. Government entities, but my gut instinct tells me that if it shows up on one place, it may take on the characteristics of a bad penny.
Reliability and Validity of the Whisper Test
Because of a lack of standardization (materials, speaker, ambient noise levels, presentation levels, etc.), it is difficult to imagine that the whisper test could be used in a systematically controlled way. A review of studies related to the whisper test was conducted by Pirozzo, etc. al. (2003). The purpose was to determine the accuracy of the whispered test in detecting hearing impairment in adults and children. This study gathered information on essentially any topic that included the words “whisper test,” and identified that a reference test (audiometry) had been performed on at least 80% of the participants. Four studies involving adults were found that met these requirements, but with different whisper test techniques used.
As to reproducibility of the whisper tests in the studies analyzed, the authors stated there was considerable room for improvement in standardizing the technique of conducting the test and in setting the threshold for hearing impairment. The study concluded that the whisper test is an accurate and simple test of hearing impairment that could be used by general practitioners, even though it has not been adequately evaluated in primary care settings; differences in accuracy among published studies could be explained by differences in conducting the test; and that the technique for conducting the test needs to be standardized to optimize sensitivity of the test. None of these concerns, along with a number of others, are surprising comments, and continue to be unresolved.
Whisper Test to Determine the Effectiveness of Hearing Aids
Now that the whisper test and how it is being used have been described, it’s time to get back to one of Gael’s initial questions : How good is the whisper test for determining if a hearing aid is performing as expected, with reference to Dr. Gil’s Whisper Test as described below?
Dr. Gil’s Whisper Hearing Test
This is a simple test suggested for home use to determine the effectiveness of worn hearing aids.
- Start by having the user adjust the hearing aid to their normal listening setting.
- In a quiet room, ask a friend or spouse to sit about 5 feet away from the hearing aid wearer. Have them whisper a question or sentence to be repeated by the wearer – listening with eyes closed to not utilize visual cues.
- The listener should easily be able to hear the question or sentence. If the whisper was not heard, the suggestion is that the hearing loss has not been corrected, meaning that the soft sounds of speech are not being amplified properly.
- If the listener is able to hear the whisper, next test the loudness settings of the hearing aid. Ask a friend or spouse to make some very loud sounds. Have them shout, bang dishes together, clap loudly, and vigorously shake a newspaper page. It is said that today’s hearing aids should easily be able to deliver whispered sound even for people with severe hearing loss. If the whisper is HEARD, but not UNDERSTOOD, the suggestion is that one needs to learn more about what the hearing aid can or cannot do, and should also contact the person from whom the aid(s) were purchased for readjustment.
Is using the whisper test in this manner useful? I suspect that it is, just as are many other approaches that utilize casual speech when asking a person how they are performing with hearing aids. And, I would guess that the most frequently-used casual speech utterance to a person wearing a hearing aid is “How does this sound to you?” As with the use of the whisper test to determine if a hearing loss is evident, the use of the whisper test for hearing aid performance use is subject to the same criticisms related to uncontrollable unknowns and lack of standardization.
When Gael asked HHTM fellow bloggers what we thought of the Whisper Test to determine if a hearing aid performed as it should, the response was underwhelming. It was like planning for a big steak dinner and someone changed the menu to macaroni and cheese. I had long ago relegated the whisper test to ancient history. On the other hand, it did offer an opportunity to describe its place in the historical events related to the discipline of hearing, and especially to the evaluation of hearing. What is perhaps the most interesting thing about this discussion is that it again proves the point that the wheel seems to be constantly rediscovered when it comes to hearing aids. The use of the whisper test to casually determine how a hearing aid is performing was taught in early Sonotone (and most likely other manufacturers’) sales manuals (1960s).
- Pfingsten, G.W. Vieljährige Beobachtungen und Erfahrungen über die Gehörfehler der Taubstummen als Winke beim Galvanisieren zu gebrauchen, nebst Beschreibung einer neuen Art von Hörrohr. Kiel, 1802↵
- Schmalz, E. Erfahrungen über die Krankheiten des Gehörs und ihre Heilung, B. G. Teubner, Leipzig, 1946↵
- Frank, M. Practische Anleitung zur Erkenntniß und Behandlung der Ohrenkrankheiten; ein Handbuch der practischen Ohrenheilkunde. F. Enke, Erlangen, 1945↵
- Tröltsch, A. Die Krankheiten des Ohres, ihre Erkenntnis und Behandlung, Stahel, Würzburg 1962, 149↵
- Macphee G, Crowther J, McAlpine C. A simple screening test for hearing impairment in elderly patients. Age Ageing. 1988;17(5):347-351↵
- Pirozzo, S. Whispered voice test for screening for hearing impairment in adults and children: systematic review. British Medical Journal, 24:327 (7421):967, October, 2003↵
- Davis, H., and Silverman R., Audiometry: pure tone and simple speech tests, Hearing and Deafness, Chapter 7, pp. 181-182, Holt, Rinehart and Winston, New York, 1970↵
- Williams, E., Wallace, P. Health checks for people aged 75 and over [Occasional paper 59], London, Royal College of General Practitioners, 46, 473-474, 1993↵
- U.S. Department of Transportation, Federal Motor Carrier Safety Administration, Physical qualifications for drivers, (49 CFR 391.41(b)(11), Medical Fitness Standards and Guidelines for CMV drivers in the United States, August 30, 2012↵
- Pirozzo, S., Papinczak, T., and Glasziou, P. Whispered voice test for screening for hearing impairment in adults and children: systematic review, British Medical Journal, 327(7421) 967, October 25, 2003↵