Guidelines for Best Practice in the Audiological Management of Adults With Severe and Profound Hearing Loss

Seminars in Hearing

Turton, L., Souza, P., et al. (2020).

Seminars in Hearing, 41(3), 141-246.

This guideline informs best-practice regarding the audiological management of adults with severe and/or profound degree of hearing loss.

Phonak

This guideline reports the following general recommendations regarding assessment: <ul> <li>“Prior to the hearing assessment, enquire if communication support (e.g., palantypists for captioning, note takers, interpreters) is required.” (p. 148; Level 6, Grade D Evidence). </li> <li>“It is beneficial to take an extensive, chronological otological history, taking the client back to the start of their hearing problems to fully understand their journey so far and enable problem solving to take place when developing a treatment plan later in the assessment.” (p. 148-149; Level 4, Grade C Evidence) </li> <li>“Often the client will be returning for a reassessment of their hearing, rather than attending for a first assessment and, in such cases, the medical history should focus on any changes since their last assessment.” (p. 149; Level 4, Grade C Evidence). </li> <li>Information should be gathered regarding cognitive ability, mental health status, physical status (i.e. mobility and craniofacial status), general health, dexterity, and visual status (Level 1, 4, & 6 , Grade A-D Evidence) </li> <li>“Hearing care professionals with training may perform these additional tests outside the scope of audiology (e.g., tests of dexterity, vision, cognition, and depression) or make recommendations for an onward referral for completion of these tests if required.” (p. 149; Level 3 & 6, Grade C)</li> <li>Hearing care professionals should interview the client to get a thorough assessment of their current hearing needs as well as their current use and success of communication strategies to assist in the identification of factors that could impact motivation, unrealistic expectations, appropriate amplification, and other treatment options. (Level 3,4, 6, Grade B-D Evidence) </li> <li>“The needs analysis could be completed using a self-report instrument (with open-ended questions) such as the Client-Orientated Scale of Improvement (COSI), the Glasgow Hearing Aid Benefit/Difference Profile (GHABP and GHADP), or the Speech, Spatial and Qualities of Hearing scale (SSQ-12). These questionnaires then later assess whether the respective treatment improved the client’s specific needs (to determine benefit and satisfaction levels at their follow-up)” (p. 152; Level 6, Grade D Evidence) </li> <li>Assessment should consider the impact of the client’s hearing loss on their close friends and family as well as the role of the communication partners to inform the development of effective intervention strategies and device management plans. ( Level 3, 4, & 6, Grade B & D Evidence)</li> </ul>

This guideline makes the following recommendations regarding specific evaluation measurements for adults with severe to profound hearing loss: <ul> <li>“The measurement of the degree and type of hearing loss should include both threshold and uncomfortable loudness levels to ascertain the dynamic range for both ears.” (p. 149; Level 3 & 4, Grade B-C Evidence)</li> <li>"Speech recognition testing is beneficial in considering amplification strategies, setting expectations, and onward referral for cochlear implants. The hearing care professional and the client should consider what they want to measure (e.g., evaluating amplification or considering a cochlear implant assessment). Speech testing can be a useful qualitative measure of both communication abilities and hearing aid benefit. Speech testing may be dictated by local/ national protocols for cochlear implant referrals, but ideally, it should be flexible enough to assess auditory speech perception, auditory-visual speech perception, and conversational fluency either through one test or through a battery of tests available to the hearing care professional.” (p. 149; Level 3 & 4, Grade B Evidence)</li> <li>" Cochlear dead region testing might be undertaken to consider the success of amplification or candidacy for cochlear implants (p. 149; Level 3, Grade B Evidence)</li> </ul>

“In the case of sudden onset of severe and profound hearing loss or acute tinnitus, the hearing care professional must refer the client for ENT investigation. This should be treated as a medical emergency and the client should be seen urgently.” (p. 149; Level 1, Grade A Evidence).

This guideline made the following recommendations regarding assessment in the presence of comorbid conditions: <ul> <li>“Tinnitus management should be investigated and implemented if required.” (Level 3 & 4, Grade B Evidence)</li> <li>“Clients presenting with significant neurological disorders/cognitive impairment may require an assessment test battery that is adapted appropriately. Tests which are assessed verbally must be administered carefully to avoid confusing hearing and cognitive aspects.” (p. 149; Level 1, 4, &6, Grade A-D Evidence)</li> <li>“Hearing care professionals should make appropriate referrals for onward management where significant non-auditory needs are discovered requiring further support.” (p. 149; Level 3 &4, Grade C & D Evidence)</li> <li>“The communication impairment and association of other long-term health conditions with severe and profound hearing loss will render referrals in and outside of the health system.” (p. 149; Level 1, 4, & 6 , Grade A-C Evidence)</li> </ul>

This guideline made the following recommendations regarding general treatment: <ul> <li>Hearing care professionals should provide audiological services in a person-centered manner, which is linguistically and culturally sensitive, recognizing that the client is an expert about the impact of their hearing loss (Level 3 & 4, Grade C Evidence). </li> <li>Discussions regarding the potential for amplification should be transparent regarding expectations (Level 3, Grade C Evidence). </li> <li>Treatment options should always consider options wider than amplification, including cochlear implants or supportive technologies (Level 3,4, & 6, Grade B, C, & D) </li> <li>Treatment plans should be agreed upon, recorded in a personalized care plan, and given to the client as a copy. It should be flexible and updated on an ongoing basis. (Level 1 & 4, Grade A & B Evidence)</li> </ul>

The treatment plan should be made in collaboration with the client and should consider: <ul> <li>results from pure tone audiogram and speech testing as well as the impact the hearing loss might have on communication,</li> <li>information regarding current use of communication strategies along with any relevant audiological and non-audiological history which may influence treatment options, and</li> <li>priorities identified from the results of needs analysis (Level 3 & 4, Grade B & C Evidence). </li> </ul> All options for managing hearing needs should be discussed, outlining the potential benefits and limitations of each option, while promoting independence and self-management using counseling, information sharing, education, and discussion. Treatment plan development should consider: <ul> <li>the fitting of hearing aids as part of the treatment plan,</li> <li>counseling and rehabilitative support, communication strategies, lip reading, and aural rehabilitation counseling for people with severe and profound hearing loss, with linking to their needs analysis,</li> <li>assistive listening devices in isolation or as supplements to hearing aids, as needed, with demonstration of use for any appropriate device and consideration for remote microphone systems to improve communication in adverse situations,</li> <li>referral for a cochlear implant evaluation if appropriate,</li> <li>provision of information about and/or referring to other organizations and support groups,</li> <li>referral for medical or surgical treatments if indicated, and</li> <li>documentation of all treatment options in the client’s treatment plan (Levels 1, 3, 4, & 6, Grades A-D).</li> </ul> For more detailed information regarding the development of a comprehensive treatment plan, see section 1.4 (p. 154-155) of this guideline.

When selecting and programing hearing aids, selections should be made to: <ul> <li>improve speech discrimination while avoiding and/or reducing loudness discomfort,</li> <li>provide a speech quality that is acceptable to the client,</li> <li>preserve and/or enhance usable acoustic cues for phonetic identification,</li> <li>improve signal to noise ratio, ease of listening, and overall listening comfort in background noise,</li> <li>support communication in various situations, including on the telephone,</li> <li>have reliable ability to access hearing assistive technologies, and</li> <li>limit maximum output to avoid further hearing loss (Level 3, 4, & 5, Grade B & C Evidence). </li> </ul>  For further information regarding amplitude compression, device choices and programs, frequency lowering, prescriptions and verification, selecting technology for asymmetrical hearing loss, and maximum power output and threshold shift, see sections 2.0 and 2.1 (p. 155-159).

When selecting remote microphone systems, the following should be considered: <ul> <li>the communication demands on the person with hearing loss,</li> <li>the connectivity potential assistive technology including wireless technology in the community and workplace,</li> <li>reducing the complexity/minimizing the number of components of the system, and</li> <li>charging options and battery life and their impact on the user (Level 3, 4, & 6, Grade B-D Evidence).</li> </ul> For additional information regarding the ongoing management of remote microphone systems, see sections 2.2.1 and 2.2.2 (p. 160- 162) of this guideline.

When verifying remote microphone systems, the following should be considered: <ul> <li>equivalent output,</li> <li> minimal additional circuit noise and distortion, </li> <li>behavioral performance increases with use of remote microphones, and </li> <li>that comfortable listening is maintained (Level 3 & 6 Grade B & D Evidence)</li> </ul> For additional information regarding the verification of remote microphone systems, see section 2.2.3 (p. 162-163) of this guideline.

Regarding the referral for cochlear implantation, hearing health professionals should: <ul> <li>be comfortable in starting the conversation with clients, </li> <li>understand the benefits of bimodal fittings, and </li> <li>understand the limitations of other implantable devices for this population (Level 1-4 & 6, Grade A-C Evidence).</li> </ul> For additional information regarding referral for a cochlear implant see section 2.3 (p. 164-166) of this gudeline.

Clients with severe and profound hearing loss benefit from rehabilitation targeting psychosocial aspects of hearing loss to ensure success, including: <ul> <li>help in adjusting to hearing loss and its impacts,</li> <li>training to develop effective communication strategies, behaviors, and attitudes with consideration of communication partners,</li> <li>contact with peers to provide support and to reduce isolation, and</li> <li>guidance in selecting and using appropriate assistive listening device solutions (Level 1-4 & 6, Grade A-D Evidence).</li> </ul> For additional information regarding the client and careparter training and counseling, contact with peers, psychosocial aspects of the rehabilitation process, and guideance for selecting and using assistice listening devices see sections 3.1-3.4 (p. 166- 173) of this guideline.

Regarding the treatment and management of tinnitus, this guideline recommends the following: <ul> <li>Otoscopic examination should exclude cerumen as a likely source of tinnitus. </li> <li>The hearing care professional should refer new clients or clients with long-standing tinnitus with changes in their tinnitus profiles for ENT investigation rule out underlying pathology and for provision of any appropriate medical treatments to relieve the tinnitus. This is especially true in the case of sudden onset of severe and profound hearing loss or acute tinnitus, which should be treated as a medical emergency and the client should be seen urgently. </li> <li>Returning clients with long-standing tinnitus should be reviewed at regular intervals. </li> <li>Hearing loss should be addressed as the first step in tinnitus management, with review of hearing aid fitting as applicable to ensure that the maximum benefit for environmental sounds and speech is achieved. </li> <li>In cases of not aid-able hearing loss, consider referral for cochlear implant assessment to address the hearing loss, with client counseling regarding the impact of hearing loss management on tinnitus relief. </li> <li>Use tinnitus noise generators with caution and avoid applying masking noise in speech programs due to potential impact on sparce speech cues and dynamic range. </li> <li>When sound enrichment is used, use in combinations with a dedicated tinnitus noise generator separate-for-tinnitus-only hearing aid program. Ensure that the level of the enrichment sound is sufficient to be audible by the person with hearing loss, but not so loud as to be heard by nearby listeners. </li> <li>Environmental sound enrichment sources (e.g. radio, TV, or HiFi music system) should be used with caution, with volume level that is audible and effective, but not loud enough as to block important safety and environmental sounds (e.g. phone, doorbell, and alarms) or cause undue disturbance nearby listeners. </li> <li>If, following audiological management, tinnitus is still distressing, consider specialized tinnitus management. Cognitive behavioral therapy is recommended and tinnitus retraining therapy is no longer recommended by current clinical guidelines, but might provide relief to some individuals with tinnitus. </li> <li>Due to the severity of hearing loss, any tinnitus therapies should be delivered face-to-face  when possible to ensure successful communication. </li> <li>Consider referral for specialized treatment of anxiety and depression for any suspected signs of these disorders, with immediate referral given any clinical signs ( Level 1, 3, 4, & 6, Grades A-D)</li> </ul>

Following assessment and treatment, this guideline recommends the following components for follow-up sessions: <ul> <li>measurement of outcomes and assessment of treatment goals, </li> <li>the exploration of alternative interventions and screening for any additional referrals (i.e. cochlear implants or behavioral health specialists), and </li> <li>the monitoring of receipt of appropriate ongoing care (Level 1, 2, 3, 4, & 6, Grade A-D Evidence)</li> </ul> For additional information regarding the measurement of patient outcomes, assessment of need for ongoing referral, and ongoing care management, see sections 5.1-5.3 of this guideline (p. 176-179).

American Speech-Language-Hearing Association

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