Frank Lin

Article / Updated 08-03-2023

Hearing loss is about clarity not volume. Most people think of hearing loss as simply turning down the volume on a TV, which makes all sounds quieter. But hearing loss is more like turning down the volume on only specific frequencies or pitches of sound so while some sounds are quieter others are just as loud. Many people aren’t a very good judge of their own hearing. In fact, most people tend to believe their hearing is better than it actually is, according to research from our own team at Johns Hopkins University. Why are we such bad judges of our own ability to hear? Barely noticeable changes One answer is that hearing loss happens gradually and slowly over time. The snail-like pace at which our hearing declines may make it difficult to notice any changes. Early signs of hearing loss may be situational. We might miss a word here and there over dinner in a noisy restaurant or have trouble following a conversation with someone soft-spoken. It is easy to shrug off the seemingly isolated early incidents. Everyone else is mumbling! For most people, hearing loss affects their ability to hear high frequencies (whistling or birds chirping) while leaving the ability to hear low frequencies (animal grunts or thunder) relatively untouched. But not all sounds fit neatly into low or high frequencies. Speech has sounds from several frequencies. In fact, a single word can represent multiple frequencies. For example, the word “show” includes “sh” (high-frequency) and “ow” (low-frequency). With the most common types of hearing loss, the “sh” would be difficult to hear while “ow” would be perfectly audible. This results in a phenomenon where you would hear someone talking, but what they’re saying isn’t clear. This is why a common phrase among those with hearing loss is “I can hear you but you’re mumbling!” Hearing some sounds but not others affects clarity, which isn’t always something people think of when they think of hearing loss. Hence, sometimes it’s hard to make that leap to suspecting hearing loss. Compensating until you can’t Our brain plays a big role in making it tough to recognize hearing loss, especially when it first starts. Generally, our brains are great at their job of processing incoming information and can often still make sense of unclear speech. The brain does this by using contextual information like the general topic of conversation to fill in the blanks. This means that as we develop hearing loss, our brains initially do a pretty good job of making up for any hearing loss. But compensating for hearing loss requires a lot of extra energy and effort from our brains. Over time, our hearing tends to worsen and our brain’s ability to compensate lessens until it actually starts to slow down as well from the fatigue of keeping up with all the unclear sound. Don’t know what you’re missing Our brains are good at noticing new auditory information and ignoring common and mundane sound. Think about being in your own home versus visiting a place for the first time. In our own homes, we tend to ignore familiar sounds — the humming of appliances, creaking floorboards, or squeaking doors. But in a new place, our brains are on high alert, and we notice every single new sound. The same concept goes for common environmental sounds when we aren’t specifically listening for them: traffic noise from other cars while driving or chirping birds while walking through the park. When we aren’t specifically listening for a sound, it often becomes forgotten background noise. This makes it difficult to realize what we miss when we have hearing loss. Has your hearing declined? Given how difficult it is for us to judge our own hearing ability, consider having a conversation with those close to you to help you identify any hearing loss. Your hearing loss can impact them, too. In many situations, it is a spouse, child, companion, or other frequent communication partner who first detects signs of hearing loss — from little things like noticing you turn the TV up louder to feeling isolated from you because conversation has become more difficult. The perceptions of those around you is a great way to gauge your own hearing. It is also often helpful to look for clues in how hearing may be affecting your day-to-day life. Consider, for example, any changes in your social activity, communication patterns, and regular activities to help identify any hearing loss. You may be subconsciously avoiding situations or even altering the way you engage with people because of difficulty hearing. Take a minute to ask yourself some of the following questions to get a better feel for whether you may have some hearing loss: Are you asking others to repeat things more often? In follow-up, do you find others saying things like “Never mind, I’ll tell you later” when you ask them to repeat something? This may be a sign that others have begun to notice your hearing difficulties. Are you having trouble following conversations in meetings? Do you find yourself believing many other people mumble too much? Do you have difficulty hearing people when you aren’t looking directly at them when they speak or when they turn away from you during conversation? Have you felt embarrassed to contribute to conversations because you’re unsure of the topic? Do you feel excluded at dinner or other group conversations or unable to keep up? Do you have any difficulty hearing small children? (People with hearing loss often find children’s voices, which are higher pitched, difficult to understand.) Do you turn up the volume on electronics such as the television? Do you avoid talking on the telephone because it’s fatiguing and hard to make out what the other person says? Do others around you complain that the TV is too loud? Do you find yourself avoiding restaurants or social gatherings more than you used to because they’re too noisy? Do you find yourself more tired than usual when engaging in conversation? Are you avoiding activities you used to regularly participate in, such as attending concerts, plays, meetings, or religious services? If you answered “yes” to any of these questions, it’s a good idea to get your hearing tested. Read on to find out more. When to get your hearing tested Hearing loss is very common and more than half of all adults over the age of 60 experience hearing loss. It may be a good idea to schedule a hearing test when you turn 60 if you notice any of the signs of hearing loss mentioned above, whichever comes first. Screening, testing, and diagnostics You may see the terms hearing screening or hearing testing thrown around and sometimes you’ll see the term diagnostic hearing test versus self-guided hearing test. Here’s what these mean: Hearing screening refers to any assessment or task that helps identify whether or not you likely have some hearing loss but offers little details. Hearing screenings vary in how they’re performed and could be anything from whether you can hear someone whisper in your ear to a task where you have to identify numbers spoken in the presence of background noise. Hearing testing refers to pure-tone audiometry tests (see Chapter 7) that provides sufficient detail to describe your hearing in each ear using either the hearing number or categories like mild, moderate, severe, or profound. Self-guided hearing testing refers to hearing testing that is performed by you without the help of a professional, such as on a smartphone. Diagnostic hearing testing refers to a full battery of tests performed by a hearing professional, usually an audiologist, for the purpose of diagnosing hearing loss. Establishing a baseline A baseline hearing test simply refers to your first diagnostic hearing test, the results of which become the baseline or reference point for future hearing tests to keep track of any changes in hearing. The baseline test also helps hearing professionals create a custom plan for you based on patterns in changes in your hearing over time. We recommend establishing a baseline as soon as you suspect hearing loss or at least by the time you turn 60, even if you’re not particularly concerned with your hearing at the moment. Making the appointment Here are the details you need to know to make an appointment: Insurance, including Medicare, usually covers at least one diagnostic hearing test a year when ordered by a physician (check with your provider when in doubt). An audiologist will usually perform the diagnostic hearing test. Request a referral from your primary care provider (if required by your insurance company). Search online for a local audiologist near you that accepts your insurance or use websites like HearingTracker.com, which maintains a directory of audiologists from across the country with patient reviews. Curious about testing your own hearing? Try one of numerous smartphone- or web-based hearing tests and screeners such as Mimi Hearing or SonicCloud, which are free and can be found in your smartphone app store. You could also try the AARP at-home hearing screener found at nationalhearingtest.org (free for AARP members!).

Article / Updated 04-17-2023

Bluetooth technology and the wide array of smartphone apps make customizing strategies to aid in improving day-to-day functions with hearing loss a whole lot easier. Working with Bluetooth and hearing aids Bluetooth is amazing wireless connection technology. It is a short-range wireless connection platform that allows data transfer or connections between two or more electronic devices over ultra-high frequency radio waves that don’t interfere with other signals. Thousands of companies across the globe, including hearing aid manufacturers, have agreed on Bluetooth as the standard in wireless connection and have teamed up to form a special interest group that manages the technology, fosters Bluetooth tech advances, and maintains high security standards. Bluetooth allows hearing aids to directly connect to other devices, including smartphones and tablets, to stream clear audio such as music or phone calls. Many hearing aid companies now offer smartphone apps that connect to hearing aids via Bluetooth and allow the user to control hearing aid settings such as volume and programs or check on the hearing aid battery life. Most hearing aids connect to smartphones by making sure Bluetooth is activated on the smartphone and then turning the hearing aid off and back on. This prompts the two devices to pair. After the first connection, the devices will remember one another and automatically pair. Consult your hearing aid user manual, contact a tech savvy friend, or ask your hearing care professional when in doubt. Some hearing aids require a streamer (see “Streaming all your devices" below) to connect to other devices via Bluetooth. This is usually worn around the neck or kept in a pocket. But this is becoming increasingly rare as modern technology allows for a direct connection. Check product labels or speak with a hearing professional for how hearing aids connect to Bluetooth if you want to avoid using an extra device. Navigating smartphone apps You can find many, many smartphone apps for hearing loss — some free, some not — and it can be difficult to distinguish the good from the not-so-good. There are two main categories specific to enhancing your hearing: Apps to amplify sounds in your environment just like a handheld amplifier Apps to customize sound you listen to through your smartphone, such as when you take calls or stream music, so that it is tailored to your hearing But how do you know whether an app is going to be reliable? Here are some tips: Look for apps that are popular and have lots of downloads. Read reviews and comments by users. Download apps only from official app stores. Look at apps that have a history of regularly updating. Pay attention to permissions the app asks for on your phone; predatory apps may ask for permission to access unnecessary information (like an app to amplify sound requesting access to your photos or contacts). Hearing aid accessories Hearing aid accessories can be the difference between doing okay and thriving with hearing aids. Many companies offer a lineup of complementary accessories that can boost your experience with hearing aids and improve listening in certain situations. Every company has a different specific name for these products, but there are four common types: a remote control, a remote microphone, a TV connector, and a streamer. Using a remote control A remote control acts as a handheld operations center for your hearing aids. It allows you to discretely control your hearing aids without needing to locate and press any buttons on the hearing aids themselves. This can be especially useful for adults with stiff, numb, or arthritic fingers. With a remote control you can: Adjust the volume or mute the hearing aids. Change the programs to match the situation you’re in. Manage connections to other streaming devices. Trying out a remote microphone A remote microphone is a stand-alone or portable microphone that transmits a direct signal to hearing aids from a distance. Remote microphones excel in helping with hearing in difficult listening environments from noise or overcoming distance issues. Hearing aids can mute or dampen any other sounds around you while focusing only on the remote microphone to substantially improve clarity. Remote microphones are one of our favorite accessories and something we recommend to almost every hearing aid user who has trouble with hearing aids in noisy situations. We compare the remote microphone for those with extra trouble with speech in noise to using snow tires for driving in cold weather areas: It’s a must-have accessory! There are two main styles of remote microphone: one-on-one remote mic and group setting remote mic. One-on-one remote mic The most common style is a portable personal microphone for focused conversation when you’re only interested in hearing one specific person speak at a time. The person speaking can hold it, wear it around their neck, or clip it to their shirt or jacket lapel. The sound from the microphone is channeled directly into your hearing aid. Let’s go through some examples of when the remote microphone comes in handy: If you are at a noisy restaurant for dinner, you can have the person you’re dining with wear the remote microphone so that you receive a more direct signal of their voice with less background noise. In some social settings with lots of noise, like a large gathering or at a bar, we tend to move from conversation to conversation. You can bring the one-on-one remote microphone and either hold it yourself near the person (see the figure below) or ask the person you’re speaking with to hold to it for a boosted signal. Lectures can be difficult if you’re forced to sit far away from the speaker. Even if the venue has a sound system, it can still be difficult to understand the speaker depending on the acoustics as well as the quality and placement of the speakers. You can either place the remote microphone on the podium or request the speaker wear it to give you a direct signal (see the figure below). The range on remote microphones varies from roughly 30 to 90 feet depending on the manufacturer. If you’re in a small group setting with the one-on-one remote mic, like a noisy restaurant with a group of three, you can try placing the microphone on the table between your dining companions or ask them to pass it back and forth as needed. It’s an extra step but will make for a smoother and more enjoyable conversation for everyone. Group setting remote mic A newer version of the remote microphone is a table remote microphone that is specially designed for group conversations. This product sits on a table and uses a combination of advanced signal processing and special microphones called beamformers to identify and focus on anyone speaking at the table and transmit that signal directly to your hearing aids. The table remote microphone is a great option when in a restaurant or at home with multiple people or for use at work meetings around a conference table (see the figure below). At the publication of this book, this is a newer product and is only available through a few hearing aid manufacturers, but the initial popularity among patients suggests it’s going to quickly become a widely offered product. Connecting to the TV The TV connector serves a very specific role of transmitting the audio signal from any home audio device, namely TVs and stereos, directly to your hearing aids (see the figure below). Simply plug the TV connector into the audio port on your TV or stereo to connect to your hearing aids. This can make listening to TV much more enjoyable with a direct and sometimes clearer signal compared to using your hearing aids alone. Many companies now offer the capability for the TV connector to stream to multiple sets of hearing aids if you are watching TV with a friend or family member! Streaming all your devices Technology is rapidly evolving, and some hearing aids can directly connect to smartphones and other accessories mentioned in this section. However, some hearing aids will require a streamer (see the figure below) to act as an intermediary transmitter to allow hearing aids to connect to other products. The streamer is usually worn on a lanyard around a hearing aid user’s neck or kept in their pocket. For some hearing aid manufacturers, the streamer and remote control are combined into a single product to make your life easier. Make sure you do a little research first to find out if your hearing aids require a streamer to connect to accessories and your smartphone. When purchasing hearing aid accessories, make sure they are compatible with your hearing aids. At the time of this book, most hearing aids are only compatible with accessories made by the same manufacturer. Even within a single manufacturer, new generation technology does not always work with older technology. You can always ask your hearing care professional to help you navigate the accessories market.

Article / Updated 01-26-2023

Modern hearing aids are sleek, and many styles are nearly invisible. This is a far cry from early hearing aids that required body-worn accessories (to visualize that, imagine something like the old Discman CD player worn on your belt with wires attached to headphones). It’s also a far cry from the mental image many people have when they picture hearing aids as large and bulky pieces of plastic that stick out from behind the ear connected to huge earpieces sitting in your ear canal. Hearing aids come in several different shapes and sizes to customize the fit to the wearer. This article covers the broad-style categories but always remember that other variants exist and different manufacturers use different names. Generally, there are two main styles of hearing aids: behind-the-ear and in-the-ear. Each has some subtypes. A good hearing aid fit is important to prevent that buzzing sound that is known as feedback. This happens when the amplified sound coming out of the hearing aid speaker is picked up again by the hearing aid microphone and reamplified. Behind-the-ear hearing aids Behind-the-ear hearing aids, often known as BTEs, are the most common style of hearing aid. It sits behind the ear — hence, the name — while a tube runs to the front of the ear where it connects to either an earmold or dome in the wearer’s ear canal, as shown in the figure below. While earmolds are custom made to fit a wearer’s ear, domes are premade mushroom-shaped silicone pieces that come variety of sizes and designs to find the best fit for the wearer’s ear canal. BTEs have evolved into several subtypes, each with its own advantages and disadvantages. Earmolds require a custom impression of your ear canal. There are at-home, do-it-yourself earmold impression kits, but we recommend you use these with caution. Improper use can leave silicone material in the ear which requires a professional to remove. When in doubt, see a hearing care professional to make your earmold impressions. Traditional BTEs The traditional BTE (see the figure below) houses all the components of the hearing aid (the microphone, amplifier, processor, and speaker) in a single space that sits behind the ear. It is connected to a custom earmold using flexible, medical-grade plastic tubing. The BTE is a fairly rugged product that provides ample space for more powerful hardware, which can accommodate the needs of any degree of hearing loss. There are even “power” models for profound hearing loss. While the traditional BTE is the most versatile of hearing aid design, it has not always been perceived as the most discrete, so engineers have come up with newer versions of the BTE: slim tube and receiver-in-the-canal BTEs. Slim tube style BTEs Like the traditional BTE, the slim tube BTE (see the figure below) also houses all the components of the hearing aid behind the ear, but it uses much smaller tubing for a more discrete look. Rather than using a larger custom earmold that fills up the ear, slim tube BTEs use a dome or smaller custom earmold that sits deeper in the ear canal. The smaller size limits the slim tube style to mild to moderate hearing losses. In some cases, the slim tube style can work for severe hearing loss, but it is pushing the boundaries of this style’s capabilities. Receiver-in-the-canal style BTEs With a newer receiver-in-the-canal (RIC) BTE (see the figure below), the receiver or speaker sits in the dome or small earmold in the wearer’s ear canal and is connected to the body of the hearing aid behind the ear via a wire. This means that the signal output is being delivered right into the wearer’s ear rather than having to travel through tubing from the hearing aid body sitting behind the ear. This style may result in a clearer, crisper signal and can reduce feedback. Its design is smaller and more discrete. The major drawback to this style is that the receiver and wire are delicate and require regular maintenance and a gentle touch to avoid becoming damaged easily. Open and closed styles Slim tube and RIC styles often use domes rather than custom earmolds for the part that sits in the ear canal. These domes can be open or closed fit, which refers to whether the domes have holes in them (open fit) or not (closed fit). People with milder, high-frequency hearing losses can use open fit domes, which allow for more natural sound to enter the ear canal and allow for the ear canal to breathe. Conversely, closed fit domes are used for more moderate or severe hearing loss as they block outside sound and amplify low-frequency sounds. Open domes help prevent the occlusion effect — that is, when your ears feel plugged up and your voice sounds louder to you with an echo-like quality. You might also refer to this sound quality as “hollow” or “booming.” This happens because when we move our jaw to speak or chew, we create vibrations in the ear canal. When the ear canal is completely blocked with a hearing aid or earmold, those vibrations can’t escape and result in the occlusion effect. People who have better low-frequency hearing and use closed domes, earmolds, or ITE-style hearing aids are more likely to report experiencing the occlusion effect. Should you run into this issue, check with your hearing professional. Fun fact: You can simulate the occlusion effect by repeating words and sentences aloud with and without your fingers plugging up your ear canal (alright, maybe not that fun). In-the-ear hearing aids With in-the-ear hearing aids, also known as ITEs, the entire device sits in the wearer’s ear (see the figure below). These devices are custom made and require an earmold impression to be sent to a manufacturer. Popular smaller variants of the ITE are referred to as completely-in-the-canal (CIC; see the figure below). These styles are even smaller and, as the name implies, sit deeper in the ear canal. In fact, the CIC is essentially invisible and so small it requires an attached removal handle to get it in and out of the ear canal. The primary purpose of the CIC is cosmetic. A major drawback is that the small size comes at the expense of power. These small hearing aids are intended for mild hearing loss and cannot address the needs of more moderate or severe loss. The size of the CIC also limits the features available; CICs often can’t use advanced technology features like directionality. Some users who choose these styles become disappointed in their hearing aids and believe them to be ineffective when, in reality, these people have been fit with a hearing aid that is inappropriate for their level of hearing loss or hearing needs. ITEs are a great option when the user has problems inserting and manipulating behind-the-ear–style hearing aids due to numbness in their fingers or arthritis. The custom shape of the ITE makes it somewhat easier to slip into the ear. Pros and cons of hearing aid styles Picking the right hearing aid for you requires checking out the pros and cons of each style of hearing aid. Take a look at the table below to see which style may be the one for you. Hearing Aid Styles Pros and Cons Type Used For Pros Cons Traditional behind-the-ear All degrees of hearing loss from mild to profound Extremely versatile device with widest range of available features Relatively larger in size and most visible to the eye Slim tube behind-the-ear Mild to moderate hearing loss with some flexibility to fit severe hearing loss depending on the specific device Less visible than traditional BTE and can use open domes for more natural sound Requires enough dexterity to manipulate smaller size than traditional BTE and doesn’t meet the needs of most severe and profound hearing losses Receiver in the canal behind-the-ear Mild to moderate hearing loss Smallest BTE, clear sound from placement of speaker in the ear Most fragile BTE In-the-ear Mild to severe hearing loss Custom fit that is easiest to use when wearer has limited dexterity Smaller size may limit a few features Completely in-the-canal Mild hearing loss Nearly invisible Small size limits power and features like directionality

Cheat Sheet / Updated 10-21-2022

Hearing loss among adults is common. Almost half of all adults over the age of 60 have hearing loss. Understanding and treating hearing loss is important for our emotional, cognitive, and even physical health. In fact, recent research suggests hearing loss is a risk factor for social isolation, loneliness, falls, cognitive decline, and dementia. It’s important to know about hearing loss, the signs of hearing loss, strategies to use to talk to someone with hearing loss, and how to tackle hearing care.