Lyric-The Extended-Wear Hearing Device
Tech Topic: Extended Wear Hearing Aids | March 2014 Hearing Review
By Mark J. Sanford, MS, Tamara Anderson, and Christine Sanford
The InSound Medical Lyric hearing device (now owned by Sonova and sold under the Phonak brand since January 2010) was developed over the past 12 years in Newark, Calif, and was offered commercially for the first time in January 2007.
Lyric is the first hearing device that can be worn continuously in the ear canal 24 hours a day for up to 4 months. This extended wear device was developed on several key concepts:
- Sound quality improves with proximity to the tympanic membrane;
- Some people with hearing impairment resist wearing hearing aids due to stigma associated with hearing loss; and
- People want an invisible and hassle-free solution to their hearing loss.1
- There are many benefits to having a device deep in the ear canal, including2,3:
- An overall increase in gain and output, especially in the high frequencies;
- Reduction in the occlusion effect;
- Ability to use the telephone and other ear level listening devices (headphones, stethoscopes) without feedback;
- Security of fit and retention;
- Reduction of wind noise; and
- Improved localization.
Sergei Kochkin has documented through his MarkeTrak studies that the market penetration of hearing aids is approximately 25%. Therefore, even with all the improvements in technology during the past decade—directional microphones, Bluetooth compatibility, multiple programs, etc—the percentage of hearing-impaired people using hearing aids has not changed or, more importantly, increased. The Lyric device has the benefit of being a device placed deeply in the ear canal and eliminates the stigma of wearing a hearing device due to its invisibility and convenience.
The Lyric device received approval by the FDA to be placed by an ear nose throat (ENT) physician in 2002. In May 2008, InSound Medical received approval by the FDA that audiologists and hearing aid dispensers also could size and place the Lyric device with proper training. It also received clearance from the FDA to be worn for up to 120 days continuously by a patient.
Integrating Lyric into a Practice
The Lyric device is very different compared to fitting a traditional hearing aid. The equipment, the evaluation of the ear canal, and skills of the clinician are critical to being successful with the Lyric. In addition, the medical issues that should be considered make the learning curve substantial.
Fitting the Lyric Device
Candidacy. There are three steps to evaluating a patient for the Lyric hearing device. First, the ear canal is evaluated otoscopically to determine if a patient’s ear is an appropriate candidate for the device. Second, an audiogram is performed to determine if the patient’s hearing loss is in the fitting range. Third, the ear canal is then sized by the Lyric fitting procedure, ideally under a high-magnification microscope, to determine if the patient’s ears can accommodate the Lyric device. There are some medical conditions that are contraindications for some patients: transplant recipients, uncontrolled diabetes, radiation to head and neck, and autoimmune compromised patients.
The otoscopic examination is the foundation for placement and successful fitting of Lyric. The bony portion of the ear canal is very sensitive, and visualizing where the medial seal should/will sit in this part of the ear canal is extremely important. Discomfort is the number-one reason patients do not keep the Lyric, and 95% of pain complaints come from this area when fitting Lyric. The discomfort or pain is almost always on the floor of the ear canal or on the lower sides of the canal wall. In some cases, the top of the ear canal by the tympanic membrane can be sore.
The customary hearing aid evaluation for Lyric takes 45-60 minutes if you decide to test, size, fit, and counsel all at the same appointment. Approximately 5-20% of patients who are sized will need to return for fitting 5-10 days later due to sensitive skin that may appear slightly bruised during cerumen removal and/or during the sizing procedure. As a practitioner gains experience and knowledge, the number of patients who need to return for an initial fitting after bruising from initial sizing will decrease to less than 5%.
The Lyric device is sold on a subscription basis, so patients will want to be “re-fit” as soon as possible after the device ceases to function.. A re-fit generally takes only 5-10 minutes, depending on if it is a unilateral or bilateral change. When a pattern of device longevity develops for a patient, they may decide to come in at regular intervals before a device becomes weak and runs out of power.
Subscription model. Lyric is sold on a subscription model, meaning the cost the patient pays covers all services for a year. The subscription is usually for 1 year, and patients can buy extended years, especially if they have an insurance benefit that covers more than the cost of 1 year. There are a few patients whose devices last 120 days, but this cannot be determined in the beginning for a patient trying the Lyric. The patient’s ear adapts to Lyric over time and a fairly consistent interval of service life develops. Most patients will come in at regular time intervals to have their Lyric(s) changed for a new device(s).
There is an interesting irony with patients who wear the Lyric: they have an invisible device, but they tell everyone about it. They say to their friends to look in their ears that they have this great new device. The hearing aid industry has been trying to be cosmetically oriented for years to reduce the stigma of wearing an aid, and now there is a device that is basically so invisible that our patients want everyone to know they are wearing a device.
Additional benefits. The Lyric differentiates our clinic from local and even national competitors. In many ways, the Lyric sells itself and should be introduced to all patients, especially those who will not use a traditional device. The patients who do wear Lyric provide incredible word of mouth about the device, creating a higher referral rate for the practice.
Lyric changes the clinic’s perception of hearing as patients are extremely satisfied, happy, and want to wear a hearing device. This is compared to many traditional device users who tend to have more negative feelings toward their devices.
We believe the relationship between the patient and practitioner also changes. The practitioner is much more involved with the patient when sizing and fitting the Lyric compared to a traditional device. This intimacy makes the patient more loyal and “tied” to the office than with a traditional hearing device that the patient can think they can get from any dispensing office.
The Lyric hearing device is a great option for hearing-impaired patients, and we believe that it is tapping into people with hearing loss who normally would not wear a traditional device. It has been fit on thousands of patients successfully who have the appropriate anatomy and hearing loss for the Lyric, and the latest version of the device has proven to fit a high percentage of ears.
Tricks to protect Musicians Hearing
Musicians Like to Turn the Volume Up and Most Don’t Really Care
Everyone would agree that rock and roll needs to be loud. When working with musicians or people who like to listen to rock and roll, this is a given, and telling them to turn down the volume will “fall on deaf ears.” Well, actually if you tell them to turn down the music, a certain finger (which will remain nameless) may go up in the air.
It may be true that rock needs to be loud, but it doesn’t have to be at a high sound level. Exploiting this difference between sound level and loudness can add significantly to the hearing care professional’s toolbox of hearing loss prevention strategies.
Unlike sound level, which can be measured with a sound level meter (or even a Smartphone app), there is no loudness meter. Loudness is a subjective attribute of sound that allows us to place it on a scale going from soft to loud without relation to any physical measure. As such, loudness can be affected by background noise, the nature of the noise or music spectrum, the degree of vibro-tactic response, and even your mood or whether you have a hangover.
Add this to the fact that 85 dBA (the sound level where noise or music will start to have a long-term effect if listened to long enough), is simply not loud. We hear 85 dBA sound levels everywhere. The dial tone on a telephone land line is 85 dBA; the tone during testing of admittance is in excess of 85 dBA; and the sound of the toilet flushing (with your head in the bowl) is about 85 dBA. Humans are wonderful at discerning differences in frequency (especially those with perfect pitch), but we are not great at discerning differences in sound level. And this makes sense: a change in sound level does not yield a linguistic change in meaning because it is not linguistically distinctive. Imagine a language that ascribes a different meaning to the vowel /a/ as in “father” if it was spoken at a louder level. That language just wouldn’t work. Shouted speech would have a different meaning than softly spoken speech.
Dial It Down and Give Them More Bass and Vibration
More bass. One strategy that is frequently used when counseling musicians is to turn up the bass. This is something that many rock musicians do in any event and, besides, rock music sounds cooler that way. This increase in low frequency sound energy “deludes” the musician into thinking that the music is at a higher sound level than it really is—the musician feels that it is loud, but at a lower sound level. Since it is sound level that contributes to hearing loss and not loudness, I feel that I have done a good day’s work!
More vibration. Another way to “delude” a musician is to provide vibro-tactile feedback in addition to listening to the music. There are some devices on the marketplace with various trade names such as Bass Shakers™ or Tactile Sound Transduces™ (www.sensaphonics.com). These can be bolted to the vertical bar on the seat of a drummer or bolted onto a 1-square-foot piece of 3/4” plywood and placed in the playing area of the drummer or bass player. When a bass note is played or a bass drum is hit, this ultra-low frequency sub-woofer loudspeaker vibrates and this causes the musicians in the area to feel that the music is sufficiently loud…but at a lower sound level.
Both cases—turning up the bass and using additional vibro-tactile loudspeakers/vibrators—can be very helpful, and both are predicated on the fact that sound levels can be reduced while still maintaining adequate loudness. Rock and roll just needs to be loud but not intense (… I mean, “but not at a high sound level”).
Benefits of iphone FaceTime for hearing aid users
Everyone has experienced how difficult it can be to carry out a phone conversation in a noisy situation. For hearing instrument wearers, using the phone can be very challenging even in quiet situations and impossible in the presence of any background noise. While the ability to use the phone may seem of secondary importance, phone use is an important communication medium to which everyone should have access. In fact, phone use has been linked to self-reported quality of life.
Numerous factors contribute to hearing instrument wearers’ experienced difficulties communicating on the phone. These include presence of background noise, inappropriate or inadequate coupling to the phone, handset positioning difficulties or constraints, and absence of visual cues.
Many hearing instruments have the option to operate in one of three modes for phone conversations: Acoustic phone, inductive coupling (telecoil), and digital wireless coupling.
Acoustic mode. Hearing instruments operating in acoustic mode (holding the phone receiver to the hearing instrument microphone) receive and amplify all sounds surrounding the hearing instrument wearer. Sounds amplified in this mode include the phone’s audio signal—typically conversational speech—as well as ambient sounds.
Telecoil. Hearing instruments operating via inductive coupling (telecoil) receive signals from magnetic fields generated by telecoil-compatible phones. Inductive coupling can be inductive coupling only, in which amplification of ambient sounds is avoided by turning off the hearing instrument microphones in the inductive coupling program (telecoil program). Inductive coupling can also be a combined inductive coupling and hearing instrument microphone mode (microphone-and-telecoil program) allowing the phone signal to be delivered through the inductive coupling while ambient sounds are being amplified through the hearing instrument microphones.
Wireless streaming. The third option for phone use is streaming either via a hearing aid accessory or directly from an iPhone. When streaming through a hearing instrument accessory, the accessory is paired to a Bluetooth compatible phone. When using the phone, the sound streams from the phone to the accessory, via Bluetooth, to the hearing instruments via another digital wireless technology.
As with inductive coupling, streaming from the phone can be done with and without the hearing instrument microphones activated, and thereby allow either amplification of or removal of ambient sounds. Inductive coupling and streaming improves the signal-to-noise ratio (SNR) by streaming the phone signal (typically speech). The degree of SNR improvement depends on the technology used and whether the hearing instrument microphones are activated or not. Deactivation of the hearing instrument microphones may be needed for some in order to be able to carry out a phone conversation, whereas activation of the hearing instrument microphones might be preferred by others to allow awareness of the environmental sounds around them.
Streaming, whether via an accessory, removes the reliance on correct placement of the phone handset. Streaming also allows the listener access to the phone conversation in both ears, which has been shown to provide significant benefit even in the presence of several different noise configurations. This benefit has been attributed to binaural summation (or binaural redundancy), and binaural squelch.
It is estimated that visual information makes up approximately two-thirds of all communication.3 Most of us are probably unaware of our usage of visual cues in many situations, but become aware of them when in challenging communication situations like in background noise. The absence of visual cues might be the reason why people with normal hearing periodically experience difficulties hearing on the phone when in background noise. The addition of visual cues is also helpful for people with hearing impairment. In fact, those with very severe losses rely as much or more on visual information as on auditory information.
One of the advances that have come with smartphones and tablets is the possibility to carry out video calls. This means that the camera on the smart device can be used to pick up and transmit an animated image of the face of the caller at the same time he or she is talking. In this way, the call recipient can both see and hear the caller.
Many different apps exist that can be downloaded to smart devices for video calling. They require that both the caller and call recipient are using the same app. Assuming that the same benefit of visual cues is available on a video call, this technology could provide an important benefit for hearing instrument users. In particular, for those with severe-to-profound hearing losses, this technology could make the difference between successful phone use and no phone conversation at all.
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