Speech perception and quality of life of open-fit hearing aid users

ABSTRACT Objective To relate the performance of individuals with hearing loss at high frequencies in speech perception with the quality of life before and after the fitting of an open-fit hearing aid (HA). Methods The WHOQOL-BREF had been used before the fitting and 90 days after the use of HA. The Hearing in Noise Test (HINT) had been conducted in two phases: (1) at the time of fitting without an HA (situation A) and with an HA (situation B); (2) with an HA 90 days after fitting (situation C). Study Sample Thirty subjects with sensorineural hearing loss at high frequencies. Results By using an analysis of variance and the Tukey’s test comparing the three HINT situations in quiet and noisy environments, an improvement has been observed after the HA fitting. The results of the WHOQOL-BREF have showed an improvement in the quality of life after the HA fitting (paired t-test). The relationship between speech perception and quality of life before the HA fitting indicated a significant relationship between speech recognition in noisy environments and in the domain of social relations after the HA fitting (Pearson’s correlation coefficient). Conclusions The auditory stimulation has improved speech perception and the quality of life of individuals.


INTRODUCTION
speech when in the presence of competing background noise, which may affect their social interaction. The auditory deprivation causes consequences in the individual's life and affects the ability to properly understand acoustic information, as well as in the way they relate to their environment, which can cause a decisive impact on their quality of life (QoL).
Individuals who exhibit hearing loss restricted to high frequencies (above 1 kHz) in adverse conditions, such as when speech is distorted, or in in speech intelligibility because the number of auditory cues drops considerably. The speech intelligibility depends on the consonant sounds that present sound spectrum with frequencies above 2 kHz. The fact that the consonants are low intensity sounds in relation to vowels makes them more slope hearing loss 9 provide an emphasis on high frequencies sounds, providing audibility of speech signal without generating acoustic feedback or distortion, and avoiding autophonia from the occlusion of the external auditory canal (EAC) by the earmold. The total or partial occlusion of the EAC with an earmold causes the loss of natural resonance of the EAC, of 3-4 kHz. Therefore, some strategies should be considered during the hearing aids (HAs) selection 8 .
(BTE -HA) that uses a thin sound tube and a soft vented silicone eartip holding the tube in place inside the canal without using an earmold. Open-to assess the improvement in speech recognition, particularly in noisy environments, which could possibly lead to an improvement in the individual QoL.
Over the years, many tests of speech perception in noise have been developed in an attempt to better evaluate the individual's performance in noisy environments, seeking to maximize the approach in situations of daily life such as CTS -Connected Speech Test, SIN -Speech in Noise Test, QuickSIN-QuickSpeech-in-Noise Test, BKB-SIN -Bamford-Kowal-Bench Speech-in-Noise Test, SPIN -Speech Perception In Noise, and HINT -Hearing in Noise Test. There are differences between the tests in the speech intelligibility in noisy environments 15 . Tests that contain sentences in noisy environments, such as HINT, represent everyday speech and are understanding speech by exposing the individual to different variations in the signal-to-noise ratio (SNR) in each environment 13 . The HINT is widely HAs, evaluate and verify HAs algorithms such as directional microphones, expansion, noise reduction, wireless and various other models of HAs 5,7,11,14,[18][19][20][21] .
Literature shows that the verification and of returns and increased the patient's satisfaction with HAs. Thus, the author suggested perception of speech in noise tests for validation 6 . Several studies point to a negative assessment of QoL in individuals with hearing loss, but few the QoL, such as the WHOQOL-Breef, related to hearing loss. These surveys are scarce in the literature, which makes this topic a necessary study subject in the audiology area 2 .
in audiological clinics. Subjects with the slope in the silence, thus they do not present hearing complaints, since they have normal hearing up to 1 kHz and moderate loss to high tones, which causes of HA for this population should be based on the test is an important tool that can objectively show the improvement for the patients, therefore improving their quality of life.
Studies on the QoL and the speech perception of individuals with hearing loss at high frequencies may fundamentally contribute to the field of making process regarding the prescription of HAs and providing more support for the counseling and The aim of this study was to analyze the relationship between speech perception and QoL in adults and elderly with hearing loss at high frequencies, before and after the adaptation of OF HAs.

METHODS
This prospective cohort study has been conducted after approval by the Ethics Committee for Research in Humans (607.178) and after the agreement and informed consent of the subjects.
The study included 30 individuals who have met the following inclusion criteria: Aged more than 30 years; Diagnosed with sensorineural hearing loss with a slope hearing loss, restricted at high frequencies (above 1 kHz), compatible with a conventional OF digital technology; No prior experience with the use of HAs; Absence of other pathology associated with hearing loss; Ability to understand the WHOQOL-BREF answering the questions, they would be excluded from the sample.

Participants
The sample consisted of 11 female and 19 male aging from 34 to 78 years (mean: 61, 41 sd: 9, 67). The audiometric threshold averages are in Figure 1.

Procedures
In order to select the type and model of HA, the audiological features and communicative needs of the participants have been analyzed. According to this analysis, the OF HAs were selected. The HAs selected was the miniature digital BTE type, with four channels, a directional microphone system, digital noise reduction, and feedback cancellation by reversed phase technology. All HAs were the same manufacturer and model.
The HAs have been programmed via HI-Pro and date of birth, gender, and audiometric thresholds, have been input into the NOAH platform version 3.0 (HIMSA -Copenhagen, Denmark). When programming the enterprise software, as "experienced", with the aim to reach target. Information related to the acoustic characteristics of the thin tube and probes have been added. The NAL-NL1 prescriptive method has been used based on the previously entered thresholds. The algorithms for digital noise reduction and directional microphones have been activated for all participants. After programming the HAs, a verification procedure using measurements from a probe microphone has been performed. This procedure has been performed in an acoustically treated Middelfart, Denmark). The following measurements have then been performed: real-ear unaided occluded response (REOR) always equal to the realear unaided response (REUR), and real-ear aided response (REAR).
The values of the REAR at frequencies from 0.25 to 6 kHz for input levels of 50, 65, and 80 dB SPL have been respectively compared with the NAL-NL1 targets. Responses were considered equivalent when the difference between the target and the REAR value did not exceed 10 dB 3 . The responses have reached targets for all subjects.

Evaluation of speech perception
The assessment of speech perception has been performed using the HINT adapted to Brazilian Portuguese 1 under two conditions: Sentences presented in a quiet environment (quiet); Sentences presented in competitive noise; the type used was masking composite noise, with only the frontal position noise being used (noise front); In both conditions the sentences have been The HINT test have been performed in three situations and divided into two phases as follows: unaided (situation A) and aided (situation B).
The test has been conducted in an acoustically evaluation conditions, the signal (speech and noise) was presented from a single speaker at 0° azimuth, 1 m from the listener at a height of the head. The system calibration has been performed by placing a microphone at the reference corresponding to the participant's head center location and 1 m away from the speaker. A list of 20 sentences has been randomly presented by the HINT PRO software for each condition. Participants have been instructed orally as to the guidelines contained in the HINT manual.
The sentence was considered correct by the measurer when all essential words were repeated correctly. In this case, the examiner pressed the "yes" button on the software screen, and the next sentence was presented at 2 dB below the intensity of the previous sentence.
For the sentences in quiet condition, the presentation level was initially set at 45 dB(A). The presentation level was increased in steps of 2 dB until the participant correctly repeated the sentence. The score for this test was expressed as dB(A) level, at which the participant correctly repeated 50% of the sentences. sentences and the presentation level was initially set at 65 dB(A). The level of presentation of the sentences varied in the same manner as described for the sentences in quiet condition. The score was expressed in dB as being the SNR after the presentation of a list of 20 sentences. Therefore, the lower the SNR is, the better the speech perception for the participant under this condition.

Assessment of QoL
The WHOQOL-BREF questionnaire was used to assess different aspects of QoL of the participants. This questionnaire is an abbreviated version of the WHOQOL-100 developed by the World Health
The WHOQOL-BREF consists of 26 questions with two pertaining to general QoL issues and the other 24 questions representing each of the 24 facets that compose the original instrument (WHOQOL-100). Thus, the 24 questions cover four domains (physical, psychological, social relationships, and environment) and each facet is represented by a question 5 . The WHOQOL-BREF domains are: 1. Physical domain: corresponding to issues related to pain, discomfort, energy, fatigue, sleep, resting, mobility, activities of daily living, dependence on medication or treatment, and the ability to work.
2. Psychological domain: corresponding to questions about positive feelings, thinking, learning, memory and concentration, self-esteem, body image and appearance, negative feelings, spirituality, religion, and personal beliefs.
3. Environment domain: corresponding to questions about physical safety and protection, care, accessibility and quality of opportunities to acquire information and skills, opportunities and participation in recreation and leisure, the physical transportation.
4. Social relations domain: corresponding to questions about personal relationships, social support, and sexual activity.
After the questionnaire had been completed, general and domain (physical, psychological, environmental, and social relations) values were calculated, allowing for an evaluation of the individual QoL. This analysis has been performed according to the syntax described by the translators using the Statistical Package for Social Science (SPSS) 10.0 for Windows.
The participants completed the questionnaire

Statistical analysis
The results have been analyzed using descriptive and inductive statistical analysis. All statistical procedures have been performed on STATISTICA software version 5.1 (StatSoft, Inc., Tulsa, USA).

cases.
In the comparison of speech perception (HINT) of variance and Tukey's test have been applied.
Comparisons of the results of the WHOQOL-BREF unaided and aided have been performed using paired t-tests. The Pearson's correlation test has been applied to determine whether there has been a correlation between speech perception and QoL scores in the different domains of the WHOQOL-BREF.

RESULTS
situations unaided (situation A), aided (situation are shown in Table 1. The analysis of variance and Tukey's test comparing the three HINT situations under quiet and noisy conditions have showed significant improvements comparing situation A to B (0.00012) and A to C (0.00076), but there has been no difference between situations B and C (0.17659).
The results of the WHOQOL-BREF unaided and aided are described in Table 2.
Comparisons relations domain, followed by the self-assessment of QoL domain. The relationship between speech perception and QoL in situations A and C has been performed using p and r are described in Table 3.

DISCUSSION
The HINT has been used as an outcome measurement for HAs. The mean threshold for speech recognition in quiet conditions aided (situation B) was 5.31 dB lower than unaided (situation A). Comparing the results after 90 days of fitting to the results without an HA (situation C and A), the difference was 3.74 dB. These differences were statistically significant (p=0.00012; p=0.00076) and demonstrated that quiet 11 .
In relation to the performance in speech perception in noise, the SNR scores comparing were respectively 0.5 dB and 2.11 dB lower. These differences were also significant (p=0.00018; p=0.00012). It is important to note that at the time of this evaluation, the algorithm of directional microphones was enabled, which may have contributed to an improved speech perception in noisy environments, since some studies have indicated the advantages of using this algorithms for improved speech perception in noisy environments 5,18 .
These findings are extremely significant, especially when comparing the performance of OF HAs with directional microphones and OF HAs to  omnidirectional microphones. The literature shows that speech recognition performance in noisy environments using OF devices with omnidirectional microphones resembles the performance unaided.
In order to ensure that this variant of the HA microphone 18 . Differences between HINT scores unaided and aided have been clear (comparing situations A to B and A to C), but the results immediately after the to C) were very similar for silence. These differences were 1.67 dB and 0.59 dB of noise. Considering the standard deviation for the Portuguese HINT 1 of 1.7 dB for silence and 1.2 dB for noise, it is not possible to say that there has been an improvement or worsening in the results. improvement in social relations was expected, since individuals who are able to listen better are consequently better socializers, participate more actively in groups, and avoid social isolation caused by hearing loss 12,16 .
Some researches demonstrated improvement could be explained as a result of the short duration of use of HAs, since the re-evaluation questionnaire has been conducted just 1 month after the acclimatization process during this period 16 . Data from this study demonstrate that the physical domain. This can be justified by the mean age of the subjects evaluated (61.96 years) involving issues related to pain, discomfort, energy, fatigue, sleep, resting, mobility, activities of daily life, dependence on medication or treatment, and ability to work 10 . In the literature, few papers have related QoL with hearing loss using the WHOQOL-BREF. Some studies have investigated the relationship among QoL, age, sex, and the presence of hearing impairment, and found that these factors were not associated with hearing impairment 10,17 .
When we compared the results between the HINT and WHOQOL-BREF in situation A, there was by the fact that the individuals selected for this study showed a slope hearing loss with hearing preserved to 1 kHz, and in most cases, individuals good speech recognition performance in quiet situations 9 . In addition, the individuals evaluated had moderate losses at high frequencies, with an average threshold at 8 kHz of around 60 dBNA, which contributes to better speech recognition.
Comparing the results between the HINT relationship, only between HINT noise and the domain of social relations, has been observed. These that individuals with better speech perception in noisy environments have a better QoL regarding This is important in this population, since individuals with hearing loss limited to high speech in quiet environments, while in adverse conditions, such as when speech is distorted or in the presence of noise, the person may have the number of auditory cues drops considerably 8 .
There are no studies in the literature relating speech perception with QoL. The results of this improve the speech perception of individuals with hearing loss at high frequencies, both in quiet situations and in competitive noise. in all areas assessed by the WHOQOL-BREF. Individuals with better speech recognition in noisy environments who use HAs have a better QoL.
demonstrates the importance of conducting studies provide for individuals with slope hearing loss, thus improving the decision-making process regarding the prescription of HAs.

CONCLUSIONS
The acoustic stimulation in hearing loss in high frequencies through the use of OF HA favors the speech recognition and improves the QoL of individuals especially in the social relations domain.