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ELVAS sightings: Cochlear implants and hearing aids get wired

Dybala, Paul D.

doi: 10.1097/01.HJ.0000286486.43703.60
Page Ten

In the brave new world of 21st century technology, hearing aids may soon be multi-tasking along with the rest of us. The author explains how through converging technologyes what was once merely an amplifying device for the hearing impaired may soon be part of an entire ear-level communication system.

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1 Now I'm as much of an acronym hound as the next person, but yours is pretty obscure! What (or possibly who) is ELVAS?

Figure. D

Figure. D

A few years ago, I was invited to submit an article on “Audiology in the New Millennium” for a special issue of Audiology Today.1 My article was on the future of hearing aids, focusing on the convergence of communication devices (hearing aids, cell phones, computers, etc.) and how they would be able to talk to one another wirelessly.

I called this device an ear-level voice-activated system or ELVAS, as it would be worn in or over the ear and function by responding to voice commands. I found the idea compelling, as it offered the potential to solve several technologic and social issues related to hearing aids. Still, when the article was written, I wondered how long it would be until I experienced my first “ELVAS sighting” or even a “near-ELVAS sighting.”

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2 So why are you talking about ELVAS sightings now, 7 years later?

I read (or do my best to read) a monthly collection of research and trade journals so I can keep up with the latest clinical and research trends in hearing healthcare. My reading list also includes several other publications, mostly in the areas of business, computers, and Internet technology.

Normally, the content areas that I read about in these two groups of periodicals are nearly as separate as the Ricardos' beds in the old I Love Lucy show. So, imagine my excitement when I opened up my November 2005 issue of Wired and found three different items that related to—or got me thinking about—the hearing healthcare profession and the ELVAS-type concept. That's right, Wired, the groundbreaking, award-winning magazine on modern technology and business, was writing about hearing healthcare! These three items got me to thinking about a trend that could have a major impact on our field.

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3 I've certainly heard of Wired, but never read it. So, what were the ELVAS-related items you found?

Here they are in the order of appearance:

  1. A two-page spread advertising the Plantronics Voyager 510 wireless Bluetooth headset. On the left-hand page was a young woman posed like a dancer and wearing a wireless headset as she looked at the ad on the right-hand page. It featured two wireless Bluetooth mobile phone headsets.
  2. “My Bionic Quest for Boléro,” an article by Michael Chorost about his quest for finding an improved processing strategy for listening to music with his cochlear implant.2
  3. “Battle for the Soul of the MP3 Phone,” by Frank Rose. It tells the story of how Apple and Motorola combined the sleek RAZR phone with the iPod MP3 player and why the author thought the companies fell short of creating the ultimate music phone.3
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4 That's all very interesting, but I don't see how the Boléro article relates to the other two items or what any of them have to do with ELVAS!

I'll admit that, except for the Boléro article, these items may not seem related to hearing healthcare at all! But when you look at them in the current context of technology convergence, things begin to get interesting.

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5 So for starters, what in-trigued you about the Boléro article?

Well, let me first tell you about the author. He has an undergraduate degree in English from Brown University and a PhD in computer sciences from the University of Texas at Austin. When he lost his hearing and obtained a cochlear implant, he effectively used these two backgrounds to write some very interesting accounts of his adjustment to hearing loss and the technology in his implant. These were published in his book Rebuilt: How Becoming Part Computer Made Me More Human (a preview of the first chapter was published on Audiology Online).

Chorost's article in Wired was a continuation of his life experiences with hearing loss. He focused on his search for new cochlear implant processing software that would improve his perception and enjoyment of music. As he was late-deafened, he had his own reference point to what certain music should sound like, his own internal “gold standard.” Specifically, he used Maurice Ravel's musical masterpiece, Boléro, as his litmus test, looking for the software that would make the music sound “right.”

What was additionally compelling to me as an audiologist was his description of the research and development occurring in our field. Chorost effectively told the story of an industry that is advancing technology to improve the lives of persons with hearing impairment and, despite some limitations, doing it pretty impressively.

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6 But we see advances in hearing aids and cochlear implants every year. What's so novel about that?

Of course we do, those of us in the field, but that's part of my point. That a prominent story in Wired, a mainstream magazine, was talking about some of these technologic advances was highly satisfying to me. The hard work that has been done to improve the lives of persons with hearing impairment was being showcased in a great light—a light with 2.1 million monthly subscribers!

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7 Okay, Dr. Chorost wrote an interesting article. But how does that connect with the other articles?

Well, reading his story prompted me to think more specifically about hearing aids and the low rate of adoption by users. Despite the amazing technology we now have in hearing aids, including the positive evidence showing that people who hear better actually live better,4–7 we still have low market penetration. Over the past couple of decades the percentage of hearing-impaired people who wear hearing aids has remained stuck in the range of 20–24%.8

Naturally, people ask, “Why is this?” We know that a leading factor is the unfair stigma that is associated with hearing aid use. The technical hurdles that stand in the way of perfecting hearing aids are daunting enough, but the attitudinal hurdles that consumers have to overcome to wear hearing aids are even harder to surmount. I was reminded of one possible solution to this issue when I saw the other two items in Wired, especially the ad for the Plantronics wireless Bluetooth headset.

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8 Okay, okay. But I have to interrupt you again. This is the third time you've used the term “wireless Bluetooth”! Isn't that redundant, sort of like saying HINT test?

You're right. It is a bit like saying hot-water heater, CFY year, and the KEMAR manikin, as Bluetooth is a wireless standard. I use “wireless Bluetooth” to specify the type of wireless connection, as there are other wireless technologies available. It also helps define what Bluetooth is for Page Ten readers who may be unfamiliar with the technology. I would invite readers to take a look at several other resources explaining how wireless Bluetooth is being implemented in hearing health technology.9–13

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9 I'll check them out. So, tell me again, what was the big deal about the ad for a wireless Bluetooth headset in Wired?

Well, we've all observed people wearing their mobile phone headsets in malls, on the street, and at airports. I am seeing more and more of them. Some even include lights that turn on so everyone knows that the person is talking on the phone (I guess they don't want people thinking they're talking to themselves!).

But think about this for a moment. These trendsetters have a light to make it more obvious that they are wearing a device on the ear. While some of you might consider this conspicuous consumption, I think it's simply the wave of the future. It was not that long ago that having a mobile phone was considered an extravagance. Now, it's a necessity, and a high-tech accessory at that.

Getting back to your question, take a look at the high-tech wireless Bluetooth headset displayed in Figure 1. This is the one that was being advertised in Wired and also worn by an attractive young woman in the ad.

Figure 1

Figure 1

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10 I'm looking at it right now. Very interesting!

Right. Most anyone in hearing health looks at this device and says, “That's an interesting looking hearing aid!” I would guess that a lot of other people who are not in hearing healthcare and are under age 65 look at this device and say, “That's an interesting looking mobile phone headset!”

For me, personally, this was a “near-ELVAS sighting,” and I must admit when I saw this image for the first time I got pretty excited! I looked at it and said, “Hearing aids are going mainstream!” The idea of creating ELVAS-type technology that converges hearing aids with other devices such as mobile phones could have far-reaching implications for our profession.

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11 Now I see where you're going with this. What else can you tell us about this convergence trend?

Convergence of technologies within the mobile phone industry is an exciting trend that has been going on for quite a while now, and this relates to the third item I saw in Wired, “Battle for the soul of the MP3 phone.”3

As you probably know, the Motorola RAZR and the Apple iPod are currently the two hottest items in their respective categories, mobile phones and MP3 players. The marriage of these two electronic celebrities in the technology world was not that much different from when human celebrities wed. It was highly anticipated, widely reported, and criticized when it didn't work out. Sadly, this cover story in Wired mostly discussed what went wrong with this high-profile combination of technologies and what needed to be done to improve it.

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12 Too bad about the marriage. But what does this have to do with audiology and hearing aids?

I'm getting to that. The article got me thinking about two things: the ubiquity of mobile phones today and how this technology has become the centerpiece of convergence technology. There are about 300 million people in the US14 and about 194 million of them are mobile phone subscribers.15 That's about a 65% penetration rate.

Some European countries (Czech Republic, Finland, Italy) have penetration rates of 90% or higher.15 The mobile phone has quickly become one of the most widely used pieces of portable/wearable technology in the world. Therefore, it's not surprising that almost every type of technology has been converged with the mobile phone.

Flipping through my handy November issue of Wired looking for examples, I came up with a list of 19 different technologies that had been converged with mobile phones. Everything from Internet access to GPS-based guidance systems, cameras, and video cameras, not to mention the capabilities of a full-featured PDA. My hope is that very soon we commonly will see “hearing aid” added to this list.

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13 What prompted you to start thinking about all this?

I'll be the first to admit that I'm not talking about anything new, and I don't claim to be the first person to come up with this concept. In fact, I was looking back in the Audiology Today issue I mentioned earlier and noticed an article by David Fabry in which he made some predictions.16 One of them was that “crossover products” would transform hearing aids into “hearing enhancement devices.”

My dissertation adviser, Linda Thibodeau, liked to tell her hearing aids class, “They should put radios and phones and music players in hearing aids. Then everyone would want one!” The difference is that in today's market, instead of having to convince consumers to purchase a technologically enhanced hearing aid, we already have a “device for the ear” that is widely accepted and adopted. It's called “the mobile phone.”

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14 So what's the next step?

The task now is for more mobile phones to become hearing aid-enabled. Or, another option would be to make the wireless headsets that work with mobile phones hearing aid-enabled. In fact, several companies are now offering such devices.

The widespread adoption of these ear-level devices would have long-term effects. The convergence of hearing aid and ear-level mobile phone technology could alleviate the stigma associated with hearing aids. The device that the “younger” executive is wearing would essentially be the same as the one worn by the “older” executive! Behind-the-ear devices would be so common they wouldn't draw a second glance.

The new cosmetic solution to hearing aids would not be to hide them, but to bring them out in the open. Think about it, if there was a way to get everyone or—almost everyone—to wear “hearing aids,” then no one would notice them.

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15 That's an interesting thought. This sounds as if it could open up new markets for hearing aids. Do you think it would impact hearing aid prices for the consumer?

I'm glad you asked. A good way to answer is to look at some numbers that put mobile phone and hearing aid use in perspective:

  • Number of mobile phones sold in the US during Q3 2005: 31.6 million17
  • Average cost of mobile phones sold in US in 2004: $17418
  • Number of hearing aids sold in the US during Q3 2005: 582,00019
  • Average cost of hearing aid sold in US in 2004: $177620

Depending on which study you look at, cost is sometimes ranked as an even higher barrier than stigma to the purchase of hearing aids.5 The average retail cost of a hearing aid purchased in 2004 was $1776 per ear,20 which in most cases also included the evaluation, fitting, and clinical follow-up needed for these devices. For the majority of hearing losses that are bilateral, the total purchase cost would have been $3552, which in most cases was not covered by insurance.

When one considers all the advanced technology and professional services that these costs cover and the all-day usage patterns of hearing aids, one could argue that the benefit-cost ratio is very high. Still, $3500 is no small sum for the average hearing-impaired consumer.

One reason that hearing aids cost as much as they do is the relatively small number of them manufactured and sold compared with consumer electronic devices. For example, mobile phones outsold hearing aids in third quarter of 2005 by a ratio of 54 to 1. With hearing aids, as with any product, greater sales volume would lower the price per unit.

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16 This now begs the question, if mobile phones all become hearing aids, what will hearing aid manufacturers manufacture?

Let me be clear about this. I believe this trend would be positive for hearing aid manufacturers and hearing care professionals alike. The hearing-impaired consumer will always need specialized algorithms, transducers, and earmolds.

Also, many of the technologies that are commonly used by hearing aid companies could be useful for persons with normal hearing. For example, they could take advantage of the noise-reduction algorithms, graphic equalizer-type tuning, and directional-microphone technologies that the hearing aid industry has developed. If you do any flying, you've probably seen the ads for the Bose Quiet Comfort Noise Canceling Acoustic Headphones. So, the demand for these types of technologies is there.

If hearing aid companies partnered with mobile phone manufacturers, it might lead to sharing of technology and a reduced cost of hearing aids to the consumer. As I mentioned, there are already several companies producing personal hearing healthcare-related products that use Bluetooth technology. These include: Gennum (, Phonak (, SoundID (, and Starkey (

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17 You mentioned hearing care professionals. How could this impact them?

Bluetooth-compatible phones are becoming more prevalent, so instead of mobile phones being enabled with hearing aid capability, we might see more hearing aid-compatible headsets become available in addition to those used by normal hearers. This could expand our patient base, if hearing professionals offered both types of headsets.

Users with hearing loss would get an amplification solution that was instantly compatible with their mobile phone. Users with normal hearing would get a custom-programmed headset (especially for mild losses), which is essentially the same device available at the mobile phone store. And if normal-hearing people wanted the comfort for extended use that a custom-molded device provides,14 they would go to a hearing professional for an earmold impression. After all, who else knows as much as a hearing professional about custom-fitting an ear-mounted device?

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18 So, are you saying that this trend could benefit both normal-hearing and hearing-impaired people?

Yes, and I'll tell you why. We can agree that both groups experience problems hearing in background noise. If all of the ELVAS-type devices were compatible, they could work with each other to act like FM systems or provide noise-reduction advantages the way hand-held directional microphones do today. On-the-fly listening networks could be created at the dinner table so that everyone could tap into everyone else's earpiece and the busy noise of a restaurant or social hall would be minimized.

I'm just scratching the surface of how these systems could be used. The basic idea is that once the technology is converged within devices, it would be compatible across devices. And when that happens, the possibilities multiply.

I see the future of hearing aids being influenced by the mobile phone industry and the future of mobile phones being influenced by the hearing industry.

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19 This all seems pretty futuristic. Do you think we will start seeing more devices like ELVAS soon?

Actually, we're already seeing headsets that look like hearing aids, and there are even some hearing aids that function as mobile phone headsets! I've just written an article about this that you can check out on Audiology Online. Read the article on our web site and take the “quiz” to see if you can tell the difference between the two devices!

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20 I'm going to start paying more attention to this trend. But what should I do if I have an ELVAS sighting? Is there some sort of hotline?

Yes! Scan in a copy of the ad/article/ brochure or wherever you have seen ELVAS and send it to me at Oh, and if you happen to sight the original ELVIS, take a picture with him and send that along, too!

In this month's Page Ten we're going to talk a little about the future. But to get there, let's start with the past. The year is 1979. To refresh your memory, this was when Rhodesia became Zimbabwe, Kurt Russell starred in the move Elvis, and Earl Harford described a clinical procedure called “probe-microphone measurements.”

For many of us, however, the most important event of 1979 occurred on July 1. This was when the Sony TPS-L2 Walkman was introduced. Prior to that date, to listen to a high-quality stereo version of My Sharona, you had to be in your home or car. But now, you could use your portable stereo!

It also was around this time that cellular telephones were becoming portable, and in 1983 Motorola introduced the 16-ounce DynaTAC phone into commercial service. You probably know that we also had portable hearing aids back in those days! But do you think anyone ever confused a hearing aid with a cellular telephone? Or a hearing aid with a portable stereo system? Well, things have changed, and that is what we're going to talk about in this month's Page Ten.

Our guest author is Paul Dybala, PhD, president and editor-in-chief of Audiology Online. You're probably familiar with his excellent editorials and tutorial articles. He also serves as adjunct associate professor at the University of Texas at Dallas, where he is involved in the AuD program. Additionally, he is president of the Scott Haug Audiology Foundation Board.

Dr. Dybala is truly a pioneer in the Internet world. A decade ago, when many of us were still trying to figure out how to send an e-mail attachment (or maybe even the message itself), 24-year-old Paul launched a web site dedicated to audiologists ( He also had the first audiology search engine at His latest Internet venture is, where the lighter side of audiology and music meet in cyberspace.

When he's not sitting in front of his computer, you might find Paul traveling through the Texas Hill Country with his bicycle club. Except for during the holiday season that is, when he is spinning tunes and telling stories as the DJ for the 95.5 FM radio station he operates out of his home (I'm not making this up—check out

Dr. Dybala's article gives us plenty to think about. Even if you weren't an Elvis fan in 1979, I think we'll all get to know ELVAS-like products in the near future.

Gus Mueller

Page Ten Editor

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© 2006 Lippincott Williams & Wilkins, Inc.