Otolaryngology–Head and Neck Surgery (2006) 134, 1043-1050

REVIEW

Hearing aids: A review of what’s new

Harold H. Kim, MD, and David M. Barrs, MD, Portland, Oregon;
and Scottsdale, Arizona
aids currently available. Today’s hearing aids offer higher
OBJECTIVE: To review the recent innovations in hearing aid fidelity of sound, greater overall amplification, directional
technology. sound detection, and frequency-specific amplification. This
STUDY DESIGN: Review of the literature. paper will review recent advances in hearing aid technology
SETTING: Private tertiary referral otology/neurotology practice.
and its effect on the hearing impaired.
RESULTS: Recent innovations including digital signal process-
ing (DSP), directional microphone technology, and open mold
hearing aid fitting have resulted in improved satisfaction with
current hearing aids.
CONCLUSION: Current hearing aid technology with its inno- AMPLIFICATION IN SENSORINEURAL
vations better meet needs of individuals who are hard of hearing. HEARING LOSS
SIGNIFICANCE: The image commonly held of hearing aids by
the general public is a negative one that can be improved with A conductive loss requires only simple amplification to
greater education. increase loudness. The patient with SNHL has multiple
© 2006 American Academy of Otolaryngology–Head and Neck deficits in hearing, however, and is a much more complex
Surgery Foundation. All rights reserved. problem for amplification.3 First, the audiogram is
downsloping in more than 90% of adult and 75% of

H earing impairment affects an estimated 28 million

individuals in the United States.1 Predictably, hear-
ing impairment becomes more prevalent with age. Of
childhood SNHL,4 so some sounds are not heard at all
(decreased audibility). Since the loudness of speech
comes mainly from the low frequencies, speech will seem
those older than 65 years of age, 314 in 1000 individuals loud enough but comprehension is poor because the high-
are hearing impaired. In fact, almost half of those over frequency information is missing. This leads to the com-
the age of 75 years are hard of hearing. These numbers mon complaint that the patient can hear but not under-
are expected to rise as the baby boom generation contin- stand speech. This is accentuated in background noise.
ues to age. Only 5% have a conductive hearing loss that Second, the loss of cochlear outer hair cells in SNHL
can be helped either medically or surgically, with the results in cochlear tuning curves that are not as sharply
remaining 95% having a sensorineural hearing loss defined to a specific frequency. This results in the inabil-
(SNHL). Regrettably, only 1 in 5 individuals who stand ity of the cochlea to differentiate speech from noise when
to benefit from hearing aids acquires one2 and a quarter the two sounds are close in frequency. Hearing-impaired
of those patients do not wear a hearing aid due to prob- people need more information in noise than a normal
lems hearing in everyday background noise. hearing person. In acoustic terms, they need a higher
The past decade has seen many advances in hearing aid signal-to-noise ratio (SNR) to bring speech out of back-
technology and performance. Thus, the large, conspicuous ground noise. The SNR is calculated by subtracting noise
hearing aid squealing with feedback and providing only levels from speech. A 70-decibel (dB) speech signal in 60
low-fidelity output is no longer an accurate image of hearing dB of background noise would be a SNR of 10 dB.5

From the Wilson Ear Clinic, Portland (Dr Kim); and the Department Reprint requests: Harold H. Kim, MD, 911 NW 18th Ave., Portland,
of Otolaryngology–Head and Neck Surgery, Mayo Clinic, Scottsdale OR 97209.
(Dr Barrs). E-mail address: [email protected].
This is a review by the AAO-HNS Subcommittee on Hearing Aids.

0194-5998/$32.00 © 2006 American Academy of Otolaryngology–Head and Neck Surgery Foundation. All rights reserved.
doi:10.1016/j.otohns.2006.03.010
 10976817, 2006, 6, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1016/j.otohns.2006.03.010 by National Taiwan University, Wiley Online Library on [27/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1044 Otolaryngology–Head and Neck Surgery, Vol 134, No 6, June 2006

Lastly, while reduced word recognition and maximizing provement in the past decade and are discussed in the
SNR are bigger challenges, decreased dynamic range is also sections below.
a difficult problem for a hearing aid fitting. Dynamic range
is the difference between the threshold of audibility and the
loudness discomfort level. With a hearing loss this dy-
namic range is decreased in part because the hearing DIGITAL SIGNAL PROCESSING
thresholds are elevated, while the level of discomfort re-
mains the same or less. With a decreased dynamic range, Since the introduction of electronic hearing devices, the
amplification cannot be linear, meaning amplifying soft, hearing aid has been comprised of a microphone to convert
medium, and loud sounds by the same amount. If soft sound to electrical signals, a sound amplifier to increase the
sounds are amplified to the point that they are heard, then strength of the signal, a receiver that is a miniature loud-
medium and loud sounds may be too loud. Probe micro- speaker to convert the electrical signal back to sound, a
phone measurements must be used adjust the aid to be coupler to the ear canal termed an “ear mold,” and a power
above threshold but below discomfort. source.3 That is still the basic configuration of modern
hearing aids. The most notable change in hearing aids dur-
ing the past decade has been the transition from analog to
digital signal processing (DSP) technology. Analog hearing
HEARING AID EVALUATION aids receive sound through the microphone and transform
the acoustic energy into an electrical signal. The electrical
A detailed description of a hearing aid evaluation is beyond voltage is “analogous” to the sound pressure level, which is
the scope of this paper, but the counseling involved is where the name “analog” comes from.6 Amplification is
crucial to the success of a hearing aid fitting in the individ- obtained by alteration of voltage to the electrical signal
ual patient. Poorly done, it is a significant reason for failure before being again converted to an acoustic signal. The
of the patient to accept the hearing aid. A candidate for a complaints common among users of analog hearing aids
hearing aid is anyone, adult or pediatric, who is having include the distortion of sound when greater amplification is
communication problems related to hearing. The evaluation needed, poor fidelity of sound, and feedback.
for hearing aids includes a history of problem areas with Since the introduction of DSP in hearing aids a decade
hearing, an audiogram, counseling about hearing aids, and a ago, the issues of signal distortion, feedback, and sound
specific recommendation for rehabilitation. fidelity have been addressed in a positive manner. In DSP,
After the initial evaluation, the patient will have to de- sound is represented by a series of numbers. Analog signals
cide on several hearing aid options: 1) monaural vs binaural, from the microphone are processed in an analog-to-digital
2) size and style, and 3) circuitry and options. The advan- converter. These are placed through a sound filter that re-
tages of binaural fitting include hearing from both sides, a duces signal distortion. This electrical signal is then “sam-
subjective improvement in sound quality and clarity, and a pled” before conversion into a digital signal. Sampling
2- to 3-dB boost in SNR.5 A monaural hearing aid may be occurs at an extremely high rate, designed to be at least
considered when the hearing needs are minimal, when there twice the highest frequency contained in the signal.6 For
is a significant asymmetry of hearing, or when finances are example, if a hearing aid amplifies signals up to 10,000
a concern. The size and style of the hearing aid depends on hertz (Hz), then the signal such as speech is sampled at least
the size and shape of the ear canal, the power requirements every 1/20,000th of a second. This gives an extraordinary
to correct the degree of the hearing loss, the features needed amount of information about the incoming sound.6 Each
to address the hearing problem areas, and cosmetic concerns sample is assigned a binary number (0 or 1). The sampled
of the patient. Current progressively smaller sizes of hearing signal is then processed through a predetermined algorithm
aids are: behind the ear (BTE), in-the-ear (ITE), in-the-canal in the central processing unit (CPU), or amplifier. That is,
(ITC), and completely-in-the-canal (CIC) (Fig 1). Advances the sampled signal is altered in terms of volume, frequency
in circuitry and options are the biggest technological im- response, and loudness growth. Subsequently, the digitized
signal is again converted into acoustic energy that is then
filtered another time to reduce signal distortion prior to
introduction into the ear canal.
Digitally programmable hearing aids are a combination
of these two technologies. The sound is still analog but
digital programming allows greater flexibility in providing
multiple, preset programs that allow changes in the output
of the hearing aid for different situations. For example,
programs can be set for quiet listening or noisy back-
Figure 1 Examples of in-the-canal (ITC), in-the-ear (ITE), and grounds, which the patient manually selects by a switch on
behind-the-ear (BTE) hearing aids. (Courtesy of Oticon, Inc., the hearing aid or a remote unit. Analog hearing aids can do
Somerset, NJ.) many of the functions of digital hearing aids, but the digital
 10976817, 2006, 6, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1016/j.otohns.2006.03.010 by National Taiwan University, Wiley Online Library on [27/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Kim and Barrs Hearing aids: A review of what’s new 1045

aid does them better. The advantages of digital aids are that clipped off at a level below the uncomfortable sound level.
more complex processing can be performed, and with less This is effective, but too much auditory information is lost,
power and circuit size.7 This allows the potential of a so the sound is distorted. The more widely accepted method
smaller hearing aid and reduced battery demand. is compression. Compression implies that softer sounds are
Fully digital hearing aids have allowed greater flexibility amplified more than louder sounds. With DSP, the input
to better meet the specific needs of the hearing aid user. signal such as speech can be split into different frequency
Through filtration of the acoustic signal, distortion has been widths or bands, and each individual band can then be
significantly reduced. Through greater manipulation of the manipulated for frequency or gain intensity. Theoretically,
frequency response, the auditory gain provided better ap- the more frequency bands that can be manipulated, the
proximates the individual’s audiogram configuration. Fur- more control the programmer has over the output signal.
thermore, changes can be introduced such that the hearing Wide-range dynamic compression is the term used for the
aid can automatically accommodate the different auditory capability to compress discrete frequencies throughout the
environments the hearing aid user encounters. Digital hear- auditory spectrum and is currently the industry standard.3,5
ing aids have also allowed greater auditory gain while Compression also takes the place of a volume control since
maintaining greater battery life and sound fidelity owing to with loud sounds the compression takes effect and decreases
greater power efficiency of the circuitry. Additionally, output intensity. Realistically, however, patients may still
greater fidelity output has been possible despite the amount want to manually change volume, and a volume control can
of auditory gain necessary. be an added option.
Interestingly, overall satisfaction by the hearing aid user
has not significantly improved when comparing fully digital Noise Reduction
hearing aids to analog hearing aids.8-11 For example, Parv- Control of background noise has traditionally been through
ing found that 71.4% of those utilizing digital hearing aids low-frequency gain reduction, which unfortunately also cuts
were likely to be very satisfied or satisfied with it, whereas out some of the low-frequency speech information. Digi-
a very similar 68.1% of those using nonprogrammable an- tally programmable analog instruments, as noted above,
alog hearing aids were likely to be very satisfied or satis- could be programmed with multiple programs, including a
fied.8 By contrast, the greater sophistication of the digital noise reduction program that attenuates low frequencies and
hearing aids required an additional visit with the audiologist enhances high frequencies. Current digital hearing aids,
to appropriately fit the aid. Likewise, Taylor et al, in a however, attempt to differentiate noise from speech since
meta-analysis of hearing aid trials investigating the cost- noise is a constant input, while speech modulates. The
effectiveness of digital hearing aids, found that there was hearing aid can then take the noise signal and selectively
not a greater preference for digital hearing aids when com- decrease low-frequency gain, while maintaining all the fre-
pared to nondigital aids.9 In certain circumstances, digital quencies in the speech signal. This strategy is more effective
hearing aids objectively provided improved benefit when if there are a high number of frequency channels, or bands,
greater auditory gain is needed.10-12 This was found by to evaluate, since control can be more frequency specific.
Wood and Lutman, who found greater speech recognition The second characteristic of noise control is the speed of
when an auditory gain of 75 dB or greater was needed and onset of the noise reduction protocol. If the noise reduction
significantly improved sound quality with digital hearing program is slow then speech information is lost during the
aids.10 transition, while the opposite is true if the instrument is
Despite conflicting data in regard to improved hearing capable of fast onset. Fast onset time constants allow the
aid user satisfaction with digital processing, digital hear- noise reduction function to operate even between words or
ing aids comprise a growing share of aids sold. In 2004, syllables and speech is potentially much clearer in back-
digital aids comprised 83% of hearing aids dispensed, in ground noise.14
contrast to 35% in 2001.13 This is secondary to the low cost
of manufacturing digital aids as well as the increased flex- Feedback Suppression
ibility and programming for optimal results. Ultimately, In analog hearing aids, feedback suppression is, for the most
digital hearing aids will almost certainly be considered the part, accomplished by reducing gain, usually in the high
basic hearing aid, replacing analog hearing aids, much as frequencies. With DSP, the hearing aid can be set to pro-
vacuum tubes in hearing aids were replaced by transistors. duce a counter-phase signal that nullifies the feedback. This
The following sections will describe some of the special is an optional setting and is determined when the hearing aid
features of DSP technology. is fitted. If a feedback signal is detected, it can be nullified
as opposed to decreasing gain.
Compression
Since most patients with SNHL have reduced dynamic
range, the output of a hearing aid must be limited so sound DIRECTIONAL MICROPHONES
will not be uncomfortable. There are various ways of doing
this, with a more traditional method being peak clipping. In The directional microphone is probably the biggest advance
this technique the tops of the sound waves are “chopped” or for hearing in noise.12,15-17 As the standard hearing aid
 10976817, 2006, 6, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1016/j.otohns.2006.03.010 by National Taiwan University, Wiley Online Library on [27/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1046 Otolaryngology–Head and Neck Surgery, Vol 134, No 6, June 2006

Thus, the point of greatest noise suppression is not 180° but

varies depending on the acoustic situation.
Improved speech recognition in a noisy environment is
observed with directional microphones regardless of whether
they are in analog or digital hearing aids. With digital hearing
aids, additional algorithms exist to further filter out noise and
minimize distortion.15,16 Investigations seem to bear out im-
proved hearing in noise with directional hearing aids. For
instance, Bentler et al compared individuals using direc-
tional microphone– equipped digital hearing aids in a noisy
environment to normal-hearing individuals and found that
these hearing aids provided significant benefit with hearing
in noise, approaching that of normal-hearing individuals.17
Similarly, Wouters et al discovered that the signal-to-noise
ratio reduction was 3.4 dB when the sound source was
introduced 90° from the microphones in the directional
microphone configuration as compared to an omnidirec-
tional microphone configuration.18 Lurquin found that noise
reduction using directional hearing aids was 6.6 dB in their
Figure 2 Polar pattern of directional microphones in many cohort as compared to omnidirectional microphones.19 In
current hearing aids. (Courtesy of Oticon, Inc., Somerset, NJ.) real-world situations, Walden et al established that their
cohort preferred the directional microphone setting in back-
ground noise situations. Omnidirectional microphones were
contains an omnidirectional microphone that indiscrimi- most often used when in a quiet environment or when in a
nately collects all auditory input without regard for the noisy environment where the sound source of the back-
direction of input, all noise is amplified. Directional micro- ground noise was far away.20
phones have attempted to address this problem. Current Though adaptive directional microphone technology of-
directional microphones exist mostly in a dual-microphone fers more specific noise suppression, Kuk et al discovered
configuration with two omnidirectional microphones that that in a noisy environment, adaptive directional micro-
can switch, whether manually or automatically, to a direc- phones functioned similarly to fixed directional micro-
tional mode. One microphone is directed anteriorly while phone– equipped aids.21 Likewise, Bentler et al did not find
the other is directed posteriorly. Aids with directional mi- significantly improved performance of fully adaptive direc-
crophones work by creating a polar pattern where a point tional microphone– equipped hearing aids when compared
relative to the microphones (ie, directly in front of ) has the to those equipped with fixed directional microphones.22 By
greatest sensitivity (Fig 2). Additionally, another polar pat- contrast, Ricketts et al found that when noise was presented
tern is created where a point relative to the microphone (ie, from the lateral position relative to the head, adaptive di-
directly in back of ) is preferentially acoustically delayed rectional microphone– equipped hearing aids produced bet-
and subtracted from input arriving from the front. Thus, ter speech intelligibility than fixed directional microphone–
input from a specific direction relative to the position of the equipped hearing aids.23
microphones (ie, in front of ) is preferentially amplified
while sounds that originate from another location (ie, from
behind) are preferentially suppressed. Therefore, an im- OPEN FITTING HEARING AIDS
proved signal-to-noise ratio is produced resulting in im-
Though not a new concept, open fitting hearing aids are gain-
proved speech recognition in noise. The most common
ing popularity. A vented mold has long been used to create a
example is a patient sitting in a restaurant talking to another
hole through the ear mold to allow low-frequency sound to
person sitting across the table. The directional microphone enter the ear canal and to try to prevent the occlusion effect of
amplifies the sound coming from across the table and sup- tight-fitting ear molds. An open fitting mold attempts to ac-
presses the unwanted noise coming from behind the listener. centuate the venting concept by making the ear mold a shell
Adaptive directional microphone technology also exists. that is wide open and does not block the canal or create the
In hearing aids equipped with adaptive directional micro- sense of an ear plug being present. The greatest benefit is for
phone technology, the anterior hemisphere is maintained as those with normal or near-normal hearing in the low frequen-
the most sensitive direction. By contrast, the direction of cies with hearing loss being isolated to the higher frequencies.
greatest acoustic delay and suppression is determined by an Individuals with high-frequency SNHL, especially steep-slop-
auditory sweep and calculation of the polar pattern yielding ing losses, are traditionally the most difficult to rehabilitate
the highest signal-to-noise ratio at each frequency. Based on with amplification as the auditory gain has to be isolated to a
this calculation, the suppressive polar pattern is determined. specific frequency spectrum.
 10976817, 2006, 6, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1016/j.otohns.2006.03.010 by National Taiwan University, Wiley Online Library on [27/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Kim and Barrs Hearing aids: A review of what’s new 1047

imal amplification of the lower frequencies, with up to 30

dB amplification of frequencies higher than 2000 Hz. Kuk
found in a cohort with high-frequency hearing loss and
minimal or no impairment of frequencies below 1000 Hz
that elimination of the occlusion effect could be accom-
plished while providing adequate amplification with good
overall cohort satisfaction.20 What did suffer as a result of
the open fitting was the benefit of directional microphones.
In their study, the signal-to-noise ratio benefit as compared
to omnidirectional microphone mode was only 1.8 dB. It
should be noted that this was not a comparative study with
occluding hearing aids and the study population was small
(n ⫽ 8). There are scant data on the comparative efficacy of
open fitting hearing aids for the rehabilitation of the indi-
vidual with a sloping audiogram.

CROS AIDS: A TOOL FOR

SINGLE-SIDED DEAFNESS
A hearing aid that routes auditory signals from one ear to
the contralateral side, or CROS (Contralateral Routing Of
Figure 3 An open mold in-the-canal hearing aid. (Courtesy of Sound) hearing aid, is a tool that is available for those with
Oticon, Inc., Somerset, NJ.) single-sided deafness. The device is conceptually simple
and presents an option for those with only one functioning
ear. A microphone is placed in the “bad ear.” This micro-
A new generation of products has recently been made
phone is connected to a processor, power source, and am-
available to capitalize on the concept of open canal fittings.
plifier that reintroduces the auditory signal to the “good
Several manufacturers attempt to make in-the-ear products
ear.” Thus, the CROS hearing aid user wears two hearing
that are open (Fig 3). As one would expect, the geometry of
aids, with the hearing aid in the poor ear conducting sound
the ear canal will influence the size of a vent that can fit in
to the hearing aid in the functioning ear. The presence of a
an in-the-ear product. The majority of the new open fittings
microphone in the “bad ear” in those with unilateral deaf-
are behind-the-ear style aids. By placing the electronics
ness lessens the head shadow effect that can dampen sounds
behind the ear, a minimally occluding ear piece can deliver
by as much as 60 dB in the functioning ear.
the sound to the canal. The open fitting allows low-fre-
CROS hearing aids can exist in several configurations,
quency sound to enter the ear canal unaided. Amplification
though the usual configuration is of a BTE hearing aid
is provided only in the channels that correspond to the
connected to another BTE or ITE hearing aid. Externally, a
high-frequency hearing loss.
receiver is also worn that is connected magnetically to the
Perhaps even more important, open fittings allow the
internal receiver, as in a cochlear implant. In the past, user
low-frequency sound pressure generated by one’s own
acceptance was impeded by the presence of a wire connect-
voice to escape. The annoying echo or hollow sound that
ing the two aids, and the poor fidelity of sound reported by
hearing aid users hear when they talk is called the occlusion
users. Wireless CROS aids are now available using fre-
effect. Occluding the ear canal with a hearing aid or ear
quency modulation (FM) or BlueTooth technology, result-
mold traps low-frequency signals in the canal. The more
ing in greater fidelity of sound and no wire connecting the
open the ear canal remains, the more low-frequency sound
two aids. This combination may help overcome both the
pressure is vented. Next to background noise, the occlusion
cosmetic and functional complaints common with CROS
effect is the most common complaint among hearing aid
users.
users. When an open fitting is possible, it can eliminate or at
least reduce the occlusion effect to an acceptable level.
Although eliminating the occlusion effect of traditional
hearing aids, the amount of auditory gain can be limited by INDUCTION LOOPS (TELECOILS AND
the lower threshold for feedback. Kuk reported that the FM SYSTEMS)
maximum gain that can be provided with open fitting before
feedback was only 19 dB.24 This dilemma has been reme- The least interference from background noise occurs if
died somewhat with digital signal processing as there is speech is transmitted directly from the lips of the speaker to
active cancellation of feedback. The result is 10 to 12 dB the ear of the hearing-impaired person. This can be accom-
more auditory gain before feedback.25 What results is min- plished by induction loops, FM transmission systems, direct
 10976817, 2006, 6, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1016/j.otohns.2006.03.010 by National Taiwan University, Wiley Online Library on [27/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1048 Otolaryngology–Head and Neck Surgery, Vol 134, No 6, June 2006

auditory input, or BlueTooth technology. Induction is the

phenomenon of an electrical current flowing through a wire
inducing a magnetic field around it.6,7 Sound can be con-
verted into an electrical signal that flows through a wire, in
turn inducing a magnetic field around the wire. In reverse
fashion, this magnetic field can be sensed by a coiled wire,
converted into an electrical current and then to an audio
signal. This technology can be used, for example, in audi-
toriums that are surrounded by wire loops in the walls. The
speaker’s voice is transmitted from a microphone to the
induction wires. The patient wears a loop around his or her
neck which senses the magnetic field, and converts it to an
electrical signal and an auditory signal heard by the person’s
earphones or headset. On a much smaller scale, a “telecoil”
in a hearing aid uses the same technology to detect the
magnetic field in a telephone receiver or other small
speaker, so sound is transmitted directly to the hearing aid Figure 4 Cartoon representation of the BAHA in situ. (Cour-
rather than the hearing aid hearing the sound from the phone tesy of Entific Corp, Gothenberg, Sweden.)
through air. The “T” coil in a hearing aid is only compatible
with certain phones. Generally speaking, any phone with a
cord is hearing aid compatible. Cordless phones can be, but The BAHA requires a surgical procedure where a 2 ⫻
the majority of them still are not. Cellular phones do not 3-cm retro-auricular area is made hairless and devoid of
generate the magnetic field required for T coil use but there subcutaneous tissue and the titanium implant with its per-
are adapters available that can be plugged into a cell phone cutaneous coupling is placed. This procedure is short, can
to make it hearing aid compatible. be performed under either general or local anesthesia, and is
With an FM system, the speaker wears a transmitter to usually performed as an outpatient procedure or even as an
send the signal by radio-frequency transmission to a re- office procedure. Children require a two-stage approach
ceiver worn by the hearing-impaired person. This FM re- where the removal of hair and subcutaneous tissue and
ceiver can be attached to the hearing aid by a boot, usually insertion of the percutaneous coupling is performed 3 to 6
on the bottom of the aid, or can be incorporated into the months after the initial procedure, whereas it is usually
hearing aid itself. An audio signal can also be hooked into performed in one stage in adults. After the surgical proce-
the hearing aid directly by a wire, called direct audio input. dure, a period of 3 months is required to allow for osseointe-
The disadvantage is the necessity for a hard wire. gration of the titanium implant.
Greatest attention has been given to the benefits of the
BAHA in those with single-sided deafness. Whereas the
CROS hearing aids have not received popular support by
SURGICAL OPTIONS FOR the medical community or the hearing impaired, the BAHA
HEARING ENHANCEMENT seems to provide improved subjective and objective benefit
BAHA Implants that is superior to the CROS aids. Subjectively, not only do
BAHA implants work through transcranial stimulation of BAHA users report significant auditory benefit, they also
the cochlea, regardless of side. Thus, the BAHA is an option show disease-specific improvement in their quality of life.26
for improved hearing in individuals with a conductive hear- Objectively, BAHA improved hearing in quiet and noise
ing loss as well as those with single-sided deafness. Initially significantly. Furthermore, this improvement was signifi-
introduced in 1977 for conductive hearing loss, the BAHA cantly greater when compared to CROS aids.27,28 What is
has subsequently received United States Food and Drug not achieved with the BAHA is directional hearing.29
Administration approval for use in single-sided deafness.
The BAHA is comprised of a titanium implant, a percuta- Implantable Hearing Aids
neous coupling, and an electromechanical processor-trans- Brief mention will be made of implantable hearing aids, a
ducer (Fig 4). In cases of conductive hearing loss, the still-evolving technology and an option for those with sen-
BAHA works by directly stimulating the cochlea, overcom- sorineural loss. Implantable hearing aids transfer the driving
ing any conductive component to the hearing loss. For force of amplification from the ear canal with traditional
single-sided deafness, the BAHA is applied to the nonfunc- hearing aids, to the ossicular chain itself. As of this writing,
tioning side. Thus, auditory input from the “bad ear” is the Vibrant Soundbridge (VSB) (Med El Corporation,
conducted transcranially to the functioning ear. Again, the Durham, NC) is the only commercially available implant-
auditory results when only considering pure-tone thresholds able hearing aid. In the VSB, an external processor is
are predictable as they reflect the bone conduction thresh- connected magnetically to an internal receiver. This internal
olds of the functioning ear. receiver is connected to a floating mass transducer (Fig 5).
 10976817, 2006, 6, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1016/j.otohns.2006.03.010 by National Taiwan University, Wiley Online Library on [27/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Kim and Barrs Hearing aids: A review of what’s new 1049

Figure 5 Components of the Med El Vibrant Soundbridge

implantable hearing aid (Med El Corp., Durham, NC). (A) Exter-
nal processor. (B) Internal processor with attached floating mass
transducer. (C) The floating mass transducer.

Figure 7 Audiogram for candidates of the Med El Vibrant

The internal receiver is placed in a bed drilled into the skull, Soundbridge. (Courtesy of Med El Corp., Durham, NC.)
much like that of a cochlear implant, and the connected
floating mass transducer is applied then to the long process
of the incus. Sound is received at the external device and fidelity of sound and better speech comprehension in quiet
transmitted to the internal receiver, and the floating mass and noise when compared to conventional hearing aids
transducer is electrically driven to displace the ossicular despite programming to similar gain.30 Predictably, patient
chain, thus amplifying the received sound. There are no satisfaction exceeds 83%.31 These findings, though, have
components in the external ear (Fig 6). been refuted by Schmuziger et al, who found that subjective
Current candidacy for implantable hearing aids includes and objective assessment of speech comprehension were
speech discrimination above 50% in the candidate ear, nor- comparable with conventional hearing aids as compared to
mal middle ear function, and pure-tone thresholds as shown those with the VSB device.32 Furthermore, they found that
in Figure 7. The VSB device seems to result in higher the operated ear, in the long term, had greater deterioration
of pure-tone thresholds as compared to the nonoperated ear.
Implantable hearing aids require a surgical procedure
that depends on the device chosen. The VSB requires a
mastoidectomy with the creation of a large facial recess.
Through the facial recess, the floating mass transducer is
clipped onto the long process of the incus. Postoperatively,
the device is activated 4 to 6 weeks after surgery and
programmed, much as the process for a cochlear implant.

CONCLUSION
The inability to communicate as a result of hearing loss can be
severely disabling, resulting in humanity’s quest to amplify
sound dating to ancient times. There has been tremendous
improvement in the ability to amplify sounds since the ear
trumpet, but hearing aids are still not regarded with much
enthusiasm by the general public. Unfortunately, despite the
tremendous strides that have been made with hearing aids in
providing high-fidelity amplification that can be more accu-
rately tailored to the hearing aid user’s needs, ignorance by the
Figure 6 Cartoon representation of the Med El Vibrant Sound- general public and health care providers is the rule. With these
bridge implantable hearing aid in situ. (Courtesy of Med El Corp., advances, the elimination or attenuation of hearing impairment
Durham, NC.) with the use of hearing aids is a reality that needs to be relayed
 10976817, 2006, 6, Downloaded from https://aao-hnsfjournals.onlinelibrary.wiley.com/doi/10.1016/j.otohns.2006.03.010 by National Taiwan University, Wiley Online Library on [27/06/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1050 Otolaryngology–Head and Neck Surgery, Vol 134, No 6, June 2006

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