To the benefit of all of our members who have hearing issues, or who have family members or friends who do, RCFC member and Doctor of audiology Shana Tidrick gave us an overview of the range of hearing problems and some of the possible methods of addressing those problems for our first in-person meeting of 2023.
After inviting us to think about our favorite sounds and the emotions and connections that those sounds create, Dr. Tidrick gave us a brief overview of her background. She comes from a family whose members tend to live long lives but tend to develop hearing problems at relatively young ages. She is a Doctor of Audiology by training and has experience working in both clinical and educational settings. For the past 15 years she has worked for Demant, a global hearing healthcare and audio technology group. Within the company, she first worked for Oticon in the pediatric sector before moving to Oticon Medical to focus on hearing implant technology.
She says that the questions that she gets asked most often are: why are hearing aids so expensive; what is the best aid; and what do you think of over-the-counter (OTC) hearing aids? To get to those questions, she started by establishing hearing problems as a healthcare issue, not simply a hearing issue. As such, and given the complexity of how we hear, there is a wide range of hearing technology. This includes, but is not limited to, the following devices:
Cochlear Implants: for individuals with the most profound hearing losses who cannot benefit from standard hearing aids
BAHS, bone anchored hearing systems/implants: for individuals with outer or middle ear pathologies
Hearing aids: available in a variety of styles and price ranges, these devices are customizable for adults and pediatrics with all types of hearing loss, must be fit by an audiologist or hearing instrument specialist
OTC (over the counter) hearing aids: programmable devices for adults with perceived mild to moderate losses
Otolaryngologists, more commonly known as ear-nose-throat physicians (MD or DO plus 5-7 years of residency) are trained to treat pathologies and perform surgeries. Audiologists (a 4-year degree plus an AuD, PhD, or ScD) are trained in hearing and balance disorders, hearing aids and implants, and are qualified to work with both adults and pediatrics.
Hearing instrument specialists (minimum requirements of a high school diploma or GED plus an apprenticeship or an associate degree) are trained to work with adults and hearing aids.
Understanding of an individual’s hearing loss may start with an audiogram which tests the hearing threshold (loud to soft) against a range of sound frequencies (low pitch to high pitch) across the range of normal sounds with which humans have to deal. Although this is important, two individuals with the same audiogram might require quite different assistance with their hearing. The auditory system is complex-sound travels from vibrations in the air, to mechanical vibrations (bones of the middle ear), to vibrations in the fluids (cochlea) before being converted to electrical impulses which are sent to the brain. Our brain is where hearing takes place, the ear is a simply a conduit.
Approximately 5% of hearing loss (including excessive ear wax, ear infections, or trauma/missing anatomy) is due to issues with the external or middle ear. The other 95% is considered sensorineural and may be caused by aging, noise exposure (damage to the cochlea or auditory nerve), disease, or genetics. Finding the correct solution for one’s hearing loss requires consultation with an audiologist or hearing instrument specialist or, if the problem is medical, an otolaryngologist and audiologist.
Hearing loss creates two problems. First, it makes the brain work harder to interpret the sounds that are heard. The actual action of hearing requires real-time processing to effect the combination of listening, understanding, and predicting what will be said and requires considerable input from the brain. That real-time processing is the part of the hearing process that most rapidly declines. This is exacerbated by noise or competing sounds, which can become difficult even for 40 year-olds – so comprehensive evaluations should include speech-in-noise testing. The second problem is that, with hearing loss, the part of the brain that is dedicated to hearing processing is slowly taken over by other brain activities and, if not stimulated for hearing, is difficult to recover. Early identification (within the first 2-3 years of life) and fitting of hearing aids is critical. A child who is not fit during this early period, will have language and learning difficulties and in the worse cases, may never learn to speak. Adults, and children who lose their hearing after the age of two, have access to an auditory cache. As long as they are fitted with devices, will often perform similar to those with normal hearing in cognitive tests. However, the longer the brain goes without sound, the more difficult it is for those pathways to be regained. The bottom line is that hearing aids work.
Considering insurance coverage for hearing devices, there is a large amount of variability, between insurance companies, between countries, and between types of aid. In the US, most standard hearing aids are not covered. Cochlear implants are usually covered, and bone anchored implants are sometimes covered. Coverage is similar for adults and children and is more dependent on type of insurance than age. This is particularly concerning for children, as lack of amplification hinders or impedes speech development. An interesting sidelight is that for adult patients with sensorineural hearing loss, there is little difference in penetration between countries where aids are well covered by insurance and those where coverage is spotty or inconsistent.
Why are hearing aids so expensive? They don’t really have to be since there is typically a range of prices. However, effective aids are not just amplification devices – they include algorithm(s) to account for different noises and they are customized for each individual’s hearing loss. Over the counter hearing aids are limited in programmability and often do not include the support of a hearing healthcare provider. They can provide help for those with limited funds or access to providers. Before moving forward with any device, it is important to have a comprehensive hearing evaluation.
Bottom line, and most importantly, the best hearing aid is the one that you will wear!
Questions:
What about hearing help for ADHD/Autistic individuals who are overwhelmed by loud sounds?
A hearing evaluation should consider the individual as whole. This may include recommendations to other professionals, or a team of individuals (including the audiologist) to make sure patient needs are met. There are support groups both online and in person; help is available, but it may not always be in the first place you look.
Is there any connection between hearing loss and balance problems? As the inner ear is responsible for balance, the two are often connected. For some pathologies, a person may notice a hearing anomaly just before the appearance of a balance issue. Ongoing balance issues usually requires testing by an audiologist somewhere along the way.
More discussion about insurance coverage? Medicare usually covers implants, but it does not cover standard hearing aids. Alley’s Act https://earcommunity.org/about/allys-act-h-r-5485/
has been proposed to cover costs for implants for children and adults up to the age of 64. The recent approval of OTC aids will make access to standard hearing aids more available, but they do not include access to providers and are not appropriate for more significant hearing losses. Although other countries have better insurance coverage for adult patients, the uptake is still about the same.
Hearing aids have evolved from simple sound amplification to digital processing to address individual problems. What is next? Several possibilities: fully implantable cochlear implants; stem cell regeneration, and increasingly “smart” digital technologies.
What differences exist between individuals who have never had hearing and those who have lost their hearing at some point? After a brief discussion of differences in sign language across the world, she pointed out that there is a specific part of the brain that is normally allocated to hearing. For a child who has never had any hearing, that part of the brain never develops the framework for interpreting sound and, even with the most advanced technology providing sound to the brain, the individual may never be able to process the vibrations as interpretable sound. For adults and children who lose their hearing-if that hearing loss is not treated, access to the part of the brain that “hears sound” can be next to impossible to recover. The bottom line there is that you must use it or lose it. Hearing aids in a drawer do not work, no matter how good the hearing aids might be.