A Modest Proposal: The Case for Speech-in-Noise Testing

The audiometric test battery is getting a little long in the tooth and could use some rejuvenation.  For about the last 50 years the time-honored suite of tests has been in place virtually unchanged.  Why should it change?  After all, hearing is hearing. 

The auditory mechanism hasn’t changed.  And hearing aid technology, well, we are still dealing with output, gain and compression, just like the old days, right?  (Oh, I forgot – irony sometimes does not translate well on the page.  Add a little irony emoji to that last statement.)

Nothing against the traditional battery.  Solid, well designed and useful tests all – though poor SRT is a little under the gun these days.  Hope it survives, but if not, it has had a good run.  

The addition of speech-in-noise (SIN) testing to the test battery has been bandied about quite a bit over the last several years and I would like to add my voice to the chorus (after all, being a baritone, it’s all about the bass.)  This just may be the essay that turns the tide and brings everyone around to administering SIN testing.  (Again, add irony emoji).  

QuickSIN is the test about which I am most familiar.  It was developed by Mead Killion and his minions and has been around since the early aughts but has yet to catch on with most hearing care providers.  Which is a great shame. 

I used the test routinely for several years clinically before I became a trainer and have been advocating and training its use for the last 12 years.  I am a true believer and cannot understand why more hearing care providers don’t use it.  Well, that’s not completely true.  I do understand why.  It is unfamiliar, it’s new(ish) and inertia is a powerful force.  Turning the oil tanker of what is familiar, comfortable and entrenched in routine can be a formidable task.  

I wonder how many of us would be comfortable going to, say, an oncologist who doesn’t refer patients for MRI because it is a new(ish) thing and they just don’t want to be bothered with the time and effort involved in learning about it.  I just wonder……  

So why should we consider SIN testing?

1. Most of the hearing aids dispensed today have directional microphones.  D-mics help our patients to better understand speech in noise.  It stands to reason (to me, anyway) that it would be helpful to know how well or poorly our patients understand speech in noise.
2. It gives you a small but valuable competitive advantage.  It is likely the “guy-down-the-street” is not doing SIN testing.  (Better be quick, because after this article, that all changes 😉.)
3. It is a test that possesses a face validity absent in the rest of the standard test battery.  In my experience, at least, few patients complain of an inability to hear pure-tone beeps presented at threshold intensity or understand one-syllable words in isolation presented at MCL.  But every day your patients encounter situations in which they are talking to someone while others are talking at the same time.  That is QuickSIN.  Your patient will get it intuitively.  
4. SIN testing will identify patients for whom directional microphones are unlikely to provide much benefit.  This is the very patient whose primary complaint is likely to be difficulty understanding speech in noise.  As a competent hearing professional, we assure them that their hearing aids will have directional microphones and (famous last words) “you’re gonna do great!”  And then they don’t do great and eventually come back, bag in hand, for you did not solve their number one issue.  Had SIN testing been performed, resulting in a very poor Signal to Noise Ratio (SNR) loss, that promise may not have been made. Among the better solutions might be assistive technology (remote mics or FM system) that would improve signal-to-noise ratio to a greater degree than is possible via conventional directional microphones.  

Still, objections abound!  

I don’t have the time! 

• Yes, SIN testing takes time.  Everything we do takes time.  Not too much, though.  No more than 5 minutes, perhaps less when you become facile, which shouldn’t take too long.  But it’s well worth it, for the reasons listed above.

How about patients with extremely poor thresholds, and/or poor word recognition ability?

• You can probably predict that patients with severe/profound hearing loss will do poorly on a SIN test.  Same with patients with poor WRS.  You may not want to frustrate them any more than necessary.  But they might just surprise you, and wouldn’t that be good to know?

What about patients with cognitive issues?

• If your patient has difficulty following instructions for pure-tone testing, you can bet they will have trouble with directions for SIN testing, which are necessarily a bit more complex.  Again, cognizance of your patients’ possible anxiety/frustration could be a limiting factor.  

If a patient has normal or near normal hearing, why would SIN testing be necessary?

• SIN testing may tell you why someone with pretty good hearing is coming to you with complaints about understanding in difficult situations.  It can function as an informal screening for CAPD.  

The time for SIN testing to become a standard component of the audiometric test battery is…..  well, it was several years ago, actually. 

Still, I encourage you to turn that oil tanker just a little bit, give Etymōtic Research a good month and start to incorporate SIN testing.  You will hear your patients say, (as I have heard many times), “That is the first time I’ve been given a hearing test where a problem I’ve been having was actually tested.”