极重度听力损失患者需要考虑三个方面的因素:听阈、不舒适响度级(UCL)和听觉分辩率。传统的解决方法是采用大功率的线性助听器,这类助听器中采用提供高增益的方法提供足够的放大量以获得言语可听度。
极重度听力损失重要特点是:听力损失不仅表现在灵敏度下降方面,而且影响到处理各种声音的能力;虽然可听到声音但不能有效地从信号中提取有用信息。
全自动非线性放大患者对轻声言语信号获得好的可听度,对中等及强声提供好的声音质量,随着听力损失的加剧,相应地需要增加增益和压缩将全范围的言语放入到残余动态范围中。按此类推,将整个言语范围放入到极重度听力损失中。
但是提供更多的增益和压缩以匹配极重度听力损失患者动态范围是有局限性的,原因是在有些频率点的信号对使用者来讲是无法利用的。快速压缩系统是大程度减小信号瞬间幅度变动带来的影响,正常听力耳可以从压缩信号中提取有用信号,但是听力严重受损耳则不能很好处理如此压缩的信号。全范围语音信号被压缩在很小的残余听力范围内,这种平坦信号轮廓不能被一些极重度听力损失耳所利用,因此试图采用宽动态压缩解决极重度听力损失者的助听器选配问题成功率受到限制。非线性放大用于解决这类听力问题还受到制约。
实际上,对于超过70 dB HL的听力损失,增益的补偿趋于全部。但是如前所述,简单响度模式和增加压缩率以补偿更窄的残余动态范围的方法是不合适的,这样处理不能保证足够的言语理解度,过多的压缩信号会导致理解困难,建议压缩率不超过2.5:1。
针对极重度听力损失的特点,极重度听力损失选配算法不仅是对ASA算法的扩展,也应该作进一步修正。有些极重度听力损失患者需要信号的线性成分较多(我们称之为类型1患者),而有些患者可以完利用通过ASA算法进行中等压缩信号(类型2患者)。类型1的患者内耳损伤严重,剩余完整的内毛细胞很少,因此过多的压缩对他们会造成不良影响.除了对纯音,他们的信号分辩力很低,只能利用言语信号的波峰部分.而有些极重度听力损失患者可以很好地利用ASA选配算法压缩的信号(类型3患者).这些患者外毛细胞损失严重,但内毛细胞损失程度并不严重(导致听阈很高),因此有足够的信号分辨能力从压缩信号中提取有用信息.因为患者的个体差异,像ASA这类通用的选配方法可能不能适用.
模式1:同模式2相比,高低频通道的释放时间延长了,可对快速变化语音信号处理提供更多的线性。此外,在高、低频通道减小了对小信号输入时的增益约8 dB。其结果等效于减小了压缩率。这些处理的总体效果是对快速变化输入信号给予更多线性处理,并提供基本的言语波峰部分给患者。而对于较慢速变化的输入信号继续提供足够的放大。
模式2:默认的选配原理,同ASA选配算法相似,采用低频通道的快速音节压缩和高频通道慢速适应增益。其目的是提供中等的压缩输出信号,以获得中等强的语音信号及良好的可听度,轻声语音可通过调节手动音量控制器增加可听度。
模式3:同模式2相比,在高频通道缩短了释放时间,在低频和高频增加了增益(因此增加了压缩率)。使更多的言语信号压缩于残余动态范围中,对于有足够的能力从压缩信号中分辨语音的患者,这种方式效果好。
多数的患者助听器的设置可以采用模式2,表明他们可以利用中等压缩的信号,特别是当高频通道压缩释放时间不是很短(默认ASA原理是230ms)的情况。有些极重度听力损失患者可以使用更多的压缩(类型3),他们有足够的能力使用残余的动态范围中的言语信息,他们中的大多数对模式2的设置表示满意,但往往会寻求好的言语理解度。这些患者在需要获得好的分辩率时才需要调整微调。而另一些患者听觉系统损失极为严重,即使是模式2中的中等压缩对他们来讲也是非常大的。他们会反映从线性转换到非线性处理使得言语变得“太混浊”或者抱怨声音“太嘈”。即使是使用模式2,他们也会对线性助听器更为青睬,使用模式1后,往往会感觉好。
在极重度听力损失的患者选配助听器时,还要注意确定精神的动态范围。对于大多数听力损失患者,通过选配软件根据听阈(HTL)值可以估算出不适阈值(UCL)。虽然这种方法还不准确,实际选配工作中效果是良好的。然而对于重度到极重听力损失患者,要充分利用残余听力范围,实测每个频率点的UCL。此外,选配人员应检查患者助听器UCL设置情况,几个分贝的增益增加也可能会对他们非常有帮助。
许多具有长时间线性助听器使用经验的极重度听力损失患者是使用新型非线性大功率助听器的潜在用户。为这类患者选配新型助听器时首先要保证他们熟悉的“听感觉”。只要患者不是非常依靠这种类型的信号,他们会逐步适应从线性到非线性的转换。就理论上来讲,如果极重度听力损失患者可以从失真的削峰信号中提取出有价值的信息,他们就能从非线性助听器中获得更多信言语息,当然患者需要时间在正确指导下发现并利用这些信息。
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