Your Audiologist is Wrong: Real Ear Measurements are ESSENTIAL for Your Hearing Aids to Work Well

Apologies for the delayed response; I was away on a trip and just have more peaceful time now.

@Neville said:

RECD will correct this, but if not RECD is available then testing should be done with circumaural phones because the ratio of the increase will be smaller relative to the much larger calibrated ear canal size for circumaural (because it’s over the ear).

So it’s safer to make audiogram with the circumaural phones? Interesting.

@Neville said:

Sorry I’m stuck on my mobile right now, but what jumps out at me is…is your RECD sitting that it was measured with an earmold? Aren’t you in RICs? It would have been measured with a foam tip, unless that’s an old RECD taken at a time when you were in a BTE.

Your assumptions about BTE could definitely be right! I used a Phonak BTE Bolero V-70P with an earmould, and I had REM in December 2019 with the same HCP. Then, one year later, I bought my first RIC – the Paradise 90 – and have had REM, so it’s definitely possible that they use REM from the old BTE Bolero.

Has the RECD from the old BTE made the REM in Paradise 90 unreliable?

Thanks for the info, tomorrow (18 hours from now) I’ll have my first REM with my Sphere 90 and Paradise 90 as a spare, so your input about RECD will be very useful. I am at the very end of my trip in my capital (Warsaw), so I wanted to take advantage of the opportunity.

The REM will be performed with the MedRx equipment.

@Bimodal_user said:

So it’s safer to make audiogram with the circumaural phones? Interesting.

IF there’s a perforation and IF no RECD will be measured, then yes. If there is no perforation or if there will be an RECD measured, then no typically insert is better. Unless the ear canal is difficult for tip insertion and there is a leak that cannot be managed then circumaural may be better for accuracy in the lows. Alternatively, circumaural can aggravate canal collapse and be less accurate in the highs. Masking is also harder with circumarual, so any conductive gaps or asymmetries are often better with inserts. There are just a bunch of factors to consider and in grey areas it’s not uncommon for clinicians to switch transducers and retest. Good clinicians.

@Bimodal_user said:

Has the RECD from the old BTE made the REM in Paradise 90 unreliable?

Not necessarily. It’s just important that the software be set correctly. So if it was indeed measured with an earmold then the software needs to be set to earmold, but if it was measured with an insert tip it needs to be set to that. If the clinician can’t find their notes or forgot to note it, then they need to re-do it to be sure. For what it’s worth, that does LOOK like a BTE RECD to me, but I’m used to looking at it on the REM machine screen and I’m not sure how the phonak target would typically make it look. With pediatrics, their ears are growing so quickly and we’re updating the RECD so regularly that I seldom bother entering it into the software.

@cvkemp said:

But that doesn’t necessarily mean you do the REM and stop there. It is a starting point. Actually the REM for me leaves me with no speech understanding.

@jeffrey said:

Hmmm…that’s not a powerful endorsement of rem, as you intend.

Not really. Thanks to REM you have much less guesswork, which gain from HA is adequate to achieve needed amplification. In my case it can be even 10-20 dB from the first-fit.

@Roberto said:

namely not being able to hear people behind me in the car if they don’t speak loudly

Could you have a program set with Directionality set as Omni-directional? That might help?

This is a pretty egregious example, but here is the REM measure for the hearing aids of a patient who came in from a clinic that did not do REMs for a second opinion:

To orient people to this a bit, X-axis is frequency and y-axis is sound level low to high. The red line is the hearing loss, so anything under that the patient cannot hear and anything above it he can. The pink and blue lines are the average output of the hearing aid (in response to 65 dB [medium] and 55 dB [soft] inputs), the pink and blue crosses are the prescriptive targets (where the pink and blue lines SHOULD be). The speech intelligibility index (SII), a measure of speech audibility, is also calculated at both levels on the little bar graphs below–19% and 9%.

Here’s the refit:

Patient was happier.

There were some errors in the fitting made by the first clinic, yes, but gain also needed to be cranked up ~16 steps in some places to hit targets, which I imagine the first clinic may have been hesitant to do when they couldn’t confirm what was actually happening in the ear. So instead. . . what, you give your patient 9% audibility for soft speech and then “counsel on realistic expectations”? Pisses me off.

Thank you for that. A picture says a 1000 words. I do like my current audio as he is a lot better than the previous one, but I do agree with you. It is shocking that REM is not mandatory because this is exactly what I suspect is the problem for most people (myself included - even with my enhanced NAL-NL2 super powers!

I’ve had several times where I fit or refit someone in a similar circumstance and then later they come back because the other person set their hearing aids BACK to first fit. Sometimes even with a note or told the person directly that the settings were way off of where they were supposed to be!

Why? I had DSL 5 pediatric and I have completely deaf second ear and it wasn’t horrific, not at all.

I was referring to the ‘before’ set of REM’s that Neville posted an image of being horrific: /uploads/original/2c1f36bc93c1660310deabead7e43d9146f5a18d.png

It was a low functioning adult, so still someone who couldn’t advocate for themselves. But I suppose without the protections of a general industry understanding that they need to see a pediatric audiologist that kids would get. Happily, they had a good guardian who worried that something wasn’t quite right and might not just be attributable to cognitive factors.

I live in a town outside of Lisbon and my local audiologist where i purchased my new Oticon Intent 1’s, does not speak English and they don’t have REM- yet. There is a very knowledgeable audiologist who lives in another city and we can meet on zoom in my audi’s office. I was prepared to fly to London to have REM, but they just today notified me they are getting REM set up in October, and the out of town audi is coming here to help. I will be the first person to try it here! I am relieved to not have to leave the country to have it done. Portugal is a great place to live, but hearing aids here are all about selling them, and it seems like few people have any training on how to program them. It is a hard country to be HOH in, and it wouldn’t surprise me if much of Europe except maybe Germany or Denmark, is like this.

Last Thursday I had REM. There was REUG, REOG and REAG 50, 65, 80 dB (showed as REIG). No 's" sound and RESR at 90 dB though. I didn’t have my LDL measured anyway.

I will post about it in another time, I don’t want to hijack this topic.

This is the utter truth. Anyone who is a musician and has been on platform with a bunch of teammates all using IEM knows this. There is a lot of chatter plus instruments plus “canned” background tracks playing and people talking audibly to one another regardless of all the other noise. You cannot manage all this without proper fitment forming an air seal. The difference in what you actually hear is enormous. This is why the IEM makers/packagers have learned to ship a bagful of eartips of many shapes and sizes because we will send them back to vendors if we don’t get that seal.

I don’t recall have “s” checked. Is this specific to using DSL v5 pediatric?

What does that stimulus sound like? What does that add to the REM process that 55/65/85 alone would not catch?