All audiology patients have different hearing health needs based on many factors, with one of the biggest being their degree of hearing loss.
The Hearing Review asked several members of the editorial advisory board to share their perspectives on how to determine the best hearing devices for people with severe, profound hearing loss. Participants include Douglas L. Beck, AuD, audiologist and consultant; Marshall Chasin, AuD, owner of Musicians’ Clinics of Canada; and Shari Eberts, hearing health advocate and author and founder of the Living with Hearing Loss blog.
The Hearing Review: What types of hearing aids are the best for patients with severe hearing loss?
Douglas Beck: In general, for people with pure tone averages (PTAs) in the traditional severe hearing loss range (71-90 dB HL), power aids such as RICs, RITEs, and BTEs with custom earmolds are a reasonable “go-to.” However, there are certainly people with this degree of hearing loss who choose and successfully wear custom canal aids. The key is to listen to the patient and try to meet their needs and goals, whenever possible. If we cannot fit the patient as they prefer, of course, we can offer alternatives, but I recommend trying to meet their needs and goals first.
Shari Eberts: As with all hearing devices, there is no perfect solution. The best type of hearing aid to recommend is the one the consumer will wear regularly. Therefore, it is critical to include lifestyle factors and patient preferences when recommending devices, in addition to programming and other technical parameters.
HR: What considerations determine when you recommend an ITE vs. a BTE hearing device for a patient?
Beck: My recommendations are based on the type and degree of hearing loss and the specific needs and goals of the patient. Many problems the patient lives with can be explored, revealed, and addressed using the COSI, the IOI, the SSQ, and more. With specific regard to ITE vs BTE….if we use an excellent custom earmold (I hate generic tulip domes) and a BTE/RIC/RITE, these products are generally less visible than a full shell ITE…also, the BTE/RIC/RITE will often have more programmable features. However, some people may prefer an ITE because they wear glasses and the traditional earmold may compete with space and comfort behind the ear. But again, it’s all dependent on the type and degree of hearing loss and the patient’s needs and goals.
Marshall Chasin: As a general rule, BTE hearing aids, with their larger receiver and output requirements, are better than smaller ITE-style hearing aids. The physically larger receivers have a better capability of delivering distortion-free amplified sound and the bandwidth (both low and high frequency) is typically wider than that of the smaller hearing aids. However, having said this, if the hearing loss is too severe where “chasing” sufficient audibility at 4000 Hz and above is questionable, then as far as straight amplification is concerned, smaller hearing aids can be just as useful. Also, the smaller sized hearing aids may not be able to accommodate features such as a telecoil or have Bluetooth capability.
HR: What about certain features, such as Bluetooth connectivity, telecoils, and rechargeable batteries? How important are these options when determining which hearing aids will be the best for patients?
Beck: In my opinion, Bluetooth is very important across the board. I always recommend it, if and when possible. Telecoils are also very important for many patients. I think discussing T-coils and loops (and all other options) with the patient is always useful. However, if the patient has less than (perhaps) a 50 dB PTA and if they can use their phone without hearing aids successfully, they are likely to be fine with Bluetooth streaming to two ears and may not require a T-coil. Rechargeable is nice, but to me, it is not always mandatory. I prefer to carry a card of size 10 batteries when I travel, rather than bringing another charger/case. Everyone is different and there are no hard and fast rules on this. Explore the needs and desires of the individual patient and engage as best we can to meet their specific needs and goals.
Chasin: One of the first things that any new audiologist discovers in their practice is that the phrases “severe hearing loss” and “rechargeable batteries” should not be uttered in the same sentence. If a hearing aid charger malfunctions—which clinically is the number one complaint I receive on Friday at closing time—then a person with a severe hearing loss will have few, if any, options open to them. Traditional batteries that can easily be replaced is the way to go. Many people with severe hearing losses rely on their telecoil to gain access to many environments but the exact orientation of the telecoil in the hearing aid is very important. This is another advantage of the BTE style for this degree of hearing loss- a BTE has a better chance of a properly oriented telecoil than ITE hearing aids where the outer ear shape may be the primary factor in determining how a telecoil is installed and oriented.
Eberts: For patients with severe hearing loss, recommending both Bluetooth and telecoils is critical because each is helpful in different listening situations. For example, Bluetooth is needed for streaming audio content and mobile phone calls, but telecoil is needed to access loop systems in theaters and other public spaces. Explaining how and when each feature will be useful is critical. Most people with hearing loss will have some understanding of Bluetooth but most are less likely to be familiar with hearing loops.
HR: Do you have any tips for how to best fit custom earmolds for patients who need them?
Beck: Custom products (hearing aids and/or earmolds) are (in general) best fit with a modern high illumination videootoscope to explore the ear canal, remove wax, place a cotton or foam dam appropriately, and re-inspect the ear after the impression has been removed from the ear canal.
Chasin: Dr. Bob Oliveira published a few articles in the 1980s showing that the ear canal is a dynamic creature. As one opens their mouth, the front-back dimension can significantly increase…less so for the top-bottom direction. Asking the patient to have their mouth open allows the impression to better replicate the wider front-back dimension, thereby minimizing the chances of acoustic feedback when the hard-of-hearing person speaks.
And in 1662, a few years before I started in audiology, Robert Boyle came out with “Boyle’s Law,” which, for our field, is essentially, “the longer the earmold bore, the lower the residual volume between the end of the ear mold and the ear drum, so the sound pressure can be increased by up to 5 dB.” Since this is generated in the ear canal “after the hearing aid,” the hearing aid doesn’t need to work as hard to get this free 5 dB of increased gain and output as a result of a longer bore earmold. A corollary of this, especially with very deep earmold/hearing aid fittings, as seen in the RECD, is that there will be a net high frequency boost.
HR: When is it time to consider cochlear implants instead of hearing aids?
Beck: This is ultimately a difficult and individual decision. Although there are guidelines from each of the three FDA-approved CI manufacturers which are based on the FDA guidelines, guidelines vary across the three manufacturers. As such, clinical judgement plays a pivotal role in the assessments. I would not use an audiogram by itself (ever!) to determine who is a candidate for CIs, as there are people with all types/degrees of hearing loss who get excellent results with their hearing aids, and some don’t. Therefore, I think it is very important to make sure the patient has tried a brand new, top technology hearing aid fitted with real ear measures and an excellent custom mold (specifically not an old, tired, previous technology model hearing aid with a generic fit, loose fitting, or old ear mold…). My thought is one has to consider the individual unaided and aided test results with excellent hearing aids and excellent earmolds after a 30-day adaptation time, in tandem with the patient’s goals, desires, and objectives.
I would consider: what does the adult patient want to do? What are their unaided and aided hearing and listening results? What are their expectations? What are the financial (including insurance) concerns? Do they have a reasonable understanding of what the process is (how long it takes, the surgical approach and downtime, the follow-up and programming visits)? Do they know with certainty that CIs cannot make their hearing normal? Have they visited with a CI recipient to interact and ask questions?
And finally, we need to acknowledge that this is a personal decision; it is ultimately up to the (adult) patient. Our task is to provide the very best pre-implant CI evaluation using excellent, contemporary tools across an appropriate time period, and then counsel and refer as indicated.
Chasin: Cochlear implants have improved dramatically over the past few years but, at least for music, they are less than stellar for the replication of the lower frequency/rhythm elements. The best arrangement, especially for music, is to consider a single cochlear implant with a traditional acoustic hearing aid in the other ear. This bi-modal fitting can provide the best of both worlds.
HR: Since severe hearing loss can affect so many aspects of a person’s life, what assistive devices do you often recommend for patients, and why?
Beck: As with all my responses (above), the needs and desires of the patient come first. Some people will thrive with something as simple as a Pocket-Talker; others won’t. Generally, for hearing aid wearers, I prefer to demonstrate FM and digital remote mic systems, as they wirelessly connect with contemporary hearing aids and they are relatively inexpensive, rechargeable, and small. Of course, for some people, texting via text or pictures can serve as an ALD, as do Airpods and many other Bluetooth devices.
Chasin: Assistive devices can be very useful for people with severe hearing losses. It’s almost that the hearing aids are secondary, with the primary elements being the assistive devices. With the use of Bluetooth (and the promise of Low-Energy-Audio, or LE-A) and Auracast coming down the pipeline, hearing aids need to have this capability. There are so many devices—some assistive listening devices and some assistive lipreading devices—that these can be life changing for many. There are now so many smartphone apps that can strip away background noise and others that can provide almost real-time captioning that assistive devices can be useful for more than just to improve “listening.”
Eberts: Assistive devices are life savers for people with severe hearing loss. Bluetooth and telecoil have already been mentioned, but CART and other forms of captioning can be equally helpful. CART is the gold standard, but AI-based captions are increasingly accurate, well-synced to speech, lower cost, and becoming more widely available. Speech-to-text capability is now built into most video conferencing platforms, FaceTime, and the operating systems of both Apple and Android devices. One of the best ways HCPs can help clients is to educate them about all the wonderful communication assistance that is available to help them in addition to their hearing aids.
Original citation for this article: Roundtable: Hearing Aid Selection in Severe, Profound Losses Hearing Review. 2024;31(9):22-25.
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