Working Memory and Extended High-Frequency
Hearing in Adults: Diagnostic Predictors of
Speech-in-Noise Perception
Ingrid Yeend,1,2,3 Elizabeth Francis Beach,2,3 and Mridula Sharma1,3
Objective: The purpose of this study was to identify the main factors that
differentiate listeners with clinically normal or “near-normal” hearing
with regard to their speech-in-noise perception and to develop a regres-
sion model to predict speech-in-noise difficulties in this population. We
Downloaded from https://journals.lww.com/ear-hearing by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3FJPxKcC74DFhiL3anhtKWzvkfCcPI+TokSAxTsUyLG8= on 06/13/2019
also aimed to assess the potential effectiveness of the formula produced
by the regression model as a “diagnostic criterion” for clinical use.
Design: Data from a large-scale behavioral study investigating the rela-
tionship between noise exposure and auditory processing in 122 adults
(30 to 57 years) was re-examined. For each participant, a composite
speech-in-noise score (CSS) was calculated based on scores from
three speech-in-noise measures, (a) the Speech, Spatial and Qualities of
Hearing scale (average of speech items); (b) the Listening in Spatialized
Noise Sentences test (high-cue condition); and (c) the National Acoustic
Laboratories Dynamic Conversations Test. Two subgroups were created
based on the CSS, each comprising 30 participants: those with the low-
est scores and those with the highest scores. These two groups were
compared for differences in hearing thresholds, temporal perception,
noise exposure, attention, and working memory. They differed signifi-
cantly on age, low-, high-, and extended high-frequency (EHF) hearing
level, sensitivity to temporal fine structure and amplitude modulation,
linguistic closure skills, attention, and working memory. A multiple linear
regression model was fit with these nine variables as predictors to deter-
mine their relative effect on the CSS. The two significant predictors, EHF
hearing and working memory, from this regression were then used to
fit a second smaller regression model. The resulting regression formula
was assessed for its usefulness as a “diagnostic criterion” for predict-
ing speech-in-noise difficulties using Monte Carlo cross-validation (root
mean square error and area under the receiver operating characteristics
curve methods) in the complete data set.
Results: EHF hearing thresholds (p = 0.01) and working memory scores
(p < 0.001) were significant predictors of the CSS and the regression
model accounted for 41% of the total variance [R2 = 0.41, F(9,112) =
7.57, p < 0.001]. The overall accuracy of the diagnostic criterion for pre-
dicting the CSS and for identifying “low” CSS performance, using these
two factors, was reasonable (area under the receiver operating charac-
teristics curve = 0.76; root mean square error = 0.60).
Conclusions: These findings suggest that both peripheral (auditory)
and central (cognitive) factors contribute to the speech-in-noise diffi-
culties reported by normal hearing adults in their mid-adult years. The
demonstrated utility of the diagnostic criterion proposed here suggests
that audiologists should include assessment of EHF hearing and work-
ing memory as part of routine clinical practice with this population. The
“diagnostic criterion” we developed based on these two factors could
form the basis of future clinical tests and rehabilitation tools and be used
in evidence-based counseling for normal hearers who present with unex-
plained communication difficulties in noise.
Department of Linguistics, Macquarie University, New South Wales,
1
Australia; 2The National Acoustic Laboratories, Australian Hearing Hub,
Macquarie University, New South Wales, Australia; and 3The HEARing
Cooperative Research Centre, The University of Melbourne, Victoria,
Australia.
0196/0202/2019/403-458/0 • Ear & Hearing • Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved • Printed in the U.S.A.
458
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<zdoi; 10.1097/AUD.0000000000000640>
Key words: Cochlear synaptopathy, Cognition, Extended high-frequency
hearing, Normal hearing, Speech in noise, Working memory.
(Ear & Hearing 2019;40;458–467)
INTRODUCTION
An almost universal complaint among people with hearing
loss is difficulty understanding speech in background noise
(Abrams & Kihm 2015). This problem, however, is not limited
to those with hearing loss. A proportion of listeners with nor-
mal or “near-normal” hearing also seek medical or audiological
advice for this issue (Stephens et al. 2003; Ruggles et al. 2012).
Indeed, it has been estimated that approximately 5 to 15% of
people who seek a hearing assessment because of difficulties
in challenging situations have normal audiometric thresholds
(≤20 dB HL, 0.5 to 4 kHz; Saunders & Haggard 1989; Hind
et al. 2011; Tremblay et al. 2015; ≤25 dB HL, 0.5 to 4 kHz;
Spankovich et al. 2018). Such clients are usually assured that
their hearing is fine, and there is little that clinicians can suggest
in the way of causation, diagnosis, or rehabilitation to address
these functional listening difficulties (Zhao et al. 2008). This
often results in an unsatisfactory clinical experience, leaving
the patient to feel that their hearing concerns have not been lis-
tened to or taken seriously. When the client receives the find-
ing of a clinically normal audiogram, this can “invalidate” their
problem because it focuses on the absence of observable pathol-
ogy (Pryce 2006; Pryce & Wainwright 2008), which in turn can
lead to feelings of dismissal, confusion, and increased anxiety
(Pryce & Hall 2014).
One possible cause of hearing-in-noise difficulties is thought
to be cochlear damage from excessive noise exposure. On the
basis of animal studies, Kujawa and Liberman (2009) suggested
that noise-induced cochlear synaptopathy underlies impaired
encoding of sound leading to speech-in-noise difficulties. How-
ever, conclusive evidence of a link between noise exposure,
synaptic loss, and deficits in suprathreshold sound processing
in individuals with clinically normal audiograms has not yet
been demonstrated. Some studies have indicated a relation-
ship between noise exposure and reduced auditory brainstem
response (ABR; Stamper & Johnson 2015; Bramhall et al.
2017) and increased ABR wave I/wave V ratios (Liberman et al.
2016; Grose et al. 2017). An association has also been demon-
strated between ABR wave I amplitude and frequent or con-
stant tinnitus in young military veterans (Bramhall et al. 2018).
Most studies, however, mainly those testing younger adults ≤35
years, have found no evidence of suprathreshold deficits or the
anticipated reduction in ABR wave I amplitude as a function of
increasing noise exposure (Prendergast et al. 2016, 2017; Ful-
bright et al. 2017; Grinn et al. 2017; Guest et al. 2017).
 Yeend et al. / EAR & HEARING, VOL. 40, NO. 3, 458–467 459
In our study, 122 adults (30 to 57 years) with normal or
near-normal hearing completed behavioral testing, and a subset
(n = 68) also completed electrophysiological testing. While the
electrophysiology results demonstrated a significant negative
correlation between lifetime noise exposure and the amplitude
of ABR wave I consistent with noise-induced cochlear synap-
topathy, the behavioral testing did not show a link between noise
exposure and performance on any suprathreshold auditory pro-
cessing or speech-in-noise tasks (Yeend et al. 2017; Valderrama
et al. 2018). Rather, the behavioral results identified several cog-
nitive skills (sentence closure, working memory, and attention)
and hearing factors (extended high-frequency [EHF] thresholds
and medial olivocochlear suppression strength) that were sig-
nificantly related to the ability to process speech in noise (see
Yeend et al. 2017). This set of results, while providing some
evidence of noise-induced cochlear synaptopathy in humans,
suggests that any effects of synaptopathy may be confined to
the auditory periphery, and other cognitive and auditory fac-
tors play a more important role in determining speech-in-noise
outcomes.
The focus of this study is on these “other cognitive and audi-
tory factors” that affect speech-in-noise outcomes. In particular,
several studies have now shown that elevated, EHF threshold lev-
els (above 8 kHz) are associated with increased noise exposure
(Liberman et al. 2016; Prendergast et al. 2017) or poorer speech-
in-noise perception (Badri et al. 2011; Yeend et al. 2017). These
results suggest that the basal area of the human cochlea, which is
responsive to high-frequency (HF) sound, may be more suscep-
tible to noise-related damage or damage from other causes such
as ototoxicity and aging. In this case, EHF audiometry could
provide an early indicator of cochlear injury in cases where peo-
ple report problems understanding speech in noise (Mehrparvar
et al. 2011; Rodríguez Valiente et al. 2016).
Additionally, a number of studies have shown that cognitive
processes play an important role in speech-in-noise process-
ing (Kujala et al. 2004; Rudner & Lunner 2014; Stenbäck et al.
2016; Bressler et al. 2017; Dryden et al. 2017). For example, it
is well established that performance of older listeners with hear-
ing loss on speech-in-noise tasks is affected by their working
memory capacity (Lunner 2003; Rudner et al. 2011; Classon
et al. 2013; Keidser et al. 2015; Heinrich et al. 2016), which is
commonly assessed using the Reading Span Test (RST; Dane-
man & Carpenter 1980). Yet, for normal-hearing listeners, the
impact of working memory on speech-in-noise performance
has not been as reliably demonstrated (for review see Füllgrabe
& Rosen 2016). Schoof and Rosen (2014) assessed younger
(19 to 29 years) and older (60 to 72 years) adults with normal
hearing on a comprehensive test battery, including the RST,
and concluded that age-related declines in cognitive processing
(working memory and processing speed) do not always lead to
difficulties understanding speech in noise. In contrast, Gordon-
Salant and Cole (2016) included both the Listening Span Test,
which is a working memory span test involving listening to and
recalling verbal materials (Daneman & Carpenter 1980), and
the RST. They showed that younger (18 to 25 years) and older
(61 to 75 years) listeners with normal hearing with low work-
ing memory capacity are at a disadvantage when recognizing
speech in noise. Similarly, our study of noise-exposed normal
hearers showed that working memory was one of the key fac-
tors associated with speech-in-noise performance (Yeend et al.
2017).
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Given that cognitive processes and EHF hearing are emerg-
ing as important factors in speech-in-noise perception in our
work and that of other researchers in the field, in this study,
we focused on the potential clinical application of these fac-
tors. Our aim was to devise a diagnostic criterion for speech-
in-noise difficulty that clinicians could use to help explain the
possible source of clients’ speech-in-noise difficulties. The data
set described in Yeend et al. (2017) included a wide range of
auditory and cognitive factors, as well as speech-in-noise mea-
sures. From this data set, we identified those participants with
the poorest speech-in-noise performance (n = 30) and compared
them to those who performed best (n = 30). We then identified
the main factors that separated the two groups and used these
factors to build a regression model to predict speech-in-noise
difficulties. The resulting regression formula defined the “diag-
nostic criterion,” which was then assessed to determine how
well it predicted speech-in-noise difficulties in our complete
data set of 122 participants with normal hearing.
MATERIALS AND METHODS
Ethics
Treatment of participants was approved by the Australian
Hearing and Macquarie University Human Research Ethics
Committees and complied with the National Statement on Ethi-
cal Conduct in Human Research.
Participants
One hundred and twenty-two adults, aged 30 to 57 years,
with normal (less than or equal to 20 dB HL at 0.25 to 6 kHz) or
near-normal hearing as defined by Moore et al. (2012), that is,
less than or equal to 25 dB HL up to 2 kHz; less than or equal
to 30 dB HL at 3 kHz; less than or equal to 35 dB HL at 4 kHz;
and less than or equal to 40 dB HL at 6 kHz, participated. It was
necessary to have an inclusion criteria broad enough to accom-
modate participants with a wide range of lifetime noise expo-
sures; some of whom were likely to have at least some hearing
thresholds outside the generally accepted definition of normal
(≤20 dB HL). All participants completed an online survey fol-
lowed by a comprehensive laboratory test session. The labora-
tory session included audiometry, auditory processing tasks
and cognitive measures. Full details of the test protocol can be
found in Yeend et al. (2017), but a brief description of relevant
tests is provided here.
Speech-in-Noise Measures
Speech, Spatial, and Qualities of Hearing Scale • The
average score for the speech items only (questions 1 to 5) of
the Speech, Spatial and Qualities of Hearing scale (SSQ12;
Noble et al. 2013) was used to estimate self-reported ability
to understand speech in noise. For each of the five questions,
participants’ rated their ability to follow speech when there is
competing background noise, for example, in a busy restaurant,
or room with many people talking.
Listening in Spatialized Noise Sentences • The high-cue
condition of the Australian version (2.202) of the Listen-
ing in Spatialized Noise Sentences (LiSN-S) test was used to
measure ability to understand speech in noise (Cameron et al.
2011). This condition presents target speech and background
speech spoken in a different voice and presented at ±90° and
460 Yeend et al. / EAR & HEARING, VOL. 40, NO. 3, 458–467
was selected because it is the most realistic listening scenario
of the four LiSN-S conditions. The prescribed gain amplifier
option was selected for all participants plus an additional 6 dB
of overall amplification was provided.
National Acoustic Laboratories Dynamic Conversations
Test  • Six monologues (one practice and five test passages)
from the National Acoustic Laboratories Dynamic Conversa-
tions Test (NAL-DCT), presented at −7 dB signal-to-noise ratio,
were used to assess real-world “on-the-go” speech comprehen-
sion in background noise (Best et al. 2018).
Composite Speech-in-Noise Score • This score included
the self-report measure and two speech-in-noise test results.
Although it is true that self-report measures of speech-in-noise
ability can be influenced by factors such as personality or mis-
judgment (Saunders & Haggard 1989, 1992), it is also the case
that laboratory test results do not always reflect a person’s per-
formance in real-world conditions. By combining both sub-
jective and behavioral measures, we have created a composite
score, which aims to represent both perceived and actual ability
to understand speech in noise and allow us to identify symptom-
atic versus nonsymptomatic participants within the sample. For
each participant, scores from the SSQ12 speech items, LiSN-S
high-cue condition, and NAL-DCT were transformed into stan-
dardized z scores by subtracting the sample mean and dividing
by the SD. These were then averaged to obtain an overall mea-
sure: the composite speech-in-noise score (CSS). Participants
were ranked according to CSS (a lower CSS indicates a poorer
overall performance), and two subgroups each comprising 30
participants were identified: those with the lowest scores (low
CSS) and those with the highest scores (high CSS).
Other Test Measures
Demographics  •  Participants were asked to indicate their age
(years), gender (male, female, indeterminate/intersex/unspeci-
fied), and highest level of education achieved (primary school
through to postgraduate university degree).
Ototoxicity  •  Participants were asked whether they had con-
tact with chemicals (e.g., solvents, paints, degreasers, jet fuels,
gasoline, or cleaning fluids) in current or past employment.
They were also asked whether they had ever taken potentially
ototoxic medications (e.g., aspirin, nonsteroidal anti-inflam-
matories, antibiotics, loop diuretics, anticancer drugs, or other
medications that affected their hearing) in high doses.
Noise Exposure • Total lifetime noise exposure (Pa2h) was
calculated for each participant based on their answers to an
online survey about leisure noise activities, workplace noise
exposure, and use of hearing protection during each decade
of life. This value was then transformed (log Pa2h) such that a
1-unit difference corresponds to a change in noise exposure by
a factor of 10.
Music Training  • An index of music training score was cal-
culated to indicate each participant’s highest level of musical
training (formal and informal) using responses from the Music
Use questionnaire (Chin & Rickard 2012).
Hearing Acuity  •  Hearing thresholds were tested in a sound-
treated room using a modified Hughson Westlake procedure
with a 2 dB step size (Le Prell et al. 2013). Average hearing
threshold level was calculated for three frequency regions: low-
frequency (LF) 0.25 to 2 kHz, HF 3 to 6 kHz, and EHF 9 to
12.5 kHz.
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Otoacoustic Emissions • The Mimosa Acoustics HearID
Auditory Diagnostics System (software version 5.1.9) was used
to measure distortion product otoacoustic emissions (DPOAEs).
A DPgram (2f1 − f2, f2/f1 ratio = 1.25, f1 = 65 dB SPL and f2
= 55 dB SPL) was recorded with 8 points/octave between 1 and
12 kHz (for f2). An average HF DPOAE at 3 to 6 kHz was cal-
culated for each participant.
Noise Suppression  •  An automated research module (TE50_
B2000_N60; Mimosa Acoustics 2014) was used to record
and calculate each participant’s medial olivocochlear reflex
(MOCR) strength statistic (0.5 to 2.5 kHz band) following the
method described in Marshall et al. (2014).
Threshold-Equalizing Noise • A modified version of the
threshold-equalizing noise (TEN) test with ER-3A insert ear-
phones (Moore et al. 2012) was used to assess ability to detect a
3 and 4 kHz tone presented in TEN, at an elevated level.
Temporal Fine Structure  •  The temporal fine structure (TFS)
task described in Moore and Sek (2009) was used to evaluate
sensitivity to TFS. A complex tone, with a fundamental fre-
quency of 400 Hz and centre frequency of 4400 Hz, was pre-
sented at 75 dB SPL in a TEN masker (60 dB SPL/ERBN at
1 kHz), and participants were required to choose the item in
which the sound appeared to “fluctuate.” Participants com-
pleted a practice task followed by one adaptive test run and a
TFS threshold was recorded for each participant.
Amplitude Modulation • Amplitude modulation detection
thresholds were assessed using a 3-alternative forced choice
adaptive procedure. A 3.5 kHz carrier tone modulated at 4
(AM4) and 90 Hz (AM90) was presented at 75 dB SPL with a
TEN masker (55 dB SPL/ERBN at 1 kHz).
Attention  • Subtest 3 “elevator counting with distraction”
and subtest 5 “elevator counting with reversal” of the Test of
Everyday Attention (TEA Version A; Robertson et al. 1994)
were used to assess selective attention and attention switch-
ing, respectively. The results were averaged to give a combined
attention score.
Nonverbal Intelligence  •  The matrices subtest of the multiple-
choice Kaufman Brief Intelligence Test (Kaufman & Kaufman
2004) was used to test nonverbal intelligence. Participants were
required to identify a logical pattern within an incomplete pic-
ture matrix and then choose one of four alternatives to complete
the matrix. A raw score was noted for each participant.
Working Memory  •  The Australian-English version of the RST
(Daneman & Carpenter 1980) was used to assess working mem-
ory. Participants read aloud sentences presented in blocks (3 to
6 items), indicated whether they “made” sense and when asked,
recalled either the first or last word from each sentence. The per-
centage of correct words each participant recalled was calculated.
Language Skills  • The Text Reception Threshold (TRT) test
was used to assess generalized language skills (controlled
sentence completion and lexical access; Zekveld et al. 2007;
Zekveld 2017). Fifty sentences (10 practice and 40 test trials)
from the Speech Perception in Noise Test (Kalikow et al. 1977)
were presented; each word appeared at 500 msec intervals, and
vertical masking bars were varied adaptively. An unmasked
threshold was calculated for each participant.
Presentation Mode and Level
For LiSN-S, NAL-DCT, TFS1, AM4, AM90, and TEA, stim-
uli were presented at suprathreshold levels (range 68 to 76 dB
 Yeend et al. / EAR & HEARING, VOL. 40, NO. 3, 458–467 461
SPL) and the TFS1, AM4, AM90 stimuli were focused on the
3 to 6 kHz frequency region. For DPOAEs and MOCR, stimuli
levels were lower (50 to 65 dB SPL), while the TEN test was
administered at a “loud but OK” level set by the participant. The
LiSN-S, NAL-DCT, and TEA were administered binaurally,
whereas the TFS, AM, TEN and MOCR strength tests were
administered monaurally to the test ear. The right ear was desig-
nated as the test ear for all except seven participants who either
had slightly better left ear thresholds (n = 5), a rounded right-ear
tympanometric peak (n = 1), or a narrow but normal right exter-
nal ear canal (n = 1). Pure tone audiometry and DPOAEs were
administered to both the test and nontest ears.
Analytic Methods
Missing Data • Complete data was available for 77 partici-
pants. However, the NAL-DCT and TRT tests were added to the
test battery after the study began; hence, not every participant
completed these tasks. The MOCR data set was also incom-
plete because results of sufficient quality were obtained in only
82% of participants. Multiple imputation was used to estimate
the missing data for the NAL-DCT (n = 29), TRT unmasked
threshold (n = 28), and MOCR strength (n = 22). This process
generated 10 imputed data sets by filling in missing data with
values predicted from other variables in the data set. Each of the
completed data sets are different because the predicted values
include a random component, which allows the uncertainty in
the missing values to be taken into account when doing statisti-
cal tests. Five imputed data sets are usually adequate (Rubin
1987), but to be conservative, we generated 10 sets using the
following variables: age, gender, education level, ototoxicity,
music training, SSQ12 (speech), average LF, HF, and EHF hear-
ing level, DPOAE test ear, MOCR strength, LiSN-S, NAL-DCT
passage score, TFS1, AM-4 and 90 Hz, TEN, TEA, RST, TRT,
nonverbal intelligence, and noise exposure. For all analyses, the
relevant statistical methods were applied to each imputed data
set and then combined to obtain overall results.
Data analysis was performed in Statistica (Statsoft, version
10) and R (R Core Team 2016; version 3.3.1), with the additional
R packages pROC (Robin et al. 2011; version 1.8) and Amelia
(Honaker et al. 2011; version 1.74). Differences between the
low CSS group (n = 30) and the high CSS group (n = 30) were
tested using independent samples t tests or Mann–Whitney U
tests where appropriate. After identifying the significant differ-
ences between the two groups, these were included in a multiple
linear regression model to assess the relative contribution of
each to the CSS. The significant predictors from this regression
were then used to fit a second regression model.
The resulting formula from the second regression model was
then assessed to determine how well it predicted speech-in-noise
difficulties in the complete data set of 122 participants. The per-
formance of the model on new data was estimated using Monte
Carlo cross-validation (Hastie 2009; Kuhn & Johnson 2013).
We used root mean square error (RMSE) to evaluate the mod-
el’s effectiveness in predicting CSS, and area under the receiver
operating characteristic curve (AUC) was used in relation to
predicting “low” CSS. The data sample was randomly split into
a “test” set (comprising 10% of participants, n = 12) and a “fit-
ting” set (comprising 90% of the participants, n = 110); then all
of the statistical methods, described above, including the vari-
able selection method (i.e., the t tests, Mann–Whitney U tests,
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
and two regressions described above) were repeated using the
fitting data set only. By not using the participants in the “test”
set to fit the model, overestimation of predictive accuracy was
avoided. The resulting regression formula was used to calculate
predicted CSS values for the 12 participants in the “test” set,
and these predicted values were used to calculate AUC. This
cross-validation procedure was repeated 1000 times, and the
RMSE and AUC values were averaged to produce a stable esti-
mate of model performance.
Predicting CSS  •  The accuracy of the formula for predicting
CSS was measured by the RMSE: the square root of the average
squared prediction error [prediction error = actual CSS minus
predicted CSS]. It is an absolute measure of predictive accu-
racy, that is, how close the values predicted by the regression
model are to the actual values. For each of the 12 participants in
the test set, we compared the participant’s actual CSS with the
CSS predicted by the regression formula and then calculated
the RMSE to determine the accuracy of the prediction. RMSE
is expressed in the same units as the response variable (which
in this case is the CSS), and a lower RMSE value indicates a
better fit.
Predicting “Low” CSS  •  The accuracy of the formula for pre-
dicting “low” CSS was measured by the AUC; the curve being
a plot of test sensitivity versus the false positive rate (Park et al.
2004). The AUC can be interpreted as the probability that given
two randomly chosen people, one having “low” CSS and the
other not having “low” CSS, the diagnostic criterion will cor-
rectly identify them (Hanley & McNeil 1982; Swets 1988). The
AUC value can be between 0 and 1, and a higher value indicates
a higher probability of success (with 1 indicating perfect accu-
racy and 0.5 equivalent to a random prediction). It is important
that the regression formula is able to accurately predict people
with low CSS since this group is representative of the individ-
uals we would expect to present to a hearing clinic reporting
problems hearing speech in noise.
RESULTS
Composite Speech Scores
Figure 1 shows the distribution of the CSSs for the entire
sample (n = 122). Scores ranged from −1.93 to −0.55 for the
low CSS group (Mlow CSS = −0.9, SD = 0.3) and from 0.51 to 1.76
for the high CSS group (Mhigh CSS = 0.9, SD = 0.3). Scores for
the remaining participants (n = 62) ranged from −0.53 to 0.51
(Mmid CSS = 0, SD = 0.3).
The SSQ speech results confirmed that 77% of the low CSS
group returned scores below the whole sample mean. The aver-
age SSQ speech score for the low CSS group was 5.5, and all
scored 5.0 or less on at least two of the speech questions, indi-
cating they were experiencing real-world speech in noise hear-
ing difficulties. In contrast, the average SSQ speech score for
the high CSS group was 8.6, and the majority (77%) of partici-
pants in this group had an average score greater than 8.0. Only
one participant in this group scored 5.0 or less on at least two of
the individual speech questions.
Differences Between Groups
As shown in Table 1, the low CSS group and high CSS group
differed significantly on nine of the 17 variables examined. The
low-performing group was older than the high-performing
462 Yeend et al. / EAR & HEARING, VOL. 40, NO. 3, 458–467

2.2 dB difference in the LF region, a 5.5 dB difference in the HF

region, and a 23.3 dB difference in the EHF region.
The two groups also differed in their sensitivity to TFS
(Mlow CSS = 71.8 dB; Mhigh CSS = 36.4 dB) and in the detec-
tion of amplitude modulation (AM90) (Mlow CSS = −22.7;
Mhigh CSS = −25.1), with the low-performing group attaining sig-
nificantly poorer thresholds than the high-performing group on
both tasks.
There were also differences in performance on the tests of
attention (Mlow CSS = 7.2; Mhigh CSS = 8.4) and working memory
(Mlow CSS = 45.1; Mhigh CSS = 56.1), with the low-performing group
scoring more poorly on both these tasks. Additionally, the groups
differed on the TRT threshold (Mlow CSS = 61.0; Mhigh CSS = 58.6)
with the low CSS group performing more poorly than the high
CSS group.

Multiple Linear Regression

Fig. 1. The distribution of composite speech-in-noise scores for participants
with the highest composite speech-in-noise scores (high CSS group; n =
30), those with the lowest scores (low CSS group; n = 30), and the remain-
ing participants (mid CSS; n = 62).
group, with an average difference of 6.1 years between them
(Mlow CSS = 48.1 years; Mhigh CSS = 42.0 years).
The groups also differed on hearing thresholds. As shown
in Figure 2, there were significant differences between the low
CSS and high CSS groups across all three frequency regions,
which increased as frequency increased. There was a significant
Next, we examined the relative effects of these nine signifi-
cant variables on the CSS by fitting a multiple linear regres-
sion model using data from the entire sample (n = 122). The
results showed that when all other variables were held constant,
EHF thresholds and working memory scores were the only two
significant predictors of the CSS, indicating that poorer EHF
hearing and poorer working memory capacity were associated
with reduced ability to understand speech in noise (see Table 2).
This regression model accounted for 41% of the total variance
[R2 = 0.41, F(9,112) = 7.57, p < 0.001].
We then fitted a second regression model using only EHF
and RST to determine the relative effects of these two variables,
and obtained a regression formula:
Predicted CSS = −0.75 + ( −0.015 × EHF) + (0.022 × RST )

TABLE 1.   Differences between the low CSS and high CSS groups

Low CSS High CSS

Variable Mean SD Mean SD t(58) U p

Age* 48.1 6.6 42.0 5.1 4.08 <0.001*
Gender 43%† 67%† 345 0.07
Education 4.5 1.0 5.0 0.9 326.5 0.06
Ototoxicity 0.4 0.5 0.3 0.5 405 0.40
Noise exposure 3.8 0.4 3.7 0.5 0.37 0.71
Music training 4.1 3.2 4.5 3.1 −0.50 0.62
LF hearing* 7.2 4.5 5.0 4.0 2.05 0.04*
HF hearing* 13.9 8.6 8.4 6.3 2.81 0.007*
EHF hearing* 33.5 19.7 10.2 9.7 5.78 <0.001*
MOCR 41.6 11.4 42.8 12.9 −0.35 0.73
Attention (TEA)* 7.2 2.1 8.4 2.0 −2.33 0.02*
Working memory (RST)* 45.1 11.2 56.1 9.1 −4.15 <0.001*
Language skill (TRT)* 61.0 3.1 58.6 3.2 2.76 0.008*
Nonverbal intelligence (NVIQ) 38.4 5.4 40.3 4.2 −1.53 0.13
TFS1* 71.8 44.9 36.4 25.4 3.76 <0.001*
AM4 −23.9 4.4 −25.1 3.8 1.12 0.27
AM90* −22.6 4.5 −25.1 3.9 2.23 0.03

The SD values for the TRT [low CSS (n =22), high CSS (n = 24)] and MOCR [low CSS (n = 25), high CSS (n = 27)] were calculated from the original (not imputed) data set. The degrees of
freedom for all variables was 58.
*Variables were significant at p < 0.05 and selected for inclusion in the initial (first) regression model.
†Females.
AM4, amplitude modulation detection 4 Hz; AM90, amplitude modulation detection 90 Hz; CSS, composite speech score; EHF, extended high-frequency hearing (9–12.5 kHz); HF, high-
frequency hearing (3–6 kHz); LF, low-frequency hearing (0.25–2 kHz); MOCR, medial-olivocochlear reflex strength; NVIQ, nonverbal intelligence quotient; RST, Reading Span Test; TEA, Test of
Everyday Attention; TFS1, Temporal Fine Structure task; TRT, Text Reception Threshold test.

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 Yeend et al. / EAR & HEARING, VOL. 40, NO. 3, 458–467 463

Fig. 3. Illustration of the area under the receiver operating characteristics

curve (AUC = 0.76) for the diagnostic criterion using extended high-fre-
quency (EHF) and reading span test (RST) and tested using cross-validation.
The dashed line is the chance diagonal (AUC = 0.5) and represents the
probability of diagnosing low CSS relying on chance alone. CSS, composite
Fig. 2. Mean audiograms from 0.25 to 12.5 kHz for participants with the speech-in-noise scores.
highest composite speech-in-noise scores (high CSS group; n = 30), those
with the lowest scores (low CSS group; n = 30), and the remaining partici- this simple formula is likely inadequate for highly accurate pre-
pants (mid CSS; n = 62). Error bars are 1 SD.
diction of CSS; it may be useful as a first-order approximation.
Next, we tested how well the regression formula predicted
This formula was then assessed for its usefulness as a diag- which participants were on the “low” end of the CSS perfor-
nostic criterion for predicting CSS. mance scale using the AUC method. As shown in Figure 3, the
AUC was equal to 0.76, meaning that for every 100 pairs of
Cross-Validation people, one “low” and one not “low”, the diagnostic criterion
First, we used the cross-validation results to assess whether would correctly identify which person in each pair is “low” for
our formula was able to accurately predict CSS using the RMSE 76 pairs.
method. The results yielded an RMSE of 0.60, which can be Finally, we tested whether using one of the four EHF thresh-
interpreted by noting that CSS, being the average of z scores, olds (9, 10, 11.2, or 12.5 kHz) instead of the average of the four
is expected to have a mean and SD of approximately 0 and 1, EHF thresholds would yield similar results. We reasoned that
respectively. The RMSE value of 0.60 suggests that although since threshold testing at one, rather than four, frequency is
more clinically expedient, it would be useful to know if any of
TABLE 2.   Initial multiple regression results showing coefficient the single frequencies was equivalent to the 4-frequency aver-
estimates for the nine predictor variables age. We repeated the cross-validation procedures for the four
alternative models and found that results were slightly poorer
CSS for the 9 kHz and 11.2 kHz, and to a lesser extent 10 kHz mod-
Variable b p els. These three frequencies were often not selected in the vari-
able selection procedure indicating that they had less predictive
Age −0.02 0.07
value. However, using 12.5 kHz yielded RMSE and AUC results
LF hearing −0.006 0.65
that were equally as good as, if not slightly better than, using the
HF hearing −0.007 0.44
EHF hearing* −0.009 0.01*
averaged EHF thresholds (see Table 3).
TFS1 −0.002 0.09
AM90 −0.02 0.30 DISCUSSION
TRT −0.03 0.14
Attention (TEA) −0.01 0.74
The purpose of this study was to devise a diagnostic criterion
Working memory (RST)* 0.02 <0.001* that could be used clinically for predicting or confirming “low”
speech-in-noise performance in young and middle-aged adult lis-
*Predictor variables were significant at p < 0.05. teners with normal hearing. The criterion we developed was a
CSS, composite speech score; EHF, extended high-frequency hearing (9–12.5 kHz); HF, regression formula, based on EHF thresholds and RST results,
high-frequency hearing (3–6 kHz); LF, low-frequency hearing (0.25–2 kHz); RST, Reading
Span Test; TEA, Test of Everyday Attention; TFS1, Temporal Fine Structure task; TRT, Text
and our results show that its ability to predict the CSS and
Reception Threshold test. identify “low” CSS performance was reasonable. Monte Carlo

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464 Yeend et al. / EAR & HEARING, VOL. 40, NO. 3, 458–467
TABLE 3.   The RMSE and AUC values, for the average EHF and
the four alternative models
Area Under Receiver
Extended High Root Mean Operating Characteristic
Frequency (kHz) Square Error Curve
EHF 0.60
9* 0.63
10* 0.63
11.2* 0.65
12.5 0.58
*Frequencies not always selected in the variable selection procedure indicating less predic-
tive value.
AUC, area under receiver operating characteristic curve; EHF, extended high-frequency
hearing (9–12.5 kHz); RMSE, root mean square error.
cross-validation results showed that the AUC was 0.76 indicat-
ing that the diagnostic criterion would correctly identify “low”
CSS in approximately 76 out of every 100 pairs of people, where
one was low and one was not, but it would also incorrectly iden-
tify some clients as “low” CSS when they were not. However,
this situation would occur rarely, if at all, because people who
do not self-perceive listening difficulties would be unlikely to
seek hearing assessment in the first place. The RMSE of 0.60
shows that although there was some variation between the pre-
dicted and observed values, suggesting that the formula would
not yield a highly accurate prediction of CSS, it was not so large
that the predicted CSS would not be useful clinically in provid-
ing an approximate prediction. When we replaced the four-fre-
quency average EHF with each of the stand-alone frequencies,
9, 10, 11.2 kHz, separately, results were slightly poorer, while
the formula that included the 12.5 kHz threshold was equally
as good as, if not slightly better than, the formula that used the
four-frequency average EHF.
If used in clinical practice, our proposed diagnostic criterion
would correctly identify or confirm “low” CSS in the major-
ity of clients presenting with speech-in-noise problems. While
it is acknowledged that not every client with normal hearing
presenting with difficulty understanding speech in background
noise will have elevated EHF thresholds or lower than average
RST scores, our results show that using this diagnostic crite-
rion (which is based on these two factors) would provide an
evidence-based clinical explanation that would help a substan-
tial proportion of clients to feel understood and likely result in
a better clinical encounter than a standard hearing assessment
currently provides (Pryce & Wainwright 2008; Pryce 2015).
Although EHF thresholds are not currently measured rou-
tinely, their diagnostic value is becoming increasingly rec-
ognized. Our results provide additional support of the link
between elevated EHF thresholds and poorer speech-in-noise
performance shown in several other recent studies of normal-
hearing listeners (Badri et al. 2011; Liberman et al. 2016).
Related to this are recent research results linking poorer EHF
thresholds to increased levels of noise exposure in young adults
(da Rocha et al. 2010; Liberman et al. 2016; Kumar et al. 2017;
Prendergast et al. 2017) and the suggestion that noise damage
may first appear in the EHF region (Somma et al. 2008; Le Prell
et al. 2013; Sulaiman et al. 2014). Considered collectively, there
is growing evidence that EHF thresholds in humans provide an
early indicator of subclinical auditory damage that may coin-
cide with noise-induced cochlear synaptopathy or other causes,
for example, ototoxicity and aging. This has led some authors to
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
recommended that EHF thresholds be included as part of stan-
dard testing (Rodríguez Valiente et al. 2016; Moore et al. 2017).
Our findings provide further evidence that when clients present
with difficulty understanding speech in noise (with or without a
history or noise exposure) and are found to have normal thresh-
olds for standard audiometric frequencies (≤20 dB HL, 0.25 to
0.76
4 kHz), best clinical practice would be to measure the client’s
0.72
0.73
EHF thresholds, rather than reassure them that their hearing is
0.70 “normal”.
0.78 Our results also indicate that tests of working memory could
have a valuable role to play in the diagnosis of speech-in-noise
difficulties. In our cohort, poorer RST results were a highly
significant predictor of poorer CSS, a finding that is consistent
with several other studies involving normal hearers (Besser
et al. 2013; Keidser et al. 2015; Gordon-Salant & Cole 2016).
Interestingly, we recorded more variation in working memory
scores for the low CSS (11 to 67%) than for the high CSS group
(41 to 76%), and the overlapping range of scores that straddle
the two groups (41 - 67%) suggests that for some people work-
ing memory plays a greater contributory role in understanding
speech in noise than it does for others.
To be clinically viable, a test of working memory would
probably need to be shorter than the RST or the Listening Span
task (Daneman & Carpenter 1980). Ideally, there is a need for
a standardized clinical test that can efficiently identify those
with lower working memory capacity and also differentiate per-
formance within the middle range. One possible candidate has
been developed by Smith et al. (2016). The Word Auditory Rec-
ognition and Recall Measure combines a working memory span
and a word-recognition test which can be administered easily in
the clinic. This test allows audiologists to simultaneously obtain
information about both word-recognition ability and the cogni-
tive processing required to recall words, which can then be used
clinically for planning rehabilitation. Initial evaluation of the
Word Auditory Recognition and Recall Measure with younger
(18 to 38 years) and older (60 to 84 years) listeners with nor-
mal hearing and older (60 to 85 years) listeners with hearing
loss showed that the test is clinically feasible and provides use-
ful additional information about listening abilities (Smith et al.
2016).
Perhaps most importantly, use of the diagnostic criterion pro-
posed here could provide a new avenue for counseling clients
who present with speech-in-noise difficulty. For those who have
a history of noise exposure, clinicians could point out that poor
EHF thresholds are often associated with noise exposure and
focus on the importance of avoiding excessive noise exposure,
or using hearing protection when avoidance is not possible.
For those clients without significant previous noise exposure,
clinicians could discuss other possible causes of hearing dam-
age such as ototoxicity, aging, and the interaction of these fac-
tors. For all clients, measuring one’s EHF thresholds provides a
baseline to enable regular monitoring and early identification of
hearing deterioration.
In time, future rehabilitation strategies may be developed on
the basis of the diagnostic criterion provided here. For those
with poor EHF thresholds, one approach could be to fit devices
that extend the signal bandwidth. Devices such as the Earlens
Photonic Transducer (Perkins et al. 2010) have been reported
to significantly improve normal hearers’ ability to hear target
speech in complex environments (Perkins et al. 2011; Levy
et al. 2015; Struck & Prusick 2017). Several studies have
 Yeend et al. / EAR & HEARING, VOL. 40, NO. 3, 458–467 465
demonstrated that extended bandwidth improved nonsense syl-
lable and speech test results for normal hearers (Füllgrabe et al.
2010; Levy et al. 2015), who also prefer the sound quality these
signals provide (Beck & Olsen 2008; Ricketts et al. 2008; Fül-
lgrabe et al. 2010).
Another remediation approach, used alone or in combination
with a device, could be to develop training packages that focus
on working memory. To date there have been mixed research
findings in relation to the efficacy of working memory train-
ing (Owen et al. 2010; Melby-Lervåg & Hulme 2013; Fergu-
son & Henshaw 2015; Ingvalson et al. 2015; Mackenzie 2015;
Whitton et al. 2017), implying that further work is needed to
develop training packages that cater to individual client needs
and motivation levels; are sufficiently rewarding; and produce
sustainable outcomes that withstand rigorous evaluation. Even
if such evaluation reveals that working memory training pro-
vides only modest improvements in performance, offering it to
clients may help to “legitimize” their concerns. This would be
preferable to the status quo, which can leave clients questioning
whether they are in fact experiencing an actual communication
problem. In any case, it has been noted that even when signifi-
cant improvements in post-training test scores only translate to
small real-world effects, a client’s levels of confidence and self-
efficacy may be significantly enhanced (Mackenzie 2015). For
many clients, this may provide enough justification to undertake
training.
Study Limitations
The results of this investigation may have been affected
by several factors, which should be taken into account when
interpreting the findings. First, the procedure we used to seg-
regate high and low performers meant that not everyone in
the low CSS group was necessarily experiencing significant
real-world listening difficulties. This may have influenced the
results obtained; however, even considering this, the diagnostic
criterion still yielded reasonable predictive accuracy. Second,
rather than use a cross-validation procedure (which can over-
estimate model performance), it could be argued that it would
be preferable to evaluate the efficacy of the diagnostic criterion
by testing the procedure on a new population. Recruiting more
participants was beyond the scope of this study; however, it is
possible that existing data sets from other research groups could
be used in this way.
CONCLUSION
Our study demonstrated that EHF hearing levels and work-
ing memory are significant predictors of the ability to under-
stand speech in noise in normal-hearing adult listeners. The
diagnostic criterion we developed based on these two factors
was found to have reasonable predictive accuracy and could
form the basis of future clinical tests and rehabilitation tools for
those experiencing communication difficulties in noise. It may
also assist clinicians to provide evidence-based counseling for
normal hearers who present with otherwise unexplained com-
munication difficulties in noise.
ACKNOWLEDGMENTS
The authors thank Jermy Pang for data collection and Mark Seeto for advice
on statistical analysis and interpretation. I.Y. designed and performed
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
experiments, analyzed data, and wrote the article; E.F.B. and M.S. designed
experiments and provided interpretative analysis and critical revision. All
authors discussed the results and implications and commented on the manu-
script at all stages.
This work was funded by the National Health and Medical Research Council
[APP1063905, 2013] and the Hearing Industry Research Consortium.
This work was also supported by the Australian Government Department
of Health and the HEARing CRC, established and supported under the
Cooperative Research Centres Program—Business Australia.
The authors have no conflicts of interest to disclose.
Address for correspondence: Ingrid A. Yeend, National Acoustic
Laboratories, Australian Hearing Hub, Level 5, 16 University Avenue,
Macquarie University, New South Wales, 2019, Australia. E-mail: ingrid.
yeend@nal.gov.au
Received March 4, 2018; accepted June 8, 2018.
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