A Hearing Aid Buyer’s Guide

I began practicing audiology in 1992. Over those years I’ve seen thousands of patients and have been actively involved in consumer groups for hearing loss. I wrote this Buyer’s Guide to accomplish a few things:

First, I’d like more people to seek help for hearing loss. Millions of Americans (most of them seniors) suffer from hearing loss, and for nearly a century a discouraging fact remains true: just 20 percent of people who would benefit from a hearing aid wear one.1 In my experience, a big reason for that is a lack of knowledge. This guide aims to address this.

Second, I wanted to open the curtain a bit on the seemingly endless array of options. Just like buying a car, there are hundreds of makes and models to choose from, but if you zoom out a bit, all of them have four wheels, a frame, a motor and a body. Beyond that, the variables are convenience and style rather than getting to church on time. Hearing aids are much the same.

Finally, I wanted to arm you with some not-so-common tools to weed out the good, the bad and the ugly in terms of who actually fits these devices on you. To go back to the car analogy, you want a mechanic who won’t quit “wrenching” until your ride is purring like a kitten. With a bit of knowledge and healthy skepticism, you can push your “hearing mechanic” to help you hear the best you can.

What is a Hearing Aid?

Before describing what a hearing aid does, I wanted to share an amusing insight of Sam Lybarger, a pioneer in the field of hearing improvement and chief engineer of RadioEar from 1930 until his retirement 43 years later.2 When asked to describe a hearing aid, he said “It is a product that one puts off buying for ten years after he needs it but cannot do without it for thirty minutes when it has to be serviced.”3

Hearing aids can greatly improve the lives of those who have damaged inner ear sensory cells. This type of hearing loss can be a result of aging, illness, or injury and is not reversible. Hearing aids are electronic devices you use in or behind your ear to make sounds louder and easier to understand. They have one or two microphones to pick up sound, a digital amplifier to make sound louder, and a receiver that sends the sound into the ear canal.

There are several types of hearing aids, and each person should choose one that fits their hearing loss level and lifestyle.4

Receiver In Canal (RIC) – also called Receiver in Ear (RIE), this is the most popular style. It uses a thin wire and a snug silicone “dome” or earmold to attach to the ear.

Mini behind the ear (mBTE) – Similar in size to the RIC, but the speaker is inside the body of the hearing aid. Sound travels to the ear through a “slim tube” to a dome or earmold.

Behind the ear (BTE) – in this style, the electronics components are housed in a case that fits behind the ear. Tubing connects the case to an earmold inside the ear. This can be a good choice for those with significant hearing loss.

Completely in the ear (CIC) – these fit tight inside the ear and are the least visible type. The small size prevents it from being as effective in eliminating background noise or having volume adjustment.

In the canal (ITC) – custom-fitted, this style fits partially in the ear canal. It is slightly larger than CIC so it can accommodate more features like a directional microphone.

In the ear (ITE) – all electronic parts are housed in a case that sits in the outer ear. These are large enough to have volume control and longer battery life.

Hearing Anatomy 101

The human hearing system is divided into four parts.

  • The Outer Ear collects, directs and amplifies incoming sound. This section includes the Pinna (the part you hang your glasses on), the ear canal and the outer surface of the eardrum (tympanic membrane).
  • The Middle Ear is a mechanical amplifier. Behind the eardrum, the three smallest bones in the body the Hammer, Anvil and Stirrup (Malleus, Incus and Stapes for you Latin aficionados) amplify the sound energy in the ear canal and then deliver those enhanced vibrations to the inner ear. These bones are collectively called ossicles. An often-neglected part of the middle ear is the Eustachian Tube. This connects the middle ear to the back of the nose and is what allows your ears to “pop” on an airplane or when scuba diving.
  • The Inner Ear includes the cochlea and vestibular, or balance system. The cochlea contains roughly 30,000 tiny receptors called hair cells which convert the vibrations in the cochlear fluid into nerve impulses. The inner ear’s balance components convert movement into nerve impulses.
  • The Central Auditory System is the “computer” of hearing. It includes a sophisticated group of structures in the auditory nerve, brainstem and several areas of the brain that decode the nerve impulses from the inner ear into perceptions of pitch, loudness and duration. This is combined with memory to allow us to hear and understand speech and other sounds.

Causes and types of hearing loss

Our ability to hear is described in terms of how much we can hear (sensitivity) and how accurately we can hear (discrimination). We separate hearing ability into which parts of the hearing mechanism are affected (type of loss), and how loud sounds need to be for you to hear (severity of loss).

  • Conductive Hearing Loss is caused by a reduction of function if the outer or middle ear. This generally affects sensitivity (the world gets quieter) but not discrimination (making things louder improves understanding). Conductive hearing loss in adults accounts for roughly 10% of hearing loss and is generally treatable medically. Common causes of conductive hearing loss are:
    • Blockage of the ear canal by naturally occurring wax (cerumen) or foreign objects. Either can be removed by an appropriately trained professional (physician, physician’s assistant, nurse practitioner, audiologist, hearing instrument specialist). Ear wax can also be removed at home using softening drops (cerumenolytics) and gentle water irrigation, but it is prudent to have one of these professionals clear the obstruction as well as evaluate the health of your ear canal and hearing.
    • Eustachian Tube Dysfunction can be caused by allergies, a cold or a sinus infection. When the Eustachian tube doesn’t work properly, the eardrum is pulled into the middle ear by negative air pressure and you lose hearing sensitivity for low and high-pitched sounds. If left untreated, this can progress to fluid in the middle ear called effusion. This can become a breeding ground for bacteria leading to an infection called otitis media. Eustachian Tube Dysfunction (ETD) can be evaluated and treated by your primary healthcare provider, but if it doesn’t resolve within a few weeks, you should request a referral to an Ear, Nose and Throat specialist (otolaryngologist).
    • Middle Ear Bone disease or injury reduces the amplifier effect of the ossicles. Some of these disorders can be surgically corrected, so evaluation by an otolaryngologist who sub-specializes in ear surgery called and otologist, is warranted.
    • Eardrum perforations can occur following untreated middle ear effusion, or from traumas such as explosions, close-range gunfire, rapid altitude change or inability to clear the ears when scuba diving. They often heal on their own but need to be evaluated by an otolaryngologist.
  • Sensorineural Hearing Loss involves dysfunction of the cochlea or auditory nerve and accounts for approximately 90% of hearing loss in adults, Commonly called “nerve deafness” this type of hearing loss is more accurately a functional deficit of the hair cells in the cochlea. Sensorineural hearing loss can either be present at birth (congenital) or acquired over time. For readers of this website, acquired loss is much more common. As an audiologist, I look at acquired hearing loss based on which parts of the inner ear are likely affected.
    • Presbycusis (Latin for “old hearing”) begins with loss of function of the outer hair cells. These “pre-amplifiers” of the inner ear make soft sounds loud enough to hear. In this early stage of hearing loss, it is most common to hear, but not always understand exactly what people are saying. Increasing the volume of a sound generally solves the problem and therefore, people with early presbycusis are ideal candidates for amplification. The function of these hair cells can be measured using a test called Otoacoustic Emissions (OAE), which we’ll discuss a bit later in this article.
      In the later stages of presbycusis, the inner hair cells become affected. This creates a greater degree of impairment due to reduced discrimination. Increasing volume makes it easier to hear (audibility), but many sounds remain unclear. This doesn’t preclude the use of hearing aids but may require the use of specialized technologies covered later in this article to optimize speech understanding.
    • Ototoxicity is damage to the hearing or balance system caused by chemical agents or medications. Many common drugs may cause or exacerbate hearing loss or tinnitus (ringing, buzzing, humming in the ears). If you are reading this article, chances are you’re questioning your hearing. As part of overall wellness, you should be aware of the effects of your medications on hearing. A very good resource for ototoxicity is Dr. Neil Bauman’s website5 but you can also ask your physician or pharmacist to check into the possibility that the medications you need to take might adversely affect your hearing, or aggravate tinnitus. If you need to take medicines that are known to be ototoxic, ask the prescribing provider to arrange for you to see an audiologist for a baseline examination and then regular monitoring. Many ototoxic effects are seen on the OAE test mentioned above, so that can be a good way to monitor any effects over time.
    • Loud sound exposure is another common cause of sensorineural hearing loss. Historically, the medical community used the term “noise exposure” but in my clinical experience, that only looks at work-related loud sound. Seniors today sowed their wild oats in the 60’s, 70’s and 80’s. Your inner ear doesn’t treat long term exposure to very loud music differently than 40 hours a week in a factory, so it’s more correct to consider loud sound exposure over time to be a risk. This affects the outer hair cells first but can also degrade the inner hair cells if the exposure persists for several years.
    • Autoimmune disorders have more recently been linked to some hearing loss.6 The scope of these effects are still being studied, but if you have any autoimmune problems, it’s wise to request a referral to an audiologist or otolaryngologist for a baseline hearing evaluation as well as regular monitoring, particularly is your symptoms or medications change.
    • Other medical conditions and disorders can also affect hearing. These include, but are not limited to diabetes, Meniere’s syndrome, labyrinthitis, meningitis, and various viral infections. If you have a complicated medical history, or active conditions that affect circulation, or the immune system, it’s a good idea to get a baseline hearing evaluation even if you’re not experiencing any specific difficulty hearing.

How to Know if you have Hearing Loss and Getting a Hearing Test

Now that we know a little about what might cause hearing to go south in general, let’s talk about how to find out if yours isn’t up to snuff.
People with hearing loss tend to exhibit one or more of the following behaviors:

  • Asking people to repeat themselves, particularly in settings with background noise (restaurants, stores, offices)
  • Listening to television or other media at a louder volume than family or friends
  • Avoiding social situation that require listening (meetings, houses of worship, parties)
  • Missing the punch lines of jokes
  • A decreasing level of confidence that you are understanding what people say
  • Monopolizing conversations to avoid having to hear and understand other people

If you do any of these things more often than you change the oil in your car, you should have your hearing evaluated. There are two basic forms of checking out your hearing: a screening and an evaluation.

  • A Hearing screening identifies if there is a probable hearing loss. This is not a diagnostic test, and it will not identify the specific type of hearing loss, or the likely cause. They generally only address the sensitivity part of hearing, but are quick, usually free and like other health screenings, let you know if further investigation is needed. There are several ways to screen hearing including:
    • Questionnaires either in print or online. These ask you to rate your hearing and/or listening abilities in different situations and then score the results. A very common, standardized self-report questionnaire is the Hearing Handicap Inventory for the Elderly–Screening Version or HHIE-S;( Newman, Jacobson, Hug, Weinstein, & Malinoff, 1991). This tool takes just a few minutes to complete either on your own, or with a hearing care professional. This ten-item tool identifies areas of reported difficulty and groups them into Emotional or Social aspects of possible hearing impairment. Once scored, it allows the scorer to determine the likelihood of hearing loss, which would result in a referral for formal evaluation.
    • Smartphone App-based hearing screenings are becoming more common as the use of smartphones increases. While not calibrated to the same accuracy as a formal hearing evaluation, many of these will give a fair approximation of hearing ability. At a minimum, they allow you to see the general pattern of your hearing ability and if there is a large difference between ears (which should be evaluated by an otolaryngologist). There are many such apps on both the iOS (Apple) and Android platforms, most of them free. Hearing aid manufacturers often produce screening apps to cultivate sales leads.
    • Pure Tone Audiometric Screening is provided by either a hearing care professional (audiologist or hearing instrument specialist) or at a physician’s office. These are identical to the hearing test you had in the nurse’s office back in elementary school. Like the smartphone apps, they provide a hint into your hearing abilities and indicate if further testing is warranted.
  • What about Telemedicine?
    • COVID-19 has forced all medical practices to rethink the concept of where and how services are provided. Hearing testing and hearing aids have been highly computerized for years, but ironically, tele-medicine models haven’t been aggressively explored. App and web-based screenings are certainly possible, but diagnostic testing is a bit more of a challenge. This should improve in time, but for the time being, diagnostic testing needs to be done in person.
  • Hearing Evaluation
    • If your hearing screening suggests that you may indeed have hearing loss, it’s in your best interest to have a complete hearing evaluation. This can be performed by either an audiologist or a licensed hearing instrument specialist. There is a lot of debate about which person is “better” at addressing hearing. Without getting into the politics of it, here are the main differences:
      • Audiologists have at least a Master’s degree. If they were trained after 2007, they will have a clinical Doctorate called an AuD. Audiologists are not medical doctors. The training for the AuD is similar to that of a Chiropractor. Some audiologists have additional training in specialty areas such as balance or cochlear implants and may have a certification from a professional organization. These certifications (CCC-A or ABA) look impressive on the wall, but the privilege to practice is determined by state license, not those certifications. Audiologists can be credentialed by Medicare, Medicaid and other 3rd party insurance payors, but Medicare and many other plans require a referral from a physician for the claim to be paid.
      • Hearing Instrument Specialists (aka Hearing Aid Dispensers, Hearing Aid Dealers) are also licensed, but the educational requirements vary greatly from state to state. They may not bill Medicare for testing but may be credentialed to provide hearing aids through Medicaid and some 3rd party payors.

Hearing loss and its treatment are a marathon, not a sprint. The relationship you have with your provider is, in my experience, much more important than the specific credential.

Both version of the hearing test should include the following:

    • A visual inspection of the outer ear (pinna) looking for an injury, suspicious lesions, or possible evidence of congenital deformity.
    • A careful inspection of the ear canal and eardrum. This is called otoscopy and can either be an eyeball view using a magnified light called an otoscope, or a more high-tech version called video otoscopy which uses a small endoscope to view and record the ear canal and eardrum. Significant amounts of ear wax or other abnormalities should be addressed or referred for medical evaluation.
    • An evaluation of the function of the middle ear. This can be done in two ways. A direct measurement of the physical movement of the eardrum and ossicles called Tympanometry is standard practice for most audiologists and many Specialists. A small rubber tip is placed in the ear canal and a hum is produced. Next, a small pump changes the air pressure and the machine measures the change in the hum, which relates to the movement of the eardrum. It feels like a very short airplane ride for most people with normal middle ears. Tympanometry reveals the integrity of the eardrum (shown by the physical volume of the ear canal), the mobility of the ossicles (shown by the shape and height of the graph) and the condition of the Eustachian tube (shown by the position of the peak of the movement).The second measure of middle ear function is bone conduction audiometry. Using a small box behind your ear, you are asked to respond each time you hear a “beep” at different pitches and loudness produced at calibrated levels by a machine called an audiometer. If you hear the tones better by bone conduction than by air conduction (described below), then the middle ear is not working optimally and a referral to otolaryngology is warranted.
    • Pure tone audiometry by both air conduction and bone conduction. Air conduction testing is the same as described above, except that you will hear the sounds through earphones. The earphones will either fit over your ears with a headband, or clip onto your collar with thin tubes and disposable foam inserts. Both are calibrated to yield equal results, so one if not “better” than the other. Some providers will have both to accommodate patient preference of anatomy. The softest sounds you can hear for each pitch and for each ear will be plotted on a graph called an Audiogram. The lower the marks are on the page, the more difficulty you have hearing. This addresses the “sensitivity” part of hearing and is important, but not the whole story. Each mark is called a “threshold.” I’ll walk through the audiogram in detail a bit later in this article.
  • Speech audiometry assesses how well you understand what you hear. It includes several measures.
    • Speech Reception Threshold (SRT) determines the softest level you can repeat two-syllable words called Spondees (e.g. Baseball, Hot Dog, Cowboy) with 50% accuracy. This should be close to the average of the marks on your audiogram at 500, 1000 and 2000 Hz.
    • Word Recognition aka Speech Discrimination measures the percentage of one-syllable words repeated correctly at a level significantly louder than your SRT. For “flat” audiograms, this is generally about 40 dB above the SRT. If the curve slopes down like the example above, the level will be between 10 and 25 dB above the threshold at 2000 Hz depending on how far down the curve drops.
    • Most Comfortable Loudness (MCL). Most people with sensorineural hearing loss perceive loudness in an exaggerated way called “recruitment.” In these cases, the typical estimated levels for Word Recognition testing may seem too loud. The MCL documents the loudness that you prefer to hear speech at. It is usually measured by the provider speaking to you and adjusting the loudness so that it’s close to the loudness you would set the TV to id you were listening to the news.
    • Uncomfortable Loudness (UCL). This is a measurement of the loudest speech you can tolerate. Measures just like MCL, except the level is raised until you indicate that it’s beyond “loud, but OK” and very nearly uncomfortable. UCL can also be measured for pure tones and may help provide a more accurate hearing aid fitting, especially if you have a lower than expected UCL for speech.
    • The difference between your threshold (SRT) and UCL is your “Dynamic Range.” If measured carefully, it can provide important information to the person fitting your hearing aids.

Additional tests that you may have would include the OAEs mentioned earlier and a Speech in Noise test. Both are considered part of best practice and are worth inquiring about when you make your appointment.

    • Otoacoustic Emissions (OAE) measures the sound that the outer hair cells make when they react to external sounds. A small rubber-tipped microphone is placed in the ear and you hear a series of clicks and chirps. If the outer hair cells are healthy, the OAE machine will record a response. The absence of an OAE response is not a hearing threshold but can provide a preview of pattern of hearing loss. OAEs are not expected in people over age 75 or with active middle ear problems but are considered “best practice” for most adult hearing evaluations.
    • Speech in Noise Testing is an extension of speech audiometry and provides a closer estimate of your ability to hear in the “real world.” The most common test is the Quick SIN (Speech In Noise) developed by Mead Killion of Etymotic Research.7 This test, which is integrated into many audiometers, presents recordings of an adult female speaker reading sentences at a comfortably loud level. Your job is to repeat the sentence. Sounds easy right? The trick is that mixed in with her voice is a recording of multiple people talking, like you’d hear at a party. Each sentence gets more difficult because the loudness of the background voices increases until it is the same as her voice. The results are reported as “SNR (signal-to-noise ratio) Loss” where scores under 5 suggest very little difficulty with noise, and scores over 10 strongly suggest the use of not only hearing aids, but additional assistive technology.

Understanding Your Hearing Test Results

In general, results for the right ear are displayed in red, and those for the left in blue. Let’s look at some typical results of a hearing evaluation.

Tymp Tympanometry

The results shown here are normal for both ears. The sharp, high peak of the curve indicates normal movement of both the eardrum and the middle ear bones. The position of the peak is consistent with normal Eustachian tube function.

Symbol Key:
O = Right Ear Air Conduction
< = Right Ear Bone Conduction
X = Left Ear Air Conduction
] = Left Ear Bone Conduction
U = UCLAudiogram

Pure Tone Audiometry

These results would be reported as:

Right Ear (Red):
o Severity: Normal (less than 25) in the low frequencies (250 to 1000 Hz); mild sloping to moderate-to-severe in the high frequencies.
o Type: Sensorineural (air conduction and bone conduction are the same).
Left Ear (Red):
o Severity: Normal (less than 25) in the low frequencies (250 to 1000 Hz); mild sloping to profound in the high frequencies.
o Type: Sensorineural (air conduction and bone conduction are the same).

Quick SIN at 75 dB

SNR loss
Right Ear: 5
Left Ear: 10
Binaural: 8SRT

Speech Audiometry

SRT is consistent with the average hearing thresholds in the low to mid frequencies (500, 1000, 2000)

Word recognition at average conversational levels (50 dB) is good in the right (84%) but poor in the left (56%)

Word recognition improves in both ears at amplified levels (75 dB) and further improves when both ears are stimulated together (96% in the “B” – Binaural condition).

QuickSIN results suggest mild to moderate difficulty in noise.

The first thing I’d do if this were my patient is to refer them to an otolaryngologist to investigate why the left ear is worse than the right. There are many possible reasons for this kind of asymmetry from very benign to quite serious, so a comprehensive medical evaluation is prudent. In a case like this, an MRI will usually be ordered.

If all that comes back fine, I would recommend that this person be fitted with hearing aids as well as some additional assistive technology. Let’s look at that process and some of the things you should look for when getting hearing aids for the first time.

Where do I buy a hearing aid, and do I need a prescription?

Hearing aids are classified by the Food and Drug Administration (FDA) as medical devices and are defined as “any wearable instrument or device designed for, offered for the purpose of, or represented as aiding persons with or compensating for, impaired hearing,” [ 21 CFR 801.420(a)(1)]. This means that not all devices that amplify sound are technically hearing aids. Devices in this category must be fitted by a licensed audiologist or hearing instrument specialist. This model has historically restricted access to hearing care to a typical work week. This may be one reason that despite incredible advances in technology, only 20% of those who could benefit from hearing help get it.

Currently, hearing aid can be obtained in the following settings:

  • Private practice audiology clinics
  • Otolaryngology offices
  • Manufacturer-owned retail chains such as Miracle Ear, Beltone, Audibel, Connect Hearing, Hearing Life, etc.
  • VA Medical Centers. With very few exceptions, all Veterans who served two years are eligible for hearing aids and assistive technology at no cost from the VA. You do not need a service connection for hearing, nor do you need to have a VA Primary Care Provider. Simply verify that the clinic has audiology and report to establish eligibility for VA health care. You’ll need your DD-214, a few years of tax returns as well as your banking information so they can determine if your income requires a nominal copayment. If you also have private health insurance, bring those cards too as th VA can sometimes bill your primary insurance and then just cover the unpaid portion of care. After that you will schedule a hearing evaluation and if you need them, the VA will provide premium level hearing aids from one of the “big 6” major manufacturers (GN ReSound, Oticon, Phonak, Starkey, Signia, Widex) and any other technology you need to help you hear.
  • Online. With advances in technology, new products have been developed by companies like Lively that allow real-time remote fitting by qualified dispensers. These hearing aids meet the same FDA criteria as devices sold through traditional channels but do so in a new paradigm that is particularly relevant in the current COVID-19 situation. Pandemic aside, true remote hearing care also provides convenience, discretion and in most cases, significant cost savings.

What types of hearing aids are there?

Hearing aids fall into two major categories and a few subcategories in terms of style or shape. In general, the internal electronics are the same across styles of a given model, but some features may not be available in certain styles due to size. The currently available styles are as follows:

Style Name Hearing Loss Range Picture
Invisible In Canal (IIC) Mild to moderate IIC
Completely In Canal (CIC) Mild to Moderate-to-Severe CIC
In The Ear (ITE) Mild to Severe ITE
Receiver In Canal (RIC) Mild to Severe RIC
Behind The Ear (BTE) Mild to Profound BTE
Extended Wear Mild to moderate Extended Wear

*All images are courtesy of Phonak

As you can see, there are a lot of options when it comes to the size and shape of hearing aids. Most people would prefer not to advertise their hearing loss, so those looking for very discreet hearing aids should see if the IIC or Extended Wear options are appropriate. Unless you are completely bald, the RIC style, if color-matched to the hair, is nearly invisible in most cases. Hearing aids that look good (or at least acceptable) are very desirable, but it’s important to realize that going that small means you will most likely have to compromise on some of the features below.

Hearing Aid Features to Consider

Current hearing aids are miniature computers that process sound digitally in real-time. They offer many features that can be confusing. To make it worse, there is no standard lingo for them. Instead, each manufacturer has its own catchy names. Below are the most common hearing aid features described in as generic terms as possible.

Power

Hearing aids, like all electronics, need power to operate. This was traditionally accomplished with a small “button” battery. Current versions of these use a “Zinc-Air” technology that provides between 2 and 14 days of use depending on the size and power requirements of the hearing aids. Zinc-Air batteries cost $1 each (less in bulk or online) and use a standard color-code on the labels:

Size Color Approximate Life Image
10 Yellow 3-7 days Size 10 Battery
312 Brown 7-10 days Size 312 Battery
13 Orange 10-14 days Size 13 Battery
675 Blue 14-18 days Size 675 Battery

In the last few years, rechargeable options have become widely available. The most common in new hearing aids is Lithium-Ion. This is available in RIC and BTE hearing aids and provides a very convenient way to power your hearing aids. Most current devices will fully charge in a few hours and provide a full 24 hours of use time. LiOn hearing aids generally come with a desktop charger, but travel chargers are available with secondary power packs that allow you to charge your devices a few times on the road.

Number of Channels

Hearing aids will generally advertise how many “channels” they have. Think of these like a graphic equalizer on a high-end stereo. It seems logical that more channels will provide a better match to your hearing, but it really depends. The number of channels is less important than the location of those channels compared to the shape of your audiogram since the fitting is based on that curve. If you have a gently sloping loss, a device with 8 or 10 channels might be fine. If your loss steeply drops off in the higher pitches, more channels will allow the fitter to match that curve better.

Directional Microphones

Everyone, even those with perfect hearing, has more difficulty understanding speech in background noise. Directional microphones lessen that difficulty somewhat. The degree to which directional microphones allow you to hear successfully in noise depends on the amount of difficulty you have (as shown on your Quick SIN test) and the level of noise in the environment. The difference between the loudness of speech and noise is called Signal-to-Noise Ratio (SNR) and is measured in deciBels (dB). The very best directional microphone systems available on hearing aids can improve SRN by about 15 dB. If the SNR of the room is -20 (room noise is 20 dB louder than speech), then the SNR reaching your brain will still be -5. If your Quick SIN SNR loss is 2 dB, then you’re golden. If your SNR loss is 10 dB, then you are still 5 dB in the hole and will struggle even though the hearing aids are performing as designed.

In almost 30 years of fitting hearing aids, I rarely encounter patients who hear their best in the real world of noise with just their hearing aids. Fortunately, there are tools to help.

Wireless Accessories

Nearly all ITE, RIC and BTE and some CIC hearing aids can connect wirelessly to external devices, collectively called accessories. The idea is to overcome the challenges of distance, reverberation and background noise by capturing the desired signal (speech, music, TV, etc.) in an ideal condition, and beam it to the hearing aids across distances ranging from 30 to 80 feet depending on the wireless technology. Wireless hearing aid accessories fall into a few categories.

Remote Microphones

These small devices clip onto the speaker of interest and capture their speech at an SNR of up to +24 dB. This optimized signal is then beamed to the hearing aids so that regardless of the SNR of the room, you hear as if your hearing aid is as close to the speaker as your remote microphone. Most of the current remote microphones can sense their position and automatically adjust the microphone sensitivity. They range in price from a few hundred to over a thousand dollars but make a significant difference. In my practice, I demonstrate and measure the effect of remote microphones for anyone with an SNR loss on the Quick SIN over 10 dB.

Media Streamers

Hearing well on the television depends on the size and shape of the room, whether you’ve updated the shag carpet you installed in the 70s, the quality of the speakers and the recording quality of the program. A media streamer neutralizes all these variables by taking a direct, hard-wired audio signal from the TV or cable box (RCA or Digital TOSLink) and then beaming that signal to the hearing aids, just like the remote microphone. Most are easy to set up and once they are, they either automatically connect, or you just tap a button on the hearing aid or use a smartphone app to activate streaming.

Remote Control

Even the largest hearing aids have really small buttons. Those with wireless capability offer the option to control volume, programs for different listening situations, and streaming using either a smartphone app or a dedicated remote control. The stand-alone remote controls are usually the size of a key fob and either use a long-life watch type battery or are rechargeable.

Smartphone Apps

Almost all wireless hearing aids offer a smartphone app. These are generally available on both Apple (iOS) and Android platforms and are provided free from the manufacturer. In addition to basic hearing aid controls like volume and program selection, some apps offer geotagging. This serves two purposes. First, it allows you to fine-tune the hearing aids and accessories in specific settings like your favorite bistro, then have them automatically go to those settings every time you walk in the door. Secondly, geotagging allows the app to “find” a misplaced hearing aid.

Telecoil

This is actually a very old technology, making its first appearance in hearing aids in the 1930s. Telecoils are electromagnetic receivers that pick-up sound transmitted from hearing aid compatible telephones and special public address systems called “hearing loops.” Hearing loops are becoming more popular around the US and using them provides the same benefit as a remote microphone without having to clip anything on the presenter. Telecoils are recommended in all hearing aids by the Hearing Loss Association of America8 and are so effective that several states require a signature indicating that a discussion of them occurred during your hearing aid consultation.

Direct streaming

If a hearing aid can use wireless accessories, it probably also can stream directly from your iPhone, iPad, etc. All of the “big 6” provide at least one “made for iPhone” option and Phonak has a way to also connect to Android devices in their Marvel line of products. Direct streaming uses the Bluetooth LE technology and can enhance your ability to understand on the telephone, but also to hear anything on that device better such as streaming media (YouTube, Netflix, etc.) and alerts.

Moisture Resistance

Modern hearing aids, particularly Lithium-Ion rechargeable models, have all been designed to resist moisture and dust. They generally are rated IP67 or IP68 which means they are essentially impervious to dust and can withstand splashes and even submersion in up to 3 feet of water for several minutes. While not technically “waterproof” they can hold their own in the gym or in humid climates.

Programming Features

In addition to the above “hardware” features, hearing aids often have several software abilities that may help you hear better.

  • Automatic scene analysis attempts to figure out what the primary signal is hitting the hearing aids (speech in quiet, speech in noise, music, etc.) and sets the hearing aid accordingly. These systems are continuously evolving, but they provide a great deal of convenience.
  • Datalogging records things like hours of use, which programs are active and the hearing aid’s best guess of the environments you were in based on the automatic scene analysis. Using these data, the audiologist or hearing instrument specialist can make fine tuning adjustment tailored to your actual use of the devices. Some products use this to actively “learn” your habits and adjust over time. This “machine learning” is still in its early stages and will be evolving over the next several years.
  • Lifestyle monitoring. Fall detection, activity tracking and mental engagement tools are beginning to make an appearance in hearing aids. Still early days and limited to only a few manufacturers, but if you like all that stuff, ask about it when discussing options.
  • Manual controls are the “trust everyone but cut the cards” of hearing aids. Automatic analysis and volume adjustments are great but having a manual override just in case can be helpful to overhear that great stock tip or to tune out your boring cousin at dinner.
  • Feedback control reduces the likelihood that the hearing aid will whistle in your ear, especially when chewing or giving a loved one a hug.
  • Frequency lowering captures critical speech sound at pitches where you hear very poorly and moves them to lower pitches where you hear better. It takes a little getting used to, but most people with very poor hearing at high pitches and poor word recognition improve up to 20% when this feature is used. All of the “big 6” have one form of frequency lowering.
  • Technology Level is akin to the “Trim” level of an automobile. Hearing aids usually use terms like “Essential/Basic, Value, Standard, Advanced and Premium.” The basic hardware is usually the same, but more of the options above are “turned on” in the software as you go up the chain of technology levels. The concept is that the more complex your listening needs, the more advanced (and more expensive) your hearing aids should be. This is often true, but if you also use the accessories described above effectively, you may be able to function as well or better with a lower technology hearing aid as part of a “system” than a more advanced stand-alone hearing aid.

Making the purchase

After you figure out that you need hearing aids and the features you want, it’s time to pull the trigger and buy them. But, it’s a heavy lift. Hearing aids can be your third largest purchase after your home and vehicle. Prices vary widely, but a few commonalities exist.

Return Option (aka Trial Period)

By law, all hearing aids sold in the US must come with at least a 30-day return option. This may be called a trial period, but it's really your right to cancel the sale if you find the devices unsatisfactory. There will almost universally be a small fee retained by the dispenser which is detailed in the sale agreement and regulated state but state. Some providers will offer a longer return option to separate themselves from the competition.

Price

As suggested above the more bells and whistles, the higher the price. Medicare does not cover hearing aids at all, but some Medicare “Advantage” programs offer a hearing aid benefit. This is typically available only through a limited number of contracted providers, but it can offset the price of hearing aids significantly. The Hearing Loss Association of America and AARP are actively working to add hearing aid coverage to Medicare.9

Most Medicaid programs cover hearing aids and follow-up services, usually in the “Standard” tier of technology. The specific criteria for eligibility vary from state to state.

There is a wide range of coverage for hearing aids among private third-party insurance carriers. Some provide direct payment to providers at or near “street price.” The provider usually needs to be contracted with the insurance company and may have to submit positive evidence of benefit (outcome measures) and an extended return option. Others provide a fixed allowance per ear within a given benefit cycle (usually 3 years) that can either be paid directly to the provider or reimbursed to the patient after they have paid in full themselves and submitted a claim.

Large warehouse membership companies like Sam’s Club and Costco have been offering hearing aids to their members for many years. Both sell only to their members, and the products offered generally are either modified “big 6” products or, in the case of Sam’s Club, manufactured by a smaller company (Lucid Hearing) exclusively for Sam’s.

The advantage to these outlets is that due their buying power, they can purchase the instruments at a much lower price, and then pass those savings to their members. There’s a lot of chatter among traditional dispensing professionals about the good and bad of these options, but having looked at both, it still comes down to the quality and attentiveness of the person fitting the instrument. Both stores employ both audiologists and hearing aid specialists and offer quality products and follow up care.

Another way to get more bang for your buck is to get your hearing aids from a community clinic at an audiology training program. Yes, you will be seen by students, but they will be directly supervised by licensed audiologists. The prices tend to be a bit lower than the local average and because the students are learning, you may get a bit more time at each appointment. The potential downsides include a rotating group of providers (some people really like seeing the same professional every time they need care) and the reality that most university clinics shut down or reduce access between semesters.

If all of the above still make hearing aids outside your budget, there are financing options such as Care Credit and a few charitable options like the Starkey Hearing Foundation.10 Some Lion’s clubs refurbish and donate hearing aids to needy community members.

The Big Day

Once you’ve made your purchase, you need the device fitted and programmed to your specific hearing needs. In some cases, the office has stock RIC-style instruments that you can walk out the door with on the same day as your test. More commonly, the hearing aids you select will be ordered and you will return for a fitting anywhere between two days and a few weeks.

At that fitting appointment, the following should occur:

  • Verifying the physical fit of the hearing aid. Custom hearing aids, like dentures, might need minor modification which can be done in the office. For RIC hearing aids, a “dome” will be selected that keeps the speaker securely in place. Once this is done, the hearing aids should be roughly set to your loss and turned on to ensure there is no acoustic feedback. If so, adjustments to the dome or hearing aid need to be made.
  • Setting the hearing aid levels. The American Academy of Audiology, the American Speech-Language Hearing Association and the Hearing Loss Association of America all recommend the use of Probe Microphone (aka Real Ear) measurement to ensure that the hearing aid settings are such that all speech sounds are audible at low levels, comfortable at conversational levels and tolerable at loud levels. The UCL measures discussed earlier are plugged into the Probe microphone system along with the audiometric thresholds to generate target values.

If these are your first hearing aids, these target values will probably sound too loud. Ask your provider to verify the hearing aids at target and then reduce them to comfort. Nearly all hearing aids can activate a timer so that the hearing aids return to the target values over one or two months (auto acclimatization). This allows you to gradually get used to the hearing aids but ensure that you don’t stay at the sub-optimal amplification levels longer than necessary.

Reviewing the Features

Next, you should be shown each of the features you and your provider selected. Be sure you understand all the controls, how to change batteries or charge the devices and what each program and accessory does, and when to use them. Practice inserting and removing the devices as many times as you need until you feel comfortable and independent.

Set a Benchmark for Progress

Ask your provider to complete a standard outcome measure with you such as the Abbreviated Profile of Hearing Aid Benefit (APHAB) or the International Outcome Inventory for Hearing Aids (IOI-HA). Both are integrated into the “Noah” hearing aid framework that most providers use or are available for download. In addition to Probe Microphone Measures, the use of an outcome measure is part of recommended best practice. This measure will be the “unaided” baseline. Just before the end of your return option, arrange to meet and complete the “aided” section of the outcome measure. If the fitting is appropriate and successful, you should see measurable improvement compared to the baseline. Additional cycles of this process can be used anytime major changes or new accessories are added to your hearing system.

Parts and Labor

As noted earlier, hearing aids are well protected from the elements, but the part that goes in your ear (the speaker) is susceptible to damage or clogging. Your hearing aid will come with some “wax guards” that you will change every month or so, but sometimes, something else goes wrong under the hood and the device needs to go into the manufacturer for service.

Hearing aids should come with at least a one-year warranty that covers repairs as well as a one-time loss and damage claim. Additional years of service are generally available to purchase either in the form of additional years of warranty from the manufacturer, or as a “service contract” from the provider. These packages usually include quarterly cleanings, batteries and a limited number of adjustments.

Adjustments

If properly fitted, hearing aids shouldn’t need many adjustments, but it’s important to specify exactly how many are included in the price and how much additional service might cost. Hearing aids have historically been sold in a “bundled” models where a higher up-front cost is justified because all service after the sale is “included.” It’s prepaid, and if you don’t need a lot, or are an experienced user, it’s very hard to see a positive return on that investment. To combat that, some providers offer an “unbundled” model. The initial payment is for the hearing aid, and an itemized list of services like fitting, Real Ear measurement and orientation. A few adjustments are included, but then subsequent visits are handled a la carte. Both models work for many people, and neither is inherently better. Ask which your provider uses and why. If that matches your needs, go for it. If not, shop around and ask hard questions.

Wrapping Up

As you can see, getting hearing aids is not as simple as grabbing a pair of cheaters off the rack at the drugstore. Neither is it an insurmountable task. Hearing is one of our primary senses because it connects us with the thoughts and emotions of those in our lives. As such keeping it tuned up is worth the effort to do some research, ask hard questions and be patient to find a solution and provider that matches your needs and personality.
After the devices hit your ears, a process or neural rewiring begins that can take up to three months, so be patient. Seek the advice of others who have walked in these new and louder shoes.
On the lighter side, remember that the volume control on your new hearing aids give you the superpower of reducing the rhetoric and amplifying the awesome!

Facts and Statistics About Hearing Loss

  • Globally, 466 million people have disabling hearing loss.11
  • Hearing loss is the third most common physical condition behind arthritis and heart disease.[/citaiton]
  • 91% of those experiencing hearing loss in the US are over the age of 50. Those with untreated hearing loss had a 52% greater risk of dementia, a 41% higher risk of depression and an almost 30% greater risk for falls when compared with those who had no hearing 13loss.12

Hearing aid adoption

  • Across the globe only 17% of those who need a hearing aid actually use one.14
  • 4.2 million hearing aids were sold in the US in 2019.15
  • 80% of adults between 55 and 74 who would benefit from a hearing aid don’t wear one. Hearing aids are generally not covered by health insurance or Medicare which is a major reason many people who need them do not get them.16
  • Older adults who use hearing aids have reduced signs of depression and an improved quality of life.17

Recent Innovations

  • In August 2020, the FDA is required to give guidelines for over the counter hearing aids. This is expected to mean there will be high-quality hearing aids that meet government standards available at a lower cost. The latest hearing aids can connect to a smartphone, making it easier to talk on the phone and allowing the wearer to make adjustments using an app. Hearing aid batteries can now be recharged, helping older adults avoid changing small batteries and giving around 30 hours of use per charge. Some hearing aids can now monitor health and wellness information like heart rate and steps and can even detect when someone has fallen.18

Hearing aid market

  • The average hearing aid in America costs $2,300.19
  • In 2018 the global hearing aid market was estimated at $8.4 billion.20
  • Europe and North America are the industry’s largest markets, though Asia Pacific is growing the fastest.21

As a practicing audiologist since the 1990’s, Brad Ingrao, AuD has fitted thousands of hearing aids to seniors and people of all ages. Brad is the Official Audiologist for the International Committee on Sports for the Deaf and a well-known speaker. Dr…. Learn More About Brad Ingrao

Since graduating from Harvard with an honors degree in Statistics, Jeff has been creating content in print, online, and on television. Much of his work has been dedicated to informing seniors on how to live better lives. As Editor-in-Chief of the personal… Learn More About Jeff Hoyt