The Future of Audiometry: Going Beyond the Sound Booth with Renée Lefrançois of SHOEBOX

shoebox portable audiometry
June 5, 2023

Can valid clinical testing be done outside the traditional sound booth in the audiology clinic? This week, Bob Traynor sits down with Renée Lefrançois of SHOEBOX to discuss this question. They explore the benefits of web-based audiometry and use of portable clinical audiometers for testing outside sound-treated environments.

In recent years, validation studies by highly respected institutions like the Mayo Clinic have shown the clinical validity of web-based audiometry, offering a reliable and accessible option for diagnostic testing.

More information can be found on the SHOEBOX website here.

Full Episode Transcript

Welcome to This Week in Hearing. Hi, I’m Bob Traynor, your host for this episode. And the first question I have, have you ever wanted to assess somebody outside of a sound room? Of course, we all want all of our patients to have a hearing evaluation inside a double walled, sound treated environment, if it’s all possible, but there are times when that’s not available to us today. My guest is from Shoebox Audiometry, who’s going to tell us how we may be able to conduct a valid audiometric assessment outside of that sound treated environment. Welcome Renée Lefrançois, audiologist at Shoebox, and thanks so much for being with us here at this Week in Hearing. Thanks for having us, Bob. So let’s start a little bit by telling me and my group here a little about your journey that brought you to Shoebox. And Shoebox is kind of a new company to most of us, so maybe a little about Shoebox as well. I’d be very happy to. Shoebox started out as conception in 2010 with the launch of Apple’s first generation of iPads. For the first four years after that, there was a lot of work that was done by our founding brothers, Julian and Matt Bromwich. Julian’s background is as an engineer, and Matt Bromwich is a pediatric ENT who was doing Locums in northern Canada and wanted to find a novel solution to help with automated audiometry pre and post surgery. It’s hard to retain audiologists in some of these rural areas, and yet medical care needs to continue. And so in 2014, Shoebox Limited was founded, in which the company itself did have a brick and mortar office, and I was employee number eight, and we haven’t looked back since so in that time. So we’re coming up on our ten year anniversary in 2024. We’ve really branched out into almost every area of the marketplace in audiology, so from schools to occupational hearing testing to diagnostic testing, humanitarian efforts, as well as education and research. So we’ve had a myriad of products that have become available over that nine year time frame, but it really did all start with an automated platform that was based on the modified Houston- Westlake protocol on an iPad that could be delivered by a non hearing healthcare professional in terms of myself. I am a Canadian audiologist who’s been practicing for 23 years. The first 15 years of my career were spent in cochlear implantation. And in 2014, I saw this opportunity with Shoebox, which Nowhere to villai was maybe 300ft from actually where I reside here in Ottawa, Ontario, Canada. And I just felt that it was meant to be. And I jumped in with both feet first. And we’re really proud of the offerings that we’ve been able to provide to clinicians and non clinicians alike. And I look forward to discussing that in more detail with you today. Great. Well, thanks for being with us. I understand that our topic today is really boothless diagnostic testing. And again, as we talked earlier in our discussion, that double wall sound room is the gold standard. Of course. So tell us a little about how I can do a diagnostic test outside of this sound treated environment. ANSI has really helped pave the way with this, with the standard known as specifications for audiometers, which is the ANSI standard S 3.6, which was most recently revised in 2018. But way back, in terms of when it was first published, I believe in 1960s, 1970s, they actually published what’s known as Maximum permissible Ambient Noise Levels, or M panels for short. And essentially, the research has shown that if you are able to be in a sound controlled environment in which frequency by frequency, the ambient noise is below these prescribed maximum limits, and you do a hearing test, that you can be confident in those results, and they would be considered clinically valid. So the gift that ANSI has given to us and OSHA shortly followed suit with their own set of M panels is basically saying, if you’re able to do noise monitoring or room scans and you’re confident that that noise environment is stable, that you are able to conduct clinically valid hearing testing in that environment. And those standards have been used those earlier standards have been used in hearing conservation for quite a long time, and now we now have maybe a product that will capitalize on that for us to some degree. Well, you guys did a study in 2022 that kind of demonstrated that web based audiometry can actually be equivalent to in person audiometry by a hearing professional. Correct. So we’ve been fortunate enough that we’ve had five full fledged validation studies by such. Well known institutions as the Mayo Clinic, McGill University, the University of Ottawa, and most recently, this study that came out of Paris, France, in which digital audiometry was used over an Internet connection. And what that does is it really throws something else into the mix, which is the connectivity that we rely so much on on a day to day basis. But we also know that it can be variable from time to time. And when you’re testing someone diagnostically, you need to eliminate any sources of variability that might interfere with the test. And so in that study, hearing instrument specialists were able to measure and that is the profession that tests hearing in France. There are no audiologists per se in France. So they actually took 30 individuals and they tested them in a randomized order, either with manual conventional audiometry or with digitized online audiometry. And they found that the results were largely within five dB test re-test, therefore demonstrating that this was a clinically valid way to test hearing. Wow. So that means that we can do some of the evaluation things online without having to worry too much about the variability of what’s going on in that system and in that environment. Well, can all of the tests be performed outside the sound treated environment or some of them? Do we still have to do some of them in the sound treated situation to continue with the validity that we’re looking for? Excellent question. So any test with ears covered certainly provides additional attenuation, which helps the possibility of meeting and being under those maximum noise levels. So that would include air conduction, audiometry, bone conduction with ears covered. But of course, you need to take into account the Occlusion effect when that occurs. And that can be different depending on the volume of the ear canal. And so we’ve taken quite a lot of time to take a look at the studies that are available to us to be able to provide some generalized correction factors for that Occlusion effect. We are able to also perform speech testing and speech and noise testing again, because we are using circumaural headphones, which provide really excellent attenuation. The headphones that we suggest include the insert earphones, which are an industry standard, but also the formally of Sennheiser, now of Radioear db450 headphones that provide best in class attenuation right now with audio metric headsets. Wow, things have changed so much. Those of us that have been around a while, when we started doing stuff in the 70s, late seventies, eighties or so, these were only things that were the dreams were made out of. I mean, if you had audiology dreams, I guess you might make a dream that you could test someone outside of a sound treated environment. So which populations have you and your colleagues found the most successful with this web based boothless audiometry? Well, we actually have had the luxury of testing many different types of populations with the automated platform we recommend ages six and up. We have many schools that use it for their annual school testing right on site. But we also have had lots of success in the international realm, so even in countries that don’t have audiologists per se. So the drug resistant Tuberculosis research avenue has been one that has been really interesting and we’ve learned a lot from. We’ve been working together with an organization called the Union Against Tuberculosis and Lung Disease that has used Shoebox in over 40 countries to measure hearing loss after the administration of canomycin, which we know is largely ototoxic and significantly Ototoxic. And so the learnings that we’ve had from there have led us actually with a new iteration of automated testing. So the automated test that we have currently on the iPad is one in which the patient can actually drive the test themselves. They would actually push an indicator and if they heard a sound, they would drag and drop to a green bucket. If they didn’t hear a sound, they drag and drop to a red bucket. But what we found with some of the pediatric populations, geriatric populations, as well as those who might be in poor health, is that they often don’t have the energy to take the 30 to 45 seconds per frequency that’s needed in order to produce a clinically valid full audiogram. So, Shoebox again, is proud that we took those learnings from the field and we created something called assisted mode. Assisted mode is when the test administrator, who doesn’t need to be a hearing healthcare professional, actually drives the test themselves. But the modified Houston Westlake algorithm is in the background. And so what they’re doing is they’re presenting tones, including catch tones. Catch tones are when there’s no tone at all, which is important to be able to monitor the consistency of responses. And so. That person is actually holding the iPad driving the test. And it makes it easier for the individual who’s taking the test to be able to complete a full diagnostic evaluation. Again. Technology marches on, doesn’t it? Since this sound treated environment has always been the gold standard for audiometric assessment, do you find clinicians are resistant to the idea out of testing people outside their sound environment? I mean, it’s probably okay for the international groups who haven’t been used to it, but for those of us here in Canada, the United States and other more developed areas for our profession, have you found that to be kind of an uphill battle at times? Yes, and it’s actually one of my favorite discussions to have because I value due diligence in clinical excellence and I like to see it from others as well. And we can expect every hearing healthcare clinician to have inherent knowledge of all of the standards behind the scenes in terms of what is allowable in terms of audiometers and sound environments. So when I actually bring up that both the OSHA and ANSI standards had this laid out for us in the 1970s, people do react with some surprise because, of course, if it wasn’t applicable to their testing practices at the time, then there wasn’t any need to actually go into that deep dive into those standards. But it really does. I have to give OSHA and Ansie the credit here to be able to pave the way to allow for these technologies to emerge. Probably those that are CAOHC certified and those kinds of credentials have probably been your biggest supporters, I would think, in the use of this type of technology to evaluate not only the workers, but also to kind of keep things simple for the companies as well. I can’t tell you the amount of positive comments that we’ve had from health and safety managers saying how much more a part of the hearing conservation program they feel when they bring hearing testing on site to their locations. Not only do the test administrators and hearing conservation program managers feel more in control, so do the employees. They’re used to sitting in a booth, holding their breath, waiting for a tone, unsure if they heard it or not. Whereas when they’re driving the test themselves, some of that anxiety is reduced naturally just because they are in control of their hearing test. And also that doubt of was a tone present or not. Well, when they’re actually presenting the tones themselves, you’re eliminating that waiting game, which has been really key. So we’ve had very large enterprises start with small pilots and there is always the aspect of financial savings, time savings, productivity savings. But really one of the resounding positive comments that have driven this forward has been the employee reaction of saying I used to dread getting my hearing tested and now I feel like I’m much more committed to protecting my hearing because I see the outcome and I’m a part of the program. Well, a lot of the hearing conservation programs farm out their routine evaluations and to have them brought back into the company run by somebody that they kind of know anyway is probably a huge benefit for the hearing conservation program and for you and your colleagues as you develop the technology and move it even further forward. So what kinds of things do clinicians need to consider when they’re looking at testing people outside the sound treated environment as opposed to inside the sound treated environment? Excellent question. So something that comes top of mind is certainly privacy and confidentiality. The sound treated environment, although it’s not built to provide a private environment, it’s inherent in terms of the nature of sound booths. And so when you’re testing someone in an open room environment, it’s important to be mindful of the windows of that environment who can potentially see the screen that the individual is working with and also just allowing them to feel that they’re not being watched. So each clinician might have a slightly different strategy here, but what I would do, we actually have a progress bar at the top of the iPad that will tell us how many frequencies per ear, so how much longer there is until the test completes. And so I would actually wait and watch, not over the shoulder, but kind of just at a bit of a distance to ensure that that first frequency was achieved successfully and that the individual was comfortable with the automated test. If I felt that they were comfortable, then I would step out of the room, I would set my timer and I would check in again closer to the end of the test. Therefore, one giving the confidence in the individual that they could test their own hearing and giving them the privacy that if they wanted to do the test more quickly or more slowly, that there wasn’t any judgment there now that was focusing on the automated platform, but we also have manual testing options. And so again, with the privacy aspects of that, really important to make sure that if there are windows to the environment you’re testing in, that there are some blinds or covers so that the individual feels that they are being seen in a one on one private. Environment and also just making sure that they’re comfortable in terms of proximity of the clinician. You don’t want to be staring them down and adding to any potential anxiety. You also want to make sure that the sound environment is consistent. Now, Shoebox has not only a room scan feature that you can run prior to the test, it also has ongoing noise monitoring. Sometimes as humans, when we have low frequency noise in the 250 to 500 Hz range, we tend to filter that out pretty automatically. And those are the frequencies that are often the most impacted by background noise. And so you can rest assured that you’re not using a human ear to assure that the sound environment is consistent, that the very sensitive and highly sophisticated iPad microphone is doing that for you during the test. Wow. You may have mentioned this already, but what are the advantages of having clinical audiometers that can perform diagnostic tests outside this sound treated environment? My assumption is that the Shoebox Audiometer has quite a clinical function. And so what are some of those advantages? Well, there has never been a better example than our recent pandemic with COVID-19. And so we really had to pivot very quickly and creatively to provide the very needed services to our patients in a clinically valid way, but in a non contact situation. And so that’s where remote audiology, tele audiology really came to the forefront like it never has in our history. And so the tests that the Shoebox Audiometer can do at the moment in terms of consultant remote capabilities include video otoscopy at a distance as well as case history, pure tone, bone conduction, speech testing, speech in noise testing, and masking for all of the above. So I would be remiss if I didn’t mention some of the things that I didn’t just list in that breakdown. And that includes tympanometry and reflex testing as well as OAE or ABR testing, as well as hearing aid verification and programming. So it’s really important in our industry that the technology leaders focus on what they’re good at. And at Shoebox, we are a diagnostic company. We feel that there are excellent options out there right now for tympanometry, reflex and Otoacoustic emission testing. The functional components that are required to perform those tests, such as a pump for tympanometry and reflex testing, are really a niche area. And we don’t believe in one company doing. Everything because that would just really, I think, dissolve some of the expertise that’s required to be best in class in that particular area. So, should a clinician wish to do tympanometry and reflex testing, which most do, we recommend partnering with a currently available portable option that has all of that in one in conjunction with the Shoebox audiometer for your audio metric needs. Wow. With all of that innovation, there has to be some things that are going to be going on in the future for Shoebox. With the innovators like yourself and all those 40 people around the world that are doing developing, there has to be some innovative things that are going to take us beyond just a new century and to the middle of the century. Yes, Bob, you are bang on the money with that one. I’d like to give a shout out to our software development teams who work day in and day out to try and bring the most innovative hearing healthcare advancements to the Shoebox products. We have a list of over 400 feature requests that we work through and prioritize. Of course, we can’t get to them all at the same time, but we do take all of the input and feedback that we receive from our customers quite seriously. We document it all and together with our product management teams, we are able to really prioritize those efforts. So in the past six months, we’ve been able to launch QuickSIN as an integrated portion of our Shoebox remote and consult products. Looking ahead to the future, we would like to include more speech testing capabilities, some advanced testing capabilities, and who knows what’s coming down the pipeline. We know that there are advancements in other areas of medicine as well, using AI for example, or automatic data mining, which could also potentially be interesting for automated audiometry in terms of classifying audiograms in certain groupings to help, for example, with primary care physicians or geriatricians in knowing what hearing actually looks like and what next steps should be. So you can rest assured that the whole team of over 100 employees at Shoebox are really working hard to try and give as much as possible in our products to the clinicians and provide as much functionality as we can. That’s fabulous stuff. And of course, now with being able to do an Otoscopic exam on an iPhone and those kinds of things, it just makes sense that we may be able to incorporate that into our clinical outside the clinic kinds of assessments. Well, so today my guest has been Renée Lefrançois from Shoebox is their audiologist and sounds like one of their innovators as well. And by the way, Shoebox has been one of the sponsors of The Future of Hearing Healthcare Conference. And I understand you have a presentation there as well, discussing things about how you go about doing some of the things you guys do at Shoebox. Um, by the way, we appreciate all the sponsors because Future of Hearing Healthcare is sponsored by this Week in Hearing, and Hearing health and Technology matters. So thanks to Renee, who has presented us kind of a heads up on how we can not ditch the sound treated environment, but certainly use that for routine assessments, but how we can move out of the sound room and out of the clinic and provide some very good clinical assessments of each and every one of our patients if necessary. So thanks again for being with us and thank you for being with us at this Week in Hearing. Thanks very much, Bob.

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About the Panel

Renée Lefrançois, M.Sc.(A), Reg. CASLPO, CAOHC PS/A Director of Audiology. She has been practicing audiology since 1999 and has been with SHOEBOX Ltd. since 2014. After 15 years of working with cochlear implants, she eagerly took on a new challenge of diving into diagnostics and hearing conservation for her current role as Director of Audiology. Renée leads both the internal Clinical Team at SHOEBOX, as well as the SBX External Audiology Network which provides state-licensed review and professional supervision services in the US and Canada. She lives in Ottawa, Canada and when not working, enjoys all things outdoors.


Bob Traynor - Co-Host, This Week in HearingRobert M. Traynor, Ed.D., is a hearing industry consultant, trainer, professor, conference speaker, practice manager and author.  He has decades of experience teaching courses and training clinicians within the field of audiology with specific emphasis in hearing and tinnitus rehabilitation. He serves as Adjunct Faculty in Audiology at the University of Florida, University of Northern Colorado, University of Colorado and The University of Arkansas for Medical Sciences.



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