Symphonia and Ecological Momentary Assessment

Introduction

In hearing healthcare, one of the ongoing challenges is helping clinicians connect what is measured and demonstrated in the clinic with what patients actually experience in their everyday listening environments. In this interview, Dave Fabry, PhD, Madison Levine, BC-HIS, and Blaise M. Delfino, M.S. - HIS, discuss how Symphonia can complement Ecological Momentary Assessment by recreating realistic listening scenarios within the clinic and supporting counseling, personalization, and patient-centered care.

AudiologyOnline: How can Symphonia help hearing care professionals bridge the gap between the clinic and the patient’s real-world listening environments?

Dave Fabry: In hearing healthcare, we have always tried to better understand how patients communicate beyond the walls of the clinic. Ecological momentary assessment, or EMA, captures a patient’s behaviors, emotions, listening challenges, and experiences in real time within their natural environment. It helps us understand what patients are experiencing in the real world, whether at restaurants, family gatherings, places of worship, meetings, or other complex listening environments. EMA has also been described in hearing research as a valuable way to better understand real-world listening experiences and the potential future clinical applications of real-time patient feedback (Timmer et al., 2018).

Symphonia approaches this from a different but complementary angle. Rather than measuring the patient in their natural environment, Symphonia allows the clinician to simulate real-world listening environments inside the clinic. That distinction matters. Ecological momentary assessment evaluates the patient’s lived experience outside the clinic, while Symphonia helps recreate realistic listening scenarios in a controlled clinical setting.

This creates an important bridge. We can verify hearing aid performance with real-ear measurement, conduct speech-in-noise testing, and counsel the patient based on their goals. However, when the patient asks, “What will this sound like when I leave your office?” Symphonia gives us a way to demonstrate that experience before they walk out the door.

AudiologyOnline: Why do simulated listening environments matter?

Dave Fabry: For decades, clinicians have looked for ways to make hearing aid technology more tangible for patients. Years ago, this may have meant using a speaker, an iPad, or restaurant noise in the office to demonstrate the benefit of amplification, directional microphones, or noise reduction. The goal was simple: help the patient hear and feel the difference.

Symphonia brings that concept into a more refined and repeatable format. Instead of only telling a patient that their hearing aids can adapt to background noise, prioritize speech, or improve comfort in complex environments, the clinician can demonstrate those features in real time. This is especially important as today’s hearing aids include increasingly sophisticated tools such as automatic environmental classification, noise management, machine learning, deep neural network processing, and patient-controlled sound adjustments.

This type of demonstration is valuable because hearing aid fittings are not just about meeting prescriptive targets. Real-ear measurement remains essential because it verifies audibility, comfort, and output across input levels. Research supports the importance of probe-microphone verification as part of evidence-based hearing aid fitting, but verification alone does not fully represent the dynamic environments patients encounter after leaving the clinic (Almufarrij et al., 2021).

Speech-in-noise testing helps add another important layer. Speech-in-noise ability is often more closely related to the listening challenges patients report in daily life than traditional speech testing in quiet. A systematic review found that speech-in-noise measures had some of the strongest associations with hearing aid satisfaction, suggesting that these tests deserve a greater role in auditory rehabilitation (Davidson et al., 2021). Similarly, Billings and colleagues emphasized that speech-in-noise testing can provide individualized information that may not be captured by the audiogram or word recognition testing in quiet (Billings et al., 2023).

Once the patient leaves the clinic, they enter a much more dynamic listening world. Symphonia gives the clinician another tool to help the patient understand how their devices may respond in that world.

AudiologyOnline: How can Symphonia be used as a counseling and personalization tool?

Madison Levin: One of the most powerful uses of Symphonia is counseling. Patients often struggle to understand what hearing aid features are doing, especially when those features are automatic or operating in the background. By placing the patient in a simulated listening environment, the clinician can demonstrate how different programs, noise management settings, comfort settings, or clarity-focused adjustments may affect the listening experience.

This is where the research becomes clinically relevant. Davidson, Marrone, and Souza found wide variability in QuickSIN performance among adult hearing aid users and reported that advanced hearing aid features were not always set in a way that aligned with the patient’s speech-in-noise abilities (Davidson et al., 2022). In other words, two patients may have similar audiograms but very different needs when it comes to background noise, directionality, hearing assistive technology, and counseling.

Simulated listening environments can also help clinicians evaluate and demonstrate these differences more meaningfully. Best and colleagues measured speech reception thresholds in a simulated reverberant cafeteria and found that performance and hearing aid benefit could differ from results obtained in a more traditional laboratory noise condition (Best et al., 2015). Walravens, Keidser, and Hickson also found that listener preferences for hearing aid settings, including intensity, gain-frequency slope, and directionality, varied across simulated real-world environments (Walravens et al., 2020). These findings support the idea that realistic listening simulations can provide useful information for counseling, personalization, and expectation-setting.

This is especially helpful for first-time hearing aid users. If environmental sounds are too sharp, too loud, or too overwhelming, the patient may quickly lose confidence. By combining real-ear measurement, loudness discomfort levels, speech-in-noise testing, experience management, and simulated listening environments, hearing care professionals can better prepare patients for the sounds they will encounter outside the clinic.

AudiologyOnline: How does Symphonia keep the hearing care professional in the driver’s seat?

Blaise M. Delfino: Technology continues to advance, but the role of the hearing care professional remains central. Tools like Symphonia do not replace clinical expertise; they enhance it. The clinician is still responsible for interpreting the audiogram, verifying the fitting, understanding the patient’s communication goals, counseling the patient and family, and making appropriate adjustments.

In many ways, Symphonia fits naturally into the larger “orchestra” of audiological tools. Real-ear measurement verifies audibility and comfort. Speech-in-noise testing provides insight into real-world listening difficulty. Symphonia adds another layer by allowing patients to experience simulated real-world environments in the clinic.

This matters because patients do not judge hearing aid success based only on how they perform in a quiet treatment room. They judge success at dinner with family, in a busy restaurant, during a meeting, at church, or in the car with road noise. Symphonia gives the clinician a way to bring some of those listening environments into the appointment, creating a more meaningful conversation around benefit, limitations, and personalization.

Conclusion

Symphonia is not intended to replace real-world validation or ecological momentary assessment. Rather, it helps bridge the gap between the controlled clinical setting and the complex listening environments patients face every day. As hearing technology becomes more advanced, patients still need a clinician who can translate technology into real-world benefits. Symphonia gives hearing care professionals another way to create that experience.

Resources for More Information

For clinicians interested in further exploring Symphonia and its role in hearing aid fitting, counseling, and real-world listening simulation, additional AudiologyOnline resources are available offering complementary perspectives on its clinical applications and integration into daily practice.

• Understanding the Impact of Symphonia on Hearing Aid Users: A Survey-Based Analysis
• Symphonia Virtual Sound Environment Software from Inventis Enables Patients to Experience the Benefits of Hearing Aids in Simulated Real World Environments
• Symphonia - the Software for Virtual Sound Environment Creation

For more information about Inventis, visit https://www.inventis.it/en-na

References

Almufarrij, I., Dillon, H., & Munro, K. J. (2021). Does probe-tube verification of real-ear hearing aid amplification characteristics improve outcomes in adults? A systematic review and meta-analysis. Trends in Hearing, 25. doi:10.1177/2331216521999563

Best, V., Keidser, G., Buchholz, J., & Freeston, K. (2015). An examination of speech reception thresholds measured in a simulated reverberant cafeteria environment. International Journal of Audiology, 54(10), 682–690. doi:10.3109/14992027.2015.1028656

Billings, C. J., Olsen, T. M., Charney, L., Madsen, B. M., & Holmes, C. E. (2023). Speech-in-noise testing: An introduction for audiologists. Seminars in Hearing, 45(1). doi:10.1055/s-0043-1770155

Davidson, A., Marrone, N., Wong, B., & Musiek, F. (2021). Predicting hearing aid satisfaction in adults: A systematic review of speech-in-noise tests and other behavioral measures. Ear and Hearing, 42(6), 1485–1498. doi:10.1097/AUD.0000000000001051

Davidson, A., Marrone, N., & Souza, P. (2022). Hearing aid technology settings and speech-in-noise difficulties. American Journal of Audiology, 31(1), 21–31. doi:10.1044/2021_AJA-21-00176

Timmer, B. H. B., Hickson, L., & Launer, S. (2018). The use of ecological momentary assessment in hearing research and future clinical applications. Hearing Research, 369, 24–28. doi:10.1016/j.heares.2018.06.012

Walravens, E., Keidser, G., & Hickson, L. (2020). Consistency of hearing aid setting preference in simulated real-world environments: Implications for trainable hearing aids. Trends in Hearing, 24. doi:10.1177/2331216520933392