Hearing Aids

It Doesn’t Really Matter If I Wear My Hearing Aids, Right?

WRONG! According to ScienceDaily (Sep. 20, 2011), mild hearing loss has now been linked to brain atrophy in older adults. Anecdotally, over the course of my 30+ years in private practice as a board certified audiologist, I’ve observed this to be true. But now, more and more research is indicating strong correlation between failure to obtain or use hearing devices and increased problems with understanding speech and cognition.

We have all heard (or perhaps experienced) the complaint that despite the fact that speech is audible, it’s not understandable. “I hear, but I can’t understand,” is probably the most commonly voiced concern in my office. So, if someone has hearing loss, and if their hearing aids make sounds louder, why doesn’t that solve all hearing related issues? Well, like lots of things in life, it’s just not that simple.

A person’s audiogram (or those little blue X’s and red O’s on the graph of your responses to the beeps) tells us a lot, but it does not yield the whole story. Hearing thresholds (or the point at which someone is just barely able to detect sound across the frequency range) are certainly important, but they don’t give much information regarding how well someone will understand when speech sounds are made sufficiently loud. Word recognition testing, with and without noise, provides additional information regarding this capability, and as a by-product, an indirect measure of the distortional component inherent to sensorineural hearing loss.

We now have mounting evidence that those who have hearing loss, but who fail to get and/or use hearing devices, run the risk of depriving their auditory system of sufficient loudness, which in turn results in degradation of the mechanisms responsible for understanding speech. A new study by researchers from the Perelman School of Medicine at the University of Pennsylvania shows that declines in hearing ability may accelerate gray matter atrophy in auditory areas of the brain and increase the listening effort necessary for older adults to successfully comprehend speech. When any one of our senses (smell, taste, sight, hearing, or touch) is changed in some way, the brain reorganizes and adjusts. In the case of those with hearing loss, researchers found that the gray matter density of brain in areas specific to hearing was lower in people with decreased hearing ability, suggesting a link between hearing ability and brain volume.

So, “use it or lose it” may be the prevailing philosophy. Take heart (and USE those instruments that you have!). According to this study, early intervention for hearing loss with the consistent use of amplification can slow the progression of speech comprehension difficulty. “As hearing ability declines with age, interventions such as hearing aids should be considered not only to improve hearing but to preserve the brain,” said lead author Jonathan Peelle, Ph.D., research associate in the Department of Neurology. “People hear differently, and those with even moderate hearing loss may have to work harder to understand complex sentences.”

In two recent research studies, researchers measured the relationship of hearing acuity to the brain, first measuring the brain’s response to increasingly complex sentences and then measuring cortical brain volume in auditory cortex. Results indicate that older adults (60–77 years of age) with normal hearing for their age were evaluated to determine whether normal variations in hearing ability impacted the structure or function of the network of areas in the brain supporting speech comprehension.

The studies found that people with hearing loss showed less brain activity on functional MRI scans when listening to complex sentences. Poorer hearers also had less gray matter in the auditory cortex, suggesting that areas of the brain related to auditory processing may show accelerated atrophy when hearing ability declines.

In general, research suggests that hearing sensitivity has important consequences for neural processes supporting both speech perception and cognition. Although most of the research has been conducted in older adults, the findings also have implications for younger adults, including those concerned about listening to music at loud volumes. “Your hearing ability directly affects how the brain processes sounds, including speech,” says Dr. Peelle. “Preserving your hearing doesn’t only protect your ears, but also helps your brain perform at its best.”

Physicians should monitor hearing in patients as they age, and everyone should have a baseline audiogram performed by a board certified audiologist, looking specifically at speech recognition abilities even in the presence of normal hearing. Patients should talk to their physician or audiologist if they are experiencing any difficulty hearing or understanding speech. If your physician has not referred you for hearing evaluation, take action!

The research cited above in this article appears in the latest edition of The Journal of Neuroscience and was funded by the National Institutes of Health.


Hearing Aids

Consumer Protection Laws for Hearing Aid Purchases

Here in California — as in many states — purchasers of hearing aids are afforded protections under state laws and regulations administered by the Department of Consumer Affairs (DCA) through the Speech-Language and Audiology and Hearing Aid Dispenser Board (SLPAHADB).

The SLPAHADB was formed on January 1, 2010 by combining the Speech Language Pathology and Audiology Board with the Hearing Aid Dispensers Board. Previous laws and regulations remain virtually unchanged except that audiologists are no longer required to hold dual licensure for practicing audiology and dispensing hearing aids.

This board’s mission is ensuring the competency and fair practices of hearing aid dispensers. It does so by providing licensure through testing, ethical guidelines, boundaries for advertising practices, and acts as a vehicle for consumer complaints, ultimately providing enforcement and disciplinary functions.

While political discussion in the media about government intrusion in our lives is a hotbed topic, consumer protection laws are generally an accepted interaction between the citizenry and government. Who wants to buy poisonous food, cars that don’t run, or housing that collapses in the slightest breeze, to name just a few examples?

Why should it be any different with hearing aids? Purchasers have a right to expect fair and honest treatment as well as professional expertise from those they seek help. It could be argued that hearing aid purchasers — many of which are our senior citizens — should receive an added degree of protection as many of our laws are designed to protect us as we age beyond our more active years, and thereby tend to rely on the care and guidance of those who are younger.

While all the laws and regulations are too lengthy to list here, these are several of the most important. For the full listings, visit the SLPAHADB website at

  • 30-day warranty — The Song-Beverly Consumer Warranty Act provides a 30-day warranty on all new and used hearing aids. If the hearing aid is not specifically fit for the buyer’s particular needs, the device may be returned to the dispenser within 30 days of the of the date of the actual receipt by the buyer or completion of fitting by the seller, whichever occurs later. If the buyer returns the device, the seller must either adjust or replace the device or promptly refund the total amount paid.

It should be noted that while many dispensers advertise things like “30-day risk-free guarantee,” they are merely staying within the state mandated minimum trial period of 30 days.  My professional opinion is that for many purchasers, 30 days is too short, as it does not allow enough time for the brain to get used to hearing again. In my practice, I offer a 75-day trial period in order to make certain my patients have all the time they need to be successful.

  • Mail-order and Internet sales  — California law provides that mail-order/Internet hearing aids may only be purchased through a dispenser licensed in California. The law also states that that when hearing aids are purchased by mail order/Internet, there must be no fitting, selection, or adaptation of the instrument and that the seller must not give any advice with respect to the taking of an ear impression(s). Anyone contemplating this avenue should be aware of potential risks as to work effectively, hearing aids must fit correctly. If a sale doesn’t involve personal contact between the dispenser and buyer, it is difficult to assume that proper fitting and follow-up care could occur.
  • In-home contracts and cancellation rights — If you sign a hearing aid purchase contract in your home, federal and state laws allow you to cancel it for any reason by midnight of the third business day after you signed the contract.
  • Advertising guidelines —  Did you know that in California, hearing aid dispensers are not licensed to perform diagnostic hearing evaluations (only audiologists are licensed to do so) and are therefore not allowed to charge a fee for testing?  That is why they advertise “free” tests, BUT they must state that the test is “to determine if you could be helped by a hearing aid.”

No one selling hearing aids in California can refer to themselves as a “specialist” without including the title “hearing aid dispenser,” nor can anyone refer to certification by putting a bunch of letters after their name. For example, this listing: “John Doe, NB-HIS” is unlawful.  The correct listing should be:  “John Doe, Hearing Aid Dispenser, Lic. No. XXXX, NB-HIS, Certified by the National Board of Certification in Hearing Instrument Sciences.”

Have you ever received one of those “rebate coupons” that resemble checks as part of a direct mail solicitation? It is a violation to send those to anyone living in California.

And finally, no California-licensed hearing aid dispenser can use the terms “doctor,” “physician,” “clinic,” or “audiologist” or any derivation thereof, except as authorized by law.

These are just a few of the consumer protections for purchasing hearing aids. I urge you to be good consumers by getting the facts and educating yourself about where you stand and whom it is that you are considering doing business with. You’ve worked hard all your life and deserve to be treated fairly, professionally, and with what is in your best interest…Because hearing is a wonderful gift! 

Hearing Loss

Sound Advice for Shooters

I watched as the next IDPA shooter stepped up to the firing line. You could tell he had done this before.

He carefully but purposefully loaded a magazine into his handgun and chambered a round. On cue, he drew and shot a perfect score in amazing time. His handgun seemed like an extension of his arm. The bullets landed exactly where he willed them to on the cardboard target. After safely holstering he stepped back, turned around, and flashed a smile, which told you he was pleased with his results and all that training and endless hours of practice had finally paid off. As he made it back to the observer area, I walked over and congratulated him for a job well done. Curious as to what type of handgun he was using I asked him, “What kind is it?” He replied, “It’s 2:30pm.”

It never ceases to amaze me the high number of shooters that I come in contact with that do not wear any type of hearing protection while shooting. Granted, some things in our lives we cannot control. However, noise-induced hearing loss (NIHL) and acoustic trauma are phenomenon that we most certainly do have control over and yet many shooters ignore the very basic principle of wearing hearing protection.

When is firearm noise is too much? When do we cross that line between loud and damagingly loud? Table 1 [1] displays some of the decibel (dB) levels of various sounds found in our daily lives. A decibel is a unit of measurement, and for our purposes here it is measured on a logarithmic scale. There is a 10-fold increase in noise energy for each 10-dB increase. Said another way, an increase of 10 dB doubles the loudness level.

Sounds over 140 dB can cause pain, and prolonged exposure to noise over 85–90 dB can result in permanent hearing loss. Gunfire may be categorized as an impulse noise, which has the characteristic of an explosive burst. Impulse noise of sufficient intensity and pressure is often a cause of acoustic trauma. Generally, studies have shown that such impulse sounds may result in the shifting, skewing, bending, swelling, bursting, tearing, fusing and/or severe mechanical damage to the inner ear cells, structures, and auditory pathways. That is, short-duration sounds of sufficient intensity (e.g., a gunshot or explosion) may result in an immediate, severe, and permanent hearing loss, which is termed acoustic trauma. The degree of hearing impairment seen after acoustic trauma varies and can range from a mild to profound hearing loss.

Figure 1 (Pickles & Heumen; 2001) compares electron microscopy of normal, healthy outer hair cells (specialized hearing cells in our inner ear) to damaged ones. Once such damage occurs, it is permanent. There is no method of regenerating these cells or curing the damage. Bear in mind that this is only one site where such damage can occur from noise exposure along our auditory pathway.

There is evidence to suggest that once deterioration of certain specialized hearing cells (spiral ganglion cells) has begun, there is a corresponding deterioration within the central nervous system at areas higher up in the auditory system (Kim et al., 1997; Morest et al., 1998). Thus, once damage has occurred at lower levels, it is not isolated there but rather may progress upward through the auditory pathway. This is very characteristic of impulse noise, such as gunfire, that causes acoustic trauma. The inner ear, then, is not the only structure at risk from such exposure.

Figure 1. Normal, healthy outer hair cells (L) vs. damaged outer hair cells (R).

Virtually all of the structures of the ear and hearing system can be damaged from gunfire noise (NIH Consensus Statement; 1990). Generally, for sound levels below 140 dB, different types of sounds produce the same hearing loss. This does not appear to be the case at levels above 140 dB, where impulse noise creates more damage than would be predicted. This may imply that impulse noise above a certain critical level results in acoustic trauma from which the ear cannot recover (NIH Consensus Statement; 1990).

Exposure to noise between 90 and 140 dBA (dBA denotes a decibel measure made with a filter that adjusts for human auditory sensitivity) damages the inner ear metabolically rather than mechanically and causes injury depending on the level and duration of exposure. Noise-induced hearing loss, in contrast to acoustic trauma, develops slowly over years and is caused by any regular and consistent exposure exceeding a daily average of 85–90 dBA (Clark & Bohne; 1999). Acoustic trauma may occur from just one unprotected exposure to gunfire noise.

For sounds between 75 and 90 dBA, the ear has a natural protective mechanism to reduce its sensitivity to low frequency impact sounds through what is termed the middle ear reflex. Generally speaking, muscles in our middle ear contract and stiffen three tiny bones (the smallest bones in the human body called ossicles; see Figure 2) that relay sound to the inner ear. However, a delay of 300–500 milliseconds is required to set this protection fully in operation. Most naturally occurring impact sounds can easily be dealt with by the middle ear, but many manmade sounds, such as explosions from guns and certain industrial noises, occur so quickly that our middle ear protective mechanism cannot respond quickly enough. The hearing loss caused by such sounds is permanent acoustic trauma (Truax; 1999).

Peak sound levels from rifles and shotguns can range from 132 dB SPL (sound pressure level is another unit of measurement) for small-caliber rifles to more than 172 dB SPL for high-powered firearms. Americans collectively own more than 230 million guns, and more than half of men in the American industrial workforce occasionally use guns. The National Rifle Association estimates that 60–65 million Americans collectively own more than 230 million guns. Because guns are so prevalent in our culture, shooting firearms is the most important source of excessive noise outside the workplace. The severity of injury produced by impulsive noise exposure and the prevalence of shooting by Americans makes gun noise America’s most serious non-occupational noise hazard. The acoustic energy in a single report from a high-powered rifle or shotgun is equivalent to almost 40 hours of continuous exposure at 90 dBA. In other words, one bullet equals one week of hazardous occupational noise exposure. An avid target shooter can be exposed to an entire year’s worth of hazardous occupational noise in just a few minutes (Clark & Bohne, 1999; NRA, 1999).

What about firearms themselves? Is a .22 LR any better on your ears than a .45 ACP? Table 2 [2] compares the dB levels of various cartridges.

Recall that sounds over 85–90 dB without hearing protection can lead to permanent hearing damage. As can be seen from Table 2, even firing a .22 LR (134 dB) has the potential of causing permanent, irreversible, inner ear damage.

There are various kind of hearing loss. Conductive hearing loss refers to physical damage, infection, or fluid build up in the middle ear cavity (Figure 2). If the gun blast is of sufficient intensity, a conductive loss may be seen and accompanied by such symptoms as eardrum rupture or middle ear bone damage.

Conductive losses are typically open to medical treatment from a physician who specializes in diseases of the ear (otologist or otolaryngologist). Sensorineural hearing loss refers to damage within the inner ear. This is usually, incorrectly, referred to as nerve-type deafness, which really only occurs in about 1% of the American population (Mueller and Hall, 1998). Sensorineural hearing loss is the most common type of hearing loss in America, and noise induced hearing loss or acoustic trauma from firearms is typically sensorineural. It is permanent; irreversible; and with proper hearing protection, can be avoided or minimized.

Probably the most common excuse I have heard from shooters is that “my ears have toughened up from shooting and I don’t have to wear hearing protection.” Well, I’m sorry to say that this is not possible. What is more likely is that you have sustained sensorineural hearing loss and some sounds just don’t seem as loud any longer (along with speech). However, it is still critical to wear hearing protection as the hearing you do have left can still be harmed from unprotected firearm exposure. As researchers and educators have noted, “Ears don’t get tough, they get deaf” (Mueller & Hall, 1998).

Typically, noise-induced hearing loss and acoustic trauma affect the high frequencies first. Our ears respond to sounds across a wide range of frequencies, from about 20–20,000 Hertz (Hz). Speech frequencies are roughly located between 250–8,000 Hz. Low frequencies are used to hear people, while the highs are what we use to understand what they say. To put it another way, the power of speech (vowels) is located in the low frequency range while the clarity of speech (consonants such as s, k, th, sh, f, th) is located in the highs. High-frequency consonants are necessary to maximize speech intelligibility. Noise damage from firearms affects these high frequencies first due to, some believe, anatomical reasons (Mueller & Hall, 1999). Figure 3 [4] depicts an audiogram (record of one’s hearing) of a sensorineural hearing loss typical of shooters.

As such, many people complain that “I hear people, but sometimes I don’t understand what they said.” Women’s and children’s voices, typically in the high frequency range, are usually the most difficult to understand when one has such a high frequency hearing loss. Add to all this that our hearing gets worse just from the normal aging process, and you quickly realize just how important hearing protection really is.

Other factors also determine how susceptible one is to firearm noise exposure. For example, blue-eyed individuals may be more susceptible than people with greater melanin content in their eyes. Some studies have shown that males are more susceptible to noise-induced hearing loss (NIHL) than females. Newborns and older individuals also seem to be more likely to develop hearing loss from NIHL. Finally, some studies have also shown that smoking increases one’s chances of acquiring hearing loss from noise. This may be due to the carbon monoxide in the smoke (Henderson, Subromaniam, & Boettcher; 1993).

I’ve also noticed that some shooters will wear their hearing protection, but only while shooting. When observing from just a few yards away, they do not wear their hearing protection. This is simply not good hearing conservation practice and is against competition rule #7 of the IDPA manual. In fact, if one were to comply with this rule, anyone within 50 yards of the firing line must wear not only hearing protection, but eye protection also. Some handguns at IDPA produce a very discernible boom that can still damage your ears (see Table 2), even if you are not shooting and are only a few feet to yards away. Of course, this will vary with the type of firearm, cartridge, and distance from the shooter, but Table 2 clearly shows that even a report from a .22 can damage your ears. Though not relevant to IDPA purposes, the use of muzzle brakes and ports dramatically increases the level of noise exposure from firearms.

In the consideration of sounds that can damage hearing, one point is clear: it is the acoustic energy of the sound reaching the ear, not its source, which is important. That is, it does not matter if the hazardous sound is generated by a machine in the workplace, by a loudspeaker at a rock concert, by a lawnmower, or a firearm during an IDPA event. Significant amounts of acoustic energy reaching the ear can create damage — at work, at school, at home, or during leisure activities. Although there has been a tendency to concentrate on the more significant occupational and transportation noise, the same rules apply to all potential noise hazards, including and especially firearms (Clark and Bohne; 1999).

Sound advice dictates that when at the gun range, by all possible means, take appropriate measures to practice safe gun handling. Wearing hearing protection (along with eye protection) falls into this category, whether you are the shooter or an observer. Think of it this way: Hearing aids could cost you anywhere from $600–$8,000 per pair! Protect your hearing and you could spend that on more important things…like firearms, ammunition, training, and IDPA.

[1] Mueller and Hall (1998).

[2] William Kramer, Ph.D.

[3] Mestel, 2000.

[4] E.A.R. Inc.