Franz Zenker IMPORTANCIA DE LOS SISTEMAS DE FM EN EL NIÑO IMPLANTADO COCLEAR Franz Zenker Gracias a la Dra. Amparo Postigo y a AEDA por su invitación La Clínica Barajas fue fundada hace más de 100 años por el Dr. Luciano Barajas en Madrid pero pronto se trasladaría a S/C de Tenerife. Fue la primera clínica privada de España. La actividad clínica que se lleva acabo está relacionada con la otorrinolaringología pero con una especial dedicación por la audiología. Es tradición de esta institución mantener una actividad investigadora que le permita contribuir de forma significativa en diferentes foros científicos tanto nacionales como internacionales. La inspiración del estudio que vamos a presentar hoy tenemos que buscarla en las I Jornadas sobre las Pruebas Verbales llevadas acabo hace 3 años. En aquel momento uno de los asistentes llevó acabo la sigueinte pregunta: CHU Insular Materno Infatil – GRAN CANARIA – 17 Abril 2008

PORQUÉ ES NECESARIO EL USO DE SISTEMAS DE FM EN EL COLEGIO ¿Cómo son las características acústicas de las aulas en Canarias?.¿Son apropiadas?. ¿Los niños con IC/Audífonos necesitan condiciones acústicas especiales en el aula? ¿Los sistemas de FM mejoran el rendimiento escolar del alumno en el aula?

Consejería de Educación, Franz Zenker Castro. Clínica Barajas. Rosa Mora Espino. Fundación Dr. Barajas. José Juan Barajas de Prat. Universidad de La Laguna. Ana Coello Marrero. Consejería de Educación. Tenerife. Jose Luis Mesa Suárez. Consejería de Educación. Canaria. Mª del Carmen Rodríguez. Universidad de La Laguna. Mª Suarez Suarez. Universidad de La Laguna. Gobierno de Canarias Consejería de Educación, Cultura y Deportes Universidad de La Laguna

2005 – ESTRATEGIAS DE MEJORA DE LA AUDIBILIDAD DEL AULA 2005 – ESTRATEGIAS DE MEJORA DE LA AUDIBILIDAD DEL AULA. 2ª Sesión sobre ruido en el aula y sistemas de frecuencia modulada. Programa Infantil Phonak. Madrid, España, 16 de Septiembre del 2005. 2006 - ANÁLISIS ACÚSTICO Y VERIFICACIÓN EN EL AULA DE LAS FM. Curso Avanzado de Sistemas de Frecuencia Modulada. CosmoCaixa. Barcelona. España. 9 de Marzo de 2006. 2007- SPEECH RECOGNITION IN NOISE BY HEARING-IMPAIRED CHILDREN USING FM SYSTEMS. Mora Espino, R., Zenker Castro, F., Rodríguez Jiménez, M.C., Mesa Suárez, J.L., Coello Marrero, A. y Barajas de Prat, J.J. VIII EUROPEAN FEDERATION OF AUDIOLOGY SOCIETIES (EFAS) CONGRESS. Heidelberg, Alemania, 6 - 9 Junio del 2007. 2007 - PREDICTION OF SPEECH PERCEPTION FROM THE ACOUSTIC CONDITIONS OF UNOCCUPIED CLASSROOMS. (Poster). Mora Espino, R., Zenker Castro, F., Rodríguez Jiménez, M.C., Mesa Suárez, J.L., Coello Marrero, A. y Barajas de Prat, J.J. VIII EUROPEAN FEDERATION OF AUDIOLOGY SOCIETIES (EFAS) CONGRESS. Heidelberg, Alemania, 6 - 9 Junio del 2007. 2007 - A VERIFICATION PROTOCOL OF FM SYSTEMS FOR CHILDREN WITH COCHLEAR IMPLANT. Zenker Castro, F., Mora Espino, R., Rodríguez Jiménez, M.C., Mesa Suárez, J.L., Coello Marrero, A., Suárez Rodríguez, M. y Barajas de Prat, J.J. VIII EUROPEAN FEDERATION OF AUDIOLOGY SOCIETIES (EFAS) CONGRESS. Heidelberg, Alemania, 6 - 9 Junio del 2007. 2007 - EVALUATION OF THE BENEFITS OF FM SYSTEMS IN COCHLEAR IMPLANTS AND HEARING AID USERS. Barajas , J.J., Mora, R., Fernández, R., De Lucas, G. y Zenker, F. 1st Conference EHDI. Johannesburg, South Africa, 13 – 14 Agosto del 2007. 2007 – EL USO DE LAS EMISORAS DE FM EN EL AULA. Curso organizado por la Consejería de Educación, Universidades, Cultura y Deporte del Gobierno de Canarias. CEP La Laguna y CEP Las Palmas II. 21 y 21 de Junio. Horas como profesor: 20 Horas. 2007 – EL USO DE LAS EMISORAS DE FM EN EL AULA. Curso organizado por la Consejería de Educación, Universidades, Cultura y Deporte del Gobierno de Canarias. CEP La Laguna y CEP Las Palmas II. 10 y 11 de Diciembre. Horas como profesor: 10 Horas. Mora Espino, R., Zenker Castro, F., Rodríguez Jiménez,M.C., Mesa Suárez, J.L., Coello Marrero, A. (2006). LOS SISTEMAS DE FRECUENCIA MODULADA EN ALUMNOS CON IMPLANTE COCLEAR. [en-linea]. Auditio: Revista electrónica de audiología. 1 Diciembre 2006, vol. 3(2), pp. 32-36. http://www.auditio.com/revista/pdf/vol3/2/030201.pdf Mora Espino, R, Zenker Castro, F., Rodríguez Jímenez, M.C, Mesa Suárez, J.L , Coello Marrero, A., Barajas de Prat, J.J. (2007). SPEECH RECOGNITION IN NOISE BY HEARING- IMPAIRED CHILDREN USING FM SYSTEMS. [CD-ROM]. 8th EFAS Congress / 10th Congress of the German Society of Audiology. Mora Espino, R., Zenker Castro, F., Rodríguez Jímenez, M.C., Mesa Suárez, J.L., Coello Marrero, A., Barajas de Prat, J.J. (2007). PREDICTION OF SPEECH PERCEPTION FROM THE ACOUSTIC CONDITIONS OF UNOCCUPIED CLASSROOMS. [CD-ROM]. 8th EFAS Congress / 10th Congress of the German Society of Audiology. Zenker Castro, F., Mora Espino, R., Rodríguez Jiménez, M.C., Mesa Suárez, J.L., Coello Marrero, A., Suárez Rodríguez, M. and Barajas de Prat, J.J. (2007). A VERIRFICATION PROTOCOL OF FM SYSTEMS FOR CHILDEN WITH COCHLEAR IMPLANT. [CD-ROM]. 8th EFAS Congress / 10th Congress of the German Society of Audiology.

Consejería de Educación, Gobierno de Canarias Consejería de Educación, Cultura y Deportes CANARIAS FM PROJECT CLASSROOM ACOUSTICS Background Noise (BN). Reverberation Time (RT). Speech Audibility Index (SAI). FREQUENCY MODULATED SYSTEMS Selection of Candidates FM Fitting and Verification This study was undertaken in colaboration between Barajas Foundation, La Laguna University and the Educational Authorities of the Canary Islands. 16 FM systems were provided as pilot study to hearing impaired children from Tenerife and Gran Canaria. A study was carried on in order to establish the acoustic of the hearing impaired classrooms and the need of the FM system. In a second stage, we try to establish a profile of candidates to use the FM system. Finally, we verify over time the FM benefits in the selected children.

ACÚSTICA DE LAS AULAS DE GRAN CANARIA CEIP AMELIA VEGA MONZÓN: Ctra. de Los Picos, 37. El Ejido, Telde. Tel: 928 69 39 82.  Mapa Google. Página Web del Colegio: http://www.gobiernodecanarias.org/educacion/1/usr/ameliavega/    CEIP REYES CATÓLICOS: C/Sor Simona 1, Las Palmas de Gran Canaria. Tel: 928-252251Mapa Goolge.  Página Web del Colegio: http://www.gobiernodecanarias.org/educacion/1/usr/Reyescat/  CEIP NESTOR DE LA TORRE: C/. Joaquín Belón, 26 . Las Palmas de Gran Canaria. Tel: 928 39 81 39 . Mapa Google. Página Web del Colegio: http://www.gobiernodecanarias.org/educacion/1/usr/nestordelatorre/  IES LA MINILA: C/ Concejal García Feo 28. Las Palmas de Gran Canaria. Tel: 928 27 04 02 / 928 27 04 04 . Mapa google. Página Web del Instituto: http://www.gobiernodecanarias.org/educacion/1/usr/ieslaminilla/  CEIP LEÓN Y CASTILLO: C/. Guaydera, 17 . Las Palmas de Gran Canaria. Tel:928 46 43 25 . Mapa Google. Página Web del Instituto:  http://www.gobcan.es/educacion/DGC/DirCentros/scripts/Resultado1.asp?Codigo=35001301&categoria=37    CEIP TINGUARO: C/La Cerruda, 16.Vecindario, Santa Lucia. Gran Canaria. Tel: 928-752352 . Mapa Google. Página Web del Instituto: http://www.proyectocame.org/tinguaro/  CEIP MAESTRO MANUEL CRUZ SAAVEDRA:

ACÚSTICA DE LAS AULAS DE TENERIFE CEIP CASTRO FARIÑA: Ctra. Gral. Norte 279. 38340 Tacoronte (Tenerife). Tel: 922 56 13 03. Mapa Google. Página web del Colegio: http://www.gobcan.es/educacion/DGC/DirCentros/scripts/Resultado1.asp?Codigo=38006915&categoria=37  CEIP CÉSAR MANRIQUE: Avda. Blás Pérez 15. Puerto de la Cruz. Tenerife. Tel: 922 38 25 09. Mapa Google. Página Web del Colegio: http://www.gobiernodecanarias.org/educacion/1/usr/cpcesarmanrique/    CEIP PÉREZ VALERO: C/ Los Sabandeños s/n. Los Cristianos. Tenerife. Tel: 922 79 08 03. Mapa Google. Página Web del Colegio: http://www.gobcan.es/educacion/DGC/DirCentros/scripts/Resultado1.asp?Codigo=38000421&categoria=37     CEIP CAMINO LARGO: Avda. República de Argentina 1. San Cristobal de La Laguna. Tenerife. Tel: 922 25 70 03 / 922 31 55 08. Mapa Google. Página Web del Colegio:http://www.gobiernodecanarias.org/educacion/1/usr/caminolargo/ 

PROMEDIO DE AULA CANARIA Superficie: 54 m2 Techo: Forjado Bidireccional de Hormigón armado formando casetones (cemento). Revestimiento de mortero monocapa tipo gotelé. Suelos: Pavimento de granito con mortero de agame y artesado de hormigón ligero. Paredes: Bloques de 20 al exterior e interiores con tabicas de 9. Revestimiento de mortero monocapa tipo gotelé. Ventanas: Cristales sin cámara de aislamiento. ANCHO: 6,31 m LARGO: 9,78 m ALTO: 3,03 m

MEAN REVERBERATION TIME (N=24) The acoustic conditions of the classrooms show that Reverberation time range from 0,7 to 1,7 msec.for all frequency band studied. In general this values were greater than those recomended by ASHA estandar established in 0,6 msec. The construction materials of the classrooms studied are very reflective since the climate conditions of the Canary Islands establish as a priority to have fresh and well ventilating classrooms. This reflective construction materials justify this high reveberation values found in this study. UNE en ISO 3382 (2001) “Acoustic measurements of the reverberation time of rooms with referent to other. Acoustical parameters” (1997)

MEAN BACKGROUND NOISE (N=24) NOISE RATING CURVES (NRC) Background noise is a well know disturbin factor afecting speech perception in classroom. Our acoustic measurements show that background noise in a range from the silence classrooms to 61 dB the noise classrooms. Following the noise rating curves established by the ISO estándar classrooms must no exceed the NC 35. As you can see in this slide, most of the classrooms studied fit inside this criteria. The reason is that in general schools in the Canary Islands are far away from noisy places. Noise Rating Curves (NRC) - ISO

CLASSROOMS ACOUSTIC N=24 SAI: 52% INFREQUENTLY WORDS PSR = 90 % % Predicted Speech Recognition (PSR) PSR = 48 % Hearing Impaired Normal Hearing % Speech Audibility Index (SAI)

FM SYSTEM TRANSMITTER RECEIVER A FM system consists of two elements, the FM transmitter, also called wireless or remote microphone , and teh FM receiver, which provides an audio signal to the audio input of the hearing instrument. An FM system replaces the wire between the remote microphone and the hearing instrument´s audio input by a radio transmission system.

UNILATERAL COCHLEAR IMPLANT SUBJECTS (n = 23) n=16 RANGE OF AGE: 5 – 14 YEARS UNILATERAL COCHLEAR IMPLANT (n = 7) HEARING AID (n = 9) BILATERAL UNILATERAL (n = 2) 16 subjects participated in this study. Agest range from 5 To 14 Years old. Subjects were selected with a well capacity of speech recognition measure with a scale developed for this proposite. All subjects have a score over 40%. In this study, participated 9 children with hearing aids and 7with cochlear implants. 7 were unilateral cochlear implant user and from the hearing aid group 7 had a billateral fitting and 3 were unilateral.

Speech Discrimination Test High Frequency Words Examples: Vaca- casa peluche- cepillo LEXICAL FREQUENCY (% of correct phonemes recognition) Low Frequency Words Examples: Bufón- bizón, flácida- tímpano

PROCEDURE Speech Discrimination Test WITHOUT FM WITH FM QUIET ☺ ☺ The % correct phonemes recognition was determined in 4 conditions: Without Fm and noise Without FM and quiet With FM and noise With FM and quiet Each condition included one test list of 20 words, divided between frequently and infrequently words. NOISE ☺ ☺

TEST CONDITION In this slide, we show testing was carry out at each hearing impaired children classrooms. Students were tested in quiet and in noise with and without the FM system. Noise was recorded multi talked babble. It was produced from four loudspeaker placed four meters from, and facing, the four corners of the rooms at 30 inches above the floor. Average root- mean level was 55 dB SPL at the student location. The student were seated in the arc of a circle of 3 meters. Test words were produced by one of us.Ensuring the students could not speech read. Speech level was 75 dB SPL at the teacher microphone and 60 dB SPL at student location. When the noise was present the corresponding signal- to- noise ratio was 5 dB at the student location.

VALIDACIÓN Video no disponible IAA=62% IAA=83% URV = 95 dB nHL MD = 72% Pérdida: 95 dB Incapacidad: 100% URV = 85 dB nHL MD = 88% Pérdida: 71 dB Incapacidad: 69% IAA=62% IAA=83%

FREQUENTLY WORDS WITH FM AND BACKGROUND NOISE ☺ FREQUENTLY WORDS WITH FM AND BACKGROUND NOISE CLASSROOM ACOUSTIC BNICRA = 65 dBA RT60 = 1,28 mseg SNR = 7 dB SAI = 52% HEARING CORRECTION FM = Phonak Campus + Micro Link HA= Phonak Supero 412 Video no disponible

INFREQUENTLY WORDS WITHOUT FM AND BACKGROUND NOISE ☺ INFREQUENTLY WORDS WITHOUT FM AND BACKGROUND NOISE CLASSROOM ACOUSTIC BNICRA = 65 dBA RT60 = 1,28 mseg SNR = 7 dB SAI = 52% HEARING CORRECTION FM = Phonak Campus + Micro Link HA= Phonak Supero 412 Video no disponible

Superficie: 68 m2 Nº alumnos: 25 TR60: 1,28 mseg (0,6 mseg) RF: 55 dBA (35 dB A)

LISTA DE FRASES COMPLEJAS SIN FM+RUIDO - Condición I RFICRA = 65 dBA TR60 = 1,28 mseg SNR = 7 dB SAI = 52% FM = Phonak Campus + Micro Link CI IC = Cochlear Nucleus Sprint 22 Video no disponible

LISTA DE FRASES COMPLEJAS CON FM+RUIDO - Condición II RFICRA = 65 dBA TR60 = 1,28 mseg SNR = 7 dB SAI = 52% FM = Phonak Campus + Micro Link CI IC = Cochlear Nucleus Sprint 22 Video no disponible

RESULTS

RESULTADOS INDIVIDUALES

RESULTADOS INDIVIDUALES

% PHONEMES RECOGNITION IN FUNCTION OF THE LEXICAL FREQUENCY

% PHONEMES RECOGNITION IN FUNCTION OF THE LEXICAL FREQUENCY

% PHONEMES RECOGNITION IN FUNCTION OF THE LEXICAL FREQUENCY

MAIN EFFECTS HEARING CORRECTION FM

MAIN EFFECTS LEXICAL FREQUENCY BACKGROUND NOISE

INTERACTIONS FM X BACKGROUND NOISE FM X LEXICAL FREQUENCY

FM BENEFIT > 85 % Sens: 62,5 Spec: 60,3 Receiving Operation Curves (ROC) - Dot Diagram > 85 % Sens: 62,5 Spec: 60,3 % SCORE PHONEMES RECOGNITION WITH FM WITHOUT FM

Receiving Operation Curves (ROC) FM BENEFIT Receiving Operation Curves (ROC) 57% In order to establish a criterion value of FM benefit, the receiving operation curves were obtained. At the right of the slide, we represent the dot diagram with the sensitvity and the specificity of the speech test presented in this study.As you can see here,we are on risk of obtain a higgh number of false positive and false negative. We can obtaine better values of sensitiviy and specificity if we look for each subtest. The ROC curves obtained for the frequently words show as no significant differences between noise and quiet conditions. In the other hand, if we look to the infrequently words graph significant differences were obtained beteween the noise and quiet conditions. A specificity of 62,5%, sensitivity of 62,5% and cut-off of 84,5 was obtained for this subtest. In conclusion, in order to establish the FM benefit only the subtest of infrequently words in noise is neccesary.

CONCLUSIONS Speech test in noise are a useful way to establish selection criteria candidates and to verify the FM system benefit FM benefit can be established from the infrequently used words in quiet and noisy subtest. This subtest allow us to establish a selection criteria with a high accuracy that allow us to identify those subject that can benefit from the FM systems. In general speech test in noise are a usefull way to establish slection crietira candidates nad to verify the FM system benefit

9th EFAS CONGRESS JORNADAS DE LA ASOCIACIÓN ESPAÑOLA DE AUDIOLOGÍA 20 – 24 de Junio del 2009 Tenerife, Isla Canarias, España