FAQs hearing aids and hearing

Q. WILL YOU BE ABLE TO TELL ME IF I NEED HEARING AIDS?

A. Ultimately, only you can decide if you NEED hearing aids. Occasionally, someone with a very significant hearing loss tells us, "I hear everything I need to hear," and we can't argue with that.

However, after an audiological evaluation, we CAN tell you if you would BENEFIT from hearing aids. Here is a list of "clues" that will help you decide if you would benefit from hearing aids:

* people seem to "mumble" more than they used to
* you turn the television up louder than other people do
* you find yourself answering the wrong question or responding inappropriately to other peoples' comments more often, and
* you lose your ability to carry on a conversation if there is noise or other conversation nearby.

Q. OK, THAT SOUNDS LIKE ME. BUT IS IT POSSIBLE THAT MY HEARING LOSS COULD BE TEMPORARY, OR "CURED" MEDICALLY?

A. Yes, depending on the type of hearing loss you have.

To better answer your question, let us first give you a brief description of the hearing process. Our hearing mechanism consists of several segments, running from the outer ear to the brain. These segments are:

1) the outer ear - this includes the auricle (the "flap" attached to the side of our head) and the ear canal;

2) the middle ear - this begins with the eardrum, on the other side of which is a small space where three very small bones (the "hammer," "anvil" and "stirrup") transmit sound energy from the outer ear to the inner ear;

3) the inner ear - located deeper in the skull, this area contains the cochlea, a bony structure where the actual organ of hearing is located (the Organ of Corti);

4) the auditory nerve - one of the 12 cranial nerves, it carries nerve impulses from the inner ear to the brainstem (and back again);

5) the auditory pathways - these are nerve fibers ascending and descending from the brainstem to the brain; and,
6) the regions of the brain that receive nerve impulses and interpret them as sounds (for example, the speech recognition area is located in the left temporal lobe of the brain).

So, to return to your question - your hearing loss may possibly be "cured" if the underlying problem that caused the hearing loss can be treated. This depends mainly on where in your hearing system the problem is.

If your hearing loss is being caused by an outer ear or middle ear problem - e.g., ear wax that completely blocks the ear canal, a hole in the eardrum, or a sinus condition that causes middle ear air pressure problems - then there is a very good chance that the problem can be treated medically, and that your hearing will return to normal. Hearing loss caused by these kinds of problems, by the way, is called "conductive" hearing loss.

However, if your hearing loss is the result of a problem in the inner ear, or with the auditory nerve - for example, damage to the inner ear from noise exposure, or deterioration of the auditory nerve from the aging process - then the problem most likely is NOT treatable medically and your hearing will not get better. This type of hearing loss is called "sensorineural" hearing loss (more commonly known as "nerve deafness").

If your hearing loss is the result of damage in the brain's cortex or brainstem - e.g., from a stroke or head trauma - then your hearing loss most likely will not get better because such problems are usually not fully correctable medically or surgically.

More than 90% of all hearing losses in adults are sensorineural, i.e., the result of damage to the inner ear (by far the most common reason), the auditory nerve, the auditory pathways in the brainstem, or the auditory cortex. Although this underlying damage can seldom be treated medically, sensorineural hearing losses which are the result of inner ear damage can almost always be helped by hearing aids. Hearing losses that are primarily the result of brain or brainstem damage can be more difficult to help with traditional hearing aids.

One thing to keep in mind is that, occasionally, even sensorineural hearing loss may be temporary, a side effect of underlying medical conditions that CAN be treated. For this reason, the Food and Drug Administration requires a medical evaluation and medical clearance before a person can be fitted with hearing aids. Individuals can sign a waiver saying that they do not want a medical evaluation, but it is definitely not in their best interests to do so.

Q. WELL, I'VE BEEN TOLD THAT MY HEARING LOSS IS CAUSED BY "NERVE DEAFNESS" AND THEREFORE IS PERMANENT. BUT ARE HEARING AIDS THE ONLY SOLUTION TO MY COMMUNICATION PROBLEMS?

No, you may find significant help from products called "assistive listening devices" (ALDs).

ALDs are products designed for specific listening situations, such as amplified telephones, infrared headsets for listening to the television, and alerting devices that will, for example, cause a lamp to flash whenever the telephone rings.

There are also "personal listening systems" in which you would wear a headset, connected by a wire to a microphone that the person you're having a conversation with speaks into.

All of these devices work quite well, and are less expensive than hearing aids, but are limited to the specific situations that they were designed for. Actually, many people use ALDs in addition to their hearing aids.

Q. SO IF I WANT TO HEAR WELL IN ALL OF THE VARIOUS LISTENING SITUATIONS I'M IN DURING THE COURSE OF A DAY, I GUESS I NEED HEARING AIDS. BUT I KNOW NOTHING ABOUT THEM - WHAT DO I NEED TO KNOW, AND HOW DO I KNOW WHAT WILL WORK BEST FOR ME?

A. People considering hearing aids have three primary decisions to make:

1) what level of technology to get,

2) what size hearing aid(s) to get, and

3) assuming the person has a hearing loss in both ears (as most people do), whether to get a hearing aid for one or both ears.

So the answer to the first part of your question is, the pros and cons of these 3 decisions are the most important things for you to know about hearing aids.

As for what will work best for you, your audiologist, who knows the specifics of your hearing loss, and who will ask you about your particular listening needs, is the person who will help you decide what will work best for you. That decision involves many factors, including the type and degree of your hearing loss, the specific places and situations where you want to be able to hear better, your ability to handle smaller objects, the size and shape of your ear, and others issues as well.

Q. SO WHAT ARE THE PROS AND CONS OF HEARING AID SIZE? I KNOW THAT I WANT MY HEARING AID TO BE AS SMALL AS POSSIBLE.

A. People with mild-to-moderate hearing loss can generally use the smallest hearing aids available. People with more significant hearing loss (moderately severe or worse) generally need to use larger hearing aids, which have larger amplifiers and speakers and thus can produce more output.

However, there is more to it than that. Some people with mild hearing loss may not be able to handle the smallest hearing aids (and the very small batteries that they use), due to arthritis, thick fingers, poor vision, and so on.

Also, a person purchasing hearing aids today should expect those hearing aids to be adequate for their hearing loss for at least 5-7 years down the road. A very small hearing aid may be barely adequate for a person's hearing loss today, but if that person's hearing loss continues to worsen (as many do), it may need to be replaced with a larger hearing aid in just a few years. So getting a somewhat larger hearing aid today may mean a longer useful lifetime for it.

Most people with moderate-to-moderately severe hearing loss do very well with mid-sized hearing aids, what we call In-the-Canal (ITC) or Half-Shell (HS) sizes. Not only are these sizes more than adequate for most hearing losses, but, depending on the size and shape of the person's ear, they often can be cosmetically appealing as well.

Also, ITC and HS sizes can accomodate options that the smallest shell sizes cannot, such as directional microphones (which are very helpful in noisy situations) and telecoils (which let you use hearing aid-compatible telephones without any feedback).

However, if cosmetics is a significant issue for you, there is a very small hearing aid size available called Completely-in-the-Canal (CIC). But keep in mind that even CIC hearing aids are not "invisible," as some advertisements imply. How much of the hearing aid is exposed and noticeable depends PRIMARILY on the size and shape of your ear.

Disadvantages of CICs include potential physical discomfort (due to the "deep canal" nature of the fit) and what's known as the "occlusion effect," which is when a person hears his or her own voice as if they're "talking in a barrel." Although the occlusion effect can occur with any size hearing aid, it is much more common with CICs, which have minimal room for a vent to relieve the sound pressure that causes the occlusion effect.

Because of their small size, CICs are also more prone to produce feedback, a "whistling" sound that occurs when amplified sound leaks out of the ear canal (the larger the hearing aid shell size is, the better it will seal the ear canal to prevent such leaks). Feedback is especially common when a person with a more severe hearing loss tries to use a CIC. And because CIC hearing aids go deeper in the ear canal, they are more prone to be clogged with wax, and thus more prone to malfunction and need repair.

A final disadvantage of CICs is financial - for any particular level of technology, the smaller the hearing aid shell is, the more expensive it will be. This is because:
1) more money has been spent to develop the very small, high fidelity microphones, amplifiers, integrated circuits and speakers used in CICs, and
2) smaller hearing aids are generally returned for credit more often than larger hearing aids, and manufacturers factor these costs into the price.

There are some advantages associated with CICs. Because their microphones are usually somewhat deeper in the bowl area of a person's ear, CICs may be less likely to produce feedback when used with a telephone, especially with mild-to-moderate hearing losses. For the same reason, CICs are also less likely to pick up wind noise. (These problems, however, can be addressed even with larger hearing aids).

Also, due to the fact that CICs take up less space in the bowl area of the ear, high frequency sounds resonate better in that area. This resonance provides some natural amplification of these sounds that would be lost if the bowl area was filled by a larger hearing aid shell. This natural amplification of high frequencies means that the hearing aid needs to provide less amplification of these sounds, which generally means the hearing aid will produce a more natural sound quality.

However, all of these acoustic advantages of CIC hearing aids are relatively minor - for most people, CICs primary advantage is simply cosmetic. And again, keep in mind that the PRIMARY factor in how visible your hearing aid will be, even if it's a CIC, is the size and shape of your ear and ear canal.

We'll show you all the different shell sizes when you come in for your no-obligation hearing aid evaluation.

Q. THAT PRETTY WELL ANSWERS MY QUESTION ABOUT SIZES. BUT YOU MENTIONED SOMETHING ABOUT PUTTING A HEARING AID IN BOTH EARS - WOULDN'T USING JUST ONE EAR BE SUFFICIENT?

A. Possibly, again depending on the degree of your hearing loss and what your particular listening needs are.

Assuming that you have a mild-to-moderate degree of hearing loss in both ears, and that your main need is to hear better in the quiet of your own home (watching television with your spouse, having a conversation with a visitor, using the telephone, etc.), then yes, you may find that using a hearing aid in just one ear is of adequate benefit.

However, by using a hearing aid in only one ear, you will be addressing only half of your problem. The auditory system is designed to work with a balanced input from both ears, and you will likely find that whenever your listening environment gets a little more difficult than those mentioned above, your ability to follow a conversation will deteriorate quickly.

For example, if someone isn't facing you directly, or speaks to you from a distance (a stage, a pulpit, another room), or there are other conversations going on around you, you will probably find it very difficult to understand what is being said if hearing well with just one ear. For people with moderately severe or worse hearing loss, using a hearing aid in both ears is almost essential if they want to be able to participate in conversations even in relatively easy listening situations.

In addition to improved speech understanding in various situations, there are several other very good reasons to use a hearing aid in both ears:

1) using a hearing aid in just one ear will make it difficult to tell which direction a particular sound is coming from, which can be a safety concern when driving a car, crossing a street, etc.;

2) hearing with one good ear and one poorer ear is mentally fatiguing - you have to strain more to follow a conversation;

3) hearing equally well with both ears will give a much more natural sound quality to both speech and music;

4) similar sounds can be better distinguished when heard equally by both ears; and

5) one amplified ear tends to "take over" all hearing, and the unamplified ear can gradually lose some of its ability to understand speech - a "use it or lose it" phenomenon.

If you're not certain about this, the best thing to do is start out using two hearing aids, and during your trial period (minimum of 30 days by law in PA) experiment with using one vs. two hearing aids in various situations.

If at the end of the trial period you feel that you are doing fine with just one hearing aid, you can return the other one for full refund. (You can also decide to try a different level of technology - with a new trial period - or return both hearing aids for a refund).

Q. THAT SOUNDS REASONABLE, AND THAT APPROACH SEEMS TO MAKE THE MOST SENSE. SO I GUESS THE ONLY OTHER THING I NEED TO UNDERSTAND ARE THE PROS AND CONS OF THE DIFFERENT TECHNOLOGIES. THIS IS GOING TO GO OVER MY HEAD, ISN'T IT?

A. No, not at all. Although the issue of technology can be complicated, we're going to keep it very basic. First of all, there are two things you need to know before we go any further:

1) when we speak of hearing aid technology, we are referring to the electronic parts inside the hearing aid shell, and what those parts do to sounds that enter the hearing aid (this is known as "sound processing") - we are NOT referring to the size of the hearing aid, as many people mistakenly believe; and

2) no hearing aid sound processing technology, even the very best, will make your hearing completely "normal" again. Your hearing loss is the result of damage to certain structures in your ear, and no hearing aid technology can "fix" that damage - hearing aid technology only compensates for the damage to your ears, and that compensation will always be imperfect to some degree. A hearing aid is an "aid" to better hearing, not a "cure" for hearing loss.

In other words, no matter how loud and clear a hearing aid makes someone's speech (or any other sound) as it leaves the hearing aid and travels down the ear canal, when that sound reaches the damaged part of your ear, that damage is still going to cause some distortion of the sound.

If the damage in your ears is relatively mild or moderate, the distortion that your ears create will be mild or moderate, and there's a very good chance that hearing aids can make speech and other sounds seem fairly "normal" to you.

But if the damage in your ears is more severe, then the result is going to be less than ideal - even though speech will be amplified, and people won't have to shout at you to be heard, the damage in your ears will probably still cause you some difficulty in distinguishing certain sounds from others (an "f" from an "s," or a "t" from a "p," e.g.).

There are other challenges as well in fitting more severe hearing losses; these include maintaining proportionality between soft, medium and loud sounds, controlling feedback, and reducing background noise.

We can make an analogy to vision here - with near- or far-sightedness, there is no damage to the eye itself (the lens around th eye has simply "sagged" somewhat), and vision can be "corrected" to 20/20; but with glaucoma or cataracts, where damage HAS occurred to the eye, vision may be improved but not restored to normal. As the damage to the eye becomes more severe, it becomes more difficult to help a vision-impaired person see well again.

Generally speaking, the better the hearing aid sound processing technology is, the better it will compensate for the damage in your ears, and thus the better it will help you understand speech in a wide variety of listening situations. Also, the better the technology is, the more natural speech and other sounds will seem .

The best hearing aid sound processing technologies available today can address the issues mentioned above far more effectively than what was available just 5 years ago, even for those with severe hearing loss. But, they will still not make your hearing completely "normal."

Q. OK, I UNDERSTAND THAT MY HEARING WON'T BE PERFECTLY NORMAL AGAIN. BUT WHAT'S THIS BUSINESS ABOUT ELECTRONIC PARTS AND SOUND PROCESSING? I'M NOT AN ENGINEER, YOU KNOW.

A. Neither are we, so the good news is that we can't get too technical with you even if we wanted to! Again, we're going to keep this very basic.

"Sound processing," as we mentioned earlier, is what a hearing aid's electronic parts do to sounds that enter the hearing aid. Essentially, there are only 2 types of sound processing technology - analog and digital.

In hearing aids using ANALOG sound processing (ASP), the sounds that enter the hearing aid's microphone are first turned into electric signals. These electric signals are then boosted by an electronic amplifier, and then converted back into sound by a speaker.

With hearing aids using DIGITAL sound processing (DSP), sounds entering the microphone also get converted into electric signals first, but then those electric signals are converted into digital signals - i.e., series of 0's and 1's, digits! - which is the "language" a computer chip speaks. The computer chip inside the hearing aid then takes this digitized signal and does all sorts of things to it - basically, amplifies it, but because of all the processing power a computer chip has, it can manipulate the sound in ways that an analog hearing aid simply cannot do.

USUALLY this means that with a DSP hearing aid, we can:
1) program the output of the hearing aid to better match your particular hearing loss, and
2) use other sound-processing techniques, such as automatic volume control and noise reduction, to give speech and other sounds a more natural sound quality and to help you understand speech better in noisy places.

Q. DOES THAT MEAN THAT ANY "DIGITAL" HEARING AID IS ALWAYS GOING TO SOUND BETTER AND BE MORE APPROPRIATE FOR MY HEARING LOSS?

A. Not necessarily. Unfortunately, you have to be careful because there is some deceptive advertising out there trying to take advantage of this thinking.

First of all, some hearing aid sales shops advertise "digitally programmable" hearing aids. Such hearing aids actually use analog sound processing but can be programmed by means of a computer (a "digital" instrument) in the dispenser's office. While this programmability is somewhat advantageous, these hearing aids do NOT use digital sound processing, and thus are significantly more limited in their ability to compensate for hearing loss than the better DSP hearing aids. Because the sound processing in "digitally programmable" hearing aids is analog, they should properly be referred to as "analog programmable" hearing aids; however, the term "digitally programmable" is used in advertisements to make people think it's a digital sound processing hearing aid being advertised.

Secondly, some of these sales shops advertise hearing aids that DO use digital sound processing but are NOT programmable - that is, the hearing aids cannot be programmed by a computer and typically have only 2 or 3 rudimentary controls to shape the output; thus, they have very limitied ability to be shaped to your hearing loss.

So be careful about the "digital" trap. You want to be certain the hearing aid you're getting uses digital sound processing and is programmable.

Q. THANKS FOR THE TIPS. BUT HOW WILL I KNOW WHAT LEVEL OF TECHNOLOGY IS MOST APPROPRIATE FOR ME?

A. To answer this question, you must sit down with your audiologist and discuss what your most important listening needs are.

He or she should then present you with some choices - a good-better-best type of list, which will probably include both analog and digital options - and you can decide which fits your budget best.

Q. BUT HOW WILL I KNOW IF "GOOD" WILL BE GOOD ENOUGH?

A. Remember, as we said earlier, by law you have a 30 day trial period in PA when you purchase a hearing aid(s).

At the end of the 30 day trial period, if you're not satisfied with the benefit of the hearing aids you initially chose, one of your options is to try a different level of technology. You would pay whatever the difference is in price, and you would get a new 30 day trial period with that product.

At the end of a 30 day trial period, whether its the first one, a second one or even a third one, you always have the option of returning the hearing
aid(s) for credit, if for some reason they weren't satisfactory to you, in which case you would get your money back less a small fee for ear impression material and professional services.

Q. THAT'S GOOD TO KNOW. YOU HAVEN'T LOST ME SO FAR, SO COULD YOU TELL ME A LITTLE MORE ABOUT THE DIFFERENT LEVELS OF TECHNOLOGY?

A. Absolutely. We'll start with digital sound processing technology.

As mentioned earlier, digital sound processing hearing aids can be divided into high-end, mid-level and entry-level categories. Let's start with the features that you would find on high-end digital hearing aids:

1) adaptive directional microphones - these are very helpful when listening in noisy situations. When activated, these microphones will attenuate sounds coming from behind and to the sides of you, but provide full amplification for sounds coming from the direction you're looking in. In high-end products, the hearing aid actually monitors your surroundings and automatically switches into the directional program when you enter into a noisy situation. It will also track the location with the most noise and provide the most attentuation for that area.

2) feedback cancellation - this gives us better control over feedback or "whistling". The hearing aid monitors itself and when it recognizes that feedback is about to occur, it will do something internally to prevent it, without reducing gain and therefore benefit. This usually allows us to provide more gain without feedback.

3) noise reduction - this provides more listening comfort for the wearer when in situations with steady background noise, i.e. road or refrigerator noise. The hearing aid splits the incoming sound into many different frequency bands and when it recognizes a band that has mostly noise in it (it is relatively steady state with no pauses), it will reduce the amplification in that band, while the bands with speech (which fluctuates and has pauses) receive the full amount of amplification.

4) automatic volume control - the most difficult thing technologically for hearing aids to do is to provide appropriate proportionality between soft, medium and loud sounds. Because of the damage in the ear of a person with "nerve deafness," it is impossible physiologically to restore a completely normal sense of loudness growth and sensation. However, the best technology will come the closest to providing loudness proportionality.

5) telecoil - this feature allows the user to use a corded telephone without feedback, which can sometimes occur when you bring a phone up to a hearing aid. This feature can be either automatic; the hearing aid will switch into this program as you bring a phone up to it, or it can be accessed manually though a push-button.

Some features that you would find in mid-level digital hearing aids are:

1) directional microphones - these work almost the same way as in the high-end products, but rather than tracking the movement of speech and noise in front of you and behind you, the hearing aid is in a "fixed" pattern, where the hearing aid is always providing the most attenuation for sound coming from directly in back of you, and the most amplification for speech sounds coming from directly in front of you.

2) feedback cancellation - some manufacturers give us the option of providing this high-end feature in their mid-level products. For those who don't, a "feedback manager" system is usually available, which attempts to eliminate feedback while minimizing gain and benefit reduction. Feedback manager systems are sometimes useful and successful, sometimes not, usually depending on how severe the hearing loss is.

3) automatic volume control - but not as many "stages" of amplification as in high-end DSP hearing aids, so the proportionality between soft, medium and loud sounds will not be as good

4) telecoil - same as in high-end DSP hearing aids

Some features that you would find in entry-level digital hearing aids are:

1) directional microphones - fixed, and not automatic, i.e., you have to push a button on the hearing aid to go into the directional program

2) feedback manager - same as in mid-level DSP hearing aids

3) automatic volume control - usually the same as that in mid-level DSP hearing aids

3) telecoil - same as in high-end DSP hearing aids

Q. THERE SEEMS TO BE A LOT OF DIFFERENT OPTIONS AS FAR AS SIZE AND TECHNOLOGY GO, SO WHERE DOES COST FIGURE INTO ALL OF THIS?

A. Well, there are several factors that affect the cost of a hearing aid. First, is the size of the hearing aid itself; as we mentioned before, as the shell of the hearing aid gets smaller, the price gets more expensive. This is because more research has gone into making hearing aids and their components smaller. The second factor is the type of technology. Obviously, as you go up in technology; you also go up in price. This also has to do with the cost of research but in this case the research is for finding options to help the user in different listening situations and perfecting those options, such as directional microphones.

In addition to this is the cost of the time your audiologist provides programming, fitting, and adjusting the hearing aids for you. Keep in mind, hearing aids are not like glasses; we don't just program them once, put them on you and send you on your way. The information we gather from the audiological examination is minimal in the fitting process. Once the initial settings are programmed into the hearing aids, we use the patient's own experiences and input to make further adjustments to the hearing aids. This can take 2, 3, or even more visits during the trial period before we get it right and that's just to the sound of the hearing aids. Keep in mind that these things sit in the ear all day and they're plastic and it's not uncommon for the shell of the hearing aid to rub the ear the wrong way and cause some discomfort or even a sore. This is also something that needs be taken care of during the trial period, either by filing the shell of the aid down in the office or in some cases sending it back to the manufacturer to have it remade completely. All of this is figured into the cost of the hearing aid.

Q. WOW, SOUNDS LIKE THESE THINGS COULD GET PRICEY. WHAT ABOUT THOSE ADS I SEE FOR HEARING AIDS THAT ARE $495 OR LESS?

A. Excellent question. Have you ever had a relative who had a pre-80's hearing aid and all they did was complain about how they were always messing with the volume control or everything was too loud and they ended up just putting it in a drawer, never to be seen again? Well, this is the technology that you're seeing advertised and generally there are 2 outcomes to this type of advertising. When you go in to purchase the hearing aid for $495, you walk out with a hearing aid that doesn't really do you a whole lot of good in the majority of listening situations; mostly becuase you're missing out on all the technological advances we've made in the last 10 years and you'll end up doing exactly what Uncle Albert ended up doing - sticking the hearing aid in a drawer, never to be seen again. The other scenerio is more common, when you go in to purchase the hearing aid for $495, you then get a list of reasons why that hearing aid is not right for you but the one that is more expensive is (mostly becasue is not outdated by 30 to 40 years or so). Keep that in mind when you see those ads. These are complex instruments and you get what you pay for.

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In addition to ALDs, there are a number of strategies that people with hearing loss, and those who communicate with them, can use to greatly facilitate communication. These include:
1) making sure the person with hearing loss can clearly see the face of the person speaking;
2) the person communicating with a person with hearing loss should use "clear speech" - i.e., slowing their speech down just enough so that each syllable is clearly articulated;
3) if a particular room is noisy, either turn the noise source off or move to another, quieter room; and
4) using communication repair strategies, such as rephrasing a sentence that the person with hearing loss is not understanding, rather than continuing to repeat the same words.
Again, these strategies should be used even when a person is wearing hearing aids.