One of the predominant reasons that many people choose to seek out hearing aids from a private audiology clinic rather than through the NHS is for the hope of getting very small, ideally invisible hearing aids. This is feasible for many patients, and for some people may indeed be a very good choice. There are a few things, though, to keep in mind before considering very small hearing aids, and it is important to realise that these types of hearing aids aren’t always going to be the best option for everyone.
What are the Smallest Hearing Aids Available?
In a previous article I detailed the different styles of hearing aid that are available and explored their various advantages and disadvantages. If a patient is interested in the smallest hearing aids available, this will usually entail selecting an in-the-ear (ITE) style of hearing aid. This where the hearing aid, with all its electronic components, sits in the ear canal itself or the bowl (concha) portion of the ear, without a unit sitting behind the ear. They are based on an impression taken of the ears and are therefore custom moulded to the shape of one’s ears. ITE hearing aids themselves are available in a range of different sizes, styles, and colours.
For the absolute smallest options, one would need to consider either the completely-in-canal (CIC), or the invisible-in-canal (IIC) hearing aids. These are subtypes of ITE hearing aids, and are, broadly speaking, the smallest type of hearing aid available. The IIC hearing aid sits exclusively in the ear canal itself and depending on the anatomy and shape of the patient’s ear canal, for many people this can be a truly invisible solution. The CIC is very similar to the IIC, although it is slightly larger. Because it is just a little bit bigger than the IIC, sometimes a CIC hearing aid can be made with additional options and features that can be beneficial for your hearing, that an IIC would not be able to offer. Depending on the hearing aid manufacturer and other variables, this could potentially include things like the ability to access specific programs in your hearing aids, that can help provide you with additional listening support in various situations, such as noisy environments.
Completely-in-canal (CIC): Sits completely within the ear canal, with minimal to no protrusion outside of the canal
Invisible-in-canal (IIC): Sits completely within the ear canal, with no protrusion outside of it, almost “invisible”.
Extended-Wear Hearing Aids – The Lyric
There is one further type of hearing aid to discuss, which I would be remiss to leave out. This is known by the brand name “Lyric”, which is produced by the well-known hearing aid manufacturer, Phonak. It can generically be referred to as an “extended-wear hearing aid”. The Lyric is an extremely small, analogue hearing aid that is fitted deep into a patient's ear canal. It is therefore completely invisible. The hearing aid is usually inserted by the audiologist rather than the patient and is kept in the ear for two to three months at a time. The device continues to always operate whilst it is inside the ear, until the battery dies. The patient then returns to the audiology clinic after two or three months to have the hearing aid replaced for a new one, ideally before the battery has had a chance to die. It is a simple device from a technological point of view, but due to its proximity to the eardrum, many people find it to have a very clear, natural sound quality. Some basic adjustments to the sound can also be made by the patient via a magnetic tool. The Lyric can be a very appealing option for people who want a truly invisible hearing aid, and many patients like that it is a largely “no fuss” solution with little maintenance that needs to be done on their end. The Lyric is not suitable for everyone, and an appointment with a qualified Lyric provider would be required to determine candidacy. There are several further advantages, as well as disadvantages, to the Lyric that are beyond the scope of this article, but these can be discussed with an audiologist who is familiar with Lyric. I have previously worked with Lyric myself in various settings, but do not currently offer this solution in my practice. A Lyric provider can be found by using Phonak’s “Find a Provider” search tool, where audiologists who offer Lyric will be indicated.
What are the downsides of very small hearing aids?
Generally, the smaller the hearing aid, the more likely a sacrifice may need to be made between features and size/cosmetics. This is because the hearing aid’s small size essentially limits the amount of technology that can be built into the device. A few specific limitations that are worth looking at are detailed below. I would note that these limitations can vary between hearing aid manufacturer and can also be dependent on the patient’s unique ear anatomy/shape.
1) Only one microphone
Hearing aids work by utilising a microphone to collect external sounds from the environment, which are then digitised and amplified. Most hearing aids will have more than one microphone, as this is required to achieve optimal “directionality” in one’s listening environment. Directionality is essentially the ability of the hearing aid to focus more on speech sounds, and less on distracting background noises. In a hearing aid with two microphones, for example, the amplified sound (the “output”) from one of the microphones is subtracted from the output of the other. Through advanced signal processing algorithms, this can lead to an improved signal-to-noise ratio—in other words, you would hear better in background noise. This will work best if the background noise is kept behind you, and while not a perfect solution, the use of two (or more) microphones can certainly help you. Now, in the smallest hearing aid models, such as the IIC or CIC described above, there is typically space for only one microphone. This could therefore potentially limit the benefit you could be getting with a larger hearing aid model.
2) Lack of ear-to-ear communication
In a pair of hearing aids, one hearing aid can usually communicate wirelessly with the other. This is often done via a technology known as near-field magnetic induction (NFMI). Essentially when a sound is “heard” by one hearing aid, that hearing aid can then “communicate” this information to the other hearing aid. This can allow for greater speech understanding in the presence of background noise, and a greater ability to determine which direction sound is coming from (“sound localisation”). NFMI technology has other benefits as well, such as allowing for hearing aids to have multiple programs, which I discuss a bit more below. The smallest models of hearing aid usually will not be able accommodate this technology.
3) Lack of wireless connectivity
Apart from communicating between each other, hearing aids can also communicate wirelessly to external devices, such as mobile phones, as well as accessories such as devices that can stream your TV’s sound directly into your hearing aids. This is typically done via Bluetooth technology. Activities such as talking on the telephone, and watching television are some of the most common hearing challenges that people report when coming to see an audiologist. The ability to have these sounds streamed directly into your hearing aids can be helpful, but this usually won’t be an option with the smallest models of hearing aid.
4) Lack of telecoil or other programs
Many hearing aids can have something called a telecoil built into them. This is a small copper wire that can be built inside a hearing aid, that can connect electromagnetically to hearing induction loops (special wiring that sends out magnetic signals). Hearing loops are commonly found in public places, such as banks, theatres, and places of worship. If someone has a compatible hearing aid, they can activate a hearing loop program in their hearing aid, which will then connect to an available hearing loop. For example, theatres very commonly have hearing loops built into their buildings. When at the theatre, a hearing aid wearer could activate their telecoil program which would allow them to hear the voices from the actors on the stage crisply and clearly, directly into their ears, via the hearing induction loop. This can be hugely beneficial. Telecoils can also be used with telephones (which is actually why they are called “tele”coils). This would work in a similar manner as to connecting to a public hearing loop, but to specifically give one an advantage when talking on the telephone.
Apart from telecoils, there are multiple other programs that your audiologist can provide access to in your hearing aids. Some common examples are programs that can help the microphones of the hearing aid focus directly on what is in front of you (helpful for background noise) or a program that can help improve the sound quality of music. Telecoils and other programs very often will not be an option with the smallest models of hearing aid.
5) Lack of rechargeability
The smaller in-the-ear models of hearing aid generally are always battery operated and will not have the option to be rechargeable. While this isn’t necessarily a problem, it is indeed a consideration if you are particularly keen to have a rechargeable hearing aid.
6) Less powerful
The smaller the hearing aid, the less powerful it can be. This is due to the size of the receiver of the hearing aid, which will need to be larger to allow for greater levels of amplification. This means that the smallest models of hearing aid may not actually be able to provide you with enough sound. This can lead to the hearing aid sounding distorted, or possibly cause the hearing aid to feedback, or “whistle” at you. Often just a very marginal increase in size can allow for significantly greater levels of amplification. Your audiologist will be able to guide you in what size hearing aid you will ideally require, to suit your hearing aid prescription.
What Alternatives Do I Have?
While many people first seeking hearing care are often keen for the smallest available option, they may not realise that receiver-in-canal (RIC) hearing aids are actually very small and discreet devices, even if they are, strictly speaking, not the absolute smallest. This is where the body of the hearing aid itself (which houses the microphones and most of the electronics) sits behind the ear, and a very thin wire runs down the side of the head that attaches to a tiny receiver that sits inside the ear itself. I described these devices in a little more detail in another article. Most people are often pleasantly surprised by how inconspicuous they are, and these hearing aids can usually fit most, if not all, of the above-described technologies, with minimal to no compromise when it comes to the size of the device. Therefore, if you are open to it, I would strongly recommend considering a RIC style of hearing aid over one of the more “invisible” options, as you could potentially get a lot more benefit from these devices.
Another option is to consider one of the larger models of ITE, which will sit inside the ear canal, and then protrude into, and fill the bowl portion of the ear. These hearing aids, albeit quite visible, can often be selected in a sleek, all black colour, with the idea of mimicking a wireless earbud, which are commonly worn nowadays. This option may prove to be preferable for a lot of patients as it has a modern look that is not conspicuous in today’s earbud wearing society and does not sacrifice some of the benefits you may lose with smaller models.
Some Final Thoughts
As a clinical audiologist, I’m a strong advocate for reducing the stigma around hearing loss and hearing aid use, and therefore would encourage my patients to try and look past potential aesthetic concerns around hearing aids. If anything, it can be great to claim “ownership” of one’s hearing loss, and maybe even have some fun with it. Some patients opt to make their hearing aids a bit of a fashion statement, choosing vibrant colours for their hearing aids, and wearing them with pride. However, I do very much appreciate that for many people they would like their hearing aids to be as unobtrusive as possible, and there are certainly some great options out there that can suit this need. It is important though to keep in mind that not everyone is going to be a good candidate for these types of hearing aid, and that sometimes selecting a slightly larger model will prove to be an excellent balance of both form and function. Ultimately though, the best hearing aid is one you will be willing and happy to wear, and a good audiologist will keep this in mind when making a recommendation for you.
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