The Use of Same-Day Hearing Aid Fitting with Telehealth Follow-up Care: A Case Study of a Veteran Presenting with Tinnitus and Auditory Processing Disorder Symptoms

Abstract

Providing same-day hearing aid fitting appointments to patients being seen in an audiology clinic for an audiometric evaluation may help decrease clinic wait times and reduce the need for future in-person appointments. Prior to 2020, the Veterans Administration (VA) Healthcare System did not allow hearing aid manufacturers to provide functional demonstration (demo) hearing aids to VA audiology clinics. Due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2/COVID-19) pandemic, this rule was changed to minimize the number of required in-person VA audiology appointments. The audiology clinic at the Pittsburgh VA Healthcare System developed a hearing aid fitting protocol using demo hearing aids to provide same-day hearing aid fitting appointments. This case study pertains to a female Veteran who presented to the clinic with complaints of decreased hearing and bothersome tinnitus. The patient completed a comprehensive audiometric evaluation, auditory processing disorder screening, hearing aid evaluation, and hearing aid fitting in the clinic. All follow-up appointments were scheduled to be completed via telehealth. The initial findings in this case study indicate that same-day hearing aid fittings can be successful for some patients. Future telehealth follow-up appointments will determine this patient's level of success using hearing aid–related outcome measures.

This case study examines the evaluation and treatment of a 49-year-old adult female Veteran who suffered from significant self-reported hearing loss, tinnitus, memory impairment, posttraumatic stress disorder (PTSD), anxiety, depression, chronic pain, and migraine headaches. This case will detail her medical history, evaluation of hearing, tinnitus treatment, and hearing aid fitting using the Pittsburgh Veterans Administration (VA) Healthcare System's same-day hearing aid fitting protocol with telehealth-based follow-up care developed due to the COVID-19 pandemic.

Case Presentation

The Veteran featured in this case study is a 49-year-old woman first seen in late 2020. She is currently unemployed but previously worked as a nurse. She reports that she has been unemployed since moving to Western Pennsylvania due to several medical conditions which she feels makes it too challenging to complete the duties required for the nursing profession. The Veteran scheduled the initial audiometric evaluation due to a perception of worsening hearing bilaterally, with a more significant decrease in the left ear. During this time, she also noted that her tinnitus worsened with the left ear tinnitus being worse than the right as well. The Veteran reported that she completed an audiometric evaluation in 2015 as well as several audiometric evaluations while serving in the military, all of which were found to have audiometric thresholds and word understanding ability within normal limits.

In her case history form, the Veteran reported long-standing issues with lightheadedness and unsteadiness which other medical providers have attributed to issues related to neck and back injuries as well as migraine headaches. She received medical treatment for these issues and reported improvements after chiropractic and acupuncture-based treatments. She also reported a long-standing history of aural fullness bilaterally but did not indicate how long she has been experiencing this sensation. Lastly, she reported purchasing a unilateral, ear-level personal amplifier; however, she did not find this to be beneficial as she felt it was too loud and sharp for her to use on a full-time basis.

The patient completed three questionnaires as part of her case history form, including a hearing-related activities of daily living checklist that was created by the Pittsburgh VA, the Client Oriented Scale of Improvement (COSI), and the Hearing Handicap Inventory for Adults—Screening (HHIA-S). These three measures are part of the standard Pittsburgh VA Healthcare System audiology case history form due to their abilities to identify the patient's perception of hearing impairment on daily activities as well as to be used as outcome measures after treatment is provided to measure patient success. ^{1 2} The Veteran identified hearing in background noise and hearing at work as the two main areas where she would like to improve on the COSI. The Veteran's score on the HHIA-S was 34/40 indicating a severe self-perceived hearing handicap. ³ Lastly, on a VA-developed hearing activities of daily living questionnaire, she identified the following areas as problematic ⁴ :

• Hearing during the majority of daily communication.

• Understanding conversation with one or two people in noise.

• Understanding conversation in a group setting, quiet environment.

• Understanding conversation in a group setting, background noise.

• Hearing women's voices.

• Hearing television/radio at a normal volume.

• Hearing medical providers.

• Understanding speech during religious service.

• Understanding conversation when in a meeting.

Due to these issues, the Veteran reported feeling embarrassed and feeling frustrated.

A chart review also was completed prior to the patient's appointment. During this review, it was found the Veteran had numerous medical issues. The patient was previously diagnosed with the following medical conditions: anxiety, depression, PTSD, restless leg syndrome, insomnia, low back pain, chronic pain, migraine headaches, hypothyroidism, and gastroesophageal reflux disease. All of these conditions except for hypothyroidism, gastroesophageal reflux disease, and restless leg syndrome have been found to positively correlate with Veterans having a self-perceived hearing handicap despite normal audiometric findings (Jedlicka DP, unpublished data: Co-occurring conditions in Veterans with self-perceived hearing handicap and normal audiometric findings; Pittsburgh VA Healthcare System, Pittsburgh, Pennsylvania). ⁵

Otoscopy revealed a normal examination of the external auditory canal and tympanic membrane in the right ear. The left ear was found to have significant, nonoccluding cerumen. The audiologist examining the patient at this first appointment attempted cerumenectomy; however, it was unsuccessful in completely removing the cerumen. It was recommended that the patient be seen by the Pittsburgh VA Healthcare System Ear, Nose, and Throat department to have the cerumen removed. Due to the cerumen not fully occluding the ear canal, the audiologist proceeded with the audiometric test battery.

Comprehensive audiometric testing (see Fig. 1 ) was completed using foam insert earphones and revealed normal hearing sensitivity in the right ear and normal hearing sensitivity in the left ear through 1,000 Hz sloping to a mild sensorineural loss at 2,000 and 3,000 Hz before improving back within normal limits. Speech audiometry was completed as part of the standard audiometric test battery (see Fig. 2 ). Speech reception thresholds (SRT) were consistent with the patient's pure tone averages indicating reliable responses. Word recognition in quiet at conversational levels was 92% in the right ear and 88% in the left ear (obtained using recorded NU-6 [Northwestern University Auditory Test Number Six] word lists). Tympanometry (see Fig. 3 ) was within normal limits for middle ear pressure, compliance, and ear canal volumes bilaterally. The Quick Speech in Noise Test (QuickSIN) was also administered due to the patient's report of difficulty hearing in noise. ⁶ The patient's bilateral QuickSIN SNR loss was 1.5 indicating normal speech understanding ability in noise.

Figure 1.

Audiometric evaluation results.

Figure 2.

Speech audiometry results (speech recognition threshold and word recognition scores).

Figure 3.

Tympanometry.

The audiologist evaluating the patient at her first audiometric evaluation recommended that the patient have the cerumen removed from the left ear and return to the audiology clinic for further testing. This recommendation was made due to her severe self-perceived hearing handicap in relation to having a mild hearing loss in the left ear only and bothersome tinnitus bilaterally. The Veteran was agreeable to scheduling a follow-up visit to complete auditory processing disorder testing. The Veteran was also counseled regarding her bothersome tinnitus. She was offered sound generators to use at home to help manage the tinnitus during the day and while she was sleeping; however, she declined citing limited benefit from a white noise generator that she has used in the past to help improve her quality of sleep.

The Veteran's next appointment with the audiology department was approximately 1 month after her initial visit. The Veteran elected to slightly extend her wait for an audiology testing appointment so that she could be treated for cerumen management on the same day. The Department of Ear, Nose, and Throat of the Pittsburgh VA Healthcare System was able to fully remove the cerumen prior to the patient's audiology appointment. During her appointment with audiology, the Veteran completed the Veteran Self-Assessment of Auditory Impairment (VSAAI) which is a case history form developed by the Department of Audiology of the Pittsburgh VA specifically for those with normal to near normal hearing and a perception of significant self-perceived hearing handicap. ⁶

The VSAAI case history report for the auditory processing disorder evaluation found that the Veteran served as a nurse on a critical care transport team during her time in the military. In this role, she was exposed to loud levels of noise on airplanes and did not use hearing protection during those exposures. It is not uncommon for Veterans with noise exposure, blast exposure, or head trauma to report hearing difficulties similar to this patient; however, she denies any history of blast exposure or head trauma. Questions regarding blast exposure, head trauma, and concussion are asked due to Veterans of Operation ENDURING FREEDOM (OEF) and Operation IRAQI FREEDOM (OIF) reporting hearing difficulty after experiencing these events. ^{8 9 10}

The Veteran also reported on this case history form that she does have a positive medical history for depression, anxiety, and PTSD. This is consistent with what was found during her medical chart review prior to her first audiology appointment.

In the VSAAI form, Veterans are asked to rate from 1 to 10 using a Likert scale to determine how much of an impact hearing difficulty has on their life with 1 being no impact and 10 being completely debilitating. The Veteran reported a score of 8 on this scale. The same type of Likert scale is used to ask Veterans their willingness to seek help for this disorder with 1 being “not at all likely” and 10 being “definitely” likely. The Veteran rated her willingness to seek help as a 10 on this scale.

The final portion of the questionnaire is open ended and allows the Veteran to provide further information that they feel is important for the clinician to note. In this space, the Veteran reported she continued to work as a nurse after she separated from the military. She recently left her job due to difficulty hearing her coworkers. She explained that during to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, her hearing difficulties were exacerbated by the use of masks which she felt further impaired her ability to hear due to distorted speech as well as not being able to use lip reading and facial cues. She also indicated that she needs people to call her name to get her attention before speaking; otherwise, she will not recognize that the person is speaking to her. Her goal is to improve her hearing ability so that she can return to work.

Prior to administering the SCAN-3:A Tests for Auditory Processing Disorders in Adolescents and Adults (SCAN-3:A) screening assessment, tympanometry and an ipsilateral acoustic reflex threshold screening was administered. The tympanometric results were once again within normal limits. Acoustic reflex thresholds were present at 85 dB SL at 500, 1,000, 2,000, and 4,000 Hz. The Veteran next completed the SCAN-3:A auditory processing disorder screening. The test was completed following the recommended instructions of presenting the signal in the test booth using 50 dB HL presentation level. ^{11 12} The Veteran has mild sensorineural hearing loss at 2,000 and 3,000 Hz which could negatively influence the results of the SCAN-3:A test as found in previous research due to reduced dB SL. ¹¹ The screening version of the assessment includes the following tests: gap detection, auditory figure ground—0, and competing words—free recall. The Veteran scored within normal limits for all three screening tests indicating she does not have an auditory processing disorder (see Table 1 ).

Table 1. SCAN-3:A Auditory Processing Disorder Screening Results Based on 40:0–50:11 Age Norms.

Screening test	Passing criteria	Patient outcome
Gap detection	Three consecutive correct responses of hearing two sounds between 2- and 30-millisecond gap intervals	Pass
Auditory figure ground—0	≥25 correct responses	Pass
Competing words—free recall	≥26 correct responses	Pass

Since the Veteran was reporting hearing difficulty despite all audiometric test results revealing normal to mild hearing loss along with bothersome tinnitus, the audiologist determined to complete a hearing aid evaluation to treat the mild hearing loss in the left ear and the bilateral tinnitus. The Veteran was agreeable to this which is consistent with her self-report to seek treatment for her self-perceived hearing impairment.

In 2020, the VA Audiology and Speech Pathology Central Office allowed for demonstration (demo) receiver-in-canal (RIC) hearing aids to be ordered from manufacturers on the VA Hearing Aid Contract. ¹³ These devices are intended to be used during the hearing aid evaluation process as well as to provide same-day hearing aid fittings to appropriate candidates. Each individual VA clinic is responsible for determining their own method for employing the use of these demonstration aids. The Audiology Clinic of the VA Healthcare System Pittsburgh uses the demo hearing aids to complete hearing aid fittings on the same day as the patient's audiometric evaluation and hearing aid evaluation. The VA Healthcare System Pittsburgh's demo hearing aid fitting protocol allows for all Veterans with hearing loss configurations that are appropriate for RIC style hearing aids to use this program. While all eligible Veterans are considered for same-day hearing aid fittings, most Veterans who use the same-day fitting program are previous RIC hearing aid users and new users who are active users of smartphone technology that are able to complete telehealth-based follow-up care.

The demo hearing aid fitting protocol requires the audiologist to complete a traditional hearing aid evaluation which includes the following: the completion of outcome measures (COSI and the Hearing Handicap Inventory), presentation and education of different hearing aid manufacturers, models, and device options; selection of the device's shell color; and an evaluation of the need for hearing aid accessories. When the patient completes the hearing aid evaluation, the same make and model of hearing aids the patient selected will be used from the clinic's demo hearing aid stock to fit the devices using comprehensive probe microphone measures. An electroacoustic analysis of the hearing aids is also completed. These specific settings and measurements are saved in the patient's electronic medical record.

Following the hearing aid fitting measures, the patient is fully counseled on the use of the devices, as they would be in a traditional hearing aid fitting appointment. The patient is educated on comprehensive use of the devices. Additionally, if any accessories are ordered, the patient is counseled on these devices as well. Finally, since this fitting protocol requires the use of telehealth-based app technology, the appropriate manufacturer apps to complete the telehealth-based follow-up and adjustments are downloaded to the patient's phone during the hearing aid fitting process. The patient is provided with written instructions on how to pair the hearing aids with their phone after the patient receives the devices in the mail.

At the completion of the appointment, the audiologist orders the hearing aids and any necessary accessories. The receivers that were attached to the demo hearing aids and used for the fitting are removed from the devices, placed in an individual container, and held by the fitting audiologist until the hearing aids which were ordered arrive. This is done to ensure that the universal precautions are maintained. The demo aids used in the hearing aid fitting are fully sanitized and new receivers from clinic stock are added to these devices. The demo hearing aids are returned to the clinic stock to be used for future same-day hearing aid fittings. When the hearing aids which were ordered specifically for the patient visiting to the clinic, they are programmed using the settings saved at the hearing aid fitting and paired with any accessories that were ordered. Electroacoustic analysis is completed and compared with the analysis that was recorded at the original fitting appointment. The Veteran is contacted to make them aware that their new hearing aids are being shipped and the first of two hearing aid telehealth follow-up visits are scheduled.

The Veteran in this case was deemed to be a candidate for a same-day hearing aid fitting as the audiologist determined that her current use of smartphone technology, immediate need for the devices, and ability to complete remote follow-up care would allow her to become a successful hearing aid user. The Veteran was counseled regarding the features of several hearing aid options and selected the Phonak Audeo P90-R (rechargeable) RIC. This was selected due to the ability to connect directly to her smartphone for phone calls, audio streaming, and remote programming options. She also selected this specific hearing aid due to the rechargeable battery option of the devices. The last and one of the most important reasons this device was selected was due to the ability to provide tinnitus treatment beyond standard amplification. The Phonak Audeo P90-R has a built-in sound generator that can be activated for tinnitus treatment. If the internal sound generator is ineffective in treating the patient's tinnitus, the patient will have access to additional tinnitus phone-based apps which can be streamed directly through the hearing aids.

Hearing Aid Fitting

Immediately following the hearing aid evaluation, the Veteran was fit using a set of rechargeable Phonak Audeo P90-R demo hearing aids using standard power receivers with an open dome. The hearing aids were initially programmed using the Phonak Adaptive Digital 2 fitting formula prior to completing comprehensive real ear measures. The National Acoustics Laboratory's NAL-NL2 fitting formula was used to determine target gain levels based on their strategy of making speech intelligible and overall loudness comfortable. ¹⁴ The Audioscan Verifit was used to complete Real Ear to Coupler Difference and Real Ear Aided Response Measurements (see Fig. 4 ). Measurements for soft (55 dB SPL), medium (65 dB SPL), loud (75 dB SPL), and maximum power output (MPO) were completed to ensure audibility was provided by the hearing aids while not providing amplification at an uncomfortable loudness level. The Speech Intelligibility Index (SII) was 97 in the left ear and 96 in the right ear for medium and loud input levels indicating the speech sounds being amplified are audible and useable by the patient ¹⁵ (see Fig. 5 ). The aided average SII score improved minimally in the left ear and remained unchanged in the right ear when compared with the average unaided SII score. These results are not unexpected due to having only a mild sensorineural hearing loss in the left ear and normal audiometric thresholds in the right ear.

Figure 4.

Real ear aided response measures using NAL-NL2 targets.

Figure 5.

Speech intelligibility index values. MPO, maximum power output.

The Veteran was not provided with any manual programs in the hearing aids. The aids were programmed to use only the Phonak Autosense Program to take advantage of the automatic program switching. While automatic, this program still allows the clinician to determine the percentage of time the patient is in each listening environment. Also, the tinnitus sound generator feature was not activated during the fitting. It was decided by the audiologist to not activate this feature, as amplification alone is well documented to serve as a treatment for tinnitus. ¹⁶ Additionally, the patient can have this feature activated at a future remote-adjustment appointment if she deems it to be necessary. If it is determined later that a tinnitus sound generator program is required, a new manual memory will be created with the tinnitus sound generator active for the patient to use as needed. Lastly, since the Veteran will have the hearing aids connected to her phone, she will have access to a greater variety of sound generator–based apps. The direct connectivity between her phone and the hearing aids will allow her to stream these tinnitus-based sound generator apps through her hearing aids while wear them and at night to attempt to improve her quality of sleep if she feels it is needed.

The patient was counseled regarding the use and function of the hearing aids after probe tube measurements were completed. The counseling process involves teaching the patient how to physically manipulate the hearing aids for the purposes of insertion, removal, cleaning, and placement in the charging case. The Veteran was able to independently complete these items by the conclusion of the appointment. Additionally, the Veteran was counseled on how to pair her hearing aids to her phone after she received them. The myPhonak app was downloaded to the patient's phone during the appointment. She was counseled on the app and shown how to use the remote programming feature to ensure remote follow-up visits could be completed to provide adjustments if needed and to complete the hearing aid outcome measures.

Telehealth Hearing Aid Follow-up

The Phonak Audeo P90-R hearing aids were received from the manufacturer approximately 1 week after the patient's hearing aid evaluation and fitting appointment. The hearing aids were programmed using the personalized settings that were obtained at her previous visit. An electroacoustic analysis was completed prior to mailing the hearing aids to ensure that they were performing exactly as the set of demo hearing aids which were used to complete the in-clinic hearing aid fitting. The Veteran scheduled a telehealth hearing aid follow-up appointment approximately 2 weeks after receiving the hearing aids in the mail. This telehealth visit was completed using the myPhonak app which was downloaded to the Veteran's phone at the last visit. This app allows for a video-based follow-up appointment with the possibility for remote programming to be completed.

This follow-up visit was intended to be the first of two hearing aid follow-up appointments. The first appointment is to provide further counseling to the patient, address questions from the patient, and determine if further adjustments are needed. The second telehealth hearing aid follow-up appointment serves as a traditional hearing aid follow-up appointment where hearing aid outcome measures, tinnitus outcome measures, and data logging will be measured. After this visit, the patient is expected to be seen annually for routine maintenance and repeat audiometric evaluations as needed.

The Veteran reported that she was doing well with her hearing aids. Data logging confirmed that she was using the hearing aids approximately 7.5 hours per day with the AutoSense program indicating listening in quiet nearly 100% of the time (see Fig. 6 ). The Veteran reported improved hearing ability with the hearing aids noting specifically that she was able to hear her husband better and did not need to have sentences repeated as much as before. She also reported that she was unable to try the devices in any situations with groups or background noise due to social distancing guidelines recommended due to the COVID-19 pandemic. Her perception of the hearing aids performance in background noise is the most important outcome measure, as hearing in noise is her primary hearing complaint. The Veteran was informed that we would revisit her performance in this area at her second follow-up visit once she was able to gain more experience with the hearing aids in different listening environments. The Veteran declined the offer of having programming changes made to her hearing aids at this time, as she felt satisfied with the performance of the devices.

Figure 6.

Data logging at first follow-up appointment.

While the patient did report an improvement with the devices, she did state she was having trouble charging the hearing aids. She explained that she would put the hearing aids in the charger at night, but in the morning the aids did not charge. The video feature of the myPhonak app allowed the audiologist to watch as the patient demonstrated how she inserts the hearing aids into the charger. While she did not demonstrate any inaccuracies in placing the aids into the charger, the audiologist deemed it to be likely that she was simply not pushing the aids into the charger far enough to establish a charging connection. The Veteran reported that when she found the aids were dead in the morning she would push hard on the aids until the charging lights were visible and after 2 hours, she was able to use the aids for the rest of her waking hours. She was also encouraged to wipe down the hearing aids daily to ensure no debris or moisture is preventing the aids from making full contact with the charger. Following these instructions, the telehealth hearing aid follow-up session was ended with a plan to follow up with the Veteran via a second telehealth hearing aid follow-up appointment in approximately 1 month.

Second Telehealth Hearing Aid Follow-up

The Veteran was contacted 4 weeks after her first telehealth hearing aid follow-up appointment to complete outcome measures, record data logging, and make programming adjustments as needed. The Veteran was first attempted to be contacted via a telephone call to complete this appointment. She was contacted daily for 1 week with the audiologist being unable to reach the patient. After a week, the Veteran was sent an email requesting to schedule this second telehealth hearing aid follow-up. Additional phone calls were placed without success of reaching the patient. Due to the inability to reach the patient to complete the second follow-up appointment, some of the outcome measures scheduled to be obtained at the follow-up visit such as the International Outcome Inventory for Hearing Aids (IOI-HA), HHIA-S, and the Tinnitus Handicap Inventory (THI) were mailed to the Veteran. These forms were not returned to the clinic as requested.

Results

The findings from the patient's first telehealth follow-up visit indicate that she is successfully using the hearing aids and finding some benefit in an area where she identified difficulty hearing at her initial appointment. Despite this, evidence suggests that patients with normal to near-normal hearing and self-perceived hearing handicap, specifically in noise, fit with low-gain hearing aids that are lost to follow-up have poor rates of returning for audiology-based hearing healthcare services. ¹⁶ The Department of Audiology of the Pittsburgh VA Healthcare System will continue to make an effort to follow up with this patient to ensure that her hearing healthcare needs are being met.

Discussion

This Veteran presents with a very interesting case featuring multifactorial issues which extend beyond the scope of audiology. If the patient does end up becoming lost to follow-up and does not use her hearing aids, it may be due to the devices not meeting her needs in the situations that are most problematic for her, which is hearing in the presence of background noise. Her performance on the QuickSIN, excellent SII values, and counseling toward appropriate expectations and listening strategies indicate a chance for her to become a successful hearing aid user finding benefit with these devices. The initial follow-up visit confirmed the potential for success as the patient reported an improvement hearing her husband and hearing in quiet environments.

The patient's main goal was to be able to hear well enough in noisy environments so that she could return to work as a nurse. If the patient finds a lack of benefit from the devices in more challenging listening environments that she would experience in her work setting, this may discourage her from continuing to use the devices. Despite this, the initial finding from the first follow-up visit is encouraging based on her self-perceived improvement as well as the data logging confirming near full time use of the hearing aids.

In addition to receiving audiology services, the patient may also find benefit in continuing to receive treatment for her mental health and sleep comorbidities, as these impairments may be detrimental in the areas of attention, memory, and fatigue. ^{17 18 19} A multidisciplinary, patient-centered approach in this case will serve the patient best to ensure that she has all of the resources from audiology and other disciplines to succeed in working toward her goal of being employed as a nurse in the future.

Conclusion

This case demonstrates that providing same-day hearing aid fittings with telehealth-based follow-up services is appropriate for a wide range of patients. It is the opinion of the author that individuals who are previous hearing aid users remaining with the same manufacturer and same style of hearing aid are most likely to benefit from a same-day hearing aid fitting protocol. Additionally, there are individuals such as the Veteran in this example who should also be considered for the same-day hearing aid fitting protocol if the audiologist feels that the patient is able to retain the information from the initial appointment and has the ability to access telehealth follow-up services so that programming adjustments and outcome measures can be completed.