A significant challenge faced by people who use cochlear implants—and anyone with hearing loss—is understanding speech in noisy places.  Cochlear implant technology offers options to help CI users cope with the challenges of listening in noise including directional microphones, dedicated maps/programs, streaming options, and assistive listening devices. However, more than these technology advances may be needed in certain listening situations regularly encountered.

We live in a noisy world. Some noise may be addressable, both technologically and perceptually, while noise encountered in other situations may be more difficult. For example, the noise of an air conditioner is typically constant in its nature and volume. It may be easier to understand speech in the presence of noise from an air conditioner than in the presence of noise from people talking—even if the two noise sources are of equal volume level.

Noise and Speech Levels (sometimes referenced as the Signal to Noise Ratio)
Noise level is a key variable affecting one’s ability to understand speech.  An individual with hearing loss is particularly impacted by the noise level relative to the volume of speech that the listener is attempting to hear.  The smaller the difference between noise and speech levels, the harder it is to understand speech in noise.  People with normal hearing may be able understand speech in the presence of noise that is equal to (or in some instances even greater than) the volume of the speech signal.  Most CI users need the speech level to exceed the noise level by at least 10 decibels to understand speech.

How to improve the speech to noise ratio?

Improving the ratio between speech and noise may be accomplished by distancing oneself from the noise source and/or getting closer to the speech source. This is not always possible. Sometimes, we must stand next to the noise source (for example, when washing dishes). Sometimes, noise is coming from multiple directions and it's impossible to distance ourselves from it (for example, when sitting at a table in the middle of a restaurant).

Understanding and analyzing noisy situations can help improve coping in them
The more hearing care professionals AND people with hearing loss thoughtfully analyze the acoustic environment, the better we are able to explain the problems to others, who may then know how to meet the needs of someone with hearing loss.

One way someone with hearing loss can raise awareness about the challenges that noisy environments create for them and better explain their communication needs is to explore the specifics of the intensity (or loudness) of the noise they are encountering. For that, I encourage someone to download a sound level meter app(decibel meter/noise meter) and use it to experiment and learn about the acoustic environment at home, at work, and wherever someone regularly spends time. I find that people are often surprised to discover how much noise exists in seemingly quiet environments. For example, the noise generated by the large flame on my gas stove is 45 decibels. The refrigerator generates noise which can reach an intensity of 52 decibels.  The dishwasher generates noise of 55 decibels and the water stream in the kitchen faucet creates noise 70 decibels of noise. Of course, one can be cognizant of such noise when replacing appliances. 

Speech intensity for a normal conversation range between 55 and 60 decibels with loud speech reaching 70 decibels. This means that while you are washing dishes, it may well be impossible to understand speech—even if the person speaking is standing immediately next to you.

When standing next to the stove cooking and conversing with another person, the speech will be stronger than the gas flame noise by about 10-15 decibels. If there are no additional noises and you have good speech perception skills, you may understand them without much effort. However, as the speaker moves away from you, the speech intensity will decrease, making it more difficult to understand speech. The speech intensity you hear when you six feet from the stove will may be equal to the noise intensity (or even be weaker than the speaker) so speech understanding will become a real challenge.

Knowing the average speech level and the (measured) noise level in different situations can reflect your difficulty understanding a conversation. You can explain to family members and friends that any noise of the same or higher intensity than 60 decibels (the average speech intensity in a normal conversation), or even 50 decibels, significantly affects your ability to understand speech without speech reading. Therefore, if needed, they should position themselves so that you have easy access to their faces. The same applies to talking to you from a distance greater than 3-4 feet in a non-quiet environment.

Understanding the implications of basic acoustics in everyday situations can avoid misunderstanding and discomfort.  

Basic facts you should keep in mind:

• Knowing the noise levels in the car (about 65 decibels) can demonstrate to people why they should not call you while driving, especially while using the car's speaker option. In addition, being aware of the noise level while driving with you can encourage use of your assistive listening device

• Measuring noise intensity in different restaurants can help you make informed choices for the quiet options.  Restaurant noise can vary depending on table location, so you can ask in advance to sit at a corner table or a table away from known noise (such as the bar). 
  

Measuring noise levels in the environment can help you:

• Distance yourself from noise sources and reduce controllable noises
• Know when to use technology to improve understanding of speech in noise including ensuring noise reduction programs on your processor are optimized for listening in noisy situations and you are making use of suitable assistive listening devices.
• Explain to others the challenges you face in noisy environments to help them communicate with you more constructively, suitably, and considerately.
  A better understanding of the acoustic conditions will allow you to manage everyday situations to reduce the adverse effects of noise and help you enjoy better communication with less effort.
  

Many people with hearing loss have difficulty understanding the speech of people with a foreign accent. This listening challenge is even present in favorable communication conditions, such as in a quiet environment and with speechreading. 

Foreign accented speech occurs when people use the sounds or rules of a language (usually typical to their native language) while speaking another language. Different languages affect the production of English in different ways. For example, native speakers of European languages may pronounce the English /r/ sound differently than native English speakers. One may even be able to determine the native language of the speaker, based on the way an individual pronounce specific sounds in English.

Various English dialects can add challenges in speech perception and understanding, even among those who speak English as their first language.  Understanding foreign-accented speech requires more effort and more complex auditory and linguistic processing. It may result in a strong preference for communication with people with typical speech and even avoiding interactions with people who have foreign-accented speech.

How can you improve your speech understanding of people with a foreign accent?

• The more experienced you are with a certain foreign accent, the better you will be at understanding them. People who regularly interact with people who have a foreign accent, such as family members and work colleagues, report improvement in speech understanding over time.

• Use voice-to-text apps. As this technology advances, apps may improve the accuracy of transcribing foreign-accented speech.

• Request that the speaker use shorter sentences. A study by Strori, Bradlow and Souza (2021) found that understanding foreign-accented speech in noisy conditions sometimes improved when the structure of the sentences was less complicated.

Practice listening to foreign-accented speech intentionally

• An evident improvement following a two-session intervention was found by Bieber &  Gordon-Salant (2017).  Study participants improved their sentence understanding of speakers with foreign accents and their reaction times by listening intentionally.  Although the effect was notable, it was not maintained when the participants were tested a week later. However, it is possible that a greater number of sessions and/or a more extended training period might have resulted in long-term improvement.

• Clinician-guided auditory training may help. Focused auditory training emphasizing the key acoustic characteristics of different accents can help someone to encode a speaker, resulting in better understanding of speech. 

• Self-practice. An individual may search for videos online that utilize individuals with accented-speech. Increasing one’s familiarity with the differences between the speech one normally hears and speech with a foreign accent can contribute to a better understanding of speech delivered by people with foreign accents.

Summary

Understanding foreign-accented speech is particularly challenging for people with hearing loss. It may be challenging and seem impossible. However, communicating with non-native English speakers in a global world is inevitable. Although there may be some difficulty, many people are able to improve their ability to understand foreign-accented speech. Regular communication with people who have foreign accents can result in an improvement in understanding them over time. Using voice-to-text apps may be helpful and hopefully even more accurate in the future. Focused training can contribute to better coping and a better understanding of people who speak English with foreign accents.  

Further Reading

Bieber RE &  Gordon-Salant S (2017). Adaptation to Novel Foreign-Accented Speech and Retention of Benefit Following Training: Influence of Aging and Hearing Loss. The Journal of the Acoustical Society of America, 141, 2800.

Strori D, Bradlow AR & Souza PE (2021). Recognizing Foreign-Accented Speech of Varying Intelligibility and Linguistic Complexity: Insights from Older Listeners With or Without Hearing Loss. International Journal of Audiology. 60(2) 140-150.

You have finally reached the moment you’ve been waiting for—you had your cochlear implant processor switched on and you are starting to hear with the new device!  Now the goal is to hear better. A lot of concepts may be introduced at this time: adapting to the new sound, auditory learning, and especially patience. 

What can you do to advance your progress during this early timeframe? You may be puzzled about what you should be doing.  Know that your hearing journey depends on many factors; your high motivation is one of them. The focus during the first weeks should be on adaptation and less on auditory practice.

Why is that? There are a number of reasons but the most important one is that in the first few weeks, recipients may have limited access to sound. Voices and other sounds may seem too soft, and very different from the sounds you once heard. Future mapping sessions will provide you with louder, clearer sounds.

What helps prepare you for the stage when you experiencing speech comprehension?

• Use your CI all day long
• Maintain the sound processor as suggested by your CI company (e.g., use the Dry and Store)
• Familiarize yourself with the sound processor so that you can easily change programs, settings, loudness, and connecting to other technology via Bluetooth and telecoil. Learn how the different programs are helpful in various settings. volumes).
• Experience different auditory environments but initially avoid very noisy situations. If you attend a noisy event, use your sound processor's lowest volume option.
• Use your CI exclusively (without a hearing aid) for at least one hour daily. Initially, do so in safe conditions (the least challenging communication and acoustic situations). You can start by taking off your hearing aid and using your CI alone while you're at your home alone or with a few family members. Avoid going without your hearing in demanding communication settings like the workplace, theater or social event.

Adapting is a Key Part of the Process

It may seem like you are doing nothing with your new CI, but adaptation to hearing through the CI is not trivial. Many CI users, especially during the initial stage of CI use, experience hearing as a flood of auditory stimuli. This is the case even though exposure to sounds may still be limited. The enhancements in sound experience typically occur later.

It is essential (and yes, easier said than done), that you experience and explore different sounds without self-judgment. Ask your friends and family members not to test you. Remember that what you hear during the first weeks is not what you will hear later.

What happens after your second or third mapping?

You are still at the initital stage of your hearing journey. You may consult your audiologist on his or her recommendation on when they recommend starting to consciously practice speech comprehension. 

Some possible strategies to try:

• Listen intentionally to the sounds around you and explore different acoustic environments. You might sit under a tree and listen to birds, or on a bench in a playground and listen to children's voices (without trying to understand them yet). Listen to the voices of your family members. Are you able to differentiate between them? Listen to the sounds in the house, such as running water, cooking, and appliance noises.
• What sounds do you like? Are there sounds that bother you? Note that at this early stage, weak or uncomfortable sounds may become comfortable and feel more balanced. Adapting to the quality and volume of the sounds can happen spontaneously. Patience pays off.
• If some sounds are still bothering you, remember to share that with your audiologist at your next appointment.
• If you wish to listen to music, do so carefully knowing that music will sound better in the future. Optimism, patience (again), and practice (in the future) will make it work.

Speech understanding

• Note that you are still in the first few weeks after your initial switch-on. Can you identify specific speech sounds, such as S, Sh and Z sounds? Can you differentiate between singular and plural words (e.g., cat/cats, pack/packs, bag/bags, road/road).
• Can you identify color names from a spoken series of colors? Car brands? Names of your family members or work colleagues? Can you understand simple sentences? 

In previous posts, you will find tips for your auditory trainer.  

You may already be able to log into different computer self-training apps and try to follow audiobooks. For many people, it may be too early to understand recorded speech. When using recorded speech, slow it down if possible. More tips for advanced self-training ideas may be found here.  And here.

Noise Sensitivity

In the early stages after turn-on, even people who are able to understand some speech without speechreading (or lip-reading) may be sensitive to noise and have difficulty understanding speech in noisy situations. Maintain a quiet acoustic environment when practicing, and use streaming technologies or assistive listening devices.

In Summary

Take the time that you need, become an attentive listener, embrace every achievement, and work in a hierarchical way. If possible, reach out to a Speech-Language Pathologist to help you determine an auditory learning program. Above all, maintain a positive attitude.

Good luck!

During the past decade, more adults with one ear having functional hearing have received a cochlear implant.  There is no formal definition for "functional hearing." Given expanded candidacy criteria to include those with asymmetric hearing loss, there are now CI recipients who can understand speech without lip-reading to some degree—especially in quiet conditions. They may also enjoy listening to music and carry out simple phone calls using their hearing aid in their non-implanted ear. 

Guidance given to new CI recipients who have this type of hearing loss is often to: (1) use the CI for the maximum amount of time each day and (2) practice hearing only through the CI without using the hearing aid in the other ear for portions of the day.

Many adults who have at least some significant functional hearing in their non-implanted ear have difficulty fulfilling the second task; giving up their hearing aid, even for a short period of time seems overly difficult. They may expect that the auditory learning process through their CI will occur regardless.

Many people who have functional hearing in their non-implanted ear experience spontaneous auditory learning via their CI, but others need to work towards it intentionally. The information provided from the CI is different, it might be confusing initially but recipients still need to become accustomed to the new sound and learn to interpret it as a meaningful signal. CI recipients tend to rely on the ear that provides them with the most meaningful information. When there is a relatively functional hearing in the non-implanted ear there is a risk that people might unintentionally ignore the information provided to them by their CI.

I see this occasionally in the clinic; people with functional hearing in their non-implanted ear might not efficiently utilize the information provided by the CI, even after one year or more of CI use. They might say that the CI contributes to their sense of intensity but not so much to their ability to understand speech. Many of them feel that their hearing aid provides them with better sound quality compared to the CI. Sometimes, they do not use the implant for all hours of the day because its contribution to their overall hearing is not clear enough. When I ask them whether they've ever tried to practice listening using their CI only, they often say they did not, since it was too difficult to give up the hearing provided by their HA. For these people the information provided by the CI might remain undeciphered and is in the background of what they perceive through their HA. In the situation described, people only use some of the acoustic information provided to them by their CI. In other words, they are not fulfilling their potential to enjoy it.

How might someone work towards more auditory learning in the CI ear?

• Use your CI regularly—during all waking hours 
  
  
• Develop your hearing skills in CI-only mode. You can start by choosing situations you can handle without hearing through your hearing aid, such as those times in which there are no challenging communication requirements and less pressure on you to not to make mistakes or miss important information.
  
  
• Listen to environmental sounds. You will likely find that your CI provides you with access to sounds that you miss via your hearing aid. Learn to recognize home and outdoor environmental sounds so they become meaningful and not ignored. 
  
  
• Listen to speech through your CI

• The CI allows you access to more speech sounds such “s,” “sh,” and “z.”  
• The CI provides cues that cannot be perceived solely by lip-reading and in many instances, not even by lip-reading with the hearing aid. For example, try to distinguish between the words "phase" and "vase” using lipreading.
• Listen to the differences between voices and try to recognize the voices of family, friends, and colleagues.
• As you become more comfortable with your CI only hearing, you should practice your speech perception and speech understanding skills. If you work with an audiologist or speech-language pathologist), they may be able to refer you to suitable materials to practice at home. If you practice independently, you can use the materials found on the CI companies' websites and other materials that were mentioned in previous posts. 
•  Several times a week (or more!) of self-practice in CI-only mode will make the difference!

What can you expect to happen?

• Your hearing outcomes will improve over time.
  
  
• You will feel more oriented by understanding the sounds around you.
  
  
• You will be able to more efficiently make use of the various programs on your sound processor and take advantage of them in various acoustic environments.
  
  
• You will feel that lipreading is less tiring, and you'll be less affected by the speech intelligibility of others including coping with rapid speakers or those with accents.  
  
  
• You may manage be better able to locate sound sources.
  
  
• If you develop the ability to understand speech without lipreading, you may be able to hold more challenging telephone conversations than those you could have carried out in the past using your hearing aid. Streaming sound to both your hearing aid and CI bilaterally or using assistive listening devices may be helpful.
  
  
• When listening to music, you may find that your CI helps you to understand words in songs.
  
  
• You will be better able to understand speech in noisy situations.
  
  
• When taking off your CI and using your hearing aid alone, you will feel that your hearing is lacking—not just in terms of volume but also in terms of speech understanding. The CI contribution to your communication and quality of life will be evident. 

In Conclusion

People with usable functional hearing in the non-implanted ear may face a challenging process of getting used to and utilizing the sound provided by the CI.  Effective auditory learning using CI-only mode will result in improved overall hearing and listening skills, the best possible bilateral hearing, and an improved quality of life.

Winston Churchill once said that “perfection is the enemy of progress.” This same philosophy aptly describes the rehabilitative process following cochlear implantation.

I dedicate this blogpost to some of my fearlessly perfectionist patients. Being a perfectionist is challenging. Even if we are aware of this aspect of our personality and try to mediate it, being a cochlear implant recipient and going through rehabilitation can add an additional emotional burden to our life.

Adult CI candidates and recipients in the early stages of CI-usage typically have various assessments and evaluations in which they get “low” scores. Who feels comfortable getting a score as low as 30%? Most of us would not and those who most feel negative about their evaluation outcome are those who go about their lives as over-achievers or perfectionists.

Progress after cochlear implantation can be slow and confusing. The test conditions can affect test “grades.” One of my patients noted "I have 90 percent correct in quiet but only 60 percent in noise. What does that say about me?” Another asked “How come I have only 40% correct for short (monosyllabic) words? Did I fail the test?"

The Problem with Perfection

For perfectionists, outcomes that they view as poor can be almost unbearable. They want to see progress and forward movement. They know improvement requires listening practice but repetitive exercises can be frustrating. Use of drills that involves repeating sentences and words provides clear right or wrong feedback, which may push them to stop practicing—especially if they find themselves making mistakes over and over again.

When you are dealing with these challenges alone without a professional’s oversight and encouragement, there may be no one to explain the meaning of the scores. Without a clinician’s support, it may be difficult to recognize improvement and achievement beyond numerical scores. This can be tough to bear alone. People need to find ways to challenge themselves without being frustrated; frustration can lead to a recipient abandoning rehab that could help them.

People who are perfectionists should avoid using practice materials that evoke a sense of being tested and graded. Self-practice software and apps that give true/false feedback and scores may discourage more than help. Therefore, training materials and methods that would not induce this kind of stress can be a much better option.

Dealing with Perfection in Auditory Rehab

Although pursuing perfection is the way to success for many, we also need to remember that auditory learning and improving listening skills is a gradual process that takes time. As with any kind of training, we should adjust the exercise materials and training tasks to someone’s level and carefully consider the starting point.

For example, if someone chooses to practice auditory comprehension by listening to audiobooks, I encourage them to get started by listening to short articles that are read clearly and at a slower speaking pace. You can find such on English learning sites for people who learn English as a second language.

You can also use recorded articles or text-to-speech software and apps.

When choosing recorded stories, take care to not use content with background music or environmental sounds initially; save those for the future when someone becomes a more advanced listener. Initially, choose texts with simple, everyday language. Investigate hearing comprehension while practicing different language levels.

I recommend that someone start listening as they follow the written text. Then, as someone becomes accustomed to the presenter's voice and speaking style, they can move forward by first reading one or two sentences and then listening to them without looking at the text. The more progress made, the more sentences someone will be able to repeat after reading them; this process helps develop auditory memory as well as developing listening skills.

Summary

The more that someone leans towards perfectionism, the harder it may be for them to deal with a situation in which they are not entirely successful. My advice is for such individuals to curb use of auditory training that relies on scoring as the only measure for progress. It is essential to find and use training materials that gradually increase the following:

• Complexity of the materials with which they are coping (e.g., daily conversation versus literary language)
• Complexity of the practice task (e.g., repeating versus understanding)
• Complexity of the presentation of the auditory stimuli (e.g., fast, regular, or slow-paced speech; in quiet versus in background noise)

If a CI recipient finds it too difficult to deal with the imperfection inherent to practice materials, change the process to fit the person. Find training materials that (s)he feels comfortable with, work hierarchically, and give the process time. Additionally, the recipient may benefit from keeping a journal to track their experiences over time. Doing this will provide perspective on progress. Most importantly, it will allow the individual to better enjoy the process and celebrate achievements.

Good luck!