Hearing Aids

The outer ear is made up of the pinna (the part that sticks out from the head) and the ear canal. The air-filled middle ear starts with the tympanic membrane (eardrum) that completely seals the ear canal from the middle and inner ear structures. The three tiniest bones in the human body, the ossicles, are called the malleus (“hammer”), the incus (“anvil”), and the stapes (“stirrup”).

The job of the middle ear system is to convert the sound collected by the outer ear into mechanical energy by vibrating, sending it into the inner ear at the oval window (the base of the stapes). The middle ear also has another important structure, the Eustachian (yoo-stay-shin) tube, which serves to aerate the middle ear on the other side of the tympanic membrane. This allows our ears to have the same air pressure on both sides of the tympanic membrane.

The inner ear is itself divided into three parts, by their jobs. The cochlea is the tiny, snail shell-shaped organ that changed the vibrations from the middle ear into electrical energy to travel up to the brain. In the inner ear is a fluid related to spinal fluid and many tiny structures that hold up hair cells to transmit nerve impulses to the hearing nerve. The other two parts, the vestibule, and the semicircular canals, are the vestibular system, which monitors head movements, eye movements, and posture, contributing to our ability to stay standing. When patients are dizzy we want to rule out that there is a problem in the vestibular system.

The rest of the ear is actually made up of the nerves that lead to the auditory cortex in the brain and the auditory cortex itself. The brain attaches meaning to the sound it heard, whether it is music, words, environmental sounds, or an alarm. This is called auditory processing.

Hearing loss can have many causes, which are rooted in the anatomy and physiology of the cochlea. Hearing loss can be a result of blockage in the ear canal – ear wax, foreign bodies, and ear canal infections can all cause hearing loss.

The middle ear space – behind the eardrum—may also contribute to hearing loss. Fluid in the middle ear (“Otitis media”), holes in the eardrum, or poorly functioning ear bones are some of these middle ear causes.

In many cases, hearing loss is a result of deterioration of nerves that bring hearing signals from the ear to the brain. This “sensorineural loss” is the most common source of hearing loss in adults and may be due to occupational and recreational noise exposure, or simple aging. The rise of portable listening devices such as the iPod has also been associated with hearing loss.

Syndromic, hereditary, and congenital abnormalities may also contribute to hearing loss.

An audiologist is a person who is trained to perform specialized tests of hearing and vestibular function to determine if hearing loss or a vestibular problem is present. Audiologists determine where in the system the problem is, provide rehabilitative approaches, and make appropriate recommendations.

Their scope of practice includes hearing aid dispensing, cochlear implant team, intraoperative monitoring for ear- and nervous system-related surgeries, hearing conservation design and implementation, newborn hearing screening, aural (hearing) rehabilitation, central auditory processing disorders, tinnitus management, and teaching audiology and speech-language pathology students.

Audiology professionals work with all ages, from infancy and childhood to adults and seniors. Job settings include private practice, working with ENT physicians, hospitals, universities, mobile vans for hearing conservation, military service, government settings, and schools. Most audiologists have doctoral degrees such as an Au.D, Sc.D, or Ph.D. There are only approximately 16,000 audiologists in the United States.

It is very common for people with gradually progressive hearing loss to think that nothing is wrong and that the difficulty lies in others “mumbling” or “not speaking clearly.” We often have no clue that we are struggling to hear because the brain gradually adjusts to each slight incremental change in the hearing, tricking us into believing we are just fine. Part of the answer, too, is that hearing loss, when not total, can seem “intermittent” or situational. 

Since many types of hearing loss are preventable there are seniors who have minimal or no hearing loss. Still, the majority of seniors will have some hearing loss in later years.
There is no such thing as “a normal amount of hearing loss for your age.” Many adults have gradual inner ear hearing loss during their working years; it is not limited to seniors.
Gradual hearing loss does NOT mean that a person will necessarily lose all hearing. By the same token, wearing hearing aids will not prevent further hearing loss.
Any hearing loss that is present and interferes with communication is not normal for any age and needs to be treated.

We know even a mild hearing loss or hearing loss in one ear can greatly affect a patient’s ability to communicate, in children and adults. We want to know many different things about hearing loss to guide the patient to the proper treatment.
It’s important for your audiologist to know if your hearing loss is present in one ear or both, mild or severe, middle ear or inner ear, sudden or gradual, with an illness or head trauma, and many other questions.
Does the patient also have vertigo or tinnitus? Does the patient have a family history of hearing loss? Do other family members need to get tested? Do the results show that other types of physicians should be involved in the patient’s care? Is the patient a surgical candidate or hearing aid candidate?

Studies have shown that hearing loss isolates people from their friends, loved ones, and community. This isolation can be manifested in withdrawal, depression, anxiety, and worsening of physical medical conditions. Furthermore, studies out of Johns Hopkins and the University of Pennsylvania show that untreated hearing loss can put a person at a greater risk of dementia and brain atrophy.
People with uncorrected hearing loss in the workforce also tend to earn a lower salary than their counterparts who have sought help.

Earwax (cerumen) is a common culprit of hearing difficulties in the outer ear. Many people are concerned about their ear wax and have lots of questions about why and how it accumulates—and how to prevent wax buildup. Earwax buildup may frequently occur in some individuals because of ear canal shape and some health factors.
The best way to safely clean ears is with a washcloth on the outside of the ear. The use of Q-tips may push the wax back into the canal and closer to the eardrum. In some instances, people have perforated their eardrums with Q-tip use.

The three ways that a healthcare professional can remove wax from the ears are: manually with a wax loop, by gently pressurized water, or with suction.

A wax loop is a hand tool that scoops out earwax. This is ideal if the wax is loose or soft and not adhering to the canal walls or is not too far down in the ear canal. For wax that has been in the ear canal for a while (and thus is usually dense, dark, often adhering to the canal walls), the best methods are to suction out with a mini specialized vacuum or to gently loosen it and wash it away with irrigation.

Often wax removal needs to wait after discovery to allow for softening and loosening by the patient (for more comfortable removal) with an over-the-counter product such as Debrox or equal parts hydrogen peroxide and water. This is possible after the canal has been deemed medically ready; in other words, the tympanic membrane (eardrum) has no hole in it.

Always check with your healthcare provider before using one of these products in case any change in hearing is due to eardrum perforation. People with infections and open eardrums should not use these products.

Ear candling describes the practice of placing a hollow candle in the ear canal, lighting it, and allowing the candle to burn within five to ten centimeters from the person’s ear. The manufacturer claims that it removes impurities and earwax from the patient’s ears with suction created by the candle. In fact, no suction occurs with the candles.

The residue left behind has been found to be remnants of the candle and not earwax or toxins from the body. Ear candling is not therapeutic and places the user at risk for burns of the face, ears, and eardrums. It does not remove ear wax. The manufacturer also claims that ear candling originated with the Hopi tribe, but the tribe has stated that this is not true and has asked the manufacturer to stop making that claim.

When someone has Eustachian tube dysfunction he/she may feel sensations such as ear pain, pressure, fullness, clogged ears, hearing his/her own voice in the ear very loudly, and have difficulty monitoring voice volume. Common causes are barotrauma (air travel or scuba diving) and sinus involvement.

A traditional treatment approach is for the patient to utilize nasal sprays to help to alleviate the discomfort and reduce swelling. Some patients have surgery to open the eardrum to relieve the pressure.

Many people have been treated with a newer approach that is neither invasive nor painful. It is called middle ear insufflation. It works with the body to help the Eustachian tubes open with gentle air. It can be done from age five and older, in the office or home. Most patients that have middle ear insufflation see an improvement or full relief following the treatment. Children who use the home version of this device tend to have fewer episodes of otitis media.

95 percent of all hearing losses can be successfully treated. If a hearing aid has been suggested to you, then you will probably see a significant increase in your quality of life by using one. Sadly, only one-fourth of those who could benefit from hearing instruments actually purchase one.

Some patients ignore their loss because they believe hearing instruments can’t help their specific type of loss. Others incorrectly believe they are too old to benefit from amplification. No person is ever too old to benefit from the improved communication that hearing instruments can provide.

Most people with inner ear hearing loss benefit from hearing aids, when fitted properly. Some patients may have an “unaidable” ear, in which there is too much hearing loss, the person’s ability to tolerate amplified sound is severely diminished, or there is an extremely poor understanding of speech. Even if a person was told some time ago that he “can’t be helped” or “nothing can be done,” it is important to get a new opinion because so much in amplification science has changed! We are able to help more people than ever before with new devices.

For people with aidable hearing loss in both ears, we know that the best listening happens with both ears giving the auditory cortex the same information. They will hear and understand better in quiet and in background noise; they won’t have a “useless side” in a restaurant or family gathering (the people on the unaided side get ignored); and they can better localize the direction of the sound source, which is critical in communication and for safety purposes.

We also know that a small percentage of monaurally aided patients will lose understanding of speech in the unaided ear, and we cannot predict who will experience that unfortunate situation. It is important to discuss this with the audiologist to determine the best outcome for each individual.

Custom-fit hearing aids need to go to a lab to be made, so they may take approximately two weeks to arrive at our audiology office. Aids that do not have custom-fit parts arrive quickly and the appointment for the fitting can be arranged sooner, based on the audiologist’s and patient’s availability.

Nearly all people who need hearing aids have cosmetic concerns. Others worry about what other people will think of them if it is known that they have hearing loss. Still, others are worried about the maintenance and upkeep of hearing aids. While not addressing all of these concerns, new hearing aids are a huge improvement on previous devices.

Digital hearing aids are nothing like their old analog counterparts. Older hearing aids were bigger and the sound quality was much poorer. In addition, there was relatively little adjustment for sound quality. There were few ways to avoid amplifying in areas where the wearer did not need amplification. There were no adjustments for hearing better in background noise.

Old aids used to whistle while sitting in the person’s ears, and the wearer was unable to prevent it or even hear it when it was happening. Despite these disadvantages, there were, in fact, many satisfied hearing aid wearers, even with older hearing aids. We all tended to hear about the unsatisfied patient, not the satisfied ones!

With new digital technology, we can shape the sound specifically for a person’s hearing loss, giving sound only where it is needed. This is done through a computer and a patient-worn interface at the time of the appointment, allowing the computer to send changes to the aids. We can adjust the type and method of noise management in the aids.

We can also digitally suppress feedback, the whistling that used to be common. There are even many aids which have Bluetooth capability, allowing a user to have the sound of the cell phone or television directly in the aids, for infinitely more clarity and ease of use.

Despite the amazing flexibility that the digital platform provides for hearing intervention, hearing aids still require acclimation. Remember that the hearing-impaired individual most likely gradually lost hearing over many years. Suddenly we are asking that person to listen to a lot of sounds that they have not had to process for a while. We certainly can shape it to make it comfortable but the new wearer still will hear things that have been inaudible for a very long time.

The person who patiently and consistently uses hearing aids over a period of time will be rewarded for their efforts with an ease of communication and access to a palette of music and sounds that they have been missing.

There is no dependency, as in addiction. Once the person acclimates to the new sound over a period of weeks, there is a wonderful enhancement to communication that they will notice. They will definitely notice the difference when they take the aids off for the night, but no actual permanent hearing change will happen in the head or ears. This is just the brain noticing the stark contrast between aided and unaided hearing.

Hearing aids should never hurt the wearer’s ears, either with the physical fit or by causing a greater loss of hearing. If the aids are not completely comfortable, then that needs to be communicated to the audiologist. Hearing levels should be monitored and verification of the fitting will ensure that the sound is not too intense for the person’s hearing.

Aids should be worn in almost all listening situations. They should be removed at night and placed in a dehumidifier to remove moisture from the day. If a wearer is taking a nap, it is fine to leave the aids in the ears if desired.

Hearing aids should not be worn in excessively noisy situations, when listening to music, or where water is involved (shower, hot tub, swimming, etc). Ears with hearing loss need to be protected from intense noise such as loud music, power tool use, and impact noise such as firearms of any type. Aids should not be worn to bed. If a hearing-impaired person fears not hearing alarm clocks or a fire alarm, there are special alerting devices. The audiologist can suggest the best options.

You may wear hearing aids through the security checkpoint at this time. Of course, you may be asked to remove them by the TSA agent, or regulations could change in the future which require air passengers to remove the hearing aids from their ears.

Almost all hearing aids are vented in some way in the ear canal to keep ears comfortable during the pressure changes that occur during the flight, so it is not necessary to remove hearing aids for flying if you do not wish to do so.

If you are someone who finds that the pressure changes in the cabin are bothersome to your ears, you may wish to try a pair of Ear Planes, which are available at drugstores and pharmacy areas of larger stores. These are designed to slowly change the air pressure in the wearer’s ear canals to help reduce the discomfort some people feel in their ears when flying. If you are using Ear Planes, you cannot wear hearing aids at the same time. Be certain to bring your case with you to store the aids to avoid having to roll up the aids in a tissue, an easy way to break, unintentionally launder or lose the devices.

All hearing aids use batteries, but there are different sizes. It is important to purchase the correct battery size for your aids. Just like a cell phone or watch, the wrong size will not allow the hearing aids to operate. The audiologist will tell you the correct size and may offer suggestions about where to buy batteries.

A few hearing aid manufacturers have begun offering models that use rechargeable batteries, but most of these cannot yet power the instruments for the wearer’s full day. This technology may be utilized by more hearing aid models in the future but is not yet widely available.

Battery manufacturers have begun offering mercury-free batteries and these have just started to be available in many areas. Although the manufacturers say that batteries can be thrown out in the trash, recycling is environmentally-friendly and easy to do. Many audiologists will collect spent batteries to recycle for you if you are a patient at their facility.

Batteries, no matter what chemicals comprise them, are dangerous if swallowed. Never keep batteries where a child or pet can get to them. They should never be handled near medications. Hearing aid batteries are small and pill-shaped. They should not be placed on any horizontal surface (like a counter or bureau top) other than in the case itself so that they will not be accidentally ingested with food or pills. If a pet or person is thought to have swallowed a battery, immediate emergency medical services are needed. Do NOT attempt to make the pet or person vomit to retrieve the battery. Again, emergency medical services are needed immediately to properly and safely remove the battery from the person or pet.

Batteries should not be kept in the refrigerator or a hot car. They should be stored at room temperature away from children and pets.

Each year, many hearing aids are brought back to the audiologist, damaged by a pet who chewed it. No matter how carefully the aids are cleaned, the scent of earwax will not be removed. It is the perfect size and scent for a pet appetizer. This, of course, is dangerous for both the pet and the device!

Most hearing aids have a loss and damage policy for the first year or two, but these policies always charge a deductible. If the loss and damage policy has been used, the wearer may wish to purchase new loss and damage insurance on that aid. The pet does not have loss and damage insurance on it, so for all concerned, please keep hearing aids and batteries away from pets.

Hearing aids should be wiped with a clean, lint-free cloth after each day’s use. The battery doors should be opened to prevent battery drain during the night. Moisture and wax are two common enemies of hearing aids. Wax traps at the end of the earmold or aid keep wax out of the electronics. If wax has collected in the wax trap, it is easy to change.

A wonderful place to store the hearing aids at night is a hearing aid dehumidifier. It removes the moisture that might have developed in the aids during the day. This device is good to use in any weather, not just humid days since the wearer’s body transfers moisture to the devices in the cold or heat.

Hearing aids can go anywhere a person can go, with the exception of water and noise. Never store hearing aids in extreme heat or extreme cold. It is best not to wear aids in very dusty or dirty environments.

We are always told that we should not take valuables to a hospital. There is no one who can monitor their whereabouts. The difficulty with this thinking is that patients need to communicate in the hospital with the staff, nurses, and physicians. Without their hearing aids, this can be a very difficult to impossible proposition.

If a family member is able to bring the aids each day and remember to take them home again, that is ideal. If that option is not available, ask if the hospital can loan a personal listener to the patient. Many hospitals have a loan program for these devices, which look like a Walkman with over-the-ear earphones for listening. These can be used to better hear the TV (and keep the volume down) as well as understanding essential communication with the healthcare professionals. They can be removed when the patient is resting or sleeping. These devices are returned at the end of the patient’s stay.

In long-term rehabilitation, it is more common for a patient to wear his or her hearing aids to this type of facility. For example, a container labeled with the patient’s name may be kept on the medicine cart and given to the patient each morning, returned to the cart at night with the aids inside.

Each facility has different policies; it is essential to discuss the hearing aid policy with the facility’s patient care coordinator. Specifically ask where the devices will be stored, who will handle them, who has access, and how a loss or damage claim would be handled if such a need arose.

Hearing aids can be paired with many devices to enhance the listening experience. These include Bluetooth devices that interface with cell phones, television, MP3 players, computers, etc., sending the sound directly into the wearer’s hearing aids. The listener hears as if the voices were speaking right in their ears, like wearing earphones, significantly increasing the signal to noise ratio and boosting intelligibility.

The listener can walk away from the device, in some cases up to thirty feet, and still be connected to the sound streaming from that device. The listener can choose to listen alternately to the streaming device and activating the microphones to hear someone speaking to them in the room. Phone calls are heard in both ears if desired.

People can also use a mini microphone that streams to the aids, again enhancing intelligibility by decreasing the distance and increasing the signal to noise ratio. If the mini microphone is placed on a lectern or meeting table or clipped to the person who is speaking, the listener can sit almost anywhere in the room, up to approximately thirty feet away, and hear very clearly what the speaker is saying. This mini mic may also be extremely useful in a car or in a noisy restaurant.

Alerting devices are important for helping people who have difficulty hearing alarm clocks, smoke detectors, doorbells, infant monitors, etc. The electronics are remade for hearing impaired people with different types of signals, or they can be wired to a central device that alerts the individual with flashing strobe light or vibration. For people who have difficulty hearing on the telephone, there are amplified phones or phones that send a signal directly into the hearing aids through a special program.

People who have conditions such as dementia and Alzheimer’s may have trouble using hearing aids independently. Many seniors with disabilities may have limited access to help and may not feel able to manage hearing aids. Even if help is available, hearing aids are small, need some care, and require consistent placement after removal to avoid damaging and losing them. The audiologist can suggest alternative devices, such as simple amplifiers with insert or over-the-ear headsets.

Hearing aids can be donated to various organizations that are able to remake the devices for underserved communities in the United States or abroad. Your audiologist can supply you with a list of organizations accepting donations.

Approximately 30 million people in the United States suffer from tinnitus. About 10 percent of the population will report experiencing tinnitus all of the time, and approximately 1 percent state that it affects their quality of life. 44 percent of people with tinnitus have minimal hearing loss or have thresholds in the normal range of hearing sensitivity. 1 in 4 people state that their tinnitus is loud, while 1 in 5 describes the tinnitus as disabling.

One way to reduce the possibility of getting tinnitus is to keep a distance from noise or wear appropriate hearing protection. It is essential to wear hearing protection during all noisy activities such as when using heavy equipment and power tools, riding a motorcycle, or using a snowblower or leaf blower.

It is difficult for music lovers to know if their earbuds or speakers are playing at a dangerous level that may cause permanent inner ear hearing loss and tinnitus. In general, if others can hear the music of the earphone wearer, it is too loud. If you cannot carry on a conversation over the music through earphones or speakers, the volume could be potentially damaging.

Musicians and music lovers should wear musician plugs during practice, rehearsals, and concerts. The type of music does not change the risk of music-induced hearing loss. Musician plugs evenly attenuate the intensity level of all music and lyrics, keeping the ears safer while maintaining the wearer’s listening ability.

Hunters can wear specialized hearing protection for use while hunting. Concert-goers and musicians, as well as hunters, must wear hearing protection at every exposure to effectively prevent hearing loss and subsequent tinnitus.

The relationship between hearing loss and tinnitus can be a bit confusing. Someone with a severe hearing loss will not necessarily have severe tinnitus, or tinnitus at all. Many people with tinnitus have hearing sensitivity in the normal range.

Many people with hearing loss will report having no tinnitus, although the presence of hearing loss is correlated with tinnitus for 90% of those with tinnitus. In patients who have tinnitus and hearing loss, tinnitus often improves or resolves when the hearing loss is treated.

Some parents may feel that a wait-and-see approach is best, or they may be advised to see if the baby develops speech on his own. Particularly with boys with delayed speech milestones, parents may be advised that boys are slower than girls and that they may safely wait before considering testing. This is not helpful advice. In reality, it is better to err on the side of caution and test a child as soon as hearing loss is suspected. No harm will come to a child if normal hearing is found but many difficulties can arise from the delay of diagnosing hearing loss in a child.

Children with hearing loss are capable young people who, with early and continuing guidance and assistance from their families, schools, and the medical community, can achieve and succeed at whatever they choose!

Children with hearing loss may be completely self-sufficient in the classroom or they may need assistance to achieve the best education. Hearing-impaired children should receive guidance from the Child-Study Team in the school with an IDEA or 504 Plan to guide professionals in creating a useful IEP (Individualized Education Plan).

A teacher may need to pre-teach concepts to the hearing-impaired child or follow up with each set of directions to make certain that the child understands them before moving on. The child may or may not require a teacher’s aide in the classroom. The classroom size may need to be modified. All classrooms for the hearing-impaired should have sound-absorptive material and should not be near noisy areas of the school.

In the classroom, children with hearing aids should sit close to the teacher for best hearing and visual cues. An FM system, which communicates between the hearing aids and a body-worn microphone on the teacher, provides improved signal to noise ratio for the best understanding of the teacher.

Optional accessories for hearing aids allow hearing-impaired children to use their hearing aids as their Bluetooth headset for cell, iPod, iPad, computer, etc. A miniature remote microphone is available for placing in front of or plugging directly into a TV for clear transmission.

Parents and teachers are essential for tracking their hearing-impaired student’s progress via questionnaires and continued discussion with the support team. Help from an audiologist is needed for providing the best amplification solution for the child’s listening environments and hearing needs. This includes real-ear verification measurements to help determine the best settings of the aids for that child.

Children with auditory processing disorders may have normal hearing on the hearing assessment, but they have difficulty making sense of speech at times, especially in difficult situations such as in background noise or if multiple commands are given simultaneously. Children with APD can learn to listen and understand better with appropriate auditory therapy with an audiologist or speech-language pathologist. They may benefit from hearing aids set very low or with an FM system to improve the signal to noise ratio in class.

Many children have one or more bouts of middle ear fluid, or otitis media, beginning at any age in childhood, including infancy. Some families will have a propensity for it, with one or both parents having had otitis media as a child. Other families will have just one child with frequent bouts of middle ear fluid. The fluid typically builds up in the middle ear space, behind the eardrum, after an upper respiratory infection and may or may not be painful. The child is not deaf during this period but may have hearing loss ranging from mild to moderate-severe. These children need to be seen by their physician and possibly by an ENT specialist for management of the fluid. Hearing should be tested before and after middle ear fluid management. Periodic checks with a simple eardrum test, called tympanometry, can be performed by an audiologist to monitor for the presence of middle ear fluid. Medical management of the fluid may be accomplished by a period of watchful waiting with the ENT physician, antibiotic administration if necessary, and/or removal of the fluid through the eardrum (myringotomy and pressure equalization tubes).

During the time that a child has middle ear fluid, his/her ability to hear and understand language is diminished to some degree. This can affect speech production or language learning. Children may not pay attention to parents or teachers. They may turn up the TV very loudly, or their own voice may be louder or quieter than usual. Children may have changes in behavior such as frequent crying, temper tantrums, or being quiet and withdrawn. Once the fluid has resolved the child’s hearing may return to normal, but testing should be used to determine this. For children with recurrent otitis media, hearing loss may develop permanently. Some of these children are candidates for hearing aids.

For children with hearing loss in one ear and not the other, or if they have a mild loss, that does not mean that there is no need to amplify or provide help in the classroom. These children are at greater risk than their normal-hearing peers for academic difficulty and grade retention because it is widely assumed that they will have fewer difficulties than children with greater hearing loss.

They may not be recommended for hearing aids or academic support services, when in fact, they are very much in need of these services. Even a mild loss or unilateral hearing loss causes auditory deprivation to a brain that is still learning how to process language and sound and can have long-term consequences if not treated.

Hearing aids can be expensive, but help is available. Health insurance companies may give a benefit, including Grace’s Law which in New Jersey requires insurance companies to provide $1000 per hearing-impaired ear to hearing aid purchases for children age 15 and younger. Some manufacturers of hearing aids have loaner banks to provide hearing aids for children for several months before parents decide to purchase. Help and guidance with these decisions can be made with the audiologist.

If you live in the states of New Jersey or Pennsylvania, Penn Medicine Becker ENT & Allergy Center offers hearing healthcare among its services. For a full list of services, please visit our Locations page.