Which Hearing Aid is Best? Considering the Style/Model

The first article in our series entitled "Which hearing aid is best?" will look at considering the the model or essentially “style” of the hearing aid. Roughly speaking, this is how the hearing aid “looks”. You may have noticed quite a wide range of different styles of hearing aid on friends and family members, and there is a lot more to account for than just the physical appearance of the device.

To help you understand the different types and styles of hearing aid that are available, I’ve outlined the most used models below:

Receiver-in-canal (RIC)/Receiver-in-the-ear (RITE)

In-the-ear (ITE)

Behind-the-ear (BTE)

This article is broken down into three sections corresponding to the above options. If you prefer to see a summary of the options and their key advantages/disadvantages, please feel free to click here.

Receiver-in-canal (RIC)/Receiver-in-the-ear (RITE)

The terms "RIC" and "RITE" (referring to receiver-in-canal and receiver-in-the-ear respectively) may be used interchangeably and usually refer to the same type of hearing aid. Nowadays, this is the most common type of hearing aid in the private sector. 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 speaker (referred to as the “receiver” of the hearing aid) that sits inside the ear itself.

This style has by far the greatest flexibility in terms of how the hearing aid physically fits, along with the most features, options, and technological capabilities. It is cosmetically appealing and discreet, and the behind-the-ear portion of the hearing aid can be ordered in variety of colours that can match hair or skin tones; or can sometimes even be chosen in a colour to reflect your personality, such as a bright pink!

RIC hearing aids can mostly either be rechargeable or operated by a standard hearing aid battery. Because most of the electronics are housed in the behind-the-ear portion of the device, you can usually take advantage of a full suite of features that a hearing aid can come with, without sacrificing any other options. Most of these models can offer the option for wireless connectivity (to connect to your mobile via Bluetooth, and to hearing aid accessories), along with a telecoil (something that can allow your hearing aid to connect to public hearing loop systems, commonly found in places like theatres, banks, and places of worship). There are also many other advanced features that can be built into this type of hearing aid, such as technology that can allow for greater benefit in challenging environments, such as in noisy restaurants or at family gatherings. Because the electronics are not housed exclusively within one unit, if there is a problem with the hearing aid, it is more likely that it can be solved in the clinic rather than having to send it away to the manufacturer for a repair. Furthermore, because this style of hearing aid keeps the ear itself “open” and relatively unblocked, it can retain much of the acoustic benefit that the shape of the ear naturally provides, often leading to a better, more comfortable sound quality for you.

Lastly, RIC hearing aids are easily customisable in terms of their physical fitting in and on the ear. As mentioned above, the part of the hearing aid that goes inside the ear is the receiver (the hearing aid “speaker”). A range of different options can be placed on top of this receiver, which are then fitted into the ear. The most common options are either “domes” or “moulds”.

A dome is essentially a small piece of soft plastic that fits onto the receiver. They are available in different shapes and sizes, which will consequently affect the acoustics of the sound entering the ear canal. Your audiologist will usually select the dome size and shape that is most suited to your ears and hearing loss.

Hearing aid moulds that are fitted for RIC hearing aids are based on an impression taken of the ears (similar to a dental impression of your teeth) and are therefore a custom fit for your ears only. For patients with a more severe hearing loss, a mould may be required as it seals the ear better than a dome can, essentially allowing less sound to “leak” out of the ear, leading to a better, more robust quality of sound. This can also help prevent the hearing aid from feeding back, or “whistling”. As the mould is custom fitted to the ear canal, it can also be more physically secure in the ear than a dome can be. Occasionally, some patients will find that when using a RIC hearing aid with a dome, the receiver wire keeps working its way out of their ear. While there are changes that can be made to the fitting of the dome that can help prevent this, it may be best to switch over to a mould in this case. Some people may also find it easier to insert a RIC with a mould into their ears, rather than using a dome, which may be slightly fiddlier to work with.

In-the-ear (ITE)

The next major category of hearing aid style is the in-the-ear, or as commonly referred to, the “ITE” hearing aid. Like the moulds that are used for RIC hearing aids described above, these are custom fitted, and based on an impression taken of the ears. The major difference, however, between the ITE and the RIC hearing aid, is that the ITE does not have anything fitted behind the ear. As the name implies, everything is fitted “in the ear” itself. This also means that the microphones and all the electronic components of the hearing aid are being fitted into the ear as well (either within the ear canal itself, or just outside of it in the bowl of the ear). ITEs are mostly battery operated, although there are a few manufacturers that offer a rechargeable option, but this will typically only be in their larger models.

ITEs can be further broken down into several more styles that generally correspond to the overall size of the hearing aid. These are, ordered from largest to smallest:

Full-shell: Sits in, and fills up the entire portion of the ear referred to as the concha, which is the “bowl” part of the ear outside of the ear canal

Half-shell: Sits in, and fills up half of the concha bowl of the ear

In-the-canal (ITC): Sits within the ear canal, and protrudes a bit outside of the canal

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”.

ITEs can have many benefits over RIC hearing aids. For one, they are always custom moulded and fitted to the physical shape of the ear, and more specifically the ear canal. This usually leads to a very secure fit in the ear and can therefore sometimes be a good option for someone who struggles with keeping a RIC to stay on the ear. Furthermore, many patients will find an ITE (particularly the larger models, such as the half-shell or full-shell) to be easier to insert into the ear itself, therefore making these an excellent choice for someone who struggles with their manual dexterity, or perhaps anyone who may prefer something a bit easier to handle and manipulate. Some people also simply rather not have anything sitting behind the ear itself, either for comfort or aesthetics. The smallest possible hearing aids will usually be in the form of an ITE.

Many people who seek private hearing care outside of the NHS are specifically after an ITE hearing aid and are often hoping for the smallest options possible. The smallest models, namely the CIC and IIC hearing aids, can certainly be a good choice for a lot of people who would like a very discreet solution to their hearing loss. However, not everyone will be a good candidate for these types of hearing aids, as this will depend on the degree of your hearing loss, your communication needs, and your expectations, amongst other things. Your audiologist will be able to help guide you in this.

Because all the electronic components (including the receiver) are built into one single unit, which is moulded to the shape of the ear, ITE hearing aids are therefore more limited in their technological scope in comparison to RIC hearing aids. Connectivity to mobiles, accessories, and public hearing loops may not be possible. The hearing aid’s ability to work and adapt in challenging, noisy environments may not be quite as advanced as well. Generally, the smaller the ITE becomes, the more likely a compromise will need to be made between size/cosmetics and features/performance. Furthermore, because ITEs sit within the ear itself and block it up, for some people (largely depending on the degree of hearing loss), this can cause quite an “occluded” feeling and a strong sense of “echo”. You also potentially lose some of the benefit that the shape of the ear naturally provides to hearing. This is referred to as the “pinna effect”, with the pinna being the outer, visible part of the ear (what we essentially think of as an “ear”). There can be things done by your audiologist to help reduce some of these concerns, but they do still need to be considered when deciding on a hearing aid style.

Behind-the-ear (BTE)

The final major hearing aid category to consider is the “behind-the-ear” or BTE style of hearing aid. As the name implies, this is a hearing aid that sits behind the ear. This terminology is a bit confusing as the RIC hearing aids described above sit behind the ear as well, and occasionally RICs will be categorised as a sub-type of BTE hearing aid. The difference, however, is that a BTE houses virtually all the electronic components within the unit that sits behind the ear, as opposed to the RIC, which will have the speaker of the hearing aid sitting within the ear canal itself. The BTE unit will then be attached to a hollow tube (as opposed to a wire in a RIC) that runs down the side of the ear, with either a custom fitted mould or a small plastic “dome” (same as what would be fitted onto many RIC hearing aids) that then sits within the ear canal. If using a mould, a thicker tube will be required than when using a dome. Moulds will usually be used for more severe hearing losses, while domes will suit milder hearing losses better, although many times a mould will be chosen regardless, to achieve a more secure fit within the ear. As all the electronics are house in the unit behind the ear, this part of the hearing aid will usually be a little larger than the part of the hearing aid that sits behind the ear in a RIC. Some people may find the sound quality to not be quite as clear or natural as it would be in a RIC, due to the sound having to first travel down a tube, and then into the ear—as opposed to a RIC, where the sound enters the ear directly from the receiver of the hearing aid.

BTEs are usually the type of hearing aid most fitted within the NHS, as they tend to be a more cost-effective option for NHS audiology departments to use, as opposed to RICs or ITEs. They are also commonly used for children with hearing loss. In the private sector, BTEs tend to be used for patients with severe to profound hearing losses, as they are usually capable of providing higher levels of amplification than what can be accomplished with a RIC or ITE. They can also sometimes be a good choice for a patient that suffers from chronic ear infections causing lots of debris and moisture to regularly build-up in the ear canal, as it may be preferential in this case to not house any electronic components within the ear canal.

Summary

Below is a table summarising of some the major advantages and disadvantages of each style of hearing aid. I would also end with a note that regardless of model or style, all hearing aids require you to take care of your hearing aids and regularly maintain them to ensure optimal performance. If you’ve read this far, it may not come as a surprise to learn that my first choice (as well as probably that of most other audiologists) for many patients will be the RIC hearing aid. However, ultimately the hearing aid should be one that you will be willing and happy to use and wear on a regular, consistent basis, and your needs should always be considered as part of an audiological evaluation for hearing aids.

	RIC	ITE	BTE
What is it?	"Receiver-in-canal"; the main body of the hearing aid sits behind the ear, with a thin wire running down the side of the ear, connecting to the hearing aid speaker ("receiver"), which sits inside the ear canal	"In-the-ear"; custom moulded to the ear, with all electronics including the microphone and speaker sitting inside the ear rather than behind it	"Behind-the-ear"; all electronics, including the microphone and speaker, sit behind the ear, which is connected via a tube to either a mould or dome that sits inside the ear canal
Advantages	Fits a wide range of hearing losses, highly customisable, has greatest technological scope	Custom moulded to ear, usually easy to put into ear, smallest options can be very discreet	Potentially the most powerful option, ideal for very severe hearing losses
Disadvantages	Some may not like having something sit behind the ear, some may find this style a bit tricky to put into the ear	More limited in technological scope, some may find the sound quality not as good, more difficult to resolve repair issues within the clinic	Larger model, sounds must travel down a tube rather than entering the ear directly, less customisable than other models

If you'd like to learn more about the kind of hearing care we provide for our patients at Finchley Hearing, please explore our website and feel free to get in touch with any questions. We're a private, independent audiology practice in London committed to ethical, evidence-based practices and would love to help you on your journey to better hearing.

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