Change in gain settings on first connect to Genie2

[nanowiz]

Great new!! I finally successfully completed a full fitting from scratch using In-Situ testing. I found quite a bit of difference in the profile compared to what the audiologist got. Here is the comparison, grey line is the audiologist's test results. Colored line is from my in-situ test.



I proceeded to recalculate the gains after setting the preferences and running feedback adjustment. It was important to play the audios in preferences to decide the choices. I would have picked differently without listening. Here are the results comparing the gain numbers with what the audiologist had in the hearing aids before. That has gone through several adjustments since the original hearing test, and I was still very unhappy with the results.



Note the drop in gain from 750-2500Hz on the right and pickup in gain for G50 above 2000Hz. I experienced no more annoying clanging of dishes in the kitchen and I can understand my wife's voice much better. She no longer sound tinny and cracky. I still have a major drop in gain above 3K Hz on the left ear due to feedback pushdown. I think I need to get new molds made to improve the feedback so that I can hear better with improved gains above 3K.

Since my profile is kind of flat with even loss across the frequencies, I disabled the frequency compression that shift higher frequency sounds down to lower frequencies like the audiologist had done. I think that also helped with my speech recognition. Definitely makes music sound better. I now can listen to the TV without 100% dependency on subtitles. Will venture out tomorrow into noisy environments and see how that works.

So grateful for all the help I got from this forum. Thank you.

 

[Volusiano]

My in-situ result varies slightly from my audiogram done at the office as well, so it should be no big surprise there. After all, the actual hearing aids' amplification will not match 100% to the "calibrated" device used in the hearing booth. Of course the in-situ result should be considered more accurate because it reflects the actual performance of your hearing aids, along with the actual physical fitting variances and all.

Having said that, once you re-prescribe to the in-situ result, you kind of forgo whatever REM adjustment that might have been done by your HCP at the office (assuming you had 1 done). In theory, REM is probably preferred over in-situ prescription without REM, because in-situ is very basic pure tone testing at each frequency point for a threshold level, while REM is deemed more robust because it's more real life simulated testing with a variety of sounds and noises in a simulated environment, and a calibrated mic that measures the actual sound pressure level received inside your ear canal which requires no subjective input from the client like in-situ audiometry does to determine whether the produced sound meets the target or not.

For DIY folks who are able to retain an HCP's service initially to get REM done, then the natural course of action would be to use the REM adjusted gain-curves as a starting point and go from there to get to where they want. But without the luxury of being able to use REM-based gain curves as a starting baseline to go off on, I guess in-situ prescribed gain curves would be the next best thing. And in theory, if finally adjusted to the DIY person's ultimate satisfaction, then it doesn't really matter which path you take, from REM to final result, or from in-situ to final result, as long as the end result is the same. But perhaps the path from REM to final result may be easier and/or faster to get there compared to the path from in-situ-prescription to final result.

 

[nanowiz]

Hi Volusiano, I understand you point regarding REM vs In-Situ. But my understanding of REM is that it is purely a measurement of the effect of the ear canal on the output of the hearing aid and to make adjustments to compensate. It seems to me that when you do In-Situ, the ear canal effect is included because the test in done in the actual use environment with the hearing aid in the ear canal. So In-Situ trumps REM+non in-situ. Am I missing something here?

In my case, I found the recalculated settings based on my in-situ fitting way better than what the audiologist was able to do, and that is only the initial setting without any further tuning yet. I flew to Vegas today and experienced the flight as well as loud restaurants and casinos today. So far, I am happy with the results compared to the annoying sounds with the audiologists settings. I am still missing some of the words people are saying.. Hopefully further tuning can help.

 

[Volusiano]

But my understanding of REM is that it is purely a measurement of the effect of the ear canal on the output of the hearing aid and to make adjustments to compensate. It seems to me that when you do In-Situ, the ear canal effect is included because the test in done in the actual use environment with the hearing aid in the ear canal. So In-Situ trumps REM+non in-situ. Am I missing something here?

Yes, you are missing 2 crucial things beside the effect of the ear canal shape on the output of the hearing aids. Those 2 crucial things are: 1) the (over or under or right-on-the-spot) performance of the hearing aids relative to the target gain curve, and 2) the performance of your fitting choice, whether it be open dome or closed dome (with vent or not) or power dome or custom mold.

The performance of the fitting choice usually is with regard to how well they fit generally. A well sealed fitting will not leak and can hold the sound level in the ear canal better one that leaks all over the place, for example.

As for the performance of your hearing aids, in theory, ideally, the prescription to the hearing aids based on your audiogram should match perfectly well to the target gain curves. However, in reality, they usually don't, and usually, then tend to underperform against the target curve. Not necessarily all across the board, but maybe for certain frequency range(s). Beside the performance issue of the hearing aids, there is also the prescription issue of the hearing aids. For example, if you run REM with your HAs set to the default P1 General program that's based on VAC+ selection (the proprietary Oticon fitting rationale), but your HCP's external stand-alone REM machine wouldn't be able to calculate the target curve based on the VAC+ rationale (because it's proprietary to Oticon only), then your HCP can only pick a standard rationale like the NAL-NL2. In this case, there will be some discrepancies even if the HAs perform to VAC+ target, because the NAL-NL2 target gain curve will probably look a little different than the VAC+ target gain curve.

The Oticon Genie 2 has a feature called REM Autofit. If your HCP has a REM equipment that's compatible with the Oticon REM Autofit and choose to couple and run it together with/inside the Genie 2's REM Autofit software instead of the stand-alone external REM equipment, then it's possible that Genie 2, with the knowledge of the proprietary VAC+ rationale, can calculate the target gain curves that are VAC+ based to do REM adjustment against, as opposed to doing the REM adjustment against the NAL-NL2-based target gain curve if the external software is used instead of Genie 2.

 

[nanowiz]

I still have trouble with your 2 points. Since in-situ fitting is done using my hearing aids with my dome or mold, isn't the resulting audiogram already has both of these issues already included in the fitting results? I can understand your point if it is regular fitting.

 

[nanowiz]

Also, I just realized that after I did the fitting from scratch using in-situ, I can no longer connect to my hearing aids from my iPhone Oticon Companion app. Also I am not able to changed programs with the long press of the hearing aid button. I checked the iPhone’s Settings/Accessability/Hearing Devices and I do see the hearing aids connect and able to select from the 4 programs I had put in. I was sure I did set the long press to be program change in Genie2. Not at home to double check right now though. Wonder why the iPhone app no longer connects.

 

[Volusiano]

I still have trouble with your 2 points. Since in-situ fitting is done using my hearing aids with my dome or mold, isn't the resulting audiogram already has both of these issues already included in the fitting results? I can understand your point if it is regular fitting.

Yes, of course in-situ also covers the hearing aid performance as well as the fitting issues, beside the ear canal characteristics. BUT, big but here, there are so many differences and disadvantage with in-situ:

1. In-situ is only a pure tone test in complete silence
2. it only measures the threshold level detection by your brain, nothing else
3. Also, in-situ is a tone generated internally by the hearing aids on command from Genie 2 (in turn on command from you). This results in a bias here because even if you didn't hear the threshold sound, YOU KNOW that you pushed that button to activate the pure tone sound. At least in the booth test, you don't know when the HCP activates the pure tone sound.
4. In-situ does not cover how well the microphones on your hearing aids work to pick up the real sounds because the tone is generated internally inside the HAs.
5. In-situ does not cover real life sound scenarios, albeit it's still a simulation as the sounds are generated by the speakers in the HCP office.
6. In-situ cannot verify how well your HAs (and the whole setup) amplify against a target gain curve.
7. In-situ does not verify the performance of the HA prescription against a specific fitting rationale to see if the HA mfg's calculation for the prescription against that fitting rationale is calibrated accurately to it or not.

I would generalize the use of in-situ as a poor man's verification of his HAs compared to REM being a rich man's more complete verification of his HAs.

 

[Volusiano]

Also, I just realized that after I did the fitting from scratch using in-situ, I can no longer connect to my hearing aids from my iPhone Oticon Companion app. Also I am not able to changed programs with the long press of the hearing aid button. I checked the iPhone’s Settings/Accessability/Hearing Devices and I do see the hearing aids connect and able to select from the 4 programs I had put in. I was sure I did set the long press to be program change in Genie2. Not at home to double check right now though. Wonder why the iPhone app no longer connects.

I guess it's not worth wondering what happened after your session. Best to wait until you get home to have access to Genie 2 and try to figure things out with Genie 2 available and fix or reset things while you have access to Genie 2. Do note that Genie 2 does store the pairing information of your phone and TV Adapter and ConnectClip, etc. Normally in theory, it should be enough to clear and re-pair things without needing Genie 2, but if the normal user process of clearing and re-pairing your HAs to your devices doesn't work, an extra step would be to go into Genie 2 and also delete the pairing information from the accessories in there as well.

 

[nanowiz]

I guess it's not worth wondering what happened after your session. Best to wait until you get home to have access to Genie 2 and try to figure things out with Genie 2 available and fix or reset things while you have access to Genie 2. Do note that Genie 2 does store the pairing information of your phone and TV Adapter and ConnectClip, etc. Normally in theory, it should be enough to clear and re-pair things without needing Genie 2, but if the normal user process of clearing and re-pairing your HAs to your devices doesn't work, an extra step would be to go into Genie 2 and also delete the pairing information from the accessories in there as well.

Thanks. Guess I’ll have to wait till I get home. I can get to Genie2 remotely from here, but no connection through Noaklink Wireless.

 

[nanowiz]

I talked to my AUD and she recommended that I uninstall and reinstall the Oticon app on my iPhone. I did that to the Oticon Companion app and still no go. Then I switched back to the old Oticon ON app and now it connects to the hearing aids.

 

[nanowiz]

Yes, of course in-situ also covers the hearing aid performance as well as the fitting issues, beside the ear canal characteristics. BUT, big but here, there are so many differences and disadvantage with in-situ:

1. In-situ is only a pure tone test in complete silence
2. it only measures the threshold level detection by your brain, nothing else
3. Also, in-situ is a tone generated internally by the hearing aids on command from Genie 2 (in turn on command from you). This results in a bias here because even if you didn't hear the threshold sound, YOU KNOW that you pushed that button to activate the pure tone sound. At least in the booth test, you don't know when the HCP activates the pure tone sound.
4. In-situ does not cover how well the microphones on your hearing aids work to pick up the real sounds because the tone is generated internally inside the HAs.
5. In-situ does not cover real life sound scenarios, albeit it's still a simulation as the sounds are generated by the speakers in the HCP office.
6. In-situ cannot verify how well your HAs (and the whole setup) amplify against a target gain curve.
7. In-situ does not verify the performance of the HA prescription against a specific fitting rationale to see if the HA mfg's calculation for the prescription against that fitting rationale is calibrated accurately to it or not.

I would generalize the use of in-situ as a poor man's verification of his HAs compared to REM being a rich man's more complete verification of his HAs.

Thanks for the reply. Let me respond point by point...
1. agreed
2. agreed, but it bypasses the inaccuracies/variances of the HA's amplification profile and the effect of the ear canal.
3. agreed. I took great effort to repeat each tone frequency's up/down volume changes up to 10+ times to make sure that I am not imagining that I heard it. It can be a source of error, especially with tinnitus in the way so hearing or not hearing the tone is like spotting your target person in a crowded place.
4. Yes totally agree with this point. Imagine that it is hard of DIY'ers to overcome this without expensive calibrated sound equipment. In the Phonak fitting app, there is a dynamic mode where you can play a sound with my computer's speakers and the app will show the volume heard by the HA's mic. I just do a frequency sweep and look for variations in the displayed sound level. I can do this at various sound levels. But this is not available on the Oticon Genie2 app.
5. How does REM make use of this to adjust the gain curve? Does this really make a difference?
6. Yes, but only in respect to the sensitivity profile of the mic. If there is a way to profile the HA's mic for DIY'ers, think this can be compensated to some degree like in the Phonak's case. Though i have not worked out a way to do it since it is not available in the Oticon Genie2.
7. I have doubts about how important this is. Since the HA's effective gain value vs the target gain is established by the In-Situ test, how can it be different when it is applied by the prescription? Are you thinking that this relationship is not linear over the volume range? If so, I would agree. Just have no idea the typical linearity of gain over the range of volume and frequencies are for hearing aids. Tend to think that they are very linear making this a non-issue.

 

[Volusiano]

In response to your question in 5, first off, I don't pretend like I know the details of how the REM machine is designed and set up and work, because I don't. I only understand the abstract theory of what REM does and strives to achieve. So anything I say/said is only by deduction and guesswork. But I think I already covered this either in this thread or in the other REM thread, that my understanding is that they play simulated real life sounds or sound scenes out of the speakers (how and which sound/sound scene they select probably depends on the REM system, I'm not sure if there's a standard), and use the internally placed mics inside the ear canal to measure the output of the system under test (aka the HAs and the fittings and the ear canal shape) and compare this result to a target that is a calculated result of what it should be like if it has been crunched through a fitting rationale. Gain adjustments to the hearing aids are then made to match this target curve.

It makes a difference enough that REM becomes one of the best practice most clinician should do to verify the efficacy of the whole hearing aid system. If the system under test tend to perform to par (to target) most of the times, then REM wouldn't make much difference. But if the system under test tend to underperform more often than not, then it makes a big difference to make adjustment to bring it up to par with the level of performance expected of it.

In the end, you can think of REM like buying insurance. If your system performs well right out of the gate, very little adjustment would be needed to be done during REM, but it's still worthwhile to know that an inspection has been done on it. But if it doesn't perform, then adjustment can be made right up front to bring it up to par. Maybe you can think of it like a 21-point inspection a car garage may do on your car when you bring it in. They may find that everything is up to par and end up not fixing anything. But if most of the times, they usually do find something wrong here and there worth fixing, and they fix it, then it's worth the insurance of having the inspection done so that the fixes get addressed up front. And HCPs who embrace REM tend to be those who notice underperformance from HAs more often than not. Those HCPs who don't embrace REM tend to argue that they notice most modern HAs perform up to par right away, so they don't do REM unless the client keeps struggling and requires many office visits. I personally think that that's a cop-out response, because it's best to verify up front regardless of whether adjustments are needed or not because verification is insurance, it's not wasted effort.

 

[nanowiz]

In response to your question in 5, first off, I don't pretend like I know the details of how the REM machine is designed and set up and work, because I don't. I only understand the abstract theory of what REM does and strives to achieve. So anything I say/said is only by deduction and guesswork. But I think I already covered this either in this thread or in the other REM thread, that my understanding is that they play simulated real life sounds or sound scenes out of the speakers (how and which sound/sound scene they select probably depends on the REM system, I'm not sure if there's a standard), and use the internally placed mics inside the ear canal to measure the output of the system under test (aka the HAs and the fittings and the ear canal shape) and compare this result to a target that is a calculated result of what it should be like if it has been crunched through a fitting rationale. Gain adjustments to the hearing aids are then made to match this target curve.

It makes a difference enough that REM becomes one of the best practice most clinician should do to verify the efficacy of the whole hearing aid system. If the system under test tend to perform to par (to target) most of the times, then REM wouldn't make much difference. But if the system under test tend to underperform more often than not, then it makes a big difference to make adjustment to bring it up to par with the level of performance expected of it.

In the end, you can think of REM like buying insurance. If your system performs well right out of the gate, very little adjustment would be needed to be done during REM, but it's still worthwhile to know that an inspection has been done on it. But if it doesn't perform, then adjustment can be made right up front to bring it up to par. Maybe you can think of it like a 21-point inspection a car garage may do on your car when you bring it in. They may find that everything is up to par and end up not fixing anything. But if most of the times, they usually do find something wrong here and there worth fixing, and they fix it, then it's worth the insurance of having the inspection done so that the fixes get addressed up front. And HCPs who embrace REM tend to be those who notice underperformance from HAs more often than not. Those HCPs who don't embrace REM tend to argue that they notice most modern HAs perform up to par right away, so they don't do REM unless the client keeps struggling and requires many office visits. I personally think that that's a cop-out response, because it's best to verify up front regardless of whether adjustments are needed or not because verification is insurance, it's not wasted effort.

Yes. Thank you for your detailed explanation. But my point regarding point 5 is how does REM make use of real life sound scenarios to adjust the gain curve. Real life sound is a mixture of many different frequencies and they probably have an effect on each other, like perhaps one frequency will suppress another in a repeatable way? And is the REM machine really that smart to analyze the specturm of sound received by the sense mic in a dynamic way so that it can make the proper adjustments for the specific frequencies that have this phenomenon? I kind of double it. But I can be wrong. I fully agree with you on the overall benefit of REM fitting. I am just comparing the gain curves and looking for some explanation of the changes at the various frequencies, be it a change of receiver tip type or ear canal shape, wondering if what I got is typical of what others get as well.

 

[Volusiano]

Here's a link to a good video on REM as the audi demonstrates it with a live voice in real time. There are plenty more REM videos on YouTube, of course, if you want to view more. But yes, it appears that REM machines are smart enough to do analysis of the spectrum of sounds and chart it out into a range and calculates the average. That's probably why REM machines are prohibitively expensive for DIY'ers to buy. I think they can easily run into the tens of thousands of dollars. Probably as expensive as a car.

 

[nanowiz]

Hi Volusiano, I finally got my audiologist to do a REM fitting for me with my new custom molds and the results don't quite make sense to me.

First, I was having quite a bit of feedback with my original custom molds. The feedback margin was eating into the gain curve at the higher frequencies. So I got the audiologist to make new custom molds focusing on a better fit but keeping the original 1.4mm vent. The results were good. Here you can see a comparison of my old and new mold's feedback margins as well as the change in the gain curves.



Using the new molds, I ran the in-situ test again and established a new audiogram which I gave to the audiologist to use as a basis to run the REM. Here is a comparison of the gain curves I got before and after the REM fitting:



I further plotted just the delta in gains between pre and post REM and here are the charts:

This 25-30 dB difference is hard to comprehend. I find it hard to believe that the ear canal and the HA mic is creating such a huge delta. I am wondering if the audiologist failed to insert the sensor tube properly. Even poor calibration of the sensor tube cannot account for such large delta.

Another surprise is the gain limit of the HA which I understood to be the grey region in the very first charts above, with the feedback margin reducing this limit. But when I looked at the new chart after the REM fitting, this grey region moved by a great amount. Also note that the feedback margin is no longer available. I thought a REM fitting only adjusts the gain. Here is the post REM chart with the new gain curves and grey zone:



Here is the new grey region boundary curve (in black) super imposed over the old one:



Why would the REM fitting change the gain limit of the hearing aids and by 20+ dB?

I am now trying to live with this new gain curve where everything sound so loud. Audiologist said it just take time to get used to it. I normally have to turn the volume of the HA down 2 notches. I can hear much better, but still have trouble in noisy environments as the noise is overwhelming. The nasal feedback is also a problem with the new molds especially on the left side. In a restaurant, all I can hear is myself chewing. Wondering if I should try enlarging the vent hole with a drill. My old molds' vent hole is only a couple of mm deep. The new mold has the vent hole going the whole depth of the mold like almost a cm. Wonder what is the optimal depth of this hole.

I would love to hear your's or anyone's thoughts on all this. I am sending all these to my audiologist too and awaiting her reply.