International Journal of Pediatric Otorhinolaryngology (2005) 69, 771—779

www.elsevier.com/locate/ijporl

Speech recognition abilities in noise for

children with severe-to-profound unilateral
hearing impairment
Melissa N. Ruscetta a,*, Ellis M. Arjmand b, Sheila R. Pratt a

a
University of Pittsburgh, 4033 Forbes Tower, Pittsburgh, PA 15260, USA
b
Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA

Received 29 June 2004; received in revised form 3 January 2005; accepted 11 January 2005

KEYWORDS Summary
Speech recognition
abilities; Objective: The purpose of this research was to compare the signal-to-noise ratio
Unilateral hearing required for equal performance for children (aged 6—14 years) with normal hearing
impairment; (N = 17) versus those with severe-to-profound unilateral hearing impairment (N = 20)
Binaural listening who can be at a disadvantage, particularly when sounds are presented to the impaired
ear. The listening environment is designed to approximate that which is encountered
in a typical classroom.
Methods: All signals (Hearing in Noise Test-Children and Nonsense Syllable Test) were
presented in the sound field from various azimuths with continuous noise presented
from all quadrants. The children were required to repeat twenty items, from each
test, in each listening condition. The intensity of the presentations was varied based
on the accuracy of previous items. Average signal-to-noise ratios are compared
between and within groups.
Results: (1) In most listening conditions, significantly greater signal-to-noise ratios
were needed by those with unilateral hearing impairment than those with normal
hearing, on both speech tests. (2) In every listening condition, both groups required
significantly greater signal-to-noise ratios to perform equally well on the Nonsense
Syllable Test as on the Hearing-In-Noise Test-Children. (3) For the Hearing-In-Noise
Test-Children, children with normal hearing required significantly greater signal-to-
noise ratios when facing the signal than when the signal was presented to a normally
hearing ear (monaural direct). (4) On both tests, the children with unilateral hearing
impairment required significantly greater signal-to-noise ratios when facing the signal
than in the monaural direct condition. (5) On both tests, the children with unilateral

* Corresponding author. Present address: Children’s Hospital of Pittsburgh, ENT-ADM 1st floor — MT, 3705 Fifth Avenue, Pittsburgh,
PA 15213, USA. Tel.: +1 412 692 8032/383 6540; fax: +1 412 692 6074.
E-mail addresses: melissa.ruscetta@chp.edu (M.N. Ruscetta), ellis.arjmand@cchmc.org (E.M. Arjmand), spratt@pitt.edu
(S.R. Pratt).

0165-5876/$ — see front matter # 2005 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijporl.2005.01.010
772 M.N. Ruscetta et al.

hearing impairment required significantly greater signal-to-noise ratios when the

signal was presented to the impaired ear (monaural indirect) than when facing the
signal.
Conclusions: (1) The children with unilateral hearing impairment require a more
advantageous listening condition to perform equally as well as their normally hearing
counterparts. (2) All of the children benefited from signals delivered in a monaural
direct condition. (3) The children with unilateral hearing impairment performed best
in the monaural direct condition or when facing the signal at zero degrees. (4)
Significantly greater signal-to-noise ratios were needed for both groups when
restricted contextual cues were available versus when sentential cues were available.
# 2005 Elsevier Ireland Ltd. All rights reserved.

1. Introduction ous difficult listening situations that could possibly

There is ample empirical evidence available to
demonstrate that binaural listening is superior
to monaural listening [5,8,20,35,41,44]. Those
binaural factors that contribute to a listening advan-
tage include; binaural summation [8,28,40,45], the
head shadow effect [8,20,38,44,48], localization
[26,27,29,35,37,41,49], and binaural release from
masking [8,13,21,23,29]. Research conducted pri-
marily with adults suggests that people with only
one normally hearing ear experience a variety of
listening difficulties, including difficulty in under-
standing speech under quiet and noisy conditions
regardless of the location of the sound source
[8,19,20,44]. Giolas and Wark (1967) also noted that
the participants in their study reported feelings of
embarrassment, annoyance, confusion, and help-
lessness.
Although adults are affected by unilateral hear-
ing loss, the potential impact on the development of
auditory and auditory-dependant skills in infants
and children is substantial. Infants acquire compe-
tency in their central auditory processing skills
and language and speech recognition abilities over
time. Investigations have demonstrated systematic
improvements in performance as children mature to
adolescence [24]. Anatomical studies demonstrate
that the human auditory cortex continues to
develop up until adolescence [33]. These findings
may partially explain age-related improvement in
speech recognition.
Given the listening problems encountered by
adults with unilateral hearing impairment (UHI), it
is not unreasonable to suspect that children with UHI
also can encounter similar problems, particularly in
school where a myriad of competing sounds are pre-
sent. Such listening problems may interfere with or
preclude the normal development of communicative
skills that are essential to the child’s learning.
Although there is little clinical or experimental
data on the communicative skills of children with
UHI, there appears to be sufficient evidence to
suggest that these children are subjected to numer-
compromise the normal development of language
and auditory perceptual skills [3,4,7,8,47]. Studies
have reported that children with UHI exhibit delays
in educational achievement [3,4,7,8,12,46], com-
munication problems [7,8], and behavioral difficul-
ties [8,47].
Boyd (1974) examined the effects of hearing
impairment on educational performance and noted
that many children with UHI demonstrated lags in
academic achievement including reading problems,
spelling problems, and problems with arithmetic.
Sarff [43] indicated that many school-age children
with high frequency UHI (>2000 Hz) demonstrated
deficits in educational performance. Similarly, an
unpublished report by Simon (1977) showed that
32.6% of a sample of children whose impaired ear
average was greater than 80 dB, lagged behind
expected performance by as much as 1—3.5 years.
The difficulties were in reading comprehension
or reading vocabulary and auditory memory
problems.
The affect on academic skills also is reflected by
an increased risk of academic failure. In a survey of
60 children with UHI, Bess (1986) found that 35%
failed at least one grade in school, and an addi-
tional 13% required resource assistance. Further-
more, the children with UHI, who failed a grade
also, exhibited significantly lower verbal IQs than
those children with UHI who did not fail a grade.
This study also showed that children with severe-
to-profound UHI exhibited significantly lower full
scale IQs than those with more mild losses. Tea-
chers consistently rated children with UHI as having
greater difficulty in peer relations, less social con-
fidence, a greater likelihood of acting out or exhi-
biting withdrawn behavior in the classroom,
greater frustration and an increased dependence
on the teacher, and more frequent distractions.
Oyler et al. [39] produced similar results. Of 38
children with UHI, they found that 23.5% had
repeated at least one grade and, of 54 children
with UHI, 40.7% had received some sort of special
services.
Speech-in-noise for children with severe-to-profound UHI
Little research regarding rehabilitation/treat-
ment of UHI has been completed, however, a hand-
ful of investigations on the performance of children
with UHI using CROS (contralateral routing of signal)
hearing aids are available [32,34,44]. In general, the
findings of these reports suggest that users of the
CROS technology show improvement in the ability of
children with UHI to hear and understand lower
intensity sounds and speech. A popular form of
rehabilitation used today is the FM system, which
affords a better signal-to-noise ratio (SNR) and
allows the child to better focus on the primary
signal. However, no empirical studies of perfor-
mance with this technology among children with
UHI are available.
The specific aim of the present investigation is to
compare the SNRs for equal speech recognition
performance for children with normal hearing
(NH) and for those with severe-to-profound UHI.
The speech materials, Hearing in Noise Test-Chil-
dren (HINT-C) [18], and the Nonsense Syllable Test
(NST) [15] were chosen because they allowed for
examination of performance with and without con-
textual cues. Equal performance at lower SNRs was
expected on the sentence recognition task (HINT-C)
than on the NST because of the increased linguistic
and speech acoustic contextual cues available to the
listener. Moreover, the listening environment also
was arranged in order to simulate listening from a
variety of angles of incidence to the signal.
For people with normal bilateral hearing, turning
one ear towards the signal (monaural direct [MD]
condition) allows easier listening and better speech
discrimination in noise than when listening while
facing the signal at zero degrees orientation [8]. This
finding was expected in the present investigation
with children. Also, it was anticipated that children
with severe-to-profound UHI would perform better
when in the MD condition than when they listened
while facing the signal directly. Finally, the present
investigation allowed examination of the impact of
having subjects with severe-to-profound UHI listen in
a monaural indirect (MI) condition (where the
impaired ear of the individual faces the signal).
Performance in this condition was expected to be
poorer than when the subject listened while facing
the signal directly at zero degrees (zero degrees
condition) or when in the MD condition.
2. Methods
2.1. Subjects
Two groups of both male and female school-aged
children (6—14 years) participated in the current
773
investigation. One group included seventeen children
who had normal hearing in both ears and who func-
tioned as a control group. The second group included
twenty children with UHI (defined here as a pure tone
average threshold (PTA) of 70 dB HL) in one ear, and
NH (defined here as thresholds of 20 dB HL at all
frequencies tested) in the opposite ear. Standard
audiometric procedures were used to obtain air con-
duction thresholds from 250 to 8000 Hz and bone
conduction between 500 and 4000 Hz [1].
Children with a previous diagnosis of develop-
mental delay who exhibited substantive problems
with receptive vocabulary or single word recogni-
tion were excluded from participation. The Peabody
Picture Vocabulary Test-III (PPVT-III) [14] was used
to assess receptive vocabulary. The PPVT-III allows
the tester to determine the equivalent age range at
which the child is performing. Age appropriate
receptive vocabulary was required for participation
(i.e., chronological age must fall within perfor-
mance age range). Word recognition scores were
assessed with the Northwestern University-Chil-
dren’s Perception of Speech Test (NU-CHIPS) [16].
A score of 95% or better was required for participa-
tion. Finally, normal middle ear function as indi-
cated by tympanometry [2], was demonstrated at
each visit.
The age range of 6—14 years was selected for
several reasons. Historically, children with UHI have
not been identified until the early elementary
school years. This is likely due to compensation
techniques that are employed by this group using
the normally hearing ear to their benefit. A recent
examination of 50 children with UHI, not acquired
through trauma or infection from the Hearing Cen-
ter at Children’s Hospital of Pittsburgh, indicated an
average age of diagnosis of 5 years, 2 months with a
median age of 5 years. In the future, universal
newborn hearing screening will allow the average
age of identification to continue to be lowered.
Therefore, it was believed that children as young
as 6 years of age could be identified for participation
in the present investigation. Also, children as young
as 6 years can reliably perform the required tasks
proposed herein.
The upper age limit was decided upon because;
some speech recognition abilities in noisy listening
conditions appear to be adult-like between 13 and
15 years of age [25]. It is likely that participants
aged 14 years and younger, would have similarly
immature speech recognition abilities and may be
more susceptible to the affects of hearing loss and
noise and therefore make up the population of
interest for this investigation. Interesting future
research might aim at replicating this experiment
with children with UHI, over the age of 14 years,
774
but because of speech recognition maturation
issues, this older group must be examined sepa-
rately.
The number of subjects selected for the experi-
ment resulted in an estimated power of .79 or
greater when calculated with an alpha of .05 and
a moderate effect size of .25. This effect size was
reasonable given the variability and the size of the
effects observed in previous studies with adults and
children.
2.2. Protocol
All members of each group received the same
experimental testing. The test environment was
constructed so that all target sounds were pre-
sented through an audiometer (GSI-16) and pre-
sented in the sound field. Multi-talker babble
(Auditec of St. Louis) was continuously presented
at 65 dB (peak SPL) as measured at the location of
the ear with a sound level meter. The noise was
routed through a Crown D-75A amplifier with loud-
speakers positioned at 458, 1358, 2258, and 3158
azimuths. The tasks (described below) were com-
pleted in each of the following listening conditions
relative to the signal loudspeaker:
1. The child faced the signal loudspeaker at zero
degrees orientation with the signal presented in
noise.
2. The child’s right ear faced the signal loudspeaker
and the signal was presented in noise.
3. The child’s left ear faced the signal loudspeaker
and the signal was presented in noise.
For each child, the head was not stabilized phy-
sically but was monitored visually to ensure that
head orientation did not shift during testing. The
task involved repeating the target sentences and
nonsense syllables.
2.3. Speech materials
The speech materials included the Hearing in Noise
Test-Children (HINT-C) [18], and the Nonsense Syl-
lable Test (NST) [15]. Both tests are appropriate for
the target age group. A study using the NST revealed
that children between the ages of 6—13 years
peformed similarly to an adult population [6]. The
HINT-C was developed to be used with children as
young as 6 years [18]. These tests were not used in
their traditional sense. Ordinarily, a complete list of
ten or twenty sentences from the HINT-C is pre-
sented with the noise presented continuously at
65 dB SPL. The level at which each sentence is
presented is dependant upon performance on the
M.N. Ruscetta et al.
previous sentence. If a sentence is repeated exactly,
then the signal is decreased by 2 dB; if repeated
incorrectly, the signal is increased by 2 dB. After the
complete list is administered, an average SNR is
obtained for the last 7 items (10 item list) or the
last 17 items (20 item list) and can be charted and
compared to normal performance. This procedure
(using two, 10 sentence-lists from the available 13)
was followed in this investigation, however, the
average SNRs were compared between groups, con-
ditions, and tests rather than to performance
norms. For the NST, ordinarily a list of 25 nonsense
syllables is delivered at some suprathreshold level, a
correct or incorrect response is recorded for each
item, and a percent correct is obtained. For this
study, the first 20 items from one of the six available
lists on form A were delivered in the same fashion as
for the HINT-C, and an average SNR was obtained for
each condition.
The order of presentation of the test materials
(sentences [HINT-C] versus nonsense syllables
[NST]) was randomized, and the order of the three
test conditions was randomized for each type of
stimuli.
2.4. Data analyses
Following, are results of t-test comparisons of (1)
the average SNR of the NH subjects versus the
subjects with UHI with each speech material in
each condition; (2) The average SNR needed for
the NST versus the HINT-C for each group, in each
condition; and (3) the average SNR required in
different conditions for both groups, using both
speech materials.
3. Results
A comparison of the data obtained from the right
and left ears of the control subjects revealed no
significant differences. Therefore, only the right-
ear data for the control subjects was used for
analyses.
3.1. Children with severe-to-profound UHI
compared to the control group
Significant differences are noted in the SNR needed
to achieve equal performance comparing children
with NH and those with UHI in almost all test
conditions, on both the NST and the HINT-C. The
children with UHI required more advantageous lis-
tening conditions (or greater SNR) to perform as
well as children with NH. Fig. 1 is a graphic repre-
sentation of the average amount of SNR advantage
Speech-in-noise for children with severe-to-profound UHI 775

Fig. 1 Average SNR advantage needed for the group with severe-to-profound UHI group to perform equally as well as the
control group.

needed by the group with UHI to perform equally as
well as the control group. These numbers are col-
lapsed across tests. Table 1 shows the average SNRs
needed for 50% speech recognition performance by
both groups on both tests in each listening condi-
tion. The differences were significant ( p  .05) in
every listening condition on both tests except when
the children completed the NST while sitting in the
MD condition.
3.2. Comparison of the HINT-C versus
the NST
In every listening condition, children with NH and
those with UHI needed significantly greater SNRs to
perform equally as well on the NST when compared
to the HINT-C. Fig. 2 is a graphic representation of
the average amount of SNR advantage needed.
These numbers are collapsed across all listening

Table 1 Average SNRs needed for equal performance in each listening condition
NST HINT-C
Zero Monaural Monaural Zero Monaural Monaural
degrees direct indirect degrees direct indirect
condition condition condition condition condition condition
(dB SNR) (dB SNR) (dB SNR) (dB SNR)
Control group 2.06 .89 N/A 1.84 4.23 N/A
(used .89 dB SNR) (used 4.23 dB SNR)
Severe-to-profound 6.18 3.42 9.84 dB SNR .39 2.02 3.44 dB SNR
UHI group
Difference score 4.12 2.53 8.95 dB SNR 2.23 2.21 7.67 dB SNR
(amount of
advantage needed
by S/P UHI group)
p-Value .011* .084 .000* .007* .021* .000*
*
Indicates a significant difference where p  0.5.
776
Fig. 2 Average SNR advantage needed to perform
equally well on NST as on HINT-C.
conditions. The required advantages for the control
group ranged from 3.90 dB SNR in the MD condition
to 5.12 dB SNR in the zero degrees condition. The
members of the severe-to-profound UHI group
required average advantages ranging from 5.44 dB
SNR in the MD condition to 6.40 dB SNR in the
MI condition. These differences were significant
( p  .05) in all listening conditions for both groups.
3.3. Children with NH seated at different
orientations to the signal
For children with NH, significantly greater SNRs were
needed to perform equally well on the HINT-C in the
zero degrees condition than in the MD condition, with
an average difference of 2.39 dB SNR ( p = .014).
However, while this pattern held true for the NST,
the average difference between SNR needed was not
significant at the p  .05 level ( p = .287). Fig. 3 is a
graphic representation of the average amount of SNR
advantage needed collapsed across tests.
3.4. Children with severe-to-profound UHI
seated at different orientations to the signal
For children with UHI, significantly more advanta-
geous listening conditions were needed to perform
equally well in the zero degrees condition as com-
M.N. Ruscetta et al.
Fig. 3 Average SNR advantage needed for control group
to perform equally as well in the zero degrees condition as
in the MD condition.
pared to in the MD condition. The needed advantage
ranged from 2.41 dB SNR on the HINT-C ( p = .000) to
2.76 dB SNR on the NST ( p = .023). This group also
required significantly more advantageous listening
conditions to perform equally well in the MI condi-
tion as compared to the zero degrees condition. The
magnitude of the needed advantage ranged from
3.05 dB SNR on the HINT-C ( p = .000) to 3.66 dB SNR
on the NST ( p = .021). Fig. 4 is a graphic representa-
tion of the average amount of SNR advantage
needed collapsed across tests.
4. Discussion
The superiority of binaural over monaural hearing in
adverse listening conditions is well documented for
individuals with normal hearing [5,8,20,35,41,44].
Factors potentially contributing to a binaural advan-
tage are (1) binaural summation, (2) the head
shadow effect, (3) localization abilities, and (4)
binaural release from masking. Research conducted
with adults shows that people with only one nor-
mally hearing ear experience a variety of listening
difficulties. Other studies have reported that
children with unilateral sensorineural hearing loss
exhibit delays in educational achievement [3,4,7,
Speech-in-noise for children with severe-to-profound UHI
Fig. 4 Average SNR advantage needed for severe-to-
profound UHI group to perform equally as well in more
detrimental listening conditions as in more advantageous
listening conditions.
8,47], communication problems [7,8], and beha-
vioral difficulties [8,41].
A detrimental SNR is a substantial hurdle facing
children with UHI. Several studies have illustrated
this problem. Nober and Nober (1975) reported that
the average noise intensity in four elementary class-
rooms was 65 dBA. McCroskey and Devens [31]
examined 78 occupied classrooms and found an
average noise level between 40 and 50 dBA. Finally,
Bess et al. (1984) examined 19 classrooms and found
a median noise level of 41 dBA in unoccupied class-
rooms and 56 dBA in those that were occupied.
Additionally, classrooms have been found to be far
too reverberant with the usual range equaling 0.5—
1.2 s with the typical classroom having an SNR of
+6 dB and a reverberation time of 0.8 s [8].
Several sources have demonstrated the debilitat-
ing effects of noise and reverberation on the speech
understanding of both children with normal hearing
and those with UHI [8,10,17,18,36]. In work by Ross
and Giolas [42], it was found that the mean word
recognition scores, obtained under usual classroom
conditions, were significantly lower for listeners
with minimal hearing impairment (32%) and those
with hearing impairment who were aided (20%) than
777
that for those with normal hearing (91%). This find-
ing was supported by Boney and Bess (1984) who also
noted that as the listening condition worsened, the
word recognition abilities of both those with mini-
mal hearing impairment and those with normal
hearing worsened. Hart [22] noted that children
with UHI exhibit a significant deterioration in speech
understanding under actual classroom noise and
reverberation conditions. Also, McCartney [30]
reported that subjects with UHI experienced little
difficulty understanding in quiet but they had trou-
ble when speech was presented in the MI condition.
Design and procedural problems with the two later
investigations included small sample sizes, inability
to control the test environment, and failure to
specify calibration procedures.
Subsequent studies attempted to address these
design problems. Bess et al. [9] found that the
children with UHI performed more poorly than their
normally hearing counterparts in both localization
and speech recognition of nonsense syllables. These
children also had considerable difficulty under-
standing in a background of noise. The results of a
study by Bovo et al. [11] produced similar results,
showing that children with profound or complete
UHI had difficulty in speech discrimination in
adverse listening conditions as well as difficulty with
sound localization. In the current study, children
with UHI required greater SNR than children with
normal hearing to perform equally as well on tests of
speech recognition-in-noise. This was true even in
the most advantageous listening condition. This
general finding was not unexpected and is consistent
with previous research. Some of the tests situations
(i.e., MI condition) were such that the children with
UHI were at a disadvantage because of their inability
to benefit from a positive head shadow effect.
It is interesting to note that, children with UHI did
not require significantly greater SNR to perform as
well as children with normal hearing in the MD
condition on the NST. Also, greater SNRs were not
needed for children with normal hearing to perform
equally well on the NST in the zero degrees condi-
tion versus in the MD condition. One explanation for
this might be that the restricted contextual cues
available on the NST made the task so difficult that
the children were unable to use top down processing
or take advantage of environmental cues (i.e., NH
ear facing the signal) that might normally have
aided performance.
The advantage provided by context was consis-
tent with the differences found between the NST
and the HINT-C. Significantly greater SNRs were
needed when restricted speech acoustic and pho-
nologic cues were available to the listener than
when sentential cues also were available. This
778
was true for both groups of children when seated in
all orientations to the signal.
When comparing results, within subjects, as a
function of orientation to the signal, all of the
children performed best in the MD condition. This
was expected because, as stated previously, it is
well known that turning one normally hearing ear
towards the signal allows easier listening and better
speech discrimination in noise than when listening
while facing the signal directly [8]. It also was
anticipated and confirmed in the present investiga-
tion that children with severe-to-profound UHI
would perform more poorly when they listened in
the MI condition than when they listened in the zero
degrees or the MD conditions.
5. Conclusions/future research
This study revealed that children with UHI require
more advantageous listening conditions to perform
equally as well as their normally hearing counter-
parts on tests of speech recognition performance-
in-noise. Both children with normal hearing and
children with UHI benefit from signals being deliv-
ered directly to a normal hearing ear when listen-
ing in noise. Furthermore, children with UHI
perform best when signals are delivered either
directly to a normally hearing ear or from zero
degrees azimuth.
These results suggest that, for classrooms con-
taining children with UHI, placement in a preferred
seat may provide some benefit if the positioning
of the teacher and child are relatively static. It
may reduce the distance between the child and
the teacher and allow a better SNR in some class-
rooms. However, as evidenced by the data herein,
even in the best listening conditions, children
with UHI require better signal-to-noise ratio than
do children with normal hearing to perform
equally well, suggesting that preferential seating
alone may not provide enough benefit for these
children.
Sound field amplification systems may be a bet-
ter option and would likely benefit all children in
classrooms. Children with normal hearing would
benefit if loudspeakers were placed facing either
of their ears. Children with UHI would benefit if
seated such that their normally hearing ear were
facing a loudspeaker. This environment also would
improve the SNR for most individual listeners. Per-
sonal assistive listening devices, such as FM sys-
tems, also would improve the SNR for the individual
listener although it is recognized that some chil-
dren are resistant to wearing them, while some
teachers are reluctant to wear the microphones. In
M.N. Ruscetta et al.
such cases, education and counseling may be
required.
Research into the SNR required for equal perfor-
mance on the NST and HINT-C by children with
varying degrees and configurations of UHI, in various
noise conditions, is ongoing. Future research should
include an assessment of performance on speech-in-
noise tasks with personal and/or classroom assistive
listening devices.
Acknowledgements
This study was supported in part through funding
received from the Children’s Hospital of Pittsburgh,
Eberly Family Endowed Chair in Pediatric Otolary-
nogology at the Hearing Center at Children’s Hospi-
tal of Pittsburgh.
Special thanks to Diane Sabo and Mona El-Kady for
their efforts in the development of this project.
Special thanks to Audra Webber and Jennifer Horn
for their efforts collecting and organizing the data.
Special thanks to Elaine Rubenstein for her efforts in
statistical analyses.
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