Executive summary This paper is a critical review of the evidence of the importance of supra-threshold hearing abilities on speech recognition

performance in noise for people with mild-moderate sensorineural hearing loss (Proposition B). This paper considers, among other things: y A clear understanding of audibility and supra-threshold hearing abilities in the mild-tomoderate sensorineural hearing impairment. y A review of other factors, other than audibility, that contribute to the difficulties in speech perception experienced by those with moderate or greater cochlear hearing losses. y The magnitude of noise and articulation index and their role in the determination of evidence in support of supra-threshold abilities on speech recognition of hearingimpaired patients. y The importance of different psychoacoustic factors that might affect speech intelligibility. These include loudness recruitment and frequency selectivity. y An experiment demonstrating the hard evidence that poor performance in speech recognition can only be explained by reduced supra-threshold hearing capabilities and not audibility. y Finding and conclusions of the above experiment.

Introduction Many persons with sensorineural hearing losses experience difficulties in understanding speech, even at supra-threshold levels and favourable signal-to-noise ratios. The poor performance can be explained in terms of reduced supra-threshold hearing capabilities, for example temporal resolution and frequency. Audibility would not be the true explanation for this, as this would suggest that amplifying speech and noise would eliminate this problem. Consequently, hearing aids would restore normal performance on speech in noise burden to people with mild-moderate sensorineural hearing loss (Renals & Hain 2010). Comparisons of performance between people with conducive and cochlear losses of similar magnitude can provide some insight into the role of supra-threshold factors in cochlear hearing

loss. Using subjects with pure sensorineural losses and subjects with varying degrees of conductive loss, Dubno & Morgan (1987) measured intelligibility of isolated words as a function of presentation level. The found out that at low stimulus levels, subjects with conductive loss showed poorer abilities to understand speech in quiet than subjects with cochlear loss. At high levels, the reverse was true.

Audibility and supra-threshold capabilities A common problem for people with sensorineural hearing impairment is that they can hear when a person talking, but they experience difficulty understanding what that person is saying (Moore et al., 2009, p. 550). Even with a raise in the speakers voice, the speech message remains distorted. This problem in listening can be sometimes likened to a radio that is slightly mistuned. The sound remains unclear even when the volume is increased. This example illustrates the difference between reduced audibility and supra-threshold distortion, both of which are components of hearing impairment. The former involves poorer thresholds to detect or hear the sound. Supra-threshold distortion refers to reductions or distortions in signal quality that exist even when the sound made is loud (Moore, 2007, p. 219). Unfortunately, supra-threshold distortions manifest themselves in noisy listening situations. Magnitude of noise and articulation index According to Humes and Roberts, noise may be regarded as simulating the combined effects of threshold elevation and loudness recruitment (1990). Notably, too, noise masking technique is limited to the simulation of mild-to-moderate hearing losses.

Models of Auditory Processing to Forecast Speech Recognition Performance in Noise To assess importance of supra-threshold discrimination abilities for speech perception we can stimulate the effect on a specific aspect of hearing impairment by processing the stimuli in a way that mimics the effect of this aspect. This method studies the importance of the three

psychoacoustic factors: loudness recruitment combined with threshold elevation, frequency selectivity and temporal resolution. This paper provides evidence on the importance of supra-threshold hearing abilities on speech recognition performance in noise for people with mild-moderate sensorineural hearing loss. This entails characterizing the nature and extent of supra-threshold hearing abilities in listeners with sensorineural hearing impairment. Notably, clinical assessments of hearing capacity are incapable of reliably predicting a patients speech recognition performance in noisy conditions. The below figure illustrates these points for a group of ten mild-moderate sensorineural impaired patients for a study carried out at Army Audiology and Speech Center.

Figure 1: Relation between pure-tone hearing thresholds and performance on a speech-in-noise test relative to normal hearing normative data (Source: Army Audiology and Speech Center). The two graphs illustrate the average hearing thresholds at 2000-8000 Hertz (bottom) and the average hearing threshold at 500, 100 and 2000 Hertz (top) versus a clinical speech-in-noise test scores (also known as QuickSIN scores). The Quick SIN measures speech-to-noise (SNR) ratio that would be required to obtain 50 per cent words right on a sentence test in comparison to the data obtained from normal hearing persons. The SNR is the resulting score, which is the difference between the mild-moderate sensorineural impairment score and the normal hearing score (SNR loss). As can be clearly noted, there is little correlation between the average hearing loss and the ability of the listener to recognize speech in noise. Thus, poorer performance in speech recognition can only be explained by supra-threshold capabilities and not audibility. In an effort to understand the variability across people with mild-moderate sensorineural hearing loss, some studies review models or simulations of auditory signals as they are processed through hearing-impaired ears. These models use mathematical formulations of auditory processes in transforming sound into active time-frequency fluctuations. This is vital for the brain to interpret and group speech sounds into meaningful language units. The data obtained is used to adjust the model parameters in the experiments on specific patients to mirror increased auditory thresholds, plus supra-thresholds capabilities related to reduced spectral resolution and loudness recruitment. The abnormal rapid growth of perceived loudness the input signal is increased in level is known as loudness recruitment. Individuals who are impaired have a more immediate development of loudness than individuals who hear normally. This aspect of auditory distortion is assessed by measure of cochlea compression, or the amount of output increase at varying frequencies as a function of input level. With this measure, we are able to see how much benefit the cochlear provides to the high-level, medium and weak input signals. Spectral resolution is how well listeners can handle different sounds that are presented simultaneously to different frequency regions. For instance, if a tone is played to listeners near middle C (about 256 Hz) at a loud level, can they identify a weak higher tone about a half octave

up about 362 Hz? If their hearing is normal, level of the 362 Hz tone is required to just be detected would be nearly the same. It has been found, though, that for listeners with mildmoderate sensorineural loss the tone at middle C impacts on the ability 362 tone. Also, the higher tone must be made louder that if it was played only for it to be heard. Findings For every listener that was tested, a separate auditory model incorporating threshold and amplitude compression was constructed. Similarly, a model for normal hearing was constructed with data collected from a group of normal hearing listeners. By playing noise and speech signals to the mild-moderate sensorineural patients and making a comparison with the model outputs of the normal auditory model, the researchers were able to get differences between what speech might look like to the impaired ear/brain versus the normal ear/brain (Smoorenberg 1992). The differences are used to create a score that is used to predict speech recognition. The actual scores can then be compared with the predicted scores. This is illustrated below.

Figure 2 Results of 5 patients listening to speech in a noisy environment as a SNR of -3dB (Source: Army Audiology and Speech Center.) The top graph shows results as a function of a Speech Transmission Index. This is a basic model of audibility alone. The bottom graph shows the results of including audibility and suprathreshold distortion factors. Each score is a comparison between speech alone passed through simulation of a normal ear and noise and speech passed through a simulation of the listeners distorted auditory system. The graph shows that we can account for the dissimilarities across mild-moderate sensorineural impaired listeners to a greater extent than when only suprathreshold data are considered.

Evidence and conclusion The above experiment illustrates that people with mild or moderate cochlear losses can understand speech reasonably well when in a quiet room with only one person talking. People with severe losses usually have difficulty even when listening to a single talker in a quiet room and have severe problems when background noise is present. The paper also illustrates that hearing losses for people with mild cochlear impairment can be accounted for primarily in terms of audibility. However, for those with moderate-to-severe cochlear hearing losses, supra-threshold abilities need to be considered. Here, audibility, though important, does not fully account for the difficulties experienced by such people. This study also proves that the poor performance can be explained by reduced supra-threshold hearing capabilities, for example temporal resolution and frequency. As has been seen audibility has not been able to explain this, as this would suggest that amplifying speech and noise would remove this problem. This is not the case. In the future, there should be more works to include other measures of hearing capacity e.g. pitch perception. This will enhance the efforts to model the supra-thresholds distortion brought about by mild-moderate sensorineural loss.

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