I know, yet another article about the art of fitting hearing aids. Those who have been around the block have seen these articles before. We basically know how this works because we are professionals, right?
We have all seen patients who, for one reason or another, complain about size, color, comfort, and difficult controls. The fact is, however, we all need to be occasionally reminded, and some of us need to be reinstructed. No matter how good the device sounds acoustically, patients will not be completely happy if the hearing aid is not the right style, the best color, too visible, or difficult to use. Some of these complaints may be justified, and some are perceptual. Regardless, they are real concerns, especially now with more and more people accepting hearing aids due to smaller sizes, less occlusion, and baby boomers coming of age.
Our choices are somewhat critical for patients' hearing aid acceptance. Our recommendations have to merge with patients' experiences, expectations, perceptions, and preferences. They are the ones wearing the device every day, and your inexperienced patient may look to you, the professional, for help in choosing an aid, especially if they are anxious first-time wearers. We all love it when a patient says, “I don't care what it looks like as long as it works,” but this occurs in less than 50 percent of first-time wearers. Even those who do feel this way can have a change of heart after the fitting.
Yes, the art of fitting hearing aids is still a huge part of the process. Counseling and listening to patients is also integral from the second the patient walks into the office until well after the fitting. Keep in mind, though, that it is a jungle out there with all the manufacturers, style choices, ever-changing features and technologies, and advertising that promises hearing aids will do everything short of walking your dog and cooking your breakfast. And we all flinch a little when we hear, “My friend has this hearing aid that does this and that.”
Our goal is to have a mind meld with patients, a common ground between what makes them comfortable, their expectations, what looks the best, style, coupling to the ear, and sound quality. Hopefully, the style and features choice will be the same. Counseling patients on the benefits and drawbacks of certain styles is important, and we need to emphasize that we are not only here to sell hearing aids but to offer the best hearing solutions. The device will sell itself if done right.
Finding A Style
The next time you ask a first-time wearer if he has a particular style in mind, and he responds, “Please don't give me one of those big honkers,” ponder in-the-ear (ITE) aids versus behind-the ear (BTE) aids, look at the audiogram, and reflect on these points.
- Sloping versus flat configuration loss.
- Degree of loss, and which frequencies are normal, mild, moderate, and severe.
- Shape of the ear and location (e.g., close to the head, space behind pinnae).
- Patient's ability to hold, insert, and manipulate the hearing aid.
- Speech discrimination (e.g., fair, good, poor).
- Tolerance concerns, acoustically and physically.
- Patient's mobility (e.g., active, homebound).
Don't be insulted when a patient shows you a full-page advertisement about an “ultrainvisible” hearing aid that only amplifies one person in the country. Continue to address the points previously mentioned, and decide if your choice is comparable with the one in the newspaper.
We cannot look at each of these aspects without simultaneously considering others. My philosophy is to keep a fitting as open as possible with BTE aids, short of feedback. We have to consider ITE aids, however, given patients' inability to handle BTE aids. Older patients may have tremors, neuropathy, and spatial difficulties, and some patients cannot tolerate something on top of the ear. Shape or lack of space behind or on top of the ear from surgery or genetics should also be considered. BTE aids will typically be recommended for those with severe or profound hearing loss unless fitting a BTE is prohibitive because of surgery or trauma to the outer ear. A long-term hearing aid user may want to stay with an ITE.
Choosing a Color
Manufacturers' color charts leave much to be desired. They are not always the same as the finished product. It is always better to have small plastic color samples on a keychain, which are much more accurate. Identifying some of the colors by name has gotten a bit out of hand over the years; some names are better suited for ice cream flavors than hearing aids. How many of us have been ready to order an aid in a certain color only to find the color is unavailable in that particular model?
The color should match or complement the patient's skin tone, hair color, ear shadow, and eyeglass frames. I favor a matte taupe or dark grey because they tend to blend with the shadow behind the ear, skin tone, and eyeglasses. This is where the small plastic samples come in handy. The patient will often choose a color based on skin tone until shown other choices. The patient's spouse, if present, is often helpful in this regard.
Call me biased as an audiologist or a “pinnaephile,” but my eyes are drawn immediately to a person's ears, and sometimes the hearing aids I see resemble small light bulbs. A few patients with severe hearing loss may like that their aids are visible, causing people to speak to them louder than average. My experience, however, tells me most patients want to keep the devices obscure if possible. True, color is becoming less critical these days with smaller, hidden hearing aids, but many still need larger aids with bigger controls due to loss severity, hand size, neuropathy, and tremors.
Remote Control Hearing Aids
I tend to look at ITE aids when dexterity is a concern. Sometimes completely-in-canal (CIC) aids are a good choice when patients need amplification and speech discrimination and occlusion is not an issue. Adjusting the volume takes the push of a button located on the ear canal.
I have only recently become a fan of remote controls; before, some manufacturers made these devices almost as complicated and as large as my TV remote. People do not want to carry around extra baggage, and that big remote in your pocket may look like a 9 mm, even though the shooting signal would only reach the hearing aid. I guess there may be some occasional advantages to this.
Now, however, I see some basic and simple remote control aids on the market that do not intimidate patients, and having one myself, I found I did not have to carry it with me every day. BTE aids may have some dexterity issues, but choices are available, such as removal strings on earmolds, models with larger volume controls, and certain earmold styles that are easier to insert. Again, remote controls can be a real lifesaver at times.
Comfort vs. Cosmetics
A mini or micro hearing aid can cause discomfort just as a midsize hearing aid can be cosmetically appealing. These two factors are not mutually exclusive. We have all seen patients who report discomfort from micro BTE aids with slim tubes and domes as well as patients who are fit with larger devices that are cosmetically pleasing.
A patient's ear can reveal the success probability with one or the other, but consider things such as a deep or shallow concha, size of the concha and pinnae, ear's proximity to the head and whether it protrudes, ear canal size, open or close fit, tube size, and receiver-in-canal aids. Putting these concerns and issues into perspective is where the “art” lies, and patients should be counseled if these concerns do not align with their expectations.
Listening is Key
It is not my intention to address electroacoustics or programming, but I hope all hearing healthcare professionals practice listening to each and every hearing aid (power aids excluded) before and during fittings. We all hook up hearing aids when a patient comes in complaining about sound quality. We listen to the aid and at times perform electroacoustic testing, but it is important to listen to the device before issuing it to the patient. I have found new aids on rare occasions to be dead, intermittent, distorted, and have the front and back microphones reversed.
A long-term wearer can usually tell you when the sound is not right, but a new user has no frame of reference and does not know how it should sound. A patient recently came in for a replacement of his left aid, but I heard a slight distorted static-like sound at the end of each word when I listened to his right aid. Sound was amplified and the distortion was not that bad, but it was noticeable compared with his left aid. The patient said he ran it through the wash, showered with it, and took it to a nice dinner. I offered to get it repaired, but he did not think it was serious enough to part with for two weeks. The point is to listen to hearing aids, and establish what compression, distortion, and programming adjustments sound like. The patient will be happier, and you will be a better clinician!
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