Management of Auditory Processing Difficulties Virtually: A Case Study

Abstract

Difficulty hearing in the presence of background noise is a common complaint heard by audiologists. This can be accompanied by additional difficulty in classrooms and other difficult listening situations. This was recently exacerbated by the coronavirus disease 2019 (COVID-19) shutdowns and the accompanying mask usage and virtual meetings. This article describes one such patient seen during the recent shutdown. This patient reported difficulty hearing during her college coursework for her music performance major. She was an established otology patient with an extensive middle ear history including multiple surgeries. During the shutdown, she virtually consulted with the auditory processing disorders clinic at the recommendation of her otologist to discuss her college-related difficulty and pursue educational accommodations. Challenges and solutions for seeing this patient and other, similar patients virtually are discussed as well as a review of how this patient proceeded and how the knowledge gained from this patient could apply to others with similar concerns.

The COVID-19 pandemic and shutdown have challenged auditory systems in new and unique ways. Masks have eliminated visual cues and reduced audibility. ¹ Virtual learning has added additional signal issues, audibility concerns, and processing issues for many elementary, middle, high school, and college students. ² These challenges have led many patients to pursue diagnosis, treatment, and management for underlying auditory issues that were previously untreated, as these new challenges proved to be the tipping point for many people to pursue audiologic care. ³ Just as these challenges began to present themselves, many clinics shutdown and moved to virtual operations as much as possible.

Most commonly the underlying auditory issue was previously undiagnosed or untreated hearing loss but occasionally, patients had normal audiometric thresholds while reporting significant difficulty hearing with mask usage and virtual settings. These patients could then be referred for further auditory processing testing to explore additional sources of difficulty originating in the auditory pathway. Typically, the next step following an audiogram with thresholds within normal limits (WNLs) is to complete speech in noise testing and if this is abnormal to refer on for a comprehensive auditory processing evaluation. ⁴

Auditory processing disorder (APD) is traditionally defined as difficulties in the processing of auditory information in the central nervous system and the underlying neurologic activity. ⁴ APD occurs in children, adults, and older individuals. It is believed to commonly co-occur with sensorineural hearing loss in adults and the elderly. Reported symptoms of patients with APD typically include difficulty hearing in noise, difficulty with pitch perception in speech or music, difficulty with multistep directions, difficulty with speech that is degraded due to distance or speed, and many others that are not explained by the results of a standard audiogram. ^{4 5 6} A diagnosis of APD should be made by audiologists trained in administering and interpreting a battery of behavioral tests which can additionally include electrophysiologic measures, and generally other disorders such as attention deficit, autism spectrum disorder, head injury, or stroke should be assessed so that they can be controlled for if possible during the APD evaluation. ⁴ There is no gold standard diagnostic criteria for APD; however, the American Academy of Audiology's position statement specifies that to be diagnosed with APD patients should perform 2 standard deviations or more below the mean for at least one ear on at least two different tests in the same domain within the APD test battery. ^{4 6 7} These diagnostic criteria are included in the clinic's APD protocol and were applied to the patient discussed in this case report.

As previously mentioned, APD can co-occur with sensorineural hearing loss in adults and in the elderly. This can make diagnosis difficult, as most tests are not normed for individuals with hearing loss and many sensorineural losses may have an underlying neurologic component. Frequent otitis media or other middle ear difficulties are a significant risk factor for APD. ^{4 5 6 8} It is thought that this fluctuating auditory information due to fluid does not allow the auditory central nervous system to develop accurately. It is reasonable to conclude then that APD and conductive hearing loss related to middle ear disease can co-occur as well. A conductive loss can be controlled for during testing by raising the presentation level to compensate for the conductive loss. ⁹ This should still allow for an accurate diagnostic test battery to assess patients with conductive hearing loss and suspected APD.

Once testing is completed and an APD diagnosis concluded, a research-based management plan is developed. APD management is multifaceted and consists of providing coping strategies, manipulating the patient's environment, providing auditory training and/or working with assistive listening devices and amplification. ^{4 7} Depending on the specific listening needs of each patient and the specific area of auditory processing deficit, the treatment will vary. Patients in more varied listening environments may lean toward low-gain hearing aids as a management tool. ¹⁰ Those in frequent meetings may add on remote microphone technology. Those with interaural asymmetries may pursue dichotic listening training. ¹¹ Those with temporal processing concerns look toward music therapy for treatment. ¹² Those with speech in noise difficulties may benefit from auditory training with background noise. ⁸ The treatment options are as varied as the patients and need to be tailored specifically to each individual case.

Patients with auditory processing difficulties can create challenging cases to manage as can patients who are serious musicians as both have specific listening needs. A patient who has both auditory processing difficulties and is a musician will have both difficulties processing auditory information as well as very specific listening needs. Music training and music therapy have been found to improve performance on speech in noise tests. ¹² Theoretically, if there were musician-specific norms for most APD tests, musicians should outperform their normal hearing nonmusician peers on most tasks in an APD test battery. ^{12 13} Musicians undergo significant training for their ears and hearing, and this is noted in their educational experiences where they are often tasked with transcribing the melody or harmony of a piece that is played for them along with complicated rhythm transcriptions. Their listening needs are very technical and varied compared with an average audiology patient.

For children and adult learners with APD, coping with their educational environment is a large portion of managing their APD. Under typical circumstances, classrooms are noisy reverberant environments in which students are asked to listen to an educator, have discussions with classmates, take exams, and produce quality work along with many other activities. All of these are challenging listening tasks for everyone, but they are made more so by hearing loss or APD. Classrooms can be made quieter by adding softer surfaces and those with hearing or processing challenges should be given preferential seating, which may or may not mean front and center depending on the classroom setup and teaching style. Students with APD may need more time to process exam questions especially for an oral or listening style examination such as a spelling test or music transcription exam. They may also benefit from a note taker which in a virtual learning environment is analogous to captioning and recording virtual classes. ^{4 6 14} Both typical and virtual classroom environments are challenging listening situations for those with hearing loss and APD, but appropriate management strategies can ease this burden and allow for educational success.

This case presentation features an 18-year-old female, herein given the name Charlene, who has an extensive otologic history, is a music performance college student, and reports difficulty hearing in class. The details of Charlene's case will include her otologic and audiologic history, a summary of her virtual appointments due to the COVID-19 pandemic, and the results of the in-person follow-up once clinics resumed operation.

Case Presentation

Charlene, an 18-year-old female with an extensive middle ear history, sent a note to her otologist at the beginning of the COVID-19 pandemic asking to discuss the difficulty that she was having in the classroom. Charlene has seen her current otologist since she was a 6-year-old child by which time she had already received two concurrent bilateral myringotomies with tube placements and an adenoidectomy from an otolaryngologist within the department. At that time, she had a right tympanic membrane perforation for the past year; so, the otologist recommended and shortly thereafter performed a right medial graft tympanoplasty. This was repeated 8 months later as the initial graft did not adhere completely. Audiometric results 6 months following the second tympanoplasty revealed a mild right conductive hearing loss with hearing WNLs on the left side (see Fig. 1 ).

Figure 1.

2007 audiogram. Charlene's audiometric test results from age 6 which indicate a right mild to moderate conductive hearing loss with within normal limit results in left ear.

Charlene continued to be monitored and followed up every 6 to 9 months by otology with regular audiograms. Results were consistent and continued to demonstrate residual mild conductive hearing loss on the right side. The otologist believed that this was most likely due to the handle of the malleus not making full contact with the central portion of the tympanic membrane; only the short process made contact. Charlene, her parents, and the otologist discussed the possibility of ossicular chair reconstruction should the conductive hearing loss become more significant, but at that time, the decision was made to continue monitoring yearly. No changes were noted for 5 years in ear-related symptoms, hearing, or status of middle ear except for some minor eustachian tube dysfunction noted after air travel.

As a 14-year-old, the otologist noted on her exam some concern for right cholesteatoma and ordered a CT scan. The results of the scan were positive for cholesteatoma and Charlene was scheduled for right middle ear exploratory surgery with the intent to remove the cholesteatoma as well as potentially perform the previously discussed ossicular chain reconstruction. During surgery, the cholesteatoma was found to be in the posterior inferior quadrant and was removed completely. The thinning of her right tympanic membrane prompted the need for another medial graft which was taken from the left postauricular area. The conductive hearing loss that was thought to be from stapes fixation was not addressed surgically. Her postoperative audiogram was consistent with her preoperative audiogram (see Fig. 2 ).

Figure 2.

2019 audiogram. Charlene's audiometric test results following removal of right cholesteatoma at the age of 17 years. Results indicate mild conductive hearing loss in the right ear with within normal limit results in left ear.

At that time, Charlene began to discuss playing instruments in her school band with her otologist as well as difficulty hearing in noise and utilizing closed captioning when watching television for increased clarity. She continued to be followed up annually with no change in symptoms or audiometric results until she entered college at age 18. At her regular annual follow-up, she noted minor difficulty in her college classes. She contacted the otology clinic about 5 months after her regular annual otology evaluation with audiogram reporting significant difficulty once her classes shifted to a virtual format during the COVID-19 pandemic. At that time, she was provided with contact information for the APD clinic.

Method

Immediately upon receiving the information, Charlene and her mother, DeeDee, contacted the APD clinic regarding her concerns and about scheduling testing. At that time, the audiology clinics were virtual only due to the COVID-19 shutdown. It was decided to schedule a video appointment with Charlene and her mother to gather information and determine next steps.

The video appointment was attended by Charlene, DeeDee, and the APD audiologist. This appointment was conducted interview style to determine what specific difficulties Charlene was having, how much of this difficulty could be related to her known longstanding right conductive loss, and what would be reasonable next steps. Her medical history as discussed previously was reviewed in depth. Charlene reported being a music performance major at a small local private liberal arts college and was having the most difficulty with her music classes, particularly her aural skills classes during which she is asked to do an assortment of dictation exercises. Additionally, she reported increasing tinnitus that was bilateral and high pitched in nature. She noted a perceived decrease in hearing in her right ear. She also reported that the school had already provided her with some accommodations that include high-end headphones with volume control for use during her Zoom classes and testing. She also was allowed additional repetitions of the dictation exercises.

As part of this discussion, the audiologist recommended some additional accommodations including decreasing the speed of the presentation for the listening exercises either manually or utilizing a computer program such as Audacity(R) to allow for more processing time, utilizing the already available volume control on the headphones to increase the volume for the right ear to accommodate for the known conductive hearing loss, and performing these exercises and testing in a quiet test environment. ^{4 10} The importance of practice with these processing skills was discussed and the audiologist agreed to complete the required forms for the college's Office of Disabilities. Furthermore, it was recommended that Charlene follow up with her otologist for a medical evaluation and updated audiogram given the perceived hearing change and new-onset tinnitus and pursue formal APD testing once clinics reopen. ⁵ Given Charlene's reported difficulty processing very specific tonal tests in her music class and the otologist's agreement, Charlene was preliminarily diagnosed with APD pending these further test results.

Charlene contacted the audiologist 1 week following her video visit via email requesting a letter for the school summarizing the recommendations from otology and audiology. This was completed based on the known conductive hearing loss as well as the suspected APD and detailed the recommended accommodations discussed previously. Charlene's college was compliant with most of these requests except for slower presentation speed as that was deemed impossible by her music faculty. Charlene reported that the accommodations were helpful in allowing her to fully access her educational material. ¹⁵

Results

Shortly after otolaryngology and audiology clinics reopened, Charlene was seen by her otologist regarding these new concerns. During that appointment, they reviewed her extensive middle ear history as outlined previously and discussed the auditory challenges that she was having during her college music classes as a clarinet performance major. Additionally, she is reporting ear pain and bilateral tinnitus. As part of that visit, an audiogram was completed which was overall consistent with the previous testing with a mild conductive hearing loss in the right ear (see Fig. 3 ).

Figure 3.

2020 audiogram. Charlene's audiometric test results prior to auditory processing disorder testing. Results indicate mild conductive hearing loss in the right ear with within normal limit results in left ear. Results are slightly worse compared with the previous audiogram.

The otologist found no evidence of recurrent cholesteatoma and reported that the right ear drum continued to appear well healed from the most recent tympanoplasty. They discussed scheduling for an auditory processing evaluation and potentially pursuing a right hearing aid pending the results of the evaluation.

One month later, Charlene came to the APD clinic for an evaluation. She brought her completed case history form and self-assessments with her to that appointment. In addition to the medical information address previously, Charlene reported a history of three concussions, migraines, and anxiety. She noted particular difficulty in background noise as her chief complaint and reported being highly motivated to seek solutions for this. ^{4 7} As part of her forms, she completed the Hearing Handicap Inventory for Adults (HHIA) and the Adult Auditory Performance Scale (AAPS). She scored a 34 out of 40 on the HHIA indicating severe self-perceived handicap ^{16 17} and scored a 2.5 global score on the AAPS with specific difficulty noted by the scores in the Noise and Multiple Input subscales which were 3.57 and 2.67, respectively. ¹⁸ After reviewing this information with Charlene, the auditory processing test battery was completed. This consisted of completing a minimum of two tests in each area of concern: dichotic listening, speech in noise, and temporal processing. ^{4 7} Her scores for most tests were WNL. ^{11 19 20 21 22} The results of this testing are summarized in Table 1 .

Table 1. Summary of Charlene's APD Test Battery Results.

Test	Score (s)	Interpretation
Dichotic words	Right: 92%	WNL 11
	Left: 92%	WNL 11
Randomized dichotic digits test	One pair Right: 100% Left: 100%	WNL 21
	Two pair Right: 97% Left: 100%	WNL 21
	Three pair Right: 96% Left: 94%	WNL 21
Frequency patterns	Right: 100%	WNL 20
	Left: 100%	WNL 20
Words in noise	6 dB SNR loss	Disordered 22
QuickSIN	Right: 4 dB SNR loss	Disordered 22
	Left: 0.5 dB SNR loss	WNL 22
	Binaural: 1.5 dB SNR loss	WNL 22
Gaps in noise	Right: 70%	WNL 19
	Left: 77%	WNL 19

Abbreviations: APD, auditory processing disorder; SNR, signal-to-noise ratio; WNL, within normal limits.

All tests were presented at presentation levels to compensate for her known conductive loss in her right ear. Charlene had scores within the disordered range for the Words In Noise (WIN) test and right QuickSIN which indicated a mild signal-to-noise ratio (SNR) loss. ²² This is consistent with her chief complaint and offers insight into the difficulty in noise and at college that Charlene reports beyond what would be expected with a mild unilateral conductive loss.

The audiologist discussed these results with Charlene and her mother, DeeDee. With their high motivation to pursue treatment for her hearing difficulty, it was recommended that Charlene continue to receive the accommodations already being provided by her college that were recommended during her virtual appointment. Additionally, the audiologist, with the agreement of her otologist, recommended that Charlene pursue a right hearing aid with the aim of providing better audibility and improved SNR. It was recommended that they pursue this at our local children's hospital clinic as Charlene was 18 and still met the age requirements to receive a hearing aid via state medical assistance. She was seen by a colleague there approximately 1 month later for a hearing aid evaluation where they ordered a smartphone- and remote microphone-compatible receiver in the canal hearing aid for the right ear. This was fit and verified one month later, and Charlene reported doing well with the device and college accommodations.

Discussion

Charlene is an 18-year-old female college student reporting significant difficulty in her virtual music classes during the COVID-19 shutdown. Her case was complicated by very specific listening needs and a mild unilateral conductive loss that her otologist felt did not fully explain the significant difficulty she was reporting during the shutdown. He referred on during the shutdown to our APD program to help get her the assistance she needed as this audiologist is who most typically makes recommendations to college and university programs regarding educational accommodations. While evaluation or an updated diagnosis could not be provided during this period, recommendations for reasonable and appropriate accommodations for her college classes could be provided and this aided in allowing Charlene to successfully finish out that semester.

Once clinics reopened, Charlene was able to see both her otologist and the APD clinic audiologist for diagnosis and management to more fully address these concerns and provide evidence for the recommendations made during her virtual appointments. Her APD evaluation was completed using a test battery consistent with the American Academy of Audiology Clinical Practice Guidelines for the Diagnosis, Treatment, and Management of Children and Adults with Central Auditory Processing Disorder including two or more tests in each category examined to obtain a consistent pattern of results as well as a comprehensive case history and self-assessments. ⁴ Charlene had significant difficulty on both speech in noise tests, despite the right ear being presented at a presentation level significant to compensate for her mild conductive loss; this was consistent with her self-assessment results from the HHIA and AAPS. ^{16 18 22} Charlene's results were uniform and indicate that she has a SNR loss in addition to her known right conductive loss.

History of middle ear issues and conductive hearing loss is a common risk factor for auditory processing difficulties. Charlene's long middle ear history put her at elevated risk of developing these difficulties. In Charlene's case, it is likely that this has been present since childhood but was masked by the fluctuating right hearing loss and other middle ear concerns. ⁵ It is reasonable that this only became her chief concern and complaint when tasked with the new and challenging listening environment of college-level music classes coupled with a virtual learning model necessitated by the COVID-19 shutdown. ¹⁴ A virtual or digital presentation is decidedly different than the typical volume of a lecture as presenters typically project in a way that would be unnatural virtually; so, this is something that students will need to control on their end and faculty may be tasked with providing additional supports given the changing presentation mode of classes. ^{14 23 24}

A variety of treatment options are available to manage a conductive hearing loss and a SNR loss. With any APD patient, effective treatment needs to be individualized to their specific listening needs and deficits. Auditory training, environmental modifications, and devices are discussed with each patient to assess what is most appropriate. ^{4 10 25} Charlene's chief concern was audibility and processing during her college music classes. As a right hearing aid will provide the audibility Charlene needs due to her hearing loss and may additionally provide an improved SNR, a right hearing aid was recommended and ultimately received at our local children's hospital. ¹⁰

Auditory training utilizing technology-based applications or with the involvement of a local speech language pathologist was discussed and considered. Auditory training has been found to improve speech understanding in noise and improve overall auditory performance. ²⁵ Despite possible improvement, Charlene ultimately felt that her current college schedule is too hectic to pursue at this time. This remains a reasonable addition to her current management that can always be initiated in the future. ²⁵

Environmental accommodation is probably one of the most utilized managements approached with auditory processing, especially in a classroom. Recommended classroom strategies will typically include noise reduction, direct signal via a remote microphone system, captioning or a note taker, additional test time, and a quiet testing environment. ^{4 7 26} For adult learners, such as Charlene, several of these are not appropriate or cannot be managed, but others were well adapted to be utilized in her college environment. A virtual classroom does change some of the ways in which these ideas would be utilized compared with a traditional classroom. In a virtual environment, it is the student's responsibility to make sure that their physical environment is quiet, but the teacher or professor also needs to control their physical environment as well as the virtual environment. This can mean the professor muting everyone and ensuring that they are teaching from a quiet office space. Accommodations such as direct audio access and a note taker become headphones with a volume control and a captioned virtual meeting when courses move from in person to online. For Charlene specifically, test accommodations mean getting to listen to the music she is to transcribe more to allow her additional time to process it. ^{2 12 14}

The accommodations that were recommended initially during the virtual session were very close to what was ultimately decided following the otologist's visit and APD evaluation. The in-person visits and diagnostic testing certainly allowed for more specificity and the ability to proceed with amplification, but most recommendations were able to be provided based on the virtual consultation and through case history completed at that time. These recommendations allowed Charlene to focus on school and wait for clinics to be safely opened prior to proceeding with additional intervention. This approach allowed the clinic to maintain the recommendations related to the COVID-19 shutdown while also ensuring that the patient was receiving appropriate care and educational accommodations. ^{23 27}

Conclusion

Charlene is an active and engaged music performance major in college. Proceeding with intervention in a timely fashion as she was having difficulty in her classes allowed her to finish that semester successfully. Proceeding with diagnosis and further management once clinics reopened should allow her full and equal access to her college education. Access to a virtual visit with an audiologist with experience with college classroom accommodations proved useful in acquiring the needed services as efficiently as possible. It is important to ensure that these services can be available when needed. Charlene has become a successful hearing aid user and a self-advocate to ensure that she is getting the instruction and access that she requires.

There were many factors to consider in this complex case but, ultimately, doing everything necessary to ensure audibility and improved SNR were the key for Charlene and many patients with difficulty in complex listening environments. Amplification and appropriate accommodations can provide full educational, professional, and personal engagement and access and allow for an improved quality of life.