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Hearing aid

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Behind the ear aid
For the song, see Flood (album).

A hearing aid is an electroacoustic body-worn apparatus which typically fits in or behind the wearer's ear, and is designed to amplify and modulate sounds for the wearer. Earlier devices, known as an "ear trumpet" or "ear horn"[1][2], were passive funnel-like amplification cones designed to gather sound energy and direct it into the ear canal. Similar devices include the bone anchored hearing aid, and cochlear implant.

Types of hearing aids

There are many types of hearing aids (also known as hearing instruments), which vary in size, power and circuitry. Among the different sizes and models are:

NIH illustration of different hearing aid types.

Body worn aids

This was the first type of hearing aid invented by Harvey Fletcher while working at Bell Laboratories. Thanks to developments in technology they are now rarely used. These aids consist of a case containing the components of amplification and an ear mold connected to the case by a cord. The case is about the size of a pack of playing cards and is worn in the pocket or on a belt. Because of their large size, body worn aids are capable of large amounts of amplification and were once used for profound hearing losses. Today, body aids have largely been replaced by Behind-The-Ear (BTE) instruments.

Behind the ear aids (BTE)

BTE aids have a small plastic case that fits behind the ear and provides sound to the ear via air conduction of sound through a small length of tubing, or electrically with a wire and miniature speaker placed in the ear canal. The delivery of sound to the ear is usually through an earmold that is custom made, or other pliable fixture that contours to the individuals ear. BTEs can be used for mild to profound hearing losses and are especially useful for children because of their durability and ability to connect to assistive listening devices such as classroom FM systems. Their colors range from very inconspicuous skin tones for adults to bright colors and optional decorations for children. Recent innovations in BTEs include miniature "invisible" BTEs with thin hair-like sound tubes (see open-fit devices below). These are often less visible than In-The-Ear aids (ITEs) and some keep the ear canal more open so listeners may still utilise their residual natural hearing (most helpful for those with normal hearing in the lower frequencies). Ideal for high frequency losses, these miniature versions are generally used for mild to moderate hearing loss.

In the ear aids (ITE)

These devices fit in the outer ear bowl (called the concha or pinna); they are sometimes visible when standing face to face with someone. ITE hearing aids are custom made to fit each individual's ear. They can be used in mild to some severe hearing losses. Feedback, a squealing/whistling caused by sound leaking out of the aid and being amplified again, may be a problem for severe hearing losses. Some modern circuits are able to provide feedback regulation or cancellation to assist with this. Traditionally, ITEs have not been recommended for young children because their fit could not be as easily modified as the earmold for a BTE, and thus the aid had to be replaced frequently as the child grew. However, there are new ITEs made from a silicone type material that mitigates the need for costly replacements.

Receiver In the ear aids (RITE)

At a first glance, these devices are similar to the BTE aid. There is however one crucial difference: The speaker ('receiver') of the hearing aid is placed inside the ear canal of the user and thin electrical wires replaces the acoustic tube of the BTE aid. There are some advantages with this approach: First, the hearing aid speaker ('receiver') is placed further from the hearing aid microphone. This reduces the risk of acoustic feedback, also known as "howl". Second, the tube connecting the hearing aid and the ear-plug (also commonly referred to as "dome" or ear-mould) can be made extremely thin. This makes it possible to design an even smaller hearing aid that is even more inconspicuous. [citation needed]

In the canal (ITC), mini canal (MIC) and completely in the canal aids (CIC)

ITC aids are smaller, filling only the bottom half of the external ear. You usually cannot see very much of this hearing aid when you are face to face with someone. MIC and CIC aids are often not visible unless you look directly into the wearer's ear. [3][4] These aids are intended for mild to moderately-severe losses. CICs are usually not recommended for people with good low frequency hearing, as the occlusion effect is much more perceivable.[5]

Open-fit devices

"Open-fit" or "Over-the-Ear" OTE hearing aids are small behind-the-ear type devices. This type is characterized by a small plastic case behind the ear, and a very fine clear tube running into the ear canal. Inside the ear canal, a small soft silicone dome or a molded, highly vented acrylic tip holds the tube in place. This design is intended to reduce the occlusion effect. Conversely, because of the increased possibility of feedback, they are limited to moderate high frequency losses.

Bone Anchored Hearing Aids (BAHA)

The BAHA is a auditory prosthetic which can be surgically implanted. The BAHA uses the skull as a pathway for sound to travel to the inner ear. For people with conductive losses, the BAHA, bypasses the external auditory canal and middle ear, stimulating the functioning cochlea. For people with unilateral hearing loss, the BAHA uses the skull to conduct the sound from the deaf side to the side with the functioning cochlea.

Individuals under the age of 5 typically wear the BAHA device on a headband. Over age 5, a titanium "post" can be surgically embedded into the skull with a small abutment exposed outside the skin. The BAHA sound processor sits on this abutment and transmits sound vibrations to the external abutment of the titanium implant. The implant vibrates the skull and inner ear, which stimulate the nerve fibers of the inner ear, allowing hearing.

Eyeglass aids

During the late 1950s through 1970s, before in-the-ear aids became common (and in an era when thick-rimmed eyeglasses were popular), people who wore both glasses and hearing aids frequently chose a type of hearing aid that was built into the temple pieces of the spectacles. However, the combination of glasses and hearing aids was inflexible: the range of frame styles was limited, and the user had to wear both hearing aids and glasses at once or wear neither. Today, people who use both glasses and hearing aids can use in-the-ear types, or rest a BTE neatly alongside the arm of the glasses. There still are some specialized situations where hearing aids built into the frame of eyeglasses can be useful, such as when a person has hearing loss mainly in one ear: sound from a microphone on the "bad" side can be sent through the frame to the side with better hearing.

  • This can also be achieved by using CROS or bi-CROS style hearing aids, which are now wireless in sending sound from the "bad" or "worse" side to the better side. These types of hearing aids are much more frequently used than any eyeglass style. [citation needed]

Recently, a new type of eyeglass aid was introduced. These 'hearing glasses' feature directional sensitivity: four microphones on each side of the frame effectively work as two directional microphones, which are able to discern between sound coming from the front and sound coming from the sides or back of the user. This allows for amplification of the sound coming from the front, the direction in which the user is looking, and active noise control for sounds coming from the sides or back. Only very recently has the technology required become small enough, in size, to be put in the frame of the glasses. As a recent addition to the market, the geographical market for this particular hearing aid is currently limited to a few European countries. [citation needed]

Hearing aid technology

Wireless

File:PhonakCampusS.jpg
A Phonak Campus S wireless FM system.

Recent hearing aids include wireless hearing aids. One hearing aid can transmit to the other side so that pressing one aid's program button simultaneously changes the other aid and both aids change background settings simultaneously. FM listening systems are now emerging with wireless receivers integrated with the use of hearing aids. A separate wireless microphone can be given to a partner to wear in a restaurant, in the car, during leisure time, in the shopping mall, at lectures, or during religious services. The voice is transmitted wirelessly to the hearing aids eliminating the effects of distance and background noise. FM systems have shown to give the best speech understanding in noise of all available technologies. FM systems can also be hooked up to a TV or a stereo. [citation needed]

In developed countries FM systems are considered a cornerstone in the treatment of hearing loss in children. More and more adults discover the benefits of wireless FM systems as well, especially since transmitters with different microphone settings and Bluetooth for wireless cell phone communication have become available. [citation needed]

Many theatres and lecture halls are now equipped with assistive listening systems that transmit the sound directly from the stage; audience members can borrow suitable receivers and hear the program without background noise. In some theatres and churches FM transmitters are available that work with the personal FM receivers of hearing instruments. [citation needed]

Directional microphones

Directional microphones are currently - after FM systems, see below - the best way to improve the signal to noise ratio, and thus, improve speech clarity in noise for the wearer. [citation needed]

Many hearing aids now have directional microphones, which can be a major improvement in crowded places such as restaurants and open-plan offices, because the directional microphone allows the user to focus on whoever is directly in front with reduced interference from conversations behind and to the sides. It is common for such a hearing aid to have both a directional microphone and an omnidirectional microphone and a switch that lets the user choose between hearing in all directions versus hearing only in the direction his or her head is facing. Some more-advanced models can electronically subtract signals so the user hears the directional signal minus the omnidirectional signal for improved background noise rejection.

Adaptive directional microphones are a further sophistication of the concept. The hearing aid processor is able to distinguish noise as opposed to speech and automatically reduce the particular noise source from a certain angle. The limitations are at the identification level, where a noise that behaves similarly to a speech signal is difficult to identify, thus reducing efficacy. In severe background noise, the directional microphone is less efficient, however benefits may still exist.

Directional microphones unfortunately work best when the distance to the talker is not so large. But at close range there is often less need for directional microphones. At longer range and when there is more background noise, an FM system is currently the best technology that can bridge distance and suppress background noise at the same time.

Telecoil

Telecoils (T-coils), sometimes referred to as "Telephone Coils", allow audio sources to be directly connected to a hearing aid, which is intended to help the wearer filter out background noise. They can be used with telephones, FM systems, induction loop systems and public address systems. In the UK, and some Scandinavian countries, hearing loop systems are widely used in churches, shops, railway stations, and other public places. Within the US, such installations are uncommon, and are often ineffectively and/or inconveniently installed.

T-coils are comprised of a metal core (or rod) around which ultra-fine wire is coiled. T-coils are also called induction coils because when the coil is placed in an electromagnetic (EM) field, an alternating electrical current is induced in the wire (Ross, 2002b; Ross, 2004). The T-coil detects EM energy and transduces (or converts) it to electrical energy. T-coils can also be used to pick up magnetic signals, just as a microphone picks up an acoustic signal; the T-coil then sends the signal to the hearing aid circuit or processor for amplification.

Since T-coils are effectively a wide-band receiver, interference is common. Such interference manifests as a buzzing sound, which varies in volume depending on the distance the wearer is from the source. Sources are electromagnetic fields, such as computers, electric cables, mobile phones, electric motors, airplane equipment, etc.

Since, by design, the sound processed through a T-coil is markedly different from a hearing aid's microphone. The frequency characteristics can differ, especially at the mid and low frequencies. [citation needed]

Legislation affecting usage

In the United States, the Hearing Aid Compatibility Act of 1988 (HAC Act) requires that the Federal Communications Commission (FCC) ensure that all telephones manufactured or imported for use in the United States after August 1989, and all “essential” telephones, are hearing aid-compatible (through the use of a telecoil).

"Essential" phones are defined as "coin-operated telephones, telephones provided for emergency use, and other telephones frequently needed for use by persons using such hearing aids." These might include workplace telephones, telephones in confined settings (like hospitals and nursing homes), and telephones in hotel and motel rooms. Secure telephones, as well as telephones used with public mobile and private radio services, are exempt from the HAC Act. "Secure" phones are defined as "telephones that are approved by the U.S. Government for the transmission of classified or sensitive voice communications."

In 2003, the FCC adopted rules to make digital wireless telephones compatible with hearing aids and cochlear implants. Although analog wireless phones do not usually cause interference with hearing aids or cochlear implants, digital wireless phones often do because of electromagnetic energy emitted by the phone's antenna, backlight, or other components. The FCC has set a timetable for the development and sale of digital wireless telephones that are compatible with hearing aids. This effort promises to increase the number of digital wireless telephones that are hearing aid-compatible.

DAI

Direct Audio Input (DAI) allows the hearing aid to be directly connected to an external audio source like a CD player or an assistive listening device (ALD). By its very nature, DAI is susceptible to far less electromagnetic interference, and yields a better quality audio signal as opposed to using a T-coil with standard headphones.

Processing

The inside mechanisms of hearing aids vary among devices, even if they are the same style. Three types of circuitry, or electronics, are used:

  • Analog/Adjustable: The hearing professional, an Audiologist, determines the gain and other specifications required for the patient's hearing aid, and then a laboratory builds the aid to meet those specifications. The hearing professional retains some flexibility to make adjustments. This type of circuitry is generally the least expensive and also the least effective. Many manufacturers have actually discontinued their analog devices. [citation needed]
  • Analog/Programmable: The hearing professional uses a computer to program the hearing aid. The circuitry of analog/programmable hearing aids will accommodate more than one program or setting. If the aid is equipped with a remote control device, the wearer can change the program to accommodate a given listening environment. Analog/programmable circuitry can be used in all types of hearing aids. [citation needed]
  • Digital/Programmable: The hearing professional programs the hearing aid with a computer and can adjust the sound quality and response time on an individual basis. Digital hearing aids use a microphone, receiver, battery, and computer chip. Digital circuitry provides the most flexibility for the hearing professional to make adjustments for the hearing aid. Digital circuitry can be used in all types of hearing aids and is typically the most expensive. However, digital hearing aids can be specially programmed with multiple programs for quiet situations, background noise reduction, music listening, and directionality. Many also have more powerful feedback-reduction and/or cancellation technology. Among digital hearing instruments, some companies are providing hardwired configurable platform, while others are providing software programmable platforms using programmable, low-power digital signal processors. [citation needed]

Indications

Hearing aids are incapable of truly correcting a hearing loss; they are an aid to make sounds more accessible. Two primary issues minimize the effectiveness of hearing aids:

  • When the primary auditory cortex does not receive regular stimulation, this part of the brain loses cells which process sound. Cell loss increases as the degree of hearing loss increases.
  • Damage to the hair cells of the inner ear result in sensorineural hearing loss, which affects the ability to discriminate between sounds. This often manifests as a decreased ability to understand speech, and simply amplifying speech (as a hearing aid does) is offten insufficient to improve speech perception.

Adjustment to hearing aids

  • The occlusion effect is a common complaint, especially for new users. Though if the aids are worn regularly, most people will become acclimated after a few months. If the effect persists, an audiologist can sometimes further tune the hearing aid(s).
  • The initial fitting appointment is rarely sufficient, and multiple follow-up visits are often necessary.

Purchase costs

Several industrialized countries supply free or heavily-discounted hearing aids through their publicly funded health care system.

Australia

The Australian Department of Health and Ageing provides eligible Australian citizens and residents with a basic hearing aid free-of-charge, though recipients can pay a "top up" charge if they wish to upgrade to a hearing aid with more or better features. Maintenance of these hearing aids and a regular supply of batteries is also provided, on payment of a small annual maintenance fee.[6]

Canada

In Canada, health care is a responsibility of the provinces. In the province of Ontario, the price of hearing aids is partially reimbursed through the Assistive Devices Program of the Ministry of Health and Long-Term Care, up to $500 for each hearing aid, every three years. Audiological appointments are covered through the provincial public health plan, provided they are conducted under the supervision of ear, nose and throat doctors, usually in hospital settings. Private sector hearing aid clinics also exist and the hearing aids are covered to the same extent as with the non-profit and hospital providers. A popular choice for buying hearing aids in Ontario is the Canadian Hearing Society, a non-profit organization located in cities and towns across the province.

Iceland

Social Insurance pays a one time fee of ISK 30.000 for any kind of hearing aid, however the rules are complicated and requires that both ears have a significant hearing loss in order to qualify for reimbursement. BTE hearing aids range from ISK 60.000 ISK to 300.000 ISK. [7]

UK

Within the UK, the NHS provides BTE hearing aids to NHS patients, on long-term loan, free of charge. Though BTEs are often the only style available, and private purchases are usually necessary if a recipient desires a different style. Private purchases can cost between £600 to £3,500.[8]

US

Most private US health care providers do not provide coverage for hearing aids, so all costs are usually borne by the recipient. Such costs can vary between $500 to $5,000. Though if an adult has a hearing loss which substantially limits major life activities, some state-run vocational rehabilitation programs can provide upwards of full financial assistance. Severe and profound hearing loss often falls within the "substantially limiting" category.[9]

The cost of hearing aids are a tax-deductible medical expense.[10]


Notes and references

  1. ^ Comparison of Hearing Aids Over the 20th Century. Ear & Hearing. 21(6):625-639, December 2000. Bentler, Ruth A.; Duve, and Monica R.
  2. ^ http://www.hearingcenter.com/Questions/Q_ear-horn.html Ear Horn Q&A. Accessed 6 Dec 2007.
  3. ^ The Hearing Aid as Fashion Statement, by Anne Eisenberg, September 24, 2005 on NYTimes.com. Accessed 24 Nov 2006.
  4. ^ ELVAS Sightings - Hearing Aid or Headset, by Paul Dybala, Ph.D., March 6, 2006 on AudiologyOnline.com. Accessed 3 May 2007.
  5. ^ The "Occlusion Effect" -- What it is, and What to Do About it, by Mark Ross, January, 2004 in Hearing Loss. Accessed 25 Nov 2007.
  6. ^ "Understanding the Australian Government Hearing Services Program". Retrieved 2007-12-04.
  7. ^ Social Insurance Administration - Iceland Accessed 30 November 2007
  8. ^ NHS hearing aid service fact sheet Accessed 26 November 2007
  9. ^ The U.S. Equal Employment Opportunity Commission: Questions and Answers about Deafness and Hearing Impairments in the Workplace and the Americans with Disabilities Act Accessed 26 November 2007
  10. ^ Topic 502 - Medical and Dental Expenses Accessed 26 November 2007

See also

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