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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 23  |  Issue : 1  |  Page : 7-12

Disability certificate for individuals with hearing impairment – Time to rethink


Department of Audiology, All India Institute of Speech and Hearing, Mysore, Karnataka, India

Date of Web Publication6-Feb-2017

Correspondence Address:
Hemanth Narayan Shetty
Department of Audiology, All India Institute of Speech and Hearing, Mysore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-7749.199509

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  Abstract 

Background: A retrospective research design was used to investigate the effect of degree of hearing loss on speech identification scores (SISs) and aided improvement in individuals with sensorineural hearing loss (SNHL) and auditory neuropathy spectrum disorder (ANSD). The present criteria (PWD Act, 2001) to issue disability certificate is suitable for individuals with SNHL, as there is a good agreement between their degree of hearing loss and speech understanding. In contrast, individuals with ANSD show severe speech understanding problems irrespective of their degree of hearing loss. Despite their problem, there are denied in giving disability certificate. The study also analyzed number of clients who have received the certificate of hearing disability, in both groups. Subjects and Methods: Clinical records of 165 clients who visited the Department of Audiology, All India Institute of Speech and Hearing, Mysore, India between October 2011 and October 2013 were reviewed. Results: Revealed that unlike SNHL, those with ANSD had no relation between the degree of hearing loss and SIS. In addition, aided improvement in ANSD was very limited and was not related to degree of hearing loss. All the individuals with SNHL, who had hearing loss above moderately severe degree received disability certificate. However, only 2 of the 36 clients with ANSD received disability certificate, although their hearing thresholds were above moderately severe degree. Conclusion: Pure-tone thresholds are not a deciding factor of speech understanding in ANSD. Thus, issue of disability certificate for ANSD should be based on SIS rather than pure-tone thresholds.

Keywords: Auditory neuropathy spectrum disorder, sensorineural hearing loss, speech identification score


How to cite this article:
Shetty HN, Mathai JP, Uppunda AK. Disability certificate for individuals with hearing impairment – Time to rethink. Indian J Otol 2017;23:7-12

How to cite this URL:
Shetty HN, Mathai JP, Uppunda AK. Disability certificate for individuals with hearing impairment – Time to rethink. Indian J Otol [serial online] 2017 [cited 2017 Oct 22];23:7-12. Available from: http://www.indianjotol.org/text.asp?2017/23/1/7/199509


  Introduction Top


In India, individuals with disability are permitted to have equal opportunities, equal rights and full participation (PWD Act, 2001). The Government of India has made many policies to uphold differentially abled population. The issue of disability certificate by government agencies to those individuals with hearing impairment is one among them. In India, disability certificate for individuals with hearing impairment is issued based on degree of hearing loss and speech discrimination scores (PWD Act, 2001). In case of sensorineural hearing loss (SNHL), there is a good agreement between degree of hearing loss and speech discrimination scores. Hence, disability certificate for these individuals is issued solely on the basis of their degree of hearing loss. Moreover, for calculating binaural disability in percentage only pure tone thresholds are considered (PWD Act, 2001). However, in some forms of SNHL, there is no agreement between degree of hearing loss and speech discrimination scores. Hence, issuing certificate of disability based on pure tone average in this group is an enigma.

Auditory neuropathy spectrum disorder (ANSD) is a form of SNHL in which functioning of outer hair cells is preserved, but neural mechanism is disrupted.[1] The condition is very prevalent in children and often associated with certain etiology.[2],[3] Unlike pediatric ANSD, no specific etiology could be traced in many of the adult cases reported.[3],[4] Among adults, the commonly reported age of onset is in the second decade of life.[4],[5],[6],[7] Individuals with ANSD can exhibit hearing threshold ranging from normal to profound degree.[3],[4] Inconsistencies in pure-tone thresholds are also reported. In a study cited, individuals showed inconsistent hearing thresholds varying more than 10 dB HL within a test session.[3]

Among children with ANSD, there are reports of speech understanding that is comparable to individuals with a similar degree of sensory hearing loss. Further, amplification was found to be successful in some of the pediatric ANSD clients.[2],[5] In contrast, individuals with late onset ANSD often exhibit severely impaired speech understanding irrespective of their degree of hearing loss.[6],[7] In addition, benefit derived using hearing aids, is often very limited.[4] Thus, the late onset ANSD that exhibit severe speech understanding problems and limited aided benefit presents a greater challenge in management compared to pediatric ANSD.

The present criteria to issue disability certificate is suitable for individuals with SNHL, as there is a good agreement between their degree of hearing loss and speech understanding. In contrast, individuals with ANSD show severe speech understanding problems irrespective of their degree of hearing loss. At present, individuals with ANSD who exhibit hearing loss greater than a moderately severe degree in their better ear are eligible for disability certificate as per the PWD Act (2001). On the other hand, those individuals with ANSD have hearing thresholds less than moderately severe degree in their better ear are not eligible for disability certificate, although their speech understanding is severely impaired. In addition, there are instance where individuals with ANSD exhibit presence of otoacoustic emission (OAE) in whom a lesser or a greater degree of hearing loss with severely impaired speech perception was noted. Most audiologists who evaluated subjects reported in this study refused to issue a disability certificate when OAEs were present even when speech perception was severely impaired. Hence, it is unfair to keep them in the dark on this matter.

In this background, the present study was carried out (a) to compare speech identification score (SIS) obtained in individuals with SNHL and ANSD having similar degree of hearing loss (b) to investigate the relation between degree of hearing loss and SIS in these two participant groups (c) to compare the benefit of amplification in those with SNHL and ANSD having similar degree of hearing loss and (d) to report the number of individuals who received/not received disability certificate in both the groups. Thus, the current study is a preliminary attempt to highlight why individuals with ANSD are prevented from obtaining a disability certificate using the currently used criteria for deciding hearing disability.


  Subjects and Methods Top


This retrospective study was carried out by reviewing the clinical records of clients who visited the Department of Audiology, All India Institute of Speech and Hearing, Mysore, India between October 2011 and October 2013. The diagnosis of all the clients had been carried out by experienced audiologists. During the period under review, a total of 82 clients diagnosed as ANSD (30 males and 52 females) and 83 clients with SNHL (50 males and 33 females) were included in the study. Individuals with ANSD were in the age range of 11–45 years, with the mean age being 22.8 and standard deviation (SD) being 8.3. Individuals with SNHL aged between 12 and 66 years with the mean age being 45.2 and SD being 13.7. Exact etiology could not be traced in many of the ANSD individuals, whereas in those with SNHL, hearing loss was often associated with aging and noise-induced hearing loss.

The diagnosis of ANSD was carried out according to the criteria given by Starr et al.[3] and Berlin et al.[8] As per the above criteria, clients who had preserved cochlear amplification (presence of OAE/cochlear microphonics), impaired neural response (absent or abnormal brainstem responses and middle ear reflexes), normal otological function and no space occupying lesion (identified based on clinical neurological examination) were included. The clients with ANSD were grouped based on their degree of hearing loss.[9] All of the individuals diagnosed with ANSD exhibited absent acoustic reflexes and auditory brainstem response (ABR) findings showed only present cochlear microphonics with no identifiable neural responses in the ABR.

Individuals with SNHL had hearing thresholds >20 dB HL at each octave frequencies from 0.25 to 8 kHz, with an air-bone gap <10 dB HL. All of them had SISs that were proportional to their degree of hearing loss. All the individuals had normal middle ear function, indicated by “A” type tympanogram. None of the subjects with SNHL had signs of retrocochlear dysfunction, specifically all had present acoustic reflexes and Wave V was present ≤0.8 ms between 11.1/s and 90.1/s repetition rate. The clients with SNHL were grouped based on their degree of hearing loss.[9]

Procedure

Audiological evaluation

All the investigations were carried out in a sound-treated two-room set-up. Air-conduction and bone-conduction thresholds were determined using modified Hughson–Westlake procedure.[10] The speech identification testing was administered using a recorded version of word identification test in Kannada [11] presented at a level of 40 dB SL (ref.: speech reception threshold). The test material had four lists in it each having 25 words. Each participant was instructed to repeat the words that were presented sequentially in random order from any one of the list. The total numbers of correctly identified words were recorded to calculate the SIS.

OAE was recorded for condensation click of 100 µs duration presented at 80 dB equivalent SPL. A presentation rate of 10/s was utilized. The responses of 250 clicks were averaged to compute the output. Whenever noise level exceeded 45–52 dB peSPL, the recording was paused and continued once the noise level reduced below the rejection level. The presence of OAE was confirmed when response having a signal to noise ratio more than 6 dB and reproducibility above 80%.

Auditory evoked potentials were recorded by placing noninverting electrode on vertex (Cz), inverting electrode (Ai) on test ear mastoid and ground on forehead. Click stimuli (1500 sweeps) were presented in alternating polarity to the test ear through insert receiver at 90 dB nHL with repetition rate of 11.1/s. A filter setting of 100–3000 Hz was utilized with a gain of 100,000 and artifact rejection of ±29.7 µV. The average epoch was considered if the accepted number of sweeps was 90%. Further, the waveforms obtained from two polarities were overlapped to see the presence cochlear microphonics.

Hearing aid trial

Hearing aid trial was performed for all the individuals who exhibit hearing loss greater than mild degree. The model of hearing aid was chosen based on the degree of hearing loss and financial affordability of the individual. A routine procedure was adopted for the hearing aid trial. Clients having hearing loss in both ears were recommended for binaural amplification. In the case of asymmetrical hearing loss, hearing aid was prescribed to the poorer ear when the client had hearing loss ≤60 dB HL in both ears. If hearing thresholds were ≥60 dB HL in both ears, hearing aid was prescribed to the better ear. However, in most of the clients having either symmetrical or asymmetrical hearing loss, hearing aid trial was carried out in both the ears. If indicated, then contra-lateral ear was masked.

For each client, SISs were obtained in both unaided and aided conditions. For the unaided testing, each client was made to sit one meter away from the loudspeaker at 45° azimuth. Clients were instructed to repeat the bisyllabic words presented through a loudspeaker at 40 dB HL. The maximum scores in a test condition were 25. In addition, the selected digital hearing aid was programmed using NAL-NL fitting formula using the appropriate hearing aid programming software. If the selected hearing aid was body level then volume control was kept at 2.5–3 in “normal” tone control position. The selected hearing aid was fitted into the client test ear and the aided performance was evaluated using a similar procedure. Further, aided benefit was calculated by subtracting the aided score from the unaided score.


  Results Top


Comparison of speech identification score in individuals with sensorineural hearing loss and auditory neuropathy spectrum disorder having similar degree of hearing loss

The mean SIS and SD for both groups of participants having different degrees of hearing loss are displayed in [Figure 1]. For the SNHL group, the mean SIS (SD) in mild, moderate, moderately severe, severe, and profound degrees of hearing loss were 96.57 (4.85), 86.53 (8.58), 77.38 (11.28), 63.41 (16.83), and 14.66 (16.42), respectively. In the ANSD group, mean SIS (SD) in mild, moderate and moderately severe degrees of hearing loss were 25.24 (14.55), 29.42 (21.07), and 34.22 (29.60), respectively. In those ears with a severe and profound degree of hearing loss, no measurable SIS were obtained. It can be observed in [Figure 1] that in those with SNHL, the SIS was linearly reduced with increasing degree of hearing loss. However, in case of ANSD, no observable trend was noted between SIS and degree of hearing loss. The SIS obtained from both groups having a similar degree of hearing loss was compared using Mann–Whitney U-test. It was found that there was a significant difference between the two groups having mild (Z = −3.98, P < 0.001), moderate (Z = −9.82, P < 0.001), moderately severe (Z = -7.68, P < 0.001), severe (Z = -4.49, P < 0.001), and profound degree (Z = −3.41, P < 0.001). The SIS obtained for individuals with SNHL was significantly higher than ANSD group for all five degrees of hearing loss.
Figure 1: Speech identification score in percentage with respect to degree of hearing loss in auditory neuropathy spectrum disorder and sensorineural hearing loss.

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Relation between degree of hearing loss and speech identification scores in individuals with sensorineural hearing loss and auditory neuropathy spectrum disorder

It can be found in [Figure 2] that SIS in the SNHL group reduced as the degree of hearing loss increased whereas such a trend was not observed in those with ANSD. To correlate the degree of hearing loss and SIS a Spearman's rank correlation was performed in both the groups. It was found that there was a high negative correlation between SIS and pure tone audiometry in individuals with SNHL (r = −0.70, P < 0.001). However, no such relation was found in the ANSD group (r = −0.20, P < 0.001).
Figure 2: Relationship between speech identification score and pure tone threshold in auditory neuropathy spectrum disorder and sensorineural hearing loss.

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Comparison of aided improvement in individuals with sensorineural hearing loss and auditory neuropathy spectrum disorder having similar degree of hearing loss

The mean unaided and aided SIS and SD for both groups having a different degree of hearing loss are displayed in [Figure 3] and [Figure 4]. For the SNHL group [Figure 3] the mean unaided SIS (SD) in mild, moderate, moderately severe, and severe degree were 10.85 (19.0), 7.46 (13.20), 0.49 (3.27), and 0.29 (1.06), respectively. In those ears with profound degree of hearing loss no measurable SIS were obtained in the unaided condition. The mean aided SIS (SD) in mild, moderate, moderately severe, severe, and profound degrees of SNHL were 93.71 (5.08), 87.00 (14.20), 75.29 (13.54), 62.8 (23.68), and 22.66 (18.22), respectively.
Figure 3: Unaided and aided speech identification score in percentage with respect to degree of hearing loss in sensorineural hearing loss.

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Figure 4: Unaided and aided speech identification score in percentage with respect to degree of hearing loss in auditory neuropathy spectrum disorder.

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In the ANSD group [Figure 3], the mean unaided SIS (SD) in mild, moderate, and moderately severe degrees of hearing loss were 22.66 (9.98), 5.08 (3.84), and 2.41 (3.04), respectively. In those ears with severe and profound degree of hearing loss, no measurable SIS was obtained. The mean aided SIS (SD) in mild, moderate, and moderately severe degree were 24.50 (16.52), 14.97 (9.12), and 22.23 (23.98), respectively. In those ears with severe and profound degree of hearing loss, no measurable SIS were obtained in the aided condition.

The aided improvement was calculated by subtracting the unaided SIS from the aided SIS [Figure 5]. In the SNHL group, the mean aided improvement (SD) in mild, moderate, moderately severe, severe, and profound degree were 88.25 (19.82), 79.53 (19.00), 74.80 (13.73), 62.51 (23.56), and 22.66 (18.22), respectively. In the ANSD group, mean aided improvement (SD) in mild, moderate, and moderately severe degrees were 1.83 (12.20), 9.98 (8.84), and 19.82 (22.57), respectively. In those ears with severe and profound degree of hearing loss, no measurable SIS was obtained. It can be observed in [Figure 1] that in those with SNHL, the aided improvement reduced linearly with degree of hearing loss. However, in case of ANSD, no observable trend between aided improvement and degree of hearing loss noted. The aided improvement obtained from both groups having a similar degree of hearing loss was compared using Mann–Whitney U-test. It was found that there was a significant difference between the two groups having mild (Z = −4.09, P < 0.001), moderate (Z = −9.75, P < 0.001) and moderately severe (Z = −7.88, P < 0.001) degree of hearing loss. The aided improvement obtained for individuals with SNHL was significantly higher than ANSD group for all the three degrees of hearing loss.
Figure 5: Aided improvement in percentage with respect to degree of hearing loss in auditory neuropathy spectrum disorder and sensorineural hearing loss.

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Issue of disability certificate

It can be found in [Table 1] that among those with SNHL, all the clients who had hearing loss from moderately severe to profound hearing loss received disability certificate. The percentage of disability ranged from 65% to ≥75%. Although there were 36 ANSD clients, who had hearing loss from moderately severe to profound degree only two individuals received disability certificate. The remaining 34 clients had the presence of OAEs in both ears that preclude the audiologist from issuing the disability certificate for them. For most individuals, the presence of OAEs indicates normal outer hair cell function [12] and is usually consistent with normal or near normal hearing thresholds. Hence, the majority of subjects with ANSD in this study were not provided a disability certificate because they had present OAEs even though they exhibited severe functional hearing impairment. Among the two individuals with ANSD who received disability certificate, none of them had OAEs present.
Table 1: The number of clients having auditory neuropathy spectrum disorder and sensorineural hearing loss who received disability certificate

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  Discussion Top


In this study, it was observed that for subjects with SNHL, SIS decreased with increasing degree of hearing loss. However, in case of ANSD, no such trend was observed between SIS and degree of hearing loss. Further, in those with ANSD having severe and profound hearing loss, there was no measurable SIS. The results of the current study show that individuals with SNHL face increasing difficulty in understanding speech as the degree of hearing loss increased.[13] It is well-known fact that in those with SNHL, spectro-temporal impairment increases with increasing degree of hearing loss.[14] This has resulted in reduced speech perception though the stimuli were presented well above the hearing thresholds. Unlike those with SNHL, individuals with ANSD showed SIS disproportionate to their degree of hearing loss. This shows that speech understanding in ANSD does not depend on their hearing thresholds. Previous studies have shown that in cases of ANSD, speech perception difficulties are related to temporal processing deficits rather than solely on the degree of pure tone hearing loss.[4],[6],[7],[15],[16]

Further, it was found that in SNHL, aided improvement decreased linearly with increasing degree of hearing loss. However, in those with ANSD, limited aided improvement was noted. In addition, there was no relation between hearing thresholds and aided improvement. It has previously been reported that among those with SNHL, the least amount of aided improvement was found in those having the greatest degree of hearing loss.[17] Underlying reason for this could be increased spectro-temporal impairment with increasing degree of hearing loss and alterations in the spectro-temporal cues of speech signals due to hearing aid processing.[14] In case of ANSD, amplification has shown to have limited improvement in speech perception. Literature on usefulness amplification showed mixed results in ANSD. While it is true that current, conventional hearing aids cannot improve temporal dys-synchrony resulting from neural dysfunction, many investigators have now shown that some individuals with AN receive benefit from amplification [2],[5],[15],[18],[19] while others don't.[1],[4],[18] While the population studied here did not receive benefit from amplification. It has been reported that hearing aids cannot improve temporal dys-synchrony resulting from neural dysfunction.[18]

Disability certificate was issued for the SNHL clients, who had hearing loss from moderately severe to profound degree as they met the criteria of hearing disability. However, in those with ANSD who had hearing loss from moderately severe to profound degree, only two clients received disability certificate. The remaining clients, though they were eligible for disability certificate, they were not issued. This was because they had OAEs present indicating normal outer hair cell functioning. However, studies have shown that presence of OAEs does not play any role in hearing ability as well as speech understanding.[20] Nevertheless, in the present scenario presence of OAEs preclude issuing disability certificate though the criterion of hearing disability is met. Hence, we suggest rethinking about issue of disability certificate for those who meet criterion of hearing disability but having OAEs.

It was found that speech understanding in those with ANSD who had even mild degree of hearing loss was poorer than those with SNHL having profound degree. This infers that speech understanding ability in ANSD does not depend on hearing thresholds. Hence, while issuing disability certificate for ANSD speech understanding should be the prime criteria rather than pure-tone hearing thresholds. In addition, the aided improvement in those with ANSD was very limited compared to SNHL group having a similar degree of hearing loss. Hence, in the present scenario, these individuals neither benefits from hearing aids nor get disability certificate. Hence, we suggest rethinking about issue of disability certificate for those who does not meet criteria of hearing disability but having poor speech understanding.


  Conclusion Top


The present criteria for hearing disability is based on pure-tone hearing thresholds and speech discrimination score (PWD Act, 2001). In case of SNHL, there is a good correlation between pure-tone hearing thresholds and speech discrimination score. In contrast, in those with ANSD pure-tone hearing thresholds is not correlated with their speech understanding. Moreover, fluctuating nature of pure-tone thresholds in them makes it unreliable criteria for issuing the disability certificate. Thus, SIS rather than pure-tone hearing thresholds should be the prime criterion for issuing disability certificate for individuals with ANSD. Further, the presence of OAEs should not be a hindering factor for issuing disability certificate for those with ANSD.


  Implications Top


The present study calls the attention of audiologists to rethink regarding existing criteria on decision making on hearing disability. It clearly stated that unlike SNHL, individuals with ANSD face severe problems in communication even after fitting an amplification device. This leads to poor social interaction, emotional and vocational problems. However, the present criteria for issuing the disability certificate for hearing impairment preclude individuals with ANSD being certified as disabled. In this regard, individuals with ANSD need to be empowered by issuing disability certificate that can be a help to a certain extent in terms of equal opportunities, equal rights, and full participation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Starr A, Picton TW, Sininger Y, Hood LJ, Berlin CI. Auditory neuropathy. Brain 1996;119(Pt 3):741-53.  Back to cited text no. 1
    
2.
Rance G, Beer DE, Cone-Wesson B, Shepherd RK, Dowell RC, King AM, et al. Clinical findings for a group of infants and young children with auditory neuropathy. Ear Hear 1999;20:238-52.  Back to cited text no. 2
    
3.
Starr A, Sininger YS, Pratt H. The varieties of auditory neuropathy. J Basic Clin Physiol Pharmacol 2000;11:215-30.  Back to cited text no. 3
    
4.
Shivashankar N, Satishchandra P, Shashikala HR, Gore M. Primary auditory neuropathy – An enigma. Acta Neurol Scand 2003;108:130-5.  Back to cited text no. 4
    
5.
Rance G, Cone-Wesson B, Wunderlich J, Dowell R. Speech perception and cortical event related potentials in children with auditory neuropathy. Ear Hear 2002;23:239-53.  Back to cited text no. 5
    
6.
Kumar UA, Jayaram MM. Prevalence and audiological characteristics in individuals with auditory neuropathy/auditory dys-synchrony. Int J Audiol 2006;45:360-6.  Back to cited text no. 6
    
7.
Jijo PM, Yathiraj A. Audiological characteristics and duration of the disorder in individuals with auditory neuropathy spectrum disorder (ANSD) – A retrospective study. J Indian Speech Hear Assoc2012;26:17-26.  Back to cited text no. 7
    
8.
Berlin CI, Hood LJ, Morlet T, Wilensky D, St. John P, Montgomery E, et al. Absent or elevated middle ear muscle reflexes in the presence of normal otoacoustic emissions: A universal finding in 136 cases of auditory neuropathy/dys-synchrony. J Am Acad Audiol 2005;16:546-53.  Back to cited text no. 8
    
9.
Goodman AC. Reference zero levels for pure-tone audiometers. Am Speech Hear Assoc 1965;7:262-3.  Back to cited text no. 9
    
10.
Carhart R, Jerger J. Preferred method for clinical determination of pure-tone thresholds. J Speech Hear Disord 1959;24:330-45.  Back to cited text no. 10
    
11.
Yathiraj A, Vijayalakshmi CS. Phonemically Balanced Word List in Kannada: A Test Developed at the Department of Audiology. Unpublished Dissertation. Submitted to University of Mysore; 2005.  Back to cited text no. 11
    
12.
Berlin CI, Morlet T, Hood LJ. Auditory neuropathy/dyssynchrony: Its diagnosis and management. Pediatr Clin North Am 2003;50:331-40, vii-viii.  Back to cited text no. 12
    
13.
Vanaja CS, Jayaram M. Sensitivity and Specificity of Audiological Tests in Differential Diagnosis of Auditory Disorders. Unpublished Project 2003. All India Institute of Speech and Hearing. Mysore. India; 2003.  Back to cited text no. 13
    
14.
Humes LE. Factors underlying the speech-recognition performance of elderly hearing-aid wearers. J Acoust Soc Am 2002;112(3 Pt 1):1112-32.  Back to cited text no. 14
    
15.
Jijo PM, Yathiraj A. Audiological findings and aided performance in individuals with auditory neuropathy spectrum disorder (ANSD): A retrospective study. J Hear Sci 2013;3:18-26.  Back to cited text no. 15
    
16.
Zeng FG, Oba S, Garde S, Sininger Y, Starr A. Temporal and speech processing deficits in auditory neuropathy. Neuroreport 1999;10:3429-35.  Back to cited text no. 16
    
17.
Van Tasell DJ. Hearing loss, speech, and hearing aids. J Speech Hear Res 1993;36:228-44.  Back to cited text no. 17
    
18.
Berlin CI. Auditory neuropathy: Using OAEs and ABRs from screening to management. Semin Hear 1999;21:307-15.  Back to cited text no. 18
    
19.
Walker E, McCreery R, Spratford M, Roush P. Children with auditory neuropathy spectrum disorder fitted with hearing aids applying the American Academy of Audiology pediatric amplification guideline: Current practice and outcomes. J Am Acad Audiol 2016;27:204-18.  Back to cited text no. 19
    
20.
Rance G. Auditory neuropathy/dys-synchrony and its perceptual consequences. Trends Amplif 2005;9:1-43.  Back to cited text no. 20
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
 
 
    Tables

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